Diabetic Foot Ulcer – Causes, Symptoms, Treatment

A Diabetic Foot Ulcer is an open sore or wound that occurs in approximately 15 percent of patients with diabetes and is commonly located on the bottom of the foot. Of those who develop a foot ulcer, 6 percent will be hospitalized due to infection or other ulcer-related complications.

A diabetic foot ulcer is a major complication of diabetes mellitus, and probably the major component of the diabetic foot. Wound healing is an innate mechanism of action that works reliably most of the time. A key feature of wound healing is the stepwise repair of the lost extracellular matrix (ECM) that forms the largest component of the dermal skin layer.[rx] But in some cases, certain disorders or physiological insult disturbs the wound healing process. Diabetes mellitus is one such metabolic disorder that impedes the normal steps of the wound healing process. Many studies show a prolonged inflammatory phase in diabetic wounds, which causes a delay in the formation of mature granulation tissue and a parallel reduction in wound tensile strength.[rx]

Types and Classification

A diabetic foot ulcer is a complication of diabetes. Diabetic foot ulcers are classified as either

  •  Neuropathic,
  • Neuroischaemic
  • Ischaemic.[rx]

Based on wound depth and necrotic tissue, diabetic ulcers can be classified by the Wagner ulcer classification system. 

Wagner-Meggitt Classification of Diabetic Foot 

  • Grade 0 – Foot symptoms like pain, only
  • Grade 1 – Superficial ulcers
  • Grade 2 – Deep ulcers
  • Grade 3 – Ulcer with bone involvement
  • Grade 4 – Forefoot gangrene
  • Grade 5 – Full-foot gangrene

Doctors also use the Wagner Grades to describe the severity of an ulcer. The purpose of the Wagner Grades is to allow specialists to better monitor and treat diabetic foot ulcers. This grading system classifies Diabetic foot ulcers using numbers, from 0 to 5.

Wagner Grades 0 through 5 are as follows:
  • 0. No diabetic foot ulcer is present, but there is a high risk of developing one.
  • 1. A surface ulcer involves full skin thickness but does not yet involve the underlying tissues.
  • 2. A deep ulcer penetrates past the surface, down to the ligaments and muscle. There is no abscess or bone involved yet.
  • 3. A deep ulcer occurs with inflammation of subcutaneous connective tissue or an abscess. This can include infections in the muscle, tendon, joint, and/or bone.
  • 4. The tissue around the area of the ulcer (limited to the toes and forefoot) has begun to decay. This is condition is called gangrene.
  • 5. Gangrene has spread from the localized area of the ulcer to become extensive. This involves the whole foot.


Wagner Scale
  • Grade 0: no open lesions, may have healed lesions
  • Grade 1: superficial ulcer, no penetration in deeper layers
  • Grade 2: deeper ulcer reaching tendon, bone, or joint
  • Grade 3: deeper tissues are involved, with abscess, osteomyelitis, or tendonitis
  • Grade 4: gangrene of some part of the foot
  • Grade 5: gangrene of the whole foot or enough of the foot that limb amputation is indicated


Atherosclerosis and diabetic peripheral neuropathy are the two main causes leading to a complication of diabetes such as ulcers. Atherosclerosis leads to decreased blood flow in large and medium-sized vessels secondary to thickening of the capillary basement membrane, loss of elasticity, and deposition of lipids within the walls. Further arteriosclerosis leads to small vessel ischemia. Peripheral neuropathy affects the sensory, motor, and autonomic nervous system. There are multifactorial causes such as vascular disease occluding the vasa nervorum, endothelial dysfunction, chronic hyperosmolarity, and effects of increased sorbitol and fructose.

