CBD Oil For Leg Ulcers

Canadian Study Finds CBD Helps Diabetic Foot Ulcers Canadian Study Finds CBD Helps Diabetic Foot Ulcers Posted by Lori Ann Reese on 10/13/2020 in News Updated on October 16, 2020. Topical cannabis: A pioneering approach to wound healing. Several research studies show that medical marijuana can help heal the skin. Is it a possible solution for bothersome skin ulcers & skin wounds?

Canadian Study Finds CBD Helps Diabetic Foot Ulcers

Canadian Study Finds CBD Helps Diabetic Foot Ulcers

Posted by Lori Ann Reese on 10/13/2020 in News

Updated on October 16, 2020. Medical content reviewed by Dr. Joseph Rosado, MD, M.B.A, Chief Medical Officer

Circulatory issues are a problem for everyone in our increasingly sedentary society. Have you ever calculated how much time you spend sitting? If you work in an office, you clock about eight hours per day at a desk. Maybe ten. If you drive to work or take public transit and commute, you can add another 1-2 hours per day of sedentary positioning. After dinner, and tired from the day, most of us head to the couch to watch TV for an average of 2-3 hours before bed.

That adds up to as much as 13-15 hours per day of low to no physical activity. The average American sleeps about 6-7 hours per night. That means we are only potentially active on average, for about 2-3 hours per day. And our bodies aren’t biologically designed for that kind of lifestyle.

The loss of circulation to extremities is a severe health problem for individuals with Type I or Type 2 Diabetes. And more common with people diagnosed with Diabetes for a variety of reasons. First, the bloodstream’s high glucose levels (sugar) lead to a thickening of the blood. That deposits more plaque that narrows the pathways of major arteries and veins. It restricts the blood flow (particularly to extremities like the legs and feet).

The loss of efficient circulation also impacts organ function for patients with diabetes. With a lower blood supply, the kidneys and liver can become compromised. Major organ functioning is also impaired by glucose (sugar), impacting the pancreas and preventing cardiovascular issues like an increased risk of heart attack and stroke.

What Causes Leg and Foot Ulcers for Patients With Diabetes?

Whenever your body is fighting off a virus or bacterial infection, it relies on the bloodstream to carry white blood cells. Leukocytes are the scientific name for white blood cells, and they are the chief defenders or security guards of the human body. Whenever there is an infection, the brain triggers an immune system response that sends more leukocytes to the area of disease. That’s how the body fights off infection.

One of the problems that occur when blood circulation is compromised is an impact on immune system functioning. You’ve probably heard that people who have diabetes are more prone to infections. This stems in part from issues with healthy blood circulation.

When circulation is a problem due to restricted blood flow, the body can’t deliver as many leukocytes to infection areas. All it takes is one small cut to the leg or foot to become infected. In a person who is not immune-compromised, the infection can clear up with wound care and antibiotics. But oral antibiotics also rely on the bloodstream for delivery throughout the body, and they can be less effective for people with diabetes.

Peripheral neuropathy can cause muscle weakness and loss of reflexes. This changes how a person walks and leads to deformed feet and conditions like hammertoes and Charcot’s foot. Diabetic ulcers develop when there is uneven pressure or friction on feet or ankles. Numbness from circulation loss makes it hard to detect pain in the area as well.

Infections Are Hard to Resolve for Individuals Who Have Diabetes

When the body cannot heal a wound and delivering white blood cells to the infection site is compromised by circulatory issues, the wound does not get better. In fact, the tissues in the area of the wound site can become necrotic. Gangrene can set in. When a severe infection happens to a person with diabetes, ulcers like look like open wounds can appear. And they are extremely difficult to heal because the immune system is compromised.

When a severe infection cannot be resolved and gangrene has been diagnosed, the next step is removing the necrotic tissue. This can include amputation of toes, excising tissue in the infected area, or possible leg amputation. Amputations are performed only in the most challenging situations when an infection will not resolve. And when the patient is at risk of systemic spread of the disease throughout the body and bloodstream, which can lead to sepsis, heart attack, or stroke.

Intractable Ulcers Can Be Life-Threatening When They Do not Heal.

An intractable ulcer for a patient with diabetes refers to a wound that will not heal. Patients can receive oral and IV antibiotics in varying degrees of strength to try to address the infection. But as diabetics can be severely immune-compromised, it doesn’t always work.

