What is the best treatment plan for diabetic ulcers on the lower extremities?

Best Treatment Plan for Diabetic Ulcers on Lower Extremities

Sharp debridement and appropriate offloading are the cornerstones of effective diabetic foot ulcer management, with adjunctive therapies considered only when standard care fails.

Standard of Care Components

Offloading

• Use a non-removable knee-high offloading device as first-line treatment for neuropathic plantar forefoot or midfoot ulcers to promote healing 1
• For patients with limited access to specialized offloading devices, consider felted foam in combination with appropriate footwear 1
• People with bony deformities may need extra wide or deep shoes, and those with severe deformities including Charcot foot may require custom-molded shoes 2

Debridement

• Perform sharp debridement to remove slough, necrotic tissue, and surrounding callus as the standard of care 3, 1
• The frequency of sharp debridement should be determined by the clinician based on clinical need 2, 3
• Do not use autolytic, biosurgical, hydrosurgical, chemical, or laser debridement over standard sharp debridement 2
• Do not use surgical debridement when sharp debridement can be performed outside a sterile environment 2, 3

Wound Dressings

• Use basic wound dressings that absorb exudate and maintain a moist wound healing environment 3, 1
• Do not use topical antiseptic or antimicrobial dressings for wound healing (Strong recommendation; Moderate certainty) 2, 3
• Do not use honey or bee-related products for wound healing (Strong recommendation; Low certainty) 2, 3
• Do not use collagen or alginate dressings for wound healing (Strong recommendation; Low certainty) 2, 3
• Do not use topical phenytoin or herbal remedies for wound healing (Strong recommendation; Low certainty) 2, 3

Adjunctive Therapies for Non-Healing Ulcers

Consider for Refractory Cases

• Consider sucrose-octasulfate impregnated dressing as an adjunctive treatment for non-infected, neuro-ischemic ulcers that have had insufficient change in ulcer area with best standard of care for at least 2 weeks (Conditional recommendation; Moderate certainty) 2, 3
• Consider autologous leucocyte, platelet, and fibrin patch for diabetic foot ulcers as adjunctive therapy where standard care has been ineffective and where resources exist for regular venepuncture (Conditional recommendation; Moderate certainty) 2, 3
• Consider hyperbaric oxygen therapy as an adjunct therapy in neuro-ischemic or ischemic diabetic foot ulcers where standard care alone has failed and where resources already exist to support this intervention (Conditional recommendation; Low certainty) 2
• Consider topical oxygen as an adjunct therapy to standard of care where standard care alone has failed and resources exist to support this intervention (Conditional recommendation; Low certainty) 2
• Consider negative pressure wound therapy as an adjunct therapy for post-surgical diabetic foot wounds only (Conditional recommendation; Low certainty) 2, 1

Not Recommended

• Do not use negative pressure wound therapy for non-surgical diabetic foot ulcers (Strong recommendation; Low certainty) 2, 3
• Do not use cellular or acellular skin substitute products as routine adjunct therapy (Conditional recommendation; Low certainty) 2, 3
• Do not use autologous skin graft skin substitute products as an adjunct therapy (Strong recommendation; Low certainty) 2
• Do not use growth factor therapy as an adjunct therapy to standard of care (Conditional recommendation; Low certainty) 2
• Do not use physical therapies (electricity, magnetism, ultrasound, shockwaves) for wound healing (Strong recommendation; Low certainty) 2, 3

Monitoring and Follow-up

• Adjust treatment if insufficient improvement is observed after 2 weeks 3, 4
• Monitor high-risk patients every 1-3 months and moderate-risk patients every 3-6 months 1
• Educate patients about daily foot inspection, especially important for patients with sensory deficits 1, 4
• 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

Common Pitfalls to Avoid

• Failing to provide adequate offloading, which is essential for healing 1, 5
• Overreliance on advanced therapies before optimizing standard care 5
• Using hyperbaric oxygen therapy without clear evidence of benefit for the specific patient; evidence remains inconclusive regarding clinical and cost-effectiveness 2
• Neglecting the recurrence risk after healing; therapeutic footwear with demonstrated plantar pressure-relieving effect should be prescribed for healed plantar ulcers 1, 4