Advanced Therapies for Wound Management
Introduction to Wound Management
- The American Diabetes Association recommends negative pressure wound therapy for post-surgical wounds, as well as consideration of negative pressure therapy for post-operative wounds, with a focus on diabetic foot ulcers 1
- The use of hyperbaric oxygen therapy is recommended for difficult-to-heal wounds, and topical oxygen therapy can be used as an adjunct where resources exist 1
Diabetic Foot Ulcer Management
- For neuropathic plantar ulcers, guidelines recommend the use of non-removable devices, such as total contact casts, and dressing selection should be based on wound characteristics and exudate level, as recommended by the American Diabetes Association and the Wound, Ostomy and Continence Nurses Society 2, 1, 3
- Select dressings based on wound characteristics, exudate level, exudate control, comfort, and cost, with options including continuously moistened saline gauze or hydrogels for dry or necrotic wounds, alginates or foams for exudative wounds, hydrocolloids for wounds needing autolysis, and films for moistening dry wounds, as recommended by the Wound, Ostomy and Continence Nurses Society, the Infectious Diseases Society of America, and the IWGDF 3, 1, 4
Infection Management
- For superficial infections, clean and debride necrotic tissue and calluses, and start empirical oral antibiotic therapy targeting S. aureus and streptococci, as recommended by the American Diabetes Association and the IWGDF 2, 4, 5
- For deep infections, perform urgent evaluation for surgical intervention, assess peripheral arteriopathy, and initiate broad-spectrum parenteral antibiotic therapy, as recommended by the American College of Surgeons and the Infectious Diseases Society of America 2, 4, 3
- Obtain deep tissue cultures before starting antibiotics if signs of infection are present, and adjust antibiotic regimen based on clinical response and culture results, as recommended by the Infectious Diseases Society of America and the IWGDF 2, 5
Wound Care and Offloading
- Perform frequent inspection of the wound, debridement as needed, and select dressings to control exudate and maintain a moist environment, as recommended by the American Diabetes Association and the IWGDF 2
- Implement pressure offloading to promote healing using non-removable knee-high devices (total contact cast) when possible, or removable walkers when non-removable devices are contraindicated, as recommended by the IWGDF and supported by 6, 2 6, 2
- Sharp debridement is strongly recommended as first-line treatment for diabetic foot ulcers, combined with appropriate offloading, according to the American Diabetes Association and the IWGDF 3, 1, 7
Advanced Therapies
- Consider negative pressure therapy for post-operative wounds and hyperbaric oxygen therapy for difficult-to-heal wounds, as recommended by the guideline society, with low-certainty evidence 1
- Consider topical oxygen therapy as an adjunct to standard care where resources exist, as recommended by the guideline society, with low-certainty evidence 1
- Consider autologous leucocyte, platelet, and fibrin patch where best standard care has been ineffective, as recommended by the guideline society, with low-certainty evidence 1
- Consider placental-derived products as an adjunct therapy where standard care has failed, as recommended by the guideline society, with low-certainty evidence 1
- Do not use topical phenytoin, dressings impregnated with herbal remedies, other gases (cold atmospheric plasma, ozone, nitric oxide, CO2), physical therapies, cellular or acellular skin substitute products, or autologous skin graft skin substitute products, as recommended by the guideline society, due to lack of evidence 1
- Do not routinely use Negative Pressure Wound Therapy for non-surgical toe ulcers, as recommended by the guideline society, due to lack of evidence 1
Patient Education and Follow-up
- Educate patients on daily self-examination of feet, proper footwear, and seeking prompt medical attention for any skin breakdown, as suggested by the American Podiatric Medical Association and supported by 8
- Provide regular follow-up based on risk stratification, with low risk patients requiring annual examination, moderate risk patients requiring every 3-6 months, and high risk patients requiring every 1-3 months, as recommended by 8
- Include patients in an integrated foot-care program with ongoing observation, and provide professional foot treatment, adequate footwear, and education, as suggested by 2, 8