MANAGEMENT OF DIABETIC FOOT ULCERS FOR THE HEALTHCARE TEAM
Austin Fredrickson, MD, FACP
Austin Fredrickson is an Associate Professor of Internal Medicine at NEOMED and is a board-certified general internal medicine physician.
Liz Fredrickson, PharmD, BCPS
Liz Fredrickson is an Associate Professor of Pharmacy Practice and Pharmaceutical Sciences at the Northeast Ohio Medical University (NEOMED) College of Pharmacy.
Topic Overview
Patients with diabetes mellitus can face significant health complications because of their illness, including potential retinopathy, kidney disease, and diabetic foot ulcers (DFUs). Diabetic foot ulcers are a common and serious complication of diabetes mellitus, with the potential to result in infection, hospitalization, and possible amputation if not managed appropriately. Care teams should be familiar with local care strategies for optimal healing. Treating DFUs requires a collaborative care approach involving endocrinologists, vascular specialists, podiatrists, infectious disease experts, and primary care providers. Collaborative care includes educating patients and their caregivers on self-care practices. Early detection, preventive measures, and equitable care delivery are essential to reduce the burden of diabetic foot complications, reduce systemic disparities, and improve outcomes.
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Universal Activity Number (UAN): The ACPE Universal Activity Number assigned to this activity is
Pharmacist 0669-0000-24-190-H01-P
Pharmacy Technician 0669-0000-24-191-H01-T
Credits: 2 contact hour(s) (0.2 CEU(s)) of continuing education credit
Type of Activity: Knowledge
Media: Internet/Home study Fee Information: $6.99
Estimated time to complete activity: 2 contact hour(s) (0.2 CEU(s)), including Course Test and course evaluation
Release Date: December 30, 2024 Expiration Date: December 30, 2027
Target Audience: This educational activity is for pharmacists and pharmacy technicians.
Secondary Audiences: Other healthcare professionals, such as nurses, physicians, or others who may be part of a healthcare team, may be interested in this educational topic. Healthcare-team approaches to patient care are discussed in this activity. No state board or professional organization has evaluated this activity to determine whether it meets the continuing education requirements of nurses, physicians, or other professions not listed under the “Target Audience” described above. Always verify with individual employers or supervisors whether they will accept this educational activity upon completion.
How to Earn Credit: From December 30, 2024, through December 30, 2027, participants must:
Read the “learning objectives” and “author and planning team disclosures;”
Study the section entitled “Educational Activity;” and
Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)
Credit for this course will be uploaded to CPE Monitor®.
Learning Objectives: Upon completion of this educational activity, participants should be able to:
Recall risk factors for the development of diabetic foot ulcers
Describe how to evaluate a patient with a diabetic foot ulcer
Describe strategies to prevent diabetic foot ulcers
Compare and Contrast care strategies for diabetic foot ulcers
Disclosures
The following individuals were involved in developing this activity: Liz Fredrickson, PharmD, BPCS, Austin Fredrickson, MD, FACP, and Pamela Sardo, PharmD, BS. Pamela Sardo, Liz Fredrickson, and Austin Fredrickson have no conflicts of interest or financial relationships regarding the subject matter discussed. There are no financial relationships or commercial or financial support relevant to this activity to report or disclose by RxCe.com or any of the individuals involved in the development of this activity.
© RxCe.com LLC 2024: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.
Educational Activity
Management of Diabetic Foot Ulcers for the Healthcare Team Introduction
Patients with diabetes mellitus often face significant health complications because of their illness. Complications include potential retinopathy, kidney disease, and diabetic foot ulcers. To guide treatment decisions, care team members must assess and categorize diabetic ulcers effectively. They should also be familiar with local care strategies, including wound debridement, offloading techniques, and proper wound dressing application to promote optimal healing. In this continuing education activity, participants will learn about factors that place diabetic patients at risk of developing foot ulcers. Best practices for evaluating these injuries and preventing complications are discussed. This presentation will also cover preventive and treatment strategies in the context of the healthcare team's collaborative care considerations, including educating patients and their caregivers on self-care practices.
