Ulcer
Wound Management in Diabetic Foot Ulcers (DFU)
It has been suggested that up to 85% of amputations can be avoided when an effective care plan is adopted. Unfortunately, insufficient training, suboptimal assessment and treatment methods, failure to refer patients appropriately and poor access to specialist footcare teams hinder the prospects of achieving optimal outcomes.
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
Introduction to Diabetic Foot Ulcers
DFUs are complex, chronic wounds, which have a major long-term impact on the morbidity, mortality and quality of patients’ lives. Individuals who develop a DFU are at greater risk of premature death, myocardial infarction and fatal stroke than those without a history of DFU. Unlike other chronic wounds, the development and progression of a DFU is often complicated by wide-ranging diabetic changes, such as neuropathy and vascular disease. These, along with the altered neutrophil function, diminished tissue perfusion and defective protein synthesis that frequently accompany diabetes, present practitioners with specific and unique management challenges.
Causes of Diabetic Foot Ulcer
In most patients, peripheral neuropathy and peripheral arterial disease (PAD) (or both) play a central role and DFUs are therefore commonly classified as (Table 1):
Neuropathic DFU
Ischaemic DFU
Neuroischaemic DFU
The principle aim of DFU management is wound closure, specifically at an early stage to allow prompt healing. The essential components of management are:
1) Peripheral Neuropathy
Peripheral neuropathy may predispose the foot to ulceration through its effects on the sensory, motor and autonomic nerves. Patients with a loss of sensation will have decreased awareness of pain and other symptoms of ulceration and infection.
2) Peripheral Arterial Disease (PAD)
People with diabetes are twice as likely to have PAD as those without diabetes. It is also a key risk factor for lower extremity amputation. Even in the absence of a poor arterial supply, microangiopathy contributes to poor ulcer healing in neuroischaemic DFUs.
DFUs usually result from two or more risk factors occurring together. Intrinsic elements such as neuropathy, PAD and foot deformity (e.g, from neuropathic structural changes), accompanied by an external trauma such as poorly fitting footwear or an injury to the foot can, over time, lead to a DFU.
DFUs usually result from two or more risk factors occurring together. Intrinsic elements such as neuropathy, PAD and foot deformity (e.g, from neuropathic structural changes), accompanied by an external trauma such as poorly fitting footwear or an injury to the foot can, over time, lead to a DFU.
Feature | Neuropathic | Ischaemic | Neuroischaemic |
|---|---|---|---|
Sensation | Sensory loss | Painful | Degree of sensory loss |
Callus/necrosis | Callus present and often thick | Necrosis common | Minimal callus, prone to necrosis
|
Wound bed | Pink and granulating surrounded by callus | Pale and sloughy with poor granulation | Poor granulation |
Foot temperature and pulses | Warm with bounding pulses | Cool with absent pulses | Cool with absent pulses
|
Other | Dry skin and fissuring | Delayed healing | High risk of infection
|
Typical Location | Weight-bearing areas of the foot, such as metatarsal heads, the heel and over the dorsum of clawed toes | Tips of toes, nail edges and between the toes and lateral borders of the foot | Margins of the foot and toes
|
Prevalence (based on) | 35% | 5% | 50% |
Source:
International Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers. Wounds International, 2013.
Management of Diabetic Foot Ulcers
1) Treating the underlying disease processes;
- Treating any severe ischaemia.
- Achieving optimal diabetic control.
- Addressing the physical cause of the trauma.
2) Ensuring adequate blood supply
A patient with acute limb ischaemia is a clinical emergency and may be at great risk if not managed in a timely and effective way. Aside from critical limb ischaemia, decreased perfusion or impaired circulation may be an indicator for revascularisation in order to achieve and maintain healing and to avoid or delay a future amputation.
3) Local wound care, including infection control
The European Wound Management Association (EWMA) states that the emphasis in wound care for DFUs should be on radical and repeated debridement, frequent inspection and bacterial control and careful moisture balance to prevent maceration.
Neuropathic
Ulcer
Pre debridement
Post debridement
Pre debridement
Pre debridement
*It is important to debride a wound and refer patients to a specialist for choosing the correct method of debridement. Inadequate wound management can cause rapid deterioration with potentially devastating consequences.
4) Pressure offloading
In patients with peripheral neuropathy, it is important to offload at-risk areas of the foot in order to redistribute pressures evenly. Inadequate offloading leads to tissue damage and ulceration.
No Amputation
According to the IDF guideline, amputation should not be considered unless a detailed vascular assessment has been performed by vascular staff.
Amputation may be indicated in the following circumstances:
- Ischaemic rest pain that cannot be managed by analgesia or revascularisation
- A life-threatening foot infection that cannot be managed by other measures
- A non-healing ulcer that is accompanied by a higher burden of disease than would result from amputation. In some cases, for example, complications in a diabetic foot render it functionally useless and a well performed amputation is a better alternative for the patient
Diabetic Ulcer before and after treatment with NaTH Plus
DAY 0
DAY 30
DAY 60
DAY 90
Sacral pressure sore before and after treatment with NaTH Plus
