Self-Monitoring of the Feet in Diabetes

The most common cause of amputations of the lower extremities is diabetes-related. Available health insurance data show that the prevalence of diabetic foot syndrome (DFS) in Germany is between 6.2–10% [1,2]. Consequently, approximately 550,000 to 850,000 people require treatment each year. The major amputation rate per 100,000 people in 2022 for diabetes mellitus was 10.8 [3]. Data from the Diabetes Patient Follow-Up Documentation (DPV) indicate that about one in three to four patients with diabetes will develop DFS during their lifetime [4].

How Does Diabetic Foot Syndrome Develop?

The causes of diabetic foot syndrome include polyneuropathy, micro- and macrovascular diseases, changes in bones and joints, as well as injuries and infections of the feet. In addition to medical and daily foot care, daily self-monitoring of the feet can help detect injuries, skin cracks, and other problems at an early stage and thereby limit the progression of DFS or, if necessary, encourage early consultation at a specialized foot care center.

Instructions: Self-Monitoring of the Feet in Diabetes

  • Daily inspection of the feet, especially hard-to-see areas (ball of the foot, soles, between the toes, using a mirror if necessary)
  • Look for micro-injuries and wounds, swelling, redness, inflammation (especially around the nail bed), skin cracks, corns, fungal infections, etc.
  • Appropriate foot care after self-inspection
  • Involvement of a family member if regular self-checks are difficult

Self-monitoring of the feet should be part of the daily routine of every patient with diabetes, especially if reduced sensation is already present. In such cases, the feet are considered at-risk or high-risk feet. This leads to preventive measures such as:

  • Avoid tight and constricting shoes (especially when purchasing footwear). Shoes should be soft, have soft toe caps, be breathable, optionally have shock-absorbing soles, contain no pressure-causing or chafing inner seams, and preferably have no high heels.
  • When putting on shoes, ensure that no small foreign objects are inside and that socks or stockings (preferably seamless) do not form wrinkles.
  • Do not use uncontrolled heat sources.
  • Wash the feet with lukewarm water, use only mild, neutral, moisturizing soap, and avoid skin-irritating bath additives.
  • Do not walk barefoot or only in socks, especially in summer on hot surfaces or on sandy beaches.
  • Use professional foot care services for nail trimming. Ingrown nails should always be treated by a podiatrist. If foot care is performed independently, a pedicure file should be used instead—no sharp or pointed instruments such as scissors, clippers, etc. Particular care should be taken that toenails do not press against adjacent toes (nails should be cut straight and corners rounded).
  • Patients with diabetes often develop polyneuropathy of the feet. The first sign of polyneuropathy is dry feet. Diabetic feet with polyneuropathy do not sweat. Dry feet are at risk. There is often increased callus formation and rhagades (cracks in the callused skin). Rhagades can become infected. Therefore, patients with dry feet should apply urea-containing creams or ointments twice daily. The higher the urea concentration, the better (urea > 20%).

Effects of Urea

  • The active ingredient urea is a natural component of the skin.
  • It draws water into the stratum corneum.
  • It increases skin elasticity.
  • It prevents dryness and scaling.

In diabetes, the skin is often very dry because:

  • Sweat production is reduced
  • Blood circulation may be impaired

At higher concentrations, urea has a keratolytic (callus-reducing) effect:

  • Thickened callus becomes softer
  • Pressure points are relieved
  • Crack formation decreases

References

[1] Eckhard M, Lawall H, Lobmann R, Thienel F. Diabetic foot syndrome in times of structural reforms: opportunities and risks. In: German Diabetes Health Report 2024: 103–112.
[2] Jacobs E, Rathmann W. Epidemiology of diabetes. Diabetologie 2017; 12: 437–446.
[3] Robert Koch Institute 2022. Diabetes in Germany.
[4] Bohn B, Grünerbel A, Altmeier M, et al.: Diabetic foot syndrome in patients with diabetes. A multicenter German/Austrian DPV analysis of 33,870 patients. Diabetes Metab Res Rev 2018; 34 (6): e3020.