What are the optimal management strategies for a patient with diabetic foot, including medication, wound care, and lifestyle modifications?

Optimal Management of Diabetic Foot

Diabetic foot management requires immediate vascular assessment, aggressive sharp debridement, appropriate offloading, infection control when present, and multidisciplinary team coordination to prevent amputation and reduce mortality. 1

Immediate Vascular Assessment

Measure ankle-brachial index (ABI) and ankle pressure immediately in every patient with a diabetic foot ulcer. 1, 2, 3

• If ankle pressure is <50 mmHg or ABI <0.5, pursue urgent vascular imaging and revascularization 1, 2
• If toe pressure is <30 mmHg or transcutaneous oxygen pressure (TcPO2) <25 mmHg, also consider urgent revascularization 2, 3
• Peripheral arterial disease is highly treatable if intervention is instituted promptly, and early revascularization is critical to achieving maximal limb salvage 4

Sharp Debridement Protocol

Perform aggressive sharp debridement with a scalpel to remove all necrotic tissue and surrounding callus, repeating as frequently as clinically needed (often weekly or more). 1, 3

• Sharp debridement is strongly preferred over all other debridement methods 3
• Serial debridement is a key component in preventing amputation 5
• Once infection is eradicated, observe the wound daily for prompt signs of healing including granulation tissue development within several days 4

Infection Management by Severity

Mild Infection (Superficial with Skin Involvement)

• Cleanse and debride all necrotic tissue and surrounding callus 1
• Start empiric oral antibiotic therapy targeted at S. aureus and streptococci (cephalexin, flucloxacillin, or clindamycin) 1, 2, 3
• Duration: 1-2 weeks usually suffices, but some require an additional 1-2 weeks 1
• Obtain wound culture from the debrided base to guide antibiotic adjustment 2

Moderate to Severe Infection (Deep, Potentially Limb-Threatening)

• Urgently evaluate for surgical intervention to remove necrotic tissue, including infected bone, and drain abscesses 1
• Assess for peripheral arterial disease; if present, consider urgent revascularization 1
• Initiate empiric parenteral broad-spectrum antibiotic therapy aimed at gram-positive and gram-negative bacteria, including anaerobes 1
• Duration: 2-4 weeks is usually sufficient, depending on structures involved, adequacy of debridement, and wound vascularity 1
• Adjust antibiotic regimen based on clinical response and culture/sensitivity results 1

Osteomyelitis

• Duration: at least 4-6 weeks is required, but shorter duration is sufficient if entire infected bone is removed 1
• Bone biopsy is valuable for establishing diagnosis, defining pathogenic organisms, and determining antibiotic susceptibilities 6

Common pitfall: Do not treat clinically uninfected ulcers with antibiotic therapy, as available evidence does not support this practice 6

Offloading Strategy

For plantar diabetic foot ulcers, use total contact cast or irremovable fixed ankle walking boot. 7

• For non-plantar ulcers (including heel ulcers), consider shoe modifications, temporary footwear, or orthoses 2, 3
• Instruct patients to limit standing and walking; use crutches if necessary 1, 2
• If total contact cast or other forms of biomechanical relief are not available, consider felted foam in combination with appropriate footwear 1

Critical point: Off-loading of pressure is especially crucial for healing and must be emphasized alongside wound care 1

Local Wound Care

Select dressings primarily based on exudate control, comfort, and cost—not on purported healing properties. 1, 3

• Inspect the ulcer frequently 1
• Maintain a moist wound environment while controlling excess exudate 1, 3
• Use alginates or foams to absorb purulent exudate 2

What NOT to Use

• Do not use footbaths in which feet are soaked, as they induce skin maceration 1
• Do not use silver or other antimicrobial-containing dressings with the sole aim of accelerating healing 1
• Biologically active products (collagen, growth factors, bio-engineered tissue) are not well-supported for routine wound management in neuropathic ulcers 1

Adjunctive Therapies for Non-Healing Wounds

For ulcers that fail to improve (>50% wound area reduction) after a minimum of 4 weeks of standard wound therapy, consider adjunctive options. 7

• Consider sucrose-octasulfate impregnated dressing for non-infected neuro-ischemic ulcers that are difficult to heal 1, 3
• Consider systemic hyperbaric oxygen therapy for non-healing ischemic ulcers despite best standard care 1, 2, 3
• Consider negative pressure wound therapy to reduce wound size in post-operative (surgical) wounds on the foot 1
• Consider autologous combined leucocyte, platelet and fibrin for non-infected ulcers that are difficult to heal 1

Evidence note: Systematic reviews suggest that granulocyte colony-stimulating factors and systemic hyperbaric oxygen therapy may help prevent amputations 1, 6

Multidisciplinary Team Approach

Treatment must be delivered through a multidisciplinary foot-care team, as this approach is associated with significant reductions in diabetes-related lower extremity amputations. 1, 3, 6, 5

Team Composition by Level

Level 1: General practitioner, podiatrist, and diabetes nurse 1

Level 2: Diabetologist, surgeon (general, orthopedic, or foot), vascular surgeon, endovascular interventionist, podiatrist, diabetes nurse, in collaboration with shoe-maker, orthotist, or prosthetist 1

Level 3: A Level 2 foot center specialized in diabetic foot care with multiple experts from several disciplines, acting as a tertiary reference center 1

• The team should include or have ready access to an infectious diseases specialist or medical microbiologist 1, 6
• Surgeons with experience and interest in diabetic foot should be recruited by the foot-care team 1

Prevention of Recurrence

Once the ulcer is healed, include the patient in an integrated foot-care program with life-long observation, professional foot treatment, adequate footwear, and education. 1

• The foot should never return in the same shoe that caused the ulcer 1
• Use custom therapeutic footwear in high-risk diabetic patients, including those with significant neuropathy, foot deformities, or previous amputation 7
• Provide periodic foot inspection and patient/family education 7
• Emphasize smoking cessation, control of hypertension and dyslipidemia, and use of antiplatelet therapy for cardiovascular risk reduction 2

Patient and Family Education

Instruct patients and relatives on appropriate self-care and how to recognize and report signs of new or worsening infection. 1

• Signs to report: onset of fever, changes in local wound conditions, and worsening hyperglycemia 1
• During enforced bed rest, instruct on how to prevent an ulcer on the contralateral foot 1
• Adequate glycemic control is essential for prevention 7

Follow-Up Protocol

Patients with infected wounds require early and careful follow-up observation to ensure that selected medical and surgical treatment regimens have been appropriate and effective. 1, 6

• If an infection in a clinically stable patient fails to respond to one antibiotic course, consider discontinuing all antimicrobials and, after a few days, obtaining optimal culture specimens 1