What are the recommended treatments for diabetic wounds?

Treatment of Diabetic Wounds

The foundation of diabetic wound treatment is sharp debridement combined with basic moisture-retentive dressings that absorb exudate, along with proper off-loading—avoid expensive specialized dressings, antimicrobial products, and most adjunctive therapies as they do not improve healing outcomes. 1

Standard of Care (First-Line Treatment)

Sharp Debridement

• Perform sharp debridement to remove slough, necrotic tissue, and surrounding callus at a frequency determined by clinical need. 1
• This is the cornerstone intervention and should be done regularly throughout treatment. 2, 3
• Avoid surgical debridement when sharp debridement can be performed outside a sterile environment. 1
• Do not use autolytic, biosurgical, hydrosurgical, chemical, laser, or ultrasonic debridement over standard sharp debridement (Strong recommendation). 1
• Consider enzymatic debridement only in specific situations where sharp debridement is limited by resource availability or lack of skilled personnel (Conditional recommendation). 1

Dressing Selection

• Select basic wound dressings primarily based on exudate control, comfort, and cost—not antimicrobial properties or healing claims. 2, 3
• Use simple gauze or non-adherent dressings that maintain a moist wound healing environment. 1, 2
• For high-exudate wounds, foam or alginate dressings provide superior absorption for exudate management purposes only. 3, 4

Off-Loading

• Implement proper off-loading (pressure relief) of the affected area, which is more critical than dressing choice. 2, 3

What NOT to Use (Strong Recommendations Against)

Dressings and Topical Products to Avoid

• Do not use topical antiseptic or antimicrobial dressings (including silver or iodine-impregnated products) for wound healing (Strong recommendation; Moderate certainty). 1, 3
• Do not use honey or bee-related products (Strong recommendation; Low certainty). 1, 3
• Do not use collagen or alginate dressings for the purpose of wound healing (Strong recommendation; Low certainty). 1, 3
• Do not use topical phenytoin (Strong recommendation; Low certainty). 1
• Do not use herbal remedy-impregnated dressings (Strong recommendation; Low certainty). 1, 3

Therapies to Avoid

• Do not use physical therapies (electricity, magnetism, ultrasound, shockwaves) for wound healing (Strong recommendation; Low certainty). 1, 2
• Do not use other gases (cold atmospheric plasma, ozone, nitric oxide, CO2) compared to standard care (Strong recommendation; Low certainty). 1
• Do not use pharmacological agents promoting perfusion and angiogenesis over standard care (Strong recommendation; Low certainty). 1
• Do not use vitamin and trace element supplementation to improve wound healing (Strong recommendation; Low certainty). 1
• Do not use agents that stimulate red cell production or protein supplementation for wound healing (Strong recommendation; Low certainty). 1

Skin Substitutes to Avoid

• Do not routinely use cellular skin substitute products as adjunct therapy (Conditional recommendation; Low certainty). 1, 2
• Do not routinely use acellular skin substitute products as adjunct therapy (Conditional recommendation; Low certainty). 1, 2
• Do not use autologous skin graft products as adjunct therapy (Strong recommendation; Low certainty). 1

Growth Factors and Cell Therapies

• Do not routinely use growth factor therapy (including becaplermin/REGRANEX) as adjunct therapy (Conditional recommendation; Low certainty). 1
• Do not use autologous platelet therapy (including blood bank-derived platelets) except for the specific autologous leucocyte/platelet/fibrin patch described below (Conditional recommendation; Low certainty). 1
• Do not use other cell therapies as adjunct therapy (Conditional recommendation; Low certainty). 1

Second-Line Options (When Standard Care Fails After 2+ Weeks)

Conditional Recommendations for Non-Healing Ulcers

• Consider sucrose-octasulfate impregnated dressing for non-infected, neuro-ischemic ulcers that show insufficient improvement after at least 2 weeks of best standard care including appropriate off-loading (Conditional recommendation; Moderate certainty). 1, 2, 3

• Consider autologous leucocyte, platelet, and fibrin patch where best standard care has been ineffective and where resources and expertise exist for regular venepuncture (Conditional recommendation; Moderate certainty). 1, 2, 3

• Consider placental-derived products as adjunct therapy where standard care alone has failed (Conditional recommendation; Low certainty). 1

• Consider hyperbaric oxygen therapy for neuro-ischemic or ischemic ulcers where standard care has failed and where resources already exist to support this intervention (Conditional recommendation; Low certainty). 1

• Consider topical oxygen therapy where standard care has failed and resources exist (Conditional recommendation; Low certainty). 1

Critical Pitfalls to Avoid

• Do not select dressings based on marketing claims about antimicrobial properties or accelerated healing—these have not been shown to improve outcomes and waste resources. 3
• Do not use negative pressure wound therapy for non-surgical diabetic ulcers. 2
• Do not neglect off-loading—proper pressure relief is essential and more important than dressing selection. 2, 3
• Reassess treatment if insufficient improvement occurs after 2 weeks and consider the limited second-line options above. 2, 4

Treatment Algorithm

1. Initial intervention: Sharp debridement + basic moisture-retentive dressing + off-loading
2. Ongoing management: Regular sharp debridement based on clinical need + simple dressings for exudate control
3. At 2 weeks: If insufficient improvement (less than ~30% reduction in ulcer area), consider one of the conditional second-line options listed above
4. Continue treatment: Up to 20 weeks with regular reassessment 5