If you have diabetes and you notice any break in the skin of your foot, contact your foot care service the same day or the next. Do not wait to see how it goes.
Why diabetes affects the feet
Peripheral neuropathy. Sustained high blood glucose damages the small nerves, beginning at the longest ones — which are the ones reaching the toes. The result is reduced or absent sensation, so injury is not felt. Some people also experience the opposite: burning, tingling or night pain. Neuropathy also affects the nerves controlling sweating, leaving skin dry and prone to cracking, and the nerves supplying the small muscles of the foot, producing clawing of the toes and new pressure points. The NIDDK page on diabetic neuropathy explains the forms this takes.
Peripheral arterial disease. Diabetes accelerates narrowing of the arteries supplying the legs and feet. Reduced blood flow means less oxygen and fewer nutrients for repair, so wounds heal slowly or not at all, and infection is harder to clear.
Impaired immune response. High glucose blunts the function of the cells that fight infection, so infections take hold more readily and progress faster.
Individually each is manageable. Together — an injury not felt, on a foot that cannot heal well, in a person less able to fight infection — they produce the sequence that leads to ulceration and, in the worst cases, amputation. Ulceration precedes the great majority of diabetes-related amputations, which is why the whole of diabetes foot care is organised around preventing the first break in the skin. The overview at NIDDK and the practical guidance from Diabetes UK both make the same case, and MedlinePlus collects further reading.
What raises your risk
- Loss of protective sensation, whether or not you have noticed it.
- Reduced or absent foot pulses, or a history of arterial disease.
- A previous foot ulcer or a previous amputation — the strongest predictors of a future ulcer.
- Foot deformity: clawed toes, bunions, a prominent metatarsal head, a collapsed arch.
- Callus, particularly on the sole, which raises local pressure substantially.
- Poor vision or limited mobility, which make self-inspection difficult.
- Kidney disease, particularly if on dialysis.
- Smoking, which compounds the circulatory damage.
- Long duration of diabetes and persistently high blood glucose.
The daily check
It takes two minutes and it is the single most effective thing you can do.
- Look at the whole foot, every day. Top, sole, heel, sides, and between every pair of toes. Use a mirror on the floor if you cannot lift the foot to see the sole, or ask someone else. If your eyesight is poor, have someone else do it.
- Look for: cuts, cracks, blisters, redness, swelling, warm patches, colour change, hard skin that has darkened, discharge, or anything that has changed since yesterday.
- Check your socks and the inside of your shoes. A stain on a sock is often the first sign of a wound you cannot feel. Run a hand inside each shoe before putting it on, feeling for a stone, a fold in the lining, or a protruding nail or seam.
- Wash daily in warm — not hot — water, and test the temperature with your elbow or a thermometer rather than your foot. Dry thoroughly, especially between the toes.
- Moisturise the skin of the top and sole to prevent cracking, but not between the toes, where trapped moisture encourages fungal infection and skin breakdown.
Things not to do
- Never walk barefoot, indoors or outdoors, including on the beach or by a pool.
- Never use corn plasters, callus removers or any acid preparation. They do not distinguish between hard skin and healthy skin.
- Never cut or file hard skin yourself, and never use any blade on your own feet.
- Never use hot water bottles, heat pads, electric blankets or radiators to warm your feet, and do not sit close to a fire. Burns on an insensate foot are common and severe.
- Do not cut nails down at the corners, and do not cut them very short. Straight across, filed smooth.
- Do not ignore anything. The absence of pain tells you nothing about the seriousness of what you are looking at.
Footwear and socks
Shoes should be long enough, deep enough and wide enough that nothing presses anywhere; fitted while standing, late in the day, with both feet measured. Enclosed, fastening shoes rather than slip-ons or sandals with straps that can rub. New shoes broken in over short periods with the feet checked afterwards. Socks that are seam-free or worn inside out, without tight elastic tops, changed daily. Where deformity or previous ulceration is present, specialist footwear and pressure-redistributing insoles are prescribed for a reason and should be worn as directed.
Professional review
Everyone with diabetes should have their feet examined at least annually — sensation tested, pulses checked, skin and nails inspected, footwear reviewed, and a risk category assigned. Those at higher risk are seen considerably more often. Routine nail and skin care in a high-risk foot should be done by someone appropriately qualified, not by you and not by an unregistered practitioner. See what is a podiatrist.
Get seen the same day if
- There is any new break in the skin — a cut, crack, blister, graze or ulcer.
- An area is red, warm, swollen or discharging.
- Hard skin has darkened or a blood blister has appeared.
- The foot has suddenly become hot and swollen, whether or not it hurts. A hot, swollen foot in a person with neuropathy can indicate Charcot foot, an urgent condition in which the bones of the foot fracture and collapse without pain, and in which early immobilisation prevents permanent deformity.
- The foot has become cold, pale, blue or dusky, or there is new severe pain — this may be a circulation emergency.
- You feel generally unwell, feverish or shivery alongside any foot problem.
None of these are wait-and-see situations, and none of them are overreactions. Early assessment of a diabetic foot wound is the intervention with the largest effect on the outcome. Read foot wound care and ulceration next, and when a foot problem needs professional care for the general red-flag list.