Am Fam Physician. 2009;80(8):789-790
Author disclosure: Nothing to disclose.
Diabetic foot ulceration is full-thickness penetration of the dermis of the foot in a person with diabetes. Severity is classified as Grade 1 through 5 using the Wagner system.
The annual incidence of ulcers among persons with diabetes is 2.5 to 10.7 percent in resource-rich countries, and the annual incidence of amputation for any reason is 0.25 to 1.8 percent.
For persons with healed diabetic foot ulcers, the five-year cumulative rate of ulcer recurrence is 66 percent and of amputation is 12 percent.
The most effective preventive measure for major amputation seems to be screening and referral to a foot care clinic if high-risk features are present.
Other interventions for reducing the risk of foot ulcers include wearing therapeutic footwear and increasing patient education for prevention, but we did not find sufficient evidence to ascertain the effectiveness of these treatments.
Pressure off-loading with total-contact casting or nonremovable fiberglass casts successfully improves healing of ulcers.
Removable cast walkers that are rendered irremovable seem equally effective, but have the added benefit of requiring less technical expertise for fitting.
We do not know whether pressure offloading with felted foam or pressure-relief half shoe is effective in treating diabetic foot ulcers.
Human skin equivalent (applied weekly for a maximum of five weeks) seems to promote ulcer healing more effectively than saline moistened gauze.
Human cultured dermis does not seem to be effective at promoting healing.
Topical growth factors seem to increase healing rates, but there has been little long-term follow-up of persons treated with these factors.
Systemic hyperbaric oxygen seems to be effective in treating persons with severely infected ulcers, although it is unclear whether it is useful in persons with non-infected, nonischemic ulcers.
We do not know whether debridement or wound dressings are effective in healing ulcers.
However, debridement with hydrogel and dimethyl sulfoxide wound dressings seems to promote ulcer healing.
Debridement and wound dressings have been included together because the exact mechanism of the treatment can be unclear (e.g., hydrogel).
| What are the effects of interventions to prevent foot ulcers and amputations in persons with diabetes? | |
| Likely to be beneficial | Screening and referral to foot care clinics |
| Unknown effectiveness | Education |
| Therapeutic footwear | |
| What are the effects of treatments in persons with diabetes with foot ulceration? | |
| Likely to be beneficial | Human skin equivalent |
| Pressure off-loading with total-contact or nonremovable cast for plantar ulcers | |
| Systemic hyperbaric oxygen (for infected ulcers) | |
| Topical growth factors | |
| Unknown effectiveness | Debridement or wound dressings |
| Pressure off-loading with felted foam or pressure-relief half shoe | |
| Systemic hyperbaric oxygen (for noninfected, nonischemic ulcers) | |
| Unlikely to be beneficial | Human cultured dermis |
Definition
Diabetic foot ulceration is full-thickness penetration of the dermis of the foot in a person with diabetes. Ulcer severity is often classified using the Wagner system. Grade 1 ulcers are superficial ulcers involving the full skin thickness, but no underlying tissues. Grade 2 ulcers are deeper, penetrating down to ligaments and muscle, but not involving bone or abscess formation. Grade 3 ulcers are deep ulcers with cellulitis or abscess formation, often complicated with osteomyelitis. Ulcers with localized gangrene are classified as Grade 4, and those with extensive gangrene involving the entire foot are classified as Grade 5.
Incidence
Studies conducted in Australia, Finland, the United Kingdom, and the United States have reported the annual incidence of foot ulcers among persons with diabetes as 2.5 to 10.7 percent, and the annual incidence of amputation for any reason as 0.25 to 1.8 percent.
Etiology
Long-term risk factors for foot ulcers and amputation include duration of diabetes, poor glycemic control, microvascular complications (retinopathy, nephropathy, and neuropathy), peripheral vascular disease, foot deformities, and previous foot ulceration or amputation. Strong predictors of foot ulceration are altered foot sensation, foot deformities, and previous foot ulcer or amputation of the other foot (altered sensation [relative risk (RR) = 2.2; 95% confidence interval (CI), 1.5 to 3.1]; foot deformity [RR = 3.5; 95% CI, 1.2 to 9.9]; previous foot ulcer [RR = 1.6; 95% CI, 1.2 to 2.3]; previous amputation [RR = 2.8; 95% CI, 1.8 to 4.3]).
Prognosis
In persons with diabetes, foot ulcers often coexist with vascular insufficiency (although foot ulcers can occur in persons with no vascular insufficiency) and may be complicated by infection. Amputation is indicated if disease is severe or does not improve with conservative treatment. In addition to affecting quality of life, these complications of diabetes account for a large proportion of diabetes-related health care costs. For persons with healed diabetic foot ulcers, the five-year cumulative rate of ulcer recurrence is 66 percent and of amputation is 12 percent. Severe infected foot ulcers are associated with an increased risk of mortality.