Management of Diabetic Foot Ulcers

19/10/2020 Management of diabetic foot ulcers - UpToDate
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Management of diabetic foot ulcers

Authors: David G Armstrong, DPM, MD, PhD, Richard J de Asla, MD
Section Editors: John F Eidt, MD, Joseph L Mills, Sr, MD, David M Nathan, MD
Deputy Editor: Kathryn A Collins, MD, PhD, FACS
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2020. | This topic last updated: Aug 05, 2019.
INTRODUCTION
The lifetime risk of a foot ulcer in patients with diabetes (type 1 or 2) may be as high as 34 percent [1-3].
Diabetic foot ulcers are a major cause of morbidity [4], accounting for approximately two-thirds of all
nontraumatic amputations performed in the United States [5,6]. Infected or ischemic diabetic foot ulcers
account for approximately 25 percent of all hospital stays for patients with diabetes [7]. These observations
illustrate the importance of prompt and appropriate treatment of foot ulcers in patients with diabetes.
The management of diabetic foot ulcers, including local wound care, use of mechanical offloading, treatment of
infection, and indications for revascularization, are reviewed here. The evaluation of the diabetic foot and
specific management of the threatened limb are reviewed separately. (See "Evaluation of the diabetic foot" and
"Treatment of chronic limb-threatening ischemia".)
ETIOLOGY
Risk factors that can lead to foot wounds in patients with diabetes include loss of protective sensation due to
neuropathy, prior ulcers or amputations, foot deformity leading to excess pressure, external trauma, infection,
and the effects of chronic ischemia, typically due to peripheral artery disease [1]. Patients with diabetes also
have an increased risk for nonhealing related to mechanical and cytogenic factors, as well as a high prevalence
of peripheral artery disease. (See "Evaluation of the diabetic foot", section on 'Risk factors'.)
ULCER CLASSIFICATION
The first step in managing diabetic foot ulcers is assessing, grading, and classifying the ulcer. Classification is
based upon clinical evaluation of the extent and depth of the ulcer and the presence of infection or ischemia,
which determine the nature and intensity of treatment. To assess for ischemia, all patients with diabetic foot
ulcers should have ankle-brachial index and toe pressure measurements.
University of Texas system — The University of Texas (UT, San Antonio) in the United States introduced a
clinical classification system for diabetic foot wounds that evaluates wound depth, the presence of infection,
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and peripheral arterial occlusive disease for every category of the wound assessment [8]. The UT system was
the first diabetic foot ulcer classification to be validated [9]. This system updated the Wagner classification [10].
(See 'Wagner, PEDIS, and others' below.)
Grade:
● Grade 0: Pre- or postulcerative (Stages A to D) ( picture 1)
● Grade 1: Full-thickness ulcer not involving tendon, capsule, or bone (Stages A to D) ( picture 2)
● Grade 2: Tendon or capsular involvement without bone palpable (Stages A to D) ( picture 3 and
picture 4)
● Grade 3: Probes to bone (Stages A to D) ( picture 5)
Stage:
● A: Noninfected
● B: Infected
● C: Ischemic
● D: Infected and ischemic ( picture 6)
Threatened limb classification: WIfI — To provide a more quantitative assessment of peripheral artery
disease (PAD) as a predictor and contributor to lower extremity pathology, the Society for Vascular Surgery has
proposed the structure of the Wound/Ischemia/Foot Infection (WIfI) system. Scores are assigned on a
"none/mild/moderate/severe basis (0/1/2/3)" using multiple specified criteria in the same fundamental
categories as the University of Texas system [11]. This "threatened limb" system includes, in particular, more
detailed measures and criteria for grading vascular status. It has been validated in four separate studies and
shows promise as a pragmatic means to assess the likelihood of morbidity in at-risk limbs. The classification can
be visualized as three intersecting rings of risk ( figure 1) [12]. The quantitative scores for these individual
categories can help identify the relative importance of the various factors underlying risk to a limb at a given
point in time. In applying the WIfI system, it is recommended that diabetic and nondiabetic patients be
considered in separate categories and the presence or absence of neuropathy be additionally noted in patients
with diabetes [11]. While the specifics of what constitutes "none, mild, moderate, and severe" may change over
time, the basic principles are likely to prove durable [12,13]. (See "Classification of acute and chronic lower
extremity ischemia", section on 'WIfI (Wound, Ischemia, foot Infection)'.)
Wagner, PEDIS, and others — An early and often still used classification system at hyperbaric-based wound
healing centers was originally proposed by Wagner [14]. This classification was based upon clinical evaluation
(depth of ulcer and presence of necrosis) alone and did not account for variability in the vascular status of the
foot. The ulcer classification is as follows:
● Grade 1: Superficial ulcer – Skin and subcutaneous tissue only

● Grade 2: Deep ulcer to tendon, muscle, joint capsule, or bone
● Grade 3: Deep ulcer with abscess, osteomyelitis, or tendinitis
● Grade 4: Partial foot gangrene
● Grade 5: Whole foot gangrene

The Wagner system is predictive of poor outcome, but only up to grade 3 [10]. It has fallen out of widespread
use because of the lack of specificity to describe coexistent depth, infection, and ischemia.
The International Working Group on the Diabetic Foot proposed classifying all ulcers according to the following
categories: perfusion, extent, depth, infection, and sensation (PEDIS) [15]. The PEDIS system is primarily used
for research purposes. Other ulcer classification systems have also been described [16-18].
MANAGEMENT OVERVIEW
Our management approach is consistent with multidisciplinary guidelines for the management of the diabetic
foot [19,20]. (See 'Society guideline links' below.)
General approach — The management of diabetic foot ulcers begins with a comprehensive assessment of the
ulcer and the patient's overall medical condition ( algorithm 1). Most patients with diabetes over age 40
should be offered measures to reduce their risk of developing cardiovascular complications. (See "Overview of
general medical care in nonpregnant adults with diabetes mellitus", section on 'Reducing the risk of
macrovascular disease' and "Overview of peripheral artery disease in patients with diabetes mellitus", section
on 'Risk factor modification'.)
Evidence of infection, underlying neuropathy, peripheral artery disease, edema, malnutrition, and any bony
deformities should be actively sought and addressed systematically [21]. The incidence of neuropathic (Charcot)
arthropathy may be as high as 13 percent in patients with diabetes [22]. (See "Diabetic neuropathic
arthropathy" and "Surgical management of neuropathic arthropathy (Charcot foot)".)
For patients with evidence of arterial insufficiency, we suggest referral to a vascular specialist. (See "Overview of
peripheral artery disease in patients with diabetes mellitus".)
While it stands to reason that effective glucose control and adequate nutrition are important in healing diabetic
foot wounds, there are few data to support either assumption. There are no randomized trials data to support
that glucose control affects healing [23]. A trial evaluating the effectiveness of liquid oral protein
supplementation failed to show a difference in healing between main groups but reported a significantly
greater likelihood of healing in a subset of patients with low albumin or ischemia [24,25].
Local ulcer care includes sharp debridement and proper wound coverage. When debridement is needed, we
suggest surgical (sharp) debridement. Dressings are selected based upon ulcer appearance and other wound
characteristics ( table 1 and table 2). For extensive open wounds following debridement for infection and
necrosis, or following partial foot amputation, we suggest negative pressure wound therapy, provided there is
no residual necrotic tissue or infected bone (osteomyelitis) [26]. (See 'Local care' below and 'Dressings' below
and 'Negative pressure wound therapy' below.)
Any ulcer that is subjected to sustained or frequent pressure and stress (ie, pressure-related heel ulcers or
medial/lateral foot ulcers) or repetitive moderate pressure (plantar foot ulcers) will benefit from pressure
reduction, which is accomplished with mechanical offloading. Several methods are available to achieve
mechanical offloading, including total contact casts, cast walkers, wedge shoes, and bedrest. Following surgery,
total contact casting and cast walkers are better alternatives to prolonged bed rest for the relief of pressure as
they allow for the benefits and convenience of continued ambulation. (See 'Mechanical offloading' below.)

