Management of Diabetic Foot Ulcers

Abstract

Diabetic foot is a serious complication of diabetes which aggravates the patient's condition whilst also having significant socioeconomic impact. The aim of the present review is to summarize the causes and pathogenetic mechanisms leading to diabetic foot, and to focus on the management of this important health issue. Increasing physicians' awareness and hence their ability to identify the "foot at risk," along with proper foot care, may prevent diabetic foot ulceration and thus reduce the risk of amputation.

Full text

REVIEW
Management of Diabetic Foot Ulcers
Kleopatra Alexiadou •John Doupis
To view enhanced content go to www.diabetestherapy-open.com
Received: December 23, 2011
The Author(s) 2012. This article is published with open access at Springerlink.com
ABSTRACT
Diabetic foot is a serious complication of
diabetes which aggravates the patient’s
condition whilst also having significant
socioeconomic impact. The aim of the present
review is to summarize the causes and
pathogenetic mechanisms leading to diabetic
foot, and to focus on the management of this
important health issue. Increasing physicians’
awareness and hence their ability to identify the
‘‘foot at risk,’’ along with proper foot care, may
prevent diabetic foot ulceration and thus reduce
the risk of amputation.
Keywords: Debridement; Diabetic foot;
Dressings; Neuropathy; Off-loading;
Pathogenesis; Peripheral arterial disease;
Ulceration
INTRODUCTION
Diabetic foot is one of the most significant and
devastating complications of diabetes, and is
defined as a foot affected by ulceration that is
associated with neuropathy and/or peripheral
arterial disease of the lower limb in a patient
with diabetes. The prevalence of diabetic foot
ulceration in the diabetic population is 4–10%;
the condition is more frequent in older patients
[1–3]. It is estimated that about 5% of all
patients with diabetes present with a history of
foot ulceration, while the lifetime risk of
diabetic patients developing this complication
is 15% [1–3].
The majority (60–80%) of foot ulcers will
heal, while 10–15% of them will remain active,
and 5–24% of them will finally lead to limb
amputation within a period of 6–18 months
after the first evaluation. Neuropathic wounds
are more likely to heal over a period of 20 weeks,
while neuroischemic ulcers take longer and will
K. Alexiadou
First Department of Propaedeutic Medicine, Athens
University Medical School, Laiko General Hospital,
Athens, Greece
J. Doupis (&)
Department of Internal Medicine and Diabetes
Clinic, Salamis Naval Hospital, Salamis Naval Base,
18900 Salamis, Greece
e-mail: john.doupis@joslin.harvard.edu
Enhanced content for this article is
available on the journal web site:
www.diabetestherapy-open.com
123
Diabetes Ther (2012) 3:4
DOI 10.1007/s13300-012-0004-9

more often lead to limb amputation [4]. It has
been found that 40–70% of all nontraumatic
amputations of the lower limbs occur in
patients with diabetes [5]. Furthermore, many
studies have reported that foot ulcers
precede approximately 85% of all amputations
performed in diabetic patients [5].
The risk of foot ulceration and limb
amputation increases with age and the
duration of diabetes [6,7]. The prevention of
diabetic foot is crucial, considering the negative
impact on a patient’s quality of life and the
associated economic burden on the healthcare
system [8].
Diabetic foot ulceration is a major health
problem and its management involves a
multidisciplinary approach. This review aims to
provide a synopsis of the current management
strategies of diabetic foot ulcers, from prevention
to the options for treatment. The authors believe
that it may be useful to primary care physicians,
nurses, podiatrists, diabetologists, and vascular
surgeons, as well as all healthcare providers
involved in the prevention or management of
diabetic foot ulcers.
PATHOGENESIS
The most significant risk factors for foot
ulceration are diabetic neuropathy, peripheral
arterial disease, and consequent traumas of the
foot.
Diabetic neuropathy is the common factor in
almost 90% of diabetic foot ulcers [9,10]. Nerve
damage in diabetes affects the motor, sensory,
and autonomic fibers. Motor neuropathy causes
muscle weakness, atrophy, and paresis. Sensory
neuropathy leads to loss of the protective
sensation of pain, pressure, and heat.
Autonomic dysfunction causes vasodilation
and decreased sweating [11], resulting in a loss
of skin integrity, providing a site vulnerable to
microbial infection [12].
Peripheral arterial disease is 2–8 times more
common in patients with diabetes, starting at
an earlier age, progressing more rapidly, and
usually being more severe than in the general
population. It commonly affects the segments
between the knee and the ankle. It has been
proven to be an independent risk factor for
cardiovascular disease as well as a predictor of
the outcome of foot ulceration [13]. Even minor
injuries, especially when complicated by
infection, increase the demand for blood in
the foot, and an inadequate blood supply may
result in foot ulceration, potentially leading to
limb amputation [14]. The majority of foot
ulcers are of mixed etiology (neuroischemic),
particularly in older patients [15].
In patients with peripheral diabetic
neuropathy, loss of sensation in the feet leads
to repetitive minor injuries from internal
(calluses, nails, foot deformities) or external
causes (shoes, burns, foreign bodies) that are
undetected at the time and may consequently
lead to foot ulceration. This may be followed by
infection of the ulcer, which may ultimately
lead to foot amputation, especially in patients
with peripheral arterial disease.
Structural foot deformities and
abnormalities, such as flatfoot, hallux valgus,
claw toes, Charcot neuroarthropathy, and
hammer foot, play an important role in the
pathway of diabetic foot ulcers since they
contribute to abnormal plantar pressures and
therefore predispose to ulceration.
Other risk factors for foot ulceration include
a previous history of foot ulceration or
amputation, visual impairment, diabetic
nephropathy, poor glycemic control, and
cigarette smoking. Some studies have shown
that foot ulceration is more common in men
with diabetes than in women [14,16].
Page 2 of 15 Diabetes Ther (2012) 3:4
123