Amputation is a last resort for patients with diabetes because it presents other health risks. Just as the patient cannot heal from the original foot or leg ulcers, major surgery can exacerbate symptoms. And contribute to a more severe infection. Often patients are required to be on home IV infusions of strong antibiotics for weeks after surgery.

Finding a better way to treat diabetic leg ulcers is a high priority in the medical community. Did you know that 34.2 million Americans are living with diabetes? And approximately 1 in 3 Americans have pre-diabetes (high risk to develop chronic disease). Just under 80,000 people worldwide die from complications from diabetes annually.

Is Topical CBD a New Approach to Healing Diabetic Foot and Leg Ulcers?

A new medical study from Toronto, Canada, has created hope and the potential to treat diabetic ulcers with CBD topical creams successfully. In Canada, both medical and adult-use cannabis is legalized at the federal level. This allows medical research into chronic diseases and cannabis therapeutics applications to progress unhindered, unlike the United States. Both fundings for cannabis research and access to cannabis for clinical studies is restricted.

The research conducted by the Canadian scientists was recently published in the International Wound Journal. The clinical trial involved two patients who had persistent leg ulcers. The clinical trial results are very encouraging and offer new hope for patients diagnosed with diabetic neuropathy and ulcers.

The clinical trial involved the application of a blend of cannabinoids, terpenes, and flavonoids. The patients were seniors with low immune system functioning and circulatory issues. The ulcers that inflicted both patients were treatment-resistant. Physicians had exhausted all other approaches to curing the ulcers for the patients who were facing systemic infections.

One patient saw a complete wound closure within 74 days of treatment with the proprietary blend of terpenes, cannabinoids, and flavonoids. The second patient saw complete wound healing after 77 days. Both patients reported relief of pain in the ulcerated wound areas and surrounding tissue.

What Does the New Research Mean for Patients with Diabetic Foot Ulcers?

In the not so distant future, hospitals, long-term care facilities, and home healthcare teams may be able to prescribe and administer the breakthrough treatment. One of the most beneficial aspects of a topical solution is that it presents no secondary infection risk to the patient.

Instead of unsuccessfully fighting diabetic ulcers to the extent that the tissue becomes necrotic (dead or gangrene), requiring removal, this presents a new treatment possibility. One that could save lives and prevent invasive surgical procedures like amputations in the future for patients with diabetic neuropathy and treatment-resistant ulcers.

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Topical Cannabis for Leg Ulcers

Like many great discoveries in medicine, it started with an ‘Aha’ moment when Canadian physician Dr. Vincent Maida realised that leg ulcers could be penetrated by fat-loving cannabis compounds, which in turn could reach the plethora of cannabinoid receptors below.

Very few people are more committed to finding a better solution for wound management than Dr. Maida, who amongst other things runs a tertiary wound clinic caring for the most hard-to-heal leg ulcers in the greater Toronto area.

“Integument [the outside skin, cutaneous membranes and mucous membranes] and wound is the area of healthcare with the worst outcome measures,” explains Maida. “And yet, when you look at the massive expenditures – the United States spends upwards of $80 billion a year on wounds. And most of that I can submit to you is in vain and is just silly dressings that do nothing.”

Leg wounds that refuse to heal

Unless we ourselves are elderly, or care for someone over the age of seventy, it’s unlikely we’ve ever given much thought to leg ulcers, which are defined as a long lasting sore that takes more than two weeks to heal.

In the worst of cases, open leg wounds can lead to amputations, sepsis, and even death.

I certainly hadn’t until my brother, who like me has been blessed with a hearty array of varicose veins from a tender age, started to get leg wounds that refused to close.

A largely sedentary lifestyle meant his already compromised venous flow wasn’t robust enough to provide the necessary conditions for healing some innocuous bumps and scratches, which subsequently turned into rather nasty open leg wounds.

Standard care for leg ulcers follows the ‘Wound Bed Preparation’ paradigm (in Dr. Maida’s words the ‘silly dressings’), alongside compression bandages to assist the venous return and speed up healing. Antibiotics are also routinely prescribed for any accompanying infections, although according to Maida there is a tendency to overprescribe.