Causes of Diabetic Foot Ulcer

  • Peripheral motor neuropathy – Abnormal foot anatomy and biomechanics, with clawing of toes, high arch, and subluxed metatarsophalangeal joints, leading to excess pressure, callus formation, and ulcers
  • Peripheral sensory neuropathy – Lack of protective sensation, leading to unattended minor injuries caused by excess pressure or mechanical or thermal injury
  • Peripheral autonomic neuropathy – Deficient sweating leading to dry, cracking skin. Neuro-osteoarthropathy deformities (i.e., Charcot disease) or limited joint mobility
  • Abnormal anatomy and biomechanics – leading to excess pressure, especially in the mid plantar area
  • Vascular (arterial) insufficiency – Impaired tissue viability, wound healing, and delivery of neutrophils
  • Hyperglycemia and other metabolic derangements – Impaired immunological (especially neutrophil) function and wound healing and excess collagen cross-linking.
  • Poor blood circulation
  • Insufficiently well-controlled diabetes
  • Wearing poor fitting footwear
  • Walking barefoot
  • Smoking, not taking exercise,
  • Being overweight,
  • Having high cholesterol or blood pressure can all increase diabetes foot ulcer risk.
DFUs occur due to changes in the biomechanics of the bony and soft tissue architecture of the foot,
  • peripheral neuropathy,
  • atherosclerotic peripheral arterial disease, all of which occur at a higher frequency in patients with DM.
  • Nonenzymatic glycation predisposes ligaments to stiffness.
  • Both of these contribute to loss of proprioception, poor balance, and lack of awareness of pain in the feet and lower limbs of patients with DM.
  • Ulcers usually begin as small areas of pressure or irritation or from a minor trauma that is not perceived by the insensate neuropathic patient.
The Six Stages of a Diabetic Foot as described by the 7th Practical Diabetes International Foot Conference
  • Stage 1 – Normal foot with no risk factors;
  • Stage 2 – High-risk foot
  • Stage 3 – Ulcerated foot
  • Stage 4 – Cellulitic foot
  • Stage 5 – Necrotic foot
  • Stage 6 – Foot that cannot be rescued

There are three types of diabetic foot ulcers described namely neuropathic, neuroischaemic, and ischaemic.   Sensory neuropathy leads to the majority of ulcers as a result of minor trauma which is not perceived by the patient and further goes untreated as there are no associated pain symptoms unless there is a routine evaluation to assist in identification.  Myocardial infarction is one of the most significant events related to peripheral arterial disease increased risk of ischemia. However, ischemia leading to diabetic ulcers adds severe morbidity and health care cost as it can be a chronic complication which is difficult to treat as there is the insufficient blood supply.

Diagnosis of Diabetic Foot Ulcer

History and Physical

The evaluation of patients presenting with diabetic ulcers can be divided into a clinical and radiologic assessment.

