What is the best approach to manage diabetic foot ulcers in a patient with multiple sclerosis (MS)?

Management of Diabetic Foot Ulcers in Patients with Multiple Sclerosis

For patients with multiple sclerosis and diabetic foot ulcers, the management should follow standard diabetic foot care principles with additional consideration for mobility limitations, focusing on non-removable offloading devices when possible, regular sharp debridement, and comprehensive wound care to prevent complications and reduce amputation risk.

Core Management Principles

Offloading Strategies

• Use a non-removable knee-high offloading device (total contact cast or non-removable walker) as first-line treatment for neuropathic plantar forefoot or midfoot ulcers to promote healing 1
• If non-removable devices are contraindicated due to MS-related mobility issues, consider removable knee-high or ankle-high offloading devices as second-choice treatment 1
• Do not use conventional footwear or standard therapeutic footwear for active ulcer treatment 1
• For patients with limited access to specialized offloading devices, consider felted foam in combination with appropriate footwear 1

Wound Debridement and Care

• Perform sharp debridement as the standard of care, with frequency determined by clinical need 1
• Do not use autolytic, biosurgical, hydrosurgical, chemical, or laser debridement over standard sharp debridement 1
• Consider enzymatic debridement only when sharp debridement is limited by resource availability or skilled personnel 1
• Do not use surgical debridement when sharp debridement can be performed outside a sterile environment 1

Dressing Selection

• Use basic wound dressings that absorb exudate and maintain a moist wound healing environment 1
• Do not use topical antiseptic or antimicrobial dressings for routine wound healing 1
• Do not use honey, collagen, or alginate dressings for wound healing 1
• Consider sucrose-octasulfate impregnated dressing as adjunctive treatment for non-infected, neuro-ischemic ulcers that have shown insufficient improvement after 2 weeks of standard care 1

Advanced Therapies for Refractory Ulcers

Adjunctive Treatments

• Consider hyperbaric oxygen therapy for neuro-ischemic or ischemic ulcers when standard care has failed and resources exist 1
• Consider topical oxygen therapy as an adjunct when standard care has failed 1
• Consider autologous leucocyte, platelet, and fibrin patch for diabetic foot ulcers as adjunctive therapy when standard care has been ineffective 1
• Consider negative pressure wound therapy as an adjunct therapy for post-surgical diabetic foot wounds 1

Surgical Interventions

• For neuropathic plantar metatarsal head ulcers that fail non-surgical treatment, consider Achilles tendon lengthening or metatarsal head resection 1
• For neuropathic plantar or apex ulcers on digits 2-5 with flexible toe deformity, use digital flexor tenotomy 1
• For hallux ulcers that fail non-surgical treatment, consider joint arthroplasty 1

Special Considerations for MS Patients

Mobility and Balance Issues

• Assess MS-related mobility limitations when selecting offloading devices, as balance issues may make non-removable devices unsafe in some cases 1
• For patients with significant mobility impairment, consider removable offloading devices with appropriate assistive devices 1
• Monitor for pressure points from assistive devices (canes, walkers, wheelchairs) that may contribute to ulcer formation 2

Infection Management

• Aggressively treat infections, as MS patients may have altered sensation and delayed recognition of worsening infection 3
• For mild infections with plantar forefoot/midfoot ulcers, consider non-removable knee-high offloading devices 1
• For moderate to severe infections, address the infection first while using removable offloading interventions 1

Prevention of Recurrence

• Educate patients and caregivers about daily foot inspection, especially important for MS patients with sensory deficits 1
• Prescribe therapeutic footwear with demonstrated plantar pressure-relieving effect for healed plantar ulcers 1
• Consider home temperature monitoring to identify early signs of inflammation, with instructions to reduce activity and seek care if temperature differences exceed 2.2°C between feet on consecutive days 1

Follow-up and Monitoring

• Provide integrated foot care with professional assessment, adequate footwear, and structured education 1
• Monitor high-risk patients every 1-3 months and moderate-risk patients every 3-6 months 1
• Assess for MS exacerbations that may impact mobility and increase ulcer risk 2
• Evaluate treatment response within 4 weeks; if ulcer area does not reduce by >50%, consider adjunctive therapies 2