What is the recommended treatment for a diabetic foot ulcer and should I consult a podiatrist?

Management of Diabetic Foot Ulcers and Role of Podiatry Consultation

For diabetic foot ulcers, prompt referral to a podiatrist as part of an interprofessional team is strongly recommended for comprehensive assessment and management to reduce morbidity, mortality, and improve quality of life. 1, 2

Risk Assessment and Screening

• All people with diabetes should undergo a comprehensive foot examination at least annually to identify risk factors for ulceration 1
• Risk stratification should follow the IWGDF system with examination frequency based on risk level:
  • IWGDF risk 1: Every 6-12 months
  • IWGDF risk 2: Every 3-6 months
  • IWGDF risk 3: Every 1-3 months 1
• Assessment should include history of ulceration, amputation, Charcot foot, vascular interventions, and smoking status 1
• Physical examination should evaluate for peripheral neuropathy, foot deformities, pre-ulcerative lesions, and peripheral arterial disease 1, 2

Immediate Management of Diabetic Foot Ulcers

• Cleanse and debride all necrotic tissue and surrounding callus 1
• Assess for infection and treat appropriately with antibiotics targeted at likely pathogens 1
• Provide pressure offloading with appropriate devices:
  • Total contact cast or irremovable walker (preferred)
  • Removable devices when non-removable options are contraindicated
  • Appropriate footwear modifications for non-plantar ulcers 1
• Evaluate vascular status - consider urgent vascular imaging and revascularization for patients with ankle pressure <50 mmHg or ABI <0.5 1, 2

Role of Podiatry in Diabetic Foot Care

• An interprofessional approach facilitated by a podiatrist is recommended for individuals with foot ulcers and high-risk feet 1, 3
• Podiatrists provide specialized care including:
  • Professional nail and callus care
  • Treatment of pre-ulcerative lesions
  • Management of ingrown toenails and fungal infections
  • Appropriate wound debridement
  • Biomechanical assessment and offloading strategies 1, 4
• Regular podiatric follow-up reduces ulcer recurrence rates, which can be as high as 40% within the first year 1, 5

Preventive Measures and Education

• Educate patients on appropriate foot self-care:
  • Daily foot inspection
  • Proper washing and drying (particularly between toes)
  • Use of emollients for dry skin
  • Cutting toenails straight across 1
• Advise against walking barefoot, in socks without shoes, or in thin-soled slippers 1
• Prescribe appropriate footwear based on risk level:
  • For patients with foot deformities or pre-ulcerative lesions: extra-depth shoes, custom-made footwear, custom insoles, or toe orthoses 1
  • For patients with healed plantar ulcers: therapeutic footwear with demonstrated plantar pressure-relieving effect 1

Advanced Therapies for Non-Healing Ulcers

• For chronic diabetic foot ulcers that have failed standard care, consider adjunctive treatments:
  • Negative-pressure wound therapy
  • Placental membranes
  • Bioengineered skin substitutes
  • Acellular matrices
  • Autologous fibrin and leukocyte platelet patches
  • Topical oxygen therapy 1, 5

Integrated Care Approach

• Provide integrated foot care for moderate to high-risk patients (IWGDF risk 2-3) including:
  • Professional foot care
  • Appropriate footwear
  • Structured education about self-care 1
• Repeat foot care or re-evaluate every 1-3 months for high-risk patients and every 3-6 months for moderate-risk patients 1

Common Pitfalls to Avoid

• Delaying podiatry referral - early intervention reduces amputation risk 5
• Relying solely on ankle-brachial index for vascular assessment in diabetic patients due to arterial calcification 2
• Failing to provide appropriate offloading, which is essential for healing 1, 6
• Neglecting patient education on proper footwear and foot care practices 1, 7
• Underestimating the impact of diabetic foot ulcers, which have a 5-year mortality rate of approximately 30% 5