What is the treatment for diabetic foot ulcers?

Treatment of Diabetic Foot Ulcers

The cornerstone of diabetic foot ulcer treatment is a non-removable knee-high offloading device (total contact cast or irremovable walker) combined with aggressive sharp debridement, infection control when present, vascular assessment with revascularization if needed, and simple moist wound care—all delivered through a multidisciplinary team approach. 1, 2

Immediate Assessment and Risk Stratification

Upon presentation, perform the following critical assessments:

• Ulcer depth and extent: Determine if the ulcer extends into subcutaneous tissue or beyond (Wagner Grade 2-5 or Texas Grade 1B-3D), as this affects treatment eligibility for certain therapies 1
• Vascular status: Check for palpable pedal pulses, capillary refill, and measure ankle pressure—if ankle pressure <50 mmHg or ABI <0.5, urgent vascular imaging and revascularization are required 1
  • Critical caveat: ABI can be falsely elevated in diabetic patients due to arterial calcification; use toe pressure (<30 mmHg indicates critical ischemia) or TcPO₂ (<25 mmHg) instead 3, 2
• Infection severity: Distinguish between superficial (mild) versus deep/limb-threatening (moderate-severe) infection based on depth of tissue involvement and systemic signs 1, 2

Core Treatment Components (The "Five Pillars")

1. Aggressive Offloading (Most Critical)

For neuropathic plantar ulcers, use a non-removable knee-high device as first-line treatment:

• Preferred options: Total contact cast (TCC) or removable walker rendered irremovable 1, 2
• When contraindicated: Use removable cast walker, but recognize patient compliance is typically poor 1, 4
• For non-plantar ulcers: Consider shoe modifications, temporary footwear, toe-spacers, or orthoses 1
• Adjunctive measures: Instruct strict non-weight-bearing regimen with crutches if necessary 1, 5

Common pitfall: Failing to use non-removable devices is the single most frequent error—removable devices that patients don't consistently wear are ineffective 4

2. Sharp Debridement (Repeated as Needed)

• Perform scalpel debridement at initial presentation and repeat as frequently as clinically needed throughout treatment 1, 2
• Remove all necrotic tissue, surrounding callus, and slough to facilitate granulation tissue formation 1
• This permits examination for deep tissue or bone involvement and removes colonizing bacteria 2

3. Infection Management

For superficial ulcers with mild infection:

• Cleanse and debride all necrotic tissue and surrounding callus 1, 2
• Start empiric oral antibiotics targeting S. aureus and streptococci (e.g., cephalexin, clindamycin, or amoxicillin-clavulanate) 1, 2

For deep/limb-threatening infections (moderate-severe):

• Urgently evaluate within 24 hours for surgical intervention to remove necrotic tissue, drain abscesses, and debride infected bone 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, 2
• Adjust antibiotics based on culture results from properly debrided tissue 2

4. Vascular Assessment and Revascularization

Indications for urgent vascular imaging:

• Ankle pressure <50 mmHg, ABI <0.5, toe pressure <30 mmHg, or TcPO₂ <25 mmHg 1, 2
• Goal of revascularization: Restore direct pulsatile flow to at least one foot artery, preferably the artery supplying the wound anatomical region 1
• Time-sensitive: Infected ischemic ulcers require treatment within 24 hours to prevent major amputation 1

5. Local Wound Care

• Inspect the ulcer frequently and debride with scalpel as needed 1, 2
• Select dressings primarily based on exudate control, comfort, and cost—maintain moist wound environment using sterile, inert protective dressings changed twice daily 1, 2
• Do NOT use: Antimicrobial-containing dressings (silver, etc.) as they do not accelerate healing 1
• Avoid footbaths: They induce skin maceration 1

Adjunctive Therapies (Only After Standard Care Has Failed)

Consider these ONLY when standard care alone has not achieved ~30% wound size reduction after 8-10 weeks:

Conditional Recommendations (Weak Evidence):

• Sucrose-octasulfate impregnated dressing for noninfected neuro-ischemic ulcers 1, 4
• Hyperbaric oxygen therapy for non-healing ischemic ulcers, though cost-effectiveness requires confirmation 1, 4, 2
• Autologous leucocyte-platelet-fibrin patch for noninfected difficult-to-heal ulcers 1, 4
• Placental-derived products when standard care has failed to reduce wound size 1, 4

Limited Use Recommendations:

• Negative pressure wound therapy: Consider ONLY for post-operative (surgical) wounds; strong recommendation AGAINST use in non-surgical diabetic foot ulcers 1, 4, 2
• Becaplermin gel (REGRANEX 0.01%): FDA-approved for ulcers extending into subcutaneous tissue with adequate blood supply, used as adjunct to good ulcer care 5
  • Black box warning: May increase cancer risk; carefully weigh risks versus benefits, especially in patients with prior cancer 5

Strong Recommendations AGAINST:

• Growth factors (except becaplermin in select cases), autologous platelet gels, bioengineered skin products, ozone, topical carbon dioxide, nitric oxide 1, 4
• Physical therapies using electricity, magnetism, ultrasound, or shockwaves 1, 4
• Nutritional supplementation (protein, vitamins, trace elements) specifically to improve healing 1, 4

Glycemic Control and Cardiovascular Risk Management

• Optimize blood glucose control throughout treatment 1, 2
• Address cardiovascular risk factors aggressively: These patients have 50% mortality at 5 years 1
  • Support smoking cessation 1, 2
  • Treat hypertension and prescribe statin therapy 1, 2
  • Prescribe low-dose aspirin or clopidogrel 1, 2

Patient Education and Prevention of Recurrence

• Instruct patients and caregivers on daily foot inspection, recognition of infection signs (fever, wound changes, worsening hyperglycemia), and appropriate self-care 1, 2
• During bed rest: Educate on preventing ulcers on the contralateral foot 1, 2
• After healing: Enroll in integrated foot-care program with lifelong observation, professional foot treatment, and therapeutic footwear with demonstrated plantar pressure-relieving effect 1, 4, 2
• Never return the foot to the same shoe that caused the ulcer 1

Multidisciplinary Team Structure

Organize care across three levels 1, 2:

• Level 1: General practitioner, podiatrist, diabetic nurse 1, 2
• Level 2: Diabetologist, surgeon (general/orthopedic/foot), vascular surgeon, endovascular interventionist, podiatrist, diabetic nurse, shoe-maker/orthotist 1, 2
• Level 3: Specialized diabetic foot center with all Level 2 capabilities 1

Treatment Adjustment Timeline

• Reassess at 2 weeks: If insufficient improvement (lack of ~30% wound size reduction), adjust treatment strategy 4
• Reassess at 8-10 weeks: Consider treatment failure if ulcer has not shown approximately 30% reduction in initial area; consider adjunctive therapies at this point 5
• Maximum treatment duration in trials: Up to 20 weeks, with differences in healing becoming apparent after approximately 10 weeks 5

Critical Pitfalls to Avoid

• Relying on removable offloading devices that patients don't consistently use rather than non-removable options 4
• Using ABI alone for vascular assessment in diabetic patients due to arterial calcification 3, 2
• Delaying revascularization in infected ischemic ulcers—these require treatment within 24 hours 1
• Neglecting cardiovascular risk reduction while focusing solely on local wound care 4, 2
• Failing to provide therapeutic footwear after healing, leading to preventable recurrences 4, 3