Treatment & Management of Diabetic Foot Ulcers: Prevention is better than Amputation

Introduction Diabetic Foot Syndrome or Disease (DFD), as defined by the WHO, is an “ulceration of the foot (distally from the ankle and including the ankle) associated with neuropathy and different grades of ischemia and infection.” Globally, the prevalence of ulcers in the foot due to diabetes is as high as 25%. The risk that a diabetic patient may develop a foot ulcer is 15%. People with Diabetes mellitus, male gender, old age, lower body mass index, hypertension, diabetic retinopathy, obesity, history of smoking, and patients suffering from T1DM have a high risk of developing Diabetic Foot Syndrome or Disease (DFD). Diabetic foot disease includes athlete’s foot, Onychomycosis, calluses, corns, blisters, diabetic ulcers, hammertoes, ingrown toenails, and plantar warts. This article is an overview of the treatment and management of diabetic foot ulcers, which is a severe concern in diabetic patients. How are Diabetic foot ulcers treated? When a diabetic patient visits a physician or a podiatrist, the physician carries out the general physical verification of the ulcer for diagnosis and checks the patient history. Diagnosis helps identify the severity of the disease, signs of infection, and steps to prevent any further spread of infection. Before the patient leaves the hospital, the physician or nurse carries out the following treatment on the non-infected ulcers to prevent any infection:

• Cleans the wound in the feet properly to remove the debris, dead cells, and callus formed around the ulcer.
• Drains away the fluid or abscess from the ulcer.
• If the physician finds necrotic tissue, including an infected bone, the patient must undergo surgical intervention to remove the necrotic tissue.
• The nurse then applies ointment and bandages to the wound to prevent any infection. This helps the ulcer wounds to heal.
• After dressing the patient’s feet, the physician prescribes the patient to use a wheelchair or crutches. This is required to take the weight off the recently bandaged foot.
• To eliminate any chance of infection, the physician prescribes oral or IV broad-spectrum antibiotics.

If the ulcers fail to heal after four to six weeks despite proper medical care, the physician then may carry out any one of the following additional treatment procedures:

• In patients with neuro-ischemic ulcers, the physician will put a sucrose octasulfate impregnated dressing.
• The physician will carry out a multilayered patch of autologous leucocytes, platelets, and fibrin in patients with or without moderate ischemic ulcers.
• Ischemic ulcers that do not heal even after revascularization, the physician may go for systemic oxygen therapy.

The IWGF guidelines on the prevention and management of Diabetic Foot disease suggests having at least three levels of foot-care management in diabetic healthcare systems with the following specialists as mentioned in the below table:

LEVEL OF CARE	INTERDISCIPLINARY SPECIALISTS INVOLVED
Level 1	General practitioner, podiatrist, and diabetes nurse
Level 2	Diabetologist, surgeon (general, orthopedic, or foot), vascular specialist (endovascular and open revascularization), infectious disease specialist or clinical microbiologist, podiatrist and diabetes nurse, in collaboration with a shoe technician, orthotist or prosthetist
Level 3	A level 2 foot center that is specialized in diabetic foot care, with multiple experts from several disciplines, each speciali zed in this area working together, and that acts as a tertiary reference center

Management of Diabetic Foot Ulcer Five key elements that play an essential role in the prevention and management of diabetic foot disease:

1. Identifying the foot at risk Patients with diabetes may show no signs and symptoms of diabetic foot disease. However, this does not rule out the risk of getting diabetic foot ulcers. Patients may have neuropathy, peripheral arterial disease, pre-ulcerative signs that are asymptomatic at that moment. Thus, physicians follow the IWGDF 2019 Risk Stratification System for screening diabetic foot disease.

   Category	Risk of Ulcer	Characteristics of this category	Screening frequency (based on expert opinion)
   0	Very Low	There is no loss of protective sensation (LOPS).	Once a year
   1	Low	Presence of LOPS or peripheral artery disease (PAD)	Once every 6-12 months
   2	Moderate	Presence of any one of the following: LOPS+PAD LOPS+ Foot Deformity PAD + Foot Deformity	Once every 3-6 months
   3	High	Presence of LOPS or PAD along with any one or more of the following: A patient has a history of foot ulcer Presence of renal disease along with diabetes History of lower-extremity amputation	Once every1-3 months

   
   
2. Carrying out regular clinical examination of the foot that is at risk Patients who come under Category 1-3 according to IWGDF screening need routine and more comprehensive clinical investigations for the management of diabetic foot disease. On each visit of screening, the physician:
   • Assesses the LOPs and color of the skin
   • Identify if there is any callus formation or symptoms of pre ulcer
   • Check if there is any bone or joint deformity.
   • Check if the patient feels difficulty walking.
   • Check the footwear of the patient, and also
   • Checks if there are any symptoms of peripheral artery disease.

The physician tries to diagnose the symptoms of DFU using different methods like physical examination, X-Ray, MRI scan, and biopsy.

