Management of Diabetic Foot Ulcers

Introduction to Diabetic Foot Ulcer Management

The American Diabetes Association recommends that all diabetic patients with foot ulcers require immediate comprehensive assessment including vascular evaluation, infection screening, and pressure offloading, with the primary goal of preventing amputation and promoting healing through a structured, evidence-based approach 1, 2

Evaluate every diabetic foot ulcer for peripheral artery disease (PAD) by measuring ankle systolic pressure, ankle-brachial index (ABI), and obtaining ankle or pedal Doppler arterial waveforms, as recommended by the American College of Cardiology 3, 4
Use bedside non-invasive tests: ABI 0.9-1.3, toe-brachial index ≥0.75, or triphasic pedal Doppler waveforms largely exclude PAD, according to the American Heart Association 3, 4
Note that ABI can be falsely elevated in diabetic patients due to arterial calcification, making toe pressure or transcutaneous oxygen pressure (TcPO2) more reliable, as stated by the American Diabetes Association 5
Measure skin perfusion pressure, toe pressure, or TcPO2 to assess healing potential: values of ≥40 mmHg, ≥30 mmHg, or ≥25 mmHg respectively increase healing probability by at least 25%, as recommended by the American College of Cardiology 3, 4

Examine for signs of infection: erythema, warmth, tenderness, purulent discharge, as recommended by the Infectious Diseases Society of America 6
Classify infection severity as mild (superficial skin infection), moderate, or severe (deep tissue involvement, systemic signs), according to the International Working Group on the Diabetic Foot (IWGDF) 6
Obtain wound cultures before starting antibiotics to guide therapy, as recommended by the American Society of Microbiology 6
Order complete blood count, C-reactive protein, and blood glucose levels, as recommended by the American Diabetes Association 6

Measure ulcer depth and extent to determine severity, as recommended by the American College of Cardiology 7, 6
Assess for exposed bone or joint involvement, according to the International Working Group on the Diabetic Foot (IWGDF) 6
Evaluate for peripheral neuropathy using 10g monofilament test and/or 128 Hz tuning fork, as recommended by the American Diabetes Association 6

Consider urgent vascular imaging and revascularization if any of the following are present: toe pressure <30 mmHg or TcPO2 <25 mmHg, ankle pressure <50 mmHg or ABI <0.5, signs of PAD with foot infection, or ulcer not improving within 6 weeks despite optimal management, as recommended by the American College of Cardiology 3, 4, 7
The aim of revascularization 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, according to the American Heart Association 3, 4

The preferred treatment for neuropathic plantar ulcers is a non-removable knee-high offloading device: either total contact cast (TCC) or removable walker rendered irremovable, as recommended by the American College of Cardiology 7, 6
Perform sharp debridement of all necrotic tissue and surrounding callus, repeat as needed, according to the American College of Cardiology 7, 6
Inspect the ulcer frequently and select dressings to control excess exudation and maintain moist environment, as recommended by the American College of Cardiology 7, 6
Do not use honey, collagen, or alginate dressings for wound healing, as stated by the American College of Cardiology 2

Consider negative pressure wound therapy for post-operative wounds, hyperbaric oxygen therapy as adjunct in neuro-ischemic or ischemic ulcers, topical oxygen therapy, autologous leucocyte, platelet, and fibrin patch, and placental-derived products, as recommended by the American College of Cardiology 2, 7, 6

Optimize blood glucose control, as recommended by the American Diabetes Association 6
Emphasize cardiovascular risk reduction: smoking cessation, control of hypertension and dyslipidemia, use of aspirin or clopidogrel, according to the American Heart Association 7

Educate patients at risk (IWGDF risk 1-3) to protect feet by not walking barefoot, not walking in socks without shoes, and not walking in thin-soled slippers indoors or outdoors, as recommended by the International Working Group on the Diabetic Foot (IWGDF) 1
Instruct to wash feet daily with careful drying between toes, use emollients for dry skin, and cut toenails straight across, according to the American Diabetes Association 1
Provide structured education about appropriate foot self-care, as recommended by the American Diabetes Association 1
Prescribe therapeutic footwear with demonstrated plantar pressure-relieving effect and encourage consistent wear both indoors and outdoors, according to the International Working Group on the Diabetic Foot (IWGDF) 1, 6

Treatment should involve a multidisciplinary team with rapid access to facilities for diagnosing and treating PAD; both endovascular techniques and bypass surgery should be available, as recommended by the American College of Cardiology 3, 4