Social factors, such as low socioeconomic status,
poor access to healthcare services, and poor
education are also proven to be related to more
frequent foot ulceration [14,16].
ASSESSMENT
AND CLASSIFICATION
Physical examination of the diabetic foot is
based on assessment of the skin and of the
vascular, neurological, and musculoskeletal
systems.
The dermatological examination includes a
visual inspection of the skin of the legs and feet,
particularly the dorsal, plantar, medial, lateral,
and posterior surfaces, as well as a close
examination of each toenail [17]. Other
observations to be noted include the presence
of peeling skin and maceration or fissuring of
the interdigital skin. The visual inspection may
discover signs of autonomic neuropathy and
sudomotor dysfunction [17].
People with diabetes are at high risk of
developing peripheral vascular disease;
therefore, the palpation of pulses bilaterally in
the dorsalis pedis, posterior tibial, popliteal, and
superficial femoral arteries is necessary for
assessment of the blood circulation in the
lower limbs. Inadequate perfusion of a limb,
due to peripheral vascular disease, may crucially
affect the progress of the healing of an ulcer,
often resulting in chronic unhealed ulcers that
are susceptible to infection [15]. A relatively
simple method to confirm the clinical suspicion
of arterial occlusive disease is to measure the
resting systolic blood pressure in the ankles and
arms. This is performed by measuring the
systolic blood pressure (using a Doppler probe)
in the brachial, posterior tibial, and dorsalis
pedis arteries [17]. The highest of the four
measurements in the ankles and feet is divided
by the higher of the two brachial
measurements. This ratio is referred to as the
ankle–brachial index (ABI). Normal ABI values
range from 1.0 to 1.3, since the pressure is
higher in the ankle than in the arm. Values over
1.3 suggest a noncompressible calcified vessel.
An ABI of less than 0.9 is indicative of
peripheral vascular disease and is associated
with 50% or more stenosis in one or more
major vessels. An ABI of 0.4–0.9 suggests a
degree of arterial obstruction associated with
claudication. An ABI of less than 0.4 or an ankle
systolic pressure of less than 50 mmHg
represents advanced ischemia [18]. The ABI
correlates with clinical measures of lower
extremity function, such as walking distance,
velocity, balance, and overall physical activity.
In addition, a low ABI has been associated with
a higher risk of coronary heart disease, stroke,
transient ischemic attack, progressive renal
insufficiency, and all-cause mortality [19]. A
potential limitation of the ABI is that calcified
vessels may not compress normally, possibly
resulting in falsely elevated Doppler signals.
Thus, an ABI of over 1.3 is suggestive of calcified
vessels. In such patients, an accurate pressure
may be obtained by measuring the blood
pressure in the toe and calculating the toe–
brachial index [19]. If ABIs are normal at rest
but symptoms strongly suggest claudication,
ABIs and segmental pressures should be
obtained before and after exercise on
a treadmill. This may unmask a
hemodynamically significant stenosis that is
subclinical at rest but significant on exertion.
The physician should also assess skin
temperature with the back of the hand.
Normal skin temperature ranges from warm at
the tibia to cool at the distal toes [20]. Foot-skin
temperature can be measured with a handheld
infrared thermometer on the plantar aspect of
the foot at the level of the first metatarsal head.
Diabetes Ther (2012) 3:4 Page 3 of 15
123

Elevated temperature is reported to be
associated with sudomotor dysfunction and a
higher risk for foot ulceration [21,22].
The presence of diabetic neuropathy can be
established from an abbreviated medical history
and physical examination. Symptoms such as a
burning sensation; pins and needles; shooting,
sharp, or stabbing pains; and muscle cramps,
which are distributed symmetrically in both
limbs (‘‘stocking and glove distribution’’), and
often worse at night, are usually present in
peripheral neuropathy. Diabetic peripheral
neuropathy may also be evaluated using the
Neuropathy Symptom Score (NSS), which is a
validated symptom score with a high predictive
value to screen for peripheral neuropathy in
diabetes [23,24] (Table 1).
The physical examination of the foot assesses
the perception of superficial pain (pinprick),
temperature sensation (using a two-metal rod),
light sensation (using the edge of a cotton-wool
twist), and pressure (using the Semmes–
Weinstein 5.07 monofilament). Additionally,
the physician should examine the vibration
perception using a tuning fork and/or a
biothesiometer. The examination of position
sense (proprioception) and deep tendon reflexes
(Achilles tendon, patellar) is also essential [4].
Neuropathic deficits in the feet can be
determined using the Neuropathy Disability
Score (NDS), which is derived from the
inability to detect pinprick sensation (using a
neurological examination pin), vibration (using
a 128-Hz tuning fork), or differences in
temperature sensation (using warm and cool
rods), and loss or reduction of the Achilles reflex
(using a tendon hammer) [1] (Table 1).
According to the American Diabetes
Association, a foot that has lost its protective
sensation is considered to be a ‘‘foot at risk’’
for ulceration. The diagnosis of a foot at
risk is confirmed by a positive
Table 1 Neuropathy Symptom Score (NSS) and
Neuropathy Disability Score (NDS)
Score
NSS
Description
Fatigue/cramping/aching 1
Burning/numbness/tingling 2
Location
Thighs 0
Legs 1
Feet 2
Pain exacerbation:
Daytime only 0
Day and night 1
Night 2
Have the symptoms ever woken the patient from
sleep?
No 0
Yes 1
Could any maneuver reduce the symptoms?
Sitting or lying 0
Standing 1
Walking 2
NSS: …/9
NDS
Big toe
Right
Normal 0
Abnormal 1
Left
Normal 0
Abnormal 1
Vibration perception
Right
Normal 0
Page 4 of 15 Diabetes Ther (2012) 3:4
123