In my brother’s case, twice weekly visits for dressing changes over three months were enough to see his wounds close. But according to Dr. Maida, he was one of the lucky 40% whose ulcers heal in under twelve weeks. The other 60% can go years with open leg wounds, which in the worst of cases can lead to amputations, sepsis, and even death.

Opioids slow down wound healing

Ulcers are also generally extremely painful, with around 70% of patients, according to Maida, prescribed opioids to manage the pain.

Not only does pain reduce the body’s healing capacity, but opioids themselves are now thought to slow down the healing of chronic wounds. And with the opioid crisis still wreaking havoc across North America, it’s clear that finding an alternative approach to both the management of wound pain and its overall healing must be found.

Which brings me back to Dr. Maida’s lightbulb moment.

Determined to find a more effective alternative to the current Wound Bed Preparation Protocol, Maida embarked on a Master’s Degree at the Dalai Lama School of Public Health in Toronto.

“Working in a country like Canada,” he recalls, “where the (medical cannabis) legalization pathway was evolving, it was one of those epiphany moments, I realised that there was a potential to use cannabis and the elements of cannabis in the arena of integument and wound.”

And so began the early stages of his research studying the preclinical data relating to the wound healing properties of compounds found in cannabis.

Cannabis epiphany

It should be pointed out at this stage, that we’re not just talking about cannabinoids like THC and CBD , but also terpenes such as beta caryophyllene, and the flavonoids quercetin, diosmin and hesperidin. In fact, a FDA approved drug called Daflon is already on the market in the US for the treatment of venous circulation disorders combining the flavonoids diosmin and hesperidin.

But what made these cannabis compounds so well suited to ulcer healing was their ability to enter directly through the wound and reach the endocannabinoid receptors below.

“The surface of our skin is relatively intact,” explains Maida, “and whether it’s mucous membranes, or cutaneous membranes, you don’t get much absorption through intact integument. But when you have a wound, you don’t have the epidermis. And the various molecular families can penetrate much quicker through an open wound bed.”

“And that’s where it gets exciting,” says Maida, “because we now know that the endocannabinoid system is ever present in our bodies from head to toe. It’s the most significant chemical signalling system from a homeostatic standpoint in our bodies. Not only is it represented and expressed on the surfaces of cells, but recent research is showing just how influential it is at an intracellular level, which opens up this new spectre of the ability to modulate genes, aka epigenetic mechanisms, etc.”

So, unlike the usual challenges faced by cannabis topical creams which struggle to permeate through the dermis, for wound management at least, they are a therapeutic match made in heaven.

Ulcers are extremely painful, but opioids may slow down the healing of chronic wounds.

Promising preliminary results

And the results Dr. Maida has seen with his patients appears to bear this out.

Using a proprietary blend of cannabis compounds based on his systematic review of data, Dr. Maida began tentatively treating patients in his wound clinic.

“My wound practice was the perfect environment to try to innovate something that hopefully would improve the currently unsatisfactory status quo,” he says. “So I recruited the worst of the worst, and I was able to heal the worst of the worst, which makes me think if I’m able to heal the worst of the worst, imagine what I could do for everyday wounds.”

Preliminary results cataloguing the experience of two elderly patients who despite having borne the suffering of their wounds for over six months, found total closure using Dr. Maida’s cannabis-based treatment in a mean of 73 days. Not only that, the patients’ pain was significantly reduced so that by day 63 no other analgesics were required.

A further open label study self-funded by Dr. Maida in which fourteen complex patients with recalcitrant leg ulcers were treated with his formula alongside compression bandages found that 79% patients had total wound closure in jaw-dropping 34 days.

While impressive, Maida is first to admit these are preliminary results on a small cohort of patients, and he hopes a letter of intent from an international biotech company will eventually bring about the further phases of clinical trials required to get his cannabis-based topical drug to market.

In the meantime, Dr. Maida remains very much a man on a mission.

“So, I’ve started the race,” he says, “and I’m going to sprint down the track. And then ultimately, I need to hand off to others who are going to take the marathon forward. And if nothing else, that’s my role. That’s my mission… and I think the finish line is going to yield incredible opportunities for the world of integument and wound.”

Mary Biles, a UK -based journalist, educator and Project CBD contributing writer, is the author of The CBD Book (Harper Collins, UK ). Dr. Vincent Maida’s full interview can be heard on the Cannabis Voices podcast hosted by Mary Biles.

