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] :
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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
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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] :
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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
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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
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In the absence of other forms of biomechanical relief, felted foam, in combination with appropriate footwear, can be considered
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While offloading remains important in the presence of infection or ischemia, greater caution is necessary
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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] :
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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
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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
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If an above-the-ankle amputation is being contemplated, revascularization should first be considered as an option
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Revascularization should be avoided in patients with an unfavorable risk-benefit ratio
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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
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Following revascularization, perfusion should be objectively measured to assess the procedure’s effectiveness
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Pharmacologic treatments have not been proven to benefit perfusion
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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] :
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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)
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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] :
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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
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Ulcer débridement and removal of the surrounding callus (preferably with sharp surgical instruments) should be carried out, with the procedure repeated as necessary
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Selected dressings should control excess exudation and keep the environment moist
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Foot soaking may cause skin maceration and so should not be employed in treatment
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Negative pressure should be considered as an aid to healing postoperative wounds
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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
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Diabetic ulcer of the medial aspect of left first toe before and after appropriate wound care.
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Diabetic ulcer of left fourth toe associated with mild cellulitis.
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Charcot deformity with mal perforans ulcer of plantar midfoot.
Tables
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 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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