5.07/10-g monofilament test, plus one of the
following tests: vibration test (using 128-Hz
tuning fork or a biothesiometer), pinprick
sensation, or ankle reflexes [25].
The above tests have been reported to have a
positive predictive value of 46% and a negative
predictive value of 87% for the risk of incident
neuropathy [26].
Diabetic foot ulcers are defined as:
neuropathic in the presence of peripheral
diabetic neuropathy and absence of ischemia;
ischemic if the patient presents peripheral artery
disease but no diabetic peripheral neuropathy;
and neuroischemic if neuropathy and ischemia
coexist. Apart from this rather crude
classification, many efforts have been made to
categorize foot ulcers according to extent, size
and depth, location, presence of infection, and
ischemia. The Meggitt–Wagner classification is
one of the most popular validated classifications
for the foot ulcers (Table 2). Other classification
systems for diabetic foot ulcers have also been
proposed and validated [27].
Whatever method is used for the diabetic foot
ulcer evaluation, all classification systems should
aim at facilitating the correct choice of treatment
and reliable monitoring of the healing progress
of the ulcer, while at the same time serving as a
communication tool across specialties.
Table 2 Meggitt–Wagner classification of foot ulcers
Grade Description of the ulcer
0 Pre- or postulcerative lesion completely
epithelialized
1 Superficial, full-thickness ulcer limited to the
dermis, not extending to the subcutis
2 Ulcer of the skin extending through the subcutis
with exposed tendon or bone and without
osteomyelitis or abscess formation
3 Deep ulcers with osteomyelitis or abscess
formation
4 Localized gangrene of the toes or the forefoot
5 Foot with extensive gangrene
Table 1 continued
Score
Abnormal 1
Left
Normal 0
Abnormal 1
Dorsal foot area
Temperature sensation
Right
Normal 0
Abnormal 1
Left
Normal 0
Abnormal 1
Achilles reflex
Right
Normal 0
Increased 1
Abnormal 2
Left
Normal 0
Increased 1
Abnormal 2
NDS: …/10
Peripheral neuropathy is present if there are moderate signs
(NDS[6) with or without symptoms (any NSS), or mild
signs (NDS 3–5) with moderate symptoms (NSS[5)
a
aNSS NDS
3–4: mild symptoms 3–5: mild neuropathic signs
5–6: moderate symptoms 6–8: moderate
7–9: severe 9–10: severe
Diabetes Ther (2012) 3:4 Page 5 of 15
123

TREATMENT
The gold standard for diabetic foot ulcer
treatment includes debridement of the wound,
management of any infection, revascularization
procedures when indicated, and off-loading of
the ulcer [28]. Other methods have also been
suggested to be beneficial as add-on therapies,
such as hyperbaric oxygen therapy, use of
advanced wound care products, and negative-
pressure wound therapy (NPWT) [29]. However,
data so far have not provided adequate evidence
of the efficacy and cost-effectiveness of these
add-on treatment methods.
Debridement
Debridement should be carried out in all chronic
wounds to remove surface debris and necrotic
tissues. It improves healing by promoting the
production of granulation tissue and can be
achieved surgically, enzymatically, biologically,
and through autolysis.
Surgical debridement, known also as the
‘‘sharp method,’’ is performed by scalpels,
and is rapid and effective in removing
hyperkeratosis and dead tissue. Particular care
should be taken to protect healthy tissue, which
has a red or deep pink (granulation tissue)
appearance [30]. Using a scalpel blade with the
tip pointed at a 45angle, all nonviable tissue
must be removed until a healthy bleeding ulcer
bed is produced with saucerization of the
wound edges. If severe ischemia is suspected,
aggressive debridement should be postponed
until a vascular examination has been carried
out and, if necessary, a revascularization
procedure performed.
Enzymatic debridement can be achieved
using a variety of enzymatic agents, including
crab-derived collagenase, collagen from krill,
papain, a combination of streptokinase and
streptodornase, and dextrans. These are able to
remove necrotic tissue without damaging the
healthy tissue. Although expensive, enzymatic
debridement is indicated for ischemic ulcers
because surgical debridement is extremely
painful in these cases [31].
Biological debridement has been applied
recently using sterile maggots. Maggots have
the ability to digest surface debris, bacteria, and
necrotic tissues only, leaving healthy tissue
intact. Recent reports suggest that this method
is also effective in the elimination of drug-
resistant pathogens, such as methicillin-
resistant Staphylococcus aureus, from wound
surfaces [32].
Autolytic debridement involves the use of
dressings that create a moist wound
environment so that host defense mechanisms
(neutrophils, macrophages) can clear
devitalized tissue using the body’s enzymes.
Autolysis is enhanced by the use of proper
dressings, such as hydrocolloids, hydrogels, and
films. Autolysis is highly selective, avoiding
damage to the surrounding skin [33].
In conclusion, debridement, especially the
‘‘sharp method,’’ is one of the gold standards in
wound healing management, significantly
contributing to the healing process of the
wound, including the diabetic ulcer [34,35].
Off-loading
Off-loading of the ulcer area is extremely
important for the healing of plantar ulcers.
Retrospective and prospective studies have
shown that elevated plantar pressures
significantly contribute to the development of
plantar ulcers in diabetic patients [36–38]. In
addition, any existing foot deformities may
increase the possibility of ulceration, especially
in the presence of diabetic peripheral
neuropathy and inadequate off-loading.
Page 6 of 15 Diabetes Ther (2012) 3:4
123

Furthermore, inadequate off-loading of the
ulcer has been proven to be a significant
reason for the delay of ulcer healing even in
an adequately perfused limb [30]. The value of
ulcer off-loading is increasing, as it has been
reported that the risk of recurrence of a healed
foot ulcer is high if the foot is not properly off-
loaded (in the high-pressure areas), even after
closure of the ulcer [39].
The most effective method of off-loading,
which is also considered to be the gold
standard, is the nonremovable total-contact
cast (TCC). It is made of plaster or fast-setting
fiberglass cast materials, has relatively low costs,
and permits restricted activity [40].
Nonremovable TCCs are indicated for the
effective off-loading of ulcers located at the
forefoot or midfoot. Severe foot ischemia, a
deep abscess, osteomyelitis, and poor skin
quality are absolute contraindications to the
use of a nonremovable TCC. Nonremovable
TCCs work by distributing the plantar pressures
from the forefoot and midfoot to the heel. They
allow complete rest of the foot whilst also
permitting restricted activity. Nonremovable
TCCs also reduce edema, and compliance with
treatment is necessarily high [40].
There are a number of removable cast
walkers (RCW), which usually have a
lightweight, semirigid shell that helps support
the limb whilst also providing full-cell
protection (Fig. 1). The sole is of a rocker type,
offering off-loading of the forefoot during
standing and walking. The foot base is wide
and there is enough room for dressings. In some
RCWs, overlapping air cells provide
intermittent pneumatic compression for
edema reduction. In other RCWs, there are
additional layers of foam or other soft material,
offering total contact [41].
A modification of RCWs is an instant total-
contact cast (ITCC), where there is a wrapping
layer of cohesive tape or plaster bandage around
the RCW [42]. The aim of the ITCC is to
combine the efficacy of a TCC with the easy
application of a RCW.
Half shoes are another solution for patients
who cannot tolerate other methods of off-
loading, although they provide less pressure
relief than a cast boot and are difficult to walk
in. Therapeutic shoes, custom insoles, and the
use of felted foam (Fig. 2) are alternative
methods to off-load wounds located on the
forefoot, and can reduce pressure at the site of
ulceration by 4–50% [43].
Dressings
Ulcers heal more quickly and are often less
complicated by infection when in a moist
environment. The only exception is
Fig. 1 Removable cast walker
Diabetes Ther (2012) 3:4 Page 7 of 15
123