  • Clinically pertinent history – of the type of diabetes, medication history, comorbidities, symptoms of peripheral neuropathy, and vascular insufficiency should be elucidated. Symptoms of neuropathy include hypoesthesia, hyperesthesia, paresthesia, dysesthesia, and radicular pain. Vascular insufficiency has varying presentations and most patients are asymptomatic. However, they can present with intermittent claudication, rest pain, and healing or non-healing ulcers.
  • In the examination of the legs and foot – inspection should be performed in a well-lit room with appropriate exposure. Proper documentation using descriptions of ulcer characteristics with size, depth, appearance, and location performed. The presence of discoloration, necrosis, or areas of drainage are signs of infection, and further care is required. Other abnormalities such as nail discoloration, callus formation, and deformities should be noted. Imbalance in the innervations of the foot muscles from neuropathic damage can lead to the development of common deformities seen in affected patients. Hyperextension of the metatarsal-phalangeal joint with interphalangeal or distal phalangeal joint flexion leads to hammertoe and claw toe deformities, respectively. Charcot arthropathy is a commonly seen deformity. Assessment of footwear is important as it can be a contributing factor to the development of foot ulceration. The presence of callus or nail abnormalities should be noted.
  • Examine the cardiovascular system – checking popliteal, posterior tibial, and dorsalis pedis pulse. Claudication, loss of hair, and the presence of pale, thin, shiny, or cool skin are physical findings suggestive of potential ischemia. If the vascular disease is a concern, the evaluator should measure the ankle-brachial index (ABI). ABIs can, however, be falsely elevated in patients with diabetes mellitus due to calcification of vessels. More reliable methods of assessing the potential for healing foot ulcers in patients with diabetes mellitus suspected of having peripheral ischemia involve systolic toe pressure measurements by photoplethysmography or measurement of distal transcutaneous oxygen tension.
  • The ankle-brachial index – The ankle-brachial index (ABI) is a simple bedside screening tool for the presence of peripheral arterial disease (PAD). PAD simply depends on the calculation of the ratio between the systolic pressure of the ankle arteries and the systolic pressure at the brachial arteries[]. ABI is an inexpensive method that can assess the severity of PAD as it usually correlates with the patient’s reported symptoms and functional status. The normal range is of ABI is between 0.9-1.3, falsely elevated values of ABI can result in cases of calcified, non-compressible arteries. Thus the ABI method may lead to underestimation of the severity of the disease in patients with diabetes[].
  • The toe-brachial index – The toe-brachial index is calculated similarly to the ABI, where the systolic pressure is measured using a small cuff and a Doppler probe. Measuring the toe-brachial index is helpful especially in cases of ABI values more than 1.30, as the small arteries of the lower limb are less likely to be calcified. A toe-brachial index lower than 0.70 is diagnostic for PAD[].
  • Segmental limb pressure assessment and pulse volume recordings – The technique depends on plethysmographic cuffs situated over the brachial arteries and different points on the lower limb. The extent and location of PAD can be detected from segmental systolic pressure assessment using a Doppler probe[].
  • Ultrasound velocity spectroscopy and imaging – The normal arterial Doppler velocity shows a triphasic signal. When an arterial obstruction is present proximal to the probe, there is the loss of the normal reversed flow component on transforming the waveform associated with decreased amplitude, attenuation of all parts of the spectrum, and delayed upstroke[].
  • Duplex ultrasound  – depends on combining the B-mode and the pulsed Doppler ultrasound to assess arterial flow and localized velocity information at stenotic sites. Duplex ultrasonography is widely used nowadays detecting with high sensitivity and specificity the arterial patency and extends of obstruction[]. Duplex ultrasound has certain limitations mainly difficulty in identifying close multiple separate lesions, some difficulty when assessing infrapopliteal, common, and external iliac arteries[].
  • Transcutaneous oximetry and laser – doppler flowmetry – These techniques are used mainly to assess cutaneous blood flow. Cutaneous blood flow is usually normal until late stages of proximal arterial ischemia of the atherosclerotic type, thus, this type of vascular evaluation is not used in everyday practice[].
  • Magnetic resonance angiography (MRA)[].
  • Computed tomographic angiography – CTA is superior to MRA as it can detect the presence of calcification, which is advantageous in planning revascularization strategies. The ACC/AHA guidelines recommend CTA on deciding the revascularization techniques in cases of PAD, offering a faster image than MRA[].
  • Contrast angiography – Although it is the gold standard for the diagnosis of PAD, is rarely required as a diagnostic tool due to the risks associated with invasive procedures. Computer-enhanced digital subtraction angiography can be useful in patients who present with localized stenosis so as to minimize the amount of contrast material injected and for better image resolution[].

Treatment of Diabetic Foot Ulcer

Multimodal Diabetic Ulcer Management

  • Patient Education – Education on foot care, as well as control of blood sugar levels, should be performed early. This can also be done with the aid of diabetic educators and social workers.
  • Blood-Sugar Control – This is managed using a team approach of primary care physician, podiatry, and vascular specialist and based on the severity of the disease and the patient’s attitude toward medication, especially insulin.
  • Decreasing Pressure – preventing further or new trauma: Offloading pressure to the area can be done with crutches, wheelchairs, and casting. Ulcer healing is improved with total contact casting, irremovable cast walkers compared to removable cast walkers.
  • Improve Peripheral Vascular Circulation – Antiplatelet agents are the initial drug therapy; however, insufficiency requires surgical bypass.
  • Prevent or Control Infection – Systemic and source control is achieved using antibiotics and surgical debridement. 
  • Topical Ulcer Care –  Principles of wound care include the use of topical agents with dressing and debridement
  • Neuropathic ulcers – must be protected from further injury until they heal, and strenuous efforts must be made to avoid another ulcer by wearing the correct footwear.
  • Wound offloading – which is the removal of any weight or pressure from the wound to allow it to heal. This is achieved through the use of a wheelchair, crutches, or specialized footgear or braces.
  • Debridement – which is the removal of dead skin and tissue
  • Specialized dressings that are designed to help the skin heal – including “skin substitutes” and collagen-infused dressings that provide the cellular building blocks that are necessary for the growth of new and healthy skin
  • Specialized dressings that are designed to remove excess moisture – from the wound as well as dressings infused with antibiotic medication to treat and prevent infection
  • Hyperbaric oxygen chamber treatment, which has been shown to heal wounds 75% faster – than antibiotics alone. The oxygen-rich environment in the chamber allows cells to take oxygen to the wound more efficiently and also helps to kill the bacteria in infected wounds.
  • Surgical revascularization – which improves blood flow to the area so that the skin can heal properly.Avascular or ischaemic ulcer – should be evaluated by a vascular surgeon to determine the extent of damage and whether surgery is necessary; in severe cases, this may entail partial amputation of a toe, foot or limb.
  • Whatever the cause of the ulcer – any dead tissue of the surface should be debrided (removed), the wound cleansed with antiseptic or superoxide solution, and synthetic wound dressings applied to ensure a moist environment. Honey dressings may also be useful. Expert advice should be obtained, as the best dressing will depend on the type of ulcer and stage of healing.

