Diabetic Ulcers Treatment & Management

The management of diabetic foot ulcers requires offloading the wound by using appropriate therapeutic footwear,^{[8, 21]} daily saline or similar dressings to provide a moist wound environment,^[22] debridement when necessary, antibiotic therapy if osteomyelitis or cellulitis is present,^{[18, 19]} optimal control of blood glucose, and evaluation and correction of peripheral arterial insufficiency.

Wound coverage by cultured human cells^{[20, 23]} or heterogeneic dressings/grafts, application of recombinant growth factors,^{[24, 25, 26, 27]} and hyperbaric oxygen treatments also may be beneficial at times, but only if arterial insufficiency is not present.

Physicians of diabetic patients with ulcers must decide between the sometimes conflicting options of (1) performing invasive procedures (eg, angiography, bypass surgery) for limb salvage and (2) avoiding the risks of unnecessarily aggressive management in these patients, who may have significant cardiac risk. In general, the greatest legal risks are associated with delay in diagnosis of ischemia associated with diabetic ulceration, failure to aggressively debride and treat infection, and failure to treat the wound carefully.

If a patient presents with a new diabetic foot ulcer, he or she should receive care from physicians, surgeons, podiatrists, and pedorthotists who have an active interest in this complex problem.

Treatment of diabetic foot ulcers requires management of a number of systemic and local factors.^{[28, 29, 30, 31]}

Precise diabetic control is, of course, vital, not only in achieving resolution of the current wound, but also in minimizing the risk of recurrence. Management of contributing systemic factors, such as hypertension, hyperlipidemia, atherosclerotic heart disease, obesity, or renal insufficiency, is crucial.^{[32, 33]} Management of arterial insufficiency, treatment of infection with appropriate antibiotics, offloading the area of the ulcer, and wound care are also essential.

For more information, see Diabetes Mellitus, Type 1 and Diabetes Mellitus, Type 2.

The basic principle of topical wound management is to provide a moist, but not wet, wound bed.^{[22, 34]}

For more information, see Diabetic Foot Infections.

Wound coverage

After debridement, apply a moist sodium chloride dressing or isotonic sodium chloride gel (eg, Normlgel, IntraSite gel) or a hydroactive paste (eg, Duoderm). Optimal wound coverage requires wet-to-damp dressings, which support autolytic debridement, absorb exudate, and protect surrounding healthy skin. A polyvinyl film dressing (eg, OpSite, Tegaderm) that is semipermeable to oxygen and moisture and impermeable to bacteria is a good choice for wounds that are neither very dry nor highly exudative. Wound coverage recommendations for some other wound conditions are as follows (see the Table, below):

• Dry wounds: Hydrocolloid dressings, such as DuoDERM or IntraSite Hydrocolloid, are impermeable to oxygen, moisture, and bacteria; maintain a moist environment; and support autolytic debridement. They are a good choice for relatively desiccated wounds.
• Exudative wounds: Absorptive dressings, such as calcium alginates (eg, Kaltostat, Curasorb), are highly absorptive and are appropriate for exudative wounds. Alginates are available in a rope form, which is useful for packing deep wounds.
• Very exudative wounds: Impregnated gauze dressings (eg, Mesalt) or hydrofiber dressings (eg, Aquacel, Aquacel-Ag) are useful for extremely exudative wounds. In these cases, twice-daily dressing changes may be needed.
• Infected wounds: For infected superficial wounds, use Silvadene (silver sulfadiazine) if the patient is not allergic to sulfa drugs; if a sulfa allergy exists, either bacitracin-zinc or Neosporin ointment is a good alternative. Where heavy bacterial contamination of deeper wounds exists, irrigation using one-fourth strength Dakin solution and 0.25% acetic acid may be useful for a brief period of time; a hydrofiber-silver dressing (Aquacel-Ag) can help control wounds that are both exudative and potentially colonized.
• Wounds covered by dry eschar: In this case, simply protecting the wound until the eschar dries and separates may be the best management. Occasionally, painting the eschar with povidone iodine (Betadine) is beneficial to maintain sterility while eschar separation occurs; an uninfected dry heel ulcer in a well-perfused foot is perhaps best managed in this fashion.
• Areas that are difficult to bandage: Bandaging a challenging anatomical area, such as around a heel ulcer, requires a highly conformable dressing, such as an extra thin hydrocolloid; securing a dressing in a highly moist challenging site, such as around a sacrococcygeal ulcer, requires a conformable and highly adherent dressing, such as a wafer hydrocolloid.
• Fragile periwound skin: Hydrogel sheets and nonadhesive forms are useful for securing a wound dressing when the surrounding skin is fragile.

