Diabetic Foot Ulcers Guidelines

Updated: Oct 15, 2020
  • Author: Tanzim Khan, DPM; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Guidelines Summary

In 2019, the International Working Group on the Diabetic Foot (IWGDF) published an update to its evidence-based guidelines on diabetic foot disease prevention and management. These included the following practical guidelines with regard to assessment of ulcers [35] :

  • An individual with diabetes who is at very low risk for foot ulceration (IWGDF risk 0) should, to assess the subsequent risk for ulcers, be examined annually for signs or symptoms of protective sensation loss and peripheral artery disease
  • A patient with diabetes who has protective sensation loss or peripheral artery disease (IWGDF risk 1-3) should undergo a more comprehensive examination, with the following taken into account: history, vascular status, skin, bone/joint, protective sensation loss, footwear, poor foot hygiene, physical limitations that may hinder self care of the feet (eg, problems with visual acuity, obesity), and foot care knowledge

In terms of ulcer treatment, the practical guidelines state the following with regard to pressure offloading [35] :

  • For patients with a neuropathic plantar ulcer, a nonremovable knee-high offloading device—ie, either a total contact cast (TCC) or a removable walker that is rendered irremovable by the provider who fits the device—is the preferred offloading treatment
  • In patients who cannot tolerate a nonremovable, knee-high offloading device, or if such a device is contraindicated, a removable version can be considered; should a removable device be contraindicated or if it cannot be tolerated, an ankle-high offloading device can be considered; patients must be educated with regard to the benefits of adherence to removable device use
  • In the absence of other forms of biomechanical relief, felted foam, in combination with appropriate footwear, can be considered
  • While offloading remains important in the presence of infection or ischemia, greater caution is necessary
  • Nonplantar foot ulcers, depending on their type and location, should be addressed with a removable, ankle-high offloading device, footwear modifications, toe spacers, or orthoses

With regard to restoration of tissue perfusion, the practical guidelines state the following [35] :

  • When ankle pressure is below 50 mmHg or the ankle brachial index (ABI) is less than 0.5, urgent vascular imaging and, in the presence of appropriate findings, revascularization, should be considered; revascularization should also be considered if the toe pressure is below 30 mmHg or the transcutaneous pressure of oxygen (TcpO 2) is less than 25 mmHg; however, revascularization may be considered at higher pressures should extensive tissue loss or infection occur
  • If optimal treatment does not result in ulcerative healing signs within 6 weeks, revascularization should be considered, regardless of the outcomes of the above-mentioned vascular tests
  • If an above-the-ankle amputation is being contemplated, revascularization should first be considered as an option
  • Revascularization should be avoided in patients with an unfavorable risk-benefit ratio
  • Individual factors (eg, morphologic distribution of peripheral artery disease, autogenous vein availability, patient comorbidities) and local operator expertise should be considered when selecting a revascularization technique
  • Following revascularization, perfusion should be objectively measured to assess the procedure’s effectiveness
  • Pharmacologic treatments have not been proven to benefit perfusion
  • Smoking cessation, hypertension and dyslipidemia control, and antiplatelet drug use, as the means to reduce cardiovascular risk, should be emphasized

With regard to treatment of infection, the practical guidelines state the following [35] :

  • For a superficial ulcer with limited soft tissue (mild) infection - The ulcer should be cleansed and all necrotic tissue and surrounding callus should be debrided; start empiric oral antibiotic therapy directed against Staphylococcus aureus and streptococci (unless there are indications that alternative or additional likely pathogens exist)
  • For deep or extensive (potentially limb-threatening) infection (moderate or severe infection) - The need for surgical intervention to remove necrotic tissue, including infected bone, should be urgently evaluated, and compartment pressure should be released or abscesses drained; assess for peripheral artery disease (with urgent treatment, including revascularization, to be considered if such disease is present); empiric, parenteral, broad-spectrum antibiotic therapy aimed at common gram-positive and gram-negative bacteria, including obligate anaerobes, should be initiated; the clinical response to empirical therapy, along with culture and sensitivity results, should be used to adjust (constrain and target, if possible) the antibiotic regimen

With regard to local ulcer care, the practical guidelines recommend the following [35] :

  • The ulcer must be inspected regularly by a trained health-care provider, with the severity of the ulcer, the underlying pathology, the presence of infection, the amount of exudation, and wound treatment provided determining the frequency of examination
  • Ulcer débridement and removal of the surrounding callus (preferably with sharp surgical instruments) should be carried out, with the procedure repeated as necessary
  • Selected dressings should control excess exudation and keep the environment moist
  • Foot soaking may cause skin maceration and so should not be employed in treatment
  • Negative pressure should be considered as an aid to healing postoperative wounds
  • If noninfected ulcers do not heal after 4-6 weeks of optimal clinical care, one of the following adjunctive treatments should be considered - If severe ischemia is not present in a neuro-ischemic ulcer, a sucrose octasulfate–impregnated dressing; if moderate ischemia is either present or absent, a multi-layered patch of autologous leucocytes, platelets, and fibrin; also in the presence of absence of moderate ischemia, placental membrane allografts; in ischemic ulcers in which revascularization has not led to healing, adjunctive treatment with systemic oxygen therapy