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Copyright, Project CBD . May not be reprinted without permission.

Medical Marijuana May Help Heal Skin Ulcers & Skin Wounds

Sometimes getting a cut or wound on your legs isn’t a big deal, but when it doesn’t heal as expected then you likely have a skin ulcer to contend with. When it comes to skin ulcers, it is always recommended to seek medical advice as there could be other serious underlying health issues that are causing necrosis or death of your skin. Some patients are finding that medical cannabis can help improve their skin symptoms by reducing inflammation , itching, and accelerating wound healing.

Medical cannabis contains 100s of naturally-occurring compounds including cannabinoids. When we ingest or use cannabinoids on our skin, our endocannabinoid system (ECS) kicks in. The ECS of our body consists of fat-based neurotransmitters called endocannabinoids as well as cannabinoid receptors CB1 and CB2. When cannabis and its cannabinoids, including Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD) , contact CB1 and CB2 receptors, interesting things can happen. Cannabinoids can increase or decrease our natural endocannabinoid levels which can play a role in a variety of bodily processes including maintaining proper body temperature, modulating our immune system, and pain relief, as well as how we perceive chronic pain , and nausea .

Typically, CB1 receptors are primarily found in the central nervous system while CB2 receptors are found in various tissues in the body. When it comes to our skin, researchers have found that both CB1 and CB2 receptors are found in plentiful numbers. They can be found in keratinocytes of the top layer of the skin as well as in skin nerve fibers, skin cells, melanocytes that produce skin pigment, hair follicles, and the primary sweat glands (3). This makes the skin a good target to treat with medical cannabis and its cannabinoids. Keratin-producing keratinocytes and skin cells that produce collagen, called fibroblasts, also contain large amounts of endocannabinoids. Anandamide (AEA) and 2-arachidonoylglycerol (2-AG) are found in these cells that are responsible for maintaining our skin’s structure.

Cannabinoids from medical marijuana can also interact with other chemical pathways in our bodies that are not part of the ECS. Transient Receptor Potential (TRP) receptors can be found in a variety of skin cells that are responsible for the formation and maintenance of the skin barrier and skin cell growth as well as modulating the inflammatory process and immune cells of the skin (3). Another type of receptor found in the skin that interacts with cannabinoids is called peroxisome proliferator-activated receptors (PPAR) which are responsible for regulating the expression of our genes in the skin.

Check out our ulcers guide to find more information about how various types of ulcers can be treated with medical marijuana.

Can Medical Cannabis Help Heal Wounds?

Now that you know the basics about how cannabis interacts with the skin, it’s time to find out what kind of role it can play when it comes to skin ulcers and wound management. Wound healing is a complicated process, but it can be broken down into three phases that overlap and include inflammation, proliferation, and maturation or tissue remodeling (3). Researchers believe that the ECS plays a heavy role in this process as CB1 and CB2 receptors interact with immune system cells in the skin and fibroblasts. When the cannabinoid receptors are activated and the endocannabinoid levels change, the immune cells upregulate anti-inflammation efforts and indirectly activate TRP receptors and epidermal growth factor receptors. Slowing down fatty acid amide hydrolase (FAAH), the enzyme that degrades cannabinoids, also helps prolong and promote cannabinoid treatment.

In addition to helping skin regrowth, fibroblasts also play a role in reducing inflammation and pain perception in the skin (5). Not only are they responsible for the transition from acute to chronic inflammation, but it has also been shown that if fibroblasts are impaired, they can impair a wound from properly closing.

A 2017 study tested the effects of CB2 receptors in both fibroblasts and keratinocytes with promising results. This study examined human cell cultures of both keratinocytes and fibroblasts in neonatal skin (5). Researchers found that both CB1 and CB2 receptors were stimulated by JWH015, an anti-inflammatory stimulus, in both keratinocytes and fibroblasts. This resulted in an enhanced healing response to inflammation of the skin cell samples. Though this study didn’t specifically use cannabis to activate CB1 and CB2 receptors, it is strong groundwork for the potential of cannabinoids to help assist with wound healing in humans through the same receptors. This is important because many studies talking about wound healing and cannabinoids have taken place in animals.

