Lower Extremity Diseases

Homeless patients have a variety of lower extremity disorders.9 Such patients may spend a disproportionate amount of time with their legs in a dependent position while sleeping upright or ambulating for extended periods. The poverty associated with homelessness may prevent some patients from obtaining adequate or appropriately fitting socks and shoes that are seasonally appropriate. Ulcers and wounds from lack of foot protection, blisters from poorly fitting shoes, or bites from rats or insects may occur.

Some homeless patients may not have an available change of footwear or a place to change and bathe. Socks and shoes may not be removed for days to weeks for reasons such as warmth, fear that footwear may be stolen, embarrassment, or coexisting mental illness. These factors, along with limitations in hygiene, predispose to fungal infections, which can be treated with topical or oral therapy. Also of concern in this population is the condition known as trench foot. 10 Protracted exposure to moisture around the foot (usually from wet or sweaty socks) leads to absorption of water into the stratum corneum. Over 1 to 2 days, such exposure causes inflammatory changes that result in foot pain and skin breakdown. Bacterial superinfection with Corynebacterium species and Pseudomonas species can ensue. In the absence of superinfection, analgesia, leg elevation, and drying are adequate to treat trench foot. In colder climates, frostbite from formation of ice crystals in the tissues is a serious threat to limbs, ears, and nose. Careful in-hospital management is warranted, since the environmental risks persist as long as the patient remains homeless, and compliance with treatment may be difficult if not impossible.

Patients predisposed to peripheral vascular disease can have exacerbation of their illness due to inadequate nutrition, poor protein stores, alcoholism and substance use, use of tobacco, and inability to elevate the legs while sleeping upright. The resulting edema can lead to chronic venous stasis ulcers. The ulcers can become infected with common skin flora or even maggots (fly larvae). For uninfected ulcers, the use of venous support garments, such as Una boots, is a valuable management tool. Una boots are impregnated with antibiotic ointment and require less frequent changes. Infected ulcers require admission. The erythema associated with cellulitis may be difficult to distinguish from deep venous thrombosis or venous stasis changes. When the diagnosis is unclear, an evaluation of venous flow should be undertaken. For lesions infected with maggots, chloroform is a traditional therapy for deinfestation. Chloroform may not be available due to safety issues of combustibility. Ethyl chloride is an alternative. Ironically, maggots survive by ingesting necrotic tissue, keeping ulcers clean and well d├ębrided. Once deinfestation is completed, close follow-up is mandatory, since natural d├ębridement via fly larvae is terminated. Maggot infestation is a grave sign of serious neglect and suggests the inability to manage a clinical plan outside a supervised setting.

All homeless patients need education to minimize the risk of trench foot and fungal infections. Patients should be told to change or remove all footwear when environmental conditions allow, examine the feet, and attempt to find rest with the legs elevated. Intravenous drug abusers should be warned about the risk of skin infection from drug administration into the extremities. Community resources, which can provide clean, dry socks and well-fitting shoes, should be identified. Such preventive measures are especially important for diabetic patients and those who suffer from peripheral neuropathy.

Alcohol No More

Alcohol No More

Do you love a drink from time to time? A lot of us do, often when socializing with acquaintances and loved ones. Drinking may be beneficial or harmful, depending upon your age and health status, and, naturally, how much you drink.

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