Terminology and Acronyms
Diabetic foot ulcers (DFUs) are a break of the epidermis and at least part of the dermis in a person with diabetes.1 They are a common and serious complication of diabetes mellitus, with the potential to result in infection, hospitalization, and possible amputation if not managed appropriately.1 Diabetic foot ulcers are distinct from the surface or closed lesions that have not penetrated into the dermis. These surface or closed lesions are pre-ulcerative and may manifest as calluses, blisters, warm areas, or erythema.1 Before proceeding further, Table 1 provides common acronyms that are useful when discussing DFUs.
| Acronym | Full Form | Relevance to DFU Treatment |
| ADA | American Diabetes Association | Sets guidelines for diabetes management, including foot care |
| IWGDF | International Working Group on the Diabetic Foot | Provides global recommendations for preventing and managing diabetic foot disease |
| DFU | Diabetic Foot Ulcer | Chronic complications of diabetes requiring specialized wound care |
| PAD | Peripheral Arterial Disease | Common comorbidity affecting blood flow to lower extremities |
| HbA1c | Hemoglobin A1c | Used to monitor long-term glycemic control in diabetes management |
| ABPI | Ankle-Brachial Pressure Index | Diagnostic tool to assess blood flow and detect PAD |
| TCC | Total Contact Casting | Preferred offloading method for plantar foot ulcers |
| NPWT | Negative Pressure Wound Therapy | Used for wound healing in specific DFU cases |
| MRI | Magnetic Resonance Imaging | Imaging modality to detect osteomyelitis or deep infections |
| LOPS | Loss of Protective Sensation | Indicates high risk for foot ulceration due to neuropathy |
Table 1 Acronyms
Etiology and Epidemiology
Diabetic foot ulcers are a preventable cause of morbidity among adults with diabetes, yet they remain a significant global health concern, affecting millions of people globally.2 Worldwide, over 550 million people have diabetes, including 37 million in the United States (US).2 Each year, approximately 18.6 million people with diabetes globally develop a foot ulcer, with between 19% and 34% of individuals with diabetes mellitus experiencing a foot ulcer during their lifetime.1,2 An estimated 20% of these patients will require an amputation, and 20% will require hospitalization at some point.1,2 In the US alone, more than 150,000 nontraumatic lower extremity amputations are performed annually in people with diabetes.2 Unfortunately, upwards of 10% of patients with a DFU will die within a year of diagnosis.1
Diabetic foot complications disproportionately affect marginalized and vulnerable populations, often as the result of inequitable care.1,2 Inequities in outcomes are notable, particularly among racial and ethnic minorities, individuals with lower socioeconomic status, and those in rural areas.2 Higher mortality and amputation rates have been noted among minority populations and those of lower socioeconomic status.1 For example, Medicare data finds that non-Hispanic Black (3.8%), Hispanic (2.1%), and Native American (5.1%) beneficiaries have significantly higher rates of major lower extremity amputation compared to non-Hispanic White beneficiaries (1.5%).2 Rural populations are similarly affected, with higher rates of major amputations (3.4% vs. 2.4%) compared to metropolitan residents.2
Etiology
Diabetic foot ulcers are categorized into three main types based on etiology: purely neuropathic (35%), purely ischemic (15%), and mixed neuroischemic (50%).1 Neuropathic ulcers arise from peripheral neuropathy and the resulting sensory loss, which increases the risk of injury to weight- bearing areas of the foot.1 Ischemic ulcers develop from peripheral artery disease (PAD), characterized by insufficient blood flow to tissues, leading to ischemia and poor wound healing.1 Neuroischemic ulcers, the most common type of foot ulcers in diabetics, result from a combination of PN and PAD, where sensory deficits and impaired circulation contribute to ulcer development.1
Risk Factors
