Diabetic Foot Care in Winter: A Season of Vigilance and Grace

Dr. Asif Shahariar
Patient, Proposal

13

Jan 26

Abstract
Winter presents a distinct set of challenges for patients with diabetes in Bangladesh who are at heightened risk for foot complications. The combination of peripheral neuropathy, peripheral arterial disease, impaired immune response, cutaneous dryness, and colder ambient temperatures with associated vasoconstriction, reduced physical activity, use of open or thin footwear, and exposure to damp conditions from fog, dew, and humidity creates a “perfect storm” for foot ulceration, infection, delayed wound healing, and, ultimately, amputation. This review summarizes the pathophysiology of diabetic foot risk during the cooler months in Bangladesh, highlights environmental and cultural factors that contribute to vulnerability, and examines evidence-based preventive strategies including appropriate footwear and sock use, moisture control, foot-temperature monitoring, and structured care models. The discussion also addresses patient education, socioeconomic considerations, and psychosocial barriers that influence self-care. Key evidence includes systematic review data supporting temperature monitoring and targeted footwear interventions. Clinicians should adopt a season-specific approach in Bangladesh, emphasizing vigilance, proper insulation, dryness, off-loading, and early referral for any concerning foot changes.

Keywords: diabetes mellitus, diabetic foot ulcer, neuropathy, cold weather, foot care, prevention.

Introduction
The lower-extremity complications of diabetes mellitus particularly foot ulceration, infection, and lower-limb amputation remain major contributors to morbidity, mortality, and healthcare burden. Individuals with diabetes frequently develop peripheral neuropathy, microvascular and macrovascular disease, and impaired wound healing. In Bangladesh, the winter season introduces additional hazards to foot health: colder ambient temperatures, dense fog and dew leading to damp footwear, dry indoor air from increased use of room heaters, and reduced physical activity. These conditions further worsen circulatory compromise and sensory loss, increasing the likelihood of unnoticed injury, skin breakdown, ulceration, and infection.

The purpose of this review is to highlight the particular vulnerability of the diabetic foot in winter, to collate the available evidence around preventive interventions, and to propose a clinical framework for vigilance and “grace” in care grace meaning a thoughtful, patient-centred, season-aware approach.

Winter‐related Pathophysiologic Challenges in the Diabetic Foot

  1. Peripheral neuropathy and sensory loss
    One of the hallmarks of diabetic foot risk is sensory loss, especially temperature, pain and pressure detection deficits. Patients may therefore be unable to detect trauma, cold injury or burns. Winter settings contribute additional risk: direct exposure to cold surfaces, heaters, or warming devices may result in burns that go unnoticed.1,2
  2. Impaired circulation and vasoconstriction
    Cold ambient temperatures induce vasoconstriction in superficial vessels. In individuals with diabetes who already have microvascular and macrovascular compromise, this can reduce perfusion to the distal foot tissues, impairing warmth, oxygen delivery and healing capacity.3
  3. Moisture, maceration, and infection risk
    During winter in Bangladesh, cold mornings, dense fog, and persistent dew often leave the ground and footwear damp, leading to wet socks, moisture between the toes, and softened skin. These cool and humid conditions promote maceration and support bacterial and fungal growth, increasing the risk of foot infections in people with diabetes. Professional diabetic-foot guidelines consistently emphasize maintaining dry feet as a key preventive measure during the colder months.2
  4. Dry skin, fissures and callus formation
    The combination of outside cold air and dry indoor heating (although uncommon in Bangladesh) often results in cutaneous dryness. In persons with diabetes, skin repair is impaired; cracks, fissures or callus formation can become entry portals for ulceration.3
  5. Reduced mobility

Cold mornings, damp pavements, and foggy conditions in Bangladesh can make walking uncomfortable, leading to reduced ambulation. Reduced foot movement decreases muscle activity and circulation, which may contribute to fluid stasis, swelling, or impaired blood flow in the lower limbs. While not unique to diabetes, these winter-related factors add to the overall risk of foot complications in people with diabetes.

  1. Delayed wound healing, immune compromise
    Hyperglycaemia, impaired neutrophil function and poor tissue perfusion common in diabetes are further stressed by cold-related vasoconstriction, locally decreased temperature and potentially delayed recognition of injury.3

This convergence of winter-related factors means that what might be a minor foot injury during warmer months can more easily progress to a clinically significant ulcer or infection in a person with diabetes.

