The hazards of the holiday foot: persons at high risk for diabetic foot ulceration may be more active on holiday

The pathway to neuropathic diabetic foot ulceration may be generally expressed as a consistent formula. This formula can be described as pressure (otherwise known as deformity or high plantar pressure) multiplied by cycles of repetitive stress (steps taken each day) equals failure of skin [1]. While most treatments have logically focused on pressure reduction [2–4], the other aspect of the equation, namely activity, has been largely ignored. It could be hypothesized that mitigation or perhaps modulation of activity might play a significant role in the pathogenesis and prevention of diabetic foot ulceration. It is increasingly recognized that holiday is associated with the development of diabetic foot ulcer. The term diabetic holiday foot syndrome (DHFS) [5] was first coined by Stanway and Gill. They reported six cases of foot ulceration in patients with diabetes on holiday. The main causes of ulceration were direct trauma from walking barefoot or from poorly fitting sandals. It has been further suggested by Morbach et al . [6] that unaccustomed exercise may also play a pivotal role in the development of DHFS. Experiences from our foot clinics in Manchester, UK and Tucson, Arizona, USA have revealed that despite good foot care education and advice regarding the use of correct footwear during holidays, we have anecdotally noted a marked tendency for high-risk patients to develop foot ulceration while on holiday. Our group has recently begun using novel continuous computerized activity monitors which allow us to identify not only magnitude of activity, but also the specific time when that activity occurred. This device is quite innocuous and is worn on the waistband of clothing. In a recent study of male United States military veterans at high risk for diabetic foot ulceration, we found, surprisingly, that patients were as active inside of their home as they were in the community. Unfortunately, only 15% of these subjects indicated that they wore their physician-approved shoes while in the home [7]. We have postulated that these patients might similarly be more active and therefore are at potentially higher risk of developing foot ulceration while on holiday than when they are at home. In this population of 20 men, aged 64.6 ± 1.8 (mean ± SEM ) years with peripheral neuropathy and a mean 13.4 ± 1.3 year history of diabetes mellitus, a total of 25% had taken at least 3 days’ holiday out of town during the period of continuous activity monitoring. These patients were an average 29% more active (as measured by steps taken per day) during their holiday than when they were home (3603.0 ± 663.8 vs. 2796 ± 489.1, P = 0.04). This trend toward increased activity was encountered in all patients evaluated in this study. These data are graphically illustrated in Fig. 1. The results from this brief analysis suggest that there may be increased activity in patients at risk of developing foot ulceration while on holiday. The implication, particularly if emulated by larger trials, is that patients should be given specific advice regarding foot care for holidays to minimize their risk of developing foot ulcers. Patients should be made aware of the potential problems. Good practice of foot care should be maintained while on holiday, including the use of protective footwear and the avoidance of unsuitable beach footwear or the temptation to walk barefoot. Increased surveillance of the feet is needed with at least daily inspection and urgent medical advice should be sought when required. It should be possible to plan daily itinerary to avoid prolonged periods of continuous activity or to spread activities more evenly throughout the holiday. We would suggest that patients at high risk of foot ulceration plan their holiday with care with the consultation of their physician.