The foot under risk is also checked for the severity of infection caused by the ulcer. Again, the International Working Group of the Diabetic Foot (IWGDF) has set the Perfusion, Extent, Depth, Infection, and Sensation (PEDIS) classification system in which all DFUs are classified according to four PEDIS grades as mentioned in the table below:

PEDIS GRADE	INFECTION SEVERITY	CLINICAL MANIFESTATIONS
1	Uninfected	Lack of manifestations of inflammation
2	Mild	Presence of two or more manifestations of inflammation like purulence, erythema, tenderness, warmth, or induration. The ulcer is limited to the skin with no other complications or illness.
3	Moderate	The clinical manifestations are similar to grade 2 but with the additional clinical symptoms: Cellulitis around the ulcer is greater than 2 cm Presence of deep-tissue abscess Gangrene Infection is spread beneath the superficial fascia Presence of gangrene, deep tissue abscess, and involvement of joint or muscle.
4	Severe	The patient is metabolically instable and has the following clinical conditions: Fever, chills, confusion, vomiting, acidosis Tachycardia, hypotension, and severe hyperglycemia

• Educating the patients, their relatives, and healthcare professionals The treatment of DFD is very challenging as this disease is usually irreversible and increases drastically. It is essential to give a structured education about Diabetic Foot Disease (DFD) because previous experiments have shown people to be ignorant about monitoring glucose, controlling blood sugar, and the importance of regular screening to treat early complications of DFD. Due to unawareness or lack of education:
  • Some patients do not visit hospitals for fear of amputation.
  • Almost every diabetic patient does not know the proper footwear to wear during DFD, and
  • Some patients ignore the symptoms of diabetic foot disease.

Through structured, organized, and adequate education on diabetes and diabetic foot disease by healthcare professionals to patients and their relatives, we can increase awareness & prevent complications of diabetes. An appropriately trained interdisciplinary team should take charge of providing education. In addition, the team should have a sound understanding of the principles of governing, teaching, and learning. Interdisciplinary teams providing education to patients should include:

• • A pediatric endocrinologist/ diabetologist or a physician trained in the care of children and adolescents with diabetes
  • A diabetes specialist nurse/diabetes educator
  • Psychologist, social activist, and dietician.

Educating patients include many practices which need a separate article.

4. The appropriate wearing of footwear Wearing appropriate footwear both indoors and outdoors is very much necessary to prevent diabetic foot diseases. According to IWGDF guidelines, the inside length of the shoe should be one to two cm longer than the foot of the patient. In addition, the footwear should be comfortable to wear by the patient where they can move their toes freely. Also, the footwear should have demonstrated a plantar pressure-relieving effect during walking. Patients should also wash their feet twice a day with water having a temperature of 370C. It is advised to visit a podiatrist or an orthopedist to get better knowledge on the type of therapeutic footwear that will provide you comfort and prevent Diabetic Foot Disease.
5. Managing the risk factors for ulceration The physician should look for pre-ulcerative signs, ulcerative symptoms, and other risk factors that may cause Diabetic Foot Disease in Patients. Some of the methods that manage the risk factors for ulceration include:

• • Prescribing antifungal medications to treat Onychomycosis
  • Monitoring the blood sugar level of the patient
  • Educating the patients to quit tobacco, draining the fluids or pus from the ulcer, use of broad-spectrum antibiotics to prevent infection.

Conclusion Diabetes patients should carry out health checkups every 2-3 months to track their health condition. Diabetic foot disease is caused by the severe complication of diabetes Mellitus that causes immense distress and financial burden to the individual and their family. Peripheral artery Disease and Diabetic Neuropathy are the two primary components of Diabetic Foot Disease. Diabetic foot disease, if left undiagnosed and unattended, can lead to amputation of the limbs. The burden of diabetic foot disease can only be reduced by proper screening, diagnosis, identifying the risks, and imparting structured education to patients and their relatives. References

1. Schaper NC, van Netten JJ, Apelqvist J, Bus SA, Hinchliffe RJ, Lipsky BA; IWGDF Editorial Board. Practical Guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update). Diabetes Metab Res Rev. 2020 Mar;36 Suppl 1:e3266. doi: 10.1002/dmrr.3266. PMID: 32176447.
2. Lange K et al, ISPAD Clinical Practice Consensus Guidelines 2014 Compendium Diabetes education in children and adolescents, Pediatric Diabetes 2014: 15(Suppl. 20): 77–85 doi: 10.1111/pedi.12187
3. Trudi Deakin, Structured patient education: The Diabetes X-PERT Programme makes a difference, DOI: 10.1111/j.1464-5491.2006.01906
4. Diabetic Foot Problems. Accessed at https://www.webmd.com/diabetes/foot-problems
5. Diabetic Feet. Accessed at https://my.clevelandclinic.org/health/diseases/21510-diabetic-feet#diagnosis-and-tests