dry gangrene, where the necrotic area should be
kept dry in order to avoid infection and
conversion to wet gangrene. A wound’s
exudate is rich in cytokines, platelets, white
blood cells, growth factors, matrix
metalloproteinases (MMPs), and other
enzymes. Most of these factors promote
healing via fibroblast and keratinocyte
proliferation and angiogenesis, while others,
such as leukocytes and toxins produced by
bacteria, inhibit the healing process. Moreover,
it has been reported that local concentrations of
growth factors [platelet-derived growth factor-
beta (PDGF-beta), transforming growth factor-
beta] are low in patients with chronic ulcers
[44]. The ideal dressing should be free from
contaminants, be able to remove excess
exudates and toxic components, maintain a
moist environment at the wound-dressing
interface, be impermeable to microorganisms,
allow gaseous exchange, and, finally, should be
easily removed and cost-effective [45]. Various
dressings are available that are intended to
prevent infection and enhance wound healing,
and several studies support their effectiveness
for this purpose [46,47]. However, most of
these studies were performed in wounds and
not in diabetic ulcers [44,46,47]. Available data
on their use in diabetes are scarce [35], and
therefore further randomized clinical trials are
needed to support the existing evidence for
their benefit in diabetic ulcers.
Growth Factors
PDGF-beta (becaplermin; available as
Regranex

; Ortho-McNeil Pharmaceutical, Inc.,
Titusville, NJ, USA; and Janssen-Cilag
International NV, Beerse, Belgium) has been
developed as a topical therapy for the treatment
of noninfected diabetic foot ulcers. It is applied
in the form of a once-daily gel along with
debridement on a weekly basis [48]. Initial
studies have indicated a significant positive
effect of becaplermin [49,50] on ulcer healing;
however, more recent studies have reported an
increased incidence of cancer in patients treated
with becaplermin, especially at high doses [48].
Consequently, the US Food and Drug
Administration has published a warning of an
increased risk of cancer if more than three tubes
of becaplermin are used [51]. Further studies are
necessary in order to explore the benefit-to-risk
ratio, as well as the cost effectiveness of this
therapy.
Platelet-rich plasma (PRP) is an autologous
product, extracted from the patient’s plasma,
which includes a high platelet concentration in
Fig. 2 Off-loading of a diabetic foot ulcer with felted
foam
Page 8 of 15 Diabetes Ther (2012) 3:4
123

a fibrin clot that can be easily applied to the
ulcer area. The fibrin clot is absorbed during
wound healing within days to weeks following
its application [52]. There are a few studies
reporting a shorter closure time and higher
healing percentage in patients using PRP and
platelet-derived products [53,54]. However,
further studies are required to support the
possible beneficial effect of this method in
ulcer healing.
The results of the subcutaneous
administration of granulocyte colony-
stimulating factor (GCFS) in patients with
infected foot ulcers vary, with some studies
indicating faster resolution of the infection and
faster healing [55,56], while others did not
report any significant difference [57,58]. Basic
fibroblast growth factor (bFGF) is known to be
beneficial in the formation of granulation tissue
and normal healing [59]; however, one small
study failed to prove any significant difference
between the intervention and the control group
[60]. Epidermal growth factor (EGF) acts on
epithelial cells, fibroblasts, and smooth muscle
cells to promote healing [61]. Evidence for the
use of EGF in diabetic ulcers is limited, with
only a small amount of data reporting a
significantly higher rate of ulcer healing with
EGF use compared with placebo [62].
Bioengineered Skin Substitutes
Tissue-engineered skin substitutes are classified
into allogenic cell-containing (Apligraf

Graftskin, Organogenesis Inc., Canton, MA,
USA; Dermagraft

, Advanced Biohealing
Westport, CT, USA; OrCell

, Ortec
International Inc., New York, NY, USA),
autologous cell-containing (Hyalograft

3D,
Fidia Advanced BioPolymers, Abano Terme,
Italy; Laserskin

, Fidia Advanced BioPolymers,
Abano Terme, Italy; TranCell

, CellTran Ltd.,
Sheffield, UK), and acellular (OASIS

, Cook
Biotech, West Lafayette, IN, USA;
GRAFTJACKET

, Wright Medical Group Inc.,
Arlington, TN, USA; AlloDerm

, LifeCell
Corporation, Branchburg, NJ, USA) matrices.
The first two types of matrix contain living cells,
such as keratinocytes or fibroblasts, in a matrix,
while acellular matrices are free of cells and act
by releasing growth factors to stimulate
neovascularization and wound healing.
Accumulating evidence shows that
bioengineered skin substitutes may be a
promising therapeutic adjunct therapy to the
standard wound care for the management of
noninfected diabetic foot ulcers. Nevertheless,
more studies need to be conducted in the future
in order to confirm these results [63–69].
Extracellular Matrix Proteins
Hyaff

(Fidia Farmaceutici, Abano Terme, Italy)
is a semisynthetic ester of hyaluronic acid
which facilitates the growth and movement of
fibroblasts, and controls hydration [70].
Other available products contain lyophilized
collagen from various sources (bovine, porcine),
alone or in combination with alginates,
cellulose (Promogran

