Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
wound debridement
Treatment recommended for ALL patients in selected patient group
Debridement of slough, necrotic tissue, and surrounding callus of the ulcer is recommended, after taking account of relative contraindications such as pain or severe ischaemia.[55] The goal of debridement is to create a clean wound bed and promote wound healing.
Sharp debridement of ulcers using surgical instruments remains the standard of care, despite a lack of high-quality clinical trials to support its use.
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Neuropathic ulcers can usually be debrided without the need for local anaesthesia.[36]
Numerous alternative debridement techniques exist, including using enzymes, larvae, hydrogels, lasers, and ultrasound; however, there is currently insufficient evidence to support the routine use of any of these over sharp debridement, according to the International Working Group on the Diabetic Foot (IWGDF).[55]
Debridement of diabetic foot ulcers in a hospital setting should only be done by members of the multidisciplinary foot care team, using the technique that best matches their specialist expertise and clinical experience, the site of the diabetic foot ulcer, and the patient’s preference.[9] Community-based debridement should only be done by healthcare professionals with the relevant skills and training.[9]
There is reasonable-quality evidence that negative pressure wound therapy after surgical debridement may decrease the time to healing, and both the UK National Institute for Health and Care Excellence and the IWGDF recommend its use in this circumstance.[9][55]
See Emerging treatments for discussion of adjunctive therapies to promote wound healing in diabetic foot ulcers, including hyperbaric and topical oxygen therapy.
Topical medications, vitamins, physical therapies, and gasses other than oxygen are not currently recommended for this purpose.[55]
wound dressing
Treatment recommended for ALL patients in selected patient group
The choice of wound dressing when treating diabetic foot ulcers should depend on the clinical assessment of the wound.[9]
Evidence is sparse to inform decisions about the best choice of wound dressing for diabetic foot ulcers. Dressings that maintain a moist environment, including non-adherent dressings covered with a layer of gauze or other absorptive material, are commonly used.[56]
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The UK National Institute for Health and Care Excellence (NICE) and the International Working Group on the Diabetic Foot (IWGDF) have concluded that evidence supports the use of a sucrose octasulfate-impregnated wound dressing on diabetic foot wounds after other modifiable factors such as infection have been treated.[55][57][58]
See Emerging treatments for discussion of leucocyte, fibrin and platelet patch, and placental-derived products.
No other specific types of dressings, including those containing topical antimicrobials, antiseptics, honey, collagen, alginate, herbal remedies, cell therapies, or hyaluronic acid, are recommended based on current evidence.[55][56]
Split-thickness skin grafting may be considered an option for achieving wound healing in patients with a large epithelial defect that has a tissue bed with healthy granulation. The success rate for autologous skin grafting is high; however, its use over high-pressure areas (namely, the heel and the plantar forefoot overlying the metatarsal heads) may be limited.
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There are also several skin substitutes (i.e., non-autologous xenogenic or allogenic tissues) that have been approved for use on diabetic foot wounds. In contrast to autologous skin grafts, several applications of the skin substitute are generally needed at 1- to 2-week intervals to achieve complete re-epithelialisation. There is currently little evidence to support the use of skin substitutes for diabetic foot wounds and they are not recommended by the IWGDF.[55]
NICE recommends that dermal or skin substitutes should only be considered when healing is not progressing and following advice from the multidisciplinary foot care service.[9]
offloading footwear and devices
Treatment recommended for ALL patients in selected patient group
Repetitive trauma sustained during ambulation is the most common cause of foot ulcers in patients with diabetes. All patients with diabetes should be encouraged to routinely wear appropriate footwear, even if they do not have any signs of active foot ulceration. For those with active ulceration, offloading the foot is essential to minimise or avoid this repetitive trauma, in order to achieve ulcer healing.
Total contact casts and non-removable cast-walkers are the most effective options for offloading footwear, although removable cast-walkers and modified footwear can be considered if frequent access to the wound is required.[28]
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Non-removable devices are contraindicated when there is both mild infection and mild ischaemia, or moderate infection or ischaemia, or heavy exudate present.[28]
The UK National Institute for Health and Care Excellence (NICE) recommends non-removable casting to offload plantar neuropathic, non-ischaemic, uninfected forefoot and midfoot diabetic ulcers. Offer an alternative casting device until casting can be provided.[9]
The International Working Group on the Diabetic Foot (IWGDF) recommends that in a person with diabetes and a neuropathic plantar forefoot or midfoot ulcer, a non-removable knee-high device should be used as the first choice of offloading treatment: either a total contact cast or non-removable knee-high walker, depending on the resources available, technician skills, patient preferences, and the extent of any foot deformity present.[28] If non-removable knee-high device is not tolerated or is contraindicated, a removable knee-high or ankle-high device is recommended second-line, with the patient encouraged to wear the device during all weight-bearing activities.
For neuropathic plantar rearfoot ulcers, consider a non-removable knee-high offloading device over a removable device. For non-plantar foot ulcers, use a removable offloading device, footwear modifications, toe spacers, orthoses, or digital flexor tenotomy, depending on the type and location of the foot ulcer.[28]
In any patient using a knee-high or ankle-high offloading device, consider adding a shoe lift on the contralateral limb to improve comfort and balance.[28]
surgical bypass and/or endovascular intervention
Additional treatment recommended for SOME patients in selected patient group
A revascularisation procedure should be considered for anyone with peripheral artery disease, a foot ulcer, and clinical findings of ischaemia (absent pulses, monophasic or absent pedal Doppler waveforms, ankle pressure <100 mmHg or toe pressure <60 mmHg), and for those with ulcers that do not improve within 4 weeks despite appropriate management.[11] Seek an urgent vascular opinion if there are signs of severe ischaemia: ankle-brachial pressure index <0.4, ankle pressure <50 mmHg, toe pressure <30 mmHg, or transcutaneous oxygen pressure <30 mmHg.
Revascularisation should aim to restore adequate arterial blood flow to at least one of the foot arteries. The main options for this type of procedure are endovascular (usually balloon angioplasty with or without stent placement), open (surgical bypass or endarterectomy), or hybrid (a combination of both). The choice of procedure should be based on the patient’s individual risks and preferences, limb threat severity, anatomical distribution of peripheral artery disease, and the availability of an autogenous vein for bypass.[11] In patients with infrapopliteal disease undergoing endovascular intervention by percutaneous transluminal angioplasty, addition of a stent probably increases rates of technical success of the procedure compared to no stenting, although the impact on complications, longer-term success rates and mortality is uncertain.
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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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