What is the treatment for diabetic ulcers on lower extremities?

Treatment for Diabetic Ulcers on Lower Extremities

The cornerstone of diabetic foot ulcer treatment is sharp debridement to remove slough, necrotic tissue, and surrounding callus, combined with appropriate offloading devices and basic wound dressings selected for exudate control, comfort, and cost. 1, 2

Standard of Care Components

Offloading

• Use non-removable knee-high offloading devices as first-line treatment for neuropathic plantar forefoot or midfoot ulcers 2
• Consider felted foam with appropriate footwear for patients with limited access to specialized offloading devices 2
• Patients with bony deformities may require extra wide/deep shoes or custom-molded shoes for severe deformities including Charcot foot 2

Debridement

• Perform sharp debridement to remove slough, necrotic tissue, and surrounding callus as the preferred method over other debridement techniques 1, 2
• Frequency of sharp debridement should be determined by clinical need 1, 2
• Do not use enzymatic debridement unless sharp debridement is contraindicated 1
• Do not use ultrasonic debridement over standard sharp debridement 1

Wound Dressings

• Select basic dressings primarily based on exudate control, comfort, and cost 1, 2
• Do not use topical antiseptic or antimicrobial dressings solely for wound healing purposes 1, 2
• Do not use honey or bee-related products for wound healing 1
• Do not use collagen or alginate dressings for wound healing 1
• Do not use dressings with herbal remedies 1

Adjunctive Therapies for Non-Healing Ulcers

When standard care fails after at least 2 weeks of appropriate treatment, consider:

• Sucrose-octasulfate impregnated dressing for non-infected, neuro-ischemic diabetic foot ulcers 1, 2
• Hyperbaric oxygen therapy for neuro-ischemic or ischemic ulcers where resources exist to support this intervention 1, 2
• Autologous leucocyte, platelet, and fibrin patch where resources exist for regular venepuncture 1, 2
• Negative pressure wound therapy for post-surgical diabetic foot wounds only 1, 2
• Placental-derived products where standard care has failed 1
• Consider topical oxygen therapy where standard care has failed and resources exist 1

Therapies to Avoid

• Do not use growth factors, autologous platelet gels (except autologous leucocyte, platelet, and fibrin patch), or bioengineered skin products 1
• Do not use other gases (cold atmospheric plasma, ozone, nitric oxide, CO2) 1
• Do not use physical therapies (electricity, magnetism, ultrasound, shockwaves) 1
• Do not use pharmacological agents promoting perfusion, angiogenesis, or supplementing vitamins and trace elements 1
• Do not use topical phenytoin 1
• Do not use cellular or acellular skin substitute products as routine adjunct therapy 1
• Do not use autologous skin graft skin substitute products 1

Monitoring and Follow-up

• Adjust treatment if insufficient improvement is observed after 2 weeks 2
• Monitor high-risk patients every 1-3 months and moderate-risk patients every 3-6 months 2
• Educate patients about daily foot inspection, especially those with sensory deficits 2
• Consider home temperature monitoring to identify early signs of inflammation (seek care if temperature differences exceed 2.2°C between feet on consecutive days) 2

Common Pitfalls to Avoid

• Failing to provide adequate offloading 2, 3
• Overreliance on advanced therapies before optimizing standard care 2
• Using hyperbaric oxygen therapy without clear evidence of benefit 2
• Neglecting recurrence risk after healing (prescribe therapeutic footwear with demonstrated plantar pressure-relieving effect for healed plantar ulcers) 2, 3
• Delayed recognition of infection, which can lead to osteomyelitis and increased amputation risk 3
• Failure to assess vascular status and refer for revascularization when needed 3