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Improving Wound Healing Outcomes in Patients With Diabetes and Foot Burn Injuries
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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Podiatry Today or HMP Global, their employees, and affiliates.
It is estimated that more than 2 billion people worldwide are involved in informal labor, which includes activities such as retailing goods or providing services like street food vending.1 People may pursue this type of work due to a lack of opportunities, as well as unemployment, poverty, and other factors.2
However, street vendors face several occupational challenges that can contribute to overall ill health.3,4 Studies conducted by Massago and colleagues in 2022 demonstrated that the occupational exposures and health effects of street vendors are under-researched. The occupational and environmental health hazards contribute to the morbidity of these workers.5 Most workers use fire to cook, with only a few using electrical or gas stoves. Most cooking and food preparation vendors prefer using less expensive, more accessible fuel sources such as biomass fuels, wood, coal, and kerosene, which pose additional health concerns.6
These workers can quickly come into contact with hot surfaces like grills, stoves, and hot oil, and often do not use protective gear such as gloves, spatter shields, or non-skid waterproof footwear.7 This puts them at risk of severe burns and associated complications, which may require wound care, hospitalizations, and surgical interventions.
Considerations for Burn Injuries in the Lower Extremity
When treating burn injuries, such as those that these workers may sustain, immediate assessment and classification are crucial to determine the best course of treatment. This may involve outpatient care, hospitalization, reconstructive procedures, and rehabilitation. However, lower extremity burns can be particularly challenging because they require specialized care to achieve a favorable outcome. The primary goal of treating a lower extremity burn injury is to restore functional capabilities and maintain a weight-bearing foot and ankle. These types of injuries can cause extensive damage to the skin, which serves as a protective barrier and regulates the patient's microenvironment and homeostasis.
When treating burn injuries on the foot and ankle, the clinician takes into account any existing medical conditions, such as diabetes mellitus, peripheral vascular disease, peripheral neuropathy, and impaired humoral response. These conditions increase the risk of complications, such as acute hospitalization, surgical intervention, infection, scarring, healing problems, contracture, adhesions, hypopigmentation, hyperpigmentation, and limb loss. Moreover, individuals with these conditions are more prone to limb-threatening complications due to losing protective sensation, poor circulation, and an immunocompromised state.8
It is helpful to examine the evidence-based management of scald burn injuries, especially those linked to street food vendors, and emphasize the recent guidelines released by the American Burn Association (ABA).9 Scald burn injuries are significant because they can range from minor to severe and are often complex.
To prevent future burn injuries, workers in the street food industry, patients, and clinicians should be aware of the risk of foot burns and wear proper footwear protection to prevent them helping to direct future burn prevention efforts and improve workplace safety.7
Of course, street food vendors are working with scalding hot water day in and day out, so one can assume burns are expected and not at all rare. This case presentation aims to characterize and evaluate our experience treating this type of injury in the hopes of improving limb salvage rates.
A Closer Look at the Patient Presentation and Treatment
A 65-year-old male with diabetes and a past medical history significant for peripheral neuropathy, coronary artery disease, hypertension, and benign prostatic hypertrophy presented for admission to an ABA-verified burn center with second- and third-degree hot oil scald burns to his left foot. He had burned 1% of the total body surface area on his left foot (Figure 1). There were partial- and full-thickness injuries.
Two days before admission, the patient was working on a food truck at a street fair and accidentally spilled a pot of hot oil on his left foot. He continued working for 4 hours and when he got home, removed his shoe and noticed blistering. He cleaned the burns himself with soap and water.
Forty-eight hours later, he presented to his local emergency department. He was tachycardic at 100 beats per minute and febrile at 103.8ºF. He was transferred to the burn unit and admitted for the infection. On physical examination, he had palpable pedal pulses bilaterally 3/4+. The left foot was erythematous and edematous with open blisters and adherent burned, necrotic tissue eschar. On admission, his white blood cell count was 13.3, glucose 237, and hemoglobin A1C was 9.8. Venous Doppler studies were performed and negative for deep vein thrombosis. The arterial Doppler studies showed adequate perfusion to the wound of the left foot.
A wound culture taken upon admission showed methicillin-sensitive Staphylococcus aureus. Accordingly, treatment included both ciprofloxacin and clindamycin intravenously.
