Diabetes Affects the Skin too

Diabetes is a disease that was once thought to be fairly benign.  Other than the effects it has on blood sugar and insulin, we thought it didn’t harm anything else.  We now know that diabetes adversely affects the kidneys, eyes, immune system, and blood vessels just to name a few.  Even the skin can be unfavorably affected.  Let’s discuss how diabetes can first show its ugly face through the skin.

The skin is often referred to as the window to the body because changes in it often are results from what is going on inside.  Just like every organ in our bodies, the skin needs oxygen to be maintained.   Oxygen is delivered to the skin via blood vessels that run just below the skin’s surface.  The oxygen diffuses through the vessel walls to get to where it is most needed.  However, with diabetes , the elevated blood sugar causes the vessel walls to thicken.  This not only happens to the blood vessels in the skin, but everywhere in the body.  This, at least in part, is why diabetics are at higher risk for heart attacks, strokes, kidney failure etc…

Without adequate oxygen, the overlying skin skin can atrophy (get thinner) or even die (skin necrosis).   These sores may heal, but then come back weeks later for no obvious reason.   Incredibly, in a small yet substantial number of cases, these changes to the skin may be the first indicator to someone that they are heading toward diabetes, or that they are at high risk for developing diabetes.   If you notice these skin changes soon enough, you may be able to start treatment by adjusting your eating habits and increasing exercise.  This may slow or completely reverse the progression of diabetes.

There are several different changes that occur in a diabetic’s skin.  Diabteic Dermopathy and Necrobiosis Lipoidica Diabeticorum are just two of the skin conditions we’ll discuss next post.

Tarsal Tunnel Treatments

Two posts ago we discussed tarsal tunnel syndrome.  As a reminder, tarsal tunnel is the same as carpel tunnel, except for that it occurs in the feet.  A nerve that provides sensation to the sole of your foot becomes compressed and trapped, causing discomfort and numbness.  Let’s discuss some of the options we have to treat this condition.

The treatment of choice is based on the cause of the pain.  Often, excessive pronation stretches the nerve to the point of causing tarsal tunnel symptoms.  In this case, controlling the pronation could potentially help.  This is done with custom orthotics made from molds of your feet taken at your podiatrist’s office.   The molds are then sent off to a lab that makes orthotics that are specifically made for your feet.  Once your feet get used to the inserts, the symptoms often disappear.

Tarsal tunnel can be caused by tendonitis (an inflamed tendon).  In a case of tendonitis, the extra fluid around the injured tendon may be compressing the nerve in the tunnel.  In this situation, the classic RICE (Rest, Ice, Compression, and Elevation) treatment may relieve symptoms.  This will allow the tendon to recover and repair.   In more severe cases, a small amount of corticosteroid can be injected into the area to decrease the inflammation.

If all conservative measures fail or are not indicated for your foot, surgery can be beneficial.  The surgical procedure involves releasing the thick band of tissue overlying the tarsal tunnel.  This relieves some of the pressure that is being put on the nerve.  Often in surgery, the surgeon discovers large varicose veins or some other benign space occupying lesion (ganglion cyst, lipoma etc) inside the tarsal tunnel that are small and hard to see on MRI or other medical imaging.  In these instances, the offending object is removed and surgery is very rewarding for the patient.

As mentioned before, treatment will differ depending on the cause.  Work with your doctor to decide which pathway of treatment is best for your situation.

Melanoma on the Foot

I’m sure you have heard about melanoma and its potential deadly effects. But did you know it can first appear under the toenail or the top of the foot. If unnoticed and left untreated, it can be just as fatal as melanoma found on the face or back. Let’s discuss the basics of melanoma, and then address its presentation on the foot.

Melanoma has a nice mnemonic (ABCDE) to help remind you and I how to recognize a cancerous mole before it advances too far.

“A” stands for asymmetry.

“B” stands for borders. If the borders are blurred, or not clearly defined, be suspicious.

“C” stands color. If the color of the mole is variegated, meaning different patches or streaks of irregular colors, suspect melanoma.

“D” stands for diameter. Most melanomas are at least 6mm wide, or about the size of the eraser on a pencil.

“E” stands for both elevated and evolving. You will always be able to both see and feel a melanoma because it will be elevated above the skin. Evolving means that a cancerous mole is always changing (i.e. getting bigger, changing color, becoming easier to feel). If a mole looks the same as it did 10 years ago, it probably isn’t melanoma.

Now that we know what to look for, it is important to remember that there are different types of melanoma. There is a type that seems to present more often on the palms of the hands and soles of the feet, including under the nails. How can you tell the difference between a blood blister under the nail and melanoma? A blood blister will grow out as the nail grows. If it is a melanoma, the discoloration stays in the same spot.

