Diabetes Foot Ulcer Management

Diabetic foot ulcer management is aimed at reducing mechanical pressure,  controlling infection, improving blood flow, promting wound healing, and controlling diabetes. Diabetic foot ulcer affects quality of life with increased morbidity and mortality.

Mechanism

Diabetes patients are prone to neuropathy. Neuropathy means peripheral nerve damage blunting the sensation. Decreased sensation leads to failure of perception of pain sensation. Diabetic neuropathy affects hands and foot.

Even mild injuries can lead to aggravation of wound as patient unable to feel the pain and simultaneously small wound converted to deeper wound. Wound is later on complicated as deep ulcer.

1. Wound assessment

• Assess the wound  site, size, depth, exudate, necrosis, and surrounding skin.

• Look at the pressure points in the body like lower foot, calneal bone of foot, malleolus of ankle. The pressure point bone are susceptible as decrease sensation and ignorance aggravates simple ulcer into a deep one.

• Look for infection: Diabetes patients are prone to infection. We should know the signs of infection like erythema, warmth, swelling, tenderness, purulent discharge, foul odor, systemic symptoms.        Ignorance of infection is dangerous. Because timely treatment of infection can control the ulcer, otherwise it would lead to progressive deep ulcer.

• Assess vascular status: Check for blood supply to the areais very important. We have to check peripheral pulses, capillary refill, ABI/toe pressures or Doppler when indicated.

• Assess neuropathy with 10-g monofilament and vibration testing when needed.

• Look for foot deformity, callus, Charcot foot, and inappropriate footwear.

• If we see bony wound, severe bony pain we can consider X-ray/MRI if osteomyelitis is suspected.

2. Wound care

• Dressing of wound is our primary goal in diabetes foot ulcer case management. Clean with normal saline or clean water or Superoxidized water.

• Remove devitalized tissue or callus with appropriate sharp debridement. Debridement can only help establishment of blood supply, granulation tissue formation and healing of wound.

• Maintain a moist  environment in wound with an appropriate dressing.

• Measure and document wound dimensions regularly for future reference.

3. Off-loading or Reducing Mechanical Pressure

 Mechanical pressure on the ulcer:

• Special shoes, casts, braces are designed for diabetic foot ulcer patients.

• Alternatives include removable walkers or specialized footwear when casting isn’t ideal.

• Avoid walking barefoot as it may aggravate injury.

4. Infection management

Antibiotics are indicated when there is clinical infection or complication is suspected.

• Mild infection-  usually oral antibiotics targeting gram-positive organisms like amoxycillin or amoxycillin- clavulinic acid, cloxacillin.

• Moderate/severe infection-  broader antibiotics coverage like piperacillin tazobactam, linezolid are sometimes needed.

• Obtain  deep tissue culture after cleaning/debridement when infection is significant as it can guide us to use proper antibiotics.

• Suspected osteomyelitis may require  prolonged antibiotics coverage and/or surgical management.

5. Revascularization

If someone has significant peripheral arterial disease :

• Vascular assessment is required to check blood supply.

• Revascularization should be considered  particularly with ischemia, gangrene, or a non-healing ulcer. Ischemia means poor blood supply to tissue. It leads to necrosis or death of cells with gangrene of tissues.

6. Diabetes and risk-factor control

• Optimize blood glucose while avoiding hypoglycemia with regular blood sugar testing.

• Manage hypertension and lipids profile.

• Encourage smoking cessation and alcohol withdrawal.

• Ensure adequate nutrition, particularly protein intake if deficient. with more green veggies.

6. Check sensation

Check sensation daily to avoid amputation.

7.Surgery

Surgical is indicated if following conditions are met:

• Deep abscess or ulcer

• Necrotizing infection

• Extensive necrosis or gangrene

• Severe infection or sepsis

• Osteomyelitis of bone  not responding to medical therapy

• Nonviable tissue or dead tissue requiring removal

• Critical ischemia requiring vascular intervention

Urgent referral/hospitalization

A diabetic patient with a foot ulcer needs urgent medical assessment

•  If there is rapidly spreading redness/swelling, fever or systemic illness
• Black or necrotic tissue
• Gngrene
• Osteomyelitis or exposed bone, suspected deep abscess, or a cold/pale/blue foot.