For some patients, successful offloading of a diabetic ulcer cannot be adequately achieved by mechanical
devices alone. In such cases, surgical correction of the deformity may be required. Interventions include
hammertoe corrections, bunion corrections, Achilles tendon or gastrocnemius lengthening, and Charcot foot
reconstructions. (See "Diabetic neuropathic arthropathy" and "Surgical management of neuropathic
arthropathy (Charcot foot)".)
After appropriately addressing debridement, pressure offloading, infection, and ischemia, there are a number
of adjunctive therapies that may prove helpful in augmenting wound healing. (See 'Adjunctive local therapies'
below.)
Whether such management can be accomplished in an outpatient setting and when admission to hospital is
needed depends upon the skill set of the local wound care team, the resources available, and the personality
and life circumstances of the patient.
Allowable time course for primary healing — In clinical practice, measurements of a patient's ulcer size
should be taken at every visit so that comparisons can be made and progress documented. The surface area of
a diabetic foot ulcer should decrease in size at a rate of approximately 1 to 2 percent a day. Thus, appropriate
local wound care should achieve a greater than 40 to 50 percent surface area reduction or reduction of ulcer
depth by four weeks [27]. If this rate of progress is not observed, in our system, the patient's care is transferred
from the local team to a wound consultant who works with the patient's primary care physician to address
issues such as glycemic control, edema, and other aspects of general health and nutrition. Ulcers that still do
not improve should be reevaluated for ongoing soft tissue infection or osteomyelitis, impaired extremity
vascular flow, and, most commonly, the need for more effective offloading or surgical debridement.
Coordination of care — Coordination among care providers is important for keeping rates of amputation as
low as possible. This was illustrated in a study of 10 Department of Veterans Affairs (VA) medical centers in
which decreased rates of amputation were seen in programs with the highest scores for availability of clinical
protocols, educational seminars, discharge planning, and quality of care meetings [28]. At our institution,
certified wound consultants are responsible for training and certifying local teams of nurses in each primary
care clinic to use and follow a standard protocol (evidence-based where possible) for evaluation and care of
diabetic foot ulcers. The ulcer is classified upon initial presentation and with each follow-up visit, and we ensure
consistent documentation within the electronic medical record using a standardized approach to measuring the
length, width, and depth of each wound at every visit regardless of where the patient is receiving wound care
within our system (ie, family practice outpatient clinic, surgical clinic, nursing facility, home nursing services).
Patients are seen at least once a week and sometimes more often, initially, to follow the progress of healing and
to plan further treatment. For facilities that do not have the resources to implement such a systematic approach
to care, referral to a facility with appropriate expertise in the management of diabetic foot problems (medical
and surgical) is appropriate.
Follow-up care and ulcer prevention — Once a patient has healed an ulcer, he or she remains at a very
high risk for reulceration. Once healed, ulcer recurrence is 40 percent at one year, 66 percent at three years,
and up to 75 percent at five years [4]. Therefore, people with healed ulcers should be considered "in remission,"
a term that better communicates the lifetime of visits (often bimonthly) needed to reduce the risk for severe
recurrence, if not all ulcer recurrences [1,29,30]. The goals of long-term surveillance and care are to maximize
ulcer-free, hospital-free, and activity-rich days.

Ongoing counseling regarding preventive foot care should be given to any patient whose feet are at risk for
further ulcer development, particularly patients with existing neuropathy ( table 3). Several measures can
markedly diminish ulcer formation, such as avoiding poorly fitting shoes, not walking barefoot, and stopping
smoking. (See "Evaluation of the diabetic foot", section on 'Risk factors' and "Evaluation of the diabetic foot",
section on 'Preventive foot care' and 'Mechanical offloading' below.)
Certain oral diabetes agents (ie, SGLT2 inhibitors) may be associated with an increased risk of amputation
compared with other oral treatments for type 2 diabetes [31]. If the patient is taking these agents, it should be
discontinued. This issue is discussed in detail separately. (See "Sodium-glucose co-transporter 2 inhibitors for
the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Amputations'.)
Approach by ulcer stage and depth — Treatment is based upon the ulcer classification. (See 'Ulcer
classification' above.)
Noninfected — Superficial diabetic foot ulcers (University of Texas [UT] classification: grade 1; stage A) can
typically be debrided in the clinic or at the bedside ( algorithm 1). When a clinician with expertise in sharp
debridement is not available, autolytic hydrogels can be used. For noninfected ulcers that extend to deeper
tissues (grade/stage: 2A, 3A), we suggest initial surgical debridement in an operating room setting. For
pressure-related ulcers, mechanical offloading should be implemented. (See 'Debridement' below and
'Mechanical offloading' below.)
Infected — The treatment of infected (UT classification: grades 1 to 3; stage B) diabetic foot ulcers includes
antimicrobial therapy and surgical debridement ( algorithm 1). The antibiotics chosen and duration of therapy
depend upon the depth and severity of infection [19]. Consultation with a surgeon is important for any infection
that extends beyond the dermis. (See 'Managing infection' below and "Clinical manifestations, diagnosis, and
management of diabetic infections of the lower extremities".)
Ischemic — Approximately one-half of patients with diabetes who present with diabetic foot ulcers have
some element of ischemia (UT classification: grades 1 to 3; stage C) [32]. In addition to proper local care
(debridement, wound coverage, relief of pressure), patients with significant limb ischemia should be referred to
a vascular specialist for possible revascularization ( algorithm 1). Revascularization (open, endovascular)
should be considered in patients with any degree of limb ischemia and foot ulcer that does not improve over an
appropriate time course. (See 'Allowable time course for primary healing' above and "Treatment of chronic limb-
threatening ischemia".)
Combined infection and ischemia — Infected and ischemic ulcers (UT classification: grades 1 to 3; stage D)
constitute the highest risk for nonhealing and amputation [9,32]. These patients generally require team
management by physicians and surgeons with expertise in medical and surgical control of infection and
revascularization ( algorithm 1). (See 'Infected' above and 'Ischemic' above.)
LOCAL CARE
Debridement — Debridement of necrotic tissue is important for ulcer healing [33]. The frequency of
assessment and proper care may contribute more to wound healing than the type of debridement. In a review
that examined chronic wound care among veterans, the chance of diabetic ulcer healing increased 2.5-fold

