What is the treatment for diabetes skin ulcers?

Treatment for Diabetic Skin Ulcers

The cornerstone of diabetic skin ulcer treatment is sharp debridement combined with basic wound dressings that absorb exudate and maintain a moist wound healing environment, with the frequency of debridement determined by clinical need. 1

Standard of Care Treatment Algorithm

Initial Assessment and Management

• Assess for signs of infection, peripheral neuropathy, and vascular status
• Perform sharp debridement to remove slough, necrotic tissue, and surrounding callus 2, 1
• Apply basic wound dressings that absorb exudate and maintain moisture 2, 1
• Implement appropriate pressure offloading techniques 2, 1

Wound Care Specifics

1. Debridement

   • Use sharp debridement as the primary method 2, 1
   • Frequency should be determined by clinical need 2
   • Avoid autolytic, biosurgical, hydrosurgical, chemical, or laser debridement 2
   • Consider enzymatic debridement only when sharp debridement is unavailable 2

2. Dressing Selection

   • Use basic wound dressings based on exudate control needs 1
   • Do not use:
     • Topical antiseptic or antimicrobial dressings 2, 1
     • Honey or bee-related products 2
     • Collagen or alginate dressings 2
     • Topical phenytoin 2
     • Herbal remedies 2

3. Pressure Offloading

   • Implement total contact casting when possible 2, 1
   • When non-removable devices are contraindicated, use removable walkers 2
   • For non-plantar ulcers, consider shoe modifications, temporary footwear, toe-spacers or orthoses 2
   • Instruct patient to limit standing and walking 2

Management of Infection

• For superficial infections (mild):

  • Cleanse and debride all necrotic tissue
  • Start empiric oral antibiotics targeting Staphylococcus aureus and streptococci 2

• For deep infections (moderate/severe):

  • Urgently evaluate for surgical intervention to remove necrotic tissue and drain abscesses
  • Initiate broad-spectrum parenteral antibiotics
  • Adjust antibiotic regimen based on clinical response and culture results 2, 1

Vascular Assessment and Management

• If ankle pressure <50 mmHg or ABI <0.5, consider urgent vascular imaging and revascularization 2
• Assess for peripheral arterial disease with pulse palpation and ABI measurement 1

Adjunctive Therapies

Consider these options only when standard care has failed:

1. Recommended adjunctive treatments:

   • Sucrose-octasulfate impregnated dressing for non-infected, neuro-ischemic ulcers 2, 1
   • Negative pressure wound therapy for post-surgical wounds 2, 1
   • Hyperbaric oxygen therapy for non-healing ischemic ulcers 2, 1
   • Topical oxygen therapy where resources exist 2
   • Autologous leucocyte, platelet, and fibrin patch where resources exist 2, 1
   • Placental-derived products 2, 1

2. Not recommended:

   • Growth factor therapy 2
   • Cellular or acellular skin substitute products 2
   • Autologous skin grafts 2
   • Physical therapies 2
   • Pharmacological agents promoting perfusion or angiogenesis 2
   • Vitamin and trace element supplements 2

Prevention of Recurrence

• Include patient in integrated foot-care program with ongoing observation
• Provide professional foot treatment, adequate footwear, and education 2
• Never allow patient to return to the same footwear that caused the ulcer 2

Common Pitfalls to Avoid

• Using topical antiseptics that delay healing 1
• Failing to assess for peripheral neuropathy 1
• Misdiagnosing venous stasis as cellulitis 1
• Delaying referral for vascular assessment 1
• Neglecting patient education on preventive foot care 1

The treatment of diabetic skin ulcers requires a systematic approach focusing on wound care, infection management, vascular assessment, and appropriate offloading. While numerous adjunctive therapies exist, they should only be considered when standard care fails to produce adequate healing.