Trigger Management of diabetic foot ulcers

Infection should be prevented with careful wound care and regular inspection. Antibiotics may be prescribed if there is a significant infection resulting in cellulitis or osteomyelitis.
  • Each hospital should have antibiotic guidelines for the management of diabetic foot infections.
  • Do not delay starting antibiotic therapy for suspected osteomyelitis pending the results of the MRI scan.
  • Start empirical antibiotic therapy based on the severity of the infection, using the antibiotic appropriate for the clinical situation and the severity of the infection, and with the lowest acquisition cost.
  • For mild infections, offer oral antibiotics with activity against Gram-positive organisms.
  • For moderate and severe infections, offer antibiotics with activity against Gram-positive and Gram-negative organisms, including anaerobic bacteria. The route of administration is as follows:
    • Moderate infection: oral or intravenous antibiotics, based on the clinical situation and the choice of antibiotic
    • Severe infection: start with intravenous antibiotics then reassess, based on the clinical situation
  • The definitive antibiotic regimen and the duration of treatment should be informed by both the results of the microbiological examination and the clinical response to empiric antibiotic therapy
  • Do not use prolonged antibiotic therapy for mild soft tissue infections.
  • Treat infections with MRSA in line with local and national guidance.

Debridement, dressings and off-loading

  • Debridement should only be done by healthcare professionals from the multidisciplinary foot care team, using the technique that best matches their specialist expertise, clinical experience, patient preference, and the site of the ulcer.
  • When choosing wound dressings, healthcare professionals from the multidisciplinary foot care team should take into account their clinical assessment of the wound, patient preference and the clinical circumstances, and should use wound dressings with the lowest acquisition cost.
  • Offer off-loading for patients with diabetic foot ulcers. Healthcare professionals from the multidisciplinary foot care team should take into account their clinical assessment of the wound, patient preference and the clinical circumstances, and should use the technique with the lowest acquisition cost.
  • Use pressure-relieving support surfaces and strategies in line with ‘Pressure ulcers’ (NICE clinical guideline 29) to minimise the risk of pressure ulcers developing.

Adjunctive treatments

  • Negative pressure wound therapy should not be routinely used to treat diabetic foot problems, but may be considered in the context of a clinical trial or as rescue therapy (when the only other option is amputation).
  • Do not offer the following treatments for the inpatient management of diabetic foot problems, unless as part of a clinical trial:
    • Dermal or skin substitutes.
    • Electrical stimulation therapy, autologous platelet-rich plasma gel, regenerative wound matrices and deltaparin.
    • Growth factors (granulocyte colony-stimulating factor [], platelet-derived growth factor [], epidermal growth factor and transforming growth factor beta [TGF-β]).
    • Hyperbaric oxygen therapy.

