Ulcers are open
sores in the skin. With most people, the pressure which could otherwise cause an ulcer is so unpleasant that they will refrain from whatever activities are causing the pressure, and no ulcer occurs. If a person has a
decrease in the ability to feel sensation, called a neuropathy, there is a loss of the sense of pain, hence there is no immediate impetus for the person to modify or stop the activities. Continued pressure can
cut off the blood flow to the skin and the tissues deep to the skin, resulting in death to these tissues, and then the formation of an ulcer. Examples of disease states that are associated with neuropathies are diabetes
and spinal cord injuries. A thinning out of the fat and muscle tissue between bony prominences and the skin, which occurs in greater frequency in older people, can also lead to pressures which cause ulcers. Since ulcers
are openings in the skin to deeper tissues, there is always a risk that the body can become locally, and then systemically infected. The endangers a person's limb and life.
On the foot, pressure ulcers tend to occur
over bony prominences, where pressures are higher and are applied in a repetitive fashion in activities such as walking, and with standing. The heel, the ball of the foot and the toes are areas where ulcers are
frequently found. With bedridden, debilitated people, laying in the same position for long periods of time can result in ulcer formation at the back of the heel, at the lower back and at elbows. If these people have
contracted limibs, ulcers can occur in a great number of other areas as well.
The development of ulcers is progressive. Initially, there may be areas where the skin is red and hot. These signs indicate pressure, or
friction (pressure on and motion across) on the skin. On the foot, if this is allowed to go unchecked, blistering of the skin can occur. Callus tissue may form in response to these mechanical processes. With continued
pressure, the callus is pressed into the skin, thereby increasing the pressure. An ulcer forms when the skin is no longer able to repair itself sufficiently.
Once the skin develops an ulcer, bacteria can enter the
opening. The bacteria further injure the tissues. Drainage may come from the wound. The drainage can be clear, white, yellow or green, and may be thick or watery. Bleeding from the ulcer can occur. An offensive or
unusual odor may be present. The surrounding skin may become pink or red, swollen and quite painful.
A clinical examination can allow your physician to determine if an ulcer is present or if you're
foot is predisposed to develop an ulcer. Callus tissue may require removal in order to examine the skin beneath it. The neurological part of the examination evaluates for decrease or absence in your ability to feel
pain. X-rays permit your doctor to see any bony prominences, and if there is reason to suspect an infection in the bone. Additional radiologic exams are occasionally required, such as bone scans or MRI. If infection is
apparent, a specimen is taken from the ulcer for identification of any infecting organisms.
Ideally, your doctor would be seen when your foot has developed red, hot spots, but before the skin breaks
down into a pressure ulcer. However, due to busy lifestyles and other contravening factors, people don't usually make an appointment to see their doctor until an ulcer has fully formed.
Removal of dead tissue and
application of a wound cleanser is the beginning of treatment for an ulcer. A dressing is then applied, so as to keep the ulcer clean, appropriately moist and at the proper acidity to encourage healing. There is
currently a wide range of products available to achieve this goal.
If an infection is present, you doctor may prescribe antibiotics. These may be topical (applied on the outside), or taken orally.
pressure is responsible for the formation of these ulcers, removing or lessening pressure is an essential element in getting your ulcer to heal. This can be done by special shoes and shoe inserts. With more serious
ulcers, applying a cast for a period of time may be most appropriate. Padding applied directly to the foot can be an effective treatment in some cases.
When there are bony prominences which can't be accomodated by
non-surgical means, surgery may be needed to reduce the pressure and allow the ulcer to heal. If there is a concomitant problem of insufficient arterial delivery of blood, due to narrowing of the caliber of the artery
from atherosclerosis or the like, your podiatrist may refer you to a vascular surgeon for evaluation and possible arterial bypass.
When the ulcer is seriously infected, or if you have other health problems which
affect your ability to heal, surgery may be necessary to effectively resolve the infection.
In thoses cases when bone becomes infected, it may become prudent to remove sections of bone, or entire small bones. In
either case, hospitalization, IV antibiotics and consultation with other physician specialists may be ordered.