A

ccording to the American Diabetes Association (ADA), diabetes, or diabetes mellitus, is a disease in which the body does not produce or properly use insulin. Insulin is the hormone that is necessary to convert sugar, starches, and other food sources into energy needed for basic functioning and daily life. The cause of diabetes continues to elude us, although genetics and environmental factors, such as lack of exercise and poor diet, appear to play a role. With 18.2 million or 6.3 percent of the population of the United States affected by diabetes, only 13 million people are diagnosed, and an estimated 5.2 million people (or almost one-third) are unaware that they have the disease.1
       There are three major types of diabetes. Type 1 diabetes, previously called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes, develops when the body's immune system destroys pancreatic beta cells, the cells that make the hormone insulin and regulate blood glucose. Insulin "unlocks" the cells of the body, allowing glucose to enter and provide fuel. Although it can occur at any time, this type of diabetes often strikes children and young adults. It is estimated that 5 to 10 percent of Americans who are diagnosed with diabetes have type 1. Risk factors include autoimmune, genetic, and environmental factors.
       Type 2 diabetes, previously called non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes, results from insulin resistance (a condition in which the body fails to properly use insulin) combined with relative insulin deficiency. As the need for insulin rises, the pancreas gradually loses its ability to produce insulin. Type 2 diabetes is associated with older age, obesity, family history, physical inactivity, and race/ethnicity. Approximately 90 to 95 percent or 17 million Americans diagnosed with the disease have type 2 diabetes.
       Pre-diabetes is a condition that occurs when blood glucose levels are higher than normal but not high enough to diagnose type 2 diabetes. People are considered to have pre-diabetes if they have impaired fasting glucose (IFG) of between 100-125mg/dL and/or impaired glucose tolerance (IGT) of between 140-199mg/dL after a two-hour glucose tolerance test. It is estimated that at least 20.1 million Americans have pre-diabetes in addition to the 18.2 million with diabetes.
       The disease seems to affect men and women equally with 0.25 percent of people under the age of 20, 8.7 percent of people age 20 and over, and 18.3 percent of people over the age of 60 affected by diabetes.1 African Americans, Hispanic/Latino Americans, Native Americans, and Asian Americans have the highest prevalence of diabetes.1 Diabetes was also the sixth leading cause of death listed on US death certificates in 2000. The risk for death among people with diabetes is about two times that of people without diabetes.1
       In 2002, the cost of diabetes in the US was $132 billion--$92 million in direct medical costs and $40 billion in indirect costs, such as disability, work loss, and premature mortality.1
       With the illness come potential deadly complications that can cause ailment to vital organs, such as heart disease and stroke, hypertension, blindness, kidney disease, nervous system disease or neuropathy, dental disease, immune system problems, and amputations. More than 60 percent of nontraumatic lower-limb amputations in the US occur among people with diabetes making it the single most common underlying cause of lower-extremity amputation. Early detection and appropriate treatment of these ulcers may prevent up to 85 percent of amputations.2 One of the projects outlined in the US Department of Health and Human Services' "Healthy People 2000" is a 40-percent reduction in the amputation rate for patients with diabetes. A savvy specialist I know always recommends a second opinion when amputation is considered. Often a wound care specialist can offer a more conservative approach before something as radical as amputation.
       Now that we understand the causes and types of diabetes, let's uncover the diabetic ulcer mystery.

Risk and Cause
       Patients with diabetes are prone to foot ulcerations due to both neurologic and vascular complications. Patients with diabetes usually present with sensory, motor, and autonomic neuropathy. Peripheral sensory neuropathy can cause altered or complete loss of sensation in the foot and leg resulting in the inability to perceive pain or injury. We can all relate to the feeling of a "fat lip" after a dentist's injection of local anesthesia. Similarly, the patient with diabetes with advanced disease and neuropathy looses all sharp and dull discrimination. Any cuts or trauma to the foot can go unnoticed for days or weeks in

