Treatment of Diabetic Ulcers:

Guiding Principle
The primary treatment goal for diabetic foot ulcers is to
obtain wound closure as expeditiously as possible.
No relevant disclosures
 Debbie Christensen RN CWOCN
Manager Wound and Ostomy Department
Sacred Heart Medical Center

dchristensen@peacehealth.org
Office phone 541-222-2560
The urgency to close DFU’s
• 10 year prospective study of patients over 65, a
neuropathic ulcer was predictive for a 45% mortality rate
over 5 years.1

• Three most common factors leading to limb amputation:

– Gangrene, infection, non-healing wound4

1. Iversen, Tell, Riise, et al 2009

4. Rogers, L. 2010
Standard Treatment Fails to Heal DFU’s
Standard treatment:
• Wound Bed preparation: Debridement
• Infection Control
• Revascularization
• Off Loading
Only 25% of patients who received this standard
treatment healed by 16 weeks.5,6

5. Steed and colleagues J AM Coll Surg 1996 Multicenter randomized

6. Margolis and colleagues, Diabetes Care 1992 Meta-analysis
• A systematic review of literature revealed that between
30% - 40% of patients were not being treated according
to current evidence.2
• A 2010 consensus panel identified that 20-30% of the
care provided was inappropriate or dangerous.3

2. Schuster and colleagues

3. Snyder, Kirsner and colleagues 2010 Consensus Report
 Evidence Based DFU Treatment
Guidelines abound
Association for the Advancement of Wound Care
American College of Foot and Ankle Surgeons
American Diabetes Association
American Orthopedic Foot and Ankle Society
Wound Ostomy Continence Nurses Society
Wound Healing Society
Guidlelines
• Provide a standard framework for assessment and
diagnosis.
• Establish best practice standards for basic wound care
interventions and expected progress.
• Provide guidance for evidence based use of advanced
wound therapies.
• Provide a reference from which to measure outcomes.
Medical Management

Glucose Control: HbA1c. <7%.

Neurologic Testing: Monofilament 5.07
Vascular Assessment
Edema Management: Elevation vs. compression
Nutrition: Diabetic education, Pre-albumin
Social barriers: Living situation, lack of family support, financial
Patient beliefs and motivation: Motivational interviewing8

8. CARL J. POSSIDENTE, and colleagues

Am J Health-Syst Pharm. 2005
Wound Assessment
Measure the wound:
Length x width x depth
Consistency is key to tracking progress
Probe to Bone Controversy8,9
Use appropriate size probe for the wound
Can identify underlying foci of indolent infection in otherwise healthy
appearing wound
Wound tissue and Infection
Healthy tissue is pink with advancing, adherent edge. Friable, dark tissue
with undermined edges is not.

8.Lavery, et al Diabetes Care 2007

9. Grayson and colleagues, JAMA 1995
Basic Standard Wound Care
Off load :
If the offloading device can be removed it will be
Caution in use of wheel chairs and crutches9
Debridement
Reduces bacterial bioburden, reduces infection
Converts wound to an active, proliferative state.
Suggested weekly and as needed5
Surgical and Sharp recommended.
Enzyme: Santyl the only one still on market.
Manage /Rule Out Infection
Provide Moist Wound healing

9. Orsted and colleagues, WoundCare 2007

5. Steed and Colleagues Regranex study, numerous other studies
Basic Standard Wound Care:
Moist Wound Healing
Goals: Maintain a moist wound surface
Minimizes trauma to the wound tissue
Minimize risk of infection
Manage drainage to preserve peri-wound skin.
50% Reduction in wound size at 4 weeks

Dressing selection should be based on choosing the most

cost effective dressing which meets wound needs9
9. Orsted and colleagues, WoundCare 2007
Basic Standard Wound Care:
Moist Wound Healing
Cleanse with noncytotoxic cleansers10
Saline, clean water, wound cleansers, surfactants
Wound gels and pastes:
Amorphous wound gel, Cadexomer Iodine wound paste, Manuka
honey
Wound Fillers:
Gauze, Calcium alginate, collagen
Cover dressings:
Gauze, foam , hydrocolloids, composite dressings, film dressing,
silver impregnated dressings
10. WOCN guideline2004
Home or Skilled Care Wound Supplies
• Most Insurers cover primary and secondary dressings.
• Coverage requires a complete prescription
– Wound dimensions, date of assessment, supplies and
frequency of change.
• Limit number of dressing prescribed to accommodate for revised
dressing needs as the wound changes.
• Nursing Facilities and Home Health organizations are on strict
formularies and need wound care orders written in generic terms.
i.e.
– Adhesive foam dressing vs. propriatary Allevyn, Hydrasorb , Polymem
– Hydrocolloid
– Calcium alginate
Reassess wounds regularly

• Frequency based on needs of the wound and the patient.

