What is the recommended treatment for pressure ulcers on the foot?

Comprehensive Treatment of Pressure Ulcers on the Foot

The optimal treatment for pressure ulcers on the foot requires a multistep approach including pressure offloading, wound debridement, appropriate dressing selection, infection management, and vascular assessment. 1

Assessment and Classification

• Document pressure ulcer details including:

  • Size, location, depth
  • Presence of necrotic tissue and granulation
  • Exudate amount and odor
  • Signs of infection
  • Vascular status of the foot

• Classify according to stage:

  • Stage I: Intact skin with non-blanchable erythema
  • Stage II: Partial-thickness skin loss
  • Stage III: Full-thickness skin loss
  • Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle

Core Treatment Components

1. Pressure Offloading (Critical First Step)

• For plantar ulcers: Use a non-removable knee-high offloading device, either total contact cast (TCC) or removable walker rendered irremovable 1
• When non-removable devices are contraindicated, use removable offloading devices
• For non-plantar ulcers: Consider shoe modifications, temporary footwear, toe-spacers or orthoses
• Limit standing and walking; use crutches if necessary

2. Debridement

• Remove slough, necrotic tissue, and surrounding callus with sharp debridement (strong recommendation) 1
• Consider relative contraindications such as pain or severe ischemia
• Urgent debridement is essential for infected wounds

3. Wound Cleansing

• Use saline irrigation as the standard for cleansing 2
• Avoid soaking feet in footbaths as they induce skin maceration 1

4. Dressing Selection

• Select dressings based on exudate control, comfort, and cost (strong recommendation) 1
• For minimally exuding wounds: Hydrocolloid dressings 3
• For moderately exuding wounds: Foam dressings 3
• For heavily exuding wounds: Highly absorbent dressings
• Consider sucrose-octasulfate impregnated dressing for non-infected, neuro-ischemic ulcers that are difficult to heal 1

5. Infection Management

For superficial infection (mild):

• Cleanse and debride all necrotic tissue
• Start empiric oral antibiotic therapy targeting Staphylococcus aureus and streptococci 1

For deep infection (moderate or severe):

• Urgent surgical intervention to remove necrotic tissue and drain abscesses
• Initiate empiric, parenteral, broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic bacteria 1
• Adjust antibiotics based on culture results and clinical response

6. Vascular Assessment and Management

• In patients with ankle pressure <50 mmHg or ABI <0.5: Consider urgent vascular imaging and revascularization 1
• If toe pressure <30 mmHg or TcpO2 <25 mmHg: Consider revascularization
• For ulcers not healing within 6 weeks despite optimal management: Consider revascularization regardless of initial vascular assessment 1

Adjunctive Therapies

Consider these for ulcers that are difficult to heal despite standard care:

• Negative pressure wound therapy for post-operative wounds (weak recommendation) 1, 4
• Electrical stimulation to accelerate healing (weak recommendation) 3
• Systemic hyperbaric oxygen therapy for non-healing ischemic ulcers (weak recommendation) 1
• Placental-derived products when standard care has failed to reduce wound size (weak recommendation) 1
• Autologous combined leucocyte, platelet and fibrin patch for non-infected ulcers that are difficult to heal (weak recommendation) 1

Nutritional Support

• Consider protein supplementation to reduce wound size 3
• Ensure adequate overall nutrition and hydration

Prevention of Recurrence

• Once healed, include patient in an integrated foot-care program with:
  • Lifelong observation
  • Professional foot treatment
  • Appropriate footwear
  • Patient education 1
• The foot should never return to the same shoe that caused the ulcer 1

Patient Education

• Instruct patients and caregivers on appropriate self-care
• Teach recognition of signs of new or worsening infection (fever, changes in wound, worsening hyperglycemia) 1
• During bed rest, provide instruction on preventing ulcers on the contralateral foot

Common Pitfalls to Avoid

1. Failing to adequately offload pressure from the wound
2. Neglecting to assess and address vascular insufficiency
3. Delayed recognition and treatment of infection
4. Using antimicrobial dressings without clinical evidence of infection
5. Overuse of antibiotics for non-infected wounds
6. Neglecting nutritional status of the patient
7. Failing to educate patients about preventive measures

Following this comprehensive approach will optimize healing outcomes and reduce the risk of complications including amputation, infection, and ulcer recurrence.