Ulcer treatment

If treatment is based on the following principles healing rates of 80-90% can be attained. The best wound care cannot compensate for continued injury, ischemia or infection. Patients with an ulcer deeper than the subcutis should be treated aggressively and, depending on local resources and infrastructure, hospitalization must be considered.

Principles of ulcer treatment

Relief of pressure

• Non weight bearing is essential
  • Limitation of standing and walking
  • Crutches, etc.
• Mechanical unloading
  • Total contact casting/other casting techniques
  • Temporary footwear
  • Individually molded insoles

Restoration of skin perfusion

• Arterial revascularization procedures (results do not differ from non-diabetic patients, but distal bypass-surgery is needed more frequently)
• The benefits of pharmacological treatment to improve perfusion have not yet been established
• Treat smoking, hypertension and dyslipidemia.

Treatment of infection

• Superficial ulcer with extensive
  • Debridement with removal of all necrotic tissue and oral antibiotics aimed at Staphylococcus aureus and streptococci
  • No topical antibiotics
    
• Deep (limb-threatening) infection - Surgical drainage as soon as possible (emergency referral) with removal of necrotic or poorly vascularized tissue, including infected bone
  • Revascularization if necessary
  • Broad-spectrum antibiotics intravenously, aimed at Gram-positive and negative micro-organisms, including anaerobes.

Metabolic control and treatment of comorbidity

• Optimal diabetes control, if necessary with insulin (blood glucose < 10 mmol/l or < 180mg/dl)
• Treat edema and malnutrition.

Local wound care

• Frequent wound debridement (with scalpel, e.g. once a week)
• Frequent wound inspection
• Absorbent, non-adhesive, non-occlusive dressings
• Growth factors have been shown to be effective in plantar neuropathic ulcers, but their exact place in treatment has yet to be determined
• The following treatments are still experimental
  • Bio-engineered tissue
  • Hyperbaric oxygen treatment
• Footbaths are contra-indicated as they induce maceration of the skin.

Instruction of patient and relatives

• Instruction should be given on appropriate self-care and how to recognize and report signs and symptoms of (worsening) infection, such as fever, changes in local wound conditions or hyperglycemia.

Determining the cause and preventing recurrence

• Determine cause as ulceration is a recurrent disease
• Prevent ulcers on contralateral foot and give heel protection during bed rest
• Patient must be included in a comprehensive foot-care program with life-long observation.

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