Professional Documents
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Management of Diabetic Foot Lesions
Management of Diabetic Foot Lesions
Section Editors
John F Eidt, MD
Joseph L Mills, Sr, MD
David M Nathan, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS
Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2013. | This topic last updated: mar 27, 2013.
INTRODUCTION The lifetime risk of a foot ulcer for patients with diabetes (type 1 or 2) may be as high as 25
percent [1-3]. Diabetic foot ulcers are a major cause of morbidity and mortality, accounting for approximately twothirds of all nontraumatic amputations performed in the United States [4,5]. This observation illustrates the
importance of prompt treatment of foot ulcers in patients with diabetes. The management of diabetic foot lesions is
provided here. Evaluation and prevention of foot ulcers and the treatment of diabetes-related foot infections (cellulitis
and osteomyelitis) are discussed separately. (See "Evaluation of the diabetic foot" and "Clinical manifestations,
diagnosis, and management of diabetic infections of the lower extremities".)
WOUND CLASSIFICATION The first step in managing diabetic foot ulcers is classifying the wound.
Classification is based upon clinical evaluation of the extent of the lesion and, in some classification systems, an
assessment of the vascular status of the foot. The intensity and duration of treatment can be determined after
clinical evaluation of the ulcer. (See "Evaluation of the diabetic foot", section on 'Wound evaluation'.)
A widely used classification of diabetic foot ulcers is that proposed by Wagner [6]:
Grade 0 No ulcer in a high-risk foot
Grade 1 Superficial ulcer involving the full skin thickness but not underlying tissues (picture 1)
Grade 2 Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess
formation (picture 2)
Grade 3 Deep ulcer with cellulitis or abscess formation, often with osteomyelitis (picture 3)
Grade 4 Localized gangrene (picture 4)
Grade 5 Extensive gangrene involving the whole foot
The Wagner classification is based upon clinical evaluation (depth of ulcer and presence of necrosis) alone and
does not account for the vascular status of the foot. A modified system that is frequently used by orthopedic
surgeons individually scores the components of wound depth and ischemia [7]. Other ulcer classification systems
have also been published [8-11]. The International Working Group on the Diabetic Foot proposed classifying all
ulcers according to the following categories: perfusion, extent, depth, infection, and sensation (PEDIS) [12]. The
PEDIS system is primarily used for research purposes.
The usual approach to the management of lesions of each Wagner grade is given below, followed by a discussion of
some newer approaches.
GRADE 0 LESIONS Counseling regarding preventive foot care should be given to any patient whose feet are at
risk for ulcer development, particularly patients with existing neuropathy. There are several measures that can
markedly diminish ulcer formation, such as avoiding poorly fitting shoes, walking barefoot, and smoking. This topic
is reviewed separately. (See "Evaluation of the diabetic foot", section on 'Risk factors' and "Evaluation of the
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Another study measured foot pressures using an in-shoe pressure measurement system (Novel Pedar) in
18 healthy subjects while wearing a cast walker or total contact cast [38]. Peak foot pressures using the
cast walker were significantly reduced in the forefoot (12 versus 18 N/cm2) and foot as a whole (14 versus 19
N/cm2) compared with a fiberglass total contact cast, but no differences were found for the heel or midfoot.
These studies suggest these prefabricated products are at least as good as total contact casting for off-loading the
foot and equalizing foot pressures when the foot anatomy is normal, but data are not available demonstrating these
effects for patients with diabetic foot deformities.
Cast walkers have been used for the treatment of neuropathic plantar ulcers but these devices, thus far, have not
been found to be superior to total contact casting in randomized trials. In one trial, the rate of ulcer healing was
significantly higher in those randomly assigned to total contact casting compared with a half-shoe or removable
cast walker [30]. Another trial that randomly assigned 48 patients to total contact casting or a removable cast
walker (ie, Stabil-D), found no difference in the number of days to achieve healing (35 versus 39 days) [39].
