A stubbing problem

April 18, 2005|by JULIE E. GREENE

Usually when you've got a pebble in your shoe or you stub your toe, you react immediately.

There's an "Ouch!" and you take the shoe off to shake the pebble out or hop around on your good foot repeating "Ow. Ow. Ow. Ow. Ow."

That's not necessarily the case with diabetics who lose feeling in their feet.

A simple pebble or stubbed toe easily could lead to a foot ulcer or hole in the foot that becomes infected, said Dr. Daniel Michaels, a podiatrist and foot surgeon with Reconstructive Foot & Ankle Institute LLC in Hagerstown and Frederick, Md.

In some cases, such an ulcer, without proper, timely treatment, can lead to amputation, Michaels said.

That was almost the case for southern Washington County resident Doris Elaine Coulter.

Michaels used a fairly new product called Dermagraft to help heal Coulter's big toe.

Dermagraft is a patch of living dermal cells grown in a lab from newborn foreskin that was circumcised, said Carol Gray, advanced technology manager for Smith & Nephew Wound Management, which makes Dermagraft.


One foreskin can grow six football fields of the specialized skin graft, she said. The skin that results is like a person's dermal layer, the red skin underneath the epidermis, she said. A 2-inch-by-3-inch piece costs $562.

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A product like Dermagraft was first researched for burn victims, but companies found there was a large market for people with diabetic foot ulcers, said Dr. Dale Herman, a podiatrist with Podiatry Associates of Hagerstown.

Michaels said he sees five to 10 patients with diabetic foot ulcers a day and Herman sees four or five a week.

The Maryland Department of Health & Mental Hygiene estimates 9.6 percent of Washington County residents, or 12,928 residents, had diabetes in 2002, spokesman John Hammond said.

The high blood sugar diabetics have can lead to a weak immune system, poor blood flow and neuropathy, which is when the nerves stop working, Michaels said. These conditions can lead to foot ulcers.

Coulter's story

Coulter, 70, of Yarrowsburg, used to walk barefoot around her house and yard until last summer when she noticed something unusual on her left foot.

Although she felt no pain due to her diabetic neuropathy, Coulter said she noticed her toe had turned a blackish purple. In the next few days, the bruise got darker, leading her to point it out during a doctor's appointment. That wasn't the doctor's specialty, but the doctor told her to seek treatment immediately.

She saw a couple of doctors, including Michaels.

Antibiotics were clearing up the infection, but a hole the size of a quarter had developed in her toe, Coulter said.

Michaels operated, cutting the tendon to relieve pressure.

He also tried rebuilding the skin using a product based on skin from a cadaver a couple of times, he said.

It was when Michaels used Dermagraft that they saw dramatic improvement in Coulter's foot ulcer.

The procedure cost about $1,300 a treatment and she has received eight treatments, Coulter said. Almost a year later, the wound is close to healed.

Michaels and Coulter said she was in danger of having her toe amputated.

Few diabetics require amputations, but Michaels said it seems like a higher percentage of diabetics in this area end up with amputations.

Technological advances

Treatment options have increased substantially in the last five to six years for diabetic foot ulcers, said Herman, who's been treating those types of wounds the entire 27 years he's been in practice.

Before the more technological treatments, Herman said the way to treat diabetic foot ulcers was to get a patient's weight off the ulcer using a cast or special shoe.

The wound is debrided - or dead tissue is cut away - the doctors said.

Then the doctor works with the patient to get the infection and the diabetes under control to provide the best environment for the body to heal itself, Herman said.

Specialized skin grafts aren't needed every time, Herman said.

Beyond the basic approach, there are a variety of more technological treatments, Herman and Michaels said.

One class of drugs is designed to stimulate the body to grow granulation or filler tissue, Herman said. The drug, called becaplermin, is a gel applied in a thin layer into the ulcer.

If becaplermin doesn't work, a matrix stimulator could be used, Herman said.

Similar to a trellis for roses, a matrix stimulator is a dissolvable matrix that encourages the growth of granulation tissue and gives the tissue something to hang onto and fill in the wound, Herman said.

If that doesn't work, Herman said he uses Dermagraft, which he prefers over Apligraf. Apligraf doesn't always have to be sutured to the wound, but usually works better when it is, he said.

Apligraf is a bilayered skin substitute with the lower dermal layer containing bovine collagen and human dermal cells, according to on the Web.

Dermagraft is strictly dermal tissue and is naturally sticky so it adheres to the wound, Herman said. A patient doesn't have to go to the operating room to have it applied.

Herman said the wound usually heals quicker with Dermagraft, which stimulates tissue growth.

"The technology's really blossomed in the past five or six years," he said.

If you go ...

WHAT: America's Walk for Diabetes

WHEN: Saturday, May 21. Registration is from 8:30 to 9:45 a.m. The walk starts at 10 a.m.

WHERE: Veterans Affairs Medical Center, 510 Butler Ave., Martinsburg, W.Va.

DIRECTIONS: From Hagerstown, take Interstate 81 south to exit 12. Turn left onto W.Va. 9. Go 4 1/2 miles. The VA Medical Center is on the left, near a traffic light.

For more information, call 1-888-342-2383 or

1-304-768-2596 or visit on the Web.

In the know

For more information about diabetes, visit the American Diabetes Association at on the Web or call 1-800-DIABETES


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