Diabetics & Pedicures..

Celebrity Q and A's QUESTION I have a potential client that is a diabetic and would like to start getting pedicures. I know that there is extra care and precautionary measures that need to be taken with diabetics, but I really dont know why or what they are. Any help would be wonderful. Kelly 9/7/04

Diabetics heal slowly, especially on the extremities, and even more so on the feet so it is unwise to take chances with wounding them. Also, water that is too hot is a danger as they may have damage to their nerve ending on their feet - water that is too hot can burn diabetics. Even a slight wound on a diabetic can cause them to ultimately loose a toe or such due to the poor healing. Just take extra care - trimming cuticles is a serious issue here - and you can have a client forever.
Janet McCormick

Here are my recommendations that appeared in an article in Nails Magazine in 1995 or 1996. This should help the pedicurist provide services for selected diabetics. There is a section in my book "The Salon Professional's Guide to Footcare" which has a similar section on diabetic footcare.
Dr. Oscar Mix


Have you ever looked into the reasons why you should or should not give foot services to the diabetic?  Is it safe to give a pedicure to the diabetic client?  Can I ever give a pedicure to a diabetic client? These are questions I am asked when I lecture at the various shows around the country.  This discussion will take some of the mystery out of diabetes. I will discuss what to look for in your diabetic clients that will enable you to service selected individuals safely and professionally.

Before starting this discussion a word of CAUTION!  If you have any question whether to give a foot service or not to give a service to your diabetic client DO NOT PERFORM THE SERVICE!  Refer the client on to their podiatrist or physician for care.  In a number of past articles I have stressed the importance of developing a close working relationship with a podiatrist.  It is extremely important that you have done this if you give foot services to selected diabetic clients.  Prevention is the by word for the diabetic.  A knowledgeable Nail Professional providing professional pedicure services can be a great help in this area.

It is estimated that one out of every 20 people in the United States are diabetic.  Poor circulation is one of the major complications of this disease.  The intermediate sized arteries (arterioles) are most involved in this complication.  Since the majority of the arteries in the lower leg and foot fall in this category many severe problems arise here.  Improper nourishment to the nerves as the result of high blood sugar levels causes injury to the nerve.  This results in decreased sensation particularly in the feet.  Over forty-thousand lower extremity amputations, which are not a result of injury, are caused by diabetic complications.  This is almost 1\2 of all non-injury amputations of the leg in the United States!

Picture #1
Poor circulation and the lack of sensation results in many skin problems in the diabetic.  One-third of all diabetics will have some skin related condition during their life time.  Because of fluctuations in the blood sugar levels the small blood capillaries in the skin are easily injured.  The production of natural skin lubricants from the glands in the skin is reduced or may even cease.  All this results in dryness, cracking and itching.  Susceptibility to infection of the skin is increased.  The diabetic cannot fight infections well because the disease reduces the effectiveness of the white blood cells role in destroying bacteria.  Thus any minor skin irritation or injury has the potential of becoming a severe life threatening condition.

Diabetes is the result of the bodies inability to utilize blood sugar (glucose).  This is caused by a decrease in the production of insulin by the pancreas.  Genetic factors, disease or actual injury to the pancreas causes this decrease in insulin production.  In some cases the body develops a resistance to its' own insulin.  Insulin is the key ingredient necessary to allow the glucose to transfer from the blood stream into the surrounding cells where it is utilized for energy.  Thus without insulin the blood sugar becomes elevated and the condition of diabetes is the result.

The primary cause of diabetes is a genetic or inherited trait which stops the production of insulin by the pancreas.  Secondary causes are injury to the pancreas through the excessive use of alcohol or an actual infection of the pancreas.  Some drugs such as water pills (diuretics), cortisone, and some blood pressure medications may reduce the production of insulin.  Pregnancy in rare instances may cause a resistance to ones' own insulin resulting in a diabetic condition.  This resistance reverses after the birth of the baby.

