How to treat a diabetic foot ulcer on the right big toe with slough in the base and a burning sensation?

Treatment of Diabetic Foot Ulcer with Slough and Burning Sensation

Perform sharp debridement to remove all slough, necrotic tissue, and surrounding callus from the ulcer, then apply a simple sterile dressing selected for exudate control and cost, while simultaneously offloading the toe and assessing for infection and vascular compromise. 1

Immediate Wound Management

Sharp Debridement (First Priority)

• Remove all slough, necrotic tissue, and surrounding callus using sharp debridement with a scalpel 1
• This is the single most important intervention and should be repeated at each visit as needed 1
• Sharp debridement is preferred over all other methods (hydrogels, enzymatic agents, larval therapy) because it is most effective, least expensive, and universally available 1
• Contraindications to consider: severe ischemia (ankle pressure <50 mmHg or ABI <0.5) or excessive pain 1
• If severe ischemia is present, urgent vascular imaging and revascularization must be considered before aggressive debridement 1

Wound Dressing Selection

• Select dressings based on three factors only: exudate control, patient comfort, and cost 1
• Use sterile, inert dressings that maintain a warm, moist environment 1
• Do NOT use antimicrobial dressings (including silver-containing products) as they do not accelerate healing or prevent infection 1
• Clean the ulcer with clean water or saline at each dressing change 1

Assessment for Complications

Vascular Assessment (Critical)

The burning sensation raises concern for ischemia, which must be ruled out immediately:

• If ankle pressure is <50 mmHg or ABI <0.5, obtain urgent vascular imaging and consider revascularization 1
• Ischemia is a contraindication to aggressive debridement and will prevent healing regardless of other interventions 1

Infection Evaluation

Assess for signs of infection at every visit:

• Mild infection (superficial): purulent discharge, erythema, warmth, or tenderness extending <2 cm from ulcer 1
  • Cleanse and debride all necrotic tissue 1
  • Start empiric oral antibiotics targeting S. aureus and streptococci 1
• Moderate/severe infection (limb-threatening): erythema >2 cm, deep tissue involvement, systemic signs 1
  • Urgently evaluate for surgical debridement to remove infected tissue and drain abscesses 1
  • Initiate parenteral broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic bacteria 1

Offloading the Toe

Offloading is as critical as debridement for healing:

• For toe ulcers, consider shoe modifications, temporary footwear, toe spacers, or toe orthoses 1
• Instruct the patient to limit standing and walking; use crutches if necessary 1
• The patient must never return to the same footwear that caused the ulcer 1

Addressing the Burning Sensation

The burning sensation likely represents one of three conditions:

• Diabetic neuropathy: Most common cause in diabetic foot ulcers 2, 3
• Ischemic pain: Must be ruled out with vascular assessment as described above 1
• Infection-related inflammation: Assess for signs of infection as outlined 1

Adjunctive Therapies (Only After Standard Care Fails)

Do NOT use these as first-line treatment:

• Consider sucrose-octasulfate impregnated dressings only for difficult-to-heal neuro-ischemic ulcers after standard care has failed 1
• Consider hyperbaric oxygen therapy only for non-healing ischemic ulcers despite optimal standard care 1
• Do NOT use growth factors, bioengineered skin products, platelet gels, or physical modalities (ultrasound, electrical stimulation) in preference to standard care 1

Common Pitfalls to Avoid

• Never soak the foot in footbaths as this causes skin maceration 1
• Do not use antimicrobial dressings routinely 1
• Do not skip vascular assessment in the presence of burning sensation 1
• Do not use expensive adjunctive therapies before optimizing standard care (debridement, offloading, infection control) 1, 4
• Ensure the patient understands they must inspect the foot daily and report any worsening signs 1

Follow-Up Protocol

• Inspect and debride the ulcer at every visit (typically weekly initially) 1
• Measure and document wound size at each visit 1
• If the ulcer fails to show improvement after 4-6 weeks of optimal standard care, reassess for unrecognized ischemia, persistent infection (including osteomyelitis), inadequate offloading, or malignancy 1, 5
• Most diabetic foot ulcers require at least 20 weeks to heal with optimal care 1