What is the primary management for diabetic foot?

Primary Management of Diabetic Foot

The primary management of diabetic foot centers on a multidisciplinary approach with seven core pillars: aggressive pressure offloading, sharp debridement, infection control, vascular assessment with revascularization when needed, appropriate wound care, metabolic control, and patient education—all coordinated by a specialized foot-care team. 1, 2

Immediate Assessment and Risk Stratification

When a diabetic foot problem presents, immediately assess for:

• Peripheral neuropathy (loss of protective sensation using monofilament testing) 1
• Peripheral arterial disease (measure ankle-brachial index and ankle pressure; if ankle pressure <50 mmHg or ABI <0.5, urgent vascular imaging is required) 1, 2, 3
• Presence and depth of ulceration (probe to bone to detect osteomyelitis) 2, 4
• Signs of infection (erythema, warmth, purulence, or systemic toxicity) 1

Categorize patients using the IWGDF Risk Classification System to determine follow-up frequency: Category 0 (no neuropathy) annually, Category 1 (neuropathy alone) every 6 months, Category 2 (neuropathy plus PAD or deformity) every 3-6 months, and Category 3 (prior ulcer/amputation) every 1-3 months. 1

The Seven Pillars of Diabetic Foot Management

1. Pressure Offloading (The Most Critical Intervention)

For neuropathic plantar ulcers, use a non-removable knee-high offloading device—either a total contact cast or a removable walker rendered irremovable—as this is the single most effective intervention to promote healing. 1, 2, 4

• When non-removable devices are contraindicated or unavailable, use removable offloading devices, though patient compliance is typically poor 1, 2
• For non-plantar ulcers (including heel ulcers), employ shoe modifications, temporary footwear, toe-spacers, or orthoses 1, 3
• Instruct patients to limit standing and walking activities, use crutches if necessary, and ensure heel protection during bed rest 1, 3

2. Sharp Debridement

Perform scalpel debridement at initial presentation and repeat as frequently as clinically needed throughout treatment—often weekly or more frequently. 2, 3

• Debridement removes colonizing bacteria, necrotic tissue, and surrounding callus, facilitates granulation tissue formation, and permits examination for deep tissue or bone involvement 1, 2
• This is non-negotiable for healing and must be done aggressively 1

3. Infection Management

For mild superficial infections:

• Cleanse and debride all necrotic tissue and surrounding callus 1, 2
• Start empiric oral antibiotics targeting S. aureus and streptococci (cephalexin, flucloxacillin, or clindamycin) 1, 2, 3
• Obtain wound cultures from the debrided base before starting antibiotics 1, 5

For moderate-to-severe or limb-threatening infections:

• Urgently evaluate for surgical intervention to remove necrotic tissue, drain abscesses, and debride infected bone 1, 2
• Initiate empiric parenteral broad-spectrum antibiotics covering gram-positive cocci, gram-negative rods, and anaerobes 1, 5
• Assess for peripheral arterial disease and consider urgent revascularization 1, 2
• Adjust antibiotics based on culture results and clinical response 1, 5

Duration of antibiotic therapy:

• Mild infections: 1-2 weeks, extending to 2-4 weeks if needed 1, 5
• Moderate-to-severe infections: 2-4 weeks depending on structures involved and adequacy of debridement 1, 5
• Osteomyelitis: minimum 4-6 weeks, or shorter if all infected bone is removed 1, 5

4. Vascular Assessment and Revascularization

Consider urgent revascularization if ankle pressure <50 mmHg, ABI <0.5, toe pressure <30 mmHg, or TcpO₂ <25 mmHg. 1, 2, 3

• Peripheral arterial disease is present in up to 50% of diabetic foot ulcer patients and is a major risk factor for amputation 1
• When an ulcer shows no signs of healing within 6 weeks despite optimal management, consider revascularization regardless of initial vascular test results 1
• Before contemplating major (above-ankle) amputation, always first consider revascularization options 1, 2
• The goal is to restore direct flow to at least one foot artery, preferably the artery supplying the wound's anatomical region 1

5. Local Wound Care

Clean wounds regularly with water or saline, select dressings that control excess exudation while maintaining a moist environment, and avoid footbaths that cause skin maceration. 1, 2

• Use alginates or foams for wounds with purulent exudate 3
• There is insufficient evidence to recommend specific wound dressings, silver-containing dressings, or biologically active products (collagen, growth factors) for routine use 1, 2
• Consider negative pressure wound therapy only for post-operative wounds, not for routine non-surgical ulcers 1, 2

6. Metabolic Control and Comorbidity Management

Optimize glycemic control to reduce infection risk and improve wound healing. 1, 4

• Address cardiovascular risk factors: smoking cessation, control of hypertension and dyslipidemia, and use of aspirin or clopidogrel 1, 2, 3
• Manage end-stage renal disease and other metabolic derangements that impair neutrophil function and wound healing 1

7. Patient and Family Education

Instruct patients and caregivers on daily foot inspection, appropriate self-care, recognition of infection signs, proper footwear, and the importance of never walking barefoot. 1, 2

• After ulcer healing, enroll patients in an integrated foot-care program with lifelong observation, professional foot treatment, and therapeutic footwear 2
• Educate on preventing ulcers on the contralateral foot during periods of bed rest 2

Multidisciplinary Team Coordination

Diabetic foot infections require coordinated management by a multidisciplinary foot-care team that includes or has ready access to an infectious diseases specialist or medical microbiologist. 1, 5

The team should ideally include: general practitioner, podiatrist, diabetic nurse, diabetologist, vascular surgeon, endovascular interventionist, orthopedic or plastic surgeon, and orthotist/shoe-maker. 2

Adjunctive Therapies (Use Selectively)

• Hyperbaric oxygen therapy may be considered for poorly healing wounds after standard care has failed, though cost-effectiveness requires confirmation 1, 2, 3, 5
• Granulocyte colony-stimulating factors may help prevent amputations in severe infections unresponsive to standard therapy 1, 5

Critical Pitfalls to Avoid

• Never treat clinically uninfected ulcers with antibiotics—this promotes resistance without benefit 1, 5
• Never rely on removable offloading devices without ensuring patient compliance—non-removable devices are vastly superior 1, 2
• Never delay vascular assessment in non-healing ulcers—ischemia is present in 50% of cases and must be addressed 1
• Never use footbaths—they induce skin maceration and worsen outcomes 1