William Lear, MD, FRCPC, FAAD, Dermatologist, Silver Falls Dermatology PC, Salem, OR, USA.
Jennifer Akeroyd, RN, PhD student, Oregon Health & Science University, Portland, OR, USA.

In this article, we discuss skin findings affecting older adults, with a focus on pruritus, flushing, dermatitis, and ulcers, and consider related internal diseases. Our goal is to make this information readily transferable to the clinical setting for the non-dermatologist.
Key words: dermatology, skin manifestations, older adults, pruritus, flushing, dermatitis, ulcers.

Robert J. Hinchliffe, MD, MRCS, Clinical Lecturer in Vascular Surgery, St George’s Regional Vascular Institute, St George’s Hospital and St George’s University of London, London, UK.
William Jeffcoate, FRCP, Professor, Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, Nottingham University Hospitals, City Hospital Campus, Nottingham, UK.

Individuals with ulceration of the foot should be identified and referred urgently to a specialist. Unfortunately there is little formal health care education in diabetic foot ulceration and often no specialist referral pathway. We discuss the common modes of presentation of patients with diabetes and foot ulcer. The clinical implications of a range of symptoms and signs will be explained, including the most common diagnostic pitfalls in everyday primary care practice.
Key words: diabetes, peripheral vascular disease, ulcer, vascular surgery, peripheral arterial disease, diabetic foot.

Madhuri Reddy, MD, MSc, FRCPC, Assistant Professor, Department of Medicine,
University of Toronto, Associate Editor, Geriatrics & Aging, Toronto, ON.

R. Gary Sibbald, BSc, MD, FRCPC (Med), FRCPC (Derm), MACP, DABD, Associate Professor and Director of Continuing Education, Department of Medicine, University of Toronto, Toronto, ON.

Prevention of diabetic foot wounds is of crucial importance. Diabetic foot wounds are basically pressure ulcers due to improper footwear, and therefore the most critical aspect of prevention is wearing proper shoes, checked regularly by a reputable orthotist. Once foot wounds have occurred in a person with diabetes, proper footwear continues to be
crucial. Also of importance are adequate vascular supply, treatment of infection, and surgical debridement, if necessary. All diabetic foot wounds should be probed in order to evaluate depth. If the wound probes to bone, osteomyelitis should be presumed unless proven otherwise.

Key words: diabetes, wounds, ulcers, vascular, infection.

Prevention is the Best Form of Care

Madhuri Reddy, MD, Dermatology Day Care (Wound Healing Clinic) Sunnybrook and Women's College Health Care Centre, Toronto, ON, Associate Editor, Geriatrics & Aging.

R. Gary Sibbald, BSc, MD, FRCPC (Med), FRCPC (Derm), MACP, DABD,
Associate Professor and Director of Continuing Education
Department of Medicine, University of Toronto, Toronto, ON.

Introduction
The most common reason for hospitalization of individuals with diabetes is a foot wound. Persons with diabetes are forty times more likely than are non-diabetics to have a non-traumatic amputation, and the most common precipitating events are infection in a non-healing ulcer and gangrene. Those who undergo a lower-extremity amputation have a 50% chance of amputation in the contralateral limb within five years.¹

The systemic nature of diabetes requires a team approach, involving wound care specialists (e.g. physicians, nurses) and foot care specialists (e.g. chiropodists, podiatrists, occupational therapists, pedorthists). Prevention of ulcers is the best form of care for the diabetic foot. Teaching prevention should occur in the setting of comprehensive diabetic care.