When a Tingling Sensation Is Cause for Concern

By Emory Hsu, MD

You’re taking good care of your diabetes. You’re eating healthier. You’ve cut out sodas and sugary drinks. You’re exercising several times a week. And you’re following the treatment plan prescribed by your endocrinologist.

But one day, you have a pesky tingling pain in your foot. Is it just a little itch, or a sign of something more serious?

Sensations can be complex – many different types of nerves go from your brain to your spinal cord, then from your spinal cord to your skin. Often a little tingling every now and then may not mean much. However, for people with diabetes, it is important to let your endocrinologist know, as it could be a sign of diabetic neuropathy.

Diabetic neuropathy is a common condition that affects around a third of people with diabetes. It comes in many different forms, and symptoms may be different from one person to the next, but it most often affects long nerves, with the longest — the nerves that go out to the feet — impacted the most. Sensory changes in the foot are the most common form of diabetic neuropathy. Other diabetic neuropathies may involve the nerves to the stomach and intestines (gastrointestinal neuropathy), while some may cause symptoms such as dizziness and low blood pressure when standing up. While we do not completely understand how diabetes causes neuropathy, it is thought that high levels of glucose in the bloodstream can cause various types of stress to the nerve cell and lead to damage, particularly to the sensory nerves.

Common symptoms are based on sensation. These include sensations such as tingling, burning and stabbing pain, as well as loss of sensation, such as numbness. Sensations are frequently symmetrical – that is, occurring on both right and left sides. Usually, nerves that carry sensations are affected first, before the nerves that transmit motor signals. Most of the time, people with diabetic neuropathy are still able to walk without any difficulty.

Then why worry? Here’s why: Decreased sensation can mean that cuts and scrapes don’t get detected as easily, especially on hard-to-see places such as the bottom of your feet. In turn, these can lead to ulcers and infections. That’s why it’s important to regularly check the bottom of your feet, including in between the toes. If you have problems seeing or with being able to bend your legs, ask someone close to you to help check your feet regularly. In fact, if you have loss of sensation in your feet, we recommend checking every day! This easy step helps prevent complications down the road.

Tingling or pains are also common symptoms of sensory changes with diabetic neuropathy. Some people describe them as like standing on hot coals, while others may feel a deeper, gnawing pain. Again, there is no one uniform description. If you have pain, let your endocrinologist know.

Your doctor can do a foot exam to make sure you don’t have other causes of pain or sensory loss in the feet. These may include checking blood work, making sure your vitamin B12 level is sufficient, and doing a physical exam to check for other nerve or blood vessel disorders. If your endocrinologist feels like you have severe diabetic neuropathy, a referral to a podiatrist may be recommended. The podiatrist will be able to screen and treat for any ulcers or conditions on the foot and may be able to suggest good socks and shoes, which are actually quite helpful in taking better care of your feet.

The best way to treat diabetic neuropathy is simply taking good care of yourself, the foundation for treating any diabetes complications. This includes healthy eating habits such as avoiding high spikes of carbohydrates or sugarladen foods or drinks. In general, the better your blood glucose control, the less likely you are to develop symptoms of diabetic neuropathy, so stay committed to lifestyle interventions like diet and exercise.

However, if the neuropathyrelated pain progresses, your physician can prescribe medications to help you. One medication is a topical pain-relieving cream called capsaicin. You can get low-dose versions over the counter or ask your endocrinologist for prescription-strength capsaicin. If creams are not enough, there are other medications that are prescribed for diabetic neuropathy pain. Gabapentin and pregabalin are two of the most common ones. Gabapentin will probably be started at a low dose, and your doctor will advise you on how to increase the dose gradually until at the appropriate concentration. Others include various types of antidepressants. Duloxetine is one in a class called “selective norepinephrine and serotonin reuptake inhibitors.” Others are in classes called tricyclics. Some, but not all, of these medications may cause a little sleepiness when first started, so be sure to discuss potential side effects with your doctor before you start. Your doctor can discuss other possible side effects of the drug, such as weight gain, or caution use when the patient also has certain heart conditions. In general, though, drugs such as gabapentin and pregabalin are well tolerated by most people.

Some people may wonder if painkillers such as narcotics (opioids) should be used for diabetic neuropathy. While narcotics may temporarily dull the pain, long-term use may cause medication tolerance, requiring higher and higher doses until they may become less effective. Furthermore, there is a very high risk of addiction and abuse. Thus, narcotics are generally not prescribed for diabetic neuropathy.

While that tingling in your feet may be just an itch, it also may be a symptom of diabetic neuropathy. Don’t worry, though. With help from your endocrinologist, you can exercise damage control by stabilizing your blood sugar so it stops damaging nerves and reduce the risk of further diabetic neuropathy symptoms.