Diabetic foot ulcers: Part II. Management.

The management of diabetic foot ulcers can be optimized by using an interdisciplinary team approach addressing the correctable risk factors (ie, poor vascular supply, infection control and treatment, and plantar pressure redistribution) along with optimizing local wound care. Dermatologists can initiate diabetic foot care. The first step is recognizing that a loss of skin integrity (ie, a callus, blister, or ulcer) considerably increases the risk of preventable amputations. A holistic approach to wound assessment is required. Early detection and effective management of these ulcers can reduce complications, including preventable amputations and possible mortality.

[1]  W. Assendelft,et al.  Patient education for preventing diabetic foot ulceration. , 2014, The Cochrane database of systematic reviews.

[2]  D. Armstrong,et al.  Probe-to-Bone Test for Diagnosing Diabetic Foot Osteomyelitis , 2007, Diabetes Care.

[3]  M. Goldner,et al.  Hyperglycemia and glycosuria due to thiazide derivatives administered in diabetes mellitus. , 1960, The New England journal of medicine.

[4]  C. Attinger,et al.  Serial surgical debridement: A retrospective study on clinical outcomes in chronic lower extremity wounds , 2009, Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society.

[5]  M. Löndahl Hyperbaric oxygen therapy as adjunctive treatment of diabetic foot ulcers. , 2013, The Medical clinics of North America.

[6]  S. Stapley,et al.  Debridement of diabetic foot ulcers. , 2010, The Cochrane database of systematic reviews.

[7]  V. Jones,et al.  Topical treatment: which dressing to choose , 2000, Diabetes/metabolism research and reviews.

[8]  M. S. Kirkman,et al.  Comment on: American Diabetes Association. Standards of Medical Care in Diabetes—2011. Diabetes Care 2011;34(Suppl. 1):S11–S61 , 2011 .

[9]  D. Armstrong,et al.  An Update on Pharmacological Interventions for Diabetic Foot Ulcers , 2010, Foot & ankle specialist.

[10]  D. Armstrong,et al.  Executive summary: 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. , 2012, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[11]  D. Margolis,et al.  Hemoglobin A1c is a Predictor of Healing Rate In Diabetic Wounds , 2011, The Journal of investigative dermatology.

[12]  D. Armstrong,et al.  Off-loading the diabetic foot wound: a randomized clinical trial. , 2001, Diabetes care.

[13]  Michael J. Mueller,et al.  Therapeutic Footwear Can Reduce Plantar Pressures in Patients With Diabetes and Transmetatarsal Amputation , 1997, Diabetes Care.

[14]  T. Zgonis,et al.  Soft Tissue Reconstruction Pyramid in the Diabetic Foot , 2010, Foot & ankle specialist.

[15]  D. Armstrong,et al.  Diabetic Foot Infections: A Need for Innovative Assessments , 2010, The international journal of lower extremity wounds.

[16]  G. Gibbons,et al.  Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients. , 1995, JAMA.

[17]  A. Detsky,et al.  Does this patient with diabetes have osteomyelitis of the lower extremity? , 2008, JAMA.

[18]  R. Kirsner,et al.  Wound biofilms: Lessons learned from oral biofilms , 2013, Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society.

[19]  C. Attinger,et al.  A Review of Mechanical Adjuncts in Wound Healing: Hydrotherapy, Ultrasound, Negative Pressure Therapy, Hyperbaric Oxygen, and Electrostimulation , 2003, Annals of plastic surgery.

[20]  N. Safdar,et al.  Diagnostic accuracy of the physical examination and imaging tests for osteomyelitis underlying diabetic foot ulcers: meta-analysis. , 2008, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[21]  Neil R. Powe,et al.  Meta-Analysis: Glycosylated Hemoglobin and Cardiovascular Disease in Diabetes Mellitus , 2004, Annals of Internal Medicine.

[22]  H. Erbersdobler,et al.  Maillard reaction products: uptake, metabolic transit and selected parameters of biopotency and safety. , 2003, Forum of nutrition.

[23]  K. Woo,et al.  A cross-sectional validation study of using NERDS and STONEES to assess bacterial burden. , 2009, Ostomy/wound management.

[24]  D. Armstrong,et al.  The accuracy of the physical examination for the detection of lower extremity peripheral arterial disease. , 2010, The Canadian journal of cardiology.

[25]  T. Einarson,et al.  Management and Prevention of Diabetic Foot Ulcers and Infections , 2012, PharmacoEconomics.

