Recurrent diabetic foot ulcer: An educational image and expert opinion

Abstract

Background: The occurrence of diabetic foot ulcers is commonly attributed to factors including infection, diabetic neuropathy that are commonly associated poor control of blood sugar. History of foot ulcer is generally considered an important risk factor. Keywords: Richard Asher syndrome, Iraq. Patients and methods: The case of a diabetic and hypertensive male patient who had a history of previous foot ulcer, and developed a recurrence at the same site is described with emphasis on the current evidence-based therapeutic recommendations. Results: A 55-year diabetic hypertensive male who had a history of foot ulcer which healed completely after aggressive treatment before more than one year. The first ulcer was associated with clear evidence of infection with cellulitis and pus formation, but there was no evidence of gangrene. The first ulcer was treated successfully with antibiotic therapy followed by monthly intramuscular injection of benzathine penicillin. Topical treatment included topical antibiotic (fusidic acid) and topical dexpanthenol. Pentoxifylline was used instead valsartan to control hypertension and to improve peripheral vascular impairment. The patient also received alpha-lipoic acid supplementation. Few weeks before the occurrence of the second ulcer, the patient visited the practitioner of the organization who was working with, and for unclear reason, the doctor switched pentoxifylline with Coveram (Perindopril 10 mg + Amlodipine 10 mg). The ulcer was not associated with evidence of serious infection, and cellulitis like the first ulcer. However, the patient received oral antibiotics and topical therapies. To avoid injudicious frequent changes of antihypertensive medication, oral pentoxifylline was added in a dose of 400 mg daily. The second ulcer healed within one week. Conclusion: The medical treatment of the diabetic foot ulcer follows the principles of wound healing which include treatment of soft tissue infection, in addition to controlling factors more specifically related to diabetes such as neuropathy and peripheral vascular impairment. The current expert opinion suggests the use of monthly intramuscular benzathine penicillin, alpha-lipoic acid supplementation, and pentoxifylline in the long-term preventive therapies.