Possible presenting scenarios
A new or worsening of pre-existing ulcer will present will the following:
- Worsening exudate
- Purulent discharge
- Cellulitis
- Gangrene (new or extending)
- Pain (often no pain or very minimal increase in pain)
A new hot swollen foot without ulcer (and potential Acute Charcot Foot) will include:
- Usually no ulcer
- Erythema on the dorsum
- Increase focal warmth
- Recent trauma (but often no recollection of trauma)
What examination the GP should do
First, you should ascertain if this is a new problem or worsening of pre-existing issue.
Then:
- Palpate pulses (dorsalis pedis and posterior tibial) or review available vascular assessment
- Differentiate between: Mild infection (ulcer limited to subcutaneous tissue and erythema extends to >2 cm2 around ulcer); and more severe forms of infection (erythema extends to >2 cm2, tendon, muscle or joint exposed, systemic features present (flu-like symptoms, drowsiness, fever, tachycardia etc)
- Look for new/worsening gangrene or extending tissue loss
- Look for features of acute limb ischaemia (pale, pulseless, cold, paraesthetic/painful, weak limb)
- Assess for features of systemic inflammatory response/sepsis
- Consider the possibility of acute Charcot foot
What warrants immediate admission to hospital?
Reserved for those with limb or life-threatening features:
- Acute limb ischaemia
- Severe infection with necrosis requiring urgent debridement
- Worsening foot with sepsis features (note concomitant risk of COVID19)
What requires urgent review in secondary care multidisciplinary foot service (MDFS)?
- New ulcer – to allow clear planning including follow up strategies
- Significant deterioration of pre-existing ulcer
- New gangrene or necrosis but systemically stable
- features of chronic peripheral arterial disease have deteriorated within past 2 weeks
- Any suspected acute Charcot foot
What the GP can/should do as a ‘holding measure’ if there is a delay in getting the patient seen (as there might be currently)
- Treat infection promptly – Follow recommendations from NICE NG19 sections 1.6.7, 1.6.8 and 1.6.9.
- Send a specimen (e.g. ulcer swab, tissue or pus) for up-to-date microbiology
- Advice to rest the foot
- Provide offloading to reduce pressure on the ulcer, where possible and available. Suggestions include semi-compressed felt with a donut cut-out around the ulcer or a standard off-loading shoe (e.g. Darco or Promedics shoes). Community foot protection units may help source them.
- Organise follow up consultation in 48 -72 hrs – virtually if possible.
- Involve community podiatry service for the frail – can they support with home visits and simple debridement?
Most MDFS are continuing to provide active essential service and can be contacted as per local pathways
Dr Prash Vas, is a consultant in diabetes foot medicine, King’s College Hospital, London
NICE NG19: https://www.nice.org.uk/guidance/ng19/chapter/Recommendations#diabetic-foot-infection
