What is the best course of action for managing pain and promoting wound healing in a diabetic patient with a painful corn excision site?

From the Guidelines

For a 71-year-old male diabetic patient with persistent pain following corn excision, I strongly recommend against using the proposed treatment plan of soaking the left foot in warm water with Epsom salt, debriding with a pumice stone, and applying salicylic acid gel, as it may not be the most effective approach for wound healing in diabetic patients, according to the guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update) 1.

Instead, I recommend the following home treatment plan:

• Soak the left foot in warm water for 10 minutes nightly to soften the skin and reduce inflammation
• Thoroughly dry the area to prevent fungal infection, which is especially important for diabetic patients
• Gently debride the area with a pumice stone to remove dead skin without causing trauma
• Apply a dressing to absorb exudate and maintain a moist wound healing environment, as recommended by the IWGDF Practical Guidelines 1
• Cover the area with a band-aid to provide protection and keep the dressing in place

For diabetic patients, foot care is particularly crucial due to potential circulation issues and delayed healing. The patient should monitor for signs of infection (increased redness, warmth, swelling, or drainage) and discontinue any treatment if skin irritation occurs. Regular follow-up appointments are essential to ensure proper healing and prevent complications.

It is also important to note that the use of topical antiseptic or antimicrobial dressings is not recommended for wound healing of diabetes-related foot ulcers, as stated in the guidelines 1. Additionally, the guidelines suggest not using cellular skin substitute products as a routine adjunct therapy to standard of care for wound healing in patients with diabetes-related foot ulcers 1.

The patient's treatment plan should be based on the best standard of care, which includes sharp debridement and basic wound dressings, and should be adjusted according to the patient's specific needs and response to treatment, as recommended by the guidelines 1.

From the FDA Drug Label

The preferable method of use is to apply Salicylic Acid 6% thoroughly to the affected area and to cover the treated area at night after washing and before retiring. The patient's treatment plan to apply salicylic acid gel to the affected area and cover with a band-aid after a foot bath and debridement is consistent with the recommended dosage and administration instructions for salicylic acid 6% 2.

• The use of Epsom salt and warm water for a foot bath may help to hydrate the skin, which is preferable before applying salicylic acid.
• It is important to note that excessive repeated application of salicylic acid will not necessarily increase its therapeutic benefit, but could result in increased local intolerance and systemic adverse effects such as salicylism 2.

From the Research

Treatment of Diabetic Foot Ulcers

• The patient's treatment plan includes using Epsom salt and warm water for a left foot bath every night for 10 min, drying well, using a pumice stone to debride gently, then applying salicylic acid gel to the affected area, and covering with a band-aid 3.
• Studies have shown that debridement strategies and specialized wound dressings are essential in the treatment of diabetic foot ulcers, in addition to pharmacological interventions 3.
• Topical antimicrobial agents have been used to treat diabetic foot ulcers, with some studies suggesting that antimicrobial dressings may increase the number of wounds that heal 4.
• Surgical debridement, reducing pressure from weight bearing on the ulcer, and treating lower extremity ischemia and foot infection are first-line therapies for diabetic foot ulcers 5.

Prevention of Diabetic Foot Ulcers

• Preventative strategies, including annual diabetic foot screening and diabetic foot care interventions, have been implemented to enable early identification of diabetic patients at high risk of diabetic foot complications 6.
• Multidisciplinary care, typically consisting of podiatrists, infectious disease specialists, and vascular surgeons, in close collaboration with primary care clinicians, is associated with lower major amputation rates relative to usual care 5.
• A multidisciplinary approach to care for the diabetic foot is recommended, which includes annual assessments by a primary care physician and referral to a podiatrist and vascular surgeon for diabetics with a foot ulcer 7.

Management of Diabetic Foot Ulcers

• The goals of treatment are to achieve a healed foot and keep the patient ambulatory 7.
• Randomized clinical trials support treatments to accelerate wound healing and culture-directed oral antibiotics for localized osteomyelitis 5.
• Approximately 30% to 40% of diabetic foot ulcers heal at 12 weeks, and recurrence after healing is estimated to be 42% at 1 year and 65% at 5 years 5.