Figure 1. Example of a Charcot foot deformity and a mid-foot plantar surface wound in its late stages. Photo courtesy of Carol Paustian, RN, BSN, CWOCN.

someone who is insensate. It is common to make a home visit to one of these clients and find an advanced wound that the patient didn't even know he or she had. Sometimes the patient will appear in the clinic or doctor's office complaining that a wound "just happened," when in truth the ulcer had been developing for some time without his or her knowledge. Motor neuropathy contributes to wasting of the intrinsic muscles of the foot, muscle imbalance, structural foot deformities, and limited joint mobility. Autonomic neuropathy causes shunting of blood and loss of oil and sweat gland function leading to dry, cracked, and vulnerable skin.
       An extreme example of the results of diabetic neuropathy is the Charcot foot deformity. This occurs as a result of decreased sensation, tissue ischemia, and necrosis leading to plantar ulceration, microfractures in the bones and later disfigurement, chronic edema, and extra bony prominences (see Figure 1).
       Three mechanisms of injury that cause foot ulcers have been identified: ill-fitting shoes (prolonged or constant low pressure), repetitive moderate forces on the soles of the feet (resulting in pressure on weight-bearing areas), as well as penetrating or puncture injuries and trauma (solitary exposure to direct high pressure).
       Screening for sensory neuropathy can be accomplished by performing several tests including a Semmes-Weinstein (SWM) assessment with a 10gm (5.07 log) monofilament. This is a low-cost, simple, noninvasive way to check for alterations in sensation and diagnose patients at risk for ulcer formation due to peripheral sensory neuropathy.3 The monofilaments are often available as free, value-added tools from diabetes and wound care manufacturers and distributors.
       The test is performed by touching the thin, nylon monofilament to 10 specific spots on the feet, bilaterally:
* plantar aspect of the first, third, and fifth digits
* plantar aspect of the first, third, and fifth metatarsal heads
* plantar mid-foot medially and laterally
* plantar heel
* dorsal aspect of the mid-foot between the great toe and second toe.
       See Figure 2 for an illustration of the spots for assessment with the monofilament.

Figure 2. Semmes-Weinstein monofilament assessment sites

       Start by touching the patient's arm to demonstrate the sensation of the monofilament. Next, ask the patient to close his or her eyes and tell you each time he or she feels the monofilament touch his or her foot. Hold the monofilament perpendicular to the patient's foot and press it against the skin until it bends to make a "C" shape without sliding for one second. Record the response on a foot-shaped diagram using "+" for a positive response and "-" for a negative response on all 10 sites, bilaterally. Make sure to test the sites randomly, not in any specific order, so that the client isn't able to guess. Research shows that the average monofilament is effective for 25 patients before it should be replaced.4
       A validated risk stratification endorsed by the International Working Group on the Diabetic Foot5 provides a great way to assess and evaluate the lower extremities to identify risk for ulceration and amputation (see Table 1).
       Peripheral vascular disease (PVD), or development of occlusive plaques and microvascular disease, is a significant problem for patients with diabetes and can lead to ulcerations and infection secondary to ischemia or lack of oxygen. One hypothesis of microvascular change proposes that increased microvascular pressure results in injury to the vascular endothelium. The injury causes microvascular sclerosis and thickening of the capillary basement membrane leading to capillary fragility and microhemorrhage. This could explain why infection spreads through tissue in patients with diabetes.6
       Vascular status should be evaluated by a trained clinician and should include a history and physical. The presence of lower-extremity ischemia is suggested by a combination of clinical signs and symptoms plus abnormal results on noninvasive vascular testing. Signs and symptoms may include intermittent claudication, pain occurring in the arch and/or forefoot at rest or at night, absent popliteal or posterior tibial pulses, thinned, shiny skin, absence of hair on the lower leg and foot, thickened toenails, redness of the affected areas when feet are dependent, and pallor when feet are elevated.7
       Noninvasive vascular tests include transcutaneous oxygen measurement (less than 40mmHg is considered abnormal), ankle/brachial index (ABI; less than 0.8 is considered abnormal), and absolute toe systolic pressure (less than 45mmHg is considered abnormal). If lower-extremity ischemia is suspected, arteriography or other imaging should be performed to confirm or rule out ischemia. Optimal tissue health and healing of ulcers require adequate perfusion. If ulcers do not heal despite aggressive topical and systemic therapy, arterial insufficiency should be suspected, and a referral to a vascular surgeon should be considered.
       Suitable control of related hypertension and/or hyperlipidemia can help to reduce the risk of peripheral arterial occlusive disease. Additionally, smoking is contraindicated, and cessation is essential for preventing progression of the disease.