Recognizing factors that increase the risk of foot ulceration and amputation in patients with diabetes is critical for effective prevention and management. Collaborative care is essential and may involve the coordinated efforts of primary care providers, endocrinologists, podiatrists, vascular specialists, and other healthcare professionals. Key risk factors include poor glycemic control, peripheral neuropathy or loss of protective sensation (LOPS), PAD, foot deformities (such as bunions, hammertoes, and Charcot's joint), pre-ulcerative corns or calluses, prior ulceration or amputation,
smoking, retinopathy, and nephropathy, especially in individuals undergoing dialysis or post-transplant care.2 Table 2 details these risk factors.1,2
Table 2
Risk Factors for the Development of Diabetic Foot Ulcers1,2
| Risk Factor | Impact on DFU |
| Age | |
| Sex/Gender | |
| Glycemic Management | |
| Overweight, Obesity, and Underweight | |
| Smoking |
Increased risk with advancing age due to cumulative effects of hyperglycemia and higher prevalence of micro- and macrovascular complications
Younger adults with DFU often present with advanced stages, reflecting poorly managed disease
Higher incidence among men, with increased rates of minor and major amputations
Likely linked to differences in PN, PAD, and cardiovascular disease prevalence, as well as access to care
Chronic hyperglycemia increases the risk of DFU, amputation, and mortality
Early intensive glucose control reduces the lifetime risk of DFU and the progression of complications
Underweight BMI is associated with an increased risk of amputation and mortality, reflecting frailty and poor nutrition
Obesity has no consistent association with the incident or recurrent DFU
Strongly associated with PN, PAD, longer healing time, nonhealing DFU, and increased risk of amputation
Smoking cessation improves amputation-free survival
CVD: Bidirectional association with DFU. Increases risk of delayed healing, amputation, and mortality. DFU and cardiovascular disease synergistically worsen outcomes
CKD, especially end-stage kidney disease, is linked to higher rates of incident DFU, slower healing, and increased amputation risk
Strongest risk observed in advanced CKD stages
High prevalence among DFU patients
Associated with progression of retinopathy and increased risk of foot trauma due to visual impairment and gait instability
History of foot ulcer
Amputation (minor or major)
End-stage renal disease
Identifying the at-risk foot
Regularly inspecting and examining the at-risk foot
Educating the person with diabetes, family and healthcare providers
Ensuring routine use of appropriate footwear
Treating risk factors for ulceration
Prevention recommendations should be tailored to each patient. Patient education is a crucial part of these strategies. It should focus on promoting protective behaviors such as avoiding walking barefoot, wearing appropriate footwear indoors and outdoors, and maintaining proper foot hygiene, including daily washing, drying, and moisturizing.4 The healthcare team should encourage patients to examine their feet daily and contact their healthcare provider if they suspect or identify lesions.4 Patients at moderate or high risk should be coached on self-monitoring foot skin temperatures, which can help detect early signs of inflammation.4 If they identify significant temperature differences between corresponding areas of the feet, they should be counseled to contact their provider and reduce activity.4 Well-fitting, accommodating footwear should be recommended to patients of all risk levels.4 Custom-made footwear or insoles can be recommended for patients with deformities.3,4 Clinicians should evaluate prescribed footcare protocols regularly, including every 1–3 months for high-risk patients and every 3–6 months for moderate- risk patients, to ensure ongoing prevention and risk reduction.4 These measures, implemented collaboratively by an interprofessional team, can help mitigate the risk of foot ulceration and improve outcomes for individuals with diabetes.
