Diabetic foot ulcers (DFUs) are a serious complication of diabetes that results in significant morbidity and mortality. Mortality rates associated with the development of a DFU are estimated to be 5% in the first 12 months, and 5-year morality rates have been estimated at 42%. The standard practices in DFU management include surgical debridement, dressings to facilitate a moist wound environment and exudate control, wound off-loading, vascular assessment, and infection and glycemic control. These practices are best coordinated by a multidisciplinary diabetic foot wound clinic. Even with this comprehensive approach, there is still room for improvement in DFU outcomes. Several adjuvant therapies have been studied to reduce DFU healing times and amputation rates. We reviewed the rationale and guidelines for current standard of care practices and reviewed the evidence for the efficacy of adjuvant agents. The adjuvant therapies reviewed include the following categories: nonsurgical debridement agents, dressings and topical agents, oxygen therapies, negative pressure wound therapy, acellular bioproducts, human growth factors, energy-based therapies, and systemic therapies. Many of these agents have been found to be beneficial in improving wound healing rates, although a large proportion of the data are small, randomized controlled trials with high risks of bias.

/pdf/update-on-management-of-diabetic-foot-ulcers-3t7shn41st.pdf

Update on management of diabetic foot ulcers.

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. In conjunction with advice from internal and external reviewers and expert consultants in the field, this update is based on a systematic review of the literature centred on the following: the Population (P), Intervention (I), Comparator (C) and Outcomes (O) framework; the use of the SIGN guideline/Cochrane review system; and the 21 point scoring system advocated by IWGDF/EWMA. This has resulted in 13 recommendations. The recommendation on sharp debridement and the selection of dressings remain unchanged from the last recommendations published in 2016. The recommendation to consider negative pressure wound therapy in post-surgical wounds and the judicious use of hyperbaric oxygen therapy in certain non-healing ischaemic ulcers also remains unchanged. Recommendations against the use of growth factors, autologous platelet gels, bioengineered skin products, ozone, topical carbon dioxide, nitric oxide or interventions reporting improvement of ulcer healing through an alteration of the physical environment or through other systemic medical or nutritional means also remain. New recommendations include consideration of the use of sucrose-octasulfate impregnated dressings in difficult to heal neuro-ischaemic ulcers and consideration of the use of autologous combined leucocyte, platelet and fibrin patch in ulcers that are difficult to heal, in both cases when used in addition to best standard of care. A further new recommendation is the consideration of topical placental derived products when used in addition to best standard of care.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/dmrr.3283

Guidelines on use of interventions to enhance healing of chronic foot ulcers in diabetes (IWGDF 2019 update).

GENERAL PURPOSE:To provide background and examine evidence for the therapeutic application of light energy treatments for wound healing.TARGET AUDIENCE:This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wo

Photobiomodulation Therapy for Wound Care: A Potent, Noninvasive, Photoceutical Approach.

The management of diabetic foot ulcers (DFU) remains a challenge, and there is continuing uncertainty concerning optimal approaches to wound healing. The International Working Group of the Diabetic Foot (IWGDF) working group on wound healing has previously published systematic reviews of the evidence in 2008, 2012 and 2016 to inform protocols for routine care and to highlight areas which should be considered for further study. The working group has now updated this review by considering papers on the interventions to improve the healing of DFU's published between June 2014 and August 2018. Methodological quality of selected studies was independently assessed by a minimum of two reviewers using the recently published 21-point questionnaire as recommended by IWGDF/European Wound Management Association, as well as the previously incorporated Scottish Intercollegiate Guidelines Network criteria. Of the 2275 papers identified, 97 were finally selected for grading following full text review. Overall, there has been an improvement in study design and a significant rise in the number of published studies. While previous systematic reviews did not find any evidence to justify the use of newer therapies, except for negative pressure wound therapy in post-surgical wounds, in this review we found additional evidence to support some interventions including a sucrose-octasulfate dressing, the combined leucocyte, fibrin and platelet patch as well as topical application of some placental membrane products, all when used in addition to usual best care. Nonetheless, the assessment and comparison of published trials remains difficult with marked clinical heterogeneity between studies: in patient selection, study duration, standard of usual care provision and the timing and description of the clinical endpoints.

