What are the latest recommendations for managing diabetic foot ulcers?

Latest Updates on Diabetic Foot Ulcer Management

Risk Stratification and Screening

The 2024 IWGDF guidelines now mandate annual screening for all diabetic patients using their updated risk stratification system (IWGDF risk 0-3), with screening frequency intensifying based on risk level. 1

• Screen patients at very low risk (IWGDF risk 0) annually for peripheral neuropathy and peripheral artery disease 1
• For patients with loss of protective sensation or PAD, extend screening to include history of ulceration, end-stage renal disease, foot deformity, limited joint mobility, excess callus, and pre-ulcerative lesions 1
• Repeat screening every 6-12 months for IWGDF risk 1, every 3-6 months for risk 2, and every 1-3 months for risk 3 1

Classification Systems for Clinical Use

The 2024 IWGDF classification guidelines recommend SINBAD as the first-line system for clinical communication and audit purposes, with IDSA/IWGDF specifically for infected ulcers. 1

• Use SINBAD classification for routine clinical documentation and nationwide audits, as it has been validated in over 76,310 patients showing higher scores correlate with lower healing rates and higher amputation risk 1
• Apply IDSA/IWGDF classification specifically when managing infected diabetic foot ulcers 1
• The WIfI (Wound, Ischemia, and foot Infection) system should be used for vascular assessment and revascularization decisions 1

Core Wound Management

Sharp debridement combined with moisture-retentive dressings remains the cornerstone of treatment, with specific avoidance of multiple ineffective modalities. 2, 3

• Perform sharp debridement of necrotic tissue and surrounding callus at frequency determined by clinical need 2, 3
• Select basic wound dressings primarily for exudate control, comfort, and cost—not based on antimicrobial properties 3
• Do NOT use topical antiseptic/antimicrobial dressings, honey, collagen, alginate dressings, topical phenytoin, or herbal remedies as first-line treatment 3
• Do NOT use autolytic, biosurgical, hydrosurgical, chemical, or laser debridement over standard sharp debridement 2, 3

Offloading Strategies

Non-removable knee-high offloading devices are now the definitive first-line treatment for neuropathic plantar forefoot or midfoot ulcers. 2, 4

• Prescribe non-removable knee-high offloading devices for neuropathic plantar forefoot or midfoot ulcers to maximize healing 2, 4
• Use removable offloading devices only for non-plantar ulcers or when balance/fall risk contraindicates non-removable devices 2
• Consider digital flexor tenotomy for neuropathic plantar or apex ulcers on digits 2-5 with flexible toe deformity 2
• For patients with limited access to specialized devices, felted foam combined with appropriate footwear is an acceptable alternative 4

Infection Management

Empiric antibiotic selection should be based on infection severity, with duration tailored to tissue involvement. 2

• Start empiric oral antibiotics targeting Staphylococcus aureus and streptococci for mild infections 2
• Initiate broad-spectrum parenteral antibiotics for moderate to severe infections 2
• Treat soft tissue infections for 1-2 weeks and osteomyelitis for 6 weeks, adjusting based on culture results 2

Advanced Therapies for Non-Healing Ulcers

Sucrose-octasulfate impregnated dressing is the preferred second-line adjunctive therapy for non-infected ulcers failing standard care after 2 weeks. 2, 3

• Consider sucrose-octasulfate impregnated dressing for non-infected, neuro-ischemic ulcers without improvement after at least 2 weeks of standard care 2, 3
• Autologous leucocyte, platelet, and fibrin patch may be considered for non-infected ulcers where resources exist for regular venepuncture 3, 4
• Hyperbaric oxygen therapy can be considered for neuro-ischemic or ischemic ulcers when standard care has failed and resources exist 4
• Becaplermin gel 0.01% (REGRANEX) is FDA-approved for lower extremity diabetic neuropathic ulcers extending into subcutaneous tissue with adequate blood supply, applied once daily as adjunct to good ulcer care 5

Common pitfall: Avoid negative pressure wound therapy for non-surgical diabetic ulcers, cellular/acellular skin substitutes as routine therapy, and physical therapies (electricity, magnetism, ultrasound, shockwaves) 3

Vascular Assessment and Intervention

Urgent vascular imaging and revascularization should be considered when ankle pressure is <50 mmHg or ABI <0.5, or if ulcers fail to show healing signs within 6 weeks despite optimal management. 2

• Perform vascular assessment checking foot pulses and ankle-brachial index at initial evaluation 2
• Consider urgent revascularization if ankle pressure <50 mmHg or ABI <0.5 2
• Reassess for revascularization if ulcers show no healing progress after 6 weeks of optimal management 2

Prevention and Patient Education

All at-risk patients (IWGDF risk 1-3) must receive structured education emphasizing never walking barefoot, daily foot washing, and immediate reporting of new lesions. 1, 2

• Educate patients never to walk barefoot, in socks without shoes, or in thin-soled slippers, indoors or outdoors 1, 2
• Instruct daily foot washing with careful drying between toes, use of emollients for dry skin, and cutting toenails straight across 1, 2
• Teach daily foot examination with immediate contact of healthcare provider if new lesions develop 1, 2
• Consider coaching moderate-to-high risk patients (IWGDF risk 2-3) to self-monitor foot skin temperatures daily, reducing activity and seeking care if temperature difference exceeds 2.2°C between feet on two consecutive days 1

Therapeutic Footwear

Patients with healed plantar ulcers must be prescribed therapeutic footwear with demonstrated plantar pressure-relieving effect to prevent recurrence. 1, 2

• Prescribe therapeutic footwear with demonstrated plantar pressure-relieving effect for all healed plantar ulcers, encouraging consistent wear indoors and outdoors 1, 2
• Consider extra-depth shoes, custom-made footwear, custom-made insoles, and/or toe orthoses for foot deformities or pre-ulcerative lesions 1, 2
• For patients without significant deformity, educate to wear footwear that accommodates foot shape and fits properly 1

Monitoring and Follow-up

High-risk patients require follow-up every 1-3 months with reassessment of integrated foot care needs at each visit. 2, 4

• Schedule follow-up every 1-3 months for patients with history of foot ulceration (IWGDF risk 3) 2, 4
• Monitor for signs of recurrence, noting that recurrence rate is 40% within one year and 65% within three years after healing 2
• Adjust treatment if insufficient improvement observed after 2 weeks of therapy 3