La escuela como espacio de aprendizaje en la educación en valores y el encuentro

Foot abnormalities are structural deformities of the feet that cause an increase in foot pressure. Foot abnormality is one of the initiating factors for DFU and ‘harmattan’ skin cracks are particularly important causes in the tropics. ⁵²

Various foot abnormalities were significantly more prevalent in the cases of DFU, most especially so, presence of dry cracked skin of lower limb;

this finding is in consonance with reports of similar studies among Nigerians. ^{113, 119} In particular, Ikem et al, reported that a myriad of

foot/skin lesions such as dry skin, callosity, fungal infection, paronychia, hyperpigmentation, yellow nails, cracked skin, ulcers, corns etc were present among patients with DM and symptomatic peripheral neuropathy compared with asymptomatic and apparently healthy individuals. It also reported that similar foot/skin problems have been previously described among European patients with DM and in indigenous Tanzanians. ¹¹³ However, there are other reports that suggest that cracked skin, calluses and fissures are less common among African patients compared to European patients with DM. ¹¹⁶

Dry skin, resulting from absence of sweating, predisposes to pruritus, a known presenting symptom of diabetes. Dry skin also cracks easily especially when scratched (pruritus); skin and plantar cracks are particularly prone to ulceration and superimposed bacterial infections and subsequent DFU. In addition, fungal infections of skin and nails are often associated with poor glyceamic control, which is itself a risk factor for peripheral neuropathy. ¹¹³

Furthermore, hyperhydrosis due to autonomic neuropathy make the feet conducive for fungal infections especially in the patient with DM as fungi thrive best in moist areas. Sensori-motor neuropathy, which may result in imbalance of internal musculature and poor standing posture coupled

with ill-fitting shoes, can cause callosities and neuropathic foot ulcers. ¹¹³ Thus foot abnormalities other than foot ulcers may occur in patients with DM and symptomatic peripheral neuropathy. Awareness of these skin and foot lesions and their sequelae, with prompt initiation of measures to limit disability may prevent limb losses/foot deformities and should be

emphasized. In this regard, the need for foot care education and frequent limb inspection can never be over emphasized. Moreover, these foot lesions may also serve as markers for the presence as well as severity of peripheral neuropathy.

In terms of pattern of footwear, a high percentage of study subjects (84.1%) used inappropriate footwear (slippers/slip-on type of foot wear) at the time of examination. This compares with a previous study among Nigerians that also reported high percentage of use of flat heeled slippers (78.1%) among its study subjects. ¹¹³

Furthermore, only one (0.9%) individual among the cases wore shoes compared with ten (8.5%) among the control subjects. This finding is discordant with earlier studies from this environment that reported frequencies of shoe wearing to vary from 12.5% to 37.9%. 113, 119

This may be due differences in study design, the latter being a retrospective study; or may in fact reflect differences in timing of the various studies resulting in variation in outdoor foot wear practices in relation to different weather conditions which may vary from hot and

humid to cold and dry. Although, the latter study was reported three decades ago, the high percentage of shoe wearing at that time may reflect the educational and socioeconomic circumstance of subjects using the facilities of the study center at that time compared to now. It may also be a hangover of the dressing pattern from the colonial era.

The low rate of shoe wearing among the study subjects is significant, as wearing of adequate and suitable shoes offer some protection against the development of DFU, especially in persons with insensitive feet due to Peripheral neuropathy. ⁷⁸

A statistically significant number of subjects with DFU compared with control subjects wore ill-fitting footwear in terms of depth and accommodation of the foot (23.1% vs. 14.5%, p= 0.003); this is important since inappropriate footwear is reported to be a major cause of foot ulceration and its use may actually initiate the pathway to lower extremity amputation in up to 50% of patients. ^{62, 100}

Thus, the increase in the use of footwear (at least within the hospital environment), comparing the present study subjects with the previous ones, has not translated to a reduction in the prevalence of DFU in this environment.

However, none of the ambulant subjects was seen without footwear. This is in consonance with a previous study among Nigerians that reported that none of its study subjects walked outdoors without

footwear although 10 (15.6%) patients admitted to not using footwear at times when indoor. ¹¹³ It is however, a departure from a previous hospital-based survey from the same center as the current study, conducted about 2 - 3 decades earlier, that reported ‘a high percentage (80%) of subjects were illiterate who often went about their daily activities without any footwear’. 52, 111, 119 It also contrasts sharply with a widely held notion that walking barefoot is a common practice in Africa.⁵¹

This discrepancy in the literature is probably related to improved educational, social and economic status of the people over the time period, or may in fact reflect different foot wear habit of subjects within and outside the home environment.

5.3.6. Laboratory Parameters