Topical Agents for Regular Dressing

  • Wet to dry dressing (simple saline dressing) – Wet to dry dressing is included in standard wound care and is considered a method for mechanical debridement since it presents a good debriding effect in the removal of the necrotic tissue and wound preparation[]. In order to minimize irritation and discomfort, adequate moistening of the dressings with normal saline is done when treating granulating wound tissues to avoid trauma and bleeding[].
  • Local antibacterial agents – Antibacterial agents can be used alone or in combination with other dressings except for dry necrotic ulcers. For effective anaerobic coverage, metronidazole gel is used and maintains a moist environment for wound healing[]. Several antibiotics have effective antibacterial action on topical applications such as Neomycin, Gentamycin, and Mupirocin. Silver dressings and polyherbal topical preparations have shown good antibacterial action[]. For effective antibacterial action against Pseudomonas, other gram-negative bacilli, and beta-hemolytic streptococci wound infections Sisomycin and acetic acid can be used. Special precautions should be considered when using povidone-iodine solution dressings, iodine has been found to be toxic at high concentrations to bacteria and fungi as well as human cells[].
  • Tulle dressings – Tulle dressings are used mainly for skin grafts and superficial wounds. They can be safely used in granulating and epithelializing tissues as they are impregnated with paraffin, having low dressing adherence properties[]. Evidence from several previous studies has shown better and faster re-epithelialization rates compared to dry dressing[].
  • Hydrogel dressings – Hydrogel dressings are considered the best choice for dry wounds with necrotic eschar. Hydrogels provide fluid and good hydration to dry and slough wounds. Although they are very good at absorbing exudates, they should be avoided in diabetic foot planter ulcers as they may cause maceration of the skin surrounding the wound[].
  • Polyurethane films – Polyurethane films are transparent films coated with a water-proof adhesive dressing. They provide permeable films allowing diffusion of gases and vapor thus an adequately moist wound environment. They have the advantage of being transparent, thus can monitor the wound progression. They also can be used for low exudates wounds, but they may cause maceration of the skin surrounding the wound[].
  • Polyurethane foam – Polyurethane foam is highly used in diabetic foot ulcers. It can absorb large amounts of exudates in a non-adherent nature thus does not cause wound sloughing or trauma on removal. They maintain the moisture environment thus allow proper preparation of wound bed and promotes better wound healing[].
  • Alginate dressings – Two forms of alginate dressings are available; calcium alginate and calcium sodium alginate. Alginate dressings can absorb large amounts of exudates up to 20 times their weight as shown by several clinical studies[].
  • Honey-impregnated dressings – The anti-inflammatory and anti-microbial actions have been shown in vitro studies but further studies are required to support strong evidence in vivo[].
  • Vacuum-assisted closure – Vacuum-assisted devices have shown efficacy in exudates removal and edema reduction. Ideally, a pressure of 125 mmHg can generate a negative topical pressure over the diabetic foot wound. It has the advantage of leaving the wound surface moist. It has several limitations; it is contraindicated in cases of osteomyelitis, ischemia, deep tissue exposure such as tendons, bones, and blood vessels, presence of necrotic tissues, and fistulas[]. Vacuum-assisted devices are also effective in promoting closure and wound healing in patients with treated infections and treated osteomyelitis[].
  • Hyperbaric oxygen therapy, Do we have evidence – A systemic treatment where oxygen is breathed but at a higher pressure than the local atmospheric pressure[]. HBOT has shown increased healing rates of diabetic foot ulcers, however it still controversial whether it can be used as adjuvant treatment or not[]. Hyperbaric oxygen therapy (HBOT) has the advantage of the reduction of tissue hypoxia, edema, increase angiogenesis and erythrocytes deformability, antimicrobial effects, and increase fibroblastic activity[]. HBOT is approved as an adjunctive treatment to be used in chronic non-healing ulcers by the Undersea and Hyperbaric Medical Society[]. The European Committee for Hyperbaric Medicine has set a type 2 recommendation for the use of HBOT in the management of diabetic foot ulcers including patients with ischemic wounds without a surgically treatable arterial lesion or as a complement after vascular surgery, in presence of non-healing wounds[].
  • The role of stem cell therapy in PAD – It is worth mentioning that our skeletal muscles have a regenerative capacity as the have multipotential and progenitor cells. In cases of critical limb peripheral arterial disease, the transplantation of progenitor cells- derived from bone marrow- has beneficial effects on angiogenesis and ulcer healing as shown in phase I and II studies. The role of therapeutic angiogenesis is a promising and safe method for the management of PAD and limb salvage[].


Consult a surgical service for all cases of moderate and severe DFIs. [rx] defines criteria for severity of infection, and guides clinicians to the appropriate surgical service based on clinical parameters, history of treatment by a surgical service, and location of the infection. Many DFIs require surgical intervention, varying from local incision and debridement to high-level amputation, depending on the severity of infection and degree of peripheral vascular disease. The goal of surgery is to control the infection while preserving maximal function and quality of life and the level of amputation is determined by the extent and severity of the infection.

