What is the best treatment approach for a wound on an elderly diabetic patient?

Treatment of Wounds in Elderly Diabetic Patients

The best treatment approach for wounds in elderly diabetic patients centers on sharp debridement combined with basic moisture-retentive dressings and appropriate offloading, while avoiding the vast majority of advanced therapies that lack evidence for improving outcomes. 1, 2

Core Standard of Care

The foundation of diabetic wound management consists of three essential components that must be optimized before considering any adjunctive therapies:

Sharp Debridement

• Perform sharp debridement (using scalpel, scissors, or tissue nippers) to remove necrotic tissue, slough, debris, eschar, and surrounding callus 1, 2
• The frequency should be determined by clinical need rather than a fixed schedule 1, 2
• This is superior to autolytic, biosurgical, hydrosurgical, chemical, enzymatic, laser, or ultrasonic debridement methods 1
• Do NOT use surgical debridement when sharp debridement can be performed outside a sterile environment 1, 3
• Relative contraindications include severe pain or severe ischemia 3

Basic Wound Dressings

• Use dressings that absorb exudate and maintain a moist wound healing environment 1, 2
• Select based on wound characteristics: hydrogels for dry/necrotic wounds, alginates or foams for exudative wounds, films for moistening dry wounds 1
• Do NOT use topical antiseptic or antimicrobial dressings for wound healing purposes (strong recommendation, moderate certainty) 1, 3, 2
• Do NOT use honey, collagen, alginate, phenytoin, or herbal remedy-impregnated dressings (strong recommendations) 1, 3

Offloading

• Use a non-removable knee-high offloading device as first-line treatment for neuropathic plantar forefoot or midfoot ulcers 2
• For patients with limited access to specialized devices, consider felted foam with appropriate footwear 2
• Patients with bony deformities may require extra wide/deep shoes or custom-molded shoes for severe deformities including Charcot foot 2

What NOT to Use (Critical to Avoid)

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

Strongly Contraindicated Interventions

• Do NOT use physical therapies (electricity, magnetism, ultrasound, shockwaves) 1, 3
• Do NOT use cold atmospheric plasma, ozone, nitric oxide, or CO2 1, 3
• Do NOT use pharmacological agents promoting perfusion/angiogenesis, vitamin/trace element supplements, red cell production stimulants, or protein supplementation 1, 3
• Do NOT use autologous skin grafts 1, 3
• Do NOT use cellular or acellular skin substitute products routinely 1, 3
• Do NOT use growth factor therapy routinely 1, 3
• Do NOT use negative pressure wound therapy for non-surgical diabetic foot ulcers (strong recommendation) 1, 3

Adjunctive Therapies (Only After Standard Care Fails)

Consider these interventions ONLY when best standard care (debridement, dressings, offloading) has been ineffective for at least 2 weeks:

Conditional Recommendations (Moderate Evidence)

• Sucrose-octasulfate impregnated dressing for non-infected, neuro-ischemic ulcers with insufficient improvement after 2+ weeks of optimal standard care 1, 2
• Autologous leucocyte, platelet, and fibrin patch (NOT other platelet therapies) where standard care has failed and resources exist for regular venepuncture 1, 2

Conditional Recommendations (Low Evidence)

• Hyperbaric oxygen therapy for neuro-ischemic or ischemic ulcers where standard care has failed and resources already exist 1, 2
• Topical oxygen therapy where standard care has failed and resources exist 1
• Placental-derived products where standard care has failed 1
• Negative pressure wound therapy ONLY for post-surgical wounds (not for non-surgical ulcers) 1

Additional Management Considerations

Infection Control

• Systemic antibiotics should ONLY be used when clinical signs of infection are present (erythema, warmth, swelling, tenderness, purulent discharge) 1
• Do NOT use topical antimicrobials for uninfected wounds 1, 2

Vascular Assessment

• Ensure adequate arterial perfusion to the wound site, as ischemia is a relative contraindication to aggressive debridement 1, 3
• Consider revascularization when indicated 1

Metabolic Optimization

• Aggressively correct hyperglycemia, as it delays wound healing through osmotic diuresis, decreased oxygenation, and impaired neutrophil function 4

Monitoring

• Reassess treatment if insufficient improvement occurs after 2 weeks 2
• High-risk patients require monitoring every 1-3 months 2
• Educate patients about daily foot inspection, especially critical for those with sensory deficits 2

Common Pitfalls to Avoid

• Failing to provide adequate offloading is the most common error 2
• Overreliance on advanced therapies before optimizing standard care (debridement, dressings, offloading) 3, 2
• Using antimicrobial dressings without evidence of infection 3, 2
• Premature use of negative pressure wound therapy for non-surgical wounds 3
• Neglecting recurrence risk after healing—prescribe therapeutic footwear with demonstrated plantar pressure-relieving effect for healed plantar ulcers 2