What are the contraindications in the treatment of diabetic foot ulcers?

Contraindications in Diabetic Foot Ulcer Treatment

The 2024 IWGDF guidelines provide strong recommendations against numerous interventions that should NOT be used in diabetic foot ulcer management, as they lack evidence for improving wound healing and may delay appropriate care.

Strong Contraindications (Do NOT Use)

Debridement Methods to Avoid

• Do not use surgical debridement when sharp debridement can be performed outside a sterile environment - surgical debridement should be reserved only for situations requiring a sterile operating room 1
• Avoid autolytic, biosurgical, hydrosurgical, chemical, or laser debridement over standard sharp debridement 2

Topical Dressings and Applications Contraindicated

• Do not use topical antiseptic or antimicrobial dressings for wound healing (Strong recommendation; Moderate certainty) - these are contraindicated when used solely to accelerate healing rather than treat active infection 1, 3
• Do not use honey or bee-related products for wound healing purposes (Strong recommendation; Low certainty) 1, 2
• Do not use collagen or alginate dressings for wound healing (Strong recommendation; Low certainty) 1
• Do not use topical phenytoin for wound healing (Strong recommendation; Low certainty) 1
• Do not use herbal remedy-impregnated dressings or topical applications for wound healing (Strong recommendation; Low certainty) 1

Gas Therapies Contraindicated

• Do not use cold atmospheric plasma, ozone, nitric oxide, or CO2 compared to standard care for wound healing (Strong recommendation; Low certainty) 1

Physical Therapies Contraindicated

• Do not use any interventions in the field of physical therapies including electricity, magnetism, ultrasound, or shockwaves for wound healing (Strong recommendation; Low certainty) 1, 4

Skin Substitutes and Grafts Contraindicated

• Do not use autologous skin graft skin substitute products as adjunct therapy (Strong recommendation; Low certainty) 1
• Generally avoid cellular and acellular skin substitute products as routine adjunct therapy (Conditional recommendation; Low certainty) 1, 4

Pharmacological Agents Contraindicated

• Do not use pharmacological agents promoting perfusion and angiogenesis to improve wound healing over standard care (Strong recommendation; Low certainty) 1
• Do not use pharmacological agents that supplement vitamins and trace elements to improve wound healing (Strong recommendation; Low certainty) 1
• Do not use pharmacological agents that stimulate red cell production or protein supplementation to improve wound healing (Strong recommendation; Low certainty) 1
• Do not use other pharmacological agents to improve wound healing over standard care (Strong recommendation; Low certainty) 1

Cell and Growth Factor Therapies Generally Contraindicated

• Generally avoid other cell therapy as adjunct to standard care (Conditional recommendation; Low certainty) 1
• Generally avoid growth factor therapy as adjunct to standard care (Conditional recommendation; Low certainty) 1
• Do not use autologous platelet therapy (including blood bank-derived platelets) as adjunct therapy, with the specific exception of autologous leucocyte, platelet, and fibrin patch (Conditional recommendation; Low certainty) 1

Negative Pressure Wound Therapy Contraindication

• Do not use Negative Pressure Wound Therapy for non-surgically related diabetic foot ulcers - this is only conditionally recommended for post-surgical wounds (Strong recommendation; Low certainty) 1, 2, 4

Clinical Context and Relative Contraindications

Sharp Debridement Relative Contraindications

• Sharp debridement should be performed with caution in patients with severe pain or severe ischemia, as these represent relative contraindications 2
• The frequency of debridement should be determined based on clinical need rather than a fixed schedule 1, 3, 2

Common Pitfalls to Avoid

• Failing to optimize standard care before considering advanced therapies - many clinicians prematurely use advanced interventions without ensuring adequate offloading, debridement, and basic wound care 3
• Using antimicrobial dressings without evidence of infection - these should only be used for infection control, not to accelerate healing 3, 4
• Overreliance on advanced therapies before optimizing the fundamentals of diabetic foot ulcer care including proper offloading, glycemic control, and vascular assessment 3
• Using hyperbaric oxygen therapy without clear evidence of benefit for the specific patient population - this should only be considered for neuro-ischemic or ischemic ulcers where standard care has failed and resources exist 3

What IS Appropriate: Standard of Care

The evidence strongly supports focusing on proven standard care components rather than the contraindicated interventions listed above:

• Sharp debridement to remove necrotic tissue and callus 3, 2
• Basic wound dressings that absorb exudate and maintain moist wound environment 3
• Non-removable knee-high offloading devices for plantar ulcers 3
• Vascular assessment and optimization 3
• Glycemic and infection control 3