Recurrence in the patient in ulcer remission: Callus for diabetic foot = breast lump for cancer

Does bleeding into callus equal a suspicious breast lump in cancer? See below for the analogy.

screenshot 2015-03-28 at 7.14.33 PM

Waaijman and coworkers from Sicco Bus’ great unit in Amsterdam have produced an important manuscript evaluating reasons for recurrence. The bottom line: a preulcerative callus in a diabetic foot is very similar to a lump in the breast of a person with cancer. 

These “minor lesions” included preulcerative callus, bleeding into callus and other irritations. Those were associated with an 11-fold greater risk for reulceration.  

The abstract is listed below. For more information about “Remission” care, have a look here.  

Risk Factors for Plantar Foot Ulcer
Recurrence in Neuropathic
Diabetic Patients
DOI: 10.2337/dc13-2470
 
Roelof Waaijman,1 Mirjam de Haart,1
Mark L.J. Arts,1 Daniel Wever,2
Anke J.W.E. Verlouw,3 Frans Nollet,1 and
Sicco A. Bus1
 
1Department of Rehabilitation Medicine, Academic
Medical Centre, University of Amsterdam,
Amsterdam, the Netherlands
2Department of Rehabilitation, Medisch Spectrum
Twente, Enschede, the Netherlands
3Department of Rehabilitation, Maxima Medical
Centre, Veldhoven, the Netherlands
Corresponding author: Sicco Bus, s.a.bus@amc
.uva.nl.
 


OBJECTIVE
Recurrence of plantar foot ulcers is a common and major problem in diabetes but
not well understood. Foot biomechanics and patient behavior may be important.
The aim was to identify risk factors for ulcer recurrence and to establish targets for
ulcer prevention.
RESEARCH DESIGN AND METHODS
As part of a footwear trial, 171 neuropathic diabetic patients with a recently
healed plantar foot ulcer and custom-made footwear were followed for 18
months or until ulceration. Demographic data, disease-related parameters, presence
of minor lesions, barefoot and in-shoe plantar peak pressures, footwear
adherence, and daily stride count were entered in a multivariate multilevel logistic
regression model of plantar foot ulcer recurrence.
RESULTS
A total of 71 patients had a recurrent ulcer. Significant independent predictors
were presence of minor lesions (odds ratio 9.06 [95% CI 2.98–27.57]), day-to-day
variation in stride count (0.93 [0.89–0.99]), and cumulative duration of
past foot ulcers (1.03 [1.00–1.06]). Significant independent predictors for
those 41 recurrences suggested to be the result of unrecognized repetitive
trauma were presence of minor lesions (10.95 [5.01–23.96]), in-shoe peak pressure
80% (0.43 [0.20–0.94]), barefoot
peak pressure (1.11 [1.00–1.22]), and day-to-day variation in stride count (0.91
[0.86–0.96]).
CONCLUSIONS
The presence of a minor lesion was clearly the strongest predictor, while recommended
use of adequately offloading footwear was a strong protector against
ulcer recurrence from unrecognized repetitive trauma. These outcomes define
clear targets for diabetic foot screening and ulcer prevention.

David G. Armstrong

Dedicated to amputation prevention, wound healing, diabetic foot, biotechnology and the intersection between medical devices and consumer electronics.

6 comments

  • After study of more than 900 debridements in foot ulcer, I agree. The callus is a predictor of ulceration. It indicates an excess of pressure. It causes greater shear forces, leading to bleeding and breakdown. But there is a third reason: it is a new growth, a strange symbiosis between human cornified cells and fungus. As breakdown proceeds greater fluid leads to greater fungal proliferation. From a pathologist viewpoint, the callus is more than just cornified cells and pressure. It is a composite biomaterial of cells and fungal polymers resembling plywood or particle board, but waterproof and impervious to industrial solvents. Steve

  • Steve: I think the more we learn about our non-human microbial overlords, the more we will find that the 9 out of 10 cells on or in us that aren’t “us” will begin to make us redefine what makes “us”, “us”! Cheers, -DGA

    • Great paper by Keisha Findley on Topographical diversity of bacteria and fungi on human skin. Nature 2013. Surprisingly In terms of fungal species Heel>Webspace>Toenail
      Steve

      • I would doubt 9/10 cells are foreign, but Findley shows the foot (cornified layer) skin is a reservoir of fungus. Add water and fungi grow. Every disease disrupting epidermis adds water. Thus almost every disease on the foot has a fungal component.

  • ALL Pressure lesions on the foot have a fungal component pathologically and microscopically.
    Callus does.
    Corns / IPK yes.
    Warts over pressure areas commonly have a hard IPK-like hard cap over the center, and those are more fungal than wart.
    Precursor callus may breakdown or ulcer at any time. Another aspect the flaky dandruff stuff emanating from precursor keeps seeding nearby ulcer. We may think the callus is ours alone, human. In a callus or fungal nail, the fungus thinks it is theirs alone. A hard fungal colony which may ulcerate at any time.

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