Diabetic Foot Ulcer Treatment: What Actually Works and When to Act Fast?

There is an association between diabetic peripheral neuropathy and the reduction in sensation in the feet that can prevent one from feeling blisters, cuts, pressure points, or even trauma, making it easy for an insignificant injury to become an ulcer. Neuropathy also causes foot biomechanical dysfunction with increased pressure in some parts.

Peripheral arterial disease is capable of causing reduced blood flow to the foot. If blood flow is compromised, then the foot wound will be receiving reduced amounts of oxygen and nutrients required for proper healing. Ischemia can therefore significantly complicate the process of foot wound healing.

Consistently high levels of blood glucose can interfere with some of the processes necessary for the healing of the wound, as well as increase the chances of infection. Control of blood glucose levels, however, remains an important aspect of treatment of foot ulcers in diabetes, but it does not constitute treatment of the foot ulcer itself.

The process of debridement helps get rid of any dead or unhealthy tissue and calluses, thus allowing wound assessment and wound healing.

Popular methods include:

• Sharp Debridement: using special tools such as a scalpel or a curette to remove non-viable tissue and calluses by a trained practitioner. Sharp debridement is a typical standard of care when applicable.
• Surgical Debridement: more thorough tissue removal, which is done in a surgical setting in case of significant necrosis, deep infections, and other indications for surgery.
• Autolytic Debridement: using dressings that promote the natural breakdown of non-viable tissue through the body’s enzymes. But according to current guidelines by IWGDF, autolytic debridement (a wound care method that use body’s own natural moisture and enzyme to break down and clear away damaged tissues) is not recommended over standard sharp debridement to improve the healing of diabetic foot ulcers.
• Enzymatic Debridement: use of some special enzymatic agents that could help break down devitalized tissues. Such agents are not typically used instead of standard sharp debridement.

What takes place at the clinic? 

The practitioner examines the wound for its size, depth, surrounding skin condition, drainage, signs of infection, sensation, and perfusion. When necessary, cleansing of the wound and callus tissue is performed, and removal of nonviable tissue takes place. The debridement rate is determined by the appearance of the wound and regrowth of the undesirable tissues.

Management of diabetic foot infection starts by understanding whether or not there is infection and, if there is one, its severity. If there is bacteria on the ulcer (or colonization of bacteria), it is not always the same as infection, and routine use of antibiotics for such ulcers should be avoided. According to IWGDF/IDSA guidelines, an infection should be diagnosed clinically based on signs of inflammation locally or systemically.

For mild or superficial infections, management will include wound debridement and cleansing together with the administration of appropriate oral antibiotics aimed at the potential pathogens. If infection is deep, extensive, or serious, it will require admission, surgical drainage or debridement, and initially parenteral (typically intravenous) antibiotics. The antibiotic regimen can then be tailored to the clinical response and culture results where appropriate.

Antibiotics should not be used to hasten healing of an uninfected ulcer. The 2023 IWGDF/IDSA guideline suggests 1-2 weeks of antibiotic use for soft-tissue diabetic foot infection.

Offloading reduces pressure and mechanical stress (body weight pressuring down and friction sliding sideways that can cause more damage to the healing tissues) from the ulcer to help the tissues in that area to heal. It is a key component in the treatment of diabetic foot ulcers, especially those located on the weight-bearing regions of the sole. 

A non-removable knee-high offloading device is the preferred intervention for a neuropathic plantar forefoot or midfoot ulcer according to the 2023 IWGDF guideline.

Total contact casting is a kind of non-removable knee-high offloading device. Other forms of offloading, like therapeutic footwear and removable offloading devices, can be done when a non-removable device cannot be done or tolerated.

Offloading may not always be followed due to the fact that an individual may walk normally, remove a removable offloading device frequently, or may not appreciate the significance of pressure applied to the wound. But reapplication of loads to an ulcer may work against all other wound management techniques. According to the IWGDF, offloading mechanical tissue stress is one of the most crucial interventions needed for the healing process.

The selected dressing must have the ability to protect the wound, handle exudates, and ensure proper moisture for wound healing without causing excess moisture injury to surrounding skin. This will depend on the wound size, depth, drainage, infection, surrounding skin, and how often the wound needs assessment.