Evidence‐based Preventive Strategies for Winter
The following strategies, informed by the literature, are particularly pertinent for winter-specific foot care.

  1. Daily foot inspection and patient education
    Annual and periodic foot examinations remain paramount; in winter the frequency of self-inspection should be emphasized. Patients should be taught to look for blisters, redness, cracking, wetness, cold feet, and to monitor their shoes/insoles for foreign objects. The information pamphlet from the American College of Foot and Ankle Surgeons (ACFAS) reinforces this.4
  2. Foot temperature monitoring
    A meta‐analysis reported that in persons at moderate or high risk, at-home foot temperature monitoring reduced diabetic foot ulcer (DFU) incidence (relative risk [RR] 0.51; 95% CI 0.31-0.84).5 A further systematic review found moderate-certainty evidence that temperature monitoring and pressure-optimized footwear reduce ulcer recurrence (RR for temperature monitoring 0.51; 95% CI 0.31-0.84).5 In the winter months in Bangladesh, thermal monitoring is especially important, as cold-related changes in blood flow can lead to localized warming (“hotspots”) on the feet that may precede skin breakdown or ulcer formation in people with diabetes.
  3. Appropriate footwear and socks
    Choosing shoes with adequate insulation, waterproofing, roomy toe box (to avoid pressure points), and non-slip soles is critical in winter. Socks for people with diabetes should be warm, moisture-wicking, and non-constrictive, as tight, or poorly fitting socks can impair circulation and worsen neuropathy-related risks. Choosing socks made from breathable, moisture-managing materials and changing them promptly when damp can significantly reduce the risk of skin breakdown, ulcers, and infection.5
  4. Moisture control and skin care
    Feet should be kept dry; wet socks should be changed promptly when outdoors. Moisturizer use is recommended for dry cracked skin—excluding application between toes (to avoid fungal overgrowth).6
  5. Avoidance of direct heat sources and burns
    Because diabetic neuropathy may blunt thermal sensation, patients may unknowingly injure feet when using heaters, heating pads, hot water bottles or fireplaces. Such exposures should be avoided.1
  6. Maintain glycaemic control and promote circulation
    Good glycaemic control, cessation of smoking, management of peripheral arterial disease and promotion of physical activity (even indoors) support foot health. While winter may reduce outdoor activity, indoor foot/leg exercises and regular ambulation (as tolerated) help preserve circulation.3
  7. Regular professional foot care and multidisciplinary approach
    Winter may increase foot-care demands; clinicians should ensure timely podiatric or foot/ankle specialist referral when risk factors abound (e.g., neuropathy, prior ulcer, PAD, renal impairment). The ACFAS recommends periodic examination to identify early signs of skin breakdown.1

Clinical Application and Season-Specific Considerations
For clinicians caring for patients with diabetes in winter, a season-specific checklist may be useful:

  • Risk stratification: Review patients’ foot-ulcer risk (neuropathy, prior ulcer/amputation, PAD, renal disease). Recognize that winter may amplify risk in even moderate-risk individuals.
  • Patient counselling: At the beginning of the colder season, reinforce foot care education: daily self-inspection, warm/waterproof footwear, avoiding damp socks, checking water/foot bath temperatures, and avoiding barefoot walking indoors.
  • Foot temperature monitoring: For those at moderate/high risk (eg, prior DFU or neuropathy), implement or review at-home foot temperature monitoring (≥6 sites per foot daily, reduce activity if >2.2 °C difference between feet for two consecutive days).6
  • Footwear/sock review: Have patients show their winter shoes; assess for appropriate fit, toe box space, insulation, water resistance, sole grip. Advise socks that are warm but not tight; wool or thermal blends plus moisture-wicking liners are optimal.
  • Moisture management: Remind patients to remove shoes/socks if wet, dry feet (especially between toes), apply foot cream (not between toes), avoid heating pads or direct heat.
  • Monitoring for cold-injury conditions: In Bangladesh, while extreme cold is uncommon, cold mornings and prolonged exposure to chilly, damp environments can still trigger conditions such as Raynaud’s phenomenon, which reduce blood flow and increase the risk of foot injury in people with diabetes. Awareness and protection of the feet during colder months can help prevent complications.7

  • Encourage movement: On days when outdoor ambulation is limited by weather, advise indoor foot/leg exercises (toe wiggling, ankle pumps, short walks) to maintain microcirculation.4
  • Prompt referral: At the first sign of foot redness, ulceration, increasing temperature/swelling, or signs of infection (especially in a cold-weather context), refer to general practitioner or wound care without delay.

