Does the use of smart wound dressings improve outcomes in patients with diabetic foot ulcers compared to standard of care (SOC)?

Smart Wound Dressings for Diabetic Foot Ulcers

Based on current evidence, smart wound dressings are not recommended as routine adjunctive therapy over standard of care for diabetic foot ulcers, with the exception of sucrose-octasulfate impregnated dressings which may be considered for specific non-infected, neuro-ischemic ulcers that have failed to respond to standard care for at least 2 weeks. 1

Standard of Care for Diabetic Foot Ulcers

The foundation of diabetic foot ulcer management includes:

1. Sharp debridement: The primary recommended method for removing necrotic tissue and slough, with frequency determined by clinical need 1, 2

   • Alternative debridement methods (autolytic, biosurgical, hydrosurgical, chemical, laser, enzymatic, ultrasonic) are not recommended over standard sharp debridement 1

2. Pressure offloading: Critical for healing

   • Non-removable knee-high devices (total contact cast) are preferred when possible 2
   • Removable walkers when non-removable devices are contraindicated 2

3. Basic wound dressings: Should absorb exudate and maintain a moist wound healing environment 1

4. Infection management: Monitor for signs of infection and treat appropriately 2

Evidence on Smart Wound Dressings

The 2024 International Working Group on the Diabetic Foot (IWGDF) guidelines provide clear recommendations regarding various wound dressing options:

Not Recommended:

• Topical antiseptic or antimicrobial dressings 1
• Honey or bee-related products 1
• Collagen or alginate dressings 1
• Topical phenytoin 1
• Herbal remedy-impregnated dressings 1

Conditionally Recommended:

• Sucrose-octasulfate impregnated dressing may be considered as adjunctive treatment for non-infected, neuro-ischemic diabetic foot ulcers that have shown insufficient improvement with standard care including appropriate off-loading for at least 2 weeks (Conditional recommendation; Moderate certainty of evidence) 1

Adjunctive Therapies with Some Evidence

For ulcers that fail to respond to standard care, certain adjunctive therapies may be considered:

1. Negative Pressure Wound Therapy: Recommended only for post-surgical diabetic foot wounds, not for non-surgical diabetic foot ulcers 1

2. Oxygen Therapies:

   • Hyperbaric oxygen therapy may be considered for neuro-ischemic or ischemic ulcers where standard care has failed 1
   • Topical oxygen therapy may be considered where standard care has failed 1

3. Biological Therapies:

   • Autologous leucocyte, platelet, and fibrin patch may be considered where standard care has been ineffective 1
   • Placental-derived products may be considered where standard care has failed 1

Common Pitfalls in Diabetic Foot Ulcer Management

1. Overreliance on advanced dressings: Many clinicians prematurely use advanced or "smart" dressings before optimizing standard care (debridement, offloading, infection control)

2. Inadequate offloading: Failure to effectively reduce pressure on the ulcer is a common reason for treatment failure 2

3. Inconsistent debridement: Sharp debridement should be performed based on clinical need rather than arbitrary schedules 1

4. Delayed vascular assessment: Inadequate perfusion will prevent healing regardless of dressing choice

5. Lack of integrated care: Diabetic foot ulcers require a multidisciplinary approach with regular follow-up based on risk stratification 2

Despite the availability of numerous advanced wound care products, the evidence supporting their use remains limited. The IWGDF guidelines emphasize that most interventions lack high-quality evidence, and many recommendations are based on low certainty evidence 1.