Diabetes is one of the disorders associated with metabolism and circulation. Skin is one of the organs affected by chronic metabolic problems that lead to nerve damage and poor circulation. Chronic leg ulcers associated with diabetes are conditions that occur over a long duration mostly in elderly people between the age of 65 to 80, with the peak occurrence at the age of 80. Venous insufficiency is commonly reported within the range of suggested aetiologies. Pain is commonly reported to affect over 89% of patients suffering from venous leg ulceration, Caballero. E and Frykberg, R.G. (1998).
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Leg ulceration is one of the chronic disabling conditions. 1-2% of the developed world population is believed to be affected. Its median duration of occurrence is 6-9 months with a range of 4 weeks to 72 years. Although healing can be accelerated, more than 40% of the patients will experience open ulceration for more than one year. Even in cases where healing is achieved, 26-69% 12-month recurrence rate has been reported. Thus some patients may suffer from leg ulceration symptoms for a lifetime, Albrant, D.H. (2000).
Factors that lead to skin lesions in diabetes
Peripheral nerve malfunction is common in uncontrolled diabetes. The mechanisms that result in neurons damage in diabetes are not well understood. Oxidative stress in the neurons due to a high level of blood glucose could be a factor. Diabetic neuropathy may involve the sensory, motor, and autonomic nervous systems. Malfunction of the sensory neurons leads to loss of feeling, problem sensing limb position, reflex loss, pain, and tingling (paresthesias). Local circulation is altered by autonomic neuropathy as motor impairment results in muscle weakness, Michelle, B and Kate, F. (2007).
Arteries, as well as arterioles, are prone to have plaque buildup in cases of chronic diabetes. The exact reason for this is not clear but Type II non-insulin-dependent diabetic patients usually suffer from diabetic dyslipidemia (abnormal blood lipid). The low-density lipoproteins particles adhere to the blood vessel walls causing vascular occlusion and the resulting lowered nutrient and oxygen supplies stress tissue resistance as well as impair the process of tissue recovery from injury.
Tissue perfusion is inhibited by repeated chronic pressure upon the skin that compresses dermal arterioles. Ulceration results from this tissue weakness that further exposes it to pathogenic microorganisms. Osteomyelitis may be initiated if the ulceration does reach the underlying bone.
Fungi and Protozoa
A common inhabitant of chronic diabetic wounds. Examples include Aspergillus and Candida where Aspergillus, Candida, Actinomycoses, Histoplasma, and Cryptococcus are neutralized by the drug Ozone. Several protozoan organisms are usually found in diabetic chronic wounds. Cryptosporidium, Giardia, and free-living amoebas such as Hartmonella, Acanthamoeba, and Naegleria are among the protozoan species sensitive to ozone, Michelle, B and Kate, F. (2007).
Physiological effects of Ozones
The oxygen that is under pressure increases local circulation and stops anaerobic bacteria proliferation when it is applied to the affected tissue. Its main two effects include;
- Arteriole vasodilation promotes tissues oxygenation and delivery of immunological factors and nutrients. Removal of toxins and venous outflow is increased by vasodilation of the veins.
- Its antipathogenic action covers a broad range of microorganisms.
The benefits of ozone are felt in diabetic leg ulcers. Diabetic ulcers treatment would include a multidisciplinary approach that may include topical, surgical as well as systemic interventions. Topical antibiotics have the disadvantage of not penetrating deep into the wound and may cause allergy and secondary dermatitis, Dyas. A., et al. (1983). Only a portion of the microorganism are prone to the effect of certain antibiotics and bacterial resistance is also common (e.g., β-lactam antibiotic resistance observed in staphylococcus resistant to methicillin. Examples of bacteria found in diabetic leg ulcers include Klebsiella, E. coli, Proteus, Pseudomonas, Enterobacter, Bacteroides, Clostridium per fringe, peptostreptococcus, and prevotella.
In diabetic ulcers, an ozone application stimulates circulation and provides broad-spectrum topical coverage. With a higher dose and increasing number of applications, it penetrates into deeper tissues attacking anaerobic bacteria.
Use of Ozone as an external therapy in diabetic skin lesions
An individual assessment must be made in relation to the skin lesion to be treated. This evaluation includes size (Lesion diameter and depth), involvement of ligaments, dermal tissues, bone, and muscle. The circulatory competence of adjacent tissue, its relative health, and the presence of necrosis and or purulence are other factors to be considered. Thus due to variations in the clinical observations, ozone therapy is individualized. Its concentration frequencies and length are adjusted in the course of treatment. In case of burns and wet ulcers, initial ozone concentrations should be low so as to avoid excessive systemic absorption but on gradual epithelization, there is a need to adjust concentrations of ozone applied Cavanagh, P.R., et al,. (2005).
Advantages associated with topical ozone therapy in diabetic patients
- It’s easy to administer therapy. On mastering the principles of ozone therapy which includes dosage adjustment and the treatment protocols, a clinician can safely administer topical ozone therapy to a wide range of afflictions related to diabetes.
