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In my February column ("Seeing Red"), I printed a summary of foot-care guidelines ("Important Steps for Foot Care") as outlined by Richard Bernstein, MD, FACE, FACN, CWS, of the Diabetes Center in Mamoroneck, New York.
DIABETES HEALTH received several letters that took exception to Bernstein's advice. To me, the most volatile of them is the controversy over whether to trim calluses. My mom's podiatrist trimmed a callus on her toe, which then became infected. It took months to heal and her toe barely escaped the knife. I think my mom's pain could have been avoided.
Dr. Bernstein, who is a certified wound specialist, outlines several points that he feels are key to successfully treating the diabetic foot. Some of the foot-care points Dr. Bernstein addresses are:
Below is a sample of the dialogue that has taken place since these guidelines were published. Write to me if you have more to contribute to this dialogue.
While we were pleased to read an article about diabetic foot care, we were surprised to see the inaccuracy regarding callus care.
In the article, Dr. Bernstein, a certified wound specialist, recommends never allowing anyone to trim calluses or corns. The ADA Diabetic Foot Care Guidelines clearly state that all necrotic tissue, non-granulating tissue and calluses should be debrided. Corns and calluses are areas of excessively thickened skin caused by increased friction and pressure over bony prominences, particularly on the tops and sides of toes and the sole of the feet and heels. Calluses must be debrided on a regular basis by a qualified foot-care nurse, a foot and ankle orthopedic surgeon, or a podiatrist to prevent the development of underlying ulceration. Prescriptive shoewear and orthotics provided by a pedorthist cannot guarantee protection against the formation of corns and calluses.
Health-care professionals must collaborate to care for persons with diabetes, educate their patients on proper foot care and routinely evaluate the condition of their feet.
Nancy Beinlich BSN, RN, CWOCN
Janet Bryant MSN, RN, CNS, CWOCN
The Wound Center of Akron General Medical Center
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Podiatrists around the world safely debride corns and calluses for people with diabetes thousands of times daily. This is an integral and important part of our training in the care of the diabetic foot. Corns and calluses act upon underlying tissues as would a foreign body such as a small pebble taped to the skin. This increased pressure of up to 29 percent (Young, et.al., Diabetes Med Suppl., 9. 55-57, 1992) is often the precipitating factor in the formation of an ulcer. Experts of the diabetic foot agree that debridement of thick calluses should be performed (Levin, The Diabetic Foot, Mosby, 2001, p.254).
Of course, this debridement should only be done by a physician who is adequately trained. Most primary-care physicians, internists and endocrinologists I know gladly send these patients to podiatric physicians for care. They understand that this is an important role that podiatric medicine plays in the care of these patients who are at risk for foot complications.
Should people with diabetes seek the assistance of a pedorthist for shoe modifications or orthoses to attempt to decrease pressure on toes and calluses as Dr. Bernstein suggests? I believe the answer is a qualified yes. I work very closely with pedorthists, and I am a member of the Pedorthic Footwear Association. But certified pedorthists will only supply an orthotic device by prescription. Medicare also requires a prescription before they will pay for shoes dispensed to a qualified patient with diabetes. These guidelines exist to protect you, the patient. The pedorthist should not be diagnosing and treating. He or she must work as part of the medical team along with the treating physician.
Your foot specialist will evaluate the area you are calling a corn or callus. Perhaps it really is a wart or other type of skin growth. I have seen patients who have come in with a self-diagnosis of a callus, which was really skin cancer. Just getting a better shoe would not have helped them at all. Also, shoes are not always the answer. I will sometimes recommend surgical correction for corns and calluses. This surgical approach can often permanently resolve the problem and avoid future ulcerations and infections.
All people with diabetes should have a foot specialist that they trust and that they see on a regular basis. If the doctor wants to debride your corn or callus, let him.
Neil Scheffler, DPM, FACFAS
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Dr. Bernstein's reply: I direct a university-based peripheral vascular disease clinic, where I have served for 18 years. We are the folks responsible for treating ulcers on the feet of people with diabetes. During my tenure, the most common cause of such ulcers has been the so-called debridement of calluses, usually by podiatrists.
This may be an instance where ADA guidelines do not serve the best interests of patients. The French physician Jean Martin Charcot addressed a related foot problem with the comment, "Theories, no matter how pertinent, cannot eradicate the existence of facts."
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In the February 2001 issue of DIABETES HEALTH, you included a summary on foot care by Dr. Richard Bernstein ("Important Steps for Footcare," p. 7). Listed in step 7, Dr. Bernstein names suitable lubricants for dry skin. He also names lubricants not to be used, one of which is petroleum jelly.
As a type 1 diabetic for the past 17 years, I have often used petroleum jelly on my feet as I have found it to be an extremely effective moisturizer; not to mention that it's affordable.
I was wondering why Dr. Bernstein advises against its use.
Manasquan, New Jersey
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Dr. Bernstein's reply: We do not recommend the use of petroleum jelly as a lubricant for skin. Animal and vegetable oils are readily absorbed into the skin, but mineral oils are not. Petroleum jelly is a mineral product. Since it is not water soluble, it is of value in preventing the maceration that occurs in the skin while swimming or bathing for prolonged periods. In fact, long-distance swimmers frequently cover their body surface with petroleum jelly before embarking on a swim. Petroleum jelly is probably more expensive than olive oil, which is a very suitable skin lubricant.
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