Your podiatrist can help you determine if a new discoloration under the toenails is something to worry about. He/she will be able to work with your primary care or dermatologist to treat the melanoma before if progresses.

Carpal Tunnel in the Feet

Almost everyone has heard of Carpal Tunnel Syndrome. With the advent and widespread use of the computer over the last 20 years, carpel tunnel has become more common than ever before. Carpal Tunnel Syndrome occurs when a nerve from the arm becomes compressed and irritated as it attempts to pass into the hand through a very small tunnel in the wrist. This causes numbness and discomfort in the hand, and if left untreated can cause permanent damage to the muscles in the hand.

Did you know there is a similar condition that exists in the feet? Similar to the hand, a nerve passes from the leg to the foot via a tunnel on the inside of the ankle. The contents of this tunnel include muscle tendons, a large artery, and veins. If anything within that tunnel becomes inflamed and enlarged (for example a varicose vein, or an inflamed tendon with extra fluid around it), the nerve within the tunnel will be entrapped and compressed. This condition is called Tarsal Tunnel Syndrome. Although there are many causes of this condition, the most common cause has to do with the mechanics of the way you walk.

Symptoms of this condition are very similar to that seen in the hand. The nerve compressed in tarsal tunnel gives sensation to the entire sole of the foot. Therefore, if Taral Tunnel Syndrome is present, you should feel a pins and needles, numbness, or shooting and burning sensations everywhere on the bottom of the foot. This pain may worsen with prolonged activity such as running or walking. In extreme situations, the pain may wake you up at night. If left untreated, the muscles in the foot may atrophy and cause hammertoes and other pressure points.

Tarsal tunnel can usually be treated by conservative measures, but without resolution, there are surgical options that exist to help decompress that area. We will discuss them in the next post.

Is Pronation Good or Bad?

Pronation is a word that I am sure you have heard at the podiatrist’s office and elsewhere in the foot and ankle world. You may even come across it when buying shoes or over the counter insoles. If you are an avid runner, you can find it used extensively in running magazines and other publications. Some say pronation is bad, or that you can “over pronate.” But what does it really mean?

An incredible amount of force is directed on your heel bone and foot joints while walking and running. Pronation is your body’s way of absorbing that force as you walk. There is a joint just below the ankle that moves in a way so that when you take a step, the foot is more mobile so it can adapt to the uneven surface that we are walking on. In podiatry, we say that your foot becomes a “loose bag of bones” or that it pronates. This allows the force to be shared equally across the foot and it spares our cartilage from being over stressed. In short, pronation is a good thing.

But just like anything else, too much of a good thing is bad. Once you have taken a step and your weight moves forward, you want to be able to push off that foot and propel yourself. At this point, you want your foot to be stiff and stable (or as we say in podiatry, in a supinated position). However, if your foot is still a “loose bag of bones,” meaning you pronate too much or for too long, you have nothing stable to push off of.

This is one reason why some people develop bunions, hammertoes, plantar fasciitis etc… You are pushing off of an unstable foot and the bones start to move in every direction, causing deformities. It would be similar to trying to hammer in a nail using a waffle. The waffle will twist and bend in every direction with nothing being accomplished.

The mechanics of feet are much more complex than the explanation I have given, but hopefully it will help you better understand how you walk.

Gout Treatments

During an acute gouty attack, the pain can be incredibly exquisite. Immediate treatment is needed to relieve the discomfort. Indomethacin is a stronger version of aspirin used to decrease the inflammation occurring in the big toe joint. This can be taken at the onset of pain and usually can decrease the pain within a couple hours. Once the pain has subsided, the drug should be discontinued due to its blood thinning effects.

Another drug that be taken on the onset of pain is colchicine. Colchicine, similar to indomethacin, will decrease the activity of the immune system within the joint, thus relieving the pain. Colchicine is most effective when it is taken within 24 hours of the onset of pain. Once the pain has subsided, colchicine (at a lower dose) can be taken to protect against gout attacks in the future. Colchicine is a strong drug that can cause nausea and vomiting, so it must be taken with caution.

While indomethacin and colchicine help with the pain, they do not address the root cause of the pain. Work with your rheumatologist to figure out if you are over producing uric acid, or not excreting enough of it. Additional treatments are available to address the origin of pain. Uloric is a newer drug that is showing promising results.

As mentioned before, consumption of foods like beer, steak, and other high protein diets can cause a spike in uric acid that can lead to gout. Avoiding these foods altogether, or minimizing the amount consumed at any given time can help to decrease uric acid levels.

If attacks become uncontrollable, there may be extensive damage to the cartilage in the joint and unrelenting pain. At this point, you may want to consider surgical options that would get rid of the pain permanently. A joint fusion is a procedure that you may consider to find relief. Discuss these options with your foot and ankle surgeon.