How should a diabetic foot ulcer be treated?

How to Treat Diabetic Foot Ulcers

The foundation of diabetic foot ulcer treatment is immediate sharp debridement with a scalpel, combined with pressure offloading using a non-removable knee-high device for plantar ulcers, while simultaneously assessing vascular status and starting empiric antibiotics even without obvious infection signs. 1, 2

Immediate Assessment and Stabilization

Vascular Status (First Priority)

• Measure ankle-brachial index (ABI) and ankle systolic pressure immediately upon presentation 1, 3
• If ankle pressure <50 mmHg or ABI <0.5, pursue urgent vascular imaging and revascularization 1, 3
• Target goals: skin perfusion pressure ≥40 mmHg, toe pressure ≥30 mmHg, or TcPO2 ≥25 mmHg 1
• Critical limb ischemia requires revascularization before any ulcer can heal 3, 2

Sharp Debridement (Cornerstone of Treatment)

• Perform scalpel debridement at initial presentation to remove all necrotic tissue and surrounding callus 4, 1, 2
• Repeat debridement as frequently as clinically needed—often weekly or more frequently 4, 3, 2
• Do not use autolytic, biosurgical, hydrosurgical, chemical, laser, ultrasonic, or enzymatic debridement routinely (strong recommendation against these alternatives) 4
• Only consider enzymatic debridement when sharp debridement is unavailable due to resource limitations 4
• Avoid surgical debridement in sterile operating rooms when sharp debridement can be performed outside this environment 4

Infection Management

Empiric Antibiotic Therapy

• Start empiric oral antibiotics immediately targeting S. aureus and streptococci, even without obvious systemic signs of infection 1, 3, 2
• Appropriate oral agents include cephalexin, flucloxacillin, or clindamycin 3
• Obtain wound culture from the debrided base to guide antibiotic adjustment 3

Deep or Limb-Threatening Infection

• Urgently evaluate for surgical intervention to remove necrotic tissue and drain abscesses 1, 2
• Initiate empiric parenteral broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic bacteria 1
• These cases require immediate referral to emergency department or multidisciplinary foot care team 5

Pressure Offloading (Critical for Healing)

Plantar Forefoot Ulcers

• Use a non-removable knee-high offloading device as first-line treatment 1, 2
• This is the most effective method to reduce pressure and promote healing 2
• Removable devices have poor patient compliance and should only be used when non-removable devices are contraindicated 2

Non-Plantar Ulcers (Including Heel Ulcers)

• Consider shoe modifications, temporary footwear, toe spacers, or orthoses 1, 3
• Instruct patients to limit standing and walking, use crutches if necessary 3
• Ensure heel protection during bed rest to prevent pressure 3

Local Wound Care

Dressing Selection

• Select dressings to absorb exudate and maintain a moist wound healing environment 4, 1, 2
• Clean the wound regularly with water or saline 2
• Use alginates or foams for wounds with purulent exudate 3

What NOT to Use (Strong Recommendations Against)

• Do not use topical antiseptic or antimicrobial dressings (strong recommendation, moderate certainty) 4, 1
• Do not use honey or bee-related products 4, 1
• Do not use collagen or alginate dressings for wound healing purposes 4, 1
• Do not use silver-containing dressings 1
• Do not use topical phenytoin 4
• Do not use herbal remedy-impregnated dressings 4

Adjunctive Therapies (Only After Standard Care Fails)

When to Consider Adjunctive Treatment

• Only after 2-6 weeks of optimal standard care shows insufficient healing 1, 2
• Standard care must include sharp debridement, appropriate offloading, infection control, and vascular optimization 4

Specific Adjunctive Options

Sucrose-Octasulfate Impregnated Dressing:

• Consider for non-infected, neuro-ischemic ulcers that have insufficient change in ulcer area after at least 2 weeks of best standard care including appropriate offloading 4, 1

Hyperbaric Oxygen Therapy:

• Consider for neuro-ischemic or ischemic ulcers where standard care has failed and resources already exist 4, 1, 3

Topical Oxygen Therapy:

• Consider where standard care has failed and resources exist 4, 1

Autologous Leucocyte, Platelet, and Fibrin Patch:

• Consider where best standard care has been ineffective and resources/expertise exist for regular venepuncture 4

What NOT to Use as Adjunctive Therapy

• Do not use other gases (cold atmospheric plasma, ozone, nitric oxide, CO2) 4
• Do not use physical therapies 4
• Do not routinely use cellular or acellular skin substitute products 4
• Do not use autologous skin graft products 4
• Do not use autologous platelet therapy (except the leucocyte, platelet, and fibrin patch noted above) 4
• Negative pressure wound therapy should only be considered for post-operative wounds, not non-surgical ulcers 2

Systemic Management

Glycemic Control

• Optimize blood glucose control to delay neuropathy progression and support healing 1

Cardiovascular Risk Reduction

• Emphasize smoking cessation 1, 3
• Control hypertension and dyslipidemia 1, 3, 2
• Use antiplatelet therapy (aspirin or clopidogrel) 3, 2

When to Refer

Immediate Emergency Department or Multidisciplinary Team Referral

• Gangrene present 5
• Limb-threatening ischemia 5
• Deep ulcers with bone, joint, or tendon visible in wound base 5
• Ascending cellulitis 5
• Systemic symptoms of infection 5
• Abscesses 5

Multidisciplinary Team Referral

• Lack of wound progress after 4 weeks of appropriate treatment 5

Common Pitfalls to Avoid

• Do not delay vascular assessment—ischemic ulcers will not heal without adequate perfusion 1, 3, 2
• Do not skip empiric antibiotics—diabetic foot ulcers should be treated as infected even without obvious signs 1, 3
• Do not use fancy dressings or topical agents as substitutes for sharp debridement and offloading—these are the proven interventions 4, 1, 2
• Do not allow patients to use removable offloading devices without close monitoring—compliance is typically poor 2
• Do not jump to adjunctive therapies before optimizing standard care for at least 2 weeks 4, 1