It is important to note that no single type of dressing works well in all cases of diabetic foot ulcers. Current recommendations by IWGDF do not favor routine use of topical antiseptic or antimicrobial dressings just for promoting healing and silver dressings for healing ulcers.

These dressing change intervals are reasonable ranges rather than hard and fast rules. It may be necessary to replace the dressing at an earlier interval if it becomes saturated, contaminated, displaced, or otherwise clinically unsuitable.

In the case of NPWT, IWGDF currently recommends that its use should be considered in adjunct with post-operative wound care in diabetic foot ulcers but should not be used regularly for non-surgical diabetic foot ulcers.

In any case, dressings are just one component of diabetic foot ulcer treatment. Debridement, off-loading, infection management in cases of infection, circulation assessment, and appropriate management of diabetes are crucial elements in diabetic foot ulcers.

Treatment of diabetic foot ulcer wounds may require the use of dressings based on the quantity of fluid in the wound, condition of the wound, and condition of the surrounding skin. It is worth noting that no dressing has been identified as the best choice for treatment of diabetic foot ulcers.

Popular choices for dressing in India include:

• Foam Dressings: These dressings can be used to absorb excess amounts of fluids from the wound.
• Hydrocolloid Dressings: They can be used in certain wounds that have low to moderate drainage and that are not infected.
• Alginate or Gelling-Fiber Dressings: They are useful in absorbing excess amounts of fluid in the wounds.
• Silver-Containing Dressings: They are very common, and they should not be used for fast healing of the diabetic foot ulcers.

Dressings should not be chosen based on them being “advanced.”

The hyperbaric oxygen therapy involves the administration of oxygen under high pressure in a specific chamber. Hyperbaric oxygen therapy has been researched as an add-on to the existing treatment regimen, especially for those difficult-to-treat chronic or ischemic diabetic foot ulcers that fail to heal even when treated with the best of care.

There has been conflicting data from human trials about this add-on therapy. While early clinical trials indicated that there was a possible benefit to certain patients with hard-to-treat ulcers from this add-on, more recent trials did not show any added benefit. Consequently, the IWGDF does not recommend the use of HBOT for all diabetic foot ulcers.

Hyperbaric oxygen therapy is not supposed to be recommended as a treatment for diabetic foot infection as such. IWGDF/IDS infection guidelines do not recommend the use of hyperbaric oxygen as a treatment for diabetic foot infection.

These types of therapies have been evaluated in ulcers that fail to heal sufficiently using conventional treatment methods. They work by facilitating activities that promote wound healing, like tissue proliferation, development of new blood vessels, and generation of new tissues.

The available evidence does not make it necessary to classify these types of products as conventional treatment for all diabetic foot ulcers. The 2023 IWGDF wound healing guidelines indicated that there was not enough evidence to recommend several cellular products, growth factor therapy, and skin substitutes as part of conventional therapy.

These therapies are hence used in special circumstances, not as alternatives to debridement, offloading, infection treatment, vascular evaluation, and wound care.

The maintenance of blood glucose levels within the patient’s prescribed target level is essential in the management of diabetes with regard to wound healing. Persistently high blood glucose levels can affect immune functions and wound healing and may predispose one to infections.

There is no generally accepted target HbA1c level with regard to the healing of diabetic foot ulcers. HbA1c targets need to be individually tailored based on a number of considerations including age, type of diabetes, diabetes duration, medication, risk of hypoglycemia, renal function, and comorbidities.

The objective, therefore, should not be forcing the HbA1c levels to any particular figure simply because there is an existing ulcer. Rather, one needs to review the diabetes management program with the treating healthcare professional to ensure safe and consistent control of glucose levels in the presence of the ulcers.

MedicoExperts defines its combination therapy as an integration of advanced homeopathy and customized Ayurveda into a combined and individualized therapy program. The therapy program can be offered as a complementary modality in conjunction with conventional medical diabetic foot care.

It is essential to make a clear distinction between this therapy program and known treatments of diabetic foot ulcers. The current level of scientific evidence does not confirm the effectiveness of homeopathy or customized Ayurveda as therapeutic interventions for the healing of diabetic foot ulcers or preventing amputations. The therapy should not substitute for debridement, off-loading, antibiotic treatment (when clinically required), vascular assessment, and any other evidence-based treatments.