Therapeutic shoes After healing of the ulcer is achieved, extra-depth and -width shoes with orthotic inserts
are often prescribed to prevent recurrent ulceration [25]. However, in one trial, 400 diabetic patients with a history of
foot ulcer were randomly assigned to wear therapeutic shoes or their usual footwear for two years [40]. The risk of
re-ulceration was not found to be different between the groups. Non-prescription rocker sole shoes (figure 2) may
also offload the foot [41,42]. In a non-randomized prospective study of 92 patients with healed diabetic foot ulcers,
the first-year annual rate of foot ulcer relapse was significantly lower in patients who used stock diabetic shoes
(rocker sole) compared with those who wore their usual footwear (15 versus 60 versus percent) [42]. In the United
States, reimbursement from insurance carriers can be expected for at least one pair of shoes and/or shoe inserts,
provided the design of the shoe/insert meets qualifying guidelines.
Wedge shoes (eg, Darco International), also called half shoes, are available as a forefoot wedge and heel wedge
shoes to off-load the forefoot and heel, respectively (figure 3). These shoes may be useful under certain
circumstances. For example, plantar heel ulcers are particularly difficult to heel because of an inability to
adequately off-load this region; the heel wedge shoe can be useful to achieve this goal.
The disadvantage of wedge shoes is that most patients, especially elderly patients or those with proprioception
abnormalities may not be able to maintain their balance, and some patients find walking in them difficult, if not
impossible.
Knee walkers Knee walkers are ambulatory assist devices that may be indicated for anyone with a lower
extremity issue where weight bearing needs to be avoided (figure 4). These devices are becoming more popular in
the treatment of diabetic ulcer as a means to off-load the foot. There are no trials evaluating the effectiveness of
these devices in healing diabetic foot ulcers.
Summary Debridement, good local wound care, and relief of pressure on the ulcer are believed to be important
components of therapy for grade 1 and 2 foot ulcers [9]. This treatment program does not require hospitalization.
Close monitoring is required, and hospitalization for bed rest and intravenous antibiotic therapy is advisable if the
ulcer does not improve. (See "Clinical manifestations, diagnosis, and management of diabetic infections of the
lower extremities".)
GRADE 3 LESIONS Before deciding upon appropriate management of deep ulcers, it is important to evaluate for
substantial peripheral vascular disease or bony involvement. A brief review is found here. These topics are
discussed in detail separately. (See "Evaluation of the diabetic foot", section on 'Physical signs of peripheral artery
disease' and "Evaluation of the diabetic foot", section on 'Signs of infection'.)
Assessment for peripheral artery disease Assessment of the adequacy of the circulation is an important
component of the evaluation of all wounds, and particularly wounds found in patients with diabetes. Symptoms of
claudication or extremity pain at rest, and physical findings of diminished or absent pulses, cool temperature, pallor
on elevation, or dependent rubor should raise suspicion about the presence of peripheral artery disease.
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Noninvasive vascular studies including ankle-brachial index, pulse volume recordings and duplex ultrasonography
should be obtained to confirm the diagnosis. (See "Evaluation of the diabetic foot", section on 'Physical signs of
peripheral artery disease'.)
The ankle-brachial index is a measurement of the ratio of blood pressure at the ankle to that in the brachial artery
that correlates with the presence and severity of arterial occlusive disease [43]. In patients with diabetes, the blood
vessels may be incompressible and ankle-brachial index values misleading. Segmental volume plethysmography
and toe-brachial index values are more reliable for determining the severity of disease. The noninvasive diagnosis of
lower extremity peripheral artery disease is reviewed in detail elsewhere. (See "Noninvasive diagnosis of arterial
disease".)
Assess for osteomyelitis Osteomyelitis is likely to be present if bone can be seen at the floor of a deep ulcer,
or if it can be easily detected by probing the ulcer with a sterile, blunt stainless steel probe. Other signs that
suggest osteomyelitis are an ulcer size larger than 2 x 2 cm and an otherwise unexplained elevation in the
erythrocyte sedimentation rate. (See "Clinical manifestations, diagnosis, and management of diabetic infections of
the lower extremities", section on 'Diagnosis of underlying osteomyelitis'.)