Discussion
Winter presents an under-appreciated yet clinically significant season of increased foot risk in people with diabetes. While much of the literature focuses on diabetic foot care generically, recognition of the seasonal exacerbating factors is critical. The evidence-base for temperature monitoring and pressure-optimised footwear is strengthening: the meta-analysis demonstrating a ~49% reduction in DFU occurrence with foot temperature monitoring (RR 0.51) is compelling.5 However, the evidence is less specific to winter conditions per se. Much of the winter-specific guidance is derived from expert consensus, patient-education materials and building physiology (eg, vasoconstriction, moisture risk) rather than randomized trials.

Importantly, winter adds multiple layering risks: cooling of the feet reduces perfusion, dampness increases infection risk, and neuropathy prevents accurate sensation of temperature/trauma. The intersection of these risks with the known diabetic foot pathology mechanisms (microangiopathy, neuropathy, immune dysfunction) makes winter a season of heightened vigilance rather than reduced concern.

From a clinical standpoint, the review underscores the need to treat foot-care not as a static annual review but as a dynamic process that adjusts for seasonal risk. For example, a patient walking happily in loafers in summer may require waterproof insulated boots and wool/thermal socks in winter. Patients with neuropathy may need additional monitoring of their indoor foot environment: do they use portable heater and are they placing their feet near the heater? Are they wearing slippers when walking on cold tile floors? Are they drying off properly after snow exposure? Are they noticing changes in skin colour, temperature, or sensation?

The review also highlights potential gaps and research opportunities: there is a need for RCTs specifically examining winter-tailored interventions (e.g., insulated footwear + temperature monitoring vs standard care in cold climate diabetic patients), and for studies exploring how indoor heating practices or cold exposure contribute to foot complication risk in diabetes. In addition, cost-effectiveness analyses of winter-specific interventions (extra socks, boot subsidies, at-home thermometry) would be valuable, particularly in low-resource settings.7

Conclusion
Winter should not be regarded as simply “same foot-care, colder weather” but rather as “heightened foot-care season” for patients with diabetes. The convergence of cold ambient temperature, moisture risk, vasoconstriction, neuropathy and reduced mobility demands a tailored, proactive approach. Clinicians should adopt a season‐aware mindset: stratify risk, educate the patient early, emphasize daily inspections and temperature monitoring in at-risk individuals, ensure appropriately insulated and fitted footwear/socks, avoid direct heat sources, and maintain glycaemic/vascular health. With this vigilance, the diabetic foot in winter can be managed not with trepidation but with grace—anticipating challenges and pre-empting complications.

Author of this article

Dr. Asif Shahariar

MBBS, CCD(Birdem), PGT

Medical Officer, Aryan Hospital & Diagnostic Centre

References

  1. Prevention of foot ulcers in persons with diabetes at risk of ulceration: A systematic review and meta-analysis. Diabetes Research and Clinical Practice. 2023; 219:111968. doi: 10.1016/j.diabres.2023.111968. (Moderate certainty evidence that temperature monitoring and pressure-optimised therapeutic footwear reduce ulcer recurrence)
  2. Efficacy of at home monitoring of foot temperature for risk reduction of diabetes-related foot ulcer: A meta-analysis. Diabetes/Metabolism Research and Reviews. 2022;38: e3560. doi:10.1002/dmrr.3560. (RR 0.51; 95% CI 0.31-0.84)
  3. Cold Weather Tips for Diabetic Foot Care. PR Newswire. October 31, 2016. (Patient education tips around dryness, footwear, avoiding direct heat)
  4. The Impact of Cold Weather on Diabetic Foot Health: Tips for Winter Foot Care. Podiatry of Greater Cleveland website. November 14, 2024. (Describes cold-weather pathophysiology: vasoconstriction, neuropathy, wet conditions)
  5. 7 Winter Foot Care Tips for Diabetics. FootFiles. (Selects appropriate socks/footwear, moisture control, exercises)
  6. The Do’s & Don’ts for Diabetic Foot Care. ACFAS infographic. (Basic educational tool emphasising dry feet, no direct heat, daily inspection)
  7. Diabetic Foot Care in Colder Weather: Essential Tips to Keep Your Feet Healthy. Podiatry of Greater Cleveland website. (Reinforces winter challenges: wet/damp feet, dryness, necrosis)