Diabetics who smoke cigarettes beware

Smoking releases a molecule known as norepinephrine, which triggers blood vessels to constrict, or narrow. When the already small vessels in the foot constrict, oxygen and the cells that fight infection and aid in healing are unable to reach tissues. Each cigarette smoked has been shown to cause oxygen levels to fall and remain low for 30 to 50 minutes. This is of great concern in those with a foot wound or incision after surgery, in which blood flow and oxygen are vital to skin healing.    

Each cigarette contains more than 4,000 natural and synthetic chemicals. Some of these chemicals include carbon monoxide, methanol (which is found in rocket fuel), ammonia, and nicotine.  Nicotine has been shown to decrease the molecules that are responsible for growth of new blood vessels and development of osteoblasts, or bone building cells. Carbon monoxide further contributes to the decrease in tissue oxygen caused by vessel constriction, by taking oxygen away from the molecule it is normally transported in in the blood. It is for these reasons that quitting smoking is imperative for individuals with foot problems. Studies have shown that there is a 2.7 times higher risk of bone not healing in smokers compared to non-smokers undergoing foot surgery.  

Prior to foot surgery involving bone, smoking should be stopped at least 6 weeks prior to the procedure if possible and then take that opportunity to stop smoking indefinitely. 

In individuals with diabetes or other disorders affecting their blood vessels, smoking is even more dangerous.  Pressure ulcers develop when sensation is diminished and the normal feeling of pain associated with a wound is not present. Tissue healing is impaired and there is a heightened risk of infection developing. Combined with smoking, such risks are furthered increased. Individuals with diabetes who notice a foot wound, whether they are smokers or not, should contact their podiatrist immediately. Early treatment can prevent infection and worsening of the wound that can potentially lead to a need for amputation.  Bill’s story in the smoking ad is a scary one, but by sharing it he may be able to prevent others from suffering a similar fate of amputation. 

Myths about wound care

1) Wound Care Centers are the gold standard for healing all wounds.

All too often we see a wound such as the one pictured above, and as a second or third opinion we need to manage this patient because the wound is not healing. Wound care centers are usually very good at treating superficial wounds, but in the foot and especially in the area of the digits, we find that even a "small superficial dry ulceration of the hallux" can be a surgical emergency because of the proximity of bone and tendon in this area and are often not treated entirely well in a wound care center which is filled with nonsurgical wound care doctors. 

2) Diabetics don't heal well.

This is not always the case in a patient who has a dopplar examination of the lower extremities, and is found to not have any significant vascular disease. If you are eating 3 meals a day, and are not on dialysis chances are you have healing potential and just need better offloading, aggressive surgical debridement, and possibly a localized bone debridement or tendon procedure. We often team up with vascular surgeons, infectious disease doctors, and endocrinology doctors to help achieve optimal conditions to prevent amputations. 

If your foot and ankle wounds are not improved after 4 weeks of care, you need to see a wound care specialist board certified in foot and ankle surgery.



Brian Timm, DPM, FACFAS