In our latest episode of “What’s Up Doc,” we had the pleasure of speaking with Him Shun Kei, a diabetic foot specialist and podiatrist in London, England. Him Shun brings extensive expertise in podiatry and diabetic foot care. This interview covered crucial topics from the mechanisms of diabetic foot issues to practical advice for foot care and neuropathy management.
The Relationship Between Diabetes, PAD, and Foot Health
Q: How does sugar lead to both diabetic foot issues and peripheral artery disease (PAD)?
Him Shun Kei explained that diabetes affects our protective sensation through peripheral sensory neuropathy, which impacts about half of the diabetic population. High blood sugar primarily affects small arteries, causing chronic inflammation and making them more leaky, which damages nerve cells in two ways: direct damage from high sugar levels and reduced blood flow to nerve cells due to microangiopathy (small circulation being affected).
“When people lose protective sensation, they may not know when they’ve injured their foot,” Him Shun noted. “It’s like a fire alarm that’s stopped working - when there’s a problem in the foot, it usually hurts, but without that sensation, you don’t know the problem exists.”
While diabetes can affect peripheral arterial circulation in a smaller but high-risk population, it typically impacts the distal circulation below the knee. When combined with other risk factors like smoking (which affects upper leg and abdominal arteries), patients face a “perfect storm” of vascular compromises.
Q: What’s the difference between diabetic foot and PAD foot?
Him Shun clarified that diabetic feet typically have lost protective sensation, leading to neuropathic ulcers on weight-bearing areas. In contrast, ischemic ulcers from PAD are usually quite painful if the patient doesn’t have diabetes.
“The biggest difference is that with a diabetic foot, you can have a problem without pain and without noticing it, whereas with peripheral arterial disease, you usually get quite a lot of pain,” he explained. However, patients can have both conditions simultaneously.
This lack of pain sensation is why many diabetic patients don’t discover arterial issues until they’re dealing with a non-healing wound, which indicates advanced PAD (critical limb ischemia).
Managing Foot Health with Diabetes and PAD
Q: What advice do you have for walking safely with neuropathy?
Walking generally doesn’t further damage nerves unless there’s an accident or injury. However, for patients with end-stage neuropathy (complete numbness), excessive exercise could potentially cause foot damage. Him Shun recommends:
Good protective footwear
Custom insoles from a podiatrist to redistribute foot pressure
Gradual increase in exercise (never suddenly increasing activity)
Breaking in new shoes slowly (15-30 minutes at home before wearing them outdoors)
Daily foot inspection to check for problems
Q: What foot creams do you recommend for dry, cracking feet?
Him Shun recommends creams containing 10% urea as excellent humectants that moisturize feet well. For heels with cracks and hard skin, 25% urea cream can be used. Common brands include CCS or Flexitol.
“It’s important to know it’s not just the cream,” Him Shun emphasized. “Sometimes it’s about wearing socks, as sandals can cause friction and make you more prone to fissures. If there’s a lot of hard skin causing cracks, you might need to see a podiatrist to remove the hard skin before applying cream.”
He also cautioned against applying cream between toes.
Dealing with Neuropathy and Foot Pain
Q: What causes random needle stabbing pain in toes, and what questions should patients ask their doctors?
This could be peripheral arterial disease, diabetic neuropathy, or other conditions like sciatica. Him Shun recommends seeing a doctor to determine the cause, as each requires different management approaches.
“There are many different causes of neuropathy,” he explained. “If it’s related to peripheral vascular disease, the pain tends to wake you up at night and improves when you put your feet down on the floor. Nerve damage pain tends to be constant regardless of position.”
Q: How can patients differentiate between poor circulation and neuropathy?
Diagnostic testing is essential. Him Shun recommends starting with a duplex ultrasound scan to assess circulation. For neuropathy, additional testing may be needed to determine if it’s related to diabetes, circulation issues, vitamin deficiencies, or other causes.
Q: Can vitamin B supplements help with neuropathy?
“Vitamin B12 deficiency is one possible cause of neuropathy,” Him Shun confirmed. “It’s particularly common in elderly people.” He recommends blood tests to confirm B12 deficiency before starting supplements, which might be given as injections or oral supplements.
Special Foot Conditions
Q: What advice do you have for Raynaud’s syndrome and chilblains?
For chilblains, Him Shun recommends avoiding extreme temperatures and wearing thermal socks, particularly cotton or land wool socks to keep feet warm. He cautions against using heating devices directly on feet, especially for those with neuropathy, to prevent burns.
Q: How should fungal nail infections be treated?
Fungal nail infections are common but generally benign except for appearance. Treatment options include:
Topical nail lacquers (requiring consistent application for 6+ months)
Good foot hygiene (changing socks daily or twice daily for sweaty feet)
Professional nail thinning by a podiatrist to help topical treatments penetrate
Oral antifungal medications (requiring 3-6 months of treatment and blood tests to monitor liver function)
Him Shun cautioned against products containing 40% urea (such as Canespro) for diabetic patients or those with PAD, as these can remove the entire nail plate, potentially causing ulceration, and may not be suitable for everyone.
Complex Cases and Hard-to-Heal Wounds
Q: How do you approach patients with Deep Vein Arterialization (DVA)?
These complex surgical procedures require careful management, and Him Shun emphasized the importance of patient commitment: “It’s not just saying ‘I will follow all the instructions,’ but thinking about putting aside other life commitments to focus on foot care.”
He acknowledged that sometimes amputation with prosthetic fitting might be a better option for some patients, depending on their life priorities and circumstances.
Q: What’s your advice for patients who need to exercise for circulation but have wounds that need to heal?
Him Shun prioritizes wound healing: “When there’s a foot ulcer, the priority is to get the wound healed, ideally within three months. The risk of losing a leg increases significantly with an open, non-healing wound.”
For patients who need to improve circulation while healing, he suggests:
Non-weight-bearing exercises like seated leg kicks
Upper body exercises to maintain cardiovascular fitness
Cycling the air (mimicking pedaling motion without weight-bearing)
Strictly adhering to prescribed offloading devices and medications
A Career-Defining Moment
When asked about a defining moment in his career, Him Shun shared a powerful story about a patient referred for a diabetic foot ulcer. Something about the hyper-granulation in the toe area seemed unusual, so he took a shave biopsy that revealed melanoma.
“I was thinking, ‘Oh my God, I now need to explain to the patient what it is,’” he recalled. Though nervous about delivering such serious news, the patient and their daughter were grateful for the correct diagnosis after seeing multiple specialists who couldn’t identify the problem.
“Within a month, they lost a toe but saved a life,” Him Shun said. “It’s something I never forget. Always do a holistic assessment and get the right diagnosis. You have a heart for the patient - they will thank you in the end, even though it’s not the best news, but they get the right treatment.”
Note: Always consult with your healthcare provider before acting on any advice offered in this article. The views and recommendations shared are those of our guest and should be considered in partnership with your medical team.
Watch the full interview with Him Shun Kei above for more detailed information about diabetic foot care and peripheral artery disease management. You can also subscribe to our Youtube.com/@TheWayToMyHeart for additional PAD educational content such as this.
If you have questions about Peripheral Artery Disease, call the Global PAD Association’s Leg Saver Hotline at 1-833-PAD-LEGS or go to PADhelp.org
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