What is the recommended management protocol for an adult patient with diabetes mellitus presenting with a foot ulcer, assuming typical risk factors such as peripheral neuropathy, peripheral arterial disease, and possible infection?

Management Protocol for Diabetic Foot Ulcers

All diabetic patients presenting with foot ulcers require immediate comprehensive vascular assessment, infection evaluation, and pressure offloading as the three pillars of management, with urgent vascular imaging and revascularization considered when toe pressure is <30 mmHg or transcutaneous oxygen pressure (TcPO2) is <25 mmHg. 1

Initial Assessment and Risk Stratification

Vascular Evaluation (Critical First Step)

• Measure ankle systolic pressure and ankle brachial index (ABI) using Doppler arterial waveforms in all patients with diabetic foot ulcers 1
• Use bedside non-invasive tests to exclude peripheral artery disease (PAD): ABI 0.9–1.3, toe brachial index ≥0.75, or triphasic pedal Doppler arterial waveforms largely exclude PAD 1
• Consider urgent vascular imaging and revascularization when:
  • Toe pressure <30 mmHg or TcPO2 <25 mmHg 1
  • Ankle pressure <50 mmHg or ABI <0.5 (these patients are at particularly high risk) 1, 2
  • Ulcer fails to improve within 6 weeks despite optimal management, regardless of bedside test results 1

Neuropathy Assessment

• Test pressure perception using 10-g Semmes-Weinstein monofilaments 1, 3
• Assess vibration perception with 128-Hz tuning fork 1
• Evaluate pin prick discrimination on dorsum of foot and tactile sensation with cotton wool 1
• Check Achilles tendon reflexes 1

Infection Evaluation

• Examine for soft tissue or bone infection—wounds without infection do not require antibiotics 4
• Most diabetic foot infections are polymicrobial with aerobic gram-positive cocci predominating 4
• Sharp debridement with scalpel, scissors, or tissue nippers is preferable to hydrotherapy or topical debriding agents for infected wounds 4
• Evaluate for osteomyelitis, which is present in approximately 43% of diabetic foot ulcer patients 5

Treatment Protocol

Pressure Offloading (Mainstay of Initial Treatment)

• Implement total contact casts, removable cast walkers, or half shoes for pressure relief 6
• Instruct patients not to walk barefoot, in socks only, or in thin-soled standard slippers 1
• For recurrent plantar ulcers, prescribe therapeutic footwear demonstrating 30% plantar pressure reduction compared with standard therapeutic footwear 1

Wound Management

• Perform sharp debridement of callus and necrotic tissue 4, 6
• Provide appropriate wound care with infection management 4
• Daily inspection of feet and inside of shoes, daily washing with careful drying between toes 1
• Use emollients for dry skin; avoid chemical agents or plasters for callus removal 1

Antimicrobial Therapy

• Empiric antibiotics can be narrowly targeted at gram-positive cocci in acute infections 4
• Patients with chronic, previously treated, or severe infections require broader-spectrum regimens and specialized care referral 4
• Staphylococcus aureus is isolated in approximately 43% of infected cases 5

Revascularization Strategy

• Evaluate the entire lower extremity arterial circulation with detailed visualization of below-the-knee and pedal arteries 1
• The aim is to restore direct flow to at least one foot artery, preferably the artery supplying the wound region, achieving minimum skin perfusion pressure ≥40 mmHg, toe pressure ≥30 mmHg, or TcPO2 ≥25 mmHg 1
• Both endovascular techniques and bypass surgery should be available; decisions made in multidisciplinary team based on PAD morphology, autogenous vein availability, patient comorbidities, and local expertise 1

Advanced Therapies for Non-Healing Ulcers

• For chronic ulcers failing optimal standard care, consider adjunctive treatments: negative-pressure wound therapy, placental membranes, bioengineered skin substitutes, acellular matrices, autologous fibrin and leukocyte platelet patches, or topical oxygen therapy 4
• Sucrose-octasulfate impregnated dressing may be considered for non-infected, neuro-ischemic ulcers with insufficient response to best standard care 4

Follow-Up and Prevention

Monitoring Frequency Based on IWGDF Risk Classification

• Category 0 (no peripheral neuropathy): Annual examination 1
• Category 1 (peripheral neuropathy): Every 6 months 1
• Category 2 (neuropathy with PAD and/or foot deformity): Every 3–6 months 1
• Category 3 (neuropathy with history of ulcer or amputation): Every 1–3 months 1, 3

Integrated Foot Care

• Provide professional foot treatment, adequate footwear, and education repeated every 1–3 months to prevent recurrent ulcers 1
• Treat pre-ulcerative signs: remove callus, protect blisters, treat ingrown/thickened toenails, prescribe antifungal treatment for fungal infections 1
• Cut toenails straight across 1

Critical Pitfalls to Avoid

• Do not attribute poor wound healing to diabetic microangiopathy ("small vessel disease")—this is not the primary cause 1
• Patients with PAD and foot infection are at particularly high risk for major limb amputation and require emergency treatment 1
• Avoid nerve decompression procedures in diabetic patients as they do not prevent foot ulcers 2
• Never delay vascular assessment in patients with absent or diminished peripheral pulses, which are present in approximately 63% of diabetic foot ulcer patients 5