An Ounce of Prevention
       Meticulous foot care is the mainstay of diabetic foot ulcer prevention. However, many factors are involved in preventing foot complications and ulcers. Systemic disease management, along with local treatment, will shine with multidisciplinary care. Tight blood sugar control can be achieved with a comprehensive team effort including dietary management, glucose monitoring, appropriate medication, exercise, and early treatment.
       Regular foot examinations by a podiatrist, nurse practitioner, clinical specialist, or physician including debridement of calluses and ingrown toenails provide an opportunity to reinforce appropriate self-care behaviors and allow for early detection of new or impending foot problems. Assessment starts as simply as a certified nursing assistant visualizing the feet during the patient's bath or dressing routine and reporting any abnormalities to the licensed practical nurse or registered nurse in charge of the patient's care. Daily foot inspection, with the help of a family member or caregiver, is key in the home care environment. If the patient can't visualize his or her feet, he or she is unlikely to be aware of any break in the skin or ulcer formation. Be sure to include a thorough foot exam, especially in patients with diabetes, in your facility's head-to-toe assessment protocol. It is easy and inexpensive. Patient education has a central role in prevention and treatment and should include foot hygiene, daily inspection, choice of proper footwear, and prompt treatment of any skin condition or ulcer, no matter how small.
       Remind the home care patient to always take his or her shoes off at clinic or home care visits. This facilitates a foot exam every time! When it comes to shoes, many patients do fine with a good pair of well fitting and supportive athletic type shoes with a deep toe box, extra depth, and a thick, flexible sole. Substantial socks made of a breathable and absorbent material and without seams are helpful. Laces or Velcro closures also help accommodate deformities, such as claw toes. Patients with foot deformities or special support needs may benefit from custom shoes. Medicare B now covers the purchase of custom shoes when the certifying physician identifies a risk factor for ulcer formation and submits appropriate documentation.
       Clinicians who are in frequent contact with patients with diabetes should be educated on the evaluation of the skin and subtle signs and symptoms of problems including reddened areas, areas of high pressure, dry flaky skin, cracks, fissures, maceration, calluses, and thickened or ingrown toe nails. Nail problems, such as onychomycosis, or fungal infection of the nail in the patient with diabetes can quickly result in cellulitis and osteomyelitis. Keep them in check!
       Foot care should include:
* Gentle cleansing with pH-neutral soaps and cleansers. Never soak the feet. Showers should be chosen over baths, if possible. Be sure to check the water temperature with a part of the body that has good sensation before exposing the feet and lower legs to the water or have a family member or caregiver draw the bath or turn the shower on to an appropriate water temperature. Home care nurses should check water heaters in clients' homes and turn them down to an appropriate level so that scalding injury is diminished. Bath time is a perfect time to inspect the feet too.
* After cleansing, the feet should be dried carefully and moisturized with a cream or lotion. Sealing the moisture in immediately after the bath increases the water content of the stratum corneum and helps increase the skin's strength and reduce dry, flaky skin. The areas between the toes should be avoided to decrease moisture build up and the chance of fungal growth.
* The feet can be checked for calluses when applying the cream. Calluses, if not trimmed, can get thick, break down, and turn into ulcers. A patient should never be allowed to cut or trim his or her own calluses or corns. Bedside "self surgery" can lead to ulcers and potential amputation.
* Toe nails, if they can be reached, can be trimmed straight across after the bath. Edges can be filed with an emery board. If nails are in any way a challenge, the trained clinician or podiatrist should attend to thick or difficult nails to decrease the chance of injury or infection. If dystrophic nails appear, a culture may be necessary to rule out fungal infection. An oral antifungal treatment, such as Lamisil® (Novartis Pharmaceuticals, East Hanover, New Jersey), or a liquid nail lacquer, such as Penlac (Dermik Laboratories, Collegeville, Pennsylvania), may be prescribed if the culture is positive or if the clinician decides to treat empirically based on the signs and symptoms. The prevalence of fungal infections of the nail in patients with diabetes is from 26 to 33 percent8--almost three times as often as individuals without diabetes.
* Patients should be advised to always wear socks and shoes and to never walk barefoot. They should also be directed to check the inside of each of their shoes before putting them on making sure that there are no foreign objects and that the lining is smooth.
* Be active and encourage blood flow to the lower legs and feet. Walking is great if the patient can tolerate it. When sitting, have the patient elevate the legs and exercise the toes, feet, and ankles to promote circulation. Advise against crossing the legs, except at the ankles.
* Heating pads, electric blankets, or any harsh topical agents, such as hydrogen peroxide, povidone iodine, rubbing alcohol, or astringents, such as witch hazel, should never be used.