, Johnson & Johnson,
New Brunswick, NJ, USA), or antibiotics.
Collagen seems to induce the production of
endogenous collagen and to promote platelet
adhesion and aggregation. It has been reported
to be safe and effective as an adjunctive therapy
in the management of foot ulceration; however,
evidence is still limited [71].
MMP Modulators
Matrix metalloproteinases regulate the
extracellular matrix components. During
normal wound healing, there is a balance
between the construction and the destruction
Diabetes Ther (2012) 3:4 Page 9 of 15
123

of the extracellular matrix. In chronic wounds,
a high expression of MMP-2 in fibroblasts and
the endothelium is detected and is believed to
favor destruction. Thus, downregulation of
MMP-2 expression may enhance the healing
process [72].
DerMax

(Tyco Healthcare Group Lp, North
Haven, CT, USA) is a dressing containing metal
ions and citric acid, and its topical application is
associated with a lower expression of MMP-2 by
fibroblasts and endothelial cells. Metal ions
inhibit the production of reactive oxygen
species by polymorphonuclear cells, and citric
acid acts as a scavenger of superoxide anions
[72]. One pilot study provided encouraging
results [73]. Certainly, randomized trials are
necessary in order to establish the role of
DerMax in the treatment of diabetic ulcers.
Negative-Pressure Wound Therapy
Negative-pressure wound therapy (NPWT) has
emerged as a new treatment for diabetic foot
ulcers. It involves the use of intermittent or
continuous subatmospheric pressure through a
special pump (vacuum-assisted closure)
connected to a resilient open-celled foam
surface dressing covered with an adhesive
drape to maintain a closed environment. The
pump is connected to a canister to collect
wound discharge and exudate. Experimental
data suggest that NPWT optimizes blood flow,
decreases tissue edema, and removes exudate,
proinflammatory cytokines, and bacteria from
the wound area [74]. It should be performed
after debridement and continued until the
formation of healthy granulation tissue at the
surface of the ulcer. Currently, NPWT is
indicated for complex diabetic foot wounds
[74]; however, it is contraindicated for patients
with an active bleeding ulcer. Two small studies
[75,76] and one larger study [77] provide some
encouraging data concerning the possible
benefit of NPWT in the healing rate and time
of diabetic foot ulcers. However, more
randomized trials are needed in order to
confirm these results.
Hyperbaric Oxygen
There is strong evidence that fibroblasts,
endothelial cells, and keratinocytes are
replicated at higher rates in an oxygen-rich
environment [78,79]. Moreover, leukocytes kill
bacteria more effectively when supplied by
oxygen. It is also known that fibroblasts from
diabetic individuals show diminished cell
turnover in comparison with those from
nondiabetic persons. Based on these data, the
idea was that the administration of oxygen at
high concentrations might accelerate wound
healing in diabetes [78]. Treatment with
hyperbaric oxygen therapy involves the
intermittent administration of 100% oxygen at
a pressure greater than that at sea level. It is
performed in a chamber with the patient
breathing 100% oxygen intermittently while
the atmospheric pressure is increased to
2–3 atmospheres for a duration of 1–2 h. A full
course involves 30–40 sessions. A small amount
of data suggests significant reduction of the
ulcer area [79] as well as reduction of the risk for
major amputation [80]. Hyperbaric oxygen can
be applied as an adjunctive therapy for patients
with severe soft-tissue foot infections and
osteomyelitis who have not responded to
conventional treatment. Adverse effects
include barotrauma to the ears and sinuses,
pneumothorax, transient changes in visual
acuity, and seizures [81]. Furthermore, a recent
systematic review by the National Institute for
Health and Clinical Excellence (NICE)
Guidelines Development Group in the UK
concluded that the available data are
Page 10 of 15 Diabetes Ther (2012) 3:4
123

insufficient to demonstrate that hyperbaric
oxygen therapy is cost-effective [82].
CONCLUSION
The management of diabetic foot ulcers remains
a major therapeutic challenge which implies an
urgent need to review strategies and treatments
in order to achieve the goals and reduce the
burden of care in an efficient and cost-effective
way. Questions remain as to which types of
intervention, technology, and dressing are
suitable to promote healing, and whether all
therapies are necessary and cost-effective as
adjunctive therapies. The International
Working Group on the Diabetic Foot has
conducted two systematic reviews [35,83]of
the evidence and effectiveness of interventions
to enhance the healing of chronic diabetic foot
ulcers. The preliminary results are promising,
but large randomized controlled trials are
necessary in order to establish the cost-
effectiveness of the new therapies.
Prevention of diabetic foot ulceration is
critical in order to reduce the associated high
morbidity and mortality rates, and the danger
of amputation. It is essential to identify the
‘‘foot at risk,’’ through careful inspection and
physical examination of the foot followed by
neuropathy and vascular tests.
Regular foot examination, patient education,
simple hygienic practices, provision of
appropriate footwear, and prompt treatment of
minor injuries can decrease ulcer occurrence by
50% and eliminate the need for major
amputation in nonischemic limbs [84,85].
Diabetic foot ulcers should be carefully
evaluated and the gold-standard treatments
should be strictly applied in order to prevent
amputation. Further clinical studies are needed
to support the existing evidence regarding the
clinical benefit of new approaches for the
treatment of diabetic ulcers, and these
approaches should be used only as add-on
therapies to the gold-standard wound care.
ACKNOWLEDGMENTS
Dr. Doupis is the guarantor for this article, and
takes full responsibility for the integrity of the
work as a whole.
Conflict of interest. The authors declare that
they have no conflicts of interest.
Open Access. This article is distributed under
the terms of the Creative Commons Attribution
Noncommercial License which permits
any noncommercial use, distribution, and
reproduction in any medium, provided the
original author(s) and source are credited.
REFERENCES
1. Abbott CA, Carrington AL, Ashe H, North-West
Diabetes Foot Care Study, et al. The North-West
Diabetes Foot Care Study: incidence of, and risk
factors for, new diabetic foot ulceration in a
community-based patient cohort. Diabet Med.
2002;19:377–84.
2. Centers for Disease Control and Prevention. Lower
extremity disease among persons aged C40 years
with and without diabetes—United States,
1999–2002. MMWR Morb Mortal Wkly Rep.
2005;54:1158–60.
3. Lauterbach S, Kostev K, Kohlmann T. Prevalence of
diabetic foot syndrome and its risk factors in the
UK. J Wound Care. 2010;19:333–7.
4. Katsilambros N, Dounis E, Makrilakis K, Tentolouris
N, Tsapogas P. Atlas of the diabetic foot. 2nd ed.
Oxford: Wiley-Blackwell; 2010.
5. Moxey PW, Gogalniceanu P, Hinchliffe RJ, et al.
Lower extremity amputations—a review of global
variability in incidence. Diabet Med.
2011;28:1144–53.
Diabetes Ther (2012) 3:4 Page 11 of 15
123

