Diabetic Foot Ulcer Management Guidelines

Risk Stratification and Screening

The International Working Group on the Diabetic Foot (IWGDF) recommends annual screening for all diabetic patients using their updated risk stratification system (IWGDF risk 0-3), with screening frequency intensifying based on risk level 1
Screen patients at very low risk (IWGDF risk 0) annually for peripheral neuropathy and peripheral artery disease 1
For patients with loss of protective sensation or PAD, extend screening to include history of ulceration, end-stage renal disease, foot deformity, limited joint mobility, excess callus, and pre-ulcerative lesions 1
Repeat screening every 6-12 months for IWGDF risk 1, every 3-6 months for risk 2, and every 1-3 months for risk 3 1

The IWGDF recommends SINBAD as the first-line system for clinical communication and audit purposes, with IDSA/IWGDF specifically for infected ulcers 2
Use SINBAD classification for routine clinical documentation and nationwide audits, as it has been validated in over 76,310 patients showing higher scores correlate with lower healing rates and higher amputation risk 2
Apply IDSA/IWGDF classification specifically when managing infected diabetic foot ulcers 2
The WIfI (Wound, Ischemia, and foot Infection) system should be used for vascular assessment and revascularization decisions 2

The IWGDF recommends sharp debridement combined with moisture-retentive dressings as the cornerstone of treatment, with specific avoidance of multiple ineffective modalities 3, 4
Perform sharp debridement of necrotic tissue and surrounding callus at frequency determined by clinical need 3, 4
Select basic wound dressings primarily for exudate control, comfort, and cost—not based on antimicrobial properties 4

Non-removable knee-high offloading devices are now the definitive first-line treatment for neuropathic plantar forefoot or midfoot ulcers 3, 5
Prescribe non-removable knee-high offloading devices for neuropathic plantar forefoot or midfoot ulcers to maximize healing 3, 5

Empiric antibiotic selection should be based on infection severity, with duration tailored to tissue involvement 3
Start empiric oral antibiotics targeting Staphylococcus aureus and streptococci for mild infections 3
Initiate broad-spectrum parenteral antibiotics for moderate to severe infections 3
Treat soft tissue infections for 1-2 weeks and osteomyelitis for 6 weeks, adjusting based on culture results 3

Urgent vascular imaging and revascularization should be considered when ankle pressure is <50 mmHg or ABI <0.5, or if ulcers fail to show healing signs within 6 weeks despite optimal management 3
Perform vascular assessment checking foot pulses and ankle-brachial index at initial evaluation 3
Consider urgent revascularization if ankle pressure <50 mmHg or ABI <0.5 3

All at-risk patients (IWGDF risk 1-3) must receive structured education emphasizing never walking barefoot, daily foot washing, and immediate reporting of new lesions 1, 3
Educate patients never to walk barefoot, in socks without shoes, or in thin-soled slippers, indoors or outdoors 1, 3
Instruct daily foot washing with careful drying between toes, use of emollients for dry skin, and cutting toenails straight across 1, 3

Patients with healed plantar ulcers must be prescribed therapeutic footwear with demonstrated plantar pressure-relieving effect to prevent recurrence 1, 3
Prescribe therapeutic footwear with demonstrated plantar pressure-relieving effect for all healed plantar ulcers, encouraging consistent wear indoors and outdoors 1, 3

High-risk patients require follow-up every 1-3 months with reassessment of integrated foot care needs at each visit 3, 5
Schedule follow-up every 1-3 months for patients with history of foot ulceration (IWGDF risk 3) 3, 5
Monitor for signs of recurrence, noting that recurrence rate is 40% within one year and 65% within three years after healing 3