Skin Care
       Diabetes can affect every part of the body, as we've already learned. The largest organ, the skin, is no different. Often, the first indication that a person has diabetes is manifested in the skin. As many as a third of people with diabetes will have skin disorders caused or affected by diabetes at some time in their lives.1 Most skin conditions and wounds can be prevented or easily treated if caught early.
       Several types of bacterial and fungal infections are more prevalent in the skin of the patient with diabetes. The most frequent type of bacterial infection is Staphylococcus aureus and can affect the hair follicles to produce boils on the skin and the lacrimal ducts of the eye to produce sties of the eyelids. The culprit of many fungal infections is Candida albicans, a yeast-like fungus. It tends to crop up in warm, moist areas and in skin folds and creates a red rash with surrounding satellite lesions or bumps and sometimes scales. Other common fungal infections include tinea pedis (athlete's foot), tinea cruris (jock itch), and tinea corpis (body ringworm). A two-percent miconozole cream or powder or an ionic silver powder, such as Arglaes® Powder (Unomedical for Medline Industries, Inc., Mundelein, Illinois), is usually effective to clear the fungus in two weeks or less. Both are cost effective and do not require a physician's prescription.
       Other less common but bothersome integumentary conditions can affect the patient with diabetes. Most of them happen when blood glucose levels are out of control. Diabetic dermopathy, necrobiosis lipoidica diabeticorum, diabetic blisters or bullosis diabeticorum, eruptive xanthomatosis, digital sclerosis, disseminated granuloma annulare, and acanthosis nigricans need the attention of a skin care professional, such as a dermatologist. Any time a skin ailment does not respond to conventional or conservative treatment, a referral is necessary.
       The most common skin condition is itching caused by dry skin and poor circulation. Often, this is more prominent in the lower legs. Home care patients need to be advised during cold, dry months to keep their homes more humid and to bathe less often, if possible. Scratching is a "no-no" and can cause dry skin to become infected or, worse, ulcerated. Be sure that your facility is using properly moisturizing, no-residue cleansers with a neutral pH and good quality (lower water content) fragrance-free body creams on these vulnerable patients. Thick, bland, petrolatum-based creams like Eucerin® Cream (Beiersdorf Inc., Wilton, Connecticut) or Soothe and Cool® Extra Thick Moisturizing Cream or Skin Cream (Medline Industries, Inc.) provide long-lasting relief and protection.
       Specialized product lines by Carrington Laboratories, Inc., Irving, Texas (DiaB Cream), and 3M Health Care, St. Paul, Minnesota (3M Cavilon Diabetes Foot Care Kit), provide custom care to the specific skin care needs of the patient with diabetes.