• Failure to achieve 50% reduction in size over 4 weeks indicates
need to reevaluate;
– Patient comorbidities
– Offloading
– Adequacy of debridement and wound care
If goals have been met in these areas consider use of advanced
wound therapies. 3,13,14,
3. Snyder, Kirsner, et al,
13. Bolton, et al N Engl J Med. 2004
14.Sheehan and colleagues, Diabetes Care 2003
Advanced Wound Therapies

It is the basic care which prepares the wound for advanced

therapies. Skip the basics and it will not make a
difference what advanced therapies you use.7

7. Frykberg, Wounds 2010

Advanced Therapies
Negative Pressure Therapy
Kalypto, Svedman, Renasys, VAC
Manage drainage, enhance wound contraction and angiogenasis
Extracellular Matrix products
Oasis, Integra, GRAFTJACKET regenerative tissue matrix,
Provide a scaffold for tissue in growth and cellular migration
Cellular Based Tissue Technologies
Apligraf, Dermagraftt. Both have FDA approval15, 16
Provide growth factors to the wound to stimulate healing
Hyperbarics
Other Advanced Therapies
• Platelet Rich Plasma
• Ultrasonic spray (MIST, Celleration)
• Electrical stimulation
• Super oxidized water ( Dermacyn)
 Advanced Wound Therapies

By using a combination of these advanced therapeutic

products based on their supporting clinical science and
evidence we should be able to improve DFU healing.

Advanced Therapies of course come at an advanced cost.

A number have a favorable reimbursement which drives
use.
Remember Bercaplamin….
The Reality of Diabetic Ulcer Healing
At the end you get back:
A diabetic patient,
With a Neuropathic foot,
Who has a very expensive layer of skin over scar tissue.

So what comes next?

 Managing Comorbidities
Lifestyle/Psychosocial Factors
Patient Compliance
1. Patient Centered Plan of Care
• The wound belongs to the patient and he must be an active
participant in the plan to heal it.
2. Motivational interviewing/Motivational Enhancement
• Discovering the barriers the patient perceives and assisting him to
discover his own solutions may result in improved compliance.
CARL J. POSSIDENTE, KATHRYN K. BUCCI, AND WALTER J. MCCLAIN
Am J Health-Syst Pharm. 2005
References
1. Iversen, Tell, Riise, et al. History of foot ulcer increases mortality among individuals with
diabetes: Norway. Diabetes Care. 2009
2. Schuster, McGlynn, Brook. How good is the quality of care in the United States? Milbank U1998
3. Snyder, Kirsner, et al; Consensus Recommendations on Advancing the Standard of Care for
Neuropathic foot Ulcer in Patients with Diabetes. 2010 http://www.o-
wm.com/files/docs/ABH_WOUNDS.pdf
4. Rogers, L. Key concepts from the 2010 consensus statement. Wounds 2010
5. Steed, Donohoe, Webster. Effect of extensive debridement and treatment on the healing of
diabetic foot ulcers J AM Coll Surg 1996
6. Margolis, Cantor, Berlin. Healing of neuropathic ulcers receiving standard treament: a meta-
analysis. Diabetes Care 1992
7. Frykenberg, Robert G. The science of advanced wound care: What should you be using in your
office. Wounds 2010
8. Lavery, Armstrong, Wunderlich, et al. Risk factors for foot infection in individuals with diabetes..
Diabetes Care 2007
9. Grayson, Gibbons, Balogh, et al. Probing to bone in infected pedal ulcers. A clinical sign of
underlying osteomyelitis, JAMA 1995
10. CARL J. POSSIDENTE, KATHRYN K. BUCCI, AND WALTER J. MCCLAIN Am J Health-Syst
Pharm. 2005
11. Orsted, Searles, Trowell, et al. Best Practice Recommendation for the Prevention, Diagnosis,
and Treatment of Diabetic Foot Ulcers: Update 2006 Adv Skin Wound Care 2007
12. WOCN Society, Guideline for Management of Wounds in Patients with Lower-Extremity
Neuropathic Disease
13. Bolton, Kirsner,Vileikyte. Clinical practice. Neuropathic diabetic foot ulcers . N Engl J Med. 2004
14. Sheehan, Casell,, et al Percent change in wound area of diabeticfoot ulcers over a 4-week
period is a robust predictor of complete helng in a 12-week prospective trial. Diabetes Care
2003
15. Cavorsi, Vicari, Wirthin, et al Best-pratice algorithms for the use of bilayered living cell
therapy…Wound Repair Regen. 2006
16. Veves, Flanga, armstrong, et al. Graftskin, a human skin equivilent, is effective in management
of noninfected neuropathic diabetic foot ulcer. Diabetes Care 2001
Resources
Patient Motivation
1. Patient-Centered Communication: Core Skills for Motivation
and Change Activity Expires: 12-01-2011
http://www.impactedu.net/index.htm

2. Motivational Enhancement Therapy (article)

http://trilogy200.respironics.com/pdf/1045805_MtvlEnhcmtTherp_Monograph.pdf

3. Motivational interviewing ( article)

http://apps.pharmacy.wisc.edu/psw/MIArticle2.pdf

4. Smoking Cessation Resource link

http://www.medicinenet.com/weight_control_and_smoking_cessation/eugene-or_city.htm

5. Diabetic Nutrition Education

http://www.peacehealth.org/apps/course/CDetails.asp?CourseID=19
http://www.oregonmedicalgroup.com/index.cfm?fuseaction=site.content&type=aafphand&destin
ation=/online/famdocen/home/common/diabetes/living/349.membersite.membersite.html
6. Wagner and University of Texas Grading Scales for Diabetic Foot Ulcers
http://www.medicalcriteria.com/site/index.php?option=com_content&view=article&id=
114%3Adbtfoot&catid=49%3Adiabetes&Itemid=80&lang=en