LAUSR

In a recent issue of the Annals of Medicine, Zhang et al. published a meta-analysis on diabetic ulcer prevalence based on 67 papers. In total, an impressive number of more than 800 000 subjects from 33 countries were included in this meta-analysis, making it one of the largest analyses of this kind. Beyond doubt, diabetes mellitus type 2 (DM2) is one of the epidemics of the dawning millennium. Some predictions say that one out of 10 people will be diagnosed with DM2 by mid-century. One of the major complications of DM is the development of chronic distal ulcers. As wound healing is an orchestrated process, a plethora of factors must be considered for chronic wounds in DM: impaired angiogenesis, reduced growth factor expression, altered signalling via RAGES (receptors of advanced glycation end products), increased inflammation at ulcer margins as well as reduced cell proliferation and centripetal cell migration. Obviously, most of this is also true for chronic wounds with different pathophysiological backgrounds. Despite multiple molecular targets, the key clinical point when treating diabetic ulcers is pressure reduction. This can be done with total (nonremovable) contact casts, cast walkers and (removable) foot pads. However, besides being a burden for patients, chronic wounds are among the most important cost drivers of today’s healthcare systems. In 2004, 12 billion USD were spent on the treatment of chronic wounds, twice as much as for dermatological cancer therapies (melanoma and nonmelanoma skin cancer) taken together. In 2006 about 30% of the total costs in dermatology were spent on treating wounds. However, this percentage is decreasing due to the high cost of novel anticancer therapies in dermatology (e.g. BRAF, CTLA4 and PD1 inhibitors). A recent study from a department of vascular surgery in New Zealand has estimated the minimum median cost for treating a diabetic foot to be 30 000 NZD. Lack of physical activity and bad diet have both contributed to the rising prevalence of DM2 and spiralling costs. In the U.S.A., the cost of diabetes has risen from 174 billion USD to 245 billion USD in only 5 years (2007–12). In New Zealand, this number has increased from 247 million NZD (2001) to 600 million NZD (2008) and is anticipated to reach 1 3 billion NZD this year. Data from the U.K.’s National Health Service (NHS) show that more than 2 million wounds were treated in 2012 and 2013. The respective annual NHS cost totals around 5 billion GBP, about the same amount needed to take care of all obesity-related diseases, DM2 and diabetic ulcers being among these problems. Unfortunately, about 30% of these wounds were not clearly classified pathophysiologically, as wound treatment is a largely nurse-led discipline. Zhang et al. identified a striking difference in the prevalence of diabetic ulcers between Europe (5 1%) and North America (13 0%). Of all countries analysed, Belgium had the highest prevalence with 16 6% and Australia had the lowest with 1 5%. Overall, diabetic ulcers were more frequent in men than in women (4 5 vs. 3 5%), and were seen more often in patients with DM2 compared with patients suffering from DM1 (6 4. vs. 5 5%). The findings from Zhang et al. make for depressing reading for dermatologists, who are sure to be seeing more diabetic ulcers in their clinical practice. Zhang et al.’s paper highlights the importance of preventive strategies and lifestyle changes (diet, exercise, etc.) to guard against the development of DM2 and subsequent diabetic ulcers. This is not only essential for patients, but also for governments to keep healthcare costs under control. Although some countries have a far higher prevalence of diabetic ulcers, the exact reasons for these differences remain to be elucidated. In conclusion, diabetic ulcers are challenging and require treatment by multidisciplinary teams including specialists from internal medicine, vascular surgery, dermatology, dietetics and podiatry. However, the bottom line is that prevention of diabetic ulcer development is by far the best management option. Dermatologists must therefore add their voices to those advising governments across the world on healthcare policy in this area. Populations in developed countries must stop being lazy: this means regular exercise for all and a switch to a healthier (sugar-reduced) diet.