Ulcer Assessment
       People with diabetes can develop many different foot problems including diabetic foot ulcers. These patients require the same local wound management as those without diabetes: correct assessment and documentation, offloading, and appropriate wound bed preparation including cleansing, debridement, infection control, and proper dressing choice. The key to wound treatment in these patients is to treat early to maximize the rate of wound healing and to reduce bioburden, since this population is at high risk for infection and consequent amputation.
       Classification can be described using the simple terms partial thickness and full thickness. Partial thickness involves the epidermis and dermis; full thickness goes beyond the dermis to the subcutaneous or underlying tissue. Also useful for the classification of depth is the Wagner scale, which scores the ulcer from grade 0--preulceration lesions, healed ulcers, or the presence of a bony deformity--to grade 5--gangrene of the foot.9 As staging is only appropriate for pressure ulcers, the Wagner scale is only suitable for diabetic/neuropathic ulcers. See Table 2 for an example of the Wagner ulcer classification scale.
       Another validated, more comprehensive method to address classification that is inclusive of infection and vascular impairment is the University of Texas diabetic wound classification system developed by Armstrong and associates in 199810 (see Table 3).
       The ADA Consensus report11 recommends that wound assessment include a systematic evaluation that includes the following questions:
* Has the patient experienced trauma? Is the ulcer a result of penetrating trauma, blunt trauma, or burn?
* What is the duration of the wound? Is the ulcer acute or chronic?
* What is the progression of local or systemic signs and symptoms? Is the wound getting better, is it stable, or is it deteriorating?
* Has the patient had any prior treatment of the wound or previous wounds? What treatments worked? What failed?
       In addition, blood glucose control and comorbidities should be evaluated. Clinical assessment should identify:
* Signs and symptoms of ischemia--adequate blood flow to heal the wound
* Signs of soft tissue or bone infection--unpleasant odor, cellulitis, abscess, or osteomyelitis
* Wound depth--undermining or exposed tendon, joint capsule, or bone
* Appearance--surrounding callus, devitalized tissue, granulation tissue, drainage, eschar, or necrosis.
       Another way to further stratify diabetic ulcers is by color. Red, yellow, and black or a mixture of the colors can be assessed and documented as a percentage of the total wound bed. Red signifies a clean granulating wound, yellow a wound with slough tissue, and black a necrotic wound. By assessing the color and depth, we can decide the appropriate care plan and dressing choice. Obviously, yellow and black wounds need to be debrided.
       Ulcer assessment includes evaluating a number of factors just as with the appraisal of any wound. These assessment parameters include location; size; length of time the ulcer has been present; condition of the periwound skin, wound base, and margins; and presence of devitalized material. A blunt, sterile probe may be used to assess for sinus tract formation and dissection into tendon, bone, or joint capsule. A positive probe-to-bone has a high predictive value for osteomyelitis12 and should immediately be reported to the physician.

Figure 3. Example of a typical diabetic ulcer located on the plantar/lateral aspect of the foot at the first metatarsal head (bony prominence). Photo courtesy of Carol Paustian, RN, BSN, CWOCN.

