DermatologyTier 1Disease (DEADMAN)

Skin ulcers - neuropathic

Description

Neuropathic (diabetic foot) ulcer - painless ulcer at pressure points, surrounded by callus, in a foot with sensory loss
Classically over the plantar metatarsal heads, heel, or toe tips - sites of repetitive pressure

Major complication of long-standing diabetes (also occurs with other neuropathies - leprosy, alcohol, B12 deficiency)
Leading cause of non-traumatic lower limb amputation

Peripheral sensorimotor neuropathy -> loss of protective sensation -> unrecognised repetitive trauma/pressure
Motor neuropathy -> foot deformity (claw toes, altered pressure distribution, Charcot foot) -> abnormal pressure points
Autonomic neuropathy -> dry, cracked skin (reduced sweating) -> fissuring, portal for infection
Often compounded by concurrent peripheral arterial disease (neuroischaemic ulcer) - assess both

Painless ulcer with surrounding callus, punched-out appearance, at a pressure point
Monofilament testing (10g) and vibration sense (128Hz tuning fork) to confirm loss of protective sensation
Always assess arterial supply concurrently (pulses, ABPI) - neuroischaemic ulcers are common and change management
Probe-to-bone test and imaging (X-ray, MRI) if osteomyelitis suspected

Offloading is the cornerstone - total contact casting or offloading footwear/boot; the ulcer will not heal while pressure continues
Debridement of callus and non-viable tissue, appropriate moist wound dressing
Treat infection aggressively if present - probe-to-bone positive suggests osteomyelitis, needs imaging +/- bone biopsy and prolonged antibiotics
Optimise glycaemic control and address peripheral arterial disease if coexisting (revascularisation may be needed before healing is possible)
Multidisciplinary diabetic foot team - podiatry, vascular, endocrinology
Charcot foot - immobilisation (total contact cast) to prevent progressive deformity

Osteomyelitis, cellulitis, sepsis - infection is the major driver of amputation risk
Charcot neuroarthropathy
Peripheral arterial disease frequently coexists (neuroischaemic ulcer)

Healing is slow and requires sustained offloading - recurrence is common without ongoing pressure-relief footwear and foot care
Untreated/complicated by infection - progresses to osteomyelitis and risk of amputation
Structured foot care programs and patient education substantially reduce amputation rates

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