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Diabetic Foot Ulcers Are Deservedly Feared

Dear Dr. Roach: My father is an 84-year-old diabetic. He has had a wound on his foot (on the inner side of his right foot, near his big toe) for about five months. He has been treated by a podiatrist, who has debrided the wound every week. He prescribed antibiotics when the wound has looked infected. A visiting nurse and my mother have changed and dressed the wound regularly during these months.

This week, the podiatrist said he could see the bone in my dad’s foot, and recommended hyperbaric treatment. Could you tell me what your opinion is of this treatment in my father’s case? Do you know if it has a high percentage of success? — C.O.

Answer: Foot ulcers in diabetes are common and feared. Diabetes damages blood vessels, both large and small. Also, longstanding diabetes decreases the effectiveness of the inflammatory response and immune system. Finally, poor nerve function in people with diabetes combines with these other factors to predispose one to developing breakdown of the skin and development of ulcers. These ulcers can get large and deep, and when the bone is visible (and sometimes even when it’s not), the bone is infected. In this case, there is a high risk of the need for amputation.

By far, the best way to deal with diabetic foot ulcers is to not get them in the first place. Good control of diabetes, proper footwear, regular checks by a professional and daily self-checks of the feet for people at high risk can reduce the likelihood of developing ulcers. Early and aggressive treatment of precursor lesions, even mild redness of the skin, ingrown toenails or fungal infection of the feet, should prompt urgent evaluation by a podiatrist.

Once the ulcer has progressed to the point where your dad’s is now, aggressive measures are called for. In addition to care by a podiatrist or orthopedic surgeon, evaluation by a vascular surgeon and a wound-management specialist may be limb- and even life-saving.

While hyperbaric oxygen has indeed been shown to be beneficial in several studies (reducing amputation rate from 33 percent to 9 percent in one study), only an expert with detailed knowledge of your dad’s case can decide whether this is appropriate treatment. If you trust your podiatrist, I think it may well be a useful treatment. However, I would be sure that he, or a vascular surgeon, has looked at the quality of blood flow to the foot.

Dear Dr. Roach: My dad has an extreme case of COPD and is on oxygen. He gets winded just walking across the house. Dad lives in Montana; I live in Florida and would like him to come visit me during the cold Montana winters. I have heard that it would be easier for him to breathe at a lower altitude. People have told him that if he comes to Florida, he would never be able to go back to Montana because he wouldn’t be used to the altitude any longer. Is this true? — D.W.

Answer: The lower oxygen levels at high altitude, like some cities in Montana, can be a real problem for people with any kind of chronic lung disease. In those cases, supplemental oxygen or a lower altitude can make people feel better and even live longer. Given that your dad is already on oxygen, a lower altitude would be similar to dialing up the oxygen a bit. He may certainly prefer Florida’s winters to Montana’s.

We begin to be accustomed to high altitude in a few days, but full acclimatization takes weeks. Your dad will be able to return home after his visit.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or write to P.O. Box 536475, Orlando, FL 32853-6475.