6. Lavery LA, Armstrong DG, Vela SA, Quebedeaux TL,
Fleischli JG. Practical criteria for screening patients
at high risk for diabetic foot ulceration. Arch Intern
Med. 1998;158:157–62.
7. Malgrange D, Richard JL, Leymarie F, French
Working Group On The Diabetic Foot. Screening
diabetic patients at risk for foot ulceration. A multi-
centre hospital-based study in France. Diabetes
Metab. 2003;29:261–8.
8. Prompers L, Huijberts M, Schaper N, et al. Resource
utilisation and costs associated with the treatment
of diabetic foot ulcers. Prospective data from the
Eurodiale Study. Diabetologia. 2008;51:1826–34.
9. Kumar S, Ashe HA, Parnell LN, et al. The prevalence
of foot ulceration and its correlates in type 2
diabetic patients: a population-based study. Diabet
Med. 1994;11:480–4.
10. Tesfaye S, Stevens LK, Stephenson JM, et al.
Prevalence of diabetic peripheral neuropathy and
its relation to glycaemic control and potential risk
factors: the EURODIAB IDDM Complications Study.
Diabetologia. 1996;39:1377–84.
11. Brem H, Sheehan P, Boulton AJ. Protocol for
treatment of diabetic foot ulcers. Am J Surg.
2004;187:1S–10S.
12. Bowering CK. Diabetic foot ulcers.
Pathophysiology, assessment, and therapy. Can
Fam Physician. 2001;47:1007–16.
13. Management of peripheral arterial disease (PAD).
TransAtlantic Inter-Society Consensus (TASC). Eur J
Vasc Endovasc Surg. 2000;19(Suppl. A):S1–250.
14. Prompers L, Huijberts M, Apelqvist J, et al. High
prevalence of ischaemia, infection and serious
comorbidity in patients with diabetic foot disease
in Europe. Baseline results from the Eurodiale
study. Diabetologia. 2007;50:18–25.
15. Boulton AJ. The diabetic foot—an update. Foot
Ankle Surg. 2008;14:120–4.
16. Benotmane A, Mohammedi F, Ayad F, Kadi K,
Azzouz A. Diabetic foot lesions: etiologic and
prognostic factors. Diabetes Metab. 2000;26:113–7.
17. Hoffman AF. Evaluation of arterial blood flow in
the lower extremity. Clin Podiatr Med Surg.
1992;9:19–56.
18. Puttemans T, Nemery C. Diabetes: the use of color
Doppler sonography for the assessment of vascular
complications. Eur J Ultrasound. 1998;7:15–22.
19. Williams DT, Harding KG, Price P. An evaluation of
the efficacy of methods used in screening for lower-
limb arterial disease in diabetes. Diabetes Care.
2005;28:2206–10.
20. Kravitz SR, McGuire J, Shanahan SD. Physical
assessment of the diabetic foot. Adv Skin Wound
Care. 2003;16:68–75.
21. Papanas N, Papatheodorou K, Papazoglou D,
Kotsiou S, Maltezos E. Association between foot
temperature and sudomotor dysfunction in type 2
diabetes. J Diabetes Sci Technol. 2010;4:803–7.
22. Armstrong DG, Holtz-Neiderer K, Wendel C,
Mohler MJ, Kimbriel HR, Lavery LA. Skin
temperature monitoring reduces the risk for
diabetic foot ulceration in high-risk patients. Am J
Med. 2007;120:1042–6.
23. Meijer JW, Smit AJ, Sonderen EV, Groothoff JW,
Eisma WH, Links TP. Symptom scoring systems to
diagnose distal polyneuropathy in diabetes: the
Diabetic Neuropathy Symptom score. Diabet Med.
2002;19:962–5.
24. Daousi C, MacFarlane IA, Woodward A, Nurmikko
TJ, Bundred PE, Benbow SJ. Chronic painful
peripheral neuropathy in an urban community: a
controlled comparison of people with and without
diabetes. Diabet Med. 2004;21:976–82.
25. Boulton AJ, Armstrong DG, Albert SF, American
Diabetes Association; American Association of
Clinical Endocrinologists, et al. Comprehensive
foot examination and risk assessment: a report of
the task force of the foot care interest group of the
American Diabetes Association, with endorsement
by the American Association of Clinical
Endocrinologists. Diabetes Care. 2008;31:
1679–85.
26. Perkins BA, Orszag A, Ngo M, Ng E, New P, Bril V.
Prediction of incident diabetic neuropathy using
the monofilament examination: a 4-year
prospective study. Diabetes Care. 2010;33:1549–54.
27. Schaper NC. Diabetic foot ulcer classification
system for research purposes: a progress report
on criteria for including patients in research
studies. Diabetes Metab Res Rev. 2004;20(Suppl.
1):S90–5.
28. Doupis J, Veves A. Classification, diagnosis, and
treatment of diabetic foot ulcers. Wounds.
2008;20:117–26.
29. Hinchliffe RJ, Valk GD, Apelqvist J, et al. Specific
guidelines on wound and wound-bed management.
Diabetes Metab Res Rev. 2008;24(Suppl. 1):S188–9.
30. Lebrun E, Tomic-Canic M, Kirsner RS. The role of
surgical debridement in healing of diabetic foot
ulcers. Wound Repair Regen. 2010;18:433–8.
Page 12 of 15 Diabetes Ther (2012) 3:4
123

