Before she does anything more to a client than shake her hand, Jill Tinetti carefully checks the health history section on her new client card. With pedicure clients in particular, she carefully evaluates the client’s skin and nails and asks a few seemingly casual questions aimed at unearthing any signs or symptoms of diabetes.
As a registered nurse, Tinetti knows what to look for. And as a diabetic herself, she knows all too well what’s at stake. Years ago, long before she herself became a licensed nail tech, an accidental nick incurred in the course of a pedicure landed her in the emergency room. Diagnosed with cellulitis, she required 10 days of intravenous antibiotics to heal.
“I’m extremely careful,” declares Tinetti, who’s worked at Tall Grass Spa in Evergreen, Colo., ever since getting her license two years ago. “I never nip cuticles on a diabetic.”
With the growing popularity of pedicures and the rising number of diabetics in the United States, nail techs increasingly are faced with the issue. According to the Centers for Disease Control and Prevention, more than 15.7 million Americans had diabetes in 1998. According to Douglas Albreski, D.P.M., a podiatrist who specializes in the skin disease and an assistant professor at the University of Connecticut Health Center in Farmington, Conn., that number continues to grow at a fast clip in what specialists are tagging a “diabetic epidemic.”
“Diabetes is a very serious disease,” adds Lee Sanders, D.P.M., the immediate past president of health care and education for the American Diabetes Association (ADA) and chief of podiatry at the Veterans Administration Medical Center in Lebanon, Pa. “It’s the leading cause of new cases of blindness, kidney failure, and nontraumatic amputation.”
The Diabetic Foot: What You Need to Know
Diabetes also is a leading cause of foot problems. Over time, every diabetic will experience some problems with his or her feet, says Dr. Sanders. And according to the ADA, 20% of diabetic hospital admissions can be blamed on foot problems.
“Many diabetics are diagnosed because they start to experience foot problems,” Dr. Albreski observes, adding that the three most serious foot complications for diabetics are neuropathy, poor circulation, and immune deficiencies.
Diabetic neuropathy (nerve damage directly associated with diabetes) actually encompasses a group of nerve diseases that can affect the feet in various ways. For example, damage to the motor nerve fibers weakens the muscles in the feet. This in turn, affects not only an individual’s movement but can also lead to bone fractures and foot deformities. Sensory nerve damage, on the other hand, leads to a loss of feeling, though in some cases it can also result in prickling, tingling, or painful sensations.
Poor circulation, or an insufficient flow of blood, is another common problem for diabetics. It’s sometimes confused with neuropathy because both can cause pain. Poor circulation is a concern because blood delivers oxygen to body tissues and carries metabolic wastes away. With poor circulation, it takes the body longer to heal itself and heightens the risk of infection. Once infection sets in, poor circulation again complicates healing, making the infection harder to control. In diabetics with poor circulation, even a small nick or an ingrown toenail can lead to serious health problems.
Finally, says Dr. Albreski, diabetics are more prone to certain bacterial and fungal infections of the skin and nails. Particular to the feet, diabetics are more likely to complain of dry, cracked skin, calluses, corns, and fungal infection of the nails (onychomycosis). Foot ulcers, especially over the ball of the foot or on the bottom of the big toe, also are common.
The Consultation: Should You, or Shouldn’t You?
One of the big questions for nail techs has always been, should you or shouldn’t you do pedicures on diabetic clients? The standard reply has been to get an OK from the client’s doctor. But as Judi Shakula, D.P.M., of Grady Diabetes Clinic in Atlanta, points out, the theory doesn’t work well in practice.
For one, the CDC estimates that approximately half of diabetics are as-yet-undiagnosed. Second, many of the clients who know they have the disease and are under a doctor’s care don’t want the hassle and may just seek out another pedicurist. Finally, Dr. Shakula believes many doctors will err on the side of caution and automatically say no to avoid any liability in the event of a problem.
So who can you give a pedicure? All diabetics pose a risk in the pedicure chair, emphasize the doctors we asked. However, say Dr. Shakula and Dr. Albreski, some present a greater risk than others. Anyone with neuropathy, poor circulation, a present or past foot ulcer, or amputation of all or any part of a foot (even if the feet appear healthy now, as they may with a diabetic who’s previously had an ulcer) is a high-risk diabetic and should be refused.
Low-risk diabetics, on the other hand, have full feeling in their feet, good circulation, and no signs of foot infections or deformities, says Dr. Albreski. He and Dr. Shakula recommend assessing the condition of each client’s feet and asking some basic questions to gauge the client’s suitability for a professional pedicure.
First, look for the following.
- Thickened, yellow nails. These may indicate a fungal infection of the nails. A diabetic is twice as likely as the average person to suffer from onychomycosis.
- Any major foot deformities. This includes hammertoes and bunions as well as excessively built-up calluses and corns.
- Thin, waxy-looking skin. This suggests poor circulation, which makes diabetics more prone to serious infections on their feet.
- A purple, blue, or red hue. Pink is healthy; purple and blue indicate a circulatory problem; red signals a possible infection.
- A “hot spot” or excessively cold feet. If one part of the foot feels warmer than the rest, that can mean infection. Excessive cold, on the other hand, points to poor circulation.
“From the upper part of the leg to the bottom of the feet the temperature should remain consistent,” Dr. Albreski explains. “We call it the ‘gradient effect.’”
- A loss of sensation. Assess the feeling in your client’s foot by asking her to look away while you lightly brush the top of her foot with a tissue. Can she identify where you touched her? If not, she may have neuropathy, and you should refuse the service.
- Is there hair on the toes? While it may not please the eyes, hair on the toes is a positive (though unscientific) indicator of good circulation.
