Information
Foot ulceration occurs when there is a breakdown in the integrity of the skin. Risk factors associated with foot ulceration include diabetes, peripheral arterial disease, peripheral neuropathy, foot deformity, poorly fitting shoes or a combination of these. In the presence of diabetes, foot ulceration occurs in 5-7% of the population and is associated with poorer outcomes including infection, amputation and increased mortality.
People with foot ulcers are treated and managed by the Podiatry team throughout NHS Lothian. We see patients in community clinics, in the domiciliary setting and at our diabetic foot clinics at the Royal Infirmary of Edinburgh, Western General Hospital and St John’s Hospital, often in partnership with the community nursing teams.
Any person with an ulcer below the ankle should be referred urgently to the Podiatry team. In the presence of diabetes, referrals should be made directly to the Diabetic Foot Clinics. If diabetes is not a risk factor, referrals should be made to the Community Podiatry team.
Who can refer:
- GP’s
- Consultants and Nursing staff
- Individuals can self-refer
- Family/friends/carers can make a self-referral on behalf of an individual
Who to refer:
Refer any person with an active foot ulcer urgently
If a person has a limb-threatening or life-threatening diabetic foot problem, refer them immediately to acute services. Examples of limb-threatening and life-threatening diabetic foot problems include the following:
- Ulceration with fever or any signs of sepsis.
- Ulceration with limb ischaemia (see the NICE guideline on peripheral arterial disease).
- Clinical concern that there is a deep-seated soft tissue or bone infection (with or without ulceration).
- Gangrene (with or without ulceration)
For all other active diabetic foot problems, refer the person within one working day to the diabetic foot clinic for triage within one further working day
Who not to refer:
- Those with leg ulceration/ ulceration above ankle level
How to refer:
- Non-diabetic foot ulcer – Podiatry Community Clinics via SCI Gateway
- Diabetic foot ulcer – Diabetic Foot Clinics via SCI Gateway
Secondary care HCP’s can refer using the forms available on the Podiatry Website Access to the service (scot.nhs.uk)
Complicating factors of foot ulceration that can be addressed in primary care:
- Poorly controlled diabetes
- Smoking
- High cholesterol
- High blood pressure
- Being overweight/ weight management
- Sedentary lifestyle
If infection is suspected in an active foot ulcer at first presentation whether in primary care or hospital setting, please ensure a tissue/bone sample or swab is obtained prior to prescribing empiric antibiotics.
Any wound should be covered with an appropriate dressing and kept dry until attendance at the podiatry clinic.
Pressure relief of the affected area is essential. This should be maximised at presentation by use of changes to footwear, issue of temporary footwear e.g. Kerraped shoe, or non-weightbearing pressure relief e.g. Prolevo FootSafe Prevention Boot.
Links to the Ropper Ladder Guidelines for managing infected wounds and the Lothian Joint Formulary for guidance on appropriate dressing choices are in the Resources and Links section.
SIGN Guideline – Management of Diabetes: https://www.sign.ac.uk/assets/sign116.pdf
NICE Guideline – Diabetic Foot Ulcers: https://www.nice.org.uk/guidance/ng19/chapter/Recommendations#diabetic-foot-ulcer
NICE Guideline – Peripheral Arterial Disease: Overview | Peripheral arterial disease: diagnosis and management | Guidance | NICE
Antimicrobial Companion: https://www.antimicrobialcompanion.scot/nhs-lothian/body-systems/
Ropper ladder for infected wounds: wounds-scottish-ropper-ladder.pdf (nhs.scot)
Lothian Joint Formulary – Dressing Selection Guide: Necrotic (nhs.scot)
(327) NHS Scotland SoleSafe Instructional Video – YouTube