The safest approach for a patient considering complementary medicine would be discussing it with physicians treating the ulcer.

If you have a foot ulcer due to diabetes, inspect your foot as guided by your health care provider daily. Inspect for:

• Size of the Wound: Is it getting bigger, smaller, or remaining the same?
• Skin: Look out for the development of increased redness, swelling, warmth, discoloration, or skin breakdown.
• Fluid: Note if there is an increase in fluid, pus, bleeding, or foul odor.
• Warning Signs of Infection: An increase in redness, warmth, swelling, pain, or fever needs medical assessment.
• Pressure: Ensure you are following the appropriate offloading guidelines and are not putting unnecessary pressure on the foot.

• Dressings: Inspect if the dressing is wet, soiled, or saturated.
• Other wounds: Examine your other foot as well for any new wound formation.

Do not walk around without shoes and refrain from cutting off any dead skin or calluses on your own. Debridement needs to be determined by a health practitioner.

Nutritional adequacy ensures the availability of building blocks necessary for tissue repair. A person suffering from diabetic foot ulcers needs to follow a proper dietary pattern including sufficient protein, vegetables, fruits, carbohydrates, etc.

The requirement for protein may vary from patient to patient, especially if the patient suffers from chronic kidney disease as well.

Zinc and vitamin C are both essential elements for tissue repair, but just having a high dose of zinc or vitamin C will not necessarily cause the diabetic foot ulcer to heal faster. According to the guidelines of IWGDF on wound healing 2023, there is insufficient evidence of any benefits of using vitamin or trace element supplements routinely in order to promote wound healing in diabetic foot ulcers.

In other words, supplement usage can be recommended for deficiency of specific nutrients only.

Diabetes control is crucial to effective wound care, but no specific blood glucose level or HbA1c is established worldwide as being associated with quicker healing of diabetic foot ulcers.

The blood glucose target will have to be personalized according to different criteria, including the type of diabetes, medications, age, renal function, risk of hypoglycemia, and other medical conditions. Any changes to insulin or other medications for diabetes must be supervised by your health-care provider.

The aim is to maintain stable and safe blood glucose within recommended limits, along with correct care for the wound. The presence of frequent elevations of glucose above target means that the diabetes regimen needs adjustment.

The ulcer needs to be regularly checked to see whether there is any progress in its healing or not. Absence of progress should lead to further evaluation rather than continued use of the same treatment without improvement.

Early decrease in ulcer area has been considered a predicting factor for ulcer healing, but there is no general guideline according to which all diabetic ulcers have to reduce in size by 50% within 2 weeks. The healing of the ulcer also depends on many other factors, like ulcer size, depth, presence of infection, blood flow, pressure, neuropathy, etc.

The following situations demand early medical assessment:

• The ulcer is enlarging or deepening.
• Redness, warmth, swelling, drainage, or pain is increasing.
• Presence of fever or any other signs of systemic infection.
• Unusual coldness, pallor, blueness, or discoloration of the foot.
• Appearance of black or dead tissue.
• Lack of progress in the treatment.
• Failure in following the offloading protocol.

In cases where the ulcer does not appear to be getting better, re-evaluation may be needed of infection, offloading, perfusion, wound depth, glycemic control, and the overall management strategy. According to the guidelines of the IWGDF, effective standard care should always be at the core of any treatment process.

Surgical debridement and amputation are two different procedures.

• In surgical debridement, there is removal of infected, necrotic, and non-viable tissue in order to promote healing. This is done by creating a healthy bed for healing. This could be removal of skin, soft tissue, and infected bone depending on the wound.

• In amputation, some parts of the limb or foot are removed. This could happen in cases of tissue damage beyond repair, infection that is uncontrollable, or when the area cannot be preserved.

Remember that debridement does not automatically lead to amputation. It will depend on the degree of tissue damage, infection, vascular perfusion, and the response of the patient to treatments. Cases of severe infections such as abscesses, necrotizing tissue, and gangrene need urgent specialist assessment.