Radiologic tests Radiologic tests may be useful if the diagnosis of osteomyelitis remains uncertain. The
diagnosis is clear if osteomyelitis is visible on plain radiographs. However, radiologic changes occur late in the
course of osteomyelitis and negative radiographs do not exclude it. Other imaging techniques that may be useful in
selective cases include radionuclide bone imaging, magnetic resonance imaging and imaging with indium-labeled
leukocytes.
Bone biopsy If clinical and radiographic assessments fail to provide a diagnosis, then bone biopsy can be
considered. Bone biopsy does carry the risk of inoculating an otherwise uninfected bone if the biopsy is obtained
through an infected soft tissue bed. (See "Approach to imaging modalities in the setting of suspected
osteomyelitis".)
Treatment The treatment of grade 3 lesions includes debridement, infection control, local wound care, and relief
of pressure. The presence of osteomyelitis or peripheral artery disease warrants additional therapy [44].
Coordination of care among providers is important for keeping rates of amputation as low as possible. This was
illustrated in a study of 10 Department of Veterans Affairs (VA) medical centers in which increased rates of
amputation were seen in programs with the lowest scores for availability of clinical protocols, educational seminars,
discharge planning and quality of care meetings [45].
Antimicrobial therapy Whether it is important to make a definitive diagnosis of osteomyelitis and whether
patients with osteomyelitis should always be treated by hospitalization, intravenous antimicrobial drug therapy, and
surgical debridement of bone are debated [46]. Some authors have suggested that osteomyelitis is present in as
many as two-thirds of diabetic patients who have foot ulcers [47], but this figure is much higher than is generally
believed and may reflect bias in the severity of the cases studied. Surgical removal of infected bone may be
necessary if the ulcer is not healing. A short period of hospitalization, with surgical debridement, including culture of
material obtained from deep in the ulcer and bone biopsy, is often helpful in choosing antibiotic therapy [48].
Parenteral antibiotic therapy based upon the culture results has traditionally been given for four to six weeks in
patients with osteomyelitis. The optimal regimen and when to transition to oral therapy are dependent upon the
clinical features of each case. (See "Clinical manifestations, diagnosis, and management of diabetic infections of
the lower extremities", section on 'Antimicrobial therapy'.)
Mechanical off-loading Mechanical off-loading relieves pressure on the ulcer and enhances healing. Total
contact casting and cast walkers are alternatives to prolonged bed rest for the relief of pressure and allow for
continued ambulation. (See 'Mechanical off-loading' above.)
Revascularization Revascularization plays an important role in the management of diabetic foot ulcers in
patients with documented peripheral artery disease (to avoid the need for amputation) [9]. In patients with diabetes,
foot ulcers, and critical limb ischemia, revascularization, when possible, is associated with a lower incidence of
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amputation. As an example, in a longitudinal study of 564 patients with diabetes, foot ulcers (in 85 percent of
subjects), and critical limb ischemia (defined as ankle-pressure <70 mmHg), angioplasty (PTA) or bypass grafting
(BPG) was performed in 74.5 and 20.6 percent, respectively [49]. Neither procedure was possible in the remaining
4.9 percent. Among patients who received PTA, BPG, or no revascularization, amputations were ultimately
performed in 8.2, 21.2, and 59.2 percent, respectively.
GRADE 4 AND 5 LESIONS Patients with these more advanced lesions require urgent hospital admission and
surgical consultation, and amputation may sometimes be required. (See "Clinical manifestations, diagnosis, and
management of diabetic infections of the lower extremities".)
ADVANCED THERAPIES Several approaches have been reported that may improve ulcer healing, such as
vacuum-assisted wound closure, the use of custom-fit semipermeable polymeric membrane dressings, cultured
human dermis, and application of products such as platelet-derived growth factors and platelet releasate [50-52].
