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A Pedicurist's Education in Diabetes

• Written by Godfrey F. Mix, DPM via Nail's Magazine

Diabetes is a very serious, and very common, disease. Before providing foot care to a diabetic client, know what to look for and what questions to ask.

Have you ever looked into the reasons why you should or should not give foot services to the diabetic? “Is it safe to give a pedicure to a diabetic client?” “Can I ever give a pedicure to a diabetic client?” These are questions I am asked when I lecture at various trade shows. I will discuss what to look for in your diabetic clients that will enable you to service selected individuals safely and professionally.

First of all, a few words of caution: If you question doing a foot on a diabetic client, do not perform the service. Refer the client on to her podiatrist or physician for care. In past articles I have stressed the importance of developing a close working relationship with a podiatrist. It is extremely important that you have done this if you give foot services to selected diabetic clients. Prevention is the key word for the diabetic.

It is estimated that one out of every 20 people in the United States are diabetic. Diabetes is the result of the body’s inability to utilize blood sugar (glucose) because of a decrease in insulin production. Insulin is the key ingredient necessary to allow glucose to transfer from the bloodstream into the surrounding cells, where it is utilized for energy. Without insulin, the blood sugar becomes elevated and results in diabetes.

The primary cause of diabetes is a genetic or inherited trait that stops the production of insulin by the pancreas. Secondary causes are injury to the pancreas through excessive use of alcohol or an actual infection of the pancreas. Some drugs such as water pills (diuretics), cortisone, and some blood pressure medications may reduce the production of insulin. In rare instances, pregnancy may cause a resistance to one’s own insulin resulting in a diabetic condition. This resistance reverses after the birth of the baby.

There are two categories of diabetes. The first is Type I, or Insulin Dependent Diabetes. Type I was formerly called Juvenile Diabetes, but the name was changed because approximately 30% of this group is diagnosed after the age of 30. Type I diabetes is characterized by a sudden onset, with the symptoms being present for only a few days or weeks. Excessive urine production, thirst, and food intake are classical symptoms. Sudden weight loss is often also associated with this form of diabetes. Type I diabetics have to take insulin supplements to live.

The second category of diabetes is Type II, or Non-Insulin Dependent Diabetes. This was previously referred to as Adult Onset Diabetes. This type generally occurs in individuals over the age of 30, with the average age of diagnosis being between 60 and 65. Type II diabetes is characterized by a very slow onset of symptoms. In some individuals, the disease may be present as long as 10 years before a diagnosis of diabetes is made. The first sign of the disease may be an actual complication of the disease process itself. I remember one patient I had who presented with a large, painless infected ulcer on the bottom of his foot. You nor I could have walked on our foot if it was in this condition. Subsequent laboratory tests proved this patient to be a Type II diabetic. This patient must have been a diabetic for some time. Without first controlling his diabetes, the ulcer would have never healed no matter what treatment I provided.

Many individuals with Type II may be classified as obese, while Type I individuals are generally the opposite. Type II diabetics produce insulin, but for an unknown reason their body has developed a resistance to it. Diet, exercise, and oral medications can control the blood sugar in this group of diabetics. Some Type II diabetics will become Type I as their disease progresses.

Poor circulation is one of the major complications of diabetes. The intermediate-size arteries (arterioles) are most involved in this complication. Since the majority of the arteries in the lower leg and foot fall in this category, many severe problems arise here. High blood sugar levels improperly nourish the nerves, injuring them and resulting in decreased sensation, particularly in the feet. Over forty thousand lower extremity amputations a year, which are not a result of injury, are caused by diabetic complications. This is almost one-half of all non-injury amputations of the leg in the United States!

Poor circulation and the lack of sensation result in many skin problems in the diabetic. One third of all diabetics will have some skin-related condition during their life-time. Because of fluctuations in the blood sugar levels, the small blood capillaries in the skin are easily injured. Additionally, the production of natural skin lubricants from the glands in the skin is reduced or may even cease. All this results in dryness, cracking, and itching. Susceptibility to skin infection increases. The diabetic can not fight infections well because the disease reduces the effectiveness of the white blood cells role in destroying bacteria. Thus any minor skin irritation or injury has the potential of becoming a severe life threatening condition.

Now that you have a basic understanding of diabetes and some of the fundamental problems associated with the disease, you may be saying you’d never consider giving a foot service to a diabetic. But you may already be doing it and not even know it! This disease may be present for many years before it is diagnosed. As a nail professional who gives foot service, you must be on the lookout for any signs of this disease. You may be the first one to suspect that your client is a diabetic! If you do suspect a problem, refer the client to her physician for a medical evaluation. Do not be afraid you might be wrong. In this case it is better to be safe than sorry.

