Clinical guidelines for type 2 diabetes: Prevention and management of foot problems

This brief guideline is one of six to cover areas within type 2 diabetes. Full evidence reviews and additional recommendations will be available for all six areas. The areas covered are:

• Foot care (prevention and management of foot problems)
• Eye care (screening and early management of retinopathy)
• Raised lipid levels
• Raised blood pressure
• Renal care
• Glycaemic control.

The guidelines have been developed by a multiprofessional group and subjected to extensive professional review. The national guideline is aimed at all healthcare professionals providing care to people with diagnosed type 2 diabetes in primary and secondary care, irrespective of location. Depending on the type, stage and severity of clinical problem, the guidelines may also be valuable to those who work in the tertiary sector of diabetes care. They may also be shared with people who have type 2 diabetes.

Foot problems in type 2 diabetes
Foot complications are common in diabetes. Overall, 20–40% of people with diabetes have neuropathy and 20–40% have peripheral vascular disease (PVD), depending on the measurement and definition used. Neuropathy and PVD are secondary to poor blood glucose control and adverse arterial risk factors (smoking, dyslipidaemia). Annually, around 5% of patients develop foot ulcers. The ulcerated foot can easily become infected (especially with poor glucose control). If not managed appropriately, infection can lead to avoidable amputation.

Foot complications are further associated with social deprivation, poor vision, disability, foot deformity, and absence of professional foot care, all factors which limit a person’s ability to practise good personal foot care.

Foot care emergency
The following require referral to a specialised podiatry/foot care team within 24 hours:

• New ulceration
• Cellulitis
• Discolouration.

Evidence base
The evidence in the guideline is graded as shown in Table 1. The recommendations are graded in the complete document (which contains the full evidence base, complete set of recommendations and methodological details), but are not graded in the summary document shown opposite.

Prevention and management of foot problems in type 2 diabetes
This guideline does not deal with the management of risk factors such as raised blood glucose levels, smoking, raised lipid levels, raised blood pressure.

Principal recommendations
Foot care for all people with diabetes

• Arrange recall and annual review of complications and their risk factors, by trained personnel
• Examine feet, and lower legs, as part of annual review to detect risk factors for ulceration. Include:
  • Testing of foot sensation using a 10g monofilament or vibration
  • Palpation of foot pulses
  • Inspection of foot shape and footwear
• Classify foot risk as: low current risk or at risk or high risk or ulcerated foot

Foot care for the low current risk foot
(normal sensation, palpable pulses)

• Agree a management plan including foot care education with each person

Foot care for the at risk foot
(neuropathy or absent pulses or other risk factor)

• If previous foot ulcer or deformity or skin changes manage as high risk
• Enhance foot care education
• Inspect feet 3–6 monthly
• Review need for vascular assessment

Foot care for the high risk foot
(risk factor+deformity or skin changes or previous ulcer)

• Arrange frequent review (1–3 monthly) from specialised podiatry/foot care team
• Intensified foot education
• Specialist footwear and insoles
• Frequent (according to need) skin and nail care
• Review education/footwear/vascular status as for the at risk foot
• Ensure special arrangements for those people with disabilities or immobility

Foot care for the ulcerated foot

• Arrange, urgently, foot ulcer care from a team with specialist expertise
• Expect that team to ensure, as a minimum:
• Investigation and treatment of vascular insufficiency
• Local wound management, appropriate dressings, and debridement as indicated
• Systemic antibiotic therapy for cellulitis or bone infection
• Effective means of distributing foot pressures, e.g. specialist footwear, casts
• Tight blood glucose control

Evidence
Ib Evaluation of skin, soft tissue, musculoskeletal, vascular and neurological condition on an annual basis is important for the detection of feet at raised risk of ulceration

III Both measurement of vibration perception threshold (biothesiometer) and sensation threshold (10g monofilament) predict raised risk of ulceration

Ib An agreed plan of management between people with diabetes and healthcare professionals is important to achieve adequate levels of care

III A range of risk factors have been identified to indicate increased risk of ulceration

• Neuropathy
• Peripheral vascular disease
• Previous ulceration or amputation
• Old age
• Plantar callus
• Foot deformities
• Poor footwear
• Duration of diabetes
• Social deprivation or isolation
• Poor vision
• Cigarette smoking

Ib Implementing a screening and protection programme for patients with gross risk factors for ulceration reduces morbidity and is cost effective

III There is inadequate evidence about the relative effectiveness of different antibiotic regimens for treating serious diabetic foot infections

IIa For superficial or skin deep ulcers, there is inadequate evidence to show whether antibiotics are more effective than placebo and standard wound care

Ib There is insufficient evidence to support the effectiveness of any type of protective dressing, or topical applications/solutions, over any other for treating diabetic foot ulcers

Foot care emergency: new ulceration, cellulitis, discolouration – referral to specialised podiatry/foot care team within 24 hours

The production of the guidelines was undertaken by the RCGP Effective Clinical Practice Programme, which received funding from the National Institute for Clinical Excellence. The views expressed are those of the authors and not necessarily those of the Institute. The Royal College of General Practitioners is grateful to the foot care working group.