Management of Diabetic Foot Ulcer in Patients with Multiple Sclerosis

Initial Assessment

The International Working Group on the Diabetic Foot recommends evaluating for signs of infection and determining severity, as well as assessing ulcer depth and checking for exposed bone or joint involvement 2
The American Diabetes Association suggests screening for peripheral neuropathy using a 10g monofilament test and/or 128 Hz tuning fork, and evaluating peripheral arterial disease by checking foot pulses and ankle-brachial index 2

The European Wound Management Association recommends performing sharp debridement of necrotic tissue and surrounding callus, but not using autolytic, biosurgical, hydrosurgical, chemical, or laser debridement over standard of care 3
The Wound Healing Society suggests considering sucrose-octasulfate impregnated dressing for non-infected, neuro-ischemic ulcers that haven't improved with standard care for at least 2 weeks 3

The American College of Foot and Ankle Surgeons recommends using a non-removable knee-high offloading device for neuropathic plantar forefoot or midfoot ulcers, and removable offloading devices for non-plantar ulcers 4
The International Working Group on the Diabetic Foot suggests considering digital flexor tenotomy for neuropathic plantar or apex ulcers on digits 2-5 with flexible toe deformity 4

The Infectious Diseases Society of America recommends starting empiric oral antibiotics targeting Staphylococcus aureus and streptococci for mild infections, and broad-spectrum parenteral antibiotics for moderate to severe infections 2
The Society for Healthcare Epidemiology of America suggests adjusting antibiotic regimen based on culture results and clinical response, and treating for 1-2 weeks for soft tissue infections and 6 weeks for osteomyelitis 2

The American Heart Association recommends considering urgent vascular imaging and revascularization if ankle pressure is <50 mmHg or ABI <0.5, and revascularization regardless of initial vascular assessment if ulcers fail to show healing signs within 6 weeks despite optimal management 2

The American Diabetes Association recommends optimizing blood glucose control and addressing cardiovascular risk factors, such as smoking cessation, control of hypertension and dyslipidemia 2

The National Multiple Sclerosis Society suggests assessing mobility limitations and adapting offloading strategies accordingly, and considering removable offloading devices if non-removable devices compromise balance and increase fall risk 4
The Multiple Sclerosis Association of America recommends evaluating upper extremity function for ability to perform adequate foot self-care, and considering more frequent follow-up visits if self-care is limited 1

The American Diabetes Association recommends providing structured education about foot self-care, instructing patients to examine feet daily and contact healthcare provider promptly if new lesions develop, and educating patients not to walk barefoot or in thin-soled slippers 1
The National Institute of Diabetes and Digestive and Kidney Diseases suggests instructing patients to daily inspect feet and inside of shoes, wash feet daily with careful drying between toes, avoid chemical agents to remove callus, use emollients for dry skin, and cut toenails straight across 5

The American College of Foot and Ankle Surgeons recommends prescribing therapeutic footwear with demonstrated plantar pressure-relieving effect for healed plantar ulcers, and considering extra-depth shoes, custom-made footwear, custom-made insoles, and/or toe orthoses for foot deformities or pre-ulcerative lesions 1

The International Working Group on the Diabetic Foot recommends follow-up every 1-3 months for patients with history of foot ulceration, and re-evaluating the need for integrated foot care at each visit 1
The American Diabetes Association suggests monitoring for signs of recurrence, as recurrence rate is 40% within a year and 65% within 3 years after healing 6