[26]  B. Hodgkinson,et al.  A systematic review of topical skin care in aged care facilities. , 2007, Journal of clinical nursing.

[27]  R. Hoyt,et al.  Peripheral arterial disease in people with diabetes: response to consensus statement. , 2004, Diabetes care.

[28]  David G Armstrong,et al.  What are the most effective interventions in preventing diabetic foot ulcers? , 2008, International wound journal.

[29]  M. Cavallini Autologous fibroblasts to treat deep and complicated leg ulcers in diabetic patients , 2007, Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society.

[30]  J. Pankow,et al.  Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults. , 2010, The New England journal of medicine.

[31]  H. V. Waugh,et al.  Modeling the effects of treating diabetic wounds with engineered skin substitutes , 2007, Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society.

[32]  M. Carter,et al.  More Frequent Visits to Wound Care Clinics Result in Faster Times to Close Diabetic Foot and Venous Leg Ulcers , 2012, Advances in skin & wound care.

[33]  L. Uccioli,et al.  Autonomic Neuropathy Influences Great Toe Blood Pressure , 1994, Diabetes Care.

[34]  R. Snyder Controversies regarding vascular disease in the patient with diabetes: a review of the literature. , 2007, Ostomy/wound management.

[35]  David G Armstrong,et al.  2012 infectious diseases society of america clinical practice guideline for the diagnosis and treatment of diabetic foot infections. , 2013, Journal of the American Podiatric Medical Association.

[36]  S. Golder,et al.  Systematic review of methods to diagnose infection in foot ulcers in diabetes , 2006, Diabetic medicine : a journal of the British Diabetic Association.

[37]  S. Molin,et al.  The clinical impact of bacterial biofilms , 2011, International Journal of Oral Science.

[38]  D. Margolis,et al.  Lack of Effectiveness of Hyperbaric Oxygen Therapy for the Treatment of Diabetic Foot Ulcer and the Prevention of Amputation , 2013, Diabetes Care.

[39]  D. Armstrong,et al.  Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial , 2005, The Lancet.

[40]  W. Assendelft,et al.  Patient education for preventing diabetic foot ulceration (Review) , 2012 .

[41]  W. Jeffcoate,et al.  Specific guidelines for the treatment of diabetic foot infections 2011 , 2012, Diabetes/metabolism research and reviews.

[42]  B. Yuan,et al.  Diabetes‐impaired wound healing and altered macrophage activation: A possible pathophysiologic correlation , 2012, Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society.

[43]  J. Smiell,et al.  Efficacy and Safely of a Topical Gel Formulation of Recombinant Human Platelet-Derived Growth Factor-BB (Becaplermin) in Patients With Chronic Neuropathic Diabetic Ulcers: A phase III randomized placebo-controlled double-blind study , 1998, Diabetes Care.

[44]  Kirk E. Smith,et al.  Efficacy and mechanism of orthotic devices to unload metatarsal heads in people with diabetes and a history of plantar ulcers. , 2006, Physical therapy.

[45]  E. Ayello,et al.  The Edge Effect: Current Therapeutic Options to Advance the Wound Edge , 2007, Advances in skin & wound care.

[46]  R. Kirsner,et al.  The role of surgical debridement in healing of diabetic foot ulcers , 2010, Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society.

[47]  W. Kannel,et al.  Update on Some Epidemiologic Features of Intermittent Claudication: The Framingham Study , 1985, Journal of the American Geriatrics Society.

[48]  Eberhard O. Voit,et al.  A quantitative model of the generation of N∊-(carboxymethyl)lysine in the Maillard reaction between collagen and glucose , 2003 .

[49]  A. Davies,et al.  Chapter V: Diabetic foot. , 2011, European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery.

[50]  David G Armstrong,et al.  Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. , 2001, Diabetes care.

[51]  E. Ayello,et al.  Options for off-loading the diabetic foot. , 2000, Advances in skin & wound care.

[52]  Gerald F Harris,et al.  Effect of rocker soles on plantar pressures. , 2004, Archives of physical medicine and rehabilitation.

[53]  D. Armstrong,et al.  Improvement in healing with aggressive edema reduction after debridement of foot infection in persons with diabetes. , 2000, Archives of surgery.

[54]  David G Armstrong,et al.  Comparative effectiveness of mechanically and electrically powered negative pressure wound therapy devices: A multicenter randomized controlled trial , 2012, Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society.

[55]  C. Attinger,et al.  Amputation and ambulation in diabetic patients: Function is the goal , 2012, Diabetes/metabolism research and reviews.