Effectiveness of interventions to enhance healing of chronic foot ulcers in diabetes: a systematic review

Diabetic foot ulceration is a serious limb-threatening complication of diabetes. It is the common cause of hospital admissions and amputations. The objective of the study was to determine the prevalence of diabetic foot ulcers (DFU) and its association with age, gender, duration of diabetes, peripheral neuropathy (PN), peripheral arterial disease (PAD) and HbA1c. A total of 1940 people (≥ 30 years of age) with type 2 diabetes coming to the Sakina Institute of Diabetes and Endocrine Research (specialist diabetes clinic) at Shalamar Hospital, Lahore, Pakistan, were recruited over a period of 1 year from January 2016 to January 2017. The foot ulcers were identified according to the University of Texas classification. PN was assessed by biothesiometer and PAD by ankle-brachial index (< 0.9). Body weight, height, body mass index (BMI), HbA1c and duration of diabetes were recorded. The prevalence of DFU was 7.02%, of which 4.5% of the ulcers were on the planter and 2.6% on the dorsal surface of the foot; 8.5% of the persons had bilateral foot ulcers and 0.4% subjects had Charcot deformity. There was significant association of foot ulcers with age, duration of diabetes, HbA1c, PN and PAD, whereas no association was observed with gender and BMI. PN and PAD were observed in 26.3 and 6.68% of people with diabetes respectively. Neuropathic ulcers and neuro-ischemic ulcers were identified in 74 and 19% of the study population. Logistic regression analysis revealed significant odds ratio for peripheral neuropathy 23.9 (95% confidence interval (5.41–105.6). Peripheral neuropathy is the commonest cause of foot ulcers. An optimum control of blood glucose to prevent neuropathy and regular feet examination of every person with diabetes may go a long way in preventing foot ulceration.

/pdf/frequency-of-foot-ulcers-in-people-with-type-2-diabetes-3o7g2u4zo3.pdf

Frequency of foot ulcers in people with type 2 diabetes, presenting to specialist diabetes clinic at a Tertiary Care Hospital, Lahore, Pakistan

Foot ulcers are serious complications of diabetes mellitus (DM) and are known to be resistant to conventional treatment. This study was conducted to evaluate the efficacy of low-level laser therapy (LLLT) for the treatment of diabetic foot ulcers in a tertiary care centre (Department of Surgery, Mahatma Gandhi Memorial Medical College and Maharaja Yashwantrao Hospital, A.B. Road, Indore). A total of 30 patients with type 2 DM having Meggitt-Wagner grade I foot ulcers of more than 6 weeks duration with negative culture were studied. Patients were randomized into two groups of 15 each. Patients in study group received LLLT (660 ± 20 nm, 3 J/cm2) along with conventional therapy and those in control group were treated with conventional therapy alone. The primary outcome measure was the absolute and relative wound size reduction at 2 weeks compared to the baseline parameter. Percentage ulcer area reduction was 37 ± 9% in the LLLT group and 15 ± 5.4% in the control group (p < 0.001). For ∼75% of wounds of the treatment group, wound area reduction of 30–50% was observed. In contrast, for the control group, ∼80% of wounds showed a wound area reduction of <20% on day 15. Further, the wounds with initial wound area 1000–2000 mm2 seems to have better final outcome than the groups with larger areas. The treated groups showed higher amount of granulation than the control group. The results suggest that LLLT is beneficial as an adjunct to conventional therapy in the treatment of diabetic foot ulcers.

Fareed Khan

Papers

Low-level laser therapy as an adjunct to conventional therapy in the treatment of diabetic foot ulcers