Diabetic foot ulcers and infections: Current concepts

Advances in Skin & Wound Care, Jan/Feb 2002 by Calhoun, Jason H, Overgaard, Kristi A, Stevens, C Melinda, Dowling, James P E, Mader, Jon T

* Daily inspection of the toes and feet should be emphasized.

* Patients should be advised to wear well-fitting socks and shoes and to inspect their shoes daily for foreign objects or irregularities that can cause wounds.

* Toenails should be trimmed and rough edges should be filed with an emery board.

* Patients should be reminded to wash their feet daily and dry them well and to keep their feet warm and dry.

* Lotion should be used to avoid dryness and cracking of the skin.

* Exercise, proper nutrition, and smoking cessation are important components of a diabetic ulcer prevention program.

Many patients are not aware that they have diabetes. Almost half (43%) of all diabetic patients have their first hospital admission or diagnosis of diabetes associated with a foot ulcer or infection.41,42 After a patient has developed an ulcer, prevention techniques are useful during the wound healing process to prevent further or recurrent ulceration.

Wound Care Techniques

Management of diabetic foot ulcers is becoming more challenging and controversial with the increasing number of wound care products, protocols, and algorithms available. This difficulty is especially pronounced for health care professionals without specialized training in wound care.43 The evolution of wound management and wound care products has created the need for standardized clinical pathways for wound management in the treatment of diabetic ulcerations.

Numerous classification systems have been developed to aid in the treatment of diabetic foot ulcers and infections.42,44,45 One of the best known is the Wagner classification system.46 A useful modification of this system with the addition of treatment guidelines is presented in Table 144

Optimal treatment of diabetic foot ulcers includes a program of ongoing debridement, adequate application of dressings and frequent dressing changes, efforts to reduce pressure points on a patient's feet, and the use of adjunctive therapies and newer technologies for nonhealing wounds.

Debridement

The first step in treating a diabetic foot ulcer is to perform debridement of the wound. Debridement should be ongoing throughout the healing process. In a retrospective study by Steed et al,47 higher healing rates were seen in patients who received more frequent debridement.

Proper debridement removes all necrotic and infected tissue, leaving a clean, open wound; this is essential for healing to occur. In addition, debridement reduces the bacterial load of the wound, which can impede wound healing and lead to infection. Debridement also allows for better visualization of the wound, which helps in making an accurate assessment. Superficial debridement around the ulcer site can be performed on a neuropathic diabetic foot without the use of an anesthetic. For some wounds, however, deeper surgical debridement may be necessary.

Wound dressings

The primary function of a wound dressing is to promote a moist healing environment, which is necessary for tissue repair.48 The parameters of a particular wound dressing are often overlooked when the features of a specific dressing category are considered. Dressings are often categorized by their ability to provide protection and conformability to the wound and comfort to the patient Functional parameters of dressings include (1) exudate absorptive capacity,49 (2) the ability to debride nonviable tissue and reduce microbial contaminants, (3) promotion of wound rehydration,50 and (4) the potential for use as a vehicle for antibiotic delivery to the wound bed. Table 2 outlines the functions and indications of commonly used types of dressing materials.