31. Smith RG. Enzymatic debriding agents: an
evaluation of the medical literature. Ostomy
Wound Manage. 2008;54:16–34.
32. Margolin L, Gialanella P. Assessment of the
antimicrobial properties of maggots. Int Wound J.
2010;7:202–4.
33. Hilton JR, Williams DT, Beuker B, Miller DR,
Harding KG. Wound dressings in diabetic foot
disease. Clin Infect Dis. 2004;39(Suppl. 2):S100–3.
34. Saap LJ, Falanga V. Debridement performance
index and its correlation with complete closure of
diabetic foot ulcers. Wound Repair Regen.
2002;10:354–9.
35. Game FL, Hinchliffe RJ, Apelqvist J, et al. A
systematic review of interventions to enhance the
healing of chronic ulcers of the foot in diabetes.
Diabetes Metab Res Rev. 2012;28(Suppl. 1):119–41.
36. Veves A, Murray HJ, Young MJ, Boulton AJ. The risk
of foot ulceration in diabetic patients with high
foot pressure: a prospective study. Diabetologia.
1992;35:660–3.
37. Pham H, Armstrong DG, Harvey C, Harkless LB,
Giurini JM, Veves A. Screening techniques to
identify people at high risk for diabetic foot
ulceration: a prospective multicenter trial.
Diabetes Care. 2000;23:606–11.
38. Frykberg RG, Lavery LA, Pham H, Harvey C,
Harkless L, Veves A. Role of neuropathy and high
foot pressures in diabetic foot ulceration. Diabetes
Care. 1998;21:1714–9.
39. Pound N, Chipchase S, Treece K, Game F, Jeffcoate
W. Ulcer-free survival following management of
foot ulcers in diabetes. Diabet Med.
2005;22:1306–9.
40. Burns J, Begg L. Optimizing the offloading
properties of the total contact cast for plantar foot
ulceration. Diabet Med. 2011;28:179–85.
41. Cavanagh PR, Bus SA. Off-loading the diabetic foot
for ulcer prevention and healing. J Vasc Surg.
2010;52(Suppl.):37S–43S.
42. Armstrong DG, Lavery LA, Wu S, Boulton AJ.
Evaluation of removable and irremovable cast
walkers in the healing of diabetic foot wounds: a
randomized controlled trial. Diabetes Care.
2005;28:551–4.
43. Armstrong DG, Nguyen HC, Lavery LA, van Schie
CH, Boulton AJ, Harkless LB. Off-loading the
diabetic foot wound: a randomized clinical trial.
Diabetes Care. 2001;24:1019–22.
44. Clark RAF. Wound repair: overview and general
considerations. In: Clark RAF, editor. The molecular
and cellular basis of wound repair. New York:
Plenum Press; 1996. p. 3–50.
45. Harding KG, Jones V, Price P. Topical treatment:
which dressing to choose. Diabetes Metab Res Rev.
2000;16(Suppl. 1):S47–50.
46. Olson ME, Wright JB, Lam K, Burrell RE. Healing of
porcine donor sites covered with silver-coated
dressings. Eur J Surg. 2000;166:486–9.
47. Tredget EE, Shankowsky HA, Groeneveld A, Burrell
R. A matched-pair, randomized study evaluating
the efficacy and safety of Acticoat silver-coated
dressing for the treatment of burn wounds. J Burn
Care Rehabil. 1998;19:531–7.
48. Papanas N, Maltezos E. Benefit-risk assessment of
becaplermin in the treatment of diabetic foot
ulcers. Drug Saf. 2010;33:455–61.
49. Steed DL. Clinical evaluation of recombinant
human platelet-derived growth factor for the
treatment of lower extremity diabetic ulcers.
Diabetic Ulcer Study Group. J Vasc Surg.
1995;21:71–8 (discussion 79–81).
50. Wieman TJ, Smiell JM, Su Y. Efficacy and safety of a
topical gel formulation of recombinant human
platelet-derived growth factor-BB (becaplermin) in
patients with chronic neuropathic diabetic ulcers. A
phase III randomized placebo-controlled double-
blind study. Diabetes Care. 1998;21:822–7.
51. US Food and Drugs Administration. http://www.
fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyIn
formationforPatientsandProviders/DrugSafetyInfor
mationforHeathcareProfessionals/ucm072148.htm.
Accessed Dec 23, 2011.
52. Yang HS, Shin J, Bhang SH, et al. Enhanced skin
wound healing by a sustained release of growth
factors contained in platelet-rich plasma. Exp Mol
Med. 2011;43:622–9.
53. Margolis DJ, Kantor J, Santanna J, Strom BL, Berlin
JA. Effectiveness of platelet releasate for the
treatment of diabetic neuropathic foot ulcers.
Diabetes Care. 2001;24:483–8.
54. Driver VR, Hanft J, Fylling CP, Beriou JM, Autologel
Diabetic Foot Ulcer Study Group. A prospective,
randomized, controlled trial of autologous platelet-
rich plasma gel for the treatment of diabetic foot
ulcers. Ostomy Wound Manage. 2006;52:68–70, 72,
74 passim.
55. Cruciani M, Lipsky BA, Mengoli C, de Lalla F.
Granulocyte-colony stimulating factors as
Diabetes Ther (2012) 3:4 Page 13 of 15
123

