By Lee C. Rogers, DPM

Note to the Reader: These articles summarize the "Consensus Recommendations on Advancing the Standard of Care for Treating Neuropathic Foot Ulcers in Patients with Diabetes," authored by Robert J. Snyder et al., published as a supplement to Ostomy Wound Management in April 2010.

Published as a supplement to the April 2010 issue of Ostomy Wound Management was a pivotal reference paper titled, "Consensus Recommendations on Advancing the Standard of Care for Treating Neuropathic Foot Ulcers in Patients with Diabetes."¹ The authors are a recognized group of leading experts in the field who convened the consensus panel.

The world's population with diabetes will increase from 171 million to 366 million by 2025.² In the U.S., there are an estimated 24 million people with diabetes. Up to 25% of those with diabetes will develop a foot ulcer in their lifetimes.³ That translates roughly to 1-2% of the diabetic patients per year.

Diabetic foot ulcers (DFU) and lower extremity amputations (LEA) are a costly problem. In 2007, it was estimated that $30 billion was spent for the care of those two conditions.⁴

The recommendations from the consensus panel are important because they help to update the standard of care based on a review of 111 studies. The recommendations are divided into three categories: Assessment, Treatment, Advanced Therapies.

In this issue we will look at recommendations for the treatment of diabetic foot ulcer.

Lengthened times of wound healing increase the risk of complications, such as infection, hospitalization, and amputation. Expeditious wound closure is the goal in the patient with a DFU.

Infection Treatment

Infection treatment and control is paramount. The Infectious Diseases Society of America (IDSA) classifies DFU as uninfected, mild, moderate, or severely infected.⁶  A patient with a mild infection can generally be treated as an outpatient with oral antibiotics. Moderate and severe infections usually require hospitalization and, many times surgery. Methicillin-resistant Staphylococcus Aureus is an ongoing problem in diabetic foot infections and sensitivity-directed antibiotics should be used.

Vascular Disease

Vascular disease needs to be managed if it interferes with wound healing. A vascular surgeon should evaluate these patients. If an open bypass is not possible, some patients may benefit from endovascular techniques. 

PressureRelief

Pressure relief from the wound is key . The consensus document has a complete table of various offloading modalities and recommendations for their use based on wound location. One must also consider wheel chair, crutches, rolling crutches, and bed rest. Surgical off-loading, such as an Achilles tendon lengthening to reduce peak plantar forefoot pressure, can also be effective.

Debridement

Most wounds require regular debridement. Surgical debridement, either in the clinic or OR, is the gold standard. The goal is to remove all non-viable tissue, undermining, tunneling, and peri-ulcerative callus. There is an abundance of wound dressing choices. Selection of the appropriate dressing depends on the amount of exudate, bioburden, and pain. Wet-to-dry dressing should not be used for debridement or treatment.