Dr. Cole has practiced in Northeast Ohio for more than 22 years. She is an adjunct professor and Director of Wound Care Research at Kent State University College of Podiatric Medicine. She is board certified by the American Board of Foot and Ankle Surgery and the American Board of Wound Management. She has been a dedicated wound care advocate for two decades with interests focused on medical education, diabetic foot care, wound care, limb salvage and clinical research. Her article, “The Relationship Between Venous Insufficiency and the Diabetic Foot: It's Complicated,” recently appeared in Podiatry Today. This month, she breaks down the article and discusses the connection between venous insufficiency and diabetes, along with treatment for diabetic foot ulcers. Read the full article.
Generally speaking, what is venous insufficiency and how does it impact the lymphatic system?
Venous insufficiency is the reversal of blood flow from the deep venous system to the superficial venous system, which causes pooling of blood and fluid in the legs. With venous insufficiency, the lymphatic system will fail to effectively clear inflammatory fluids from the tissues. Fluid overload amplifies the body’s immune response and increases inflammation. Common symptoms include aching or heavy-feeling legs; difficult movements; hard, tight skin; folds developing in the skin; wart-like growths of the skin; and fluid leakage through the skin.
Are diabetics at risk for developing venous insufficiency?
Clinicians have begun to question the prevalence of venous incompetence in the diabetic population and new clinical evidence is mounting. Studies show that there can be significantly higher levels of venous system dysfunction in patients with diabetes. Why is this so? Microcirculation, the small blood vessels in the hands and feet, allows for transfer of oxygen, waste products and nutrients from the blood into the tissues. When there is a prolonged increase in blood sugar levels, as seen with uncontrolled diabetes, glucose toxicity will occur causing damage to the small blood vessels. This damage leads to fluid leaking out of the vessels and into the tissues—resulting in tissue swelling and edema.
How can venous insufficiency contribute to diabetic ulcers?
The venous dysfunction that occurs due to glucose toxicity causes edema in the foot, increased white blood cell adhesion, and the release of substances that cause tissue inflammation. If not properly managed, skin breakdown and ulceration will occur. Once a foot wound develops, these conditions will act as a barrier to tissue repair and wound healing. Thus, diabetic ulcers are among the most difficult wounds to heal.
How can diabetics and their care team help prevent or treat diabetic foot ulcers?It is important for the care team to perform a full patient and wound assessment. Patients should be forthcoming about their medical history and all medications they are taking. This will help their provider determine the best treatment plan.Treatment for diabetic ulcers can include specialized dressings and frequent wound cleansing or debridement. If the wound is on the bottom of the foot, the patient will need to wear a boot or cast to help take pressure off of the area, so it can heal. Considering the predisposition of diabetics to develop venous dysfunction, providers should also consider the use of compression dressings to control edema and lymphedema in patients with diabetic ulcers. A variety of compression dressings and systems are available, and selection should be based on the patients’ activity level, circulation and tolerance.
Any promising research on the horizon?
The effects of chronic hyperglycemia are seen throughout the tissues of the lower extremities including the venous system. When diagnosed together, these disease states can have an overwhelming negative effect. Thus, I have become an advocate of applying compression dressings in the treatment of diabetic foot ulcers. Additionally, I think clinicians should be doing more to control hemodynamic changes earlier in the disease process. By encouraging patients with diabetes to wear compression garments and use dietary supplements, such as flavonoids. Flavonoids have been shown to improve glucose metabolism, improve lipid profiles, regulate hormones and enzymes, and protect against neuropathy. These small modifications in clinical practice could reap large benefits by supporting wound healing and preventing wound development all together.
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