What is the best management plan for a 66-year-old male patient with diabetes presenting with bilateral redness on the lateral aspect of both feet, at risk for skin breakdown, who is requesting diabetic shoes?

Management of Diabetic Patient with Bilateral Foot Redness and Risk for Skin Breakdown

For a 66-year-old male diabetic patient with bilateral redness on the lateral aspect of both feet and risk for skin breakdown, therapeutic diabetic shoes with custom-made insoles should be prescribed immediately to prevent ulceration and potential complications. 1

Assessment and Risk Stratification

1. Immediate evaluation:

   • Assess for peripheral neuropathy using 10g Semmes-Weinstein monofilament test
   • Check pedal pulses to evaluate for peripheral arterial disease
   • Examine for foot deformities that may contribute to pressure points
   • Evaluate the redness for signs of pre-ulcerative lesions

2. Risk classification:

   • The patient likely falls into IWGDF risk category 2-3 due to:
     • Presence of pre-ulcerative signs (redness)
     • Risk for skin breakdown
     • Diabetes diagnosis 1

Therapeutic Footwear Intervention

1. Immediate footwear prescription:

   • Prescribe therapeutic diabetic shoes with custom-made insoles that provide at least 30% pressure relief compared to standard footwear 1
   • Ensure proper fitting that accommodates the shape of the feet and any deformities 1
   • Consider extra-depth shoes to reduce pressure on lateral aspects of feet 1

2. Footwear specifications:

   • Shoes should have adequate width and depth to prevent pressure on lateral foot areas
   • Custom insoles should redistribute pressure away from vulnerable areas
   • Consider toe orthoses if toe deformities are present 1

Additional Management Components

1. Treatment of pre-ulcerative signs:

   • Address any calluses through professional removal
   • Protect areas of redness with appropriate padding
   • Consider topical emollients for dry skin 1

2. Patient education:

   • Instruct patient on daily foot inspection
   • Teach proper foot hygiene (daily washing with careful drying between toes)
   • Advise against walking barefoot, in socks only, or thin-soled slippers 1, 2
   • Educate on signs requiring immediate medical attention

3. Follow-up schedule:

   • Schedule follow-up within 1-3 months based on risk level
   • Evaluate effectiveness of prescribed footwear
   • Assess for any progression of skin breakdown 1

Monitoring and Prevention

1. Consider home temperature monitoring:

   • Coach patient to monitor foot skin temperature daily
   • Instruct to reduce activity and seek care if temperature difference between corresponding regions exceeds 2.2°C for two consecutive days 1

2. Offloading strategies:

   • If redness persists despite footwear intervention, consider additional offloading methods
   • For severe cases, temporary use of removable walking boot may be necessary 3

Common Pitfalls to Avoid

1. Delayed intervention:

   • Do not delay prescription of therapeutic footwear while waiting for complete assessment
   • Early intervention is critical to prevent progression to ulceration 1

2. Inadequate footwear:

   • Avoid prescribing standard diabetic shoes without custom modifications
   • Ensure footwear provides demonstrated pressure relief, not just accommodation 1, 4

3. Poor adherence:

   • Address potential barriers to wearing prescribed footwear, especially at home
   • Emphasize importance of wearing therapeutic shoes at all times when weight-bearing 4

4. Neglecting follow-up:

   • Ensure regular reassessment of foot condition and footwear effectiveness
   • Adjust treatment plan based on patient response 1

By implementing this comprehensive approach with immediate prescription of appropriate therapeutic footwear, the risk of ulceration and subsequent complications can be significantly reduced in this patient with diabetes presenting with bilateral foot redness.