IWGDF Guidelines Summary: Diabetic Foot Prevention and Management
The IWGDF 2023 guidelines provide a risk-stratified approach to diabetic foot care, centered on systematic screening, patient education, therapeutic footwear, and treatment of pre-ulcerative lesions to prevent ulceration and amputation. 1
Risk Stratification System
The IWGDF uses a 4-tier risk classification (Risk 0-3) that determines screening frequency and intervention intensity:
- Risk 0 (Very Low): No loss of protective sensation (LOPS) or peripheral artery disease (PAD)
- Risk 1 (Low): LOPS or PAD present
- Risk 2 (Moderate): LOPS or PAD plus foot deformity, or PAD plus LOPS
- Risk 3 (High): Previous foot ulcer, lower-extremity amputation, or end-stage renal disease
Screening Protocols
Initial Screening (Risk 0)
Screen annually for peripheral neuropathy and PAD in all adults with diabetes. 1
Extended Screening (Risk 1-3)
When LOPS or PAD is identified, expand assessment to include:
- History of foot ulceration or amputation
- End-stage renal disease diagnosis
- Foot deformities (presence or progression)
- Limited foot/ankle joint mobility
- Excess callus formation
- Pre-ulcerative lesions (blisters, fissures, hemorrhage)
Screening frequency based on risk:
- Risk 1: Every 6-12 months
- Risk 2: Every 3-6 months
- Risk 3: Every 1-3 months
Patient Education (Risk 1-3)
Daily Foot Protection (Strong Recommendation)
Never walk barefoot, in socks without shoes, or in thin-soled slippers—indoors or outdoors. This is a critical safety measure for all at-risk patients. 1
Daily Foot Care Routine
- Wash feet daily with careful drying between toes
- Apply emollients to dry skin
- Cut toenails straight across
- Inspect feet daily for any lesions
- Immediately contact healthcare provider if pre-ulcerative lesion or ulcer suspected
Structured Education
Provide formal, structured education programs about appropriate foot self-care—not just verbal advice during visits. 1
Footwear Recommendations
Risk 1 (Low Risk, No Deformity)
Educate to wear properly fitting footwear that accommodates foot shape. 1
Risk 2-3 (Moderate-High Risk with Deformity)
Consider prescribing:
- Extra-depth shoes
- Custom-made footwear
- Custom-made insoles
- Toe orthoses
Risk 3 (Previous Plantar Ulcer)
Prescribe therapeutic footwear with demonstrated plantar pressure-relieving effect during walking. This is essential for preventing recurrence. 1
Advanced Monitoring
Foot Temperature Monitoring (Risk 2-3)
Consider coaching patients to self-monitor foot skin temperature daily. If temperature difference between corresponding regions of left and right foot exceeds 2.2°C (4.0°F) on two consecutive days:
- Reduce ambulatory activity immediately
- Consult healthcare professional for diagnosis
This helps identify early inflammation and prevent ulceration. 1
Physical Activity Guidance
For low-to-moderate risk patients:
- Consider supervised foot-ankle exercise programs to reduce ulcer risk factors
- Communicate that increasing weight-bearing activity by 1000 steps/day is likely safe regarding ulceration risk
Surgical Considerations
Non-rigid Hammertoe with Pre-ulcerative Lesion
Consider flexor tendon tenotomy. 1
Nerve Decompression
Do not use nerve decompression procedures to prevent ulceration—this is not supported by evidence. 1
Ulcer Classification Systems
For clinical communication and documentation, the 2023 guidelines recommend specific classification systems 2:
For General Communication
Use SINBAD system (Site, Ischaemia, Bacterial infection, Area, Depth) as first option. Describe individual variables rather than total score. Alternative: WIfI system when expertise and equipment available.
For Infected Ulcers
Use IDSA/IWGDF classification as first option. Alternative: WIfI system when feasible.
For Peripheral Artery Disease
Consider WIfI system to stratify healing likelihood and amputation risk.
For Population Audits
Use SINBAD score.
Key Implementation Principles
The guidelines emphasize that treating any pre-ulcerative lesion immediately is critical—don't wait for ulcer development. 1 All interventions should be delivered by properly trained healthcare professionals with appropriate expertise. 1
Common Pitfall: The most frequent error is inadequate screening frequency for higher-risk patients. Risk 3 patients require monthly assessment, not annual visits. 1
The evidence supporting these recommendations ranges from high certainty for screening protocols to low certainty for specific interventions, but the IWGDF panel made strong recommendations based on the balance of benefits versus harms and clinical experience. 1