when debridement was performed at 80 percent of visits and doubled when ischemia was assessed at the first
visit [34].
There are few data to guide choice of debridement (sharp, enzymatic, autolytic, mechanical, and biological) for
diabetic foot ulcer [35]. The types of debridement are reviewed separately. (See "Basic principles of wound
management", section on 'Wound debridement'.)
When surgeons with expertise in sharp debridement are available, we prefer this method. Sharp debridement,
the most widely used method, involves the use of a scalpel or scissors to remove necrotic tissue [36]. As an
alternative, we suggest application of a hydrogel, but data are limited to support its efficacy in promoting ulcer
healing. Enzymatic debridement (topical application of proteolytic enzymes such as collagenase) may be more
appropriate in certain settings (eg, extensive vascular disease not under team management) [37,38]. Autolytic
debridement may be a good option in patients with painful ulcers, using a semiocclusive or occlusive dressing
to cover the ulcer so that necrotic tissue is digested by enzymes normally present in wound tissue.
Larval therapy has been used in some specialty clinics in high-risk patients as an adjunct to serial surgical
debridement. There appears to be benefit from several days of targeted therapy [39]. As an example, in very
frail patients for whom the goals are comfort care and lowering the risk for infection, "wound hospice" or
"podiatric hospice" using larval therapy may increase the duration of antibiotic-free days [40]. (See "Basic
principles of wound management", section on 'Biologic'.)
Dressings — After debridement, ulcers should be kept clean and moist but free of excess fluids ( table 1).
Dressings should be selected based upon ulcer characteristics, such as the extent of exudate, desiccation, or
necrotic tissue ( table 2). Some dressings simply provide protection, whereas others promote wound
hydration or prevent excessive moisture. Wet-to-dry saline dressings are frequently used but can remove both
nonviable and viable tissue and may result in a dry wound. Other dressings are impregnated with antimicrobial
agents to prevent infection and enhance ulcer healing. For the management of foot ulcers in patients with
diabetes, there is no high-quality evidence to suggest any significant differences in wound healing outcomes
when comparing the various types of dressings [41,42]. (See "Basic principles of wound management", section
on 'Wound dressings'.)
Adjunctive local therapies — Adjunctive therapies may help improve healing of diabetic foot ulcers [43-46].
Negative pressure wound therapy — Based on randomized trials showing improved wound healing [47-
56], we suggest NPWT for extensive open wounds following debridement for infection and necrosis, or
following partial foot amputation, provided there is no residual necrotic tissue or infected bone (osteomyelitis)
[26].
NPWT, also called vacuum-assisted closure (VAC), involves the application of controlled subatmospheric
pressure to the surface of the ulcer. NPWT enhances healing by increasing wound perfusion, reducing edema,
reducing the local bacterial burden, and increasing the formation of granulation tissue. The indications,
contraindications, and uses of negative pressure wound therapy systems are discussed in detail separately. (See
"Negative pressure wound therapy".)
NPWT appears to improve healing of diabetic foot ulcers, as well as wounds following diabetic foot surgery [48-
56]. NPWT also decreases the length of hospitalization, complication rates, and costs [57-59]. Among five trials
in a systematic review, NPWT significantly increased the chance of foot ulcer healing compared with dressings

(risk ratio [RR] 1.40, 95% CI 1.14-1.72) [56]. Among three trials, NPWT reduced the risk of amputation (RR 0.33,
95% CI 0.15-0.70). There was no effect on ulcer recurrence.
For managing postoperative wounds, a multicenter trial followed 162 diabetic patients for 16 weeks following
partial foot amputation [50]. Compared with the control group, the NPWT group had a significantly higher
percentage of patients with healed wounds (56 versus 39 percent), and shorter time to complete closure (42
versus 84 days).
Skin grafts and substitutes — Human skin grafts and bioengineered skin substitutes (eg, Dermagraft,
Apligraf, TheraSkin, Graftskin, EpiFix, Zelen, Graftjacket, Hyalograft 3D, Kaloderm, OrCel) have been studied in
individuals with noninfected, nonischemic chronic plantar diabetic foot ulcers [45,60-69]. The basic principles of
skin grafting and skin substitutes are presented separately. (See "Skin autografting" and "Skin substitutes".)
A systematic review identified 17 trials using skin grafts or substitutes for the treatment of diabetic foot ulcers
[70]. The incidence of completed closure of diabetic foot ulcers was significantly improved for the skin grafts or
substitutes compared with standard care (RR 1.55, 95% CI 1.30-1.85). In two trials, there were no significant
differences for ulcer recurrence. Based upon four trials that directly compared two products, no specific type of
skin graft or skin substitute was found to be superior over another. Among two trials that reported the
incidence of lower limb amputations, skin grafts and substitutes were also associated with significantly lower
risk for amputation, although the absolute risk reduction for amputation was small (RR 0.43, 95% CI 0.23-0.81;
risk difference -0.06, 95% CI -0.10 to -0.01).
Growth factors — Tissue growth factors promote cellular proliferation and angiogenesis and thereby
improve ulcer healing. A systematic review assessed outcomes of 28 trials using 11 different growth factors
predominantly used as topical agents, including platelet-derived wound healing formula, autologous growth
factor, allogeneic platelet-derived growth factor, transforming growth factor beta 2, arginine-glycine-aspartic
acid peptide matrix, recombinant human platelet-derived growth factor (becaplermin), recombinant human
epidermal growth factor, recombinant human basic fibroblast growth factor, recombinant human vascular
endothelial growth factor, recombinant human lactoferrin, and recombinant human acidic fibroblast growth
factor [71]. Overall, the quality of the trials was low with a high risk of bias. In a meta-analysis of 12 trials, the
use of any growth factor compared with placebo or no growth factor significantly increased the number of
participants with complete wound healing (53 versus 35 percent). The results were mainly based on platelet-
derived wound healing formula (64 versus 26 percent, two trials), and recombinant human platelet-derived
growth factor (becaplermin; 48 versus 33 percent, five trials). No clear differences were apparent with respect to
amputation rates, but only two trials were included in this analysis.
Platelet-derived growth factor as a gel preparation (becaplermin) is approved by the US Food and Drug
Administration as an adjuvant therapy for diabetic foot ulcers [72]. Although effective, its use has been limited
by high cost and by postmarketing reports of an increased rate of mortality secondary to malignancy in patients
treated with three or more tubes of becaplermin, compared with controls (3.9 versus 0.9 per 1000 person-years;
adjusted rate ratio 5.2, 95% CI 1.6-17.6) [73,74].
Hyperbaric oxygen therapy — Hyperbaric oxygen therapy (HBOT) may be associated with improved healing
as a component of diabetic ulcer management, but the indications for HBOT in the treatment of nonhealing
diabetic foot ulcers remain uncertain. Most, but not all [75], meta-analyses of randomized trials suggest that
hyperbaric oxygen therapy may offer a benefit in the treatment of diabetic foot ulcers; however, each meta-