Urgent surgical consultation should be obtained for:

  • Life/limb-threatening infection
  • Critical limb ischemia
  • Gas in deep tissues
  • Necrotizing fasciitis
  • Compartment syndrome
  • Deep soft tissue abscess

Surgical consultation should also be obtained for:

  • Wounds with substantial non-viable tissue
  • Wounds with bone or joint involvement (includes positive probe-to-bone test)
  • Ulceration with drainage, erythema, or fluctuance
  • Unexplained persistent foot pain or tenderness
  • Progressive bone destruction on imaging

Determining approach

Consult vascular surgery for all patients with known critical limb ischemia or PAD (defined as ABI <0.7 or TBI <0.6). For all other patients who do not have a pre-existing relationship with a surgical service, consult podiatry. The involvement of orthopedic or plastic surgery will be determined by the podiatry service.

Determining whether to pursue amputation versus medical therapy alone or combined with local incision and debridement is complex and should be made on an individual case-by-case basis, considering the site and severity of infection as well as patient preferences. Factors favoring amputation include persistent sepsis syndrome with no alternative explanation, bony destruction that compromises foot mechanics, or progressive bone destruction despite adequate antibiotic therapy.

Predictors of amputation are the presence of peri-wound or pretibial edema, deep ulcers, positive probe-to-bone test, CRP three times the upper limit of normal, large ulcer size, and presence of peripheral vascular disease. A prospective multicenter cohort study of 575 infected diabetic ulcers demonstrated that there was an increased incidence of amputation with increased severity of the infection.

Wound Care

The wound bed should be managed to promote healing. In addition to debridement (if indicated), strategies include inspection, cleansing, surface debris removal, and wound protection.

Wound debridement should be used to remove non-viable tissue in the wound bed and stimulate a granular wound bed. Types of wound debridement include sharp/surgical debridement, mechanical debridement (wet-to-dry dressings), and enzymatic debridement (collagenase/Santyl)

Wound debridement may not be necessary in a circumstance where:

  • A granular wound bed is present
  • There is a severe peripheral vascular disease without clinical infection signs and vascular workup is pending
  • A dry stable eschar
  • There is scheduled surgical intervention such as a pending amputation.

Dressings should be selected that provides a moist wound bed, control exudate, and prevent maceration. Wound bed healing following surgical debridement of DFI can be facilitated by use of negative pressure. Decisions regarding wound dressing should be at the discretion of the surgical team. There is insufficient data to support the routine use of G-CSF for wound healing at this time.Wound care does not need to be consulted if podiatry and/or surgery has evaluated the ulcer and made wound care recommendations. If there are other wounds that need to be addressed, or if podiatry and surgery will not be consulted, it is recommended that wound care be consulted.

Antibiotic treatment

All patients with DFI, regardless of disease severity, should receive coverage for Staph aureus and Strep spp., and patients with severe or life-threatening disease should receive antibiotics that include additional coverage for MRSA and Pseudomonas aeruginosa . The IDSA guidelines for the treatment of DFIs stratify treatment recommendations by disease severity, risk factors for MRSA and Pseudomonas, and patient history. There are several studies that have identified risk factors for multi-drug resistant pathogens, which include repeated hospitalizations for the same ulcers; previous antibiotic utilization; duration of previous antibiotic therapy; severity of wound; and osteomyelitis.

There are limited data evaluating the efficacy of empiric gram-negative coverage for DFIs. A number of Phase III randomized controlled trials have evaluated the efficacy of antibiotic regimens for complex skin and skin structure infections and 10–38% of patients presented with DFIs . All published randomized controlled trials have evaluated antibiotics that cover only gram-positive pathogens. Trials evaluating the efficacy of newer antibiotics including dalbavancin, oritavancin, daptomycin, linezolid, tedizolid, tigecycline have demonstrated non-inferior activity compared to nafcillin, dicloxacillin, cloxacillin, flucloxacillin, and vancomycin.