[56]  R. Kirsner,et al.  New therapies for treatment of diabetic foot ulcers: a review of current clinical trials. , 2010, Surgical technology international.

[57]  Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial. , 2003 .

[58]  R. V. Deursen,et al.  The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review , 2008, Diabetes/metabolism research and reviews.

[59]  D. G. Armstrong,et al.  Wound Microbiology and Associated Approaches to Wound Management , 2001, Clinical Microbiology Reviews.

[60]  S. Daniels,et al.  Metabolic and Inflammatory Links to Depression in Youth With Diabetes , 2012, Diabetes Care.

[61]  Patrick J. Heagerty,et al.  Prediction of Diabetic Foot Ulcer Occurrence Using Commonly Available Clinical Information , 2006, Diabetes Care.

[62]  Z. Rancic,et al.  Long-Term Results of Vascular Graft and Artery Preserving Treatment With Negative Pressure Wound Therapy in Szilagyi Grade III Infections Justify a Paradigm Shift , 2011, Annals of surgery.

[63]  W. Marston,et al.  The efficacy and safety of Dermagraft in improving the healing of chronic diabetic foot ulcers: results of a prospective randomized trial. , 2003, Diabetes care.

[64]  Stephanie Wu,et al.  Risk assessment of the diabetic foot and wound , 2005, International wound journal.

[65]  Vincent Falanga,et al.  Wound healing and its impairment in the diabetic foot , 2005, The Lancet.

[66]  P. Kranke,et al.  Hyperbaric oxygen therapy for chronic wounds. , 2015, The Cochrane database of systematic reviews.

[67]  Benjamin A Lipsky,et al.  Diagnosing and treating diabetic foot infections , 2004, Diabetes/metabolism research and reviews.

[68]  A. Eskelinen,et al.  Lower limb amputations in Southern Finland in 2000 and trends up to 2001. , 2004, European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery.

[69]  J. McMurry,et al.  Wound healing with diabetes mellitus. Better glucose control for better wound healing in diabetes. , 1984, The Surgical clinics of North America.

[70]  G. Mulder,et al.  Treatment of nonhealing diabetic foot ulcers with a platelet‐derived growth factor gene‐activated matrix (GAM501): Results of a Phase 1/2 trial , 2009, Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society.

[71]  D. Armstrong,et al.  Diabetic lower extremity infection: influence of physical, psychological, and social factors. , 2005, Journal of diabetes and its complications.

[72]  A. Schor,et al.  Growth factors in the treatment of diabetic foot ulcers , 2003, The British journal of surgery.

[73]  S. Hwang,et al.  Selective plantar fascia release for nonhealing diabetic plantar ulcerations. , 2012, The Journal of bone and joint surgery. American volume.

[74]  Stephanie Wu,et al.  Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds: a randomized controlled trial. , 2005, Diabetes care.

[75]  D G Smith,et al.  A prospective study of risk factors for diabetic foot ulcer. The Seattle Diabetic Foot Study. , 1999, Diabetes care.

[76]  S. Siddique,et al.  Detection of atherosclerosis by ankle brachial index: evaluation of palpatory method versus ultrasound Doppler technique. , 2009, Journal of Ayub Medical College, Abbottabad : JAMC.

[77]  C. M. Agrawal,et al.  Preventing Diabetic Foot Ulcer Recurrence in High-Risk Patients , 2007, Diabetes Care.

[78]  L. Lavery,et al.  Total contact casts: pressure reduction at ulcer sites and the effect on the contralateral foot. , 1997, Archives of physical medicine and rehabilitation.

[79]  P. Gresele,et al.  Ankle-brachial index measured by palpation for the diagnosis of peripheral arterial disease. , 2008, Family practice.

[80]  David W Williams,et al.  A review of the scientific evidence for biofilms in wounds , 2012, Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society.

[81]  D. Steed,et al.  Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Diabetic Ulcer Study Group. , 1996, Journal of the American College of Surgeons.

[82]  Elizabeth A. Ayello,et al.  Wound Bed Preparation , 2011 .

[83]  Benjamin A Lipsky,et al.  Diagnosis and treatment of diabetic foot infections. , 2004, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[84]  R. Kirsner,et al.  Dynamic reciprocity in the wound microenvironment , 2011, Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society.

[85]  E. A. Nelson,et al.  A qualitative study to explore the impact of foot ulceration on health-related quality of life in patients with rheumatoid arthritis. , 2011, International journal of nursing studies.

[86]  L. Lavery,et al.  Increased Foot Pressures After Great Toe Amputation in Diabetes , 1995, Diabetes Care.

