What is the recommended wound care for an open diabetic foot wound?

Wound Care for Open Diabetic Foot Wounds

The cornerstone of diabetic foot wound care is sharp debridement combined with basic moisture-absorbing dressings that maintain a moist wound environment, while avoiding the numerous topical agents and advanced therapies that lack evidence for improving healing. 1, 2

Core Standard of Care

Sharp Debridement is Essential

• Perform sharp debridement as the primary and only evidence-supported debridement method to remove necrotic tissue, slough, and surrounding callus using a scalpel, scissors, or tissue nippers 1, 2
• The frequency should be determined by clinical need—wounds with persistent necrotic tissue or slough may require debridement at every dressing change or every other day until the wound bed is clean 1, 2
• Sharp debridement is strongly preferred over all alternatives including enzymatic, autolytic, biosurgical, hydrosurgical, chemical, laser, or ultrasonic methods (Strong recommendation) 1
• Enzymatic debridement should only be considered when sharp debridement is unavailable due to limited resources or skilled personnel (Conditional recommendation) 1

Basic Wound Dressings Only

• Use simple dressings that absorb exudate and maintain a moist wound healing environment—selection should be based on convenience and cost 1, 2
• Change dressings frequently enough to allow daily wound inspection and prevent periwound maceration 1, 2

What NOT to Use (Strong Contraindications)

The 2024 IWGDF guidelines provide extensive strong recommendations against numerous interventions that delay appropriate care:

Antimicrobial and Specialty Dressings to Avoid

• Do not use topical antiseptic or antimicrobial dressings (including silver products) for wound healing purposes (Strong recommendation; Moderate certainty) 1, 3, 2
• Do not use honey or bee-related products (Strong recommendation) 1, 3
• Do not use collagen or alginate dressings (Strong recommendation) 1, 3
• Do not use herbal remedy-impregnated dressings (Strong recommendation) 1, 3

Advanced Therapies Generally Not Recommended

• Do not routinely use cellular or acellular skin substitute products (Conditional recommendation) 1, 3
• Do not use autologous skin grafts as adjunct therapy (Strong recommendation) 1, 3
• Do not use growth factor therapy routinely (Conditional recommendation) 1, 3
• Do not use physical therapies including ultrasound, electrical stimulation, or shockwaves (Strong recommendation) 1, 3
• Do not use negative pressure wound therapy for non-surgical diabetic foot ulcers 3, 4

Critical Adjunctive Measures

Off-Loading is Mandatory

• Removal of pressure from the wound (off-loading) is crucial and non-negotiable for healing (A-I evidence) 1, 2
• Use devices that permit easy wound inspection while protecting the ulcer 1, 2

Infection Management

• Antibiotics are for treating infection, not for healing uninfected wounds 1, 5
• Cleanse and debride before obtaining culture specimens 1
• Obtain tissue specimens from the debrided wound base by curettage or biopsy—avoid swabbing undebrided ulcers (A-I evidence) 1
• Blood cultures should be performed for severe infections with systemic illness 1

Vascular Assessment

• Assess for ischemia, as severe vascular disease is a relative contraindication to aggressive debridement 1, 3
• For severely infected ischemic feet, perform revascularization early (within 1-2 days) rather than delaying with prolonged antibiotic therapy (B-II) 1

When Standard Care Fails (After 2+ Weeks)

Only after optimizing standard care including sharp debridement, appropriate dressings, and off-loading should you consider:

• Sucrose-octasulfate impregnated dressing for non-infected, neuro-ischemic ulcers with insufficient improvement after 2 weeks of optimal care (Conditional recommendation; Moderate certainty) 1, 2
• Autologous leucocyte, platelet, and fibrin patch where standard care has been ineffective and resources exist for regular venepuncture (Conditional recommendation; Moderate certainty) 1, 2
• Hyperbaric oxygen therapy for neuro-ischemic or ischemic ulcers where standard care has failed and resources already exist (Conditional recommendation) 1, 2

Common Pitfalls to Avoid

• Failing to provide adequate off-loading is the most common reason for treatment failure 2
• Using antimicrobial dressings without documented infection—these should only be used for infection control, not to accelerate healing 3, 2, 4
• Overreliance on advanced therapies before optimizing the fundamentals of sharp debridement, basic dressings, off-loading, and glycemic control 3, 2, 4
• Prescribing antibiotics for uninfected ulcers in the mistaken belief they will hasten healing 1, 5