Does the skin heat up before it breaks down in diabetic foot ulceration?
Compelling and provocative work from our Dutch colleagues. They’ve published more on this important subject in the past few years than anyone and what we may be seeing is that, for some patients, thermometry may not be as accurate. While this idea has been as much of a “sacred cow” as anything over the years– for me especially– we have to challenge all of these preconceived notions to march forward! Is it possible that the fact that, in this study, patients were asked to change their activity based on skin temp monitoring might have had some treatment-related effects? This is unclear, but the implications are no less significant.
Perhaps some of the data we have seen showing that unprotected standing might play a role in risk for ulcer development? Perhaps the time horizon may need to be adjusted. Perhaps more of our patients are neuroischemic than previous efforts. Let us keep interrogating!
Does the skin heat up before it breaks down in diabetic foot ulceration?
Aim: Most diabetic foot ulcers are caused by tissue stress from being ambulatory in people without protective sensation. These ulcers are suggested to be preceded by local skin temperature increase due to inflammation of underlying tissue, a so-called hotspot. Evidence to support this mechanism of ulcer development is meagre at best. We investigated if foot ulcers are preceded by increased skin temperature in people with diabetes and foot ulcer history.
Material and methods: Participants measured temperature at 6-8 plantar foot locations each day for 18 months and identified a hotspot with a temperature difference >2.2C between corresponding foot locations for two consecutive days. Results: Twenty-nine of 151 participants developed a non-traumatic ulcer while adherent to temperature measurements. In the two months prior to ulceration 8 (28%) had a true hotspot (i.e. at/adjacent to the ulcer) and the hotspot was on average no longer present 9 days before ulceration. Seven (24%) participants had a false hotspot (i.e. at another location) and 14 (48%) had no hotspot.
Conclusion: The skin of the majority of the ulcers does not heat up before it breaks down, or, when it does, not directly before breakdown, questioning the foot temperature increase – ulcer association.
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