What is the treatment for diabetic foot?

Treatment for Diabetic Foot

Diabetic foot treatment requires immediate multidisciplinary team involvement with systematic attention to five core pillars: pressure off-loading, infection management, vascular assessment with revascularization when needed, local wound care with sharp debridement, and glycemic control—all aimed at preventing amputation and preserving limb function. 1, 2

Immediate Assessment and Triage

Classify infection severity immediately to determine treatment intensity and urgency: 1, 2

• Mild infection (superficial): Local erythema, warmth, tenderness, induration <2 cm around ulcer, no systemic signs 1
• Moderate infection (deep): Erythema >2 cm, deeper tissue involvement, no systemic toxicity 1
• Severe infection (limb-threatening): Systemic inflammatory response (fever, tachycardia, hypotension), rapid progression, extensive necrosis/gangrene, crepitus, bullae, new onset wound anesthesia, or pain out of proportion to findings 2, 3

Check vascular status urgently: If ankle pressure <50 mmHg or ankle-brachial index (ABI) <0.5, obtain immediate vascular imaging and consider urgent revascularization. 1

Pressure Off-Loading (Critical for Healing)

Use a non-removable knee-high off-loading device as first-line treatment for plantar ulcers—either a total contact cast (TCC) or a removable walker rendered irremovable (wrapped with cohesive bandage). 1, 2

• When non-removable devices are contraindicated, use removable walkers or specialized footwear 1
• For non-plantar ulcers, employ shoe modifications, temporary footwear, toe-spacers, or orthoses 1
• Instruct patients to limit standing/walking and use crutches if necessary 1

Common pitfall: Inadequate off-loading is a leading cause of treatment failure—removable devices are often removed by patients, reducing effectiveness by 50% or more. 2

Infection Management

Mild Infections (Superficial)

• Cleanse and sharply debride all necrotic tissue and surrounding callus 1
• Start empiric oral antibiotics targeting S. aureus and streptococci: dicloxacillin, cephalexin, or clindamycin for 1-2 weeks 1, 3
• Do NOT use antibiotics if no clinical infection is present—this is a critical pitfall to avoid 2

Moderate to Severe Infections (Deep/Limb-Threatening)

• Urgently evaluate for surgical intervention to remove necrotic tissue, drain abscesses, and debride infected bone 1, 2
• Obtain post-debridement specimens for aerobic and anaerobic culture before starting antibiotics 2
• Initiate broad-spectrum parenteral antibiotics immediately covering gram-positive, gram-negative, and anaerobic bacteria: options include piperacillin/tazobactam, imipenem/cilastatin, or ciprofloxacin plus clindamycin 1, 3
• Assess for peripheral arterial disease (PAD) and treat urgently with revascularization if present 1
• Adjust antibiotics based on culture results and clinical response; narrow spectrum when possible 1
• Duration: 2-4 weeks for soft tissue infections; 4-6+ weeks for osteomyelitis unless all infected bone is surgically removed 3

Common pitfall: Delaying surgical consultation for deep or severe infections significantly increases amputation risk. 2

Vascular Assessment and Revascularization

Evaluate arterial perfusion in all infected limbs, especially with signs of ischemia (absent pulses, cool skin, delayed capillary refill, dependent rubor). 2, 3

• Urgent vascular imaging (CT angiography, MR angiography, or conventional angiography) is indicated when ankle pressure <50 mmHg or ABI <0.5 1
• Revascularization (surgical bypass or endovascular therapy) should be performed urgently in patients with critical limb ischemia to optimize wound healing 2, 4

Common pitfall: Failing to assess vascular status before aggressive debridement can lead to non-healing wounds and tissue loss. 2

Local Wound Care

Sharp debridement is the cornerstone of wound care—remove all necrotic tissue, callus, and surrounding hyperkeratosis with a scalpel, repeating as needed. 1, 2

• Inspect ulcers frequently and measure to monitor healing progress 1, 2
• Select dressings to control excess exudate and maintain a moist wound environment 1
• For dry gangrene without underlying infection, leave adherent eschar in place until it softens enough for removal 3

Adjunctive Therapies for Slow-Healing Wounds

If wound area reduction is <50% after 4 weeks of standard therapy, consider: 2, 4

• Negative pressure wound therapy for post-operative wounds 1, 2
• Systemic hyperbaric oxygen therapy for poorly healing wounds (may hasten healing) 1, 2

NOT recommended for routine use: 1

• Biologically active products (collagen, growth factors, bio-engineered tissue) in neuropathic ulcers
• Silver or antimicrobial-containing dressings
• Footbaths (these induce skin maceration and worsen outcomes)

Multidisciplinary Team Organization

Successful diabetic foot care requires a structured three-level system: 1

• Level 1: General practitioner, podiatrist, diabetes nurse 1
• Level 2: Diabetologist, surgeon (general/orthopedic/foot), vascular surgeon, interventional radiologist, podiatrist, diabetes nurse, orthotist/prosthetist 1
• Level 3: Specialized diabetic foot center with multiple experts acting as tertiary reference center 1

Evidence is clear: Multidisciplinary team care reduces amputation rates significantly compared to standard care. 1, 5, 6

Patient Education and Follow-Up

Educate patients and caregivers on: 1, 2

• Recognizing signs of new or worsening infection (fever, increased wound drainage, worsening hyperglycemia)
• Proper self-care techniques
• Preventing ulcers on the contralateral foot during bed rest

Monitor for clinical improvement: reduction in erythema, swelling, pain, and wound size. 2, 3

Prevention of Recurrence

Once healed, enroll patients in lifelong integrated foot-care program including: 1, 2

• Regular professional foot examination and treatment
• Custom therapeutic footwear (especially for patients with significant neuropathy, foot deformities, or previous amputation) 4
• Ongoing patient education
• The foot should never return to the same shoe that caused the ulcer 1