When can the well trained knowledgeable nail professional provide foot services to the diabetic client? Only when you can be certain that the service you provide will not harm the client.

To ensure your foot services won’t harm your client, you must be knowledgeable about the client both medically and as an individual. Gain this knowledge by doing a “History and Personal Evaluation” of each client. A few well-thought-out questions and visual observation the client will help you make a decision on what, if any, services to provide.

If the client is a known diabetic you want to know:

1. Does she smoke? Does she drink alcoholic beverages? A diabetic should do neither of these. Nicotine in cigarettes contributes to hardening of the arteries, adding to the diabetic arterial disease process. Alcohol, on the other hand, is converted to sugar, increasing the blood sugars and adding to the diabetic process. An occasional drink is not a bad thing; daily consumption of alcoholic beverages is what you are concerned about. If the client answers yes to either of these questions refer her to a podiatrist for foot care.

2. How long has she been a diabetic? This question will tell you a lot about her disease. Generally, the longer a person is a diabetic the more severe are the complications of the disease. As a general statement, long-term diabetics should be referred to a podiatrist for foot care.

3. What do her blood sugars generally “run”? This is an important question for two reasons. First, if she doesn’t know you should not provide services, because she is probably in denial about her disease. A diabetic must know what her blood sugar levels are in order to keep them within the limits prescribed by her doctor.

Secondly, by knowing what her “blood sugars run,” you’ll get a basic idea of the severity of her diabetes. Normal blood sugar levels are between 70 and 120; if she tells you her sugars run routinely between 250 and 300, you’ll know she’s not a good candidate for a pedicure. With levels that high, either this client is a very severe diabetic or she does not follow her doctor’s instructions about diet, exercise, and medications. In either case, you should not service that client. In the absence of other negative findings, diabetics whose blood sugars average below 150 can receive gentle, conservative foot service.

4. Is her blood sugar controlled through diet, exercise, medication (oral or injections), or a combination of these three? A diabetic whose disease is controlled through diet and exercise may receive foot services unless she has any open wounds or infections. An oral-medication-controlled diabetic may receive foot services only after answering all the above questions positively. Type I or Insulin Dependent diabetics should be referred to a podiatrist for foot care. The podiatrist may evaluate her and send her back for selected foot services to be provided by you. Only with written instructions from the podiatrist should you provide the care.

5. Once you’ve gathered her history, you need to do a “personal evaluation” of the client. You need to check the skin, the circulation, and the sensation of the lower extremity.

The skin should have no open wounds, ulcers, or infections present. It should be pliable and fairly normal in appearance. Remember, thin, fragile skin is easily injured, which in the diabetic may lead to severe consequences.

Evaluate the circulation by feeling the pulses in the foot (if you do not know how, learn before giving any foot services). You should at least be able to feel them. The extremity should be warm and have a good coloration. Is there hair on the extremity? The absence of hair growth may indicate a severe circulatory disorder. If the skin becomes discolored (bluish or deep reddish) when it is on the floor, this indicates extremely poor circulation. Thin, fragile skin and a lack of underlying fatty tissues also indicate extremely poor circulation.

Does the client have normal feeling in her feet? A rough test for this is to lightly rub your fingertip over the bottom of the foot and then do the same on the palm of the hand. If there is a difference in sensation between the two, you should refer the client for medical evaluation before doing a service.

The “History and Personal Evaluation” described above is very limited, but it should give you an insight as to whether or not to provide services to a diabetic client. Your findings should all be within the normal limits I have outlined. If you have any question, provide services only after discussing the client’s condition with her podiatrist or medical doctor.

A pedicure when provided to a selected diabetic should be gentle and given with extreme care. Do not use hot water, body temperature to 100 degrees Fahrenheit is a satisfactory range. For some reason, we Americans think the hotter the better when soaking the feet. The “Rule of Thumb” should be if you would not put the rest of your body in the hot water then DO NOT put your feet in it!

Trim the nails carefully; straight across is best. If the corners need to be removed, refer her to a podiatrist for this procedure. Do not push the cuticle back as this may cause injury, which can result in an infection. When filing the nails, be extremely careful not to abrade the skin and cause an opening for an infection.

Sloughing creams should also be used with great care for the same reasons. Select and recommend moisturizing creams that will be beneficial to the dry skin that is part of the diabetic condition. Use a gentle massage technique; do not be rough.

Use a disinfectant on the foot before and after the service. Last, but by far from least, have good sanitation procedures in place for your salon and practice them religiously.

Be alert for the subtle signs of diabetes. In the new age of managed medical care you will be seeing more diabetic pedicure clients as insurance companies deny “routine foot services” as a benefit.

It is therefore necessary that you be more knowledgeable about conditions that can affect the foot.

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