What is the primary management for diabetic foot?

Primary Management of Diabetic Foot

The primary management of diabetic foot centers on seven key pillars: pressure offloading, wound debridement, infection control, vascular assessment with revascularization when needed, metabolic optimization, appropriate wound dressings, and patient education—all coordinated through a multidisciplinary team approach. 1

Multidisciplinary Team Coordination

• Diabetic foot management requires a coordinated multidisciplinary foot-care team that includes or has ready access to infectious disease specialists, vascular surgeons, podiatrists, diabetologists, and wound care specialists 1
• This team-based approach has been shown to reduce amputation rates, hospitalization duration, and infection-related morbidities 1

The Seven Essential Treatment Pillars

1. Pressure Relief and Offloading (The Cornerstone)

For neuropathic plantar ulcers, the preferred treatment is a non-removable knee-high offloading device—either a total contact cast (TCC) or a removable walker rendered irremovable 1

• When non-removable devices are contraindicated, use removable offloading devices 1
• For non-plantar ulcers (including heel ulcers), consider shoe modifications, temporary footwear, toe-spacers, or orthoses 1
• Instruct patients to limit standing and walking activities, using crutches when necessary 1
• Common pitfall: Removable devices have poor compliance because patients remove them; non-removable devices ensure continuous offloading 1

2. Wound Debridement and Local Care

Sharp debridement with a scalpel is essential and should be repeated as frequently as needed (often weekly or more) to remove all necrotic tissue and surrounding callus 1

• Inspect the ulcer frequently during follow-up 1
• Select dressings that control excess exudation while maintaining a moist wound environment 1
• Avoid footbaths where feet are soaked, as these induce skin maceration 1

3. Infection Assessment and Treatment

The approach differs based on infection severity:

For mild superficial infections:

• Cleanse and debride all necrotic tissue and callus 1
• Start empiric oral antibiotic therapy targeting S. aureus and streptococci (such as cephalexin, flucloxacillin, or clindamycin) 1, 2

For moderate-to-severe deep infections (potentially limb-threatening):

• Urgently evaluate for surgical intervention to remove necrotic tissue, drain abscesses, and debride infected bone 1
• Initiate empiric parenteral broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic bacteria 1
• Adjust antibiotic regimen based on culture results and clinical response 1
• Critical warning sign: Infections with deep abscess, extensive bone involvement, crepitus, substantial necrosis/gangrene, or necrotizing fasciitis require immediate surgical consultation 1

4. Vascular Assessment and Revascularization

Measure ankle-brachial index (ABI) and ankle pressure immediately in all diabetic foot patients 2

• If ankle pressure <50 mmHg or ABI <0.5, consider urgent vascular imaging and revascularization 1, 2
• If toe pressure <30 mmHg or TcPO2 <25 mmHg, revascularization should also be considered 1, 2
• When an ulcer shows no healing after 6 weeks despite optimal management, consider revascularization regardless of initial vascular test results 1
• The goal is to restore direct flow to at least one foot artery, preferably the artery supplying the wound region 1
• Before contemplating major (above-ankle) amputation, always first consider revascularization options 1

5. Metabolic Control and Comorbidity Management

• Optimize glycemic control to improve wound healing and neutrophil function 1
• Emphasize cardiovascular risk reduction: smoking cessation, control of hypertension and dyslipidemia, and use of antiplatelet therapy (aspirin or clopidogrel) 1, 2

6. Adjunctive Therapies for Non-Healing Wounds

Consider systemic hyperbaric oxygen therapy for poorly healing wounds, as it may hasten wound healing and help prevent amputations 1, 2

• Consider negative pressure therapy for post-operative wounds 1
• Granulocyte colony-stimulating factors may help prevent amputations in severe infections not responding to standard therapy 1
• Not well-supported for routine use: biologically active products (collagen, growth factors), silver-containing dressings, or other antimicrobial dressings 1

7. Patient and Family Education

• Instruct patients and caregivers on appropriate self-care and how to recognize warning signs of infection (fever, wound changes, worsening hyperglycemia) 1
• During bed rest, teach prevention of ulcers on the contralateral foot 1
• Once healed, the foot should never return to the same shoe that caused the ulcer 1
• Include patients in an integrated foot-care program with lifelong observation, professional foot treatment, adequate footwear, and ongoing education 1

Critical Timing Considerations

• Patients with diabetic foot attack often delay presentation (median 9 days in one study), visiting multiple facilities before receiving definitive care 3
• Early and careful follow-up is essential to ensure treatment effectiveness 1
• Common pitfall: Treating clinically uninfected ulcers with antibiotics is not supported by evidence and should be avoided 1, 4

Prevention and Risk Stratification

• All diabetic patients should have annual foot examinations to identify ulceration risk 1
• Higher-risk patients (those with neuropathy, peripheral artery disease, foot deformities, or previous ulceration/amputation) require more frequent screening every 1-6 months based on risk category 1