What should a diabetic patient do if they have red spots on their toes and fingers that turn black and hard?

Urgent Medical Evaluation Required for Suspected Digital Ischemia and Gangrene

This patient requires immediate vascular assessment and urgent referral to a vascular surgeon or multidisciplinary diabetic foot team, as red spots turning black and hard on the toes and fingers strongly suggest digital ischemia progressing to dry gangrene, which is limb-threatening and potentially life-threatening. 1

Immediate Actions

Stop Walking and Protect the Affected Areas

• The patient must immediately cease all weight-bearing activity on affected feet to prevent further tissue damage and progression of ischemia 1
• Use crutches or wheelchair for mobility if lower extremities are involved 1
• Do not walk barefoot, in socks only, or in thin-soled slippers under any circumstances 1

Emergency Vascular Assessment Required

• Urgent vascular imaging and revascularization should be considered immediately if ankle pressure is <50 mmHg or ankle-brachial index (ABI) is <0.5 1
• Palpate pedal pulses bilaterally and assess for signs of peripheral artery disease (PAD) 1
• Measure toe pressure; if <30 mmHg or transcutaneous oxygen pressure (TcpO2) <25 mmHg, revascularization should be strongly considered 1
• The presence of black, hard tissue indicates dry gangrene from severe ischemia requiring immediate specialist evaluation 1

Critical Diagnostic Evaluation

Determine the Type of Lesion

• Classify whether this is purely ischemic, neuropathic, or neuro-ischemic through history and clinical examination 1
• Ischemic ulcers/lesions are more common on the tips of toes and lateral borders of the foot, which matches this presentation 1
• Do NOT debride necrotic tissue in non-infected lesions with signs of severe ischemia until vascular status is assessed and treated 1

Assess for Infection

• Examine for signs of deep infection including fever, purulent drainage, erythema extending beyond the lesion, warmth, and systemic signs 1
• If deep (potentially limb-threatening) infection is present, urgently evaluate for surgical intervention to remove necrotic tissue and drain abscesses 1
• Initiate empiric parenteral broad-spectrum antibiotic therapy if moderate or severe infection is present, targeting gram-positive and gram-negative bacteria including anaerobes 1

Specialist Referral Pathway

Immediate Referral Indications

• Refer immediately to a vascular surgeon for patients with acute limb-threatening ischemia 2
• The aim of revascularization is to restore direct flow to at least one of the foot arteries, preferably the artery supplying the anatomical region of the wound 1
• If contemplating major (above ankle) amputation, first consider revascularization options 1

Multidisciplinary Team Involvement

• Foot ulcers and severe ischemic lesions require care by a podiatrist, orthopedic or vascular surgeon, or rehabilitation specialist experienced in diabetic foot management 1
• Timely referral to a foot care specialist is critical for patients with high-risk conditions 1

Risk Factor Modification

Cardiovascular Risk Reduction

• Emphasize immediate smoking cessation as smoking is a major risk factor for peripheral vascular disease 1, 2
• Control hypertension and dyslipidemia aggressively 1
• Initiate aspirin or clopidogrel for antiplatelet therapy 1

Glycemic Control

• Maintain blood glucose levels as near normal as possible to prevent progression of neuropathy and vascular disease 1

Common Pitfalls to Avoid

• Never debride black necrotic tissue in ischemic lesions before vascular assessment and revascularization, as this can worsen tissue loss 1
• Do not delay referral waiting for "conservative management" when digital gangrene is present—this is a vascular emergency 1
• Pharmacological treatments to improve perfusion have not been proven beneficial; revascularization is the definitive treatment 1
• Do not assume absence of pain means the condition is not serious—diabetic neuropathy can mask severe ischemia 1
• Avoid footbaths or soaking feet, as this induces skin maceration and can worsen the condition 1