On hospital day 11, the patient underwent a debridement in the operating room and an application of a split-thickness skin graft to the dorsum of the left foot taken from the left thigh (Figure 2). Negative pressure wound therapy was applied to promote healing. The dressings were taken down and changed on postop day 3, and the skin graft had a good take. The infected second- and third-degree burns were treated with intravenous antibiotics, topical silver sulfadiazide cream, dressings, and an elastic wrap. The patient was discharged on postop day 6.
The healed burns were treated with moisture 3–4 times a day for dryness and pruritus. Sunscreen was advised for the next 12 months (Figure 3, 4).
Further Insights on Burns
The management of a patient with uncontrolled diabetes with a third-degree foot burn injury is often difficult owing to the predisposing factors, which include the severity of the burn injury, poor glycemic control, and the presence of infection.
The third-degree burn of the foot from a hot oil spill was unique because it is to our knowledge the first ever reported case in the literature of a foot burn injury associated with street food vending. Although such burns are an occupational risk, standards of wound care and ongoing efforts to improve wound healing rates and prevent limb loss necessitate the education and prevention of lower extremity burns in this at-risk population.
The medical literature does not report on the mechanism of burn injury as described in this case. However, street food vendors who frequently come into contact with hot oil may have experienced similar but unreported injuries. Reconstruction is essential when treating lower extremity burns, but the focus should also be restoring weight-bearing and ambulation. In this case, the patient underwent extensive debridement and reconstruction and, fortunately, achieved complete restoration of weight-bearing capabilities at the 12-month follow-up. Antibiotics were administered to control and mitigate the severe limb-threatening infection.
Patients with coexisting conditions, such as diabetes mellitus, peripheral neuropathy, impaired humoral response, and peripheral vascular disease, may present additional challenges to healing. In this case, the patient had poor glycemic control, but non-invasive Doppler studies showed adequate perfusion to the foot burn injury. Further research is needed to analyze the mechanisms and possible treatments to reduce limb loss associated with burn injuries. Workplace safety should also be considered when treating patients with diabetes mellitus and employment that poses occupational health risks in this at-risk population.
Furthermore, more investigation is needed to evaluate foot burn injuries in at-risk populations in efforts to decrease morbidity and determine possible strategies to mitigate long-term health problems.
In Conclusion
Street food vending is a popular form of informal employment, especially during street festivals. However, street food workers are often exposed to hot stoves, grills, and oil while preparing food outdoors, which poses occupational health risks, including thermal injuries. While burn injuries from this type of work are well-known and most likely more frequent than is reported, there is a lack of information about the mechanism of the injury and the best possible treatments. A better understanding of the assessment of burn injuries in terms of initial and prolonged treatment, as well as reconstructive and rehabilitative processes, is needed to provide proper care for these patients, particularly in the at-risk populations.
Through presentation of the above case, the authors’ aim is to raise awareness of this occupational health hazard and improve the outcomes of wound healing and reduce risk of limb loss in this subset of patients.
Created in partnership with the American Society of Podiatric Surgeons.
Jean Archer, DPM, practices at Noyes Health/University of Rochester Medical Center in Dansville, NY.
Michael L. Cooper, MD, is the Director of Jerome L. Finkelstein Regional Burn Center at Staten Island University Hospital/Northwell Health.
References
1. Women and Men in the Informal Economy: A Statistical Picture. Accessed Aug. 28, 2021.
2. The Impact of COVID-19 on Informal Food Traders in SA. Accessed Aug. 28, 2021.
3. Definitions of Environmental Health. Accessed Aug. 28, 2021.
4. Occupational Health: A Manual for Primary Health Care Workers. Accessed Aug. 28, 2021.
5. Sepadi MM, Nkosi V. Environmental and Occupational Health Exposures and Outcomes of Informal Street Food Vendors in South Africa: A Quasi-Systematic Review. Int J Environ Res Public Health. 2022 Jan 25;19(3):1348. doi: 10.3390/ijerph19031348. PMID: 35162371; PMCID: PMC8835235.
6. Amegah AK, Jaakkola JJ, Quansah R, Norgbe GK, Dzodzomenyo M. Cooking fuel choices and garbage burning practices as determinants of birth weight: a cross-sectional study in Accra, Ghana. Environ Health. 2012 Oct 17;11:78. doi: 10.1186/1476-069X-11-78. PMID: 23075225; PMCID: PMC3533864.
7. How to Prevent Burns in Commercial Kitchens. AmTrust Financial.
8. Rabjohn LV, Roberts K. Burn injuries of the foot and ankle: proper assessment and care to leads to improved results. Podiatry Management. April/May 2006
9. American Burn Association. Scald injury prevention.
