Should a diabetic toe ulcer with a necrotic cap be kept wet or dry?

Management of Diabetic Toe Ulcer with Necrotic Cap

For a diabetic toe ulcer with a necrotic cap, the wound should be kept moist to promote healing, while the necrotic tissue should be removed through sharp debridement. 1

Assessment and Debridement

• Sharp debridement is the preferred method for removing slough, necrotic tissue, and surrounding callus from diabetic foot ulcers 1
• Remove the necrotic cap through sharp debridement rather than other methods, taking into account relative contraindications such as:
  • Severe ischemia
  • Pain
  • Bleeding risk 1

Important caveat: If the limb appears severely ischemic (ABI <0.5 or ankle pressure <50 mmHg), urgent vascular imaging and possible revascularization should be considered before aggressive debridement 1

Wound Environment Management

After debridement:

1. Maintain a warm, moist environment to promote healing 1
2. Select dressings based on:
   • Exudate control
   • Patient comfort
   • Cost-effectiveness 1
3. Clean the ulcer regularly with clean water or saline 1
4. Avoid footbaths that can cause skin maceration 1

Dressing Selection Guidelines

• For heavily exudating wounds: Use absorbent dressings
• For dry wounds: Use moisture-adding dressings
• Change dressings at least daily to:
  • Apply clean covering
  • Allow for wound examination 1

Offloading Pressure

• Reduce pressure on the ulcer site through appropriate offloading techniques:
  • For plantar ulcers: Use appropriate offloading devices
  • For non-plantar ulcers: Consider shoe modifications, temporary footwear, toe-spacers, or orthoses
  • Instruct patient to limit standing and walking 1

Infection Management

• Monitor for signs of infection:
  • Redness, warmth, induration, pain/tenderness
  • Purulent secretions 1
• If infection is present:
  • For superficial infections: Clean, debride, and start empiric oral antibiotics
  • For deep infections: Consider surgical intervention and parenteral antibiotics 1

Follow-up Care

• Inspect the ulcer frequently
• Repeat debridement as needed
• Adjust dressing selection based on wound characteristics
• Consider referral to a multidisciplinary foot care team 1

Common Pitfalls to Avoid

1. Leaving dry necrotic tissue intact - except in cases of severe ischemia where debridement should be delayed until revascularization 1
2. Using antimicrobial dressings with the sole aim of accelerating healing - not recommended by guidelines 1
3. Using footbaths - these can induce skin maceration 1
4. Delaying debridement - prompt removal of necrotic tissue is essential except in severe ischemia 1
5. Neglecting offloading - continued trauma to the wound bed impedes healing 1

The evidence strongly supports maintaining a moist wound environment after appropriate debridement of necrotic tissue, with dressing selection based primarily on exudate control rather than antimicrobial properties.