Temperature as a Causative Factor in Diabetic Foot Ulceration

NewsBot · Nov 16, 2018

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Temperature as a Causative Factor in Diabetic Foot Ulceration: A Call to Revisit Ulcer Pathomechanics.
Yavuz M et al
J Am Podiatr Med Assoc. 2018 Nov 14
BACKGROUND:
Diabetic foot ulcers are a major burden to patients and to the healthcare systems of many countries. To prevent and/or treat ulcers more effectively, predictive biomarkers are needed. We examined temperature as a biomarker and as a causative factor in ulcer development.

METHODS:
37 individuals with diabetes were enrolled in this observational case-control study: nine with diabetic neuropathy and ulcer history (DFU), 14 with diabetic neuropathy (DN), and 14 non-neuropathic participants (DC). Resting barefoot plantar temperatures were recorded using an infrared thermal camera. Mean temperature in each region was determined based on 4 anatomical regions; hallux, medial forefoot, central forefoot, and lateral forefoot and separate linear models with specified contrasts between DFU, DN, and DC groups were set to reveal mean differences for each foot region, while controlling for group characteristics.

RESULTS:
Mean temperature readings in each foot region was higher than 30.0°C in the DFU and DN compared to the DC group with all temperatures below 30.0°C. Mean differences were greatest between the DFU and the DC group, with mean differences ranging from 3.2°C in the medial forefoot to 4.9°C in the hallux.

CONCLUSIONS:
Increased plantar temperatures in individuals with a history of ulcers may include acute temperature increases from plantar stresses, chronic inflammation from prolonged stresses, and impairment in temperature regulation from autonomic neuropathy. Diabetic foot temperatures, particularly in those with previous ulcers, may easily reach hazard thresholds indicated by prior pressure ulcer studies. The results necessitate further exploration of temperature in diabetic foot and how it may contribute to ulceration

NewsBot · Jul 5, 2019

Relationship between skin temperature and soft tissue hardness in diabetic patients: an exploratory study.
Seixas A et al
Physiol Meas. 2019 Jul 3

Objective: The role of skin temperature and soft tissue hardness in the development of plantar ulcers is still in debate. However, the relationship between skin temperature and soft tissue hardness has not been explored. This study intends to analyse an eventual association between skin temperature and soft tissue hardness in the foot of diabetic patients&#13; Approach: Twenty diabetic patients enrolled for this study. The analysis was done at the foot level, therefore, skin temperature and soft tissue hardness data of the plantar surface of 40 feet were obtained in eight regions of the foot, two in the heel, two in the midfoot, three in the forefoot and one in the hallux. Information regarding glycaemic control (HbA1c levels) was retrieved from the clinical records of the patients.&#13; Main Results: After averaging skin temperature and soft tissue hardness in the calcaneum (medial and lateral), in the midfoot (medial and lateral and in the metatarsal head (1st, 2nd-3rd and 4th-5th), a negative, moderate and significant association was found between skin temperature and soft tissue hardness in the metatarsal head (rho = -0.553; p &lt; 0.001), a positive, low and significant association was found in the midfoot (rho = 0.333; p = 0.036), but no association was found in the heel. The multiple linear regression models with skin temperature as dependent variable and soft tissue hardness as predictor were statistically significant in the metatarsal heads and midfoot, and explained 28.8% (R2 = 0.288, F(1,38) = 15.37, p &lt; 0.001) and 11.9% (R2 = 0.119, F(1,38) = 5.151, p = 0.029) of the variance in skin temperature, respectively. &#13; Significance: Skin temperature is negatively associated with soft tissue hardness in the metatarsal head region and positively associated with soft tissue hardness in the midfoot. These findings imply that soft tissue hardness should be considered in the assessment of diabetic foot patients and that this variable should be controlled in studies assessing the determinants of foot skin temperature.
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NewsBot · Mar 5, 2020

The Association Between Elevated Foot Skin Temperature and the Incidence of Diabetic Foot Ulcers: A Meta-Analysis
Javier Ena, MD, Juani Carretero-Gomez, MD, Jose Carlos Arevalo-Lorido, MD, ...
The International Journal of Lower Extremity Wounds February 28, 2020

Prior to the appearance of any foot ulcer, there is an increase in the local temperature due to the presence of an underlying inflammatory process. The use of thermometry to identify inflammation could make patients increase preventive measures until the inflammation disappears. We carried out a meta-analysis to determine the effectiveness of the daily measurement of the foot temperature in 6 points to prevent the occurrence of foot ulcers in patients with diabetes. Patients with temperature differences >4°F (2.2°C) between left and right corresponding sites should reduce activity and increase preventive measures until temperature is normalized. We searched the literature in MEDLINE, EMBASE, Cochrane Library, Web of Knowledge, and clinicaltrials.gov. We have only included randomized clinical trials where individuals were assigned to receive enhanced care (temperature measurement and standard care) versus standard care (education, self-care practices, and periodic clinical visits). We found 4 trials comprising 462 patients from the United States and Norway that met our inclusion criteria. The duration of follow-up varied from 4.5 to 15 months. Overall, 18 (7.9%) subjects in the enhanced foot care group and 53 (22.6%) in the standard foot care group developed foot ulcers (pooled risk ratio = 0.37; 95% confidence interval = 0.21-0.66; P = .0008; percentage of heterogeneity [I2], 25%; P = .26). The number needed to treat was 7 (95% confidence interval = 5-11). The results were robust after analysis by subgroups according to the potential risk of bias in the studies and the duration of follow-up.
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NewsBot · Dec 26, 2021

Is a Left-to-Right >2.2°C Difference a Valid Measurement to Predict Diabetic Foot Ulceration in People with Diabetes and a History of Diabetic Foot Ulceration?
Jill Featherston, Anke M. Wijlens, Jaap J. van Netten
The International Journal of Lower Extremity Wounds December 20, 2021

Monitoring foot skin temperatures at home have been shown to be effective at preventing the occurrence of diabetic foot ulcers. In this study, the construct validity of using >2.2°C difference between contralateral areas on the foot as a warning sign of imminent ulceration is explored. Thirty participants with diabetes at high risk of ulceration (loss of protective sensation and previous ulceration and/or amputation) monitored their foot temperatures at six sites, four times a day for six days using a handheld infrared thermometer. Walking activity, time of day, and environmental temperature were also monitored and correlated with foot temperatures. We found that contralateral mean skin temperature difference was 0.78°C at baseline. At single sites, left-to-right temperature differences exceeding the threshold were found in 9.6% of measurements (n = 365), which reduced to 0.4% when individually corrected and confirmed the next day. No correlation was found between contralateral temperature differences and activity, time of day, and environmental temperature. We conclude that using a >2.2°C difference is invalid as a single measurement in people at high risk of ulceration, but the construct validity is appropriate if both individual corrections and next day confirmation are applied.
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NewsBot · Feb 8, 2023

Does the skin heat up before it breaks down in diabetic foot ulceration?
Wouter B Aan de Stegge et al
Diabetes Metab Res Rev. 2023 Feb 8

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 >2.2°C 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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