What is the appropriate management for a foot ulcer?

Management of Foot Ulcers

The appropriate management of foot ulcers requires a systematic approach including debridement, pressure offloading, infection control, vascular assessment, and proper wound care to promote healing and prevent complications. 1

Assessment and Classification

• Evaluate the ulcer site, depth, and type (neuropathic, ischemic, or neuro-ischemic) to guide appropriate treatment 1
• Assess for signs of infection (redness, warmth, induration, pain/tenderness, or purulent secretions) 1
• Examine footwear as ill-fitting shoes are the most frequent cause of ulceration, even in patients with ischemic ulcers 1
• Perform vascular assessment by checking pedal pulses; if absent or if ulcer doesn't improve with treatment, conduct more extensive evaluation including ankle-brachial index (ABI) 1

Pressure Relief and Offloading

• For neuropathic plantar ulcers, use a non-removable knee-high offloading device such as total contact cast (TCC) or removable walker rendered irremovable as the preferred treatment 1
• When non-removable devices are contraindicated, use removable offloading devices 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

Debridement and Wound Care

• Debride neuropathic ulcers with callus and necrosis as soon as possible to enable adequate assessment and promote healing 1
• Do not debride ischemic or neuro-ischemic ulcers without signs of infection 1
• Inspect the ulcer frequently and perform regular debridement with a scalpel as needed 1
• Select dressings that control excess exudation and maintain a moist wound environment 1
• Clean the wound regularly with water or saline 1
• Avoid footbaths as they induce skin maceration 1

Vascular Assessment and Management

• Consider urgent vascular imaging and revascularization when ankle pressure is <50 mmHg or ABI <0.5 1
• Revascularization should also be considered when toe pressure is <30 mmHg or TcPO2 <25 mmHg 1
• When an ulcer shows no signs of healing within 6 weeks despite optimal management, consider revascularization regardless of test results 1
• Before contemplating major amputation (above ankle), always consider revascularization options 1, 2

Infection Management

• For superficial ulcers with skin infection (mild):

  • Cleanse and debride all necrotic tissue and surrounding callus 1
  • Start empiric oral antibiotic therapy targeting Staphylococcus aureus and streptococci 1

• For deep (potentially limb-threatening) infections (moderate or severe):

  • Urgently evaluate for surgical intervention to remove necrotic tissue and drain abscesses 1
  • Assess for peripheral arterial disease and consider urgent revascularization if present 1
  • Initiate empiric, parenteral, broad-spectrum antibiotic therapy targeting gram-positive, gram-negative, and anaerobic bacteria 1
  • Adjust antibiotic regimen based on clinical response and culture results 1

Adjunctive Therapies

• Consider negative pressure wound therapy to help heal post-operative wounds 1
• Consider systemic hyperbaric oxygen treatment for poorly healing wounds 1
• The following treatments are not well-established for routine management:
  • Biological active products (collagen, growth factors, bio-engineered tissue) in neuropathic ulcers 1
  • Silver or other antimicrobial agent-containing dressings 1

Metabolic Control and Comorbidity Management

• Maintain optimal diabetes control, if necessary with insulin (blood glucose <8 mmol/L or <140 mg/dL) 1
• Treat edema and malnutrition if present 1
• Emphasize cardiovascular risk reduction (smoking cessation, treatment of hypertension and dyslipidemia, use of aspirin) 1

Patient Education and Prevention of Recurrence

• Instruct patients and caregivers on appropriate self-care and how to recognize and report signs of new or worsening infection 1
• 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

Important Considerations

• Optimum wound care cannot compensate for continuing trauma to the wound bed, inadequately treated ischemia, or infection 1
• Patients with ulcers deeper than subcutaneous tissues should be treated intensively and hospitalization should be considered 1
• A multidisciplinary approach involving various specialists is essential for effective management of foot ulcers 1