Treatment Collaborative Care Approaches
Effectively treating diabetic foot ulcers requires a comprehensive, patient-centered approach that integrates interprofessional collaboration. The successful prevention and treatment of diabetes-related foot disease requires a well-organized, interdisciplinary approach that views a foot ulcer as a sign of systemic, multi-organ disease. A structured system for chronic care management, rather than just reacting to acute complications, is fundamental for effective care. Diabetes-related foot care should ideally be provided across three levels of management, ensuring interdisciplinary expertise at each stage (Table 5).6 By organizing care at these levels, interdisciplinary teams can ensure holistic, timely, and effective care for patients with DFU.6
Table 5
Care Levels for Patients with DFU (IWGDF)6
| Level of Care | Specialists Involved |
| Level 1 | General practitioner, podiatrist, and diabetes nurse. |
Level 2 | Diabetologist, surgeon (general, orthopedic, or foot/podiatric), vascular specialist (endovascular and open revascularization), infectious disease specialist or microbiologist, podiatrist, and diabetes nurse, in collaboration with a pedorthist, orthotist, or prosthetist. |
Level 3 | A Level 2 foot center specializing in diabetes-related foot disease, with multiple experts from several disciplines working together as a tertiary reference center. |
The care team must treat the DFU and address systemic and psychosocial factors that may influence healing.4 Many patients report a worsened quality of life with DFU due to amputations and a limited ability to ambulate, whereas those who have healed see increases in well-being.1 Psychosocial support should be provided to address challenges such as depression, anxiety, or frailty, ensuring the patient’s ability to adhere to treatment.4 By embracing a team-based, collaborative approach, healthcare
providers can deliver comprehensive care that meets the multifaceted needs of patients with diabetic foot ulcers.
Care Strategies
Treating diabetic foot conditions depends on the individual's risk category and emphasizes a collaborative, multidisciplinary approach to ensure optimal outcomes. Patients at no or low risk of developing a DFU can often be managed through education and self-care, including daily foot inspections and proper footwear selection.3 However, moderate or high-risk patients, including those with LOPS, PAD, or structural foot deformities, will require referral to foot care specialists or an interprofessional team for further evaluation and ongoing surveillance.3 Urgent referral is essential for patients presenting with open ulceration or unexplained swelling, erythema, or increased skin temperature to prevent complications.3
The ADA guidelines note five principles for ulcer treatment:3
Offloading plantar ulcerations
Debridement of necrotic tissue
Revascularization of ischemic wounds
Infection management
Use of appropriate topical dressings
Active Diabetic Foot Complication Management
For patients who present with no infection and a plantar wound, wound care includes using non-removable knee-high total contact casts or walkers, which are more effective than removable devices.2 Alternatively, removable knee-high or ankle-high walker devices or surgical off-loading (e.g., Achilles tendon lengthening) may be used in addition to wound care.2 Patients can be reassessed after four weeks.2 If the wound shows a good healing trajectory, the diabetic foot ulcer is considered healed, and continued surveillance for ulcer remission is recommended.2 If poor healing is observed, systemic factors affecting healing, such as diabetes control and changes in wound, ischemia,
or infection, should be reassessed.2 If no plantar wound is present, wound care involves off-loading devices, such as postoperative healing sandals.2
Antimicrobial therapy with or without debridement is initiated for patients with infection.2 Clinical assessment for ischemia is performed, and an ischemia grade (0–3) is assigned.2 If osteomyelitis is suspected, testing is performed as indicated, with bone biopsy and culture being the preferred diagnostic methods.2 If osteomyelitis is confirmed, management options include wound debridement, limb-sparing amputation, or prolonged antimicrobial therapy.2
In cases where ischemia is graded as 1–3, the likelihood of improved outcomes with revascularization is assessed.2 If revascularization is deemed beneficial, it is performed, and testing for osteomyelitis continues as needed.2 However, if revascularization is unlikely to improve outcomes, the focus shifts to comfort-focused care to prevent deterioration, hospitalization, or amputation, as appropriate.2
Off-loading stress on the foot is essential for patients, as this allows for healing by reducing pressure over the wound.2 Table 6 summarizes methods by which to reduce weight-bearing pressure.2
Table 6
Methods for Reducing Weight-Bearing Pressure2
| Off-loading methods | Description |
| Knee-high nonremovable off-loading device | Total contact cast or knee-high walker rendered nonremovable (preferred off-loading method for most patients) |