There are two categories of diabetes.  The first is Type I or Insulin Dependent Diabetes.  This was formally called Juvenile Diabetes but the name was changed because approximately 30% of this group are diagnosed after the age of 30.  Type I is characterized by a sudden onset with the symptoms being present for only a few days or weeks.  Excessive urine production, thirst, and food intake are classical symptoms.  A sudden weight loss is often also associated.  The administration of insulin is necessary to maintain life and will be required for the rest of the Type I diabetics' life span.

Picture #2
The second category of diabetes is Type II or Non-Insulin Dependent Diabetes. This was previously referred to as Adult Onset Diabetes.  This type generally occurs in individuals over the age of 30 with the average age of diagnosis being between 60 and 65.  Type II diabetes is characterized by a very slow onset.  In some of these individuals the disease may be present as long as 10 years before a diagnosis of diabetes is made.  The first sign of the disease may be an actual complication of the disease process its' self.  I think of a new patient I had who presented with a large pain free infected ulcer on the bottom of his foot.  You nor I could have walked on our foot if it was in this condition.  Subsequent laboratory tests proved this patient to be a Type II diabetic.  This patient must have been a diabetic for some time.  Without first controlling his diabetes the ulcer would have never healed no matter what treatment I provided.

Many individuals in this group may be classified as obese while Type I individuals are generally the reverse.  Type II diabetics produce insulin but for an unknown reason their body has developed a resistance to it.  Diet, exercise, and oral medications can control the blood sugar in this group of diabetics.  Some Type II diabetics will become Type I as their disease progresses.

The actual diagnosis of diabetes is made by testing the blood levels of sugar under laboratory conditions.  This test is called the Glucose Tolerance Test.  Normal blood sugars fall between 70 and 120 milligrams per cubic centimeter of blood.  To be classified a diabetic the blood sugar, after the oral administration of a measured amount of glucose, must be elevated above 200 at least once during the 2 hour test.  It also must remain above the 200 measurement at the end of the test.

Now that you have a basic understanding of diabetes and some of the fundamental problems associated with this disease you may be asking yourself why you should even think about giving a foot service to a diabetic.  The answer is you may already be doing it and not even know it!  What about the undiagnosed Type II diabetic.  Remember this disease may be present for many years before it is diagnosed.  Would any of your pedicure clients fall in this category?  The point is that as a Nail Professional who gives foot services you must be aware and on the look out for any signs of this disease.  You may be the first one to suspect that your client is a diabetic!  If you do refer that client to their physician or podiatrist for a medical evaluation.  Do not be afraid you might be wrong.  In this case it is better to be safe than sorry.

When can the well trained knowledgeable Nail Professional provide foot services to the diabetic client?  The answer is: Only when you can be certain that the service you provide will not harm the client.  How do you determine this?  You have already made the first step by starting to read this article.  Continue reading and learn more.

To provide foot services to the diabetic you must be knowledgeable about the client both medically and as an individual.  Gain this knowledge by doing a "History and Personal Evaluation" of each client.  A few well thought out questions and visually observing the client will help you make a decision on services to provide.

