Foot Care

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Keith Bowering MD, FRCPC, FACP John M. Embil MD, FRCPC, FACP

  • Key Messages
  • Recommendations
  • Figures
  • Highlights
  • Full Text
  • References

Key Messages

  • Foot problems are a major cause of morbidity and mortality in people with diabetes and contribute to increased healthcare costs.
  • The management of foot ulceration in people with diabetes requires an interdisciplinary approach that addresses glycemic control, infection, offloading of high-pressure areas, lower-extremity vascular status and local wound care.
  • Antibiotic therapy is not generally required for neuropathic foot ulcerations that show no evidence of infection.

Highlights of Revisions

  • Two new recommendations address dressing types for foot ulcers and wound healing therapies.
  • A new table describing Empiric Antibiotic Therapy for Infection in the Diabetic Foot has been added.

Recommendations

  1. 1.In people with diabetes, foot examinations by healthcare providers should be an integral component of diabetes management to identify persons at risk for ulceration and lower-extremity amputation [Grade C, Level 3 (1,2)] and should be performed at least annually and at more frequent intervals in those at high risk [Grade D, Level 4 (4)]. Assessment by healthcare providers should include the assessment of skin changes, structural abnormalities (e.g. range of motion of ankles and toe joints, callus pattern, bony deformities), skin temperature, evaluation for neuropathy and PAD, ulcerations and evidence of infection [Grade D, Level 4 (3)].
  2. 2.People at high risk of foot ulceration and amputation should receive foot care education (including counselling to avoid foot trauma), professionally fitted footwear and early referrals to a healthcare professional trained in foot care management if foot complications occur [Grade C, Level 3 (4-6)].
  3. 3.Individuals who develop a foot ulcer should be managed by a multidisciplinary healthcare team with expertise in the management of foot ulcers to prevent recurrent foot ulcers and amputation [Grade C, Level 3 (7)].
  4. 4.There is currently insufficient evidence to recommend any specific dressing type for diabetic foot ulcers [Grade C, Level 3 (8)]. General principles of wound management involve the provision of a moist wound environment, debridement of nonviable tissue (nonischemic wounds) and offloading of pressure areas [Grade B, Level 3 (9)].
  5. 5.Evidence is currently lacking to support the routine use of adjunctive wound-healing therapies, such as topical growth factors, granulocyte colony-stimulating factors, dermal substitutes or HBOT in diabetic foot ulcers, but they may be considered in nonhealing, nonischemic wounds when all other options have been exhausted [Grade D, Level 4 (10-12)].

Abbreviations:
HBOT , hyperbaric oxygen therapy; PAD , peripheral arterial disease.

References

  1. Crawford F, Inkster M, Kleijnen J, Fahey T. Predicting foot ulcers in patients with diabetes: a systematic review and meta-analysis. QJM 2007;100:65-86.
  2. Feng Y, Schlösser FJ, Bauer E, Sumpio BE. The Semmes Weinstein monofilament examination is a significant predictor of the risk of foot ulceration and amputation in patients with diabetes mellitus. J Vasc Surg 2011;53:220-6.
  3. Boulton AJ, Armstrong DG, Albert SF, et al. American Diabetes Association, American Association of Clinical Endocrinologists. Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care 2008;31:1679-85.
  4. Arad Y, Fonseca V, Peters A, Vinik A. Beyond the monofilament for the insensate diabetic foot. Diabetes Care 2011;34:1041-6.
  5. Valk GD, Kriegsman DM, Assendelft WJ. Patient education for preventing diabetic foot ulceration: a systematic review. Endocrinol Metab Clin N Am 2002; 31:633-58.
  6. McCabe CJ, Stevenson RC, Dolan AM. Evaluation of a diabetic foot screening and protection programme. Diabet Med 1998;15:80-4.
  7. Dargis V, Pantelejeva O, Jonushaite A, et al. Benefits of a multidisciplinary approach in the management of recurrent diabetic foot ulceration in Lithuania: a prospective study. Diabetes Care 1999;22:1428-31.
  8. Vermeulen H, Ubbink D, Goossens A, et al. Dressings and topical agents for surgical wounds healing by secondary intention. Cochrane Database Syst Rev 2004;2:CD003554.
  9. Steed DL, Donohoe D, Webster MW, Lindsley L. Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Diabetic Ulcer Study Group. J Am Coll Surg 1996;183:61-4.
  10. Buchberger B, Follmann M, Freyer D, et al. The importance of growth factors for the treatment of chronic wounds in the case of diabetic foot ulcers. GMS Health Technol Assess 2010;6. Doc12 doi: 10.3205/hta000090.
  11. Cruciani M, Lipsky BA, Mengoli C, de Lalla F. Granulocyte-colony stimulating factors as adjunctive therapy for diabetic foot infections. Cochrane Database Syst Rev 2009;3:CD006810.
  12. Löndahl M, Fagher K, Katzman P. What is the role of hyperbaric oxygen in the management of diabetic foot disease? Curr Diab Rep 2011;11:285e93.

 

Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.

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