Diabetic Foot Ulcers Differential Diagnoses

Updated: Oct 15, 2020

Author: Tanzim Khan, DPM; Chief Editor: Romesh Khardori, MD, PhD, FACP more...

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Diabetic Foot Ulcers

DDx

Diagnostic Considerations

The classic diabetic trophic ulcer must be distinguished from various other problems that tend to occur in persons with diabetes, such as diabetic dermopathy, bullosis diabeticorum, eruptive xanthoma, necrobiosis lipoidica, and granuloma annulare.

The leg pain of peripheral arterial disease must be distinguished from other causes of leg pain, such as arthritis, muscle pain, radicular pain, spinal cord compression, thrombophlebitis, anemia, and myxedema.

Diabetic neuropathy should be distinguished from other forms of neuropathy, including vasculitic neuropathies, metabolic neuropathies, autonomic neuropathy, radiculopathy, and many others.

Differential Diagnoses

Atherosclerosis
Basal Cell Carcinoma
Bites
Chronic Venous Insufficiency
Cutaneous B-Cell Lymphoma
Cutaneous Squamous Cell Carcinoma
Cutaneous T-Cell Lymphoma
Diabetic Foot Infections
Kaposi Sarcoma
Pressure Injuries (Pressure Ulcers) and Wound Care
Pyoderma Gangrenosum
Vasculitis and Thrombophlebitis

Workup

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Media Gallery

Diabetic ulcer of the medial aspect of left first toe before and after appropriate wound care.
Diabetic ulcer of left fourth toe associated with mild cellulitis.
Charcot deformity with mal perforans ulcer of plantar midfoot.

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Table. Characteristics and Uses of Wound Dressing Materials

Category	Examples	Description	Applications
Alginate	AlgiSite Comfeel Curasorb Kaltogel Kaltostat Sorbsan Tegagel	This seaweed extract contains guluronic and mannuronic acids that provide tensile strength and calcium and sodium alginates, which confer an absorptive capacity. Some of these can leave fibers in the wound if they are not thoroughly irrigated. These are secured with secondary coverage.	These are highly absorbent and useful for wounds having copious exudate. Alginate rope is particularly useful to pack exudative wound cavities or sinus tracts.
Hydrofiber	Aquacel Aquacel-Ag Versiva	An absorptive textile fiber pad, also available as a ribbon for packing of deep wounds. This material is covered with a secondary dressing. The hydrofiber combines with wound exudate to produce a hydrophilic gel. Aquacel-Ag contains 1.2% ionic silver that has strong antimicrobial properties against many organisms, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus.	These are absorbent dressings used for exudative wounds.
Debriding agents	Hypergel (hypertonic saline gel) Santyl (collagenase) Accuzyme (papain urea)	Various products provide some degree of chemical or enzymatic débridement.	These are useful for necrotic wounds as an adjunct to surgical débridement.
Foam	LYOfoam Spyrosorb Allevyn	Polyurethane foam has some absorptive capacity.	These are useful for cleaning granulating wounds having minimal exudate.
Hydrocolloid	Aquacel CombiDERM Comfeel Duoderm CGF Extra Thin Granuflex Tegasorb	These are made of microgranular suspension of natural or synthetic polymers, such as gelatin or pectin, in an adhesive matrix. The granules change from a semihydrated state to a gel as the wound exudate is absorbed.	They are useful for dry necrotic wounds, wounds having minimal exudate, and clean granulating wounds.
Hydrogel	Aquasorb Duoderm IntraSite Gel Granugel Normlgel Nu-Gel Purilon Gel (KY jelly)	These are water-based or glycerin-based semipermeable hydrophilic polymers; cooling properties may decrease wound pain. These gels can lose or absorb water depending upon the state of hydration of the wound. They are secured with secondary covering.	These are useful for dry, sloughy, necrotic wounds (eschar).
Low-adherence dressing	Mepore Skintact Release	These are various materials designed to remove easily without damaging underlying skin.	These are useful for acute minor wounds, such as skin tears, or as a final dressing for chronic wounds that have nearly healed.
Transparent film	OpSite Skintact Release Tegaderm Bioclusive	These are highly conformable acrylic adhesive film having no absorptive capacity and little hydrating ability, and they may be vapor permeable or perforated.	These are useful for clean dry wounds having minimal exudate, and they also are used to secure an underlying absorptive material. They are used for protection of high-friction areas and areas that are difficult to bandage such as heels (also used to secure IV catheters).

Risk classification and follow-up based on the comprehensive foot examination ^[75]

Risk category	Definition	Suggested follow-up
0	No LOPS, no PAD, no deformity	Annually
1	LOPS ± deformity	Every 3–6 months
2	PAD ± LOPS	Every 2–3 months
3	History of ulcer or amputation	Every 1–2 months

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