| Removable knee-high and ankle-high walkers | Off-loading devices that can be removed by the patient |
| Felted foam in appropriately fitting shoes | Felted foam applied to at least the ulcer region |
| Flexor tendon tenotomy | Surgical procedure for ulcers on the apex of the lesser toes |
| Achilles tendon lengthening | Surgical procedure for plantar forefoot ulcers if nonsurgical treatment fails |
Selecting the appropriate wound dressing is also an important consideration.2 Factors to consider include the location of the wound, if inflammation is present, and how much exudate is present.2 Table 7 summarizes wound dressing types. No matter which type is selected, the dressing should provide a moist environment without causing further tissue breakdown.2
Table 7 Wound Dressings2
| Dressing type | Characteristics and use |
| Alginates | These dressings form a damp gel on absorption, necessitating a secondary dressing. They are conformable, filling dead spaces and managing moderate to heavy exudate effectively. Suitable for wounds with light to moderate serous drainage. |
| Antimicrobial dressings | These dressings contain substances such as silver or iodine that inhibit bacterial growth in the wound, making them suitable for infected wounds or those at high risk of infection. However, there is a lack of strong evidence recommending their use despite their widespread application. |
| Collagens | Derived from bovine, equine, porcine, or ovine (sheep) sources, these products help stimulate wound healing. Available in various forms such as gel, pad, paste, powder, and sheets. Some dissolve entirely while others need removal per the manufacturer’s guidelines. A secondary dressing is usually required. Ideal for wounds showing granulation tissue, as they further stimulate its formation. |
| Film dressings | Thin, transparent dressings that foster a moist environment, promoting healing and enabling wound assessment without removal. Ideal for superficial wounds with minimal exudate. |
| Foams | These dressings are capable of absorbing moderate quantities of exudate and can be used under compression. |
| Gauze | Highly permeable dressing material, suitable for wound cleaning, as a cover dressing, and for securing dressings. Gauze is not generally recommended as a primary wound dressing because it can remove healthy granulation tissue during dry dressing changes. |
| Hydrocolloids | These bacteria-proof dressings facilitate autolytic debridement. They are not appropriate for infected wounds as they may damage fragile skin. Ideal for wounds with insignificant serous drainage. |
| Hydrogels | These are glycerin and water-based products available as amorphous gels, sheets, or impregnated dressings. They can be antimicrobial, donate moisture to wounds, assist in autolytic debridement, and possibly reduce pain. They require a secondary dressing and are suitable for low- exudate wounds needing additional moisture. |
Resources
Table 9 details additional resources that can assist in learning more about this topic.
Table 9 Resources
| Resource | Focus | Citation |
IWGDF Guidelines (2023) | Comprehensive guidelines for the prevention and treatment of diabetes-related foot disease. | International Working Group on the Diabetic Foot (IWGDF). 'IWGDF Guidelines on the Prevention and Treatment of Diabetic Foot Disease, 2023.' Available at: iwgdfguidelines.org |
| American Diabetes Association (ADA) | Standards of care in diabetes, including foot care, infection management, and risk stratification. | American Diabetes Association. 'Standards of Medical Care in Diabetes—2024.' Diabetes Care, 2024. |
NICE Guidelines (NG19) | Guidance on the prevention and management of diabetic foot problems, focusing on care pathways. | National Institute for Health and Care Excellence (NICE). 'Diabetic foot problems: prevention and management (NG19).' Available at: nice.org.uk |
| American Academy of Dermatology | Guidance on prevention and management | Alavi A, Sibbald RG, Mayer D, et al. Diabetic foot ulcers: Part I. Pathophysiology and prevention. J Am Acad Dermatol. 2014;70(1):1.e1-20. doi:10.1016/j.jaad.2013.06.055 |
| Centers for | Resources on | Centers for Disease Control and |
| Disease | diabetes foot | Prevention (CDC). 'Diabetes and Foot |
| Control and | care, risk factor | Care.' Available at: cdc.gov |
| Prevention | identification, and | |
| (CDC) | infection | |
| prevention. |
Summary
Many patients with diabetes mellitus will face significant health complications because of their illness, including potential retinopathy, kidney disease, and DFU. DFUs are a common and serious complication of diabetes mellitus, with the potential to result in infection, hospitalization, and possible amputation if not managed appropriately. Addressing this complex issue requires a collaborative care approach involving endocrinologists, vascular specialists, podiatrists, infectious disease experts, and primary care providers. Focusing on early detection, preventive measures, and equitable care delivery is essential to reduce the burden of diabetic foot complications, improve outcomes, and address systemic disparities.