Negative pressure wound therapy Negative pressure wound therapy (NPWT), also called vacuum-assisted
closure (VAC), involves the application of controlled subatmospheric pressure to the surface of the wound. NPWT
enhances wound healing by increasing wound perfusion, reducing edema, reducing the local bacterial burden and
increasing the formation of granulation tissue. The indications, contraindications, and uses of negative pressure
wound therapy systems are discussed in detail separately. (See "Negative pressure wound therapy".)
Randomized trials have found that NPWT reduces time to closure of diabetic foot ulcers, and wounds following
diabetic foot surgery [53-58]. In this patient population, NPWT also decreases length of hospitalization,
complication rates, and cost [59-61].
One multicenter trial randomized 342 patients with diabetic foot ulcers (stage 2 or 3 Wagner ulcers, and
adequate vascular perfusion) to negative pressure wound therapy or moist wound therapy (ie, hydrogel,
alginate) [54]. All ulcers were debrided (as needed) within two days of randomization, and the majority of the
patients also received off-loading therapy. The primary endpoint was wound closure. A significantly greater
percentage of patients treated with negative pressure wound therapy achieved wound closure within the 16
week timeframe of the study compared with alternative medical therapy (43 versus 29 percent). The negative
pressure wound therapy group also demonstrated significantly fewer amputations compared with the
alternate medical therapy group (4 versus 10 percent).
Another multicenter trial followed 162 diabetic patients for 16 weeks following partial foot amputation [53].
The percentage of patients with healed wounds (56 versus 39 percent) and time to complete closure (42
versus 84 days) were significantly improved in patients randomized to vacuum-assisted wound closure group
compared with the control group.
Skin substitutes Human skin equivalents have been studied in diabetic patients with noninfected, nonischemic
chronic plantar ulcers [51,62-65]. In one study of 208 patients, weekly application of the cultured skin equivalent
(Graftskin) for four weeks improved the healing rate compared with usual care (complete wound healing in 56 and 38
percent of patients, respectively) [62]. Bioengineered skin substitutes (Dermagraft, Apligraf) are also available for
the treatment of nonhealing diabetic foot ulcers [63,64].
Growth factors A platelet-derived growth factor gel preparation (becaplermin) is approved by the US Food and
Drug Administration as an adjuvant therapy for diabetic foot ulcers [66]. It promotes cellular proliferation and
angiogenesis and thereby improves wound healing. However, its use has been limited by high cost and by postmarketing reports of an increased rate of mortality secondary to malignancy in patients treated with three or more
tubes of becaplermin (3.9 versus 0.9 in controls per 1000 person years) [67]. In another trial, local application of
human epidermal growth factor was shown to promote healing of diabetic foot ulcers [68].
Hyperbaric oxygen therapy Hyperbaric oxygen therapy, as a component of diabetic ulcer management, may
be associated with improved healing but the indications for hyperbaric oxygen in the treatment of nonhealing
diabetic foot ulcers remain uncertain. Several metaanalyses of these trials have concluded that hyperbaric oxygen
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therapy in the treatment of diabetic foot ulcers may offer a benefit; however, each noted that the methodologic
quality of the included studies was poor and there was a potential for bias [69-73] The available trials are limited by
small sample size and heterogeneity of the wounds being treated (eg, ulcer size, ulcer depth, microbial
environment, presence of ischemia) [74-83]. No conclusions could be drawn regarding specific indications for or
timing of therapy.
A pooled analysis found significantly improved wound healing (OR 9.99, 95% CI 3.97-25.1), and decreased risk of
amputation (OR 0.24, 95% CI 0.14-0.43) [69-72]. A later metaanalysis found similar results [73]. As an example of
these effects, in one of the larger trials that included 70 patients with severely ischemic foot ulcers (Wagner grades
3 and 4), the amputation rate was 9 percent in the treatment group and 33 percent in the control [74]. In another
trial that included 94 patients, a significantly increased incidence of complete healing (Wagner 2 though 4 ulcers)
was achieved in the hyperbaric oxygen therapy group (52 versus 29 percent) compared with a placebo group [81].