analysis noted variability in methodologic quality of the included studies [75-80]. The available trials are limited
by small sample size and heterogeneity of the wounds being treated (eg, ulcer size, ulcer depth, microbial
environment, presence of ischemia) [81-92]. No conclusions could be drawn regarding specific indications for or
timing of therapy.
A pooled analysis found significantly improved wound healing (OR 9.99, 95% CI 3.97-25.1) and decreased risk of
amputation (odds ratio [OR] 0.24, 95% CI 0.14-0.43) for HBOT [77]. A later meta-analysis found similar results
[80]. As an example of these effects, in one of the larger trials that included 70 patients with severely ischemic
foot ulcers, the amputation rate was 9 percent in the treatment group and 33 percent in the control [83]. In
another trial that included 94 patients, significantly more wounds healed completely in the HBOT group
compared with a placebo group (52 versus 29 percent) [90]. However, in a later longitudinal cohort of 6259
patients with diabetic foot ulcers, use of HBOT did not result in better wound healing, and amputation rates
were similar to those not receiving the therapy [81].
Shock wave therapy — Shock wave therapy, which consists of treatment using a handheld probe to deliver
high-energy pulses locally to the wound, purportedly increases local perfusion and angiogenesis, disrupts
biofilm, and may upregulate growth factors. Observational and small randomized trials suggest that shock
wave therapy may improve healing of chronic diabetic foot ulcers [93-97]. In two proprietary trials, 336 patients
were randomly assigned to shock wave therapy (DermaPACE) or usual care consisting of wet-to-dry dressings or
debridement. At 24-week follow-up, significantly more patients in the shock wave group achieved complete
wound closure compared with usual care (44 versus 30 percent) [98].
Others — Low-level light therapy uses low-power lasers or light-emitting diodes to alter cellular function and
molecular pathways. A systematic review identified four randomized trials that included 131 patients comparing
low-level light therapy with either nontherapeutic light therapy or sham treatment for the treatment of diabetic
foot ulcers [99-103]. Each of the trials demonstrated beneficial outcomes for the light treatment with no
adverse events; however, many limitations were noted with these generally small trials.
In a separate review, for other forms of energy, such as electrical stimulation, ultrasound, normothermic
therapy, magnet therapy, and laser therapy, there was no convincing evidence of clear benefit [47]. (See "Basic
principles of wound management", section on 'Adjunctive therapies'.)
Other therapies aimed at managing chronic wounds predominantly in patients with peripheral artery disease
(PAD) have been tried, and some initial data appear promising, but further studies are required regarding
dose/duration/delivery to provide recommendations on use [104,105]. (See "Investigational therapies for
treating symptoms of lower extremity peripheral artery disease", section on 'Stem cell therapy' and
"Investigational therapies for treating symptoms of lower extremity peripheral artery disease", section on
'Therapeutic angiogenesis'.)
MECHANICAL OFFLOADING
All ulcers subjected to sustained or frequent pressure and stress (ie, pressure-related heel ulcers or
medial/lateral foot ulcers) or repetitive moderate pressure (plantar foot ulcers) benefit from pressure reduction,
which is accomplished with mechanical offloading. Offloading devices include total contact casts, cast walkers,
shoe modifications, and other devices to assist in ambulation [106]. Although nonremovable pressure-relieving

treatments improve healing, in clinical practice, the type of offloading that is used depends largely on local
resources such as whether there is a surgeon who is skilled at contact casting, or a practitioner (eg, podiatrist)
who can fit the patient with customized footwear. In the absence of such expertise, a removable cast walker
may be the best option.
Evidence from randomized trials supports the use of total contact casts and nonremovable cast walkers for
relief of pressure to improve healing of diabetic foot ulcers. A 2013 Cochrane review evaluated 14 trials
comparing various forms of pressure-relieving treatments (nonremovable, removable) and dressings [107,108].
In five trials, the likelihood of wound healing was significantly better at 12 weeks for nonremovable, pressure-
relieving casts compared with removable devices or dressings (relative risk [RR] 1.17, 95% CI 1.01-1.36). In one
trial, no significant differences were found between different types of nonremovable pressure-relieving
treatments.
Total contact cast — A total contact cast is a padded fiberglass or plaster shell designed to take pressure off
the heel or elsewhere on the foot by averaging the pressure across the sole of the foot (ie, eliminates high- and
low-pressure regions by providing contact at all points) or to generally unweight the entire foot through a total
contact fit at the calf. Disadvantages of total contact casting include expertise needed in applying the cast,
inability to inspect the foot frequently, inconvenience in activities of daily living (eg, bathing), and the risk of
developing a secondary ulcer in an ill-fitting cast (particularly in patients with neuropathy) [21]. Frequent cast
changes may be needed to avoid complications. Total contact casts should not be used in patients with infected
ulcers or wounds, osteomyelitis, peripheral ischemia (ankle-brachial index <0.6), bilateral ulceration, lower
extremity amputation, or heel ulceration [109].
Based upon randomized trials, total contact casting enhances diabetic ulcer healing and is the standard for
relieving pressure from the forefoot [107,108,110-116]. As an example, in a trial of offloading modalities in 63
diabetic patients with superficial, noninfected, nonischemic plantar ulcers, the proportion of ulcers that were
healed at 12 weeks was significantly higher in those randomly assigned to a total contact cast compared with a
half-shoe or removable cast walker (90 versus 58 and 65 percent, respectively) [112]. Patients with a total
contact cast also had faster healing. Another small trial found that, compared with the casting alone, casting
combined with Achilles tendon lengthening resulted in significantly fewer ulcer recurrences at seven months
(15 versus 59 percent) and at two years (38 versus 81 percent) [117].
Cast walkers — An alternative to total contact casting is a prefabricated brace called a cast walker that is
designed to maintain a total contact fit ( figure 2). Several cast walkers (nonremovable, removable) are
commercially available and provide the capability to offload the foot similar to contact casts. A significant
disadvantage of the cast walker is poor patient compliance if the cast walker is removed [118].
Prefabricated products are at least as good as total contact casting for offloading the foot and equalizing foot
pressures when the foot anatomy is normal, as illustrated in the studies below, but data are not available
demonstrating these effects for patients with diabetic foot deformities.
● One study compared plantar foot pressure metrics in a standard shoe, total contact cast, and cast walker
(pneumatic) [119]. Five plantar foot sensors were placed at the first, third, and fifth metatarsal heads, fifth
metatarsal base, and midplantar heel of 10 healthy male subjects who walked at a constant speed over a
distance of 280 meters. Peak pressures were significantly reduced in the pneumatic walker compared with

