What is the recommended multidisciplinary management for an adult with type 1 or type 2 diabetes who has a foot ulcer associated with peripheral neuropathy and/or peripheral arterial disease?

Diabetic Foot Ulcer Management

Immediate Multidisciplinary Assessment and Intervention

All patients with diabetic foot ulcers require immediate comprehensive vascular assessment, infection evaluation, and pressure off-loading as the foundation of management. 1

The management of diabetic foot ulcers demands urgent, coordinated action across multiple domains simultaneously, not sequential evaluation. The following algorithmic approach prioritizes life- and limb-threatening complications first:

Step 1: Emergency Vascular Assessment

Measure ankle-brachial index (ABI) with Doppler arterial waveforms, toe pressures, and transcutaneous oxygen pressure (TcPO₂) at the initial encounter for every diabetic foot ulcer patient. 1

• Bedside tests that effectively exclude peripheral arterial disease (PAD): ABI 0.9–1.3, toe-brachial index ≥ 0.75, or triphasic pedal Doppler waveforms 1
• Critical ischemia thresholds requiring urgent vascular imaging and revascularization: toe pressure < 30 mmHg, TcPO₂ < 25 mmHg, ankle pressure < 50 mmHg, or ABI < 0.5 1, 2
• Do not rely on ABI alone in diabetic patients because medial arterial calcification produces falsely elevated values 3
• Patients with PAD and foot infection represent a surgical emergency with extremely high major amputation risk 1

Step 2: Infection Evaluation and Management

Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. 1

For infected ulcers:

• Collect deep-tissue cultures via surgical debridement or wound-base scraping before starting antibiotics when hemodynamically stable 3
• Obtain two sets of blood cultures at presentation 3
• Empiric therapy for mild-to-moderate acute infections: narrow coverage targeting aerobic gram-positive cocci (most common pathogens) 1, 4
• Empiric therapy for severe infections, chronic/previously treated infections, or high risk for resistant organisms: broad-spectrum IV antibiotics covering MRSA (if local prevalence > 20%), gram-negative bacilli, and anaerobes (e.g., vancomycin + piperacillin-tazobactam) 3
• Adjust antimicrobials according to culture results 3
• Treatment duration: 2–4 weeks for severe soft-tissue infection; 4–6 weeks when osteomyelitis is confirmed 3

Step 3: Surgical Debridement

Perform sharp surgical debridement of all necrotic tissue, slough, eschar, and surrounding callus immediately and repeat as needed. 1, 2

• Sharp debridement with scalpel, scissors, or tissue nippers is preferable to hydrotherapy or topical debriding agents 1
• Obtain imaging (plain radiographs and/or MRI) to assess for underlying osteomyelitis 3
• Drain any identified deep abscesses during the same operative session 3

Step 4: Pressure Off-Loading

Pressure relief is the mainstay of initial treatment and must be implemented immediately. 5

• Patients must not walk barefoot, in socks only, or in thin-soled standard slippers 1
• Use total contact casts, removable cast walkers, or specialized therapeutic footwear designed to relieve pressure from the ulcer site 1, 5
• For recurrent plantar ulcers: prescribe therapeutic footwear that reduces plantar pressure by approximately 30% compared with standard therapeutic shoes 1

Step 5: Revascularization Planning

When critical ischemia is present, full lower-extremity arterial mapping—including below-the-knee and pedal arteries—should be performed to guide revascularization. 1

• Revascularization goal: restore direct blood flow to at least one foot artery, achieving skin perfusion pressure ≥ 40 mmHg, toe pressure ≥ 30 mmHg, or TcPO₂ ≥ 25 mmHg 1, 2
• Both endovascular techniques and surgical bypass must be available; choice should be made by a multidisciplinary team based on PAD morphology, autogenous vein availability, patient comorbidities, and local expertise 1
• If the ulcer does not improve within 6 weeks despite optimal management, proceed to vascular imaging and revascularization 2

Ongoing Wound Care

• Select dressings that control exudate while maintaining a moist wound environment 2
• Perform daily wound assessments documenting size, drainage characteristics, periwound erythema, warmth, and induration 3
• For chronic ulcers failing optimal standard care: consider adjunctive treatments including negative-pressure wound therapy, placental membranes, bioengineered skin substitutes, acellular matrices, autologous fibrin and leukocyte platelet patches, or topical oxygen therapy 1

Metabolic Optimization

Glycemic Control

• Target blood glucose < 140 mg/dL in the acute phase to reduce infection-related metabolic stress 3
• Use insulin sliding-scale with correction factor and administer prandial insulin promptly after meals 3
• Check finger-stick glucose before each meal and at bedtime 3

Nutrition

• Provide high-protein diet (1.25–1.5 g/kg/day) via dietitian-guided plan 3
• Offer high-protein oral nutritional supplements three times daily if oral intake is < 75% of prescribed meals 3

Cardiovascular Risk Reduction

Aggressive cardiovascular risk reduction is mandatory for all patients with diabetic foot ulcers. 2

• Initiate high-intensity statin therapy (atorvastatin 40–80 mg or rosuvastatin 20–40 mg daily) 2, 3
• Prescribe antiplatelet therapy: aspirin 81 mg daily or clopidogrel 75 mg daily 2, 3
• Target blood pressure < 140/90 mmHg 2, 3
• Provide smoking-cessation counseling and pharmacotherapy 2, 3

Multidisciplinary Team Coordination

A multidisciplinary approach is recommended for all individuals with foot ulcers and high-risk feet (e.g., dialysis patients, those with Charcot foot, or prior ulcers/amputation). 6

• Conduct daily multidisciplinary rounds including wound-care nursing, vascular surgery, infectious disease, endocrinology, and the primary medical team 3
• Schedule weekly full-team reassessments when healing is progressing; increase frequency if the patient's condition deteriorates 3

Surveillance and Prevention After Healing

Refer patients who smoke or have histories of prior lower-extremity complications, loss of protective sensation, structural abnormalities, or PAD to foot care specialists for ongoing preventive care and lifelong surveillance. 6

Monitoring Frequency Based on IWGDF Risk Classification:

• Category 0 (no peripheral neuropathy): annual examination 1
• Category 1 (peripheral neuropathy only): every 6 months 1
• Category 2 (neuropathy + PAD and/or foot deformity): every 3–6 months 1
• Category 3 (neuropathy + history of ulcer or amputation): every 1–3 months 1

Patient Education and Self-Care

• Daily foot and shoe-inside inspection, washing, and careful drying between the toes 1
• Use emollients for dry skin; avoid chemical agents or plasters for callus removal 1
• Cut toenails straight across 1
• Manage pre-ulcerative signs by removing callus, protecting blisters, treating ingrown or thickened toenails, and prescribing antifungal therapy for fungal infections 1

Critical Pitfalls to Avoid

• Do not postpone vascular consultation while attempting medical management alone; infected ischemic ulcers constitute a surgical emergency 3
• Do not attribute poor wound healing primarily to diabetic microangiopathy ("small-vessel disease") 1
• Failure to identify underlying osteomyelitis and incomplete surgical debridement are leading causes of treatment failure 3
• Recognize that infection raises metabolic demand while ischemia limits perfusion; both must be addressed simultaneously 3