Case Study: Severe Friction Ulcer in a Patient with Peripheral Neuropathy

Case at a Glance

A 60-year-old male with a history of peripheral neuropathy presented with a severe, painless wound on his fourth toe, discovered after a long walk. The friction blister had ruptured and deroofed, exposing the dermis. This case underscores the significant risk of limb-threatening complications in patients with sensory deficits and highlights the importance of patient education and immediate professional wound care.

Patient's Story

The patient is a 60-year-old male with a known history of peripheral neuropathy affecting his feet. He reported engaging in an unusually long walk. Due to his compromised sensation, he was completely unaware of any discomfort or injury during the activity. Upon removing his shoes later that day, he discovered a significant wound on the plantar surface (bottom) of his right fourth toe. He noted that the blister had already ruptured and that a large flap of skin, seemingly two layers deep, was completely gone. A new, smaller blister was already forming on the exposed, raw tissue.

Initial Assessment

The patient's self-report described a large, deroofed friction blister that had evolved into an ulcer. The wound base was described as looking like 'raw meat,' suggesting an exposed, weeping dermal layer. The lesion was extensive, covering the entire plantar surface of the toe and extending up the lateral and medial sides. The most critical finding was the complete absence of pain (analgesia), a hallmark of advanced peripheral neuropathy. The patient was ambulatory and planning to walk approximately four miles per day for the next two days, posing a significant risk for further tissue damage and infection.

The Diagnostic Journey

The patient self-diagnosed a 'bad blister' but was alarmed by its size and the painless nature of its formation. His immediate resources were limited to petroleum jelly and adhesive bandages. He sought informal advice, questioning the adequacy of his supplies and the appropriateness of occlusive versus open-air wound management. A key piece of feedback he received emphasized the impossibility of providing accurate advice without a visual, in-person examination. This interaction highlighted the critical need for professional medical evaluation, as remote assessment is inadequate for a high-risk wound, especially on a neuropathic foot.

Final Diagnosis

1. Complicated Friction Blister with full-thickness epidermal loss, creating a Stage 2 Ulcer on the right fourth toe.
2. Severe Peripheral Sensory Neuropathy (etiology not specified, but likely diabetes mellitus).
3. High risk for secondary bacterial infection and delayed wound healing due to continued ambulation and underlying neuropathy.

Treatment Plan

Based on the presentation, the standard-of-care recommendations would be:

1. Immediate Offloading: The patient was strongly advised to cease all non-essential walking immediately to prevent further pressure and friction on the wound.
2. Wound Care: Cleanse the area gently with sterile saline or mild soap and water and pat dry. Apply a topical antibiotic ointment to prevent infection. Cover the wound with a non-adherent primary dressing, followed by a soft, padded secondary dressing to provide cushioning and absorb any exudate. The dressing should be kept clean and dry and changed daily.
3. Avoid Maceration: Petroleum jelly alone is not ideal; a proper moisture-retentive dressing promotes healing better. The concept of 'airing out' such a wound is contraindicated as it can lead to tissue desiccation, delayed healing, and increased pain if sensation were present.
4. Urgent Referral: The patient was instructed to seek an urgent in-person evaluation with his primary care provider or a podiatrist for debridement, formal wound assessment, and management.

Outcome and Follow-up

The immediate priority was to educate the patient on the severity of the situation and the urgent need to override his travel plans in favor of medical care. With proper wound care and offloading, the ulcer is expected to heal, but the process may take several weeks due to the compromised neurovascular status of the foot. Follow-up would involve regular visits to a wound care specialist to monitor for signs of infection (erythema, edema, purulence, malodor), assess healing progress, and make adjustments to the treatment plan. This event serves as a critical opportunity for comprehensive patient education on diabetic/neuropathic foot care, including daily self-inspections, appropriate footwear, and the importance of seeking immediate care for any new lesion, regardless of pain.