IDSA guidelines generally recommend covering EnterobacteriaceaePseudomonas aeruginosa, MRSA and anaerobes for severe infections. For patients with moderate infections, the spectrum of coverage should target a minimum of MSSA and streptococci, and can expand to include gram-negative pathogens and anaerobes in select circumstances. Patient with mild diabetic foot infections can be treated with oral antibiotics

In addition to disease severity treatment, the IDSA guidelines recommend treatment based on the patient’s previous infection and treatment history, in addition to risk factors for MRSA and Pseudomonas. Patients should be empirically covered for MRSA if risk factors are present: previous MRSA infection, high local prevalence of MRSA, and failure of current therapy. UMHS is considered an area of high local MRSA prevalence. Additionally, patients should be covered for Pseudomonas if an infection develops following frequent exposure of foot ulcer to water, for residents in warm climates, and high local prevalence of Pseudomonas infections. A recent study of the microbiology of DFIs at the University of Michigan revealed very low rates of P. aeruginosa (5%).

Antibiotic initiation should be delayed until after deep cultures are obtained in patients with mild or moderate wound infections that are clinically stable and deep tissue cultures are scheduled within the next 24–48 hours. Once culture results are obtained, antibiotics should be tailored to target isolated pathogens. Duration of therapy is usually 1–2 weeks for skin and soft tissue infection, and at least 4 weeks if osteomyelitis is present. Infectious Diseases consultation is recommended to help guide antibiotic therapy and evaluate response to therapy.

Glycemic Control

Glucose management is a key component to managing patients with DFIs.

The hemoglobin A1c (HbA1c) can aid with determining the effectiveness of the patient’s current medical regimen. If a patient does not have a current A1c result available (eg. within the last 3 months), one should be obtained upon hospital admission. The standard for medical management in most patients with diabetes is an HbA1c value of <7%, which correlates to average blood glucose readings of 150 mg/dL. If blood glucose averages are >180 mg/dL or the HbA1c is over 8%, the patient is considered to have uncontrolled diabetes. Chronic hyperglycemia is negatively associated with endothelial-dependent vasodilatation, which may contribute to the development of ischemic foot ulcers. High HbA1c levels have been shown to be an important risk factor for lower extremity amputation in patients with diabetes. Achieving adequate glycemic control should be part of the management of DFIs.

Glycemic management recommendations for patients with DFIs include the following:

  • Aim for preprandial glycemic levels of 100–140 mg/dL and postprandial levels of <180 mg/dL for most hospitalized patients.
  • Any patient with a HbA1c level >8.5% should be considered for intensification of their diabetes medical regimen.
  • Insulin is the preferred agent for reducing glucose levels in hospitalized patients.
  • For additional recommendations on inpatient glycemic control, please see the Michigan Medicine Inpatient Glycemic Management Guideline.

Home Treatment Of Diabetic Foot Ulcer

  • Check your feet every day – for cuts, redness, swelling, sores, blisters, corns, calluses, or any other change to the skin or nails. Use a mirror if you can’t see the bottom of your feet, or ask a family member to help.
  • Wash your feet every day – in warm (not hot) water. Don’t soak your feet. Dry your feet completely and apply lotion to the top and bottom—but not between your toes, which could lead to infection.
  • Never go barefoot – Always wear shoes and socks or slippers, even inside, to avoid injury. Check that there aren’t any pebbles or other objects inside your shoes and that the lining is smooth.
  • Wear shoes that fit well – For the best fit, try on new shoes at the end of the day when your feet tend to be largest. Break-in your new shoes slowly—wear them for an hour or two a day at first until they’re completely comfortable. Always wear socks with your shoes.
  • Trim your toenails straight across – and gently smooth any sharp edges with a nail file. Have your foot doctor (podiatrist) trim your toenails if you can’t see or reach your feet.
  • Don’t remove corns or calluses yourself – and especially don’t use over-the-counter products to remove them—they could burn your skin.
  • Get your feet checked at every health care visit – Also, visit your foot doctor every year (more often if you have nerve damage) for a complete exam, which will include checking for feeling and blood flow in your feet.
  • Keep the blood flowing – Put your feet up when you’re sitting, and wiggle your toes for a few minutes several times throughout the day.
  • Choose feet-friendly activities – like walking, riding a bike, or swimming. Check with your doctor about which activities are best for you and any you should avoid.