Therapies that combine hyperbaric oxygen therapy with known mediators of wound healing may augment the
effects of hyperbaric oxygen. Activation and mobilization of endothelial progenitor cells (EPCs) are impaired in
patients with diabetes. These cells are known to play an important role in wound healing by participating in the
formation of new blood vessels in areas of hypoxia [84-87]. Hyperoxia effectively improves EPC mobilization, but
does not specifically target to a specific site which may, in part, explain the nonuniform improvement in diabetic
foot wounds with hyperbaric oxygen therapy alone [88]. However, in a murine model of diabetes, coadministration of
the chemokine stromal cell-derived factor-1 alpha (SDF-1 alpha) resulted in homing of activated EPCs into the
wound site [89]. These data suggest that combining hyperbaric oxygen therapy with administration of SDF-1 alpha
may be synergistic. Other combination therapies (eg, fibroblast growth factor) are also being studied [90,91].
Other agents Small trials have shown some promise for other topical agents. In a randomized study, application
of .05 percent tretinoin solution for 10 minutes a day followed by iodine gel for four weeks resulted in complete
resolution of 46 percent of the ulcers in the treatment group (n = 13) compared with 18 percent in the control group
(n = 11) [92]. In addition, electrical stimulation near the ulcer may also help slowly healing ulcers [93,94].
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and
Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the
Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the
10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with
some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
patient info and the keyword(s) of interest.)
Beyond the Basics topics (see "Patient information: Diabetes mellitus type 1: Overview (Beyond the
Basics)" and "Patient information: Diabetes mellitus type 2: Overview (Beyond the Basics)" and "Patient
information: Foot care in diabetes mellitus (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
The treatment of diabetic foot ulcers begins with a comprehensive assessment of the ulcer and the patient's
overall medical condition. Evidence of underlying neuropathy, bony deformity, and peripheral artery disease
should be actively sought. The wound is classified upon initial presentation and with each follow-up visit
using a standardized system to document the examination, plan treatment, and follow the progress of
healing. (See 'Introduction' above and 'Wound classification' above.)
Adequate debridement, proper local wound care, relief of pressure on the ulcer by mechanical off-loading,
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and control of infection (when present) are important components of therapy. Dressings are selected based
upon wound characteristics. (See 'Local wound care' above.)
Several methods are available to achieve mechanical off-loading and include total contact casts, cast
walkers, wedge shoes, and bedrest. (See 'Mechanical off-loading' above.)
Few data are available comparing methods of debridement (sharp, enzymatic, autolytic, mechanical, and
biological). In the absence of such data, we suggest surgical (sharp) debridement rather than another
method (Grade 2C). If a surgeon with clinical expertise in sharp debridement is not available, we suggest
autolytic debridement with hydrogels (Grade 2C). (See 'Method of debridement' above.) Alternatively, the
patient can be referred to a facility with appropriate surgical expertise in the management of diabetic foot
problems.
For managing extensive open wounds following debridement for infection or necrosis, or partial foot
amputation, we suggest negative pressure wound therapy (Grade 2A). All necrotic tissue or infected bone
(osteomyelitis) must be removed from the wound prior to using this device. (See 'Negative pressure wound
therapy' above and "Negative pressure wound therapy", section on 'Contraindications'.)
In patients with Wagner grade 3 and higher ulcers with critical limb ischemia, we recommend
revascularization (Grade 1B). Revascularization should also be performed in patients with any degree of limb
ischemia and a nonhealing ulcer. (See 'Grade 3 lesions' above.)
Patients with Wagner grade 4 and 5 ulcers require immediate surgical consultation. (See 'Grade 4 and 5
lesions' above.)
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12. Schaper NC. Diabetic foot ulcer classification system for research purposes: a progress report on criteria for
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GRAPHICS
Wagner grade 1 ulcer
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Dicloxacillin
C lindamycin
Linezolid
Penicillin V potassium
Trimethoprim-sulfamethoxazole (cotrimoxazole)
Doxycycline
Amoxicillin-clavulanate
C iprofloxacin
Levofloxacin
Moxifloxacin
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Wedge shoes
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Knee walker
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