What is the treatment for diabetic foot?

Treatment of Diabetic Foot

The treatment of diabetic foot requires a multidisciplinary approach including wound care, infection management, pressure off-loading, vascular assessment, and glycemic control to prevent amputation and reduce morbidity and mortality. 1, 2

Classification and Assessment

• Diabetic foot infections should be categorized by severity based on clinical features including tissue involvement, arterial perfusion, and presence of systemic toxicity 2
• Signs of potentially limb-threatening infections include systemic inflammatory response, rapid progression, extensive necrosis/gangrene, crepitus, bullae, new onset wound anesthesia, and pain out of proportion to clinical findings 2
• Infections are classified as mild (superficial), moderate (deeper or more extensive), or severe (with systemic signs) to guide treatment decisions 1

Wound Care

• Proper wound care is crucial for healing and includes:
  • Sharp debridement of callus, necrotic tissue, and surrounding hyperkeratosis 1
  • Appropriate dressing selection based on wound characteristics:
    • Continuously moistened saline gauze for dry/necrotic wounds
    • Hydrogels for dry/necrotic wounds to facilitate autolysis
    • Alginates for drying exudative wounds
    • Hydrocolloids for absorbing exudate 1
  • Regular wound inspection and measurement to monitor healing progress 1
• For dry gangrene, it may be preferable to leave adherent eschar in place until it softens enough to be removed, provided there is no underlying infection 2

Pressure Off-loading

• Off-loading pressure from the wound is vital for healing 1
• The preferred treatment for neuropathic plantar ulcers is a non-removable knee-high offloading device:
  • Total contact cast (TCC) or removable walker rendered irremovable 1
  • When non-removable devices are contraindicated, use removable devices 1
  • For non-plantar ulcers, consider shoe modifications, temporary footwear, toe-spacers, or orthoses 1

Infection Management

• Wounds without evidence of infection do not require antibiotic therapy 1
• For infected wounds, obtain post-debridement specimens (preferably tissue) for aerobic and anaerobic culture 1
• Antimicrobial therapy should be guided by infection severity:
  • Mild infections: Target aerobic gram-positive cocci with oral antibiotics (dicloxacillin, cephalexin, clindamycin) for 1-2 weeks 2
  • Moderate infections: Broader coverage with oral or initial parenteral therapy for 2-4 weeks 2
  • Severe infections: Prompt initiation of broad-spectrum parenteral antibiotics (ciprofloxacin plus clindamycin, piperacillin/tazobactam, or imipenem/cilastatin) for 2-4 weeks for soft tissue infections 2
• For osteomyelitis, generally at least 4-6 weeks of antibiotic therapy is required, but shorter duration is sufficient if the entire infected bone is removed 1, 2

Surgical Management

• Surgical consultation is necessary for all severe infections and selected moderate infections 2
• Surgery is typically indicated for infections with:
  • Deep abscess formation
  • Extensive bone or joint involvement
  • Crepitus
  • Substantial necrosis or gangrene
  • Necrotizing fasciitis 1, 2
• Amputation may be considered for patients with recurrent ulceration, irreversible loss of foot function, or those requiring unacceptably prolonged hospital care 1

Vascular Assessment and Management

• Evaluate arterial supply in infected limbs, especially with signs of ischemia 2
• In patients with either an ankle pressure <50 mmHg or ABI <0.5, consider urgent vascular imaging and revascularization when appropriate 1
• Emphasize efforts to reduce cardiovascular risk (smoking cessation, control of hypertension and dyslipidemia, use of aspirin or clopidogrel) 1

Glycemic Control

• Optimize blood glucose control to promote wound healing 3, 4
• Meticulous blood glucose control has been shown to promote rapid healing of diabetic foot lesions 3

Adjunctive Therapies

• For selected diabetic foot wounds that are slow to heal, consider:
  • Negative pressure wound therapy, which may help heal post-operative wounds 1, 5
  • Systemic hyperbaric oxygen therapy, which may hasten wound healing and reduce the risk of major amputation 1
  • Granulocyte colony-stimulating factors, which may reduce the need for surgical interventions 1
• The following treatments have insufficient evidence for routine use:
  • Biologically active products (collagen, growth factors, bio-engineered tissue) in neuropathic ulcers 1
  • Silver or other antimicrobial agent-containing dressings 1
  • Topical antimicrobials for clinically uninfected wounds 1

Follow-up and Prevention

• Early and careful follow-up is essential to ensure treatment effectiveness 2
• Monitor for clinical improvement, including reduction in erythema, swelling, pain, and wound size 2
• Once the ulcer is healed, include the patient in an integrated foot-care program with lifelong observation, professional foot treatment, adequate footwear, and education 1
• The foot should never return to the same shoe that caused the ulcer 1

Common Pitfalls to Avoid

• Failing to assess vascular status before aggressive debridement 1, 2
• Using footbaths that can induce skin maceration 1
• Delaying surgical consultation for deep or severe infections 1, 2
• Inadequate off-loading of pressure from the wound 1
• Treating clinically uninfected wounds with antibiotics 1
• Failing to obtain appropriate cultures before starting antibiotics 1