the standard shoe for all sensor locations to an equal or greater degree compared with the total contact
cast in all sensor locations.
● Another study measured foot pressures using an in-shoe pressure measurement system (Novel Pedar) in
18 healthy subjects while wearing a cast walker or total contact cast [120]. Peak foot pressures using the
cast walker were significantly reduced in the forefoot (12 versus 18 newtons [N]/cm2) and foot as a whole
(14 versus 19 N/cm2) compared with a fiberglass total contact cast, but no differences were found for the
heel or midfoot.
Cast walkers have been used for the treatment of neuropathic plantar ulcers, but these devices, thus far, have
not been found to be superior to total contact casting in randomized trials. In one trial, the rate of ulcer healing
was significantly higher in those randomly assigned to total contact casting compared with a half-shoe or
removable cast walker [112]. Another trial that randomly assigned 48 patients to total contact casting or a
removable cast walker (ie, Stabil-D) found no difference in the number of days to achieve healing (35 versus 39
days) [121].
Therapeutic shoes — After healing of the ulcer is achieved, prescriptive shoes with orthotic inserts are often
prescribed to prevent recurrent ulceration [107]. In one trial, 400 diabetic patients with a history of foot ulcer
were randomly assigned to wear therapeutic shoes or their usual footwear for two years [122]. The risk of
reulceration was not found to be different between the groups. It should be noted, however, that this study
consisted of, generally, relatively minor ulcers. Furthermore, over one-half of the patients did not have
peripheral neuropathy. A subsequent study of prescriptive shoes with customized insoles based on pressure
analysis showed a significant reduction in risk for reulceration [123,124].
Nonprescription rocker sole shoes ( figure 3) may also offload the foot [125,126]. In a nonrandomized
prospective study of 92 patients with healed diabetic foot ulcers, the first-year annual rate of foot ulcer relapse
was significantly lower in patients who used stock diabetic shoes (rocker sole) compared with those who wore
their usual footwear (15 versus 60 percent) [126]. In the United States, reimbursement from insurance carriers
can be expected for one pair of shoes and three pairs of shoe inserts, provided the design of the shoe/insert
meets qualifying guidelines.
Wedge shoes (eg, Darco International), also called half shoes, are available as forefoot and heel wedge shoes to
offload the forefoot and heel, respectively ( figure 4). These shoes may be useful under certain circumstances.
For example, plantar heel ulcers are particularly difficult to heal because of an inability to adequately offload
this region; the heel wedge shoe can be useful to achieve this goal.
The disadvantage of wedge shoes is that most patients, especially older adult patients or those with
proprioception abnormalities, may not be able to maintain their balance, and some patients find walking in
them difficult, if not impossible.
Knee walkers — Knee walkers are ambulatory assist devices that may be indicated for anyone with a lower
extremity issue where weight bearing needs to be avoided ( figure 5). These devices are becoming more
popular in the treatment of diabetic ulcer as a means to offload the foot. There are no trials evaluating the
effectiveness of knee walkers in healing diabetic foot ulcers.
MANAGING INFECTION
https://www.uptodate.com/contents/management-of-diabetic-foot-ulcers/print?search=arterial ulcer&source=search_result&selectedTitle=7~129&us… 10/40
The diagnosis of infection is clinical and is generally obvious when an ulcer contains purulent material or there
is redness, swelling, or warmth around the ulcer. Treatment is based upon the clinical stages of infection [19].
Osteomyelitis is likely if bone can be seen at the floor of a deep ulcer, or if it can be easily detected by probing
the ulcer with a sterile, blunt stainless-steel probe (wound grade/stage: 2B, 3B). Radiologic tests may be useful if
the diagnosis of osteomyelitis remains uncertain. (See "Clinical manifestations, diagnosis, and management of
diabetic infections of the lower extremities", section on 'Clinical manifestations' and "Clinical manifestations,
diagnosis, and management of diabetic infections of the lower extremities", section on 'Diagnosis'.)
Tissue samples for culture and sensitivity should be obtained by wound curettage, rather than wound swab or
irrigation, because they provide more accurate results [127]. Ideally, tissue for culture should be obtained after
debridement but prior to initiation of empiric antibiotic therapy. However, at times this may not be practical.
The most common infecting organisms in Western nations include aerobic gram-positive cocci. Other frequent
pathogens are aerobic gram-negative bacilli and anaerobes, usually as a second organism [19,128]. Empiric
antimicrobial therapy should be selected based upon the severity of infection and the likelihood of resistant
organisms. Subsequent antibiotic therapy should be tailored to the results of wound culture and susceptibility.
It is not always necessary to cover all microorganisms isolated from cultures. The duration of treatment
depends on the severity of infection and the presence of underlying or residual osteomyelitis. (See "Clinical
manifestations, diagnosis, and management of diabetic infections of the lower extremities", section on 'Empiric
therapy' and "Clinical manifestations, diagnosis, and management of diabetic infections of the lower
extremities", section on 'Duration of therapy'.)
ISCHEMIA AND REVASCULARIZATION
Assessment of the adequacy of the circulation is an important component of the evaluation of all ulcers or
postsurgical wounds, particularly those in patients with diabetes. Symptoms of claudication or extremity pain at
rest, and physical findings of diminished or absent pulses, cool temperature, pallor on elevation, or dependent
rubor should raise suspicion about the presence of peripheral artery disease. (See "Clinical features and
diagnosis of lower extremity peripheral artery disease" and "Overview of peripheral artery disease in patients
with diabetes mellitus".)
Noninvasive vascular studies (ie, ankle-brachial index, toe waveforms and pressures, pulse volume recordings)
should be obtained to confirm the diagnosis. The ankle-brachial index is a measurement of the ratio of blood
pressure at the ankle to that in the brachial artery that correlates with the presence and severity of arterial
occlusive disease [129]. In patients with diabetes, the blood vessels may be incompressible and ankle-brachial
index values misleading. Segmental volume plethysmography and toe-brachial index values are more reliable
for determining the severity of disease. The noninvasive diagnosis of lower extremity peripheral artery disease
is reviewed in detail elsewhere. (See "Noninvasive diagnosis of arterial disease", section on 'Ankle-brachial index'
and "Noninvasive diagnosis of arterial disease", section on 'Toe-brachial index'.)
Revascularization plays an important role in the management of diabetic foot ulcers in patients with
documented peripheral artery disease (to avoid the need for amputation) [21]. When achievable,
revascularization is associated with a lower incidence of amputation in patients with a diabetic foot ulcer and
severe limb ischemia. As an example, in a longitudinal study of 564 patients, angioplasty or bypass grafting was
performed in 75 and 21 percent, respectively [130]. Neither procedure was possible in the remaining 5 percent.
The amputation rates were 8.2, 21.2, and 59.2 percent among patients who underwent angioplasty, bypass, or
no revascularization. (See "Overview of peripheral artery disease in patients with diabetes mellitus".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the world
are provided separately. (See "Society guideline links: Diabetes mellitus in adults" and "Society guideline links:
Chronic wound management".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics
patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the
four or five key questions a patient might have about a given condition. These articles are best for patients who
want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education
pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade
reading level and are best for patients who want in-depth information and are comfortable with some medical
jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
"patient info" and the keyword(s) of interest.)
● Beyond the Basics topics (see "Patient education: Type 1 diabetes: Overview (Beyond the Basics)" and
"Patient education: Type 2 diabetes: Overview (Beyond the Basics)" and "Patient education: Foot care for
people with diabetes (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
● The treatment of diabetic foot ulcers begins with a comprehensive assessment of the ulcer and the
patient's overall medical condition. Evidence of underlying neuropathy, bony deformity, and peripheral
artery disease should be actively sought. The ulcer is classified upon initial presentation and with each
follow-up visit using a standardized system to document the examination and treatment plan, and to follow
the progress of healing. (See 'Introduction' above and 'Ulcer classification' above.)
● Adequate debridement, proper local wound care (debridement and dressings), redistribution of pressure
on the ulcer by mechanical offloading, and control of infection and ischemia (when present) are important
components of treatment for all ulcers, regardless of stage and depth. (See 'Management overview' above.)
● For most patients with diabetic foot ulcers, we suggest surgical (sharp) debridement rather than another
method (Grade 2C). If a surgeon with clinical expertise in sharp debridement is not available, we suggest
autolytic debridement with hydrogels (Grade 2C). Alternatively, the patient can be referred to a facility with
appropriate surgical expertise in the management of diabetic foot problems. Dressings are selected based
upon ulcer or postsurgical wound characteristics. (See 'Debridement' above and 'Dressings' above.)

