Peripheral neuropathy is a common complication encountered in people with chronic alcohol abuse. According to an estimate, the prevalence of alcoholic neuropathy is about 46.3% in people who abuse alcohol. In the United States, about 25 to 66% of chronic alcohol abusers might have some degree of polyneuropathy. However, the exact figures vary. An understanding of the pathophysiology and management of alcoholic neuropathic ulcers is critical for wound care specialists and podiatrists.

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What Is Alcoholic Neuropathy?

Alcoholic neuropathy is a term used to describe neuropathy or nerve damage resulting from excessive alcohol consumption. It is associated with long-term alcohol consumption.

The mechanism through which alcohol causes damage to the peripheral nerves is presumed to be multifactorial. One such proposed mechanism is the effect of alcohol in inducing nutritional deficiencies, especially of thiamine. Alcohol reduces the absorption of thiamine and other essential nutrients from the intestine. The absence of thiamine can affect the cellular structure in the nervous system. In addition, the metabolites of alcohol also have a direct toxic effect on the nervous system. A combination of these mechanisms can cause damage to the peripheral nerves in chronic alcoholics. 

Alcoholic neuropathy is a slowly progressive disease. Some of the symptoms patients can present with include numbness, paresthesia, and weakness in the distal extremities. As the disease progresses, symptoms might appear in more proximal parts of the limbs. 

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How Does Alcohol Consumption Affect Wound Healing?

Chronic alcohol consumption is a known risk factor for delayed wound healing. In people with chronic alcohol abuse, the response of inflammatory cells is prolonged and protracted. As a result, the wound healing process gets stuck in the inflammatory phase which leads to wound chronicity. Patients with chronic alcohol consumption also have a diminished response of T cells which play a critical role in wound healing.

Another mechanism through which alcohol delays wound healing is peripheral neuropathy. People with peripheral neuropathy have a diminished sense of sensation which means that trauma to the extremities goes unnoticed. Autonomic neuropathy that can occur in patients with chronic alcohol abuse alters the blood supply to the skin. As a result, the tissues are more vulnerable to skin trauma and delayed wound healing.

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Wound Care And Management For Alcoholic Neuropathy

The management of wounds resulting from alcoholic neuropathy is similar to the treatment of other neuropathic ulcers. A thorough assessment by a wound care specialist and a podiatrist is necessary to prevent the progression of the disease.

History And Physical Examination

Obtain a complete and thorough medical history relevant to the wound characteristics. This includes asking about its duration, site, recurrence, and history of any previous ulcers. In addition, enquire about the amount and duration of alcohol consumption.

A physical examination will reveal lower extremity sensory loss in patients with alcoholic neuropathy. Sensory testing of the lower extremities can be done with a monofilament. Another common finding is loss of deep tendon reflexes, thinning of skin in the lower legs, and lower-limb weakness and atrophy. The wound size and depth should be measured and recorded on each visit to determine the progression of the disease.

Lab Investigations

Following lab tests and investigations should be ordered for the evaluation of alcoholic neuropathy:

• Chemistry Profile: Chronic alcohol consumption results in deranged liver function tests.
• Blood sugar levels: Diabetes is a leading cause of peripheral neuropathy and lower-extremity ulcers. Therefore it should be excluded as a cause before diagnosing alcoholic polyneuropathy.
• Thiamine and folic acid levels: Nutritional deficiencies contribute to the development of polyneuropathy in patients with chronic alcoholism.
• Nerve Conduction Studies: Motor nerve conduction studies might reveal a delay in the conduction velocity. The sensory nerve potentials are also reduced or diminished in alcoholic polyneuropathy.
• Needle Electromyography (EMG): The EMG studies of the distal extremities will reveal abnormal results and patterns consistent with peripheral denervation.

Wound Management Principles

Following are the principles of wound management in patients with alcoholic neuropathy:

• Wound Pain: Neuropathic pain can be severe and debilitating. As neuropathic pain doesn’t respond well to conventional analgesics, consider offering tricyclic antidepressants or gabapentin.
• Wound Debridement: As with most chronic wounds, neuropathic wounds contain dead, necrotic tissue. The presence of devitalized tissue impedes wound healing. Wound debridement should be carried out after every 7 to 14 days for the removal of devitalized tissue. It also helps to decrease the bacterial load at the wound site.
• Offloading: Patients with polyneuropathy are at increased risk of developing pressure ulcers due to unnoticed trauma. Patients should be offered offloading devices and casts which help to redistribute the pressure over the entire foot. Some methods of offloading include total contact casting and cast walkers. Offloading has been found to reduce the recurrence of neuropathic ulcers.
• Hyperbaric oxygen therapy: Hyperbaric oxygen therapy improves the local blood supply at the wound site. Therefore, adjunct treatment with hyperbaric oxygen therapy can help improve wound healing.

Other Management Strategies

The treatment and management of wounds in patients with alcoholic neuropathy require addressing the underlying cause:

• Drinking cessation: Reducing or limiting alcohol intake can significantly improve symptoms in patients with alcohol cessation. Therefore, counsel patients for drinking cessation. Referring chronic alcohol abusers to rehabilitation services should be considered.

Thiamine Supplementation: Thiamine or vitamin-B1 deficiency is one of the main culprits behind alcohol-induced polyneuropathy. Therefore, offer thiamine and other vitamin supplements. Thiamine supplementation can help reverse some of the symptoms associated with alcoholic polyneuropathy.