What is the most appropriate dressing for a plantar ulcer in an older adult with diabetes, peripheral neuropathy and impaired perfusion?

Optimal Dressing Selection for Plantar Diabetic Foot Ulcers

Select dressings based primarily on exudate control, comfort, and cost—not on antimicrobial properties or healing enhancement claims—as basic wound contact dressings perform equally well as expensive specialized options for plantar diabetic foot ulcers. 1, 2

Primary Dressing Algorithm Based on Exudate Level

For Minimal to Moderate Exudate

• Use foam dressings as the first-line choice, providing superior absorption while maintaining an appropriate moist wound environment 3
• Simple non-adherent dressings (such as paraffin gauze) or basic absorbent dressings are equally effective alternatives and more cost-efficient 1, 2

For Heavy Exudate

• Select alginate dressings due to their superior absorption capacity for moderate to high exudate levels 3
• Foam dressings remain an acceptable alternative for high-exudate wounds based on their absorption properties 2

For Wounds with Necrotic Tissue

• Hydrogels may facilitate autolytic debridement when necrotic tissue is present, though sharp debridement remains the cornerstone intervention 1, 4

Critical: What NOT to Use

Strong Recommendations Against Specific Dressings

• Do not use antimicrobial dressings (silver, iodine, honey) with the goal of accelerating healing—a large multicentre RCT showed no difference in wound healing or infection rates between iodine-impregnated dressings and non-adherent dressings 1, 2
• Avoid collagen or alginate dressings specifically for healing enhancement—nine of 12 studies showed no difference in healing outcomes 3, 2
• Do not use honey or bee-related products for wound healing purposes 5, 2
• Avoid herbal remedy-impregnated dressings or topical phenytoin 3, 2
• Never use occlusive dressings if infection is present, as they may promote bacterial growth 3

Second-Line Option for Non-Healing Ulcers

Sucrose-Octasulfate Impregnated Dressing

• Consider this adjunctive treatment only for non-infected, neuro-ischemic plantar ulcers that fail to improve after 2 weeks of optimal standard care (including appropriate offloading and debridement) 1, 5, 2
• This recommendation is supported by one large, high-quality RCT showing 48% healing rate versus 30% in controls at 20 weeks (adjusted OR 2.60,95% CI 1.43-4.73) 5
• Do not use in infected wounds 5
• Appropriate for ulcers >1 cm² with University of Texas classification grade IC or IIC 5

Essential Concurrent Interventions (More Important Than Dressing Choice)

Offloading is Paramount

• Non-removable knee-high offloading devices (total contact cast or walker) are strongly recommended for neuropathic plantar ulcers, as meta-analyses show superiority over removable devices for healing 1, 6
• If frequent dressing changes are needed due to infection, use a removable below-knee walker initially, then transition to non-removable device once infection is controlled 1
• Offloading is more critical than dressing selection for healing outcomes 2, 6

Sharp Debridement

• Perform regular sharp debridement to remove necrotic tissue, slough, and surrounding callus—this is the single most important intervention for promoting healing 3, 2
• Debridement should be performed based on clinical need at each visit 2

Wound Cleaning

• Clean the wound regularly with clean water or saline to remove debris 3

Common Pitfalls to Avoid

• Do not select expensive advanced dressings based on marketing claims—basic dressings selected for exudate control perform equally well and are more cost-effective 1, 3, 2
• Avoid choosing dressings based on antimicrobial properties alone, as evidence does not support improved healing outcomes 1, 2
• Reassess the wound weekly and adjust treatment if no improvement is seen after 2-4 weeks 3
• Do not neglect perfusion assessment—if toe pressure <30 mmHg or ankle pressure <50 mmHg, revascularization should be considered as dressings alone will not promote healing in severely ischemic wounds 1
• Remember that foam dressings do not significantly increase plantar pressure in healthy adults, though robust trials in pathological populations are still needed 7

Practical Implementation

The evidence consistently demonstrates that dressing selection should be straightforward and cost-conscious: choose basic contact dressings or foam/alginate based solely on exudate level, ensure proper offloading with non-removable devices, perform regular sharp debridement, and reserve sucrose-octasulfate dressings only for difficult-to-heal neuro-ischemic ulcers that have failed standard care 1, 3, 2. This approach prioritizes the interventions with the strongest evidence for improving healing outcomes while avoiding unnecessary costs and unproven therapies.