Neuropathic Ulcers: Causes, Symptoms, Diagnosis, and Treatment

Neuropathic ulcers are the type of chronic wound that occurs in people with neuropathy, a condition that affects the nerves and their ability to function properly⁽¹⁾. It can lead to numbness, tingling, and loss of sensation in the affected area. This makes it difficult for the person to sense pain or injury. It can also lead to the development of neuropathic ulcers that are often located in the feet or lower legs.

Neuropathic ulcers can be extremely painful and lead to serious complications such as infection, osteomyelitis, and amputation if left untreated. Proper diagnosis and treatment are needed to improve the outcome for people with neuropathy.

Neuropathic ulcers occur due to nerve damage. The common causes of neuropathic ulcers include:

• Diabetes: High blood sugar levels can lead to damage to the nerves especially of the feet⁽²⁾.
• Peripheral Neuropathy: It is a condition in which the nerves outside the brain and spinal cord are affected due to alcohol abuse, chemotherapy, and infection⁽³⁾.
• Charcot Foot: It is a complication of peripheral neuropathy that leads to the weakening of the bones and fracture.
• Spinal Cord Injuries: Damage to the spinal cord can lead to loss of sensation in the areas of the body, making it more challenging to detect minor injuries which progress to ulcers⁽⁴⁾.
• Pressure Injuries: Prolonged pressure on a particular area of the foot can lead to tissue damage and subsequent ulceration. It occurs mostly in people with reduced sensation and nerve damage.
• Trauma: Injuries to the feet can lead to neuropathic ulcer development.

The prevalence and incidence of neuropathic ulcers depend on the underlying cause of the condition.

The most common cause is diabetic ulcers and is known to affect 50% of individuals with diabetes⁽⁵⁾.

Also, the prevalence of neuropathic ulcers is high among people with spinal cord injuries. It is estimated that 30-40% of individuals with spinal cord injuries develop a pressure ulcer at some point in their lifetime⁽⁶⁾.

Due to the growing prevalence of diabetes and other underlying condition, the prevalence of neuropathic ulcers may also increase. Early detection and treatment are crucial for preventing complications and improving outcomes.

The signs and symptoms of neuropathic ulcers may depend on the location and severity of the ulcer. People may experience pain and discomfort at the site of the ulcer due to the underlying neuropathy.

The signs and symptoms of neuropathic ulcers include:

• Open sores and wounds in the feet, leg, and hands that are slow to heal and may be accompanied by drainage and foul odor.
• Redness and swelling on the skin around the ulcer.
• The skin around the ulcer may appear shiny or may have a glossy appearance.
• There may be numbness, tingling, and loss of sensation in the affected area.
• The skin around the ulcers may be warm to the touch.
• Pain and discomfort are experienced by people with neuropathic ulcers when the ulcers get infected.

Also, pain and discomfort may not always be experienced by people with neuropathic ulcers, which may make them difficult to detect⁽⁷⁾.

The diagnosis of neuropathic ulcers may involve a combination of physical exams, medical history, and diagnostic tests⁽⁸⁾.

• Physical Exam: A healthcare professional examines the affected area and looks for the signs of ulcers and assesses for the severity of any wound.
• Medical History: The doctor enquires about any underlying condition such as peripheral neuropathy and diabetes as these increase the risk of occurrence of neuropathic ulcers.
• Sensory Testing: Sensory testing is done by the healthcare professional and it involves a monofilament test or tunic fork test. It tests the sensation of the patient in the affected areas.
• Imaging Test: X-ray and MRI scans are imaging tests that may help a doctor assess underlying bone infections or deformities and provide guidance for treatment.
• Blood Test: Blood tests help in evaluating blood sugar control or other medical condition contributing to nerve damage.
• Biopsy: A tissue sample is taken from the affected area to assess infection or underlying causes of the ulcer.

The treatment options for neuropathic ulcers may involve a combination of wound care, taking away weight from the affected area, managing any underlying condition, and medications.

The common treatment options include:

• Dressing and Wound Care: Regular care of the wound can help in promoting healing and preventing it from getting infected. The wound is cleaned, dead tissue is removed and dressing is done.
• Offloading Devices: These include shoes, braces, and casts. They redistribute the weight and reduce pressure on the affected area⁽⁹⁾.
• Medication: Topical and systemic medications are prescribed to control pain, prevent infections and enhance healing. These include antibiotics and analgesics.
• Surgery: In severe cases surgery is recommended to remove dead tissues, and repair underlying bone deformities or infection. Severely affected areas are amputated.

Proper management of underlying medical conditions is important to prevent neuropathic ulcers. Also, certain lifestyle changes such as quitting smoking, eating healthy, and exercising regularly can help in reducing the risk⁽⁷⁾.

Prevention of neuropathic ulcers involves managing the underlying conditions that contribute to the development of these ulcers.

The prevention tips include:

• Controlling Blood Sugar Levels: It is important for people with high blood sugar to keep their blood sugar levels in the target range, as it is the highest risk factor for the development of neuropathic ulcers.
• Foot Care: Proper foot care is needed which may include good foot hygiene, keeping the feet dry, and wearing properly fitting shoes. This can help prevent injury as well as the development of neuropathic ulcers.
• Regular Foot Exam: It is important for people with neuropathy to get their feet examined regularly to look for any injuries or changes that may need treatment.
• Offloading Pressure: Reducing the pressure on the feet by wearing orthotics, special footwear, and other devices can prevent the development of ulcers in high-risk individuals.
• Avoiding Smoking: Smoking impairs circulation which may increase the risk of development of neuropathic ulcers.
• Managing Medical Condition: Addressing underlying medical conditions such as high blood pressure, high cholesterol, and heart diseases can help in reducing the risk of neuropathic ulcers.

There are various complications that can occur if then neuropathic ulcers are left untreated or poorly managed.

• Infection: An open wound is susceptible to infection and a neuropathic ulcer getting infected can be a serious complication. The infection can spread and can even lead to amputation.
• Osteomyelitis: Osteomyelitis can occur in people with neuropathic ulcers, especially those with underlying foot deformities or bone abnormalities⁽⁸⁾. If left untreated osteomyelitis can lead to bone destruction.
• Cellulitis: Cellulitis is a bacterial infection that can develop in a neuropathic ulcer. There is redness, swelling, warmth, and pain and antibiotic treatment may be needed.
• Delayed Healing: An infected neuropathic ulcer may take a long time to heal. Delayed healing may increase the risk of complications.
• Amputation: This may be an option when the neuropathic ulcer has not healed or has become infected.

Regular monitoring and follow-up with a healthcare provider are necessary to prevent complications and promote healing.

The prognosis of neuropathic ulcers depends on various conditions including the severity of the underlying nerve damage, the size and location of the ulcer, and the presence of infection or other complications.

These ulcers may take a long time to heal and may also have a risk of recurrence.

Proper management of underlying medical conditions and adherence to preventive measures can help in preventing the development of new ulcers and reduce the risk of recurrence and complications.

Neuropathic ulcers are a serious complication of nerve damage, especially in individuals with diabetes or other conditions that may affect the nervous system. There can be significant pain, disability, and complication including infection, osteomyelitis, and amputation.

Preventive measures such as proper foot care, regular monitoring, and controlling underlying medical conditions are necessary to reduce the risk of developing neuropathic ulcers.

Treating neuropathic ulcers can be challenging and the outlook depends on the wound severity and the presence of the underlying condition.