9.5 Annual Screening and Treatment of Pre-Ulcerative Signs

Who Is Screened and How Often

Every person with diabetes should receive a comprehensive foot evaluation at least annually. The interval shortens when loss of protective sensation (LOPS), PAD, deformity, end-stage kidney disease, prior ulcer, or amputation raises risk. Under the IWGDF system, risk 0 is screened annually; risk 1 generally every 6 to 12 months; risk 2 every 3 to 6 months; and risk 3 every 1 to 3 months. These are integrated-care intervals, not a promise that a patient will remain safe until the next appointment.

The screen starts with history: previous ulcer or amputation, Charcot disease, vascular intervention, smoking, kidney disease, neuropathic symptoms, current foot problem, ability to inspect and care for the feet, and actual footwear use. Ask about walking barefoot, burns, falls, activity change, and any new red area, blister, callus, fissure, drainage, or nail problem.

Examination Components

Inspect dorsal, plantar, heel, interdigital, and nail surfaces. Look for dryness, maceration, fissure, callus, subcallous hemorrhage, blister, corn, deformity, edema, pressure erythema, ulcer, fungal disease, and nail-fold inflammation. Examine foot shape and joint mobility, especially prominent metatarsal heads, hallux limitation, claw or hammer toes, prior amputation, and Charcot change. Evaluate the shoes and insoles for fit, depth, seams, foreign bodies, wear, compression, and whether they are used indoors as well as outdoors.

Palpate pedal pulses and assess vascular symptoms and skin clues. An abnormal history, absent pulse, ulcer, gangrene, or nonhealing lesion calls for objective perfusion evaluation; palpation alone cannot exclude PAD. Neurologic screening includes a 10-g monofilament plus at least one other test, such as vibration with a 128-Hz tuning fork, pinprick, temperature sensation, or ankle reflex. Follow the selected protocol and test enough sites to avoid labeling LOPS from one inattentive response. At a tested site, repeated correct and incorrect responses distinguish perception from guessing.

Treating Pre-Ulcerative Signs

Prevention is active care. A dark hemorrhage within callus may hide tissue injury. A trained professional reduces callus when safe, inspects the underlying skin, and offloads the site. A blister is protected from further friction; the roof is generally preserved when intact, with drainage decisions based on size, location, infection risk, and clinical technique. A fissure is protected and surrounding dry skin moisturized while heel stress and infection are addressed. Corns and pressure erythema trigger shoe and deformity correction.

Thick nails are reduced safely when they cause shoe or adjacent-toe pressure. An ingrown margin or paronychia is treated according to inflammation, abscess, infection extent, perfusion, and recurrence. Tinea pedis and onychomycosis are managed to reduce fissuring and nail pressure, with diagnostic confirmation when systemic nail therapy is considered. Patients with neuropathy or PAD should not use chemical corn removers, blades, or heating devices.

A pre-ulcerative sign is a time-sensitive warning, but not every finding requires an emergency department. Same-day or urgent escalation is appropriate for spreading infection, wet gangrene, new necrosis, severe ischemic symptoms, a hot swollen neuropathic foot suspicious for Charcot disease, deep tissue exposure, or systemic illness. Lesser findings still receive a defined appointment and action rather than “watch and wait” without protection.

Integrated Foot Care

For moderate or high risk, prevention combines trained foot care, appropriate footwear or orthoses, structured education, and regular review. A person with deformity or pre-ulcerative signs may need extra-depth or custom options. A person with a healed plantar ulcer should receive therapeutic footwear whose pressure-relieving effect has been demonstrated and should use it consistently. Footwear is reassessed because materials compress and feet change.

Education is practical: inspect all surfaces daily using a mirror or helper, wash and dry carefully, moisturize dry intact skin but not between toes, never walk barefoot, check shoes before wearing, and seek help promptly for a lesion. Teach-back and demonstration are more reliable than handing out a brochure.

Closing the Loop

Document risk category and the findings that support it. For each abnormality, record the intervention, who will perform it, the follow-up interval, and what triggers earlier contact. Communicate with primary care, podiatry, vascular, diabetes, rehabilitation, or footwear professionals as needed. Screening prevents ulcers only when detection leads to effective care and the patient can access and follow the plan.

Example of a Closed Prevention Loop

A new dorsal-toe red mark should generate more than “monitor.” Document the matching shoe contact, protect the skin, modify or replace the footwear, set a short review interval, and tell the patient which change requires same-day contact. At review, confirm that the mark resolved and that the new accommodation did not shift pressure elsewhere. This detection-action-verification loop is the practical purpose of surveillance.

Risk-Based Surveillance

A new lesion overrides the routine interval and is evaluated sooner.