Referral

Hot red foot

A hot, red foot can be a manifestation of a number of conditions, including:

  • Foot sepsis
  • Critical ischaemia
  • Combined sepsis and ischaemia
  • Charcot's arthropathy

In critical ischaemia a number of changes occur that can confuse the clinical picture. Rather than a cold, painful foot you may find a hot, swollen foot because:

  • The ischaemic foot is maximally vasodilated
  • Perfusion increases when the foot is dependent and so the limb may have been "Hung low" for some time (typically at night)
  • Immobility causes venous stasis
  • Ischaemia can predispose to local sepsis

Inappropriate antibiotic therapy for critical ischaemia can delay diagnosis and treatment and is a common source of litigation in primary care

The key discriminator is the presence or absence of a normal arterial circulation on examination

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History and Examination

History
  • Diabetes
  • Previous vascular symptoms (intermittent claudication)
  • Vascular risk factors (smoking, hypertension, hypercholesterolaemia)
  • Pain? History of neuropathy?
  • Response to previous antibiotics (if given)
Examination
  • Presence of tissue loss or necrosis
  • Temperature
  • Compare with the other side
  • Pulse assessment and Doppler signal examination

Differential Diagnoses

The key differentials are between:

  • The foot that is hot and red due to critical ischaemia
  • The foot that is red and hot due to infection in a diabetic
  • Acute Charcot foot
  • Other causes - e.g. gout.

High index of suspicion in diabetics: contained pus in a diabetic foot is an emergency

Suspicion of severe ischaemia

If the arterial circulation is normal:

  • Patient's temperature
  • Inflammatory markers
  • Plain foot x-ray if sepsis or Charcot considered likely (particularly in diabetics)

Referral Criteria

Referral Instructions

Emergency referral to diabetic foot clinic
  • Monday – Friday telephone 01392 402204
  • Out of hours contact medical triage via switchboard 01392 411611
Urgent referral to vascular specialist
  • Immediate via ED or on call vascular specialist via switchboard
  • For discussion with a consultant ring switchboard and ask for vascular surgeon of the week

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: May 2015