       Most diabetic ulcers are located over bony prominences (see Figure 3) especially when calluses, bunions, claw feet, and hammer toes lead to abnormally prominent points. Foot deformities are thought to be more common in the diabetic population secondary to neuropathy and atrophy of the intrinsic musculature responsible for stabilizing the toes. For an example, see Figure 4. These wounds usually have even, circular, well-defined borders with low-to-moderate exudate.
       Infection is a high risk in the patient with diabetes with wounds. A combination of labile blood sugars, poor white blood cell function, and small vessel disease preclude these patients to bioburden challenges. All wounds are considered contaminated (presence of organisms) or colonized (bacteria multiply on the wound). Cultures are not necessary unless signs and symptoms of infection, such as redness, edema, warmth, and pain at the site, appear. A culture should then be obtained or the presumed infection should be treated empirically with a topical antimicrobial or a broad-spectrum antibiotic. Any wound that does not show signs of healing despite aggressive local and systemic treatment, has an increase or significant change in exudate, or produces bright red friable jelly-like granulation tissue should be suspect to critical colonization or infection. Systemic antibiotics should only be used for a known infection, cellulitis, osteomyelitis, bacteremia, and sepsis.13 Otherwise, topical antimicrobials are appropriate.
       Topical antimicrobials can offer contaminated, colonized, critically colonized, and locally infected wounds quick aid. Commonly used antimicrobials include cadexomer iodine, gentamicin sulfate cream or ointment, metronidazole gel or cream, mupirocin cream or ointment, polymixin B sulfate, and silver sulfadiazine. Many patients are sensitive or allergic to the components of these products, such as iodine and sulfa, which can cause further problems. Additionally, most of these products require a physician's prescription. Consider novel treatments, such as controlled release ionic silver in one of the newer dressing like silver-containing hydrogels. They are inexpensive, broad spectrum, have no known resistance, offer decreased dressing change regimens, and do not require a prescription.14 They are also extremely effective.

Figure 4. Bony deformity of the foot due to neuropathy. Note calluses and dry skin. Photo courtesy of Carol Paustian, RN, BSN, CWOCN.

Preparing the Wound Bed and Ulcer Care
       All diabetic wounds should be cleaned and irrigated, and all infected ulcers with devitalized material (dead slough, eschar, and blackened necrotic tissue) should be debrided. Povidone iodine or sodium hypochlorite, peroxide, or acetic acid should not be used due to their cytotoxicity.15 Rather, a commercially prepared irrigation wound cleansing solution, such as DiabKlenz (Carrington Laboratories, Inc.) or normal saline, should be used.
       The debridement method is dependent on the extent of the wound's devitalized material, the patient's vascular status, the setting, and the clinician's training, level of experience, and licensure. Sharp debridement is often considered the mainstay of diabetic ulcer therapy. Topical enzymes have not been proven effective for this purpose.16 Amorphous hydrogels provide a safe but slower form of autolytic debridement. Consider innovative approaches to debridement, such as the use of polyacrylate debridement systems like TenderWet® (Hartmann-Conco, Inc., Rock Hill, South Carolina), which debride an average of 38.11 percent of the wound's total surface per week.17 The wound is debrided quickly and the surrounding tissue remains healthy and intact. Once the infection has cleared and the wound has been debrided, healing can take place with the right dressings. Another advantage of polyacrylate debridement is that the dressing is only changed once every 24 hours.
       As with any wound, moist wound healing is the treatment of choice among diabetic ulcers. Choosing the right dressing is key depending on the ulcer's depth and amount of exudate. Fowler and associates suggest verifying the dressing's absorptive capacity, hydrating ability, adhesiveness, and conformability.18 It is important to realize that not all dressings in a certain category perform equally.
       Absorptive dressings, such as thin hydrocolloids, hydrogel sheets, alginates, foams, and composites, offer good choices to soak up exudate. Hydrating dressings like amorphous hydrogels, sheet hydrogels, transparent films, hydrocolloids, and polymer gels balance the wound's moisture. Adhesiveness can be found in many primary and secondary dressings, yet with the fragile skin of the patient with diabetes, there must be a delicate balance that is struck. The most adhesive dressings include hydrocolloids, followed by secondary dressings, such as composites and transparent films. Perhaps the most difficult issue to tackle with a diabetic foot ulcer is conformability. The foot is a small body area with many contours to address. For instance, ulcers between the toes tend to perplex the caregiver. Consider thinking outside of traditional dressings to powders and fillers. Alginates also supply a highly conformable dressing as do amorphous hydrogels.
       Dressings that offer "more bang for your buck" can often do two or more wound healing duties at once. For instance, a hydrogel sheet, amorphous hydrogel, or a powder dressing that also provides antimicrobial capabilities like sustained-release ionic silver performs several tasks, which saves time and money and provides a perfect environment for the diabetic/neuropathic wound. Examples of commercially available products include SilvaSorb Gel or SilvaSorb Sheet (AcryMed, Portland, Oregon). Another dressing category that presents with more than one feature or advantage is collagen. These dressings stimulate cellular migration and contribute to new tissue development and wound debridement. Examples include Kollagen-Medifil Particles, Gel, and Pads and Fibracol (Johnson & Johnson Wound Management Worldwide, Somerville, New Jersey).

