Sucralfate in Wound Care: Clinical Guidelines and Applications
Primary Recommendation for Diabetic Foot Ulcers
Use sucrose-octasulfate (sucralfate-based) impregnated dressings for non-infected, neuro-ischemic diabetic foot ulcers that have failed to show adequate healing after at least 2 weeks of best standard care including appropriate offloading. 1
Patient Selection Criteria
Appropriate Candidates
- Diabetic foot ulcers larger than 1 cm² with University of Texas classification grade IC or IIC 1
- Moderate ischemia with ankle-brachial index (ABI) < 0.9 or toe-brachial index (TBI) < 0.7, but toe pressure > 50 mmHg 2
- Ulcers showing less than 30% reduction in wound area after 2 weeks of optimal standard care 2
Contraindications
- Active wound infection—do not use sucrose-octasulfate dressings in infected wounds 1
Clinical Efficacy Data
The evidence supporting sucralfate-based wound dressings comes from a high-quality, double-blind, multicenter randomized controlled trial with low risk of bias 2:
- 48% complete healing rate at 20 weeks versus 30% with placebo (adjusted OR 2.60,95% CI 1.43-4.73; p=0.002) 2, 1
- Faster time to complete wound healing compared to standard dressings 2, 1
- Greater percentage area reduction compared to control 1
Mechanism of Action in Wound Healing
Sucralfate promotes epithelial wound healing through multiple pathways 3:
- Forms a protective barrier over the wound surface 3
- Stimulates epithelial healing and granulation tissue development 4, 3
- Supports the orchestrated process of hemostasis, inflammatory reaction, cell proliferation, and tissue remodeling 3
Other Wound Applications
Post-Hemorrhoidectomy Wounds
Sucralfate cream significantly increases healing likelihood compared to petrolatum cream (RR 1.50,95% CI 1.13-1.99) over 3 weeks, with lower wound pain scores. 5 This represents moderate-quality evidence from surgical wounds healing by secondary intention 5.
Radiation Proctitis
Sucralfate enemas control bleeding from radiation proctitis by stimulating epithelial healing and forming a protective barrier. 4
Safety Profile
- Favorable safety profile with few reported harms 1
- Minimal systemic absorption after topical application 6
- Well tolerated with constipation (2% incidence) being the most common side effect when used orally 6
Cost-Effectiveness
Cost-effectiveness modeling from Western healthcare systems supports the use of sucrose-octasulfate dressings, with resource use considered low to moderate. 1
Critical Caveats
Timing Considerations
- The optimal timing for initiating sucrose-octasulfate treatment remains to be established 2
- Must document failure of at least 2 weeks of best standard care before initiating 2, 1
Evidence Limitations
- This recommendation is based on a single high-quality study, making the evidence moderate and the recommendation strength weak 2
- Further studies may alter this recommendation 2
What NOT to Use
The IWGDF provides strong recommendations against several alternatives 1:
- Collagen or alginate dressings 1
- Topical antiseptic or antimicrobial dressings 1
- Honey or bee-related products 1
- Topical phenytoin 1
- Herbal remedies 1
Administration Considerations
When sucralfate is used systemically (oral), administer at least 2 hours apart from drugs that decrease gastric acidity (PPIs or H2-blockers) to avoid interaction. 4 This consideration applies primarily to oral sucralfate use for gastrointestinal indications, not topical wound applications 4.