​From regular diabetic foot screening to patient education on podiatry care, general practitioners are key to managing the growing pool of diabetes patients in Singapore. We share how collaborative care can help reduce the burden of diabetic foot complications in the community.

INTRODUCTION

Diabetic foot problems are serious complications of diabetes. They often lead to ulceration, infection, and in severe cases, amputation of the lower limbs.

With diabetes prevalence rising in Singapore, managing diabetic foot problems effectively is critical to patient care. Notably, the Healthier SG initiative emphasises proactive, preventive care that can help reduce complications, enhance quality of life and minimise healthcare costs.

General practitioners (GPs) are well-placed to manage diabetic foot problems. They can manage diabetic foot issues in line with Healthier SG goals by:

• Performing diabetic foot screenings

• Educating patients on proper foot care

• Intervening early by working closely with specialists like podiatrists

In the event of active diabetic foot problems, GPs can make appropriate referrals to the relevant medical specialties for further evaluation and treatment.

The GP’s Role in Diabetic Foot Care

1. DIABETIC FOOT SCREENING

Regular diabetic foot screening (DFS) is key to the early detection and prevention of diabetic foot complications. It is estimated that approximately 85% of lower extremity amputations can be avoided with regular screening. GPs are ideally placed to perform this as part of their patients’ regular diabetes review. 

A typical DFS should include:

A. Assessing neuropathy

Diabetic peripheral neuropathy (DPN) is a leading risk factor for diabetic foot ulcers (DFUs). A simple 10-gram monofilament test can detect any loss of protective sensation (LOPS). This is done by applying the monofilament to areas on the foot such as the hallux and plantar forefoot regions. Patients who are unable to feel the filament are at increased risk and require closer monitoring.

B. Assessing lower limb vascular supply

Peripheral arterial disease (PAD) is also common in patients with diabetes. To assess a patient’s vascular supply, the following should be carried out: 

• Palpate the key pedal pulses at the dorsalis pedis and posterior tibial artery sites (Figure 1).
  

• Confirm the sufficiency of the pedal pulses by using a handheld Doppler. If a monophasic pulse is heard, this indicates the presence of PAD. If biphasic or triphasic pulses are present, this would typically indicate sufficient vascular supply to the feet.

• Observe for signs of ischaemia, such as skin pallor, decreased temperature and delayed capillary refill.
  

C. Assessing foot structure and deformities

Patients with diabetes tend to develop foot deformities such as clawed toes because of DPN. These foot deformities can result in areas of increased plantar foot pressure, which could lead to calluses on the feet. If left unchecked, these areas of high pressure can develop into DFUs.

As such, GPs are encouraged to:

• Look out for calluses, ulcers and suspicious lesions

• Check between the toes for lesions, especially skin maceration as this can lead to tissue breakdown resulting in ulcers 

• Monitor for changes in foot shape or appearance

D. Risk stratification

DFS findings should be used to stratify patients accordingly. Risk stratification will help to inform risk-based management decisions. This would typically implicate decisions relating to: 

• Frequency of reviews
  

• Referrals to relevant medical specialties for further work-up
  

The frequency of DFS should be determined based on the patient’s risk level, as detailed in Table 1. For moderate- and high-risk patients, the need for podiatry or specialist intervention should be considered.

Table 1

2. PATIENT EDUCATION

GPs can also play a key role in educating patients on daily foot care, which includes:

A. Inspection of the feet

Remind patients to inspect for blisters, cuts, skin maceration, redness, swelling, bruising and/or wounds on the feet, especially in between the toes. Patients can use a mirror or ask someone for help to check the bottom of the feet.

B. Toenail care

Remind patients to avoid cutting their nails too short and to file the corners of the nails after trimming. This will help to reduce the incidence of ingrown toenails.

C. Moisturising the feet regularly

Provide guidance on keeping feet clean, dry and well-moisturised. Moisturisers should not be applied between the toes to prevent fungal infections. 

Suggest that patients consider using moisturisers with humectant (i.e., 10% urea) and exfoliating (i.e., AHAs or BHAs) components to soften callus sites. This can help to reduce the rate of callus build-up. It can also help to prevent dry skin that can lead to micro-tears or split skin, which could result in wounds.

D. Proper footwear (both indoors and outdoors)

Advise patients to:

• Wear covered shoes with socks when outdoors

• Check for and remove any objects in the shoes before wearing them

• When attempting to purchase new footwear, try them on physically at the store while standing. Look for new shoes towards the end of the day, as the feet tend to be at their largest then.

• Avoid walking barefoot even at home. Encourage them to wear home sandals/slippers with non-slip soles.

E. Wash and maintain good foot care/hygiene

Patients should be advised to avoid using any sharp tools on the feet. They should use a pumice stone or nail file to lightly file callus sites, and check the sites after a few strokes of filing to prevent overfiling.

Consider the V.I.P. of wound healing

If active DFUs (with or without mild infection) are detected, consider the V.I.P. of wound healing (Table 2). These are three areas that can affect a wound’s ability to heal. 

When to refer to the emergency department

If any of the active diabetic foot conditions below are detected, refer the patient to the emergency department for management:

• Signs of moderate/severe infection (i.e., wet gangrene, abscess, osteomyelitis)

• Presence of PAD/ischaemia with infection (regardless of severity)

• Acute Charcot neuroarthropathy

• Acute limb ischaemia
  

When to refer to the Rapid Access FooT (RAFT) clinic

GPs can also consider referring patients to the newly established RAFT clinic at the Singapore General Hospital.

RAFT is a multidisciplinary clinic which involves vascular specialists, endocrinologists and podiatrists coming together to provide diabetic patients with timely access to treatment, potentially avoiding diabetes-vascular-related admissions.

A referral should be considered if the patient has DFUs and/or gangrene that cannot be managed in the primary care setting.

Appointments may typically be available within the same day or within 24 hours.

REFERENCES

1. Agency for Care Effectiveness (ACE), 2024. Foot assessment in patients with diabetes mellitus. Singapore: Ministry of Health. Available at: https://www.ace-hta.gov.sg/docs/default-source/acgs/foot-assessment-in-patients-with-diabetes-mellitus-(aug-2024).pdf [Accessed 21 November 2024].
   

2. International Working Group on the Diabetic Foot (IWGDF), 2023. IWGDF Guidelines on the prevention and management of diabetic foot disease. Available at: https://iwgdfguidelines.org/wp-content/uploads/2023/07/IWGDF-Guidelines-2023.pdf [Accessed 21 November 2024].

3. Singapore Ministry of Health, 2022. Healthier SG White Paper. Available at: https://file.go.gov.sg/healthiersg-whitepaper-pdf.pdf [Accessed 21 November 2024].