Diabetic foot ulcers are defined as nonhealing or long-lasting chronic skin ulcers in diabetic patients. Anyone who has diabetes can develop a foot ulcer. They occur as an open sore or wound in approximately 15 percent of patients with diabetes and the common location is at the bottom of the foot. About 6% of people who develop foot ulcer are hospitalized due to infection or other ulcer-related complication. Approximately 85 percent of all diabetes-related lower-extremity amputations are preceded by foot ulcers. Management of foot ulcer at the diabetic foot clinic is largely determined by the severity, vascularity and the presence of infection. Multidisciplinary care for the diabetic foot with treatment results aimed at wound healing and closure are challenging.
Evaluation of diabetic foot ulcers
Management of diabetic foot ulcers involves assessing, grading and classifying the ulcer as the first steps. Checking for vascular and neurological status of the lesion and accurately assessing wounds are significant part of foot ulcer evaluation. Clinical evaluation of the extent and depth of the ulcer and the presence of infection or ischemia form the basis for classification of ulcer on which nature and intensity of treatment are determined. Patients with diabetic foot ulcers need ankle-brachial index and toe pressure measurements to assess for ischemia.
Aim of diabetic foot ulcer treatment
Successful wound healing treatments in Chennai for diabetic foot ulcers consists of addressing these three basic issues: debridement, offloading, and infection control. Treatment for diabetic foot also involves managing blood glucose levels as tightly controlling blood glucose is of the utmost importance. Other medical interventions for allied health problems are also of equal importance in allowing the wound to heal well.
Debridement – Proper removal of necrotic tissue, peri-wound callus and foreign bodies down to viable tissue is necessary to decrease the risk of infection and reduce peri-wound pressure. Debridement facilitates normal wound contraction and healing. After debridement, the wound is usually irrigated with saline or cleanser and applied with medication and dressing. The purpose of a good dressing is to prevent tissue break down, absorb excess fluid and prevent contamination. If there is an abscess, debridement of all abscessed tissue with incision and drainage is essential. While timely incision and drainage procedures have saved many limbs, failure to perform the procedure have led to the loss of many limbs. A deep abscess if treated only with antibiotics can delay appropriate therapy and result in further morbidity and mortality.
Offloading– To halt weight bearing completely on the affected foot is the most effective method of offloading to heal a foot ulcer.To wear special footgear, brace, specialized castings, or use of mobility devices like the wheelchair or crutches will reduce the pressure and irritation to the area with the ulcer and help the healing process to be faster. Postoperative shoes or wedge shoes that are large enough may also be used to accommodate bulky dressings. Total contact casts (TCCs) can be applied to significantly reduce pressure on wounds. However, inappropriate application of TCCs cause new ulcers to form. The disadvantage is that TCCs are contraindicated in deep or draining wounds or for use with noncompliant, blind, morbidly obese or severely vascularly compromised patients. The advantage of removable cast walkers are that it allows for daily wound inspection, dressing changes and early detection of infection. The biggest challenge for clinicians treating diabetic foot ulcers is to find the right of proper offloading for the ulcer.
Infection control – Mild to moderate infections with localized cellulitis are generally treated with oral antibiotics prescribed at the outpatient clinic. Whereas, severe diabetic foot infections that are polymicrobial needs hospitalization and treatment with intravenous antibiotics. Limb-threatening infections are treated with antibiotics that are selected to cover a wide spectrum of gram-positive and gram-negative organisms and provide both aerobic and anaerobic coverage. There is no surgery required to treat a majority of non-infected foot ulcers. In cases where this treatment method fails, appropriate surgical management to remove pressure on the affected area includes shaving or excision of bone and correction of diabetic foot deformities like hammertoes, bunions or bony “bumps.”
The wound size and location, pressure on the wound from walking or standing, swelling, circulation, blood glucose levels, wound care and external application are the factors that decide the healing time to may vary from weeks to several months.
Therapeutic methods for diabetic foot ulcer
A systematic approach to treatment should be taken for all diabetic foot lesions. There are different kinds of wound cleaning, debridement, skin grafting, infection control, vasodilators, pain management and different types of bandages and even fly maggots used as therapeutic methods. The multifaceted nature of foot ulcers and the numerous comorbidities that can occur in diabetic patients demands a multidisciplinary approach to be employed. Significant improvements in outcomes, including reduction in the incidence of major amputation have been demonstrated by this approach. But unsatisfactory results of these existing multidisciplinary care systems have made diabetic foot ulcer management difficult.
Laser therapy in diabetic foot ulcer treatment
Low level laser therapy (LLLT) or soft laser supplies direct bio stimulative light energy to body cells that is known to promote reduction of inflammation, angiogenesis and production of extracellular matrix components. Laser therapy devices illuminate the treatment area from a certain distance that stimulates molecules and atoms of cells without rapid or significant increase in tissue temperature. According to a study, significant reduction of wound bacterial load can be achieved through CO2 laser therapy.
Ann N Y Acad Sci. 2018 Jan; 1411(1): 153–165.
Diabetic foot ulcer clinic recommends the application of lasers to stimulate wound healing in cases of nonhealing ulcers. The body’s natural healing processes can be accelerated by using a Laser wavelength of light that is targeted to increase blood flow at the wound site. Reduced pain, accelerated tissue repair, faster wound healing along with improved nerve function and vascularity are the benefits of Laser therapy. Evidence of multiple benefits of Laser in the treatment of wound healing has risen promising scientific application of Laser therapy in the treatment of diabetic foot ulcer.