What are the primary recommendations for managing a patient with multiple sclerosis and a diabetic foot ulcer?

Management of Diabetic Foot Ulcer in a Patient with Multiple Sclerosis

The management of diabetic foot ulcers in patients with multiple sclerosis requires integrated foot care with regular follow-up every 1-3 months, including professional foot treatment, appropriate offloading devices, and structured education about self-care. 1, 2

Initial Assessment

• Evaluate for signs of infection (erythema, warmth, tenderness, purulent discharge) and determine severity (mild, moderate, or severe) 2
• Assess ulcer depth and check for exposed bone or joint involvement 2
• Screen for peripheral neuropathy using 10g monofilament test and/or 128 Hz tuning fork 2
• Evaluate peripheral arterial disease by checking foot pulses and ankle-brachial index 2
• Obtain wound cultures before starting antibiotics to guide therapy 2
• Order complete blood count, C-reactive protein, and blood glucose levels 2
• Perform plain radiography to assess for osteomyelitis or foot deformities 2

Wound Management

• Perform sharp debridement of necrotic tissue and surrounding callus 1, 2
• Do not use autolytic, biosurgical, hydrosurgical, chemical, or laser debridement over standard of care 1
• Do not use topical antiseptic or antimicrobial dressings for wound healing 1
• Do not use honey, collagen, or alginate dressings for wound healing 1
• Consider sucrose-octasulfate impregnated dressing for non-infected, neuro-ischemic ulcers that haven't improved with standard care for at least 2 weeks 1
• Consider hyperbaric oxygen or topical oxygen therapy when standard care has failed and resources exist to support these interventions 1

Offloading

• For neuropathic plantar forefoot or midfoot ulcers, use a non-removable knee-high offloading device (total contact cast or irremovable walker) 1, 2
• For non-plantar ulcers, use removable offloading devices, footwear modifications, toe spacers, or orthoses depending on ulcer location 1
• For neuropathic plantar or apex ulcers on digits 2-5 with flexible toe deformity, consider digital flexor tenotomy 1
• When using knee-high or ankle-high offloading devices, consider a shoe lift on the contralateral limb to improve comfort and balance 1

Infection Management

• For mild infections: Start empiric oral antibiotics targeting Staphylococcus aureus and streptococci 2
• For moderate to severe infections: Initiate broad-spectrum parenteral antibiotics covering gram-positive, gram-negative, and anaerobic bacteria 2
• Adjust antibiotic regimen based on culture results and clinical response 2
• Treatment duration: 1-2 weeks for soft tissue infections; 6 weeks for osteomyelitis 2

Vascular Assessment and Management

• If ankle pressure <50 mmHg or ABI <0.5, consider urgent vascular imaging and revascularization 2
• When ulcers fail to show healing signs within 6 weeks despite optimal management, consider revascularization regardless of initial vascular assessment 2

Metabolic Control

• Optimize blood glucose control 2, 3
• Address cardiovascular risk factors (smoking cessation, control of hypertension and dyslipidemia) 2

Multiple Sclerosis Considerations

• Assess mobility limitations and adapt offloading strategies accordingly 1
• Consider removable offloading devices if non-removable devices compromise balance and increase fall risk 1
• Evaluate upper extremity function for ability to perform adequate foot self-care 1
• Consider more frequent follow-up visits if self-care is limited 1, 2

Patient Education

• Provide structured education about foot self-care 1, 2
• Instruct patient to examine feet daily and contact healthcare provider promptly if new lesions develop 1, 2
• Educate patient not to walk barefoot, in socks only, or in thin-soled slippers 1
• Instruct patient to daily inspect feet and inside of shoes, wash feet daily with careful drying between toes, avoid chemical agents to remove callus, use emollients for dry skin, and cut toenails straight across 1

Footwear Recommendations

• Prescribe therapeutic footwear with demonstrated plantar pressure-relieving effect for healed plantar ulcers 1, 2
• For foot deformities or pre-ulcerative lesions, consider extra-depth shoes, custom-made footwear, custom-made insoles, and/or toe orthoses 1
• Encourage consistent wearing of prescribed footwear, both indoors and outdoors 1

Follow-up Schedule

• For patients with history of foot ulceration (IWGDF risk 3): Follow-up every 1-3 months 1, 2
• Re-evaluate the need for integrated foot care at each visit 1
• Monitor for signs of recurrence, as recurrence rate is 40% within a year and 65% within 3 years after healing 1, 3