● For managing extensive open wounds following debridement for infection or necrosis, or partial foot
amputation, we suggest negative pressure wound therapy (Grade 2A). All necrotic tissue or infected bone
(osteomyelitis) first must be removed from the wound. (See 'Negative pressure wound therapy' above and
"Negative pressure wound therapy", section on 'Contraindications'.)
● Several methods are available to achieve mechanical offloading and include total contact casts, cast
walkers, wedge shoes, and bedrest. The type of offloading that is used depends largely on local expertise.
(See 'Mechanical offloading' above.)
● For patients who present with a diabetic foot ulcer and severe limb ischemia, we recommend early
revascularization (Grade 1B). Revascularization should also be performed in patients with a nonhealing
ulcer and any degree of limb ischemia. (See 'Allowable time course for primary healing' above and
'Ischemia and revascularization' above.)
● Once a patient has healed an ulcer, he or she remains at a very high risk for reulceration. Therefore, people
with healed ulcers should be considered "in remission," a term that better communicates the lifetime of
visits (often bimonthly) needed to reduce the risk of recurrence. The goals of long-term surveillance and
care are to maximize ulcer-free, hospital-free, and activity-rich days. (See 'Follow-up care and ulcer
prevention' above.)
ACKNOWLEDGMENT
The editorial staff at UpToDate would like to acknowledge David K McCulloch, MD, who contributed to an earlier
version of this topic review.
Use of UpToDate is subject to the Subscription and License Agreement.
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patients with active ulceration may not adhere to a standard pressure off-loading regimen. Diabetes Care
2003; 26:2595.
119. Baumhauer JF, Wervey R, McWilliams J, et al. A comparison study of plantar foot pressure in a standardized
shoe, total contact cast, and prefabricated pneumatic walking brace. Foot Ankle Int 1997; 18:26.
120. Pollo FE, Brodsky JW, Crenshaw SJ, Kirksey C. Plantar pressures in fiberglass total contact casts vs. a new
diabetic walking boot. Foot Ankle Int 2003; 24:45.
121. Faglia E, Caravaggi C, Clerici G, et al. Effectiveness of removable walker cast versus nonremovable
fiberglass off-bearing cast in the healing of diabetic plantar foot ulcer: a randomized controlled trial.
Diabetes Care 2010; 33:1419.
122. Reiber GE, Smith DG, Wallace C, et al. Effect of therapeutic footwear on foot reulceration in patients with
diabetes: a randomized controlled trial. JAMA 2002; 287:2552.
123. Ulbrecht JS, Hurley T, Mauger DT, Cavanagh PR. Prevention of recurrent foot ulcers with plantar pressure-
based in-shoe orthoses: the CareFUL prevention multicenter randomized controlled trial. Diabetes Care
2014; 37:1982.
124. IWGDF Guidance on footwear and offloading interventions to prevent and heal foot ulcers in patients with
diabetes. http://iwgdf.org/guidelines/guidance-on-footwear-and-offloading-2015/ (Accessed on July 14, 20
15).
125. Brown D, Wertsch JJ, Harris GF, et al. Effect of rocker soles on plantar pressures. Arch Phys Med Rehabil
2004; 85:81.
126. Busch K, Chantelau E. Effectiveness of a new brand of stock 'diabetic' shoes to protect against diabetic foot
ulcer relapse. A prospective cohort study. Diabet Med 2003; 20:665.
127. Lipsky BA. Medical treatment of diabetic foot infections. Clin Infect Dis 2004; 39 Suppl 2:S104.
128. Lipsky BA, Pecoraro RE, Larson SA, et al. Outpatient management of uncomplicated lower-extremity
infections in diabetic patients. Arch Intern Med 1990; 150:790.
129. Fowkes FG. The measurement of atherosclerotic peripheral arterial disease in epidemiological surveys. Int
J Epidemiol 1988; 17:248.
130. Faglia E, Clerici G, Clerissi J, et al. Long-term prognosis of diabetic patients with critical limb ischemia: a
population-based cohort study. Diabetes Care 2009; 32:822.
Topic 8175 Version 42.0

GRAPHICS
Superficial diabetic foot ulcer
Foot from a diabetic patient showing a superficial ulcer that involves a partial thickness
of the skin but no involvement of the underlying tissues. This lesion healed quickly
with rest and local foot care.
Courtesy of David McCulloch, MD.
Graphic 70998 Version 3.0

Full thickness diabetic foot ulcer
Foot from a diabetic patient with a penetrating neuropathic ulcer that is not associated
with abscess formation or bone involvement.
The toes have begun to claw (ie, extension deformity at the metatarsal phalangeal
joint and flexion deformity at the proximal interphalangeal joint) because the pull of
the extensor digitorum longus, an extrinsic muscle in the anterior compartment of the
leg, overpowers the neuropathy-induced weakness of the intrinsic foot muscles. The
proximal phalanges will eventually sublux, or even dislocate, dorsally. As the
deformities progress, the metatarsal fat pad will migrate distally and the toes will lose
the ability to effectively plantarflex and offload the metatarsal heads. The combined
effect increases pressure under the metatarsal heads, predisposing to ulcer formation.

Dorsal diabetic foot wound
Dorsal diabetic foot wound following debridement of necrotizing streptococcal infection with exposed
tendon and joint capsule.

Plantar neuropathic diabetic foot wound
Plantar neuropathic diabetic foot wound following deroofing of bulla with exposed
tendon.

Deep diabetic foot ulcer involving bone
The patient presented with a fluctuant eschar on the plantar surface of the foot. The
abscess was unroofed and drained and, following debridement, exposed bone was
apparent at the base of the wound.
Courtesy of Paul Thottingal, MD.

Infected and ischemic diabetic foot ulcer
Foot from a diabetic patient with an ulcer that extends to the deep layers with signs of
local infection, cellulitis, and necrosis. This lesion healed completely after a hospital
stay involving excision of necrotic tissue but no amputation.

