By the WoundSource Editors

For people with diabetes who develop a wound, the statistics are high. The data are as overwhelming as the cost of care, and the outcome if these wounds do not heal is often deadly. The New England Journal of Medicine published these facts in 2017¹:

• Diabetic foot ulcerations are among the most common complications associated with diabetes, with a global annual incidence of 6.3%
• The lifetime incidence of foot ulcers in patients with diabetes is 19% to 34%.
• More than 50% of diabetic foot ulcers become infected, with 20% of those that develop moderate to severe infections resulting in amputation.
• Nearly 85% of diabetes-related amputations are preceded by an ulceration.
• Regular foot examinations can reduce amputation rates by 45% to 85%.
• Annual diabetes care costs $176 billion dollars, and one third of that is related to lower extremity care.
• Diabetes is a malignant disease, defined as a disease that does harm, inflicts suffering, causes distress, is highly injurious, is virulent, and tends to produce death.

These facts are alarming and should be a call to action that every diabetic foot ulcer should be treated like a "911 event." The faster we can intervene and get closure in these limbs, the better the patient outcomes and chance for a longer, fulfilled life. How do we go from ulceration to closure, and what tools do we need in our arsenal?

Identification and Management of the Underlying Cause of the Diabetic Foot Ulcer

A good mantra to keep in mind when treating diabetic foot ulcers is "It doesn't matter what dressing, device, cellular and/or tissue-based product, or other modality your order if you don't fix the underlying cause." The diabetic foot ulcer may heal but it will come back time after time. If you address the underlying cause, you address the recurrence and, ultimately, the wound.

As a clinical example, assume you are consulted on a troubling wound in a diabetic limb that just won’t heal. It gets close to closure but then breaks down and deteriorates again and again. In rounds, you watch as the nursing team assesses and measures the wound, reviews the chart, previous treatments, cultures, and antibiotics, and interviews the staff and the patient. What do you do next? Try asking the patient, "What shoes do you normally wear? Any shoes that you also wear from time to time?" The patient points to two different pairs of shoes. You pick up the shoes and notice one of the them is worn through on the inside exactly where the ulcer is. You point this out to the patient and nursing team. The patient says there is no way the shoe could cause the wound because they are "diabetic shoes." Although this is true, they are worn out. You get the patient set up for diabetic shoes with inserts after she is measured, and, sure enough, within two weeks the ulcer is completely resolved.

Diabetic Foot Ulcer Prevention Measures

The first item to add to your arsenal for your patients with diabetes is prevention. Get patients with diabetes into a routine to have their feet examined. There is guidance on how often and when, but annually is better than no examination. Have them fitted for diabetic shoes with inserts customized to their feet. Look for changes in structure and foot deformities. Assess for neuropathy using the Semmes Weinstein 10-g monofilament test, and document that assessment.

Treatment Strategies for Diabetic Foot Ulcers

If an ulcer does develop, patients need to go to a trained wound specialist right away. A trained specialist can intervene early to prevent complications and infection from setting in. Early intervention should include managing or eliminating bioburden to prevent infection from taking hold. The trained specialist can determine the underlying cause and see whether offloading inserts or boots can make a difference. Often patients are candidates for surgical intervention if the deformity is severe enough to warrant correction, thereby eliminating the underlying cause permanently. Using the principles of TIME (tissue, infection or inflammation, moisture, and edge ) should be used to encourage healing in stalled wounds.²

If the wound stalls or does not improve as expected, do not wait to implement more aggressive measures. Cellular and/or tissue-based products (or skin substitutes) can jump start a stalled wound and should not be used sparingly on diabetic limbs.³Negative pressure wound therapy is an effective tool to use to assist with granulation tissue formation and management of wound exudate.^4,5 These modalities can often be used appropriately and comfortably under diabetic shoes, boots, or even total contact casts. Removal of non-viable tissue and senescent cells through curettage and sharp debridement is a essential to effectively managing wound bioburden to support closure.

Mixed-Etiology Wounds

In assessment the diabetic foot ulcer, don’t forget to look at mixed etiology. Evidenced-based practice reminds us that peripheral arterial occlusive disease is four times more prevalent in patients with diabetes than those without.⁶ In treating underlying causes, we also must address all of these causes whether mechanical, metabolic, psychological, etc. We must look at nutrition, as well as the patient’s motivation to heal.

Conclusion

Because healing of diabetic foot ulcers depends on identification and management of the underlying cause, an accurate differential diagnosis must be urgently sought. As for treatment, with diabetic foot ulcers there is no one-stop shop and no singular approach. All methods and modalities should be considered and implemented when appropriate and medically necessary.

References
1. Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med. 2017;376(24):2367-2375.
2. Ousey K, Rogers AA, Rippon MG. Hydro-responsive wound dressings simplify T.I.M.E. wound management framework. Br J Community Nurs. 2016;21(12):29–39. Available at: https://doi.org/10.12968/bjcn.2016.21.Sup12.S39. Accessed August 21, 2019.
3. A guide to using cellular and tissue-based products. Podiatry Today. 2018;31(3).
4. Banwell PE. Topical negative pressure therapy in wound care. J Wound Care. 1999;8(2):79-84.
5. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg. 1997;38(6):563-76; discussion 577.
6. Armstrong DG, Lavery LA. Diabetic foot ulcers: prevention, diagnosis and classification. Am Fam Physician. 1998;57(6):1325-1332.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.