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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
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)
- Suspected infection in a diabetic - see Diabetic Foot infections and osteomyelitis
- Arterial insufficiency – correct risk factors for arterial disease
- If concerned urgent referral to vascular specialist
Referral Criteria
- Suspected infection in a diabetic - Emergency referral to diabetes or vascular specialist
- Arterial insufficiency - Urgent referral to vascular specialist
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