Pathophysiologic assessment in chronic foot ulcers
The conceptual diagram illustrates the interaction between the main factors that contribute to tissue loss. This scheme is
appropriate for any patient with a chronic wound/tissue loss. The clinician should ask, "Which factor or combination of
factors contributes the most to the pathophysiology of the wound? Ischemia? Infection? Wound extent?" Early assessment
helps determine initial wound management priorities, but frequent reassessment is important since the wound
environment is dynamic, and the balance toward one or another factor can change.
Adapted from:
1. Armstrong DG, Mills JL. Juggling risk to reduce amputations: The three-ring circus of infection, ischemia and tissue loss-dominant
conditions. Wound Medicine 2013; 1:13.
2. Zhan LX, Branco BC, Armstrong DG, et al. The Society for Vascular Surgery lower extremity threatened limb classification system
based on Wound, Ischemia, and foot Infection (WIfI) correlates with risk of major amputation and time to wound healing. Journal
of Vascular Surgery 2015; 61:939.
3. Mills JL Sr, Conte MS, Armstrong DG, et al. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System:
risk stratification based on wound, ischemia, and foot infection (WIfI). Journal of Vascular Surgery 2014; 59:220.

Management of diabetic foot wounds

SVS: Society for Vascular Surgery; WIfI: Wound, Ischemia, and foot Infection; ABI: ankle-brachial index; I&D: incision and drainage; MRI: magnetic resonance imaging;
MRSA: methicillin-resistant Staphylococcus aureus.
* Signs of severe infection include severe cellulitis, fever, hemodynamic instability, and purulent drainage.
¶ Plain foot radiographs may demonstrate gas in the tissues, osteomyelitis, or the presence of a foreign body. Other foot imaging (eg, MRI) may be needed to
identify fluid collections or osteomyelitis not detected on physical exam.
Δ Severe ischemia is manifest on clinical examination as severely diminished or absent pedal pulses, dependent rubor, ABI <0.40, or toe pressure <30 mmHg.
Vascular imaging is warranted for those with obvious limb ischemia. Tissue loss can manifest as ischemic ulceration or as wet or dry gangrene. Patients with stable,
dry gangrene do not require immediate debridement; vascular imaging and revascularization are preferentially performed before debridement.
◊ For severe infections, broad-spectrum antimicrobial therapy should be initiated and adjusted depending upon the results of tissue culture and sensitivity. For mild-
to-moderate infection, antimicrobial therapy should target aerobic gram-positive cocci. For patients with a prior history of MRSA infection or when the local
prevalence of MRSA colonization or infection is high, empiric therapy should also be directed against MRSA. The duration of antimicrobial therapy depends upon the
severity of infection and organism. Residual infected bone following debridement of necrotic bone may require four to six weeks of treatment or longer.
§ All ulcers subjected to excessive pressure benefit from pressure reduction, which is accomplished with mechanical offloading. Foot deformities include hammertoe,
bunion, rocker bottom deformity, and Charcot arthropathy. Optimizing foot biomechanics may include Achilles tendon or gastrocnemius tendon lengthening or
tendon transfer procedures, among others.
¥ Some patients with mild ischemia may also require revascularization to achieve wound healing.
References:
1. Mills JL, Conte MS, Armstrong DG, et al. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound,
ischemia, and foot infection (WIfI). J Vasc Surg 2014; 59:220.
2. Hingorani A, LaMuraglia GM, Henke P, et al. The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the
American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg 2016; 63:3S.
3. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot
infections. Clin Infect Dis 2012; 54:e132.

Properties of topical agents and dressing materials
Type Actions Indications/use Precautions/contraindications
Alginates/CMC* Absorb fluid. Moderate to high exuding wounds. Do not use on dry/necrotic wounds.
Promote autolytic debridement. Special cavity presentations in the Use with caution on friable tissue
Moisture control. form of rope or ribbon. (may cause bleeding).
Conformability to wound bed. Combined presentation with silver for Do not pack cavity wounds tightly.
antimicrobial activity.
Foams Absorb fluid. Moderate to high exuding wounds. Do not use on dry/necrotic wounds
Moisture control. Special cavity presentations in the or those with minimal exudate.
Conformability to wound bed. form of strips or ribbon.
Low-adherent versions available for
patients with fragile skin.
Combined presentation with silver or
PHMB for antimicrobial activity.
Honey Rehydrate wound bed. Sloughy, low to moderate exuding May cause "drawing" pain (osmotic
Promote autolytic debridement. wounds. effect).
Antimicrobial action. Critically colonized wounds or clinical Known sensitivity.
signs of infection.
Hydrocolloids Absorb fluid. Clean, low to moderate exuding Do not use on dry/necrotic wounds
Promote autolytic debridement. wounds. or high exuding wounds.
Combined presentation with silver for May encourage overgranulation.
antimicrobial activity. May cause maceration.
Hydrogels Rehydrate wound bed. Dry/low to moderate exuding Do not use on highly exuding
Moisture control. wounds. wounds or where anaerobic infection
Promote autolytic debridement. Combined presentation with silver for is suspected.
Cooling. antimicrobial activity. May cause maceration.
Iodine Antimicrobial action. Critically colonized wounds or clinical Do not use on dry necrotic tissue.
signs of infection. Known sensitivity to iodine.
Low to high exuding wounds. Short-term use recommended (risk of
systemic absorption).
Low-adherent wound Protect new tissue growth. Low to high exuding wounds. May dry out if left in place for too
contact layer (silicone) Atraumatic to periwound skin. Use as contact layer on superficial long.
Conformable to body contours. low exuding wounds. Known sensitivity to silicone.
PHMB Antimicrobial action. Low to high exuding wounds. Do not use on dry/necrotic wounds.
Critically colonized wounds or clinical Known sensitivity.
signs of infection.
May require secondary dressing.
Odor control (eg, Odor absorption. Malodorous wounds (due to excess Do not use on dry wounds.
activated charcoal) exudate).
May require antimicrobial if due to
increased bioburden.
Protease modulating Active or passive control of wound Clean wounds that are not Do not use on dry wounds or those
protease levels. progressing despite correction of with leathery eschar.
underlying causes, exclusion of
infection, and optimal wound care.
Silver Antimicrobial action. Critically colonized wounds or clinical Some may cause discoloration.
signs of infection. Known sensitivity.
Low to high exuding wounds. Discontinue after 2 weeks if no
Combined presentation with foam improvement and reevaluate.
and alginates/CMC for increased
absorbency. Also in paste form.
Polyurethane film Moisture control. Primary dressing over superficial low Do not use on patients with
Breathable bacterial barrier. exuding wounds. fragile/compromised periwound skin.
Transparent (allow visualization of Secondary dressing over alginate or Do not use on moderate to high
wound). hydrogel for rehydration of wound exuding wounds.
bed.

Other more advanced dressings (eg, collagen and bioengineered tissue products) may be considered for wounds that are hard to heal [1].
CMC: carboxymethylcellulose; PHMB: polyhexamethylene biguanide.

