Gender Differences in Diabetic Foot Ulcers
Male patients with diabetes have a significantly higher risk of developing diabetic foot ulcers compared to women, with men experiencing approximately twice the ulceration rate (40% vs 19%), but once risk factors are present, both genders face equal risk of ulceration and should receive identical aggressive management. 1
Key Gender-Based Epidemiological Differences
Ulcer Development and Recurrence
Men demonstrate a 26% increased risk of ulcer recurrence compared to women (OR = 1.26,95% CI = 1.10-1.44), making male gender an independent risk factor for recurrent ulceration 2
In prospective studies, 40% of men developed plantar foot ulcers versus only 19% of women over 30 months, representing more than double the ulceration rate 1
Underlying Pathophysiological Differences
Men present with more severe baseline risk factors that explain their higher ulceration rates 1:
Significantly worse peripheral neuropathy: Men have higher Neuropathy Disability Scores (13 ± 8 vs 8 ± 7) and elevated Vibration Perception Thresholds (36 ± 17 V vs 23 ± 16 V) 1
Higher plantar pressures: Men exhibit peak foot pressures of 6.4 ± 3.4 kg/cm² compared to 5.0 ± 2.3 kg/cm² in women 1
Reduced joint mobility: Women maintain better subtalar joint mobility (26 ± 8 degrees vs 22 ± 10 degrees) and first metatarsal joint mobility (77 ± 23 degrees vs 69 ± 24 degrees), providing protective biomechanical advantages 1
Critical Clinical Implications for Management
Risk Stratification Must Be Gender-Neutral
Once neuropathy or other risk factors are present, women have identical odds ratios for ulceration as men, with similar risk profiles for high neuropathy scores (OR 8.3 for women vs 6.1 for men), elevated vibration perception thresholds (OR 8.9 vs 6.0), and high foot pressures (OR 3.0 vs 2.7) 1
Healing Outcomes Show Gender Disparity
Female gender is independently associated with improved healing outcomes, with women demonstrating a healing risk ratio of 2.01 (95% CI 1.20-3.40) compared to men 3
Male gender, along with initial ulcer size >2 cm² and infection during treatment, increases the risk of non-closure after 12 weeks of care 3
Management Algorithm Should Address Gender-Specific Risk Factors
- Implement more aggressive neuropathy screening with lower thresholds for intervention
- Prescribe pressure-offloading footwear earlier given higher baseline plantar pressures
- Intensify recurrence prevention strategies given 26% increased recurrence risk
- Screen more frequently for smoking history (independent recurrence risk factor, OR = 1.18)
- Do not underestimate risk once neuropathy or other risk factors develop—apply identical aggressive management as for men
- Leverage better baseline joint mobility through appropriate footwear that maintains this advantage
- Recognize superior healing potential but maintain vigilance for other risk factors
Common Pitfalls to Avoid
Never assume women are at lower risk once they present with neuropathy or foot deformity—the protective gender advantage disappears entirely in the presence of established risk factors 1
Do not overlook social factors: Living alone increases ulcer recurrence risk (OR = 1.86), which may disproportionately affect one gender depending on demographics 2
Male patients require enhanced surveillance for diabetic retinopathy (OR = 1.59), diabetic nephropathy (OR = 1.37), peripheral neuropathy (OR = 1.78), foot deformity (OR = 2.51), and peripheral arterial disease (OR = 3.10)—all independent recurrence risk factors 2
Essential Management Components Regardless of Gender
Both genders require identical multidisciplinary approaches including 4:
- Strict glycemic control (HgbA1c optimization directly impacts healing) 3
- Mechanical offloading for plantar ulcers (OR = 2.44 for recurrence) 2
- Aggressive infection control (infection increases non-closure risk ratio to 2.9) 3
- Addressing peripheral arterial disease (strongest recurrence predictor, OR = 3.10) 2