Course Test
Which of the following is a risk factor for developing a diabetic foot ulcer (DFU)?
Younger age
Male sex
Obesity
Smoking cessation
During the patient evaluation, which of the following options lists the three main risk factors for developing diabetic foot ulcers (DFU)?
Loss of protective sensation, peripheral artery disease, foot deformity
Asthma, loss of protective sensation, smoking
Foot deformity, coronaviruses, chronic kidney disease
Cataracts, mechanical stress, cardiovascular disease
Which of the following relates a patient’s ulcer risk to the correct recommended foot screening frequency?
Very low; every two years
Low; every 6-12 months
Moderate; every 12 months
High; annually
Which of the following terms is the “S” in the SINBAD system for classifying and scoring foot ulcers?
Size
Sensation
Site
Secretion
Which of the following is confirmed when a patient cannot sense the monofilament and has one other abnormal foot examination result?
Loss of protective sensation (LOPS)
Peripheral artery disease (PAD)
Chronic kidney disease (CKD)
Cardiovascular disease (CVD)
Patients at moderate or high risk for DFU can be coached on self- monitoring to detect early signs of inflammation.
application of band-aids
SINBAD system scores
by measuring ulcer sizes
foot skin temperature
Which of the following is a helpful strategy a patient may use to prevent the development of diabetic foot ulcers?
Wear sandals as frequently as possible
Wash feet every other day
Ensure appropriate footwear
Increase activity levels if foot skin temperature differences are noted
Which of the following is one of the ADA’s five principles for ulcer treatment?
Infection management
Increasing mechanical load
Debriding all diabetic foot ulcers
Avoiding the use of topical dressings
For patients who present with no infection and a plantar wound, which of the following is most effective for managing off-loading?
Removable knee-high walkers and antibiotics
Felted foam with gauze pads
Achilles tendon lengthening with closed-toe shoes
Non-removable knee-high total contact casts or walkers
A clinician is seeking a wound dressing for a patient that does not require a secondary dressing. Which of the following should be selected?
Hydrogel
Gauze
Collagen
Alginate
References
McDermott K, Fang M, Boulton AJM, Selvin E, Hicks CW. Etiology, Epidemiology, and Disparities in the Burden of Diabetic Foot Ulcers. Diabetes Care. 2023;46(1):209-221. doi:10.2337/dci22-0043
Armstrong DG, Tan TW, Boulton AJM, Bus SA. Diabetic Foot Ulcers: A Review. JAMA. 2023;330(1):62-75. doi:10.1001/jama.2023.10578
American Diabetes Association Professional Practice Committee. 12. Retinopathy, Neuropathy, and Foot Care: Standards of Care in Diabetes-2024. Diabetes Care. 2024;47(Suppl 1):S231-S243. doi:10.2337/dc24-S012
Bus SA, Sacco ICN, Monteiro-Soares M, et al. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3):e3651. doi:10.1002/dmrr.3651
Ince P, Abbas ZG, Lutale JK, et al. Use of the SINBAD classification system and score in comparing outcome of foot ulcer management on three continents. Diabetes Care. 2008;31(5):964-967. doi:10.2337/dc07-2367
Schaper NC, van Netten JJ, Apelqvist J, et al. Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3):e3657. doi:10.1002/dmrr.3657
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