Offloading
       Diabetes control, optimizing perfusion, infection control, preparing the wound bed, local wound management, and offloading are all important aspects of caring for the client with diabetes. The literature, especially in podiatric medicine, has a large amount of information on the importance of offloading. For the sake of this article, only an overview of offloading techniques will be covered.
       Offloading is simply the reduction of pressure, shear, and friction forces on the foot and tends to be neglected. The following are methods and levels to offload the diabetic foot:
* Bed rest
* Seated dependent or wheel chair use
* Crutches, canes, and walkers
* Foams
* Half-shoes
* Therapeutic shoes
* Custom-made shoes
* Custom splints
* Walking boots
* Total contact casting (TCC).
       Some of these methods are quite elementary but cause further problems, like bedrest. Often, the patient is not compliant. Consider the patient's lifestyle and wishes. Education is also of utmost importance to make offloading work.
       The most effective form of offloading in plantar surface wounds is TCC.19 This method reduces pressure while allowing the patient to be ambulatory while healing the wound in six to eight weeks time. The cast is applied by a skilled clinician and is usually changed every one to two weeks. Disadvantages are that the cast is heavy, hot, and uncomfortable.

Advanced and Adjunctive Care
       A new and adjunctive treatment, becaplermin (Regranex® Gel 0.01%, Johnson & Johnson Wound Management Worldwide), an off-the-shelf platelet-derived growth factor, is approved for use on neuropathic diabetic foot ulcers. Becaplermin has been shown in a randomized, controlled trial to expedite healing, although this product only carries one of numerous growth factors, PDGF. Look to the future for more products with multiple recombinant growth factors. This is a prescription item only and is very expensive.
       Another cutting-edge treatment involves bioengineered skin substitutes, such as Apligraf® (Organogenesis, Canton, Massachusetts), and human dermal products like Dermagraft® (Smith & Nephew, Largo, Florida). These are implantable tissues derived from the fibroblasts of neonatal foreskin. They enhance healing by offering a biologic wound covering that combines with the body's indigenous tissue and supplies the entire range of growth factors and fibroblasts.
       Other adjunctive treatments include hyperbaric oxygen (HBO) therapy and electrical stimulation. Electrical stimulation has shown some benefit in a handful of studies, but HBO has not shown solid scientific evidence.20

Mystery Solved!
       Care of clients with diabetes and their skin, feet, and wounds is an immeasurable challenge for the caregiver, the facility, the clinician, and most of all, the patient. With baby boomers heading to retirement age in droves, we will continue to see patients with diabetes, perhaps in record numbers. Put your skills and knowledge to the test. Make sure that your protocols are up to date and that your facility is "in the know" with regard to prevention, assessment, and care of the skin, feet, and wounds of the patient with diabetes. Ask your manufacturers and distributors for the proper products and tools that you need to provide quality care. Don't forget to make sure that your clinical team has access to the current information contained in articles like this and the opportunity to attend educational programs and seminars on a regular basis. Get everyone involved to increase outcomes and solve the mystery. Working together, we can save feet and lives!

Helpful Websites and Phone Numbers
* http://www.diabetes.org--American Diabetes Association (ADA), 1 (800) DIABETES
* http://www.hhs.gov--US Department of Health and Human Services (HHS), 1 (877) 696-6775
* http://www.cdc.gov/diabetes--Centers for Disease Control and Prevention (CDC)
* http://www.cms.hhs.gov--Centers for Medicare and Medicaid Services (CMS)
* http://www.ndep.nih.gov--National Diabetes Education Program (NDEP)