Diabetic foot care: Tips and tools to streamline your approach

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Applied Evidence

Diabetic foot care: Tips and tools to streamline your approach

J Fam Pract. 2009 December;58(12):646-653

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References

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2 adjunctive therapies to consider

If there is no evidence to support an alternative diagnosis, consider adjunctive treatments, with hyperbaric oxygen therapy (HBOT) foremost among them.

FAST TRACK

A Cochrane review of hyperbaric oxygen therapy found that it reduced the number of major amputations in patients with chronic foot ulcers.

A Cochrane review of HBOT found that it reduced the number of major amputations in diabetes patients with chronic foot ulcers, and improved healing at 1 year.³¹ Both Medicare and Medicaid cover HBOT for patients with diabetic ulcers classified as Wagner Grade 3 or higher that have not responded to 30 days of standard treatment.

Maggots, scientifically known as Lucilia sericata (Greenbottle) fly larvae, secrete proteolytic enzymes that debride necrotic tissue but are inactivated by living tissue. One meta-analysis found that neither surgical debridement nor larval therapy showed significant benefit over hydrogel.³² A subsequent small study did show statistically improved healing in ulcers debrided with maggots, compared with surgical debridement.³³

CASE: MR. F.’S ULCER HEALS

Because Mr. F.’s ulcer is small and shallow and has been present for a short time, it has an excellent chance of healing if you follow the AIM DOC steps. You determine that he has adequate arterial supply and that the wound is uninfected (there is a strong dorsalis pedis pulse and no warmth, exudate, or erythema around the wound). Using a #15 blade, you pare away the callus surrounding the ulcer and document the length and width of the wound. You cover the ulcer with a moist dressing and instruct Mr. F to replace it twice a day, cautioning him against using alcohol or hydrogen peroxide, which could harm the healing skin. You discuss the importance of avoiding all weight bearing on the ulcerated foot, prescribe a CAM walker to wear at all times except while he’s sleeping, and schedule weekly follow-up visits to track progress.

In 2 weeks, the wound has resolved. You educate Mr. F. about his risk of ulcer recurrence and outline appropriate preventive steps. You also refer him for fitted extra-depth diabetic shoes and ongoing podiatry follow-up.

ACKNOWLEDGMENT

The authors wish to thank Gregory Mack, DPM, University of Wisconsin School of Medicine and Public Health, for his teaching and collaboration.

CORRESPONDENCE
Jennifer Eddy, MD, University of Wisconsin School of Medicine and Public Health, 617 W. Clairemont Avenue, Eau Claire, WI 54701; Jennifer.eddy@fammed.wisc.edu