Appendix 10

Diabetic Foot Ulcers: Essentials of Management

1.  Assess underlying cause(s): neuropathy and/or ischemia.
 
2.  Ulcers should be probed with a blunt-tipped instrument to detect sinus tracks or palpable bone suggestive of deep infections.
 
3.  Plantar-surface ulcers require pressure relief. Individuals with plantar-surface foot ulcers should be non-weight-bearing as much as possible and utilize off-loading footwear or appliances (1).
 
4.  Clinically noninfected ulcers do not routinely require cultures or antibiotics (2).
 
5.  More serious infections in chronic foot ulcers tend to be polymicrobial and typically require empiric use of broad spectrum systemic antibiotics as soon as possible. Antibiotics can be subsequently tailored according to culture and sensitivity results. Cultures obtained by curettage or biopsy tend to be more reliable than surface swabs (3).
 
6.  Wound bed preparation involves debridement of necrotic tissue (neuropathic wounds and noncritical ischemic wounds only) and maintenance of adequate moist wound environment with appropriate wound dressings. Hydrogels are used to increase wound bed moisture in dry or minimally draining neuropathic ulcers.
 
7.  Comorbidities need to be managed (e.g. hyperglycemia).
 
8.  Refer to a specialized wound clinic where available.
1.  Lavery LA, Baranoski S, Ayello EA. Options for off-loading the diabetic foot. Adv Skin Wound Care. 2004;17:181-186.
2.  Lipsky BA, Berendt AR, Deery HG, et al; for the Infectious Diseases Society of America. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2004;39:885-910.
3.  Frykberg RG, Zgonis T, Armstrong DG, et al; for the American College of Foot and Ankle Surgeons. Diabetic foot disorders. A clinical practice guideline (2006 revision). J Foot Ankle Surg.2006;45(5 suppl):S1-S66.

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