What are the management options for diabetic foot ulcers?

Management of Diabetic Foot Ulcers

The cornerstone of diabetic foot ulcer management is a five-pronged approach: aggressive offloading with non-removable devices, sharp debridement, infection control, vascular assessment with revascularization when indicated, and simple wound care with moist dressings—while avoiding expensive adjunctive therapies that lack strong evidence. 1

Core Management Principles

The International Working Group on the Diabetic Foot establishes five essential treatment pillars that must be addressed systematically 1:

1. Offloading (Most Critical Component)

For neuropathic plantar ulcers, use a non-removable knee-high offloading device—either a total contact cast or a removable walker rendered irremovable—as the preferred treatment. 1

• When non-removable devices are contraindicated, use removable offloading devices, though recognize these are significantly less effective due to poor patient compliance 2
• For non-plantar ulcers, consider shoe modifications, temporary footwear, toe-spacers, or orthoses 1
• Instruct patients to strictly limit standing and walking, using crutches if necessary 1
• Common pitfall: Relying on removable devices that patients inconsistently use is the most frequent management failure 2

2. Sharp Debridement

Perform scalpel debridement at initial presentation and repeat as frequently as clinically needed throughout treatment. 1, 3

• Remove all necrotic tissue, surrounding callus, foreign material, and debris 1, 3
• Sharp debridement removes colonizing bacteria, facilitates granulation tissue formation, and permits examination for deep tissue or bone involvement 3
• Inspect the ulcer frequently between debridement sessions 1

3. Infection Management

For superficial ulcers with mild infection 1:

• Cleanse and debride all necrotic tissue and surrounding callus 1
• Start empiric oral antibiotics targeting S. aureus and streptococci (cephalexin, flucloxacillin, or clindamycin) 1, 3
• Obtain wound cultures from the debrided base to guide antibiotic adjustment 3

For deep or limb-threatening infections (moderate to severe) 1:

• Urgently evaluate for surgical intervention to remove necrotic tissue, including 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 antibiotics based on clinical response and culture results 1

4. Vascular Assessment and Revascularization

If ankle pressure is <50 mmHg or ankle-brachial index (ABI) <0.5, obtain urgent vascular imaging and consider revascularization. 1

• Consider revascularization if toe pressure <30 mmHg or TcpO₂ <25 mmHg 1
• When an ulcer shows no signs of healing within 6 weeks despite optimal management, consider revascularization regardless of perfusion test results 1
• Before contemplating major (above-ankle) amputation, first consider revascularization options 1
• The goal is to restore direct flow to at least one foot artery, preferably the artery supplying the wound's anatomical region 1
• Important caveat: Pharmacological treatments to improve perfusion have not been proven beneficial 1

5. Local Wound Care

Clean the wound regularly with water or saline and maintain a moist wound environment using sterile, inert protective dressings. 1

• Select dressings to control excess exudation while maintaining moisture 1
• For exudative or purulent wounds, use alginates or foams to absorb drainage 3
• Change dressings based on wound characteristics—heavily exudating ulcers require frequent changes to prevent skin maceration 4
• Do not use footbaths where feet are soaked, as they induce skin maceration 1

Adjunctive Therapies: Limited Evidence

Therapies to Consider (Conditional Recommendations)

• Negative pressure wound therapy: Consider only for post-operative wounds; effectiveness and cost-effectiveness remain unestablished for non-surgical ulcers 1, 2
• Hyperbaric oxygen therapy: Consider for poorly healing wounds after standard care has failed; may increase healing incidence and improve long-term outcomes, though cost-effectiveness requires confirmation 1

Therapies NOT Recommended for Routine Use

The following lack sufficient evidence to justify routine use 1, 2:

• Biologically active products (collagen, growth factors, bioengineered tissue) 1, 2
• Silver-containing or other antimicrobial dressings 1
• Topical platelet-derived growth factor (becaplermin)—effectiveness remains unconfirmed despite FDA approval 1, 5
• Platelet suspension supernatants—early studies suggested benefit but no recent data 1

Critical note: The FDA label for becaplermin (REGRANEX) carries a warning about potential cancer risk, and retrospective studies show no mortality benefit, making its use difficult to justify 5

Treatment Monitoring and Adjustment

• Assess ulcer size every 1-2 weeks 5
• If the ulcer does not show approximately 30% reduction in area after 8-10 weeks, consider treatment failure and adjust management 5
• Adjust treatment if insufficient improvement is not observed after 2 weeks 2

Patient Education and Prevention

Instruct patients and caregivers on 1:

• Appropriate self-care and recognition of infection signs (fever, wound changes, worsening hyperglycemia) 1
• Daily foot inspection to prevent ulcers on the contralateral foot during bed rest 1
• After healing, enroll in an integrated foot-care program with lifelong observation, professional foot treatment, and therapeutic footwear 1
• The foot should never return to the same shoe that caused the ulcer 1

Cardiovascular Risk Reduction

Address systemic cardiovascular risk factors concurrently 1:

• Smoking cessation 1
• Control of hypertension and dyslipidemia 1
• Use of aspirin or clopidogrel 1

Multidisciplinary Team Structure

Organize care across three levels 1:

• Level 1: General practitioner, podiatrist, diabetic nurse 1
• Level 2: Diabetologist, surgeon, vascular surgeon, endovascular interventionist, podiatrist, diabetic nurse, with shoe-maker/orthotist 1
• Level 3: Specialized diabetic foot center with multiple experts from several disciplines 1