adjunctive therapy for diabetic foot infections.
Cochrane Database Syst Rev. 2009;(8):CD006810.
56. Huang P, Li S, Han M, Xiao Z, Yang R, Han ZC.
Autologous transplantation of granulocyte colony-
stimulating factor-mobilized peripheral blood
mononuclear cells improves critical limb ischemia
in diabetes. Diabetes Care. 2005;28:
2155–60.
57. de Lalla F, Pellizzer G, Strazzabosco M, et al.
Randomized prospective controlled trial of
recombinant granulocyte colony-stimulating
factor as adjunctive therapy for limb-threatening
diabetic foot infection. Antimicrob Agents
Chemother. 2001;45:1094–8.
58. Yo
¨nem A, Cakir B, Gu
¨ler S, Azal OO, Corakc¸i A.
Effects of granulocyte-colony stimulating factor in
the treatment of diabetic foot infection. Diabetes
Obes Metab. 2001;3:332–7.
59. Uchi H, Igarashi A, Urabe K, et al. Clinical efficacy
of basic fibroblast growth factor (bFGF) for diabetic
ulcer. Eur J Dermatol. 2009;19:461–8.
60. Richard JL, Parer-Richard C, Daures JP, et al. Effect
of topical basic fibroblast growth factor on the
healing of chronic diabetic neuropathic ulcer of the
foot. A pilot, randomized, double-blind, placebo-
controlled study. Diabetes Care. 1995;18:64–9.
61. Tuyet HL, Nguyen Quynh TT, Vo Hoang Minh H,
et al. The efficacy and safety of epidermal growth
factor in treatment of diabetic foot ulcers: the
preliminary results. Int Wound J. 2009;6:159–66.
62. Tsang MW, Wong WK, Hung CS, et al. Human
epidermal growth factor enhances healing of
diabetic foot ulcers. Diabetes Care.
2003;26:1856–61.
63. Edmonds M, Bates M, Doxford M, Gough A, Foster
A. New treatments in ulcer healing and wound
infection. Diabetes Metab Res Rev. 2000;16(Suppl.
1):S51–4.
64. Ehrenreich M, Ruszczak Z. Update on tissue-
engineered biological dressings. Tissue Eng.
2006;12:2407–24.
65. Uccioli L, Giurato L, Ruotolo V, et al. Two-step
autologous grafting using HYAFF scaffolds in
treating difficult diabetic foot ulcers: results of a
multicenter, randomized controlled clinical trial
with long-term follow-up. Int J Low Extrem
Wounds. 2011;10:80–5.
66. Moustafa M, Simpson C, Glover M, et al. A new
autologous keratinocyte dressing treatment for
non-healing diabetic neuropathic foot ulcers.
Diabet Med. 2004;21:786–9.
67. Niezgoda JA, Van Gils CC, Frykberg RG, Hodde JP.
Randomized clinical trial comparing OASIS Wound
Matrix to Regranex Gel for diabetic ulcers. Adv Skin
Wound Care. 2005;18:258–66.
68. Martin BR, Sangalang M, Wu S, Armstrong DG.
Outcomes of allogenic acellular matrix therapy in
treatment of diabetic foot wounds: an initial
experience. Int Wound J. 2005;2:161–5.
69. Mansbridge J. Skin substitutes to enhance
wound healing. Expert Opin Investig Drugs.
1998;7:803–9.
70. Caravaggi C, De Giglio R, Pritelli C, et al. HYAFF
11-based autologous dermal and epidermal grafts in
the treatment of noninfected diabetic plantar and
dorsal foot ulcers: a prospective, multicenter,
controlled, randomized clinical trial. Diabetes
Care. 2003;26:2853–9.
71. Veves A, Sheehan P, Pham HT. A randomized,
controlled trial of Promogran (a collagen/oxidized
regenerated cellulose dressing) vs standard
treatment in the management of diabetic foot
ulcers. Arch Surg. 2002;137:822–7.
72. Karim RB, Brito BL, Dutrieux RP, Lassance FP, Hage
JJ. MMP-2 assessment as an indicator of wound
healing: a feasibility study. Adv Skin Wound Care.
2006;19:324–7.
73. Pirayesh A, Dessy LA, Rogge FJ, et al. The efficacy of a
polyhydrated ionogen impregnated dressing in the
treatment of recalcitrant diabetic foot ulcers: a multi-
centre pilot study. Acta Chir Belg. 2007;107:675–81.
74. Xie X, McGregor M, Dendukuri N. The clinical
effectiveness of negative pressure wound therapy: a
systematic review. J Wound Care. 2010;19:490–5.
75. McCallon SK, Knight CA, Valiulus JP,
Cunningham MW, McCulloch JM, Farinas LP.
Vacuum-assisted closure versus saline-moistened
gauze in the healing of postoperative diabetic foot
wounds. Ostomy Wound Manage. 2000;46(28–32):
34.
76. Eginton MT, Brown KR, Seabrook GR, Towne JB,
Cambria RA. A prospective randomized evaluation
of negative-pressure wound dressings for diabetic
foot wounds. Ann Vasc Surg. 2003;17:645–9.
77. Armstrong DG, Diabetic Foot Study Consortium.
Negative pressure wound therapy after partial
diabetic foot amputation: a multicentre,
randomised controlled trial. Lancet.
2005;366:1704–10.
78. Broussard CL. Hyperbaric oxygenation and wound
healing. J Vasc Nurs. 2004;22:42–8.
Page 14 of 15 Diabetes Ther (2012) 3:4
123

79. Kessler L, Bilbault P, Orte
´ga F, et al. Hyperbaric
oxygenation accelerates the healing rate of
nonischemic chronic diabetic foot ulcers: a
prospective randomized study. Diabetes Care.
2003;26:2378–82.
80. Faglia E, Favales F, Aldeghi A, et al. Adjunctive
systemic hyperbaric oxygen therapy in treatment of
severe prevalently ischemic diabetic foot ulcer. A
randomized study. Diabetes Care. 1996;19:
1338–43.
81. Tiaka EK, Papanas N, Manolakis AC, Maltezos E.
The role of hyperbaric oxygen in the treatment of
diabetic foot ulcers. Angiology. 2011 (Epub ahead
of print).
82. Tan T, Shaw EJ, Siddiqui F, Kandaswamy P, Barry
PW, Guideline Development Group. Inpatient
management of diabetic foot problems: summary
of NICE guidance. BMJ. 2011;342:d1280.
83. Hinchliffe RJ, Valk GD, Apelqvist J, et al. A
systematic review of the effectiveness of
interventions to enhance the healing of chronic
ulcers of the foot in diabetes. Diabetes Metab Res
Rev. 2008;24(Suppl. 1):S119–44.
84. Larsson J, Apelqvist J, Agardh CD, Stenstro
¨mA.
Decreasing incidence of major amputation in
diabetic patients: a consequence of a
multidisciplinary foot care team approach? Diabet
Med. 1995;12:770–6.
85. Lavery LA, Wunderlich RP, Tredwell JL. Disease
management for the diabetic foot: effectiveness of a
diabetic foot prevention program to reduce
amputations and hospitalizations. Diabetes Res
Clin Pract. 2005;70:31–7.
Diabetes Ther (2012) 3:4 Page 15 of 15
123