What are the recommended management strategies for diabetic ulcers?

Management of Diabetic Ulcers

The standard of care for diabetic foot ulcers includes regular cleaning with saline or water, sharp debridement of necrotic tissue and callus, and use of sterile, inert dressings that control exudate and maintain a moist wound environment. 1

Core Management Strategies

Wound Cleaning and Debridement

• Clean ulcers regularly with clean water or saline 1
• Perform sharp debridement to remove:
  • Slough and necrotic tissue
  • Surrounding callus
  • Debris from wound surface 1
• Sharp debridement is preferred over other methods (autolytic, biosurgical, hydrosurgical, chemical, or laser) 1
• Frequency of debridement should be determined based on clinical need 1
• Consider relative contraindications to sharp debridement such as severe ischemia 1

Dressing Selection

• Select dressings primarily based on:
  • Exudate control
  • Comfort
  • Cost 1
• Use sterile, inert dressings that:
  • Control excessive exudate
  • Maintain a warm, moist environment 1, 2
• Do NOT use antimicrobial or antiseptic dressings for routine wound healing 1
• Do NOT use collagen or alginate dressings for wound healing 1
• Do NOT use honey or bee-related products 1
• Do NOT use herbal remedies in dressings 1

Off-loading

• Apply appropriate off-loading device based on ulcer location 2
• Non-removable knee-high devices are recommended for plantar ulcers 2
• Use removable devices when non-removable ones are contraindicated 2
• Limit standing and walking to reduce pressure on the ulcer site 2

Vascular Assessment and Management

• Assess for peripheral artery disease (PAD) 2
• Consider urgent vascular imaging and revascularization if:
  • Ankle pressure <50 mmHg or ABI <0.5
  • Toe pressure <30 mmHg or TcPO2 <25 mmHg
  • Ulcer fails to improve within 6 weeks despite optimal management 2
• Do not delay vascular evaluation while treating infection 2

Infection Management

• For superficial infection: cleanse, debride, and start empiric oral antibiotics targeting Staphylococcus aureus and streptococci 2
• For deep infection: consider urgent surgical intervention, initiate broad-spectrum antibiotics, and consider hospitalization 2
• Do NOT use antibiotics in non-infected wounds 2

Adjunctive Therapies

Consider these only when standard care has failed to heal the ulcer:

Recommended Adjunctive Therapies

• Consider sucrose-octasulfate impregnated dressing for non-infected, neuro-ischaemic ulcers that have had insufficient improvement with standard care for at least 2 weeks 1
• Consider negative pressure wound therapy for post-operative wounds 1, 2
• Consider hyperbaric oxygen therapy for poorly healing neuro-ischaemic or ischaemic ulcers where resources exist 1, 2
• Consider topical oxygen therapy where standard care has failed and resources exist 1
• Consider autologous leucocyte, platelet, and fibrin patch for difficult-to-heal ulcers 1
• Consider placental-derived products when standard care has failed 1

NOT Recommended

• Do NOT use growth factors, bioengineered skin products, or autologous platelet gels 1
• Do NOT use interventions based on electricity, magnetism, ultrasound, or shockwaves 1
• Do NOT use ozone, topical carbon dioxide, nitric oxide, or other gases 1
• Do NOT use topical phenytoin 1
• Do NOT use systemic treatments or nutritional supplements specifically for wound healing 1

Patient Education and Follow-up

• Instruct patients on proper wound care techniques 2
• Educate about signs requiring immediate medical attention 2
• Emphasize importance of maintaining good blood glucose control 2, 3
• Schedule regular follow-up appointments to monitor progress 2

Common Pitfalls to Avoid

• Using antimicrobial dressings with the goal of improving wound healing 1
• Delaying vascular evaluation while treating infection 2
• Attributing poor wound healing solely to "small vessel disease" without proper vascular evaluation 2
• Soaking feet, which can induce skin maceration 2
• Using antibiotics in non-infected wounds 2
• Failing to address off-loading in ambulatory patients 2

The mortality associated with diabetic foot ulcers is significant, with 5-year mortality rates estimated at 42%, highlighting the importance of prompt and effective management 4, 5.