As you make these general observations, ask your new client these questions:
- Has your doctor ever said you have poor circulation?
- Do you experience any numbness or burning in your feet?
- Do you smoke? (Smokers tend to have poor circulation, and diabetics who smoke are particularly at risk for circulatory and neuropathic disorders.)
- Do you have any loss of sensation in your feet?
- Have you ever had a foot ulcer?
- How well is your blood sugar controlled? (Well-controlled blood sugar has been shown to slow disease progression. Poorly controlled blood sugar increases the likelihood of more serious problems that appear sooner.)
- When’s the last time your doctor examined your feet? What were his observations? (Diabetics should have their feet examined by a physician at least once a year, more often if they have problems.)
A positive answer to any of the first five questions is, of course, a negative for proceeding with the service.
The Diabetic Pedicure: Step-by-Step
Even with low-risk diabetics, you should exercise extreme caution in caring for their feet. With the help of Drs. Albreski, Sanders, and Shakula, NAILS developed the following pedicure technique specifically for use with diabetic clients.
First, before you even start the service they emphasize the need for clean workstations, towels, and hands, sterile implements, and fresh disposable supplies (such as files and orangewood sticks) for all clients, but particularly diabetics. “Have a healthy regard for the possible complications and know how to avoid them,” Dr. Sanders stresses.
Similarly, they advise against using chemical or mechanical exfoliants on the feet — which include razors or blades, pumice stones, foot files, or exfoliants such as glycolic acid or sea salt scrubs. Any of these tools carry the risk of breaking or otherwise injuring the skin — a risk too great to take with a diabetic. If you have a client with diabetes who needs a callus or corn reduced, cuticles trimmed, or an ingrown nail treated, refer her immediately to a foot care specialist such as a podiatrist.
Now, on with the service.
Step 1: Gently wash her feet with an antibacterial soap and tepid water then pat dry.
Explanation: All three podiatrists recommend against foot soaks, even in tepid water. While the primary concern is that a diabetic is more easily burned because of the loss of sensation, Dr. Sanders stresses that soaking in water may worsen the dry skin so typical to diabetics.
“We’re also concerned now about cross-contamination,” notes Dr. Albreski. “The fungi that cause skin infections are everywhere, and while most people may not pick it up from a contaminated whirlpool, the diabetic just might because her immune system isn’t as strong.”
Step 2: Trim and shape the nails as desired, being especially careful not to nip the skin.
Explanation: Most diabetics are advised to file down their toenails to the desired length, but Dr. Shakula says pedicurists can trim them with care as long as the nails are not misshapen or excessively thickened.
“Don’t dig under the nail plate or gauge at the corners,” she advises. “And never use a drill on the feet.”
Step 3: Apply a mild cuticle treatment to soften cuticles. Do not, however, trim or push back the cuticles, warns Dr. Albreski.
Explanation: “The cuticle serves as a protective structure to keep bacteria and fungi from getting under the nail fold,” Dr. Sanders notes. Remember, diabetics are more prone to bacterial and fungal infections of the skin and nail. Once present, these types of infections take longer to heal and are more likely to spread and cause a serious health problem.
Step 4: Next, apply a hydrating lotion to the tops and bottoms of the feet —but avoid the spaces between the toes.
Explanation. Poor circulation can also cause problems with healing. Normally, the body keeps a steady supply of fresh blood flowing to heal damaged tissues. Poor circulation means a poor flow of blood, which slows healing. Even a small cut or ingrown nail may take a long time to heal, which increases the likelihood of an infection. However, the spaces between the toes typically trap moisture, regardless of how dry the rest of the foot is. Applying a cream orlotion between the toes only traps more moisture and may cause the skin to break down, which in turn invites infection.
As for what type of lotion to use, Dr. Albreski and Dr. Sanders recommend lotions containing lactic acid or 10% urea. Dr Shakula, on the other hand, thinks pedicurists can use most mild exfoliating creams. However, she agrees that moisturizers containing lactic acid are most effective at softening the hard, dry skin so common to diabetic feet.
Step 5: Massage each foot gently but thoroughly, stroking toward the heart.
Explanation: A favorite with most clients, diabetics in particular can benefit from massage because it improves circulation, albeit temporarily.
Step 6: Polish the nails as desired.
While a monthly pedicure is enough to maintain foot health for most clients, diabetics require daily foot care. But, as Dr. Albreski notes, “Most diabetics are aware of the need and they’ll tell you they’re on top of it, but they don’t quite follow through in practice.”
Remind these clients to carefully wash and visually inspect their feet for injuries each day. Advise them to finish their self-inspection with a liberal slathering of moisturizing lotion on the tops and bottoms of the feet to help heal and prevent dry skin.
If, after all these precautions, you accidentally nick or cut a diabetic client, Dr. Albreski urges you to admit the mistake and take action to prevent the injury from becoming serious. “It’s not malpractice or faulty workmanship to nick someone,” he says. “What will get you into trouble is not addressing the situation correctly.” Citing two lawsuits he’s aware of against pedicurists, Dr. Albreski emphasizes the need for honesty and professionalism with clients.
He recommends immediately stopping the service and performing basic first aid care: Use a styptic pencil to stop any bleeding, apply a triple antibiotic cream such as Neosporin, then lightly bandage the site. Explain to the client what you did to treat the wound, then recommend that she notify her primary care physician of the injury and seek his opinion on whether she needs a doctor’s care.
“Write down everything you did and said to the client and keep it in a file in case anyone comes back to you later,” Dr. Albreski says. You might even consider developing an accident or injury report similar to those used by some child care centers. In this case, you might briefly note the injury, how it was treated in the salon, and repeat in writing the recommendation that the client seek her primary care physician’s advice on further treatment of the injury.