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Tuesday, October 21, 2014

Medical Advisory : Diabetic Tropical Ulcer Update

Updated - four weeks into treatment

THE 5TH ESTATE ASIA
By Robert S. Finnegan
10/21/2014

Approximately four weeks ago this reporter was bitten on the left-mid leg by an Asian tiger mosquito directly above the shinbone. Treatment for the bite was initiated immediately with both topical and oral antibiotics, oral Ciprofloxacin 500mg twice a day and application of topical Garamycin.  While infection was inhibited the wound expanded and threatened to involve the shinbone.


The bite was sustained in Central Java, Indonesia where sanitation is non-existent and the mosquitos breed in open sewers that are a virtual pathogenic soup harbouring almost every communicable disease known to man (an exaggeration but close to the truth). In diabetics, every bite must be treated as and assumed to be potentially life threatening. While there is minimal diabetic neuropathy present mid-leg at the site of the injury, there is very little meat separating the skin from the shinbone through necrosis, and this is what makes an injury or bite in these areas of the leg so potentially serious.  


With medical facilities almost universally sub-standard in many ASEAN countries an amputation of any kind is almost a death sentence to a diabetic and especially to foreigners from Western countries that have immune systems which are vastly inferior to indigenous populations by virtue of genetic immunity acquired over hundreds if not thousands of years to endemic viruses and bacteria.


Following a month of unsuccessful treatment with Cipro and Garamycin a switch was made to Doxycycline. Studies done on diabetic ulcers with this drug have been promising, although they call for a 1% topical which is unavailable in Indonesia.  

Lacking this, an oral dose of 100mg twice daily was undertaken, along with the application of Cinolon-N topical. 

While exceedingly slow, the ulcer is now beginning to heal and close.  


Elevation of the leg is recommended whenever possible and the ulcer must be kept clean at all times.  Exposure to outside air should be avoided at all costs regardless of how long it takes to close the wound. Debridement of necrotic tissue must be done on a daily basis using alcohol swabs and a scalpel or razor blade.

Glucose levels must be closely monitored and kept under control at all times.




If the country you are in has a hyperbaric chamber available steps should be taken to ascertain availability and cost in advance, as a last resort.  Low-level oxygen saturation has been known to have positive effects on tropical ulcers, although studies are inconclusive to date.

Sound frightening?  It is.  As always take care of your feet and legs, examining them daily for wounds and bites that may not be felt as a result of neuropathy.  Keep them covered and protected at all times, and use insect repellent whenever possible.



Robert S. Finnegan is a retired journalist and Type 1 diabetic.  He is based in Central Java with his spouse Imas Kurniawati-Finnegan.

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