* Wound dressings may contain alginates or CMC only; alginates may also be combined with CMC.
Reference:
1. International Consensus. Acellular matrices for the treatment of wounds. An expert working group review. Wounds International 2010. Available at
http://woundsinternational.com (Accessed on March 2013).
Reproduced with permission from: McCardle J, Chadwick P, Edmonds M, et al. International Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers.
Wounds International, 2013. Copyright © 2013 Schofield Healthcare Media LTD. Available from: www.woundsinternational.com.

Wound management dressing guide
Treatment options
Type of tissue in
Therapeutic goal Role of dressing Wound bed
the wound Primary dressing Secondary dressing
preparation
Necrotic, black, dry Remove devitalized Hydration of Surgical or Hydrogel Polyurethane film
tissue wound bed mechanical Honey dressing
Do not attempt Promote autolytic debridement
debridement if debridement
vascular
insufficiency
suspected
Keep dry and refer
for vascular
assessment
Sloughy, yellow, Remove slough Rehydrate wound Surgical or Hydrogel Polyurethane film
brown, black or Provide clean bed mechanical Honey dressing
grey wound bed for Control moisture debridement if Low adherent
Dry to low exudate granulation tissue balance appropriate (silicone) dressing
Promote autolytic Wound cleansing
debridement (consider antiseptic
wound cleansing
solution)
Sloughy, yellow, Remove slough Absorb excess fluid Surgical or Absorbent dressing Retention bandage
brown, black or Provide clean Protect periwound mechanical (alginate/CMC/foam) or polyurethane
grey wound bed for skin to prevent debridement if For deep wounds, film dressing
Moderate to high granulation tissue maceration appropriate use cavity strips, rope
exudate Exudate Promote autolytic Wound cleansing or ribbon versions
management debridement (consider antiseptic
wound cleansing
solution)
Consider barrier
products
Granulating, clean, Promote Maintain moisture Wound cleansing Hydrogel Pad and/or
red granulation balance Low adherent retention bandage
Dry to low exudate Provide healthy Protect new tissue (silicone) dressing Avoid bandages
wound bed for growth For deep wounds use that may cause
epithelialization cavity strips, rope or occlusion and
ribbon versions maceration
Tapes should be
Granulating, clean, Exudate Maintain moisture Wound cleansing Absorbent dressing used with caution
red management balance Consider barrier (alginate/CMC/foam) due to allergy
Moderate to high Provide healthy Protect new tissue products Low adherent potential and
exudate wound bed for growth (silicone) dressing secondary
epithelialization For deep wounds, complications
use cavity strips, rope
or ribbon versions
Epithelializing, red, Promote Protect new tissue Hydrocolloid (thin)

pink epithelialization growth Polyurethane film
No to low exudate and wound dressing
maturation Low adherent
(contraction) (silicone) dressing
Infected Reduce bacterial Antimicrobial Wound cleansing Antimicrobial

Low to high load action (consider antiseptic dressing
exudate Exudate Moist wound wound cleansing
management healing solution)
Odor control Odor absorption Consider barrier
products
The purpose of this table is to provide guidance about appropriate dressings and should be used in conjunction with clinical judgement and local
protocols. Where wounds contain mixed tissue types, it is important to consider the predominant factors affecting healing and address accordingly.
Where infection is suspected, it is important to regularly inspect the wound and to change the dressing frequently. Wound dressings should be used
in combination with appropriate wound bed preparation, systemic antibiotic therapy, pressure offloading, and diabetic control.

CMC: carboxymethyl cellulose.
Reproduced with permission from: McCardle J, Chadwick P, Edmonds M, et al. International Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers. Wounds
International, 2013. Copyright © 2013 Schofield Healthcare Media LTD. Available from: www.woundsinternational.com.

Categories of risk for foot complications
Treatment
Risk category Definition Suggested follow-up
recommendations
0 No LOPS, no PAD, no deformity Patient education including Annually (by generalist and/or
advice on appropriate footwear. specialist)
1 LOPS ± deformity Consider prescriptive or Every three to six months (by

accommodative footwear. generalist or specialist)
Consider prophylactic surgery if
deformity is not able to be safely
accommodated in shoes.
Continue patient education.
2 PAD ± LOPS Consider prescriptive or Every two to three months (by

accommodative footwear. specialist)
Consider vascular consultation
for combined follow-up.
3 History of ulcer or amputation Same as category 1. Every one to two months (by
Consider vascular consultation specialist)
for combined follow-up if PAD
present.
LOPS: loss of protective sensation; PAD: peripheral artery disease.
From: Boulton AJM, Armstrong DG, Albert SF, et al. Comprehensive foot examination and risk assessment. Diabetes Care 2008; 31:1679. American Diabetes Association,
Diabetes Care. American Diabetes Association, 2008. Copyright and all rights reserved. Material from this publication has been used with the permission of American
Diabetes Association.

Removable cast walker

Rocker sole shoe

Wedge shoes

Knee walker

Contributor Disclosures
David G Armstrong, DPM, MD, PhD Nothing to disclose Richard J de Asla, MD Equity Ownership/Stock Options: Pfizer
[Foot and ankle surgery (Antibiotics, topical wound care products)]. Consultant/Advisory Boards: Arthrex [Foot and ankle
surgery (Foot and ankle implants and instruments)]. John F Eidt, MD Grant/Research/Clinical Trial Support: Syntactx [Clinical
events, data/safety monitoring for medical device trials]. Joseph L Mills, Sr, MD Equity Ownership/Stock Options: NangioTx
[Peripheral artery disease (Self-assembling nanotubules)]. Grant/Research/Clinical Trial Support: Voyager Trial [Peripheral
artery disease (Rivoxaraban)]. Other Financial Interest: Elsevier. David M Nathan, MD Grant/Research/Clinical Trial Support:
Abbott [Diabetes]. Kathryn A Collins, MD, PhD, FACS Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by
vetting through a multi-level review process, and through requirements for references to be provided to support the
content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

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Official reprint from UpToDate®

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● Grade 0: Pre- or postulcerative (Stages A to D) ( picture 1)

● Grade 3: Probes to bone (Stages A to D) ( picture 5)

● Grade 1: Superficial ulcer – Skin and subcutaneous tissue only

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73. http://www.regranex.com/ (Accessed on October 07, 2010).

74. http://www.drugs.com/pro/regranex.html (Accessed on February 10, 2016).

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Topic 8175 Version 42.0

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Superficial diabetic foot ulcer

Courtesy of David McCulloch, MD.

Graphic 70998 Version 3.0

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Full thickness diabetic foot ulcer

Courtesy of David McCulloch, MD.

Graphic 51991 Version 4.0

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Dorsal diabetic foot wound

Graphic 87248 Version 1.0

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Plantar neuropathic diabetic foot wound

Graphic 87421 Version 1.0

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Deep diabetic foot ulcer involving bone

Courtesy of Paul Thottingal, MD.

Graphic 71315 Version 3.0

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Infected and ischemic diabetic foot ulcer

Courtesy of David McCulloch, MD.

Graphic 63780 Version 5.0

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Pathophysiologic assessment in chronic foot ulcers

Graphic 103041 Version 3.0

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