Other topical preparations that occasionally may be useful in the management of diabetic foot ulcers are as follows:

• Platelet-derived growth factors (PDGF): Topically applied PDGF has a modestly beneficial effect in promoting wound healing. Becaplermin gel 0.01% (Regranex), a recombinant human PDGF that is produced through genetic engineering is approved by the US Food and Drug Administration (FDA) to promote healing of diabetic foot ulcers.^[25] Regranex is meant for a healthy, granulating wound, not one with a necrotic wound base, and is contraindicated with known skin cancers at the site of application.
• Enzymatic debridement: Collagen comprises a significant fraction of the necrotic soft tissues in chronic wounds; the enzyme collagenase, derived from fermentation of Clostridium histolyticum, helps remove nonviable tissue from the surface of wounds. However, it is not a substitute for an initial surgical excision of a grossly necrotic wound.
• Miscellaneous topical agents: Various other topical agents that have been used for wound management include sugar, antacids, and vitamin A and D ointment.

Cytotoxic agents, such as hydrogen peroxide, povidone iodine, acetic acid, and Dakin solution (sodium hypochlorite), should be avoided, except as noted above under infected wounds.

Table. Characteristics and Uses of Wound Dressing Materials (Open Table in a new window)

For more information, see Diabetic Foot Infections.

Vacuum-assisted closure

Clean but nonhealing deep cavity wounds may respond to repeated treatments by application of negative pressure under an occlusive wound dressing (vacuum-assisted closure [VAC]).^[35]

Hydrotherapy

Intractable, infected, cavity wounds sometimes improve with hydrotherapy using saline pulse lavage under pressure (PulsEvac).

Treatment of Charcot foot

Charcot foot is treated initially with immobilization using special shoes or braces but eventually may require podiatric surgery such as ostectomy and arthrodesis.

All patients harboring diabetic foot ulcers should be evaluated by a qualified vascular surgeon and/or podiatric surgeon who will consider debridement, revisional surgery on bony architecture, vascular reconstruction, and options for soft tissue coverage.

For more information, see Perioperative Management of the Diabetic Patient.

Debridement

Surgical management is indicated for debridement of nonviable and infected tissue from the ulceration, removal of excess callus, curettage of underlying osteomyelitic bone, skin grafting, and revascularization. The wound usually requires an initial surgical debridement and probing to determine the depth and involvement of bone or joint structures. Visible or palpable bone implies an 85% chance of osteomyelitis.

Revisional surgery

Revisional surgery for bony architecture may be required to remove pressure points.^[36] Such intervention includes resection of metatarsal heads or ostectomy.^[37]

Vascular reconstruction

In general, the indications for vascular surgery in the presence of a reconstructible arterial lesion include intractable pain at rest or at night, intractable foot ulcers, and impending or existing gangrene.^{[7, 38, 39]} Intermittent claudication alone is only infrequently disabling and intractable enough to warrant bypass surgery.

Once a wound has reached a steady clean state, a decision has to be made about allowing healing by natural processes or expediting healing by a surgical procedure. Clinical experience and observation of the healing progress in each case dictate the appropriate management. Surgical options include skin grafting, application of bioengineered skin substitutes, and flap closures.^[40]

Skin grafts

The autologous skin graft is the criterion standard for viable coverage of the partial thickness wound. The graft can be harvested under local anesthesia as an outpatient procedure. Meshing the graft allows wider coverage and promotes drainage of serum and blood.

A cadaveric skin allograft is a useful covering for relatively deep wounds following surgical excision when the wound bed does not appear appropriate for application of an autologous skin graft. The allograft is, of course, only a temporary solution.

