What are the best practices for foot ulcer management?

Best Practices for Foot Ulcer Management

The cornerstone of foot ulcer management is sharp debridement, offloading pressure, maintaining a moist wound environment, and treating underlying causes such as infection or ischemia. 1

Standard of Care Components

Debridement

• Sharp debridement is the preferred method to remove slough, necrotic tissue, and surrounding callus, taking into account contraindications such as severe ischemia or pain 1
• Debride the ulcer with a scalpel and repeat as needed based on clinical assessment 1
• Do not use autolytic, biosurgical, hydrosurgical, chemical, or laser debridement over standard sharp debridement 1
• Enzymatic debridement should only be considered in specific situations where sharp debridement is not available due to resource limitations or lack of skilled personnel 1

Offloading and Pressure Relief

• For neuropathic plantar ulcers, use a non-removable knee-high offloading device, either total contact cast (TCC) or removable walker rendered irremovable 1
• When non-removable devices are contraindicated, use a removable device 1
• For non-plantar ulcers, consider shoe modifications, temporary footwear, toe-spacers, or orthoses 1
• Instruct patients to limit standing and walking, and use crutches if necessary 1

Wound Dressings

• Select dressings principally based on exudate control, comfort, and cost 1
• Use dressings that absorb exudate and maintain a moist wound healing environment 1
• Do not use topical antiseptic or antimicrobial dressings with the sole aim of accelerating healing 1
• Do not use honey, collagen, alginate dressings, or herbal remedies for wound healing 1
• Consider sucrose-octasulfate impregnated dressing as adjunctive treatment for non-infected, neuro-ischemic diabetic foot ulcers that haven't improved after 2 weeks of standard care 1

Vascular Assessment and Treatment

• Consider revascularization when toe pressure <30 mmHg or TcpO2 <25 mmHg 1
• For patients with ankle pressure <50 mmHg or ABI <0.5, consider urgent vascular imaging and revascularization 1
• Consider revascularization when ulcers show no signs of healing within 6 weeks despite optimal management 1
• Always consider revascularization before contemplating major amputation 1

Infection Management

• For superficial infections: cleanse, debride necrotic tissue and surrounding callus, and start empiric oral antibiotics targeting S. aureus and streptococci 1
• For deep infections: urgently evaluate for surgical intervention, assess for peripheral arterial disease, and initiate broad-spectrum antibiotics 1
• Adjust antibiotic regimen based on clinical response and culture results 1

Adjunctive Therapies

Consider in Specific Situations

• Hyperbaric oxygen therapy for non-healing ischemic ulcers when standard care has failed and resources exist 1
• Topical oxygen therapy when standard care has failed and resources exist 1
• Negative pressure wound therapy for post-operative wounds 1
• Autologous leucocyte, platelet, and fibrin patch for difficult-to-heal ulcers 1

Not Recommended

• Physical therapies using electricity, magnetism, ultrasound, or shockwaves 1
• Growth factors, autologous platelet gels (except autologous leucocyte, platelet, and fibrin patch), bioengineered skin products 1
• Interventions aimed at correcting nutritional status specifically for ulcer healing 1

Patient Education and Prevention

• Instruct patients and caregivers on appropriate self-care and how to recognize signs of worsening infection 1
• During bed rest, teach prevention of ulcers on the contralateral foot 1
• After healing, include patients in integrated foot-care programs with ongoing observation, professional foot treatment, adequate footwear, and education 1

Common Pitfalls to Avoid

• Failing to address continued trauma to the wound bed through inadequate offloading 1
• Using footbaths where feet are soaked, as they induce skin maceration 1
• Relying on adjunctive therapies without first optimizing standard care 1
• Neglecting to assess and treat underlying peripheral arterial disease 1
• Using the same footwear that caused the ulcer after healing 1