LECZENIE RAN 2024; 21 (1)

Patients with diabetes and a foot ulcer are best cared for at a multidisciplinary specialist clinic to enable as many as possible to heal without amputation. However, it is all too common that many patients return with a new ulcer within a year or two on the same or on the contralateral foot [1, 2]. To support these patients trying to reduce new ulceration, some measures are recommended:

Patients with diabetes should have their feet assessed by a health care professional annually and classified according to their risk score: 0. Very low risk, 1. Low risk 2. Moderate risk, 3. High risk. Patients with loss of protective sensation and peripheral vascular disease and a history of foot ulcer are at the highest risk of ulceration and constitute the largest group of patients with a healed diabetes foot ulcer [3]. It is important that they are not abandoned by the health care system after healing.

This patient group is often at the age of retirement or older. Many suffer from multiple diabetes complications, such as neuropathy, PAD, nephropathy, retinopathy, and cardiovascular complications [3]. Subjective symptoms can be impaired vision, leg oedema, reduced mobility, and depression symptoms. Subsequently, it becomes increasingly difficult to maintain their selfcare activities, and many of them have therefore become dependent on other people for their daily living to a greater or lesser
extent [4].

When a patient with a diabetic foot has healed after being treated by a specialist clinic, his/her resources for optimal protection of the feet needs to be explored by the health care professional in charge: what does the family network look like, and what is the availability of social home care or home nursing support, primary and specialist care for the diabetes disease or other comorbidities and health issues.

It is recommended that patients with diabetes and risk for foot ulcer should be involved in their care and should have access to information and education to better understand therapy targets and their role [5, 6]. But also, all the other people involved in the patient’s daily care need the same knowledge. Therefore, the health care professional should inform the family members and the patient about how to become involved in the selfcare of the diabetic foot. The learning process can be evaluated by asking them to verbally describe how they implement the following subjects in everyday life:

• The feet need to be inspected and washed daily. A patient might have difficulties inspecting all sides of the feet and they can be assisted by a family member or social home care if available. It is important that they all know whom to contact in case of any changes in the skin condition.
• Dry feet need application of moisturising cream daily, sometimes twice or more. This might also be provided by a family member or social home care.
• Cutting the nails must be performed with care, and preferably by a professional podiatrist or other person with relevant training to do this.
• The feet need clean seamless stockings and shoe wear that have been individually adjusted by an orthopaedic shoemaker, often also individually adjusted insoles that spread the pressure to avoid plantar stress ulcer.
• The patient and the people around the patient, including health care professionals, need to take into consideration that the feet are vulnerable, while dealing with all other comorbidities that many of these patients have [3].

For health care professionals of all types, this content should be included in the curricula for all people at different levels who care for the patient: in university programs for doctors and registered nurses, in high school programs for nurse assistants, for home care staff, and for chiropodists. Diabetes foot specialists from specialist clinics would be excellent guest teachers sharing their vast experience, preferably together with a representative from the diabetes patient organisation [6]. It would be advantageous for the patients with healed foot ulcers if the professionals shared their knowledge with other professions, especially those working near the patient daily.

Circumstances and resources vary between countries and local health care organizations and a shortage of resources seems generally to be the case. It is therefore in everybody’s interest to inform patients and those around them about how to reduce the risk of a new foot ulcer after healing [7]. The risk of new foot ulcers is high for patients after healing; therefore, a patient with a healed DFU should be considered as being in remission and vulnerable to multimorbidity.