Tissue-cultured skin substitutes

Dermagraft (Smith & Nephew) is a cryopreserved human fibroblast–derived dermal substitute produced by seeding neonatal foreskin fibroblasts onto a bioabsorbable polyglactin mesh scaffold. Dermagraft is useful for managing full-thickness chronic diabetic foot ulcers. It is not appropriate for infected ulcers, those that involve bone or tendon, or those that have sinus tracts.

A multicenter study of 314 patients demonstrated significantly better 12-week healing rates with Dermagraft (30%) versus controls (17%). Allergic reactions to its bovine protein component have been reported.

Apligraf (Organogenesis) is a living, bilayered human skin substitute.^{[41, 23]} It is not appropriate for infected ulcers, those that involve tendon or bone, or those that have sinus tracts. Allergic reactions to the agarose shipping medium or its bovine collagen component have been reported.

The use of bioengineered skin substitutes has been questioned because the mechanism of action is not clear, the efficacy is questionable, and the cost is high.

Xenograft

Oasis (Healthpoint, Ltd) is a xenogeneic, acellular collagen matrix derived from porcine small intestinal submucosa in a way that allows an extracellular matrix and natural growth factors to remain intact. This provides a scaffold for inducing wound healing. Do not use this for patients with allergies to porcine materials.

Surgical wound closure

Delayed primary closure of a chronic wound requires well-vascularized clean tissues and tension-free apposition; it usually requires undermining and mobilization of adjacent tissue planes by creation of skin flaps or myocutaneous flaps.^[42]

Hyperbaric oxygen therapy is used rarely and is certainly not a substitute for revascularization.^[43] In the presence of an intractable wound and associated noncorrectible ischemic arterial disease, hyperbaric oxygen therapy may be beneficial (in selected cases).^[44] Löndahl et al found that 40 hyperbaric oxygen treatments (85 min daily, 5 d/wk for 8 wk) resulted in complete healing of chronic diabetic foot ulcers in 52% of patients in the treatment group. Among patients in the placebo group, 29% had complete healing at 1-year follow-up.^[45]

The recommended diet is diabetic and low in saturated fat.

Offloading of the ulcerated area is imperative. This may require bed rest acutely. Custom footwear or custom clamshell orthosis (for severe deformities) or total contact casting (a fiberglass shell with a walking bar on the bottom) are required for patients who are ambulatory.

The risk of ulceration and limb amputation in people with diabetes can be improved by routine preventive podiatric care, appropriate shoes, and patient education.^[46] Diabetic clinics should screen all patients for altered sensation and peripheral vascular disease.^[27] Of diabetic foot ulcers, 85% are estimated to be preventable with appropriate preventive medicine, including the following:

• Daily foot inspection
• Gentle soap and water cleansing
• Application of skin moisturizer
• Inspection of the shoes to ensure good support and fit: Medicare covers custom shoes with appropriate physician documentation confirming that the patient is at risk for ulceration.
• Minor wounds require prompt medical evaluation and treatment.
• Prophylactic podiatric surgery to correct high-risk foot deformities may be indicated.
• Avoid hot soaks, heating pads, and irritating topical agents.

Glycemic control

The Diabetes Control and Complications Trial, performed by the Diabetes Control and Complications Trial ResearchGroup,studiedthe effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus (1993).^[47] This trial found that uncontrolled hyperglycemia correlates with the onset of diabetic microvascular complications and that good glycemic control can reduce or even prevent the complications of diabetes, including nephropathy, neuropathy, and retinopathy.

Cigarette smoking should be stopped, and hypertension and hyperlipidemia should be controlled.

To see complete information on the conditions below, please go to the main article by clicking on the title:

• Diabetic Neuropathy
• Diabetic Nephropathy
• Diabetic Retinopathy

Any of the following evaluations may prove productive:

• Endocrinologist
• Cardiologist
• Nephrologist
• Infectious diseases specialist
• Vascular surgeon
• Podiatrist
• Orthopedic specialist
• Plastic surgeon
• Wound care specialist
• Nutritionist

For the most part, diabetic ulcers are managed in the outpatient setting, with brief hospital stays often occurring for initial evaluation and debridement, subsequent vascular procedures, and, possibly, flap or skin graft wound management.