Diabetic Pedicure with a Cracked Heel
A 68-year-old man with type 2 diabetes of 12 years books a pedicure before his grandson's wedding. He takes warfarin and his last HbA1c was 8.9%. He has reduced sensation in both feet and cannot feel the therapist's light touch on several toes. The right heel has a 1 cm fissure, and both feet have thickened nails and hard callus. He asks for the callus to be shaved with a blade and the cuticles cut, because "that is what the last salon did". He has no current ulcer and no foot pain. He has brought his own nail clippers but wants to use the salon's nippers as well.
1. Which parts of the requested pedicure can and cannot be carried out? Justify your answer.
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The blade cannot be used on the callus and the cuticles should not be cut. This client has diabetes with reduced protective sensation, poor glycaemic control and a heel fissure - a combination that raises the risk of infection, ulceration and poor healing. A blade can easily cause a laceration that he may not feel. Cutting cuticles breaks the seal around the nail and creates an entry point for bacteria. Warfarin also increases bleeding risk if the skin is nicked.
Gentle soaking, cleansing, filing of the nails with a single-use file, and application of an emollient around the fissure may be acceptable if the skin is intact and the therapist works within scope. Do not thin the nails aggressively, do not probe the fissure and do not apply moisturiser between the toes. If there is any doubt about tissue viability, stop and refer.
2. What referrals and record-keeping should be arranged?
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Refer him to a podiatrist for assessment of the fissure, callus and loss of sensation, and to his GP or diabetes team about his HbA1c and foot care. A simple light-touch check is not a substitute for a formal monofilament or vibration test. Document the sensory findings, the fissure, the warfarin use, the refused procedures, the services actually provided and the advice given. Record that he was told not to use blades or corn plasters at home.
Obtain informed consent for what can be done and explain why the blade and cuticle cutting are being refused. If the salon cannot provide single-use files or validated disinfection, do not proceed with reusable implements.
3. What aftercare advice should he receive, and how would you explain the risk without alarming him?
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Explain that diabetes can reduce feeling in the feet, so a small cut may go unnoticed and become an ulcer. Use plain language: "Your feet do not feel small injuries as well as they used to, so we avoid anything that can break the skin." Advise daily foot checks, including between the toes, and ask a family member to help if he cannot see the soles. Recommend well-fitting footwear, no barefoot walking, and an emollient for dry skin, avoiding the toe webs.
He should not cut calluses or corns himself, should not use medicated plasters, and should report redness, warmth, swelling or a new break in the skin promptly. Suggest a podiatry review before the wedding if possible. Give written advice and record that it was given.