Evaluation of the integument in a patient with diabetes is a critical part of identifying the subtle signs of impending injury; high-pressure areas; and cracks, maceration, or fissures in the skin.
Discolored callus or bleeding under a callus is a sign of a preulcerative lesion. Likewise, deformed and thickened nails are commonly the source of abnormal pressure on the nail bed or ingrown toenails. In patients with neuropathy, ulcerations typically form from repetitive pressure from the shoe and nail over the nail bed. Common nail disorders seen in patients with diabetes include onychomycosis (tinea unguium) and onychocryptosis (ingrown toenail). Although these are minor problems in adults without diabetes, they can result in cellulitis and osteomyelitis in patients with diabetes, neuropathy, and vascular impairment.
To help avoid skin breakdown, advise patients with diabetes to:
- keep their diabetes well controlled. High blood glucose levels may cause dry skin and reduce the patient’s ability to fight bacteria. Both conditions increase the risk of infection.
- keep their skin clean and dry. They should use talcum powder in areas where skin touches skin, such as the axilla and the groin.
- avoid very hot baths and showers. Patients with dry skin should also avoid bubble baths. Moisturizing soaps may help, and after a bath or shower, an oil-in-water skin cream should be used. Patients should avoid using a moisturizing lotion between the toes to reduce the risk of fungal infection.
- avoid scratching dry or itchy skin because the skin could tear, providing a portal for microorganisms.
- treat cuts right away. Minor cuts should be washed with soap and water. Patients should avoid antiseptics, alcohol, or iodine skin cleansers because these agents are too harsh. Minor cuts can be covered with sterile gauze. Remind the patient to seek medical care for a major cut, burn, or infection.
- keep their homes more humid during cold, dry months, and bathe less during this weather if possible.
- use mild shampoos and unscented soaps and avoid feminine hygiene sprays.
- take good care of their feet by checking them every day for wounds; wearing broad, flat shoes that fit well; and checking shoes for foreign objects before putting them on.
Adapted from Lavery LA, Baranoski S, Ayello EA. Diabetic foot ulcers. In: Baranoski S, Ayello EA, editors. Wound Care Essentials: Practice Principles. Springhouse, PA: Lippincott Williams & Wilkins; 2004. p 311–32.