What is the management (Mx) of diabetic foot?

Management of Diabetic Foot

Diabetic foot management requires a systematic approach prioritizing pressure offloading, aggressive debridement, infection control, and vascular assessment to prevent amputation and reduce mortality. 1

Immediate Assessment and Risk Stratification

Vascular Status Evaluation

• Measure ankle-brachial index (ABI) and ankle pressure immediately upon presentation 2
• If ankle pressure <50 mmHg or ABI <0.5, proceed urgently to vascular imaging and consider revascularization 1
• When available, toe pressure <30 mmHg or TcPO2 <25 mmHg also warrants revascularization consideration 1, 2
• If ulcer shows no healing after 6 weeks despite optimal management, consider revascularization regardless of initial vascular test results 1

Infection Classification and Initial Management

Mild Infection (Superficial with skin involvement):

• Cleanse and debride all necrotic tissue and surrounding callus with scalpel 1
• Start empiric oral antibiotics targeting S. aureus and streptococci (cephalexin, flucloxacillin, or clindamycin) 1, 2
• Obtain wound culture from debrided base to guide antibiotic adjustment 2

Moderate to Severe Infection (Deep, potentially limb-threatening):

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

Cornerstone Treatment: Pressure Offloading

For Neuropathic Plantar Ulcers

• Use non-removable knee-high offloading device as first-line treatment: total contact cast (TCC) or removable walker rendered irremovable 1
• When non-removable devices are contraindicated, use removable offloading devices 1
• If these are contraindicated, use footwear that best offloads the ulcer 1

For Non-Plantar Ulcers (Including Heel)

• Consider offloading with shoe modifications, temporary footwear, toe-spacers, or orthoses 1, 2
• If other biomechanical relief unavailable, use felted foam with appropriate footwear 1
• Instruct patient to limit standing and walking; use crutches if necessary 1, 2

Local Wound Care Protocol

Debridement and Dressing Management

• Inspect ulcer frequently and debride with scalpel, repeating as needed (often weekly or more frequently) 1, 2
• Select dressings to control excess exudation and maintain moist wound environment 1
• Use alginates or foams to absorb purulent exudate 2

Adjunctive Therapies to Consider

• Negative pressure wound therapy for post-operative wounds to help healing 1
• Hyperbaric oxygen treatment for poorly healing wounds may hasten wound healing 1, 2

Treatments NOT Well-Supported

• Biologically active products (collagen, growth factors, bio-engineered tissue) in neuropathic ulcers 1
• Silver or other antimicrobial-containing dressings 1
• Footbaths where feet are soaked—these induce skin maceration and should be avoided 1

Revascularization Strategy

Indications and Approach

• Aim to restore direct flow to at least one foot artery, preferably the artery supplying the anatomical region of the wound 1
• Select revascularization technique based on morphological distribution of PAD, availability of autogenous vein, and patient comorbidities 1
• Before contemplating major (above-ankle) amputation, first consider revascularization option 1
• Pharmacological treatments to improve perfusion have NOT been proven beneficial 1

Cardiovascular Risk Reduction

• Emphasize smoking cessation 1, 2
• Control hypertension and dyslipidemia 1, 2
• Use aspirin or clopidogrel for antiplatelet therapy 1, 2

Patient and Family Education

Self-Care Instructions

• Teach recognition and reporting of signs of new or worsening infection: fever onset, local wound changes, worsening hyperglycemia 1
• During enforced bed rest, instruct on preventing ulcer on contralateral foot 1
• Provide education on appropriate self-care and daily foot inspection 2

Prevention of Recurrence

Post-Healing Management

• Include patient in integrated foot-care program with lifelong observation, professional foot treatment, adequate footwear, and education 1
• The foot should never return in the same shoe that caused the ulcer—this is a critical pitfall to avoid 1

Common Pitfalls to Avoid

• Do not delay vascular assessment—peripheral arterial disease is present in up to 40% of diabetic foot infections 3
• Do not use footbaths for wound care as they cause maceration 1
• Do not rely on pharmacological treatments alone to improve perfusion without considering revascularization 1
• Do not discharge patients without arranging multidisciplinary follow-up and appropriate therapeutic footwear 1