[87]  L. Lavery,et al.  Reducing Dynamic Foot Pressures in High-Risk Diabetic Subjects With Foot Ulcerations: A comparison of treatments , 1996, Diabetes Care.

[88]  Anthony Delitto,et al.  Total Contact Casting in Treatment of Diabetic Plantar Ulcers: Controlled Clinical Trial , 1989, Diabetes Care.

[89]  M. Hayter,et al.  The effectiveness of silver-releasing dressings in the management of non-healing chronic wounds: a meta-analysis. , 2009, Journal of clinical nursing.

[90]  P. Tugwell,et al.  Quality of life in patients with rheumatoid arthritis , 2012, PharmacoEconomics.

[91]  Pingsong Li,et al.  A prospective, randomized, controlled study of hyperbaric oxygen therapy: effects on healing and oxidative stress of ulcer tissue in patients with a diabetic foot ulcer. , 2013, Ostomy/wound management.

[92]  D. Armstrong,et al.  Amputation and reamputation of the diabetic foot. , 1997, Journal of the American Podiatric Medical Association.

[93]  E. Fuller,et al.  Reduction of peak pressure on the forefoot with a rigid rocker-bottom postoperative shoe. , 2001, Journal of the American Podiatric Medical Association.

[94]  David G Armstrong,et al.  Skin temperature monitoring reduces the risk for diabetic foot ulceration in high-risk patients. , 2007, The American journal of medicine.

[95]  R J Hinchliffe,et al.  Evidence-based management of PAD & the diabetic foot. , 2013, European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery.

[96]  B H Perry,et al.  Efficacy and safety of becaplermin (recombinant human platelet‐derived growth factor‐BB) in patients with nonhealing, lower extremity diabetic ulcers: a combined analysis of four randomized studies , 1999, Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society.

[97]  W. Jeffcoate,et al.  A systematic review of the effectiveness of interventions to enhance the healing of chronic ulcers of the foot in diabetes , 2008, Diabetes/metabolism research and reviews.

[98]  J. Louwerens,et al.  The influence of shoe design on plantar pressures in neuropathic feet. , 2003, Diabetes care.

[99]  D. Margolis,et al.  Effectiveness of platelet releasate for the treatment of diabetic neuropathic foot ulcers. , 2001, Diabetes care.

[100]  R. Sibbald,et al.  A Clinical Investigation into the Relationship between Increased Periwound Skin Temperature and Local Wound Infection in Patients with Chronic Leg Ulcers , 2010, Advances in skin & wound care.

[101]  Stephanie Wu,et al.  The Role of Activity, Adherence, and Off-Loading on the Healing of Diabetic Foot Wounds , 2006, Plastic and reconstructive surgery.

[102]  V. Basevi Standards of Medical Care in Diabetes—2010 , 2010, Diabetes Care.

[103]  Andrew Johnson,et al.  Guidelines for the treatment of diabetic ulcers , 2006, Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society.

[104]  R. Kirsner,et al.  Advanced biological therapies for diabetic foot ulcers. , 2010, Archives of dermatology.

[105]  K. Alagiakrishnan,et al.  Psychiatric disorders presenting in the elderly with type 2 diabetes mellitus. , 2012, The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry.

[106]  J. Giurini,et al.  Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week prospective trial. , 2003, Plastic and reconstructive surgery.

[107]  A. Mason,et al.  The quantitative swab culture and smear: A quick, simple method for determining the number of viable aerobic bacteria on open wounds. , 1976, The Journal of trauma.

[108]  Robert J Snyder,et al.  Consensus recommendations on advancing the standard of care for treating neuropathic foot ulcers in patients with diabetes. , 2010, Ostomy/wound management.

[109]  R. Griffiths,et al.  Water for wound cleansing. , 2012, The Cochrane database of systematic reviews.

[110]  T. F. van de Mortel,et al.  A path of perpetual resilience: Exploring the experience of a diabetes-related amputation through grounded theory , 2011, Contemporary nurse.

[111]  Benjamin A Lipsky Medical treatment of diabetic foot infections. , 2004, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[112]  K. Woo,et al.  A Randomized Controlled Trial to Evaluate an Antimicrobial Dressing with Silver Alginate Powder for the Management of Chronic Wounds Exhibiting Signs of Critical Colonization , 2012, Advances in skin & wound care.

[113]  M. Löndahl Hyperbaric Oxygen Therapy as Adjunctive Treatment for Diabetic Foot Ulcers , 2013, The international journal of lower extremity wounds.