Tips For Diabetic Foot Care

Proper foot care can prevent these common foot problems or treat them before they cause serious complications. Here are some tips for good foot care:

  • Take care of yourself and your diabetes. Follow your doctor’s advice regarding nutrition, exercise, and medication. Keep your blood sugar level within the range recommended by your doctor.
  • Wash your feet in warm water every day, using a mild soap. Test the temperature of the water with your elbow because nerve damage can affect sensation in your hands, too. Do not soak your feet. Dry your feet well, especially between your toes.
  • Check your feet every day for sores, blisters, redness, calluses, or any other problems. If you have poor blood flow, it is especially important to check your feet daily.
  • If the skin on your feet is dry, keep it moist by applying lotion after you wash and dry your feet. Do not put lotion between your toes. Your doctor can tell you which type of lotion is best.
  • Gently smooth corns and calluses with an emery board or pumice stone. Do this after your bath or shower, when your skin is soft. Move the emery board in only one direction.
  • Check your toenails once a week. Trim your toenails with a nail clipper straight across. Do not round off the corners of toenails or cut down on the sides of the nails. After clipping, smooth the toenails with a nail file.
  • Always wear closed-toed shoes or slippers. Do not wear sandals and do not walk barefoot, even around the house.
  • Always wear socks or stockings. Wear socks or stockings that fit your feet well and have soft elastic.
  • Wear shoes that fit well. Buy shoes made of canvas or leather and break them in slowly. Extra wide shoes are also available in specialty stores that will allow for more room for the foot if you have a foot deformity.
  • Always check the inside of shoes to make sure that no objects are left inside.
  • Protect your feet from heat and cold. Wear shoes at the beach or on hot pavement. Wear socks at night if your feet get cold.
  • Keep the blood flowing to your feet. Put your feet up when sitting, wiggle your toes and move your ankles several times a day, and don’t cross your legs for long periods.
  • If you smoke, stop. Smoking can make problems with blood flow worse.
  • If you have a foot problem that gets worse or won’t heal, contact your doctor.
  • Make sure your diabetes doctor checks your feet during each checkup. Get a thorough foot exam once a year.
  • See your podiatrist (a foot doctor) every 2 to 3 months for checkups, even if you don’t have any foot problems.

To Avoid Serious Foot Problems That Could Result In Losing A Toe, Foot Or Leg, Follow These Guidelines.

  • Inspect your feet daily – Check for cuts, blisters, redness, swelling or nail problems. Use a magnifying hand mirror to look at the bottom of your feet. Call your doctor if you notice anything.
  • Bathe feet in lukewarm, never hot, water – Keep your feet clean by washing them daily. Use only lukewarm water—the temperature you would use on a newborn baby.
  • Be gentle when bathing your feet – Wash them using a soft washcloth or sponge. Dry by blotting or patting and carefully dry between the toes.
  • Moisturize your feet but not between your toes – Use a moisturizer daily to keep dry skin from itching or cracking. But don’t moisturize between the toes—that could encourage a fungal infection.
  • Cut nails carefully – Cut them straight across and file the edges. Don’t cut nails too short, as this could lead to ingrown toenails. If you have concerns about your nails, consult your doctor.
  • Never treat corns or calluses yourself – Any “bathroom surgery” or medicated pads. Visit your doctor for appropriate treatment.
  • Wear clean, dry socks – Change them daily.
  • Consider socks made specifically for patients living with diabetes – These socks have extra cushioning, do not have elastic tops, are higher than the ankle, and are made from fibers that wick moisture away from the skin.
  • Wear socks to bed. If your feet get cold at night, wear socks. Never use a heating pad or a hot water bottle.
  • Shake out your shoes and feel the inside before wearing them – Remember, your feet may not be able to feel a pebble or other foreign object, so always inspect your shoes before putting them on.
  • Keep your feet warm and dry – Don’t let your feet get wet in snow or rain. Wear warm socks and shoes in winter.
  • Consider using an antiperspirant on the soles of your feet – This is helpful if you have excessive sweating of the feet.
  • Never walk barefoot – Not even at home! Always wear shoes or slippers. You could step on something and get a scratch or cut.
  • Take care of your diabetes – Keep your blood sugar levels under control.
  • Do not smoke – Smoking restricts blood flow in your feet.
  • Get periodic foot exams – Seeing your foot and ankle surgeon on a regular basis can help prevent the foot complications of diabetes.

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