If the client is a known diabetic you want to know:
1. Do they smoke?  Do they drink alcoholic beverages?  -  A diabetic should do neither of these.  Nicotine contributes to hardening of the arteries thus adds to the diabetic arterial disease process.  Alcohol is converted to sugar thus increases the blood sugars which adds to the diabetic process.  A once in awhile drink is not a bad thing, daily consumption of alcoholic beverages is what we are looking for here.  If you find either of these questions is answered yes, particularly smoking, to the excess refer the client to the podiatrist for foot care.
2. How long have they been a diabetic?  - This question will tell you a lot about their disease.  In general the longer a person is a diabetic the more severe are the complications of the disease.  As a general statement the long term diabetic should be referred to the podiatrist for foot care.
3. What do their blood sugars generally "run"?  - This is an important question for 2 reasons.  First if they do not know you should not provide services.  They are probably in denial about their disease.  A diabetic must be intimately involved in their own care.  They must know what their sugars are running in order to keep them within the limits prescribed by their doctor.  They cannot leave there care in the hands of every one else.  Do not accept the responsibility for their foot under these circumstances!
Secondly by knowing where their "blood sugars run" one gets some basic idea of the severity of the diabetes.  Considering that the normal blood sugar runs between 70 and 120 you know the client is not a good risk if they tell you that their sugars run routinely between 250 and 300.  Either this client is a very severe diabetic or they do not follow their doctors instructions about diet, exercise, and medications.  In either case you should not service that client.  In the absence of other negative findings diabetics who's blood sugars average below 150 can receive gentle conservative foot service.
4.  How is their blood sugar controlled?  Diet, exercise, medication (oral or injections), or a combination of these three?  A diet and exercise controlled diabetic may receive foot services unless they have any open wounds, infections, etc..  An oral medication controlled diabetic may receive foot services only after answering all these questions positively.  Type I or insulin dependent diabetics should be referred to the podiatrist for foot care.  The podiatrist may evaluate them and send them back for selected foot services to be provided by you.  Then and only then should you provide them.
5.  In the "Personal Evaluation" of the client you need to check the Skin, the Circulation, and the Sensation of the lower extremity.
Picture #3
The skin should have no open wounds, ulcers, or infections present.  It should be pliable and fairly normal in appearance.  Remember thin fragile skin is easily injured which in the diabetic may lead to severe consequences.
The circulation is evaluated by feeling the pulses in the foot (if you do not know how, learn before giving any foot services).  You should at least be able to feel them. The extremity should be warm and have a good coloration.  The growth of hair in the extremity is an indicator of circulatory status.  The absence of hair growth may indicate a severe circulatory disorder. If the foot becomes discolored, bluish or deep reddish, when it is on the floor, this indicates extremely poor circulation.  Thin fragile skin and a lack of underlying fatty tissues also indicates extremely poor circulation.
Does the client have normal feeling in their feet?  A rough test for this is to lightly rub your finger tip over the bottom of the foot and then do the same on the palm of the hand.  If there is a difference in sensation between the two you should refer the client for medical evaluation before a service is given.

The "History and Personal Evaluation" described above is very limited but should give you an insight as to whether or not to provide services to a diabetic client.  Your findings should all be within the normal limits I have outlined.  If you have any question, provide services only after discussing the client with their podiatrist or medical doctor!

Picture #4
A pedicure when provided to a selected diabetic should be gentle and given with extreme care.  Do not use hot water, body temperature to 100 degrees Fahrenheit is a satisfactory range.  For some reason we Americans think the hotter the better when soaking the feet.  The "Rule of Thumb" should be if you would not put the rest of your body in the hot water then DO NOT put your feet in it!  Trim the nails carefully.  Straight across is best.  If the corners need to be removed do not take the chance.  Refer them to the podiatrist for this procedure.  Do not push the cuticle back as this may cause injury which can result in an infection.  When filing the nails be extremely careful not to abrade the skin and cause an opening for an infection.  Sloughing creams should also be used with great care for the same reasons.  Select and recommend moisturizing creams that will be beneficial to the dry skin conditions that are part of the diabetic condition.  Use a gentle massage technique, do not be rough.  Use a disinfectant on the foot before and after the service.  Last but by far from least have good sanitation procedures in place for your salon and practice them religiously.

Related Topics:
MSDS Sheets - the Whole Story
Contagious warts?
Anatomy of the Nail
Planters Warts
White toe nails
Diabetics and nail services.
Prevent bursitis, tendentious, back problems
Removing heavy calluses
White & flaky toe nails
Is it fungus?
Heel Spurs
Why it is bad to cut callus
Callous balls of feet & heels
Cracked Heels
Inhaling Fumes
Greenies and Stains
Speading infections
Pterygium questions.
Allergic reactions
Severe heel callus