- It has a broad spectrum of action. It inactivates facultative, anaerobic, and aerobic bacterial organisms, a wide range of viruses as well as a wide range of protozoans and fungal pathogens. If systemic antibiotics were to be used to treat these ulcerative conditions, a large assortment of them would have to be used which is not possible in normal medical practice.
- Its both preventive, chronic care, and acute care therapeutic agent. When its application is timely, it may thus deviate from the need to have a systemic therapy hence saving the patient organ stress and drugs side effect.
- It enhances tissue oxygen and blood perfusion to surface tissues that have a low blood supply.
- With its oxidizing potential, it destroys bacterial toxins that destroy tissues and that enhance a colonizing advantage for the bacteria.
- It doesn’t suffer the risk of resistance due to mutations from the microorganisms. Conventional antibiotics used should be constantly upgraded to avoid pathogen resistance.
- Topically applied oxygen/ozone mixtures are completely compatible with antibiotics systemically applied and with debridement as well as the other procedures of wound care.
Oxygen/Ozone mixtures are however not without disadvantages. They are not transportable and thus they have to be made at the time and within the site of administration. Since their administration needs to be serial in diabetic wounds, this usually translates in most cases to the daily application that has to go on until the ulcer resolves. Topical applications have limited penetrability. Although they have a panpathogenic potential on the ulcer surfaces, they cannot act at greater depths, Dyas. A., et al. (1983)
Leg ulceration has been one of the chronic conditions known to have a detrimental and significant effect upon the patients’ life. In various research findings some of the physical effects pointed out to be associated with leg ulceration include Odor, pain, itch, infection, and leakage. Pain is a common factor that most patients will complain about. A devastating effect is experienced by the patient when wound exudate is unsuccessfully managed. Although most nurses consider wound healing as the most important desirable outcome, alleviation of the disturbing symptoms is of more importance than wound closure, Albrant D.H, (2000).
Epidemiological studies that have been conducted suggest that up to 70% healing rates can be achieved in case of venous ulceration by use of compression bandaging while for arterial disease, healing rates are much lower. From these estimates thus, up to 30% of diabetic patients with leg ulcers cannot quickly and easily achieve healing. Thus in this kind of group, promotion of patients’ self-care and management of the symptoms should form the top priority.
There is no real sense of not following up and managing symptoms of a patient who has been cured since, after the first instance of leg ulcers, the patient has to put on compression hosiery. There would also be a need for a follow-up assessment in order to avoid recurrence, Caballero. E and Frykberg, R.G. (1998).
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Previous studies have shown that, within a five-year follow-up period with patients who got specialist care, there was a 26-51 percent recurrence rate. Even with wound healing with no recurrence, patients who had healed ulcers could still complain of functional limitations and pain. Thus the process of patient care route would be more encouraged than just a specialized healing system, Briggs, M. and Closs, S. J. (2003). There is a need for a change of focus that emphasizes how to manage and live with the condition among healthcare workers and the patients. Reduction of pain and improvement of mobility may have a generally positive effect on the rate of wound healing.
This change of emphasis to symptom management rather than just healing has the potential of improving care for the patients that live with chronic leg ulcer conditions and may also improve the rate of healing, Charles, H. (1995).
Diabetic leg ulcer has been shown to have a serious impact on the patients’ life. Pain is the main problem associated with a diabetic leg ulcer but there are reported differences in its severity and prevalence. Other problems associated with diabetic leg ulcers include immobility, lack of energy, sleep disturbance, limitations in leisure and work activities, lack of self-esteem, frustrations and worries, Jeffcoate, W.J and Harding, K.G. (2003).
Problems that are related to the type of treatment administered have also been reported. This may include contradictory and unclear advice given by professionals that the patient cannot follow. Thus its of most importance that nursing practice scope be expanded so as to include patients problems beyond what is commonly considered-compression therapy and wound dressings. Meaningful interventions need to be developed as well as evaluated. Guidelines on diabetic leg ulcers need to be thus adjusted to fit in the expanded scope and focus more on the problems that the patient could be experiencing.
Albrant D.H. (2000). Management of foot ulcers in patients with diabetes. J Am Pharm Assoc; 40(4): 467-474.
Briggs, M. and Closs, S. J. (2003). The prevalence of leg ulceration; a review of the literature. European Wound Management Association Journal 3(2), 14–20.
Charles, H. (1995). The impact of leg ulcers on a patient’s quality of life. Professional Nurse 10(9), 571–572, 574.
Caballero. E and Frykberg R.G. (1998). Diabetic foot infections. J Foot Ankle Surg; 37:248-255.
Cavanagh, P.R., Lipsky, B.A and Bradbury, A.W. (2005). Treatment of diabetic foot ulcers. The Lancet: 366(9498): 1725-1735.
Dyas. A., Boughton, B. and Das B. (1983). Ozone killing action against bacterial and fungal species. Journal of Clinical Pathology; 36(10): 1102-1104.
Jeffcoate, W.J and Harding, K.G. (2003). Diabetic foot ulcers. The Lancet; 361 (9368): 1545-1551.
Michelle, B and Kate, F. (2007). Living with leg ulceration: a synthesis of qualitative research Journal of Advanced Nursing 59 (4), 319–328.