Since we know how these cells function within the ECS to repair the skin, we can also see the effects of cannabinoid receptors when it comes to hypertrophic scars. These scars are caused when the skin doesn’t heal properly, leaving the scar thick, itchy, and raised. A 2020 study from Scientific Reports examined 50 female bariatric surgery patients before and after surgery. These patients were separated into groups based on whether they had normal scarring or hypertrophic scarring (8).

Endocannabinoid levels of the scar tissues and blood plasma levels were measured for AEA, 2-AG, palmitoylethanolamide (PEA), and oleoylethanolamide (OEA) as well as blood. Researchers saw no difference in measurements of blood plasma and skin endocannabinoids between the two groups. However, they did find that in the group of patients who had hypertrophic scars, that AEA concentrations were significantly lower than in normal scarring (8). Due to the deficiency of AEA, the researchers of this study believe that dysfunctions of ECS and its endocannabinoids can lead to poor wound repair. This is important because it proves that the ECS is necessary for wound healing and it also means that the skin is a potential pathway for raising endocannabinoid levels for skin healing.

CBD & Wound Healing

Though there are not many qualitative and quantitative clinical studies focusing on cannabinoids for wound and skin ulcer healing, researchers believe that CBD and other cannabinoids found in medical cannabis can help the skin repair itself.

A study reviewing three separate cases of patients with a rare skin disorder called epidermolysis bullosa shows promising results (7). Epidermolysis bullosa is characterized by fragile skin that blisters and results in pain, itching, limited mobility, and recurrent infections. CBD is known for its anti-inflammatory and analgesic, or pain-relieving abilities. This was shown to also be the cause in these three patients. All the patients experienced quicker wound healing, less blistering, and less pain after applying topical CBD to their skin. One patient was able to completely stop using opioids for pain after using the CBD topical.

In 2019 another study focused on whether the use of ethanol extracted Cannabis sativa L. (CSE) and CBD exhibited anti-inflammatory effects in the skin (21). Looking at human skin cells, fibroblasts, and keratinocytes, researchers were able to see the effects of CSE and CBD. Both the CSE and CBD did not cause toxic effects to the skin samples. The CSE inhibited the release of pro-inflammatory mediators in the skin cell samples while CBD paralleled these effects, making it a likely contributor. The CSE was found to have greater results in its role in wound healing and the inflammatory response triggered during the healing process. This may be due to the lack of the entourage effect using CBD alone.

Researchers in this study believe that because CBD did not inhibit pro-inflammatory mediators as much in this case, that potentially other cannabinoids or terpenes in the CSE were responsible for this effect (21). It is important to note that this study also cites that other studies have found that CBD does inhibit pro-inflammatory mediators in the same way as the CSE, just not as much on its own. Though more research is still needed for determining medical cannabis’ role in wound healing, these researchers believe that there are other chemical compounds (that weren’t specified) in cannabis that can also help in wound healing.

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Ulcers and Medical Cannabis: Considerations to Keep in Mind

If you believe you have a severe wound or skin ulcer that is not healing, it is crucial that you reach out to a medical professional for assistance. Your ulcer or wound may represent a serious illness, cancer , or be infected and may require antibiotic treatment. If the infection is not treated it may lead to gangrene or the affected limb being potentially amputated.

Medical use of the cannabis plant may not be right for everyone including patients with a pre-existing heart condition and kidney or liver problems. Additionally, cannabis may interact with medications. In rare cases, chronic cannabis use may cause cannabis arteritis, a type of vascular syndrome. Cannabis arteritis is a severe peripheral vascular disease that can cause skin ulcers and lead to limb loss as blood flow is restricted by the arteries which can cause a lack of oxygen in the blood and surrounding tissues (10).

Most commonly, advanced diabetes and peripheral artery disease (PAD) are leading causes of ulcers, lower-limb amputations, and even blindness in the developed world due to restricted blood flow and improper nerve and healing functions. This is why frequent foot and eye exams are essential for routine diabetes care.

It is important to note that medical marijuana has additional side effects including altered mood, increased hunger, and it may interact with drugs including those that treat epilepsy .

Another important note is that pain management is also potentially an important use of cannabis for healing skin wounds and ulcers. There are several products that can treat pain including raw cannabis flower, tinctures, and edibles. These products may be available at your local medical marijuana dispensary depending on the state that you live in.

