Advances in diabetic foot care: Focus on prevention Julie Van Onselen Independent dermatology nurse specialist Dermatology Education Partnership Ltd

Learning Outcomes By the end of this session, you will have: Increased understanding of the unmet need of managing dry skin in feet of people with diabetes Expanded your awareness of appropriate emollient therapy to treat dry skin on feet and prevent complications in people with diabetes Improved clinical confidence in advising patients and providing informed choice on emollients and formulations, specifically for diabetic patients

Background – skin problems in diabetes  80% suffer with some form of diabetic skin problem due to high blood sugar levels 1  44% of people with diabetes have dry skin, which is susceptible to breakdown 1  Dry skin on the diabetic foot (with peripheral neuropathy and vascular insufficiency) are risk factors for foot ulcers 2  Typical symptoms:  Extreme dryness, calluses, pressure ulcers, cracks, fissures, foot fungus & bacterial infection Reference: 1 Goyal A, Rania S, Kaushal S et al (2010) Pattern of cutaneous manifestations in diabetes mellitus. Indian Journal of Dermatology; 55(1): Edmunds M (2006) Diabetic foot ulcers: practical treatment recommendations. Drugs; 66(7):

Diabetes skin and feet Dry skin and fissures

Diabetes skin and feet Dry skin between toes

Diabetes skin and feet Callus

Complications Fungal and bacterial skin infections Reference: 1. Daniels R (2011) Foam creams: effective skin care in patients in diabetes mellitus. Theme Prax Rep; 11 (5): Clinical images reproduced with permission from the NewZealand Dermatological Society Incorporated website site Date accessed 1 June 2015 Cream that is not fully absorbed between toes in diabetic patients can cause moisture to build up and increase the risk of skin infections 1

Complications Necrobiosis lipoidica, infection and diabetic foot ulcers Clinical images reproduced with permission from the New Zealand Dermatological Society Incorporated website site Date accessed 1 June 2015

Prevention is key Treating dry skin is the key to preventing foot ulceration in diabetes ◦ 44% of people with diabetes suffer from dry skin which is vulnerable to breakdown 1 ◦ 2.5% of people with diabetes have foot ulcers = 80,000 foot ulcers in the UK 2 ◦ 28% of foot ulcers result in amputation = 100 amputations per week among people with diabetes 2 Reference: 1 Goyal A, Rania S, Kaushal S et al (2010) Pattern of cutaneous manifestations in diabetes mellitus. Indian Journal of Dermatology; 55(1): Diabetes UK. Diabetes: Facts and Sats. March Available at: Accessed April

NICE Guidance People with diabetes at high risk of foot ulcers i.e. with neuropathy and absent pulses, or other risk factors, should be reviewed every 1-3 months. 1 Care of people at increased risk of foot ulcers 1 Low risk – Foot care education Increased risk - Enhance foot care education High risk – Skin and nail care Care of people at increased risk of foot ulcers 1 Low risk – Foot care education Increased risk - Enhance foot care education High risk – Skin and nail care NICE recommendations 1 ‘To improve knowledge, encourage beneficial self care, minimize inadvertent self-harm, HCPs should discuss and agree with patients a management plan that includes appropriate foot care.’ NICE recommendations 1 ‘To improve knowledge, encourage beneficial self care, minimize inadvertent self-harm, HCPs should discuss and agree with patients a management plan that includes appropriate foot care.’ Reference: NICE Clinical guidance for type 2 diabetes CG10. Available htps:// Accessed May 2015.

Skin care advice and support Diabetes UK> Taking care of your feet. Available at: diabetes/Monitoring/Feet/etes.org.ukhttps:// diabetes/Monitoring/Feet/etes.org.uk Accessed May 15 Use moisturising cream every day and wear well-fitting shoes that protect and support your feet. 1 What is the best sort of cream for a Diabetic (T1) to use on their feet to keep them soft and moisturised? xxxx Cream BP is very good and not expensive. My GP lets me use xxx emollient cream, I too was told not to use this between my toes. Patient forums on line can give conflicting advice, which is not evidence based - but may be convincing!

Over to you – which emollient/s would you advise?

Complete emollient therapy The most important treatment for all dry skin diseases 1 Emollient creams and ointments Emollient wash products Emollient bath and shower products ‘Everything that goes on the skin should be emollient based and all soaps replaced with emollient wash products’ However diabetes need specific treatment tailored especially for their feet Reference: Cork MJ & Danby S (2009) A renaissance in emollient therapy. British Journal of Nursing;18:872-77

OCCLUSIVE EMOLLIENTS PROVIDE A LAYER OVER THE SURFACE OF THE SKIN  Occlusive emollient creams leave a fine occlusive layer of non-physiologic lipid or oil over the skin surface e.g. petrolatum or mineral oil  The occlusive layer reduces water loss from the stratum corneum Reference: Cork MJ & Danby S (2009) A renaissance in emollient therapy. British Journal of Nursing;18:  Occlusive emollient ointments contain a lot more oil and provide more occlusion over the surface  Occlusive emollient ointments are extremely greasy and are cosmetically unacceptable to many people Occlusive emollient cream Occlusive emollient ointment

Emollients containing urea help compensate for the reduced levels of NMF in dry skin Reference: Cork MJ & Danby S (2009) A renaissance in emollient therapy. British Journal of Nursing;18: s..  Emollients containing NMFs such as urea, produce similar rehydration effects to heavy emollients 1  Urea attracts and holds water in the stratum corneum and helps compensate for reduced levels of NMF associated with dry skin 2  NMF-containing emollients have greater cosmetic acceptability than heavy emollients due to their low oil content, and require less frequent application than occlusive emollients 1 NMF emollient 1

Foam humectant creams– a new innovative formulation  Normal skin functions are maintained  Formulation benefits with a two- dimensional protective mesh  Skin is protected & stays intact  Absorbs quickly & no occluding layer is formed  Contains 5% or 10% urea for hydration and reducing TEWL  No increase in bacterial growth, in between the toes  Can be used on whole foot, around wound edges and in between the toes FOAM CREAMS ARE UNIQUE IN PROTECTING AGAINST THE REAL RISK OF INFECTION BETWEEN THE TOES

Evidence: Rapid onset of action - Skin continues to be moisturised throughout the day Improvement in Skin Moisture Content * Source: Prophylaxis using foam creams in various dermatological indications – R. Rudolph, Norden

Conclusions Treating dry skin promptly is a key element in preventing dry cracked skin, which can result in complications in the diabetic foot NICE recommends foot care education for all patients with diabetes Informed patient choice of emollient formulation is crucial, to address all areas of dry skin on the foot and promote self-management Foam humectant creams are the only formulations clinically and medically approved for use on the entire foot, including between the toes for people with diabetes Foam creams are innovative formulations which increase patient acceptance and compliance

Thank you for listening Any Questions?