Treatment of Diabetic Foot Ulcers

Abstract

The development of diabetic foot ulcers is a well-known complication of diabetes. The pathophysiological mechanism is complex, and different clinical presentations are possible, depending on the specific underlying pathology. Diabetic foot ulcers are usually caused by several factors acting in concert, with polyneuropathy, altered biomechanics, inadequate shoes and peripheral arterial disease (PAD) as major factors. Neuropathy is present in most patients with diabetic foot ulcers, while PAD is present in 30 - 50 %; infection can be diagnosed in up to 50% of patients presenting with a foot ulcer. Therefore careful examination of the patient and identification of these specific pathologies is needed before the start of any treatment. Because most patients have lost the natural protective mechanism to relieve pressure from the wound, off-loading of these ulcers is extremely important. For plantar foot ulcers total contact casting is the current standard: with this technique up to 90% of neuropathic ulcers can be healed within two months. The recognition and treatment of infection is equally important. Diagnosing infection is a challenge in these patients because signs and symptoms can be absent. The choice of the initial antimicrobial therapy is usually empiric and based on the severity of the infection, prior antibiotic use and local resistance to most common pathogens. Evaluation of the severity of PAD is indicated in many patients. Patients with critical limb ischemia should undergo revascularisation as soon as possible, and both endovascular treatment and bypass surgery are suitable interventions to improve tissue perfusion. Most other strategies to improve wound healing, such as local application of growth factors, have failed to show significant clinical benefits. Recently, negative pressure wound therapy was shown to improve wound healing in patients with a partial foot amputation in a large randomised trial. Many patients not only have foot problems but also other health problems such as cardiovascular and renal disease and self care problems. Therefore an integrated management programme is needed, in which optimal regulation of diabetes and associated co-morbidity, and regular communication and instruction of the patient and his or her caregivers are taken care of. Keywords: peripheral vascular disease (PAD), neuropathic foot ulcer, Neovascularisation, Peripheral Bypass Surgery, Hyperbaric Oxygen Therap