Research on the Effects of Marijuana and Dermatology

A 2021 study from Experimental Dermatology put topical cannabis to the test against venous leg ulcers and had some interesting results. A total of 14 patients with leg ulcers were treated with a combination of compression bandaging and topical cannabis-based medication (16). The cannabis-based topical was reapplied every second day. Complete wound closure was achieved by 79% or 11 of the patients in a median of 34 days. The remaining patients were also showing signs of wound healing but were unable to return for follow-up. Most of these patients were considered geriatric with the average age of participants being 75.8 years old.

Because of the medical complexity of many of these patients, this study shows a lot of promise for treating venous leg ulcers with a combination of compression therapy and cannabis-based topical products (16). This area of study warrants further research with larger groups of patients that are designed as controlled trials in order to clearly determine the effects of the use of marijuana on leg ulcers. Further studies should also help explore what ratio of cannabinoids or dosing of topicals might work best in different circumstances.

Types of Skin Ulcers

Skin Ulcers are open sores that can affect any area of the skin. Many of the following ulcers typically form on the legs and they can be an indication of a more serious medical issue (22). If you suspect you have an ulcer or a wound that hasn’t healed for several weeks, it is important to see your doctor for help.

Skin ulcers can be broken down into two groups that include circulation ulcers and ulcers caused by injury or pressure. These subtypes are broken down below:

Circulation Ulcers

Circulation ulcers result from medical conditions that may cause issues with arteries or veins. They include:

Arterial Ulcers

Arterial or ischemic ulcers occur when there are blocked arteries in the legs. The arteries are responsible for taking oxygenated blood from the lungs to other organs. When they are blocked, the arteries can no longer bring oxygen to other tissues, including the skin, and this tissue starts to die, causing an ulcer to develop. These ulcers are very painful sores that are often found on the foot, ankle, and lower leg (2). They often cause more pain at night when the patient is trying to sleep.

Arterial ulcers can be caused by (2):

Venous Ulcers

Venous ulcers are long-lasting sores that typically appear on the ankle or legs. They typically are caused by damage to the valves inside your veins (22). Our veins are responsible for bringing blood back to the lungs to get more oxygen to circulate around our bodies. Venous ulcers are very painful, swollen, and can be itchy. There may be skin discoloration around the ulcer and leak a foul-smelling discharge (23).

Venous ulcers may be caused by (23):

Ulcers Caused by Injury or Pressure

In addition to circulation-related issues, there are several skin ulcers that can be caused by a wound not healing properly after an injury as well as from pressure or friction. These ulcer types include:

Ulcers can form from wounds that occur after the skin has been injured. Typically, the body can heal cuts or scrapes, but if it is persistent an ulcer can develop and become infected. These ulcers are typically painful, inflamed, swollen, or crusty (17). Sometimes they may ooze a strong-smelling green or yellow discharge. If the ulcer or wound has this abnormal discharge, prompt medical attention is necessary as you may require an antibiotic for treatment.

Pressure Ulcers

Formally known as decubitus ulcers or bedsores, these ulcers occur when pressure is put in one place over time and causes damage to the skin (9). Sitting or lying in the same position can cause your blood supply to be cut off from specific areas of the skin. Once the skin is damaged from this pressure, the tissues and skin start to die, and an ulcer develops.

Pressure ulcers are most common on parts of the body with bony prominences such as the hips, tailbone, elbows, heels, shoulder blades, knees, and the back of the head (9). If you are unwell and in bed for a long period of time, it is important that you reposition at least once every two hours, so these ulcers do not form.

The following increases your risk of pressure ulcers (9):

  • Pressure or friction on the skin
  • Moisture
  • Incontinence
  • Impaired mobility
  • Chronic medical conditions
  • Impaired sensations
  • Infection
  • Increased steroid use
  • Advanced age

Neuropathic Ulcers

The final type of skin ulcer is called neuropathic ulcers. These ulcers occur after a patient has developed poor neurological sensation of the peripheral nervous system, including their limbs. When this happens, the patients are unable to move their limbs or feel properly and pressure points cause the skin to form ulcers without the patient realizing it because of advanced neuron degeneration (11). These ulcers can be caused by several common conditions including (11):

Note: Veriheal does not intend to give this as professional medical advice. Do not attempt to self-diagnose or prescribe treatment based on the information provided on this page. Always consult a physician before making any decision on the treatment of a medical condition.