Diabetic Foot Ulcers Prevention & treatment

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Risk of foot ulcerations in diabetic patients

A diabetic foot ulcer is a frequent complication of diabetes mellitus. 25% of diabetic patients will develop a DFU during their lifetime.(1) The risk of developing a diabetic foot ulcer increases with the time.

Unfortunately, the majority of foot and lower leg amputations are performed on patients with diabetes mellitus. The top priority in treating the diabetic foot syndrome is to avoid a major amputation. It is well known that 85% of amputations can be avoided with a holistic care plan.(4)

Diabetic patients are at risk from foot ulcerations due to both peripheral and autonomic neuropathy as well as macro- and microangiopathy. Peripheral neuropathy (sensory and motor) is the most frequent cause of foot ulceration. As many patients with sensory neuropathy suffer from altered or complete loss of sensation in the foot and leg, any cuts or trauma to the foot can go completely unnoticed for days or weeks. Motor neuropathy may prompt muscle weakness (muscle atrophy), causing foot deformities which subsequently can lead to an inappropriate weight redistribution. Tissue ischemia and necrosis may occur, causing ulcerations. Additionally, autonomic neuropathy can lead to decreased sweating due to denervation of dermal structures. This induces dry skin, causing fissures, which increase the risk of infection.

Diabetic angiopathy is another risk factor for developing diabetic foot ulcers and infections, as larger arteries calcification (macroangiopathy) and small arteries capillary basement membranes thicken (microangiopathy) this can lead to impaired microcirculation.

Holistic approach(6)

Successful diagnosis and treatment of patients with DFUs involves a holistic approach that includes:

  • Optimal diabetes control
  • Effective local wound care
  • Infection control
  • Pressure relieving strategies
  • Restoring pulsatile blood flow

There are many ways to classify diabetic foot lesions. Wagner’s classification is the most widely used grading system for lesions of the diabetic foot.

Sensibility tests

Different assessing methods are available to detect diabetic peripheral neuropathy:
  • Doppler(6)
  • Tuning fork
  • Monofilament(6)

Optimizing DFU Wound Management

Classification of ulcer (based on Wagner and University of Texas/ Armstrong)(9-11)

Classification of ulcer: 0 

Description:

Severely deformed foot at risk of ulceration

Treatment objective: 

Maintain skin integrity

Prevention and treatment:

Daily hygiene and hydratation:  

  • Linovera® (12) is indicated in the care of fragile and sensitive skin by increasing skin resistance and protecting it in the risk areas.
  • Askina® Heel® (12) is a non adhesive hydrocellular heel dressing. Askina® Heel protects the heel area from shear stresses and reduces pressure from external forces.

Correct or eliminate any underlying causes of DFU :

  • Non compliant with diet discipline
  • Achieve optimal diabetic control including glycaemic control, management of high blood pressure, hyperlipidaemia
  • Address physical traumas due to inadequate foot wear

Classification of ulcer:
1 - Non-infected 

Description:
  • Superficial ulcer, not involving tendon, capsule or bone
Wound treatment objective: 
  • Provide a clean wound bed for granulation tissue
Local wound treatment:

 

Classification of ulcer:
2 - Non-infected 

Description:
  • Superficial ulcer, not involving tendon, capsule or bone, with signs of infection 
Wound treatment objective: 
  • Remove slough/callus
  • Reduce bacterial load
  • Prevent/remove biofilm
  • Manage exudate/odor
Local wound treatment:

Classification of ulcer:
2 - Non-infected 

Description:
  • Superficial ulcer, not involving tendon, capsule or bone, with signs of infection 
Wound treatment objective: 
  • Remove slough/callus
  • Reduce bacterial load
  • Prevent/remove biofilm
  • Manage exudate/odor
Local wound treatment:

Classification of ulcer:
2 - Infected 

Description:

Deep ulcer with signs of infection 

Wound treatment objective: 
  • Remove slough/callus
  • Reduce bacterial load
  • Prevent/remove biofilm
  • Manage exudate/odor
Local wound treatment:

Classification of ulcer:
3 - Non-infected 

Description:
  • Deep ulcer penetrating to bone or joint 
Wound treatment objective:
  • Remove slough/callus
  • Provide clean wound bed for granulation tissue
  • Prevent/remove biofilm
  • Manage exudate
Local wound treatment:

Classification of ulcer:
3 - Infected 

Description:

  • Deep ulcer with evidence of osteomyelitis 

Wound treatment objective:

  • Remove slough
  • Reduce bacterial load
  • Prevent/remove biofilm
  • Manage exudate/odor

Local wound treatment:

* NOTE: As Grade III DFUs may involve exposed cartilage, special caution is advised. Some products (eg Prontosan®) are contraindicated for the use on hyaline cartilage. In all cases, a careful risk:benefit assessment should be performed.
Decisions on product use must lie with the attending physician and normal saline should be used instead of Prontosan® where indicated.

References:

(1) Singh N, Armstrong DA, Lipsky BA. Preventing foot ulcers in patients with diabetes.JAMA 2005;293:217-28

(2) K Markakis, F. L. Bowling, A. J. M. Boulton. The diabetic foot in 2015: an overview. Diabetes Metab Res Rev 2016; 32(Suppl. 1): 169–178. DOI: 10.1002/dmrr.2740

(3) HAS. Seances de prevention des lésions des pieds chez le patient diabétique, par le pedicurepodologue. Juillet 2007. http://www.has-sante.fr/portail/jcms/c_2860579/fr/evaluation-des-actesrealises- par-le-pedicure-podologue-pour-la-prevention-des-lesions-des-pieds-a-risque-de-grade-1-chez-le-patient-diabetique-actualisation-de-l-evaluation-conduite-en-2007

(4) Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care 1990; 13(5):513-21

(6) International Best Pratice Guidelines: Wound Management in Diabetic foot Ulcers. Wound International, 2013. Avalaible from: www.woundsinternational.com o herunder.

(7) Wounds UK. Best Pratice Statement: Ankle brachial pressure index (ABPI) in pratice. London : Wounds uk, 2019. Avalaibe to download from : www.wounds-uk.com

(8) From Complex to Closure : Diabetic Foot Ulcer Assessment and Management Copyright © 2018 WoundSource & Kestrel Health Information, Inc. All rights reserved. www.woundsource.com/practice-accelerator

(9) Wagner FW. The dysvascular foot: a system of diagnosis and treatment. Foot Ankle 1981; 2: 64-122.

(10) Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg 1996; 35: 528-31.

(11) Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care 1998; 21(5): 855-9.

(12) Instructions of use

Related documents:

Description Document Link
DFU Quick Guide Wounds International.pdf
pdf (582.9 KB)
DFU Best Practice Guidelines.pdf
pdf (3.2 MB)
DFU Poster
pdf (1004.8 KB)