If a diabetic foot ulcer is due to peripheral arterial disease, poor circulation can impair the ability of the wound to heal. A vascular surgeon can determine if the condition requires revascularization.

Revascularization helps improve the blood supply to the affected part and may include:

• Endovascular Approach: Using minimally invasive surgical methods like angioplasty to treat blocked arteries.

• Bypass Surgery: Creating an alternative route for the supply of blood to the affected foot.

This decision is based on factors such as the extent and nature of the arterial disease, wound condition, infections, presence of other diseases, and preference of the patient. Severe ischemia requires vascular assessment.

The degree of amputation will depend upon the amount of tissue that can be saved, as well as the ability of the limb to heal.

Preservation of a functioning limb is desirable where possible. Yet, the safest point at which to perform an amputation depends on factors such as viability, infection, circulation, healing ability, and mobility. An extensive amputation is not to be performed just for having a diabetic foot ulcer.

Before undergoing a planned procedure, ask your surgeon to explain the diagnosis, the purpose of the procedure, and the available alternatives.

Before Your Surgical Consultation

Use this checklist to prepare for a discussion with your surgeon.

• What exactly is the procedure, and why do I need it?
• Is the goal to remove dead tissue, control infection, restore blood flow, or remove non-viable tissue?
• Can the wound be treated without amputation, and what are the realistic alternatives?
• How much tissue or bone needs to be removed, and how was that decision made?
• Have my blood vessels and blood flow been assessed? Would revascularization be appropriate before or alongside the procedure?
• What are the risks of delaying the procedure?
• What are the possible complications, including problems with wound healing or further infection?
• How long might recovery take, and will I need crutches, a special shoe, a prosthesis, or rehabilitation?
• What wound care, offloading, glucose management, and follow-up will I need afterward?
• Would another specialist, such as a vascular surgeon or multidisciplinary diabetic-foot team, need to review my case?

MedicoExperts can help the patient go through the process of diagnosis and connect with the right doctors. Based on the patient’s symptoms and clinical findings, the following tests may be included:

• Evaluation of the wound or ulcer
• Sensation and nerve testing
• Testing of blood circulation
• Tests for the presence of infections
• Testing of diabetes management and other health conditions

Further tests may also be advised if necessary. They may involve blood tests, vascular tests, or even nerve-conduction tests like EMG/NCV.

It will depend on the type and nature of the ulcer to be treated. Treatment includes wound cleaning and debridement, dressing, unloading of pressure, infection management in the presence of infection, and management of any factor that may be contributing to delayed healing.

If there is infection, deep ulcers, or non-healing ulcers, an evaluation from the concerned expert should be made.

Poor circulation may impair wound healing. A diagnosis of peripheral artery disease may result in a referral to a specialist who will perform a vascular assessment to establish the degree of circulatory impairment and whether it would be necessary to treat it to improve blood circulation.

MedicoExperts can assist in the identification and referral to relevant specialists if vascular assessment is necessary.

Some foot ulcers due to diabetes are resistant to treatment even with sufficient standard treatments. In case of the specific wound properties and according to the available scientific literature, there might be a need for other therapies by specialists in certain situations.

These might include negative pressure wound therapy for certain wounds, hyperbaric oxygen therapy in certain conditions, and some advanced wound care products. However, it must be noted that the above therapies are not applicable for all foot ulcers and do not substitute such essential treatments as debridement, infection management, offloading, and vascular testing if necessary.

Various treatment options, including laser and stem-cell therapies, are not to be used routinely in the treatment of foot ulcers caused by diabetes because of a lack of scientific evidence.

Foot problems related to diabetes might need a multidisciplinary approach when the issue is associated with infections, neuropathy, poor blood circulation, or serious tissue injuries. MedicoExperts can help to find the right specialist based on the patient’s condition.

• International Working Group on the Diabetic Foot (IWGDF) Guidelines — 2023 update
• IDSA Clinical Practice Guidelines for Diabetic Foot Infections
• Armstrong DG et al. — Diabetic foot ulcers and their recurrence. NEJM
• WHO Global Report on Diabetes — 2023
• ICMR Diabetes Management Guidelines (India-specific)
• Frykberg RG et al. — Diabetic foot disorders: A clinical practice guideline