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2/9/2017 Diabetic Ulcers Treatment & Management: Approach Considerations, Management of Systemic and Local Factors, Wound and

and Foot Care

Diabetic Ulcers Treatment & Management


Updated: Mar 14, 2017
Author: Vincent Lopez Rowe, MD; Chief Editor: Romesh Khardori, MD, PhD, FACP more...

TREATMENT

Wound and Foot Care


The basic principle of topical wound management is to provide a moist, but not wet, wound bed.
[10, 41]

For more information, see Diabetic Foot Infections.

Wound coverage
After debridement, apply a moist sodium chloride dressing or isotonic sodium chloride gel (eg,
Normlgel, IntraSite gel) or a hydroactive paste (eg, Duoderm). Optimal wound coverage requires
wet-to-damp dressings, which support autolytic debridement, absorb exudate, and protect
surrounding healthy skin. A polyvinyl film dressing (eg, OpSite, Tegaderm) that is semipermeable
to oxygen and moisture and impermeable to bacteria is a good choice for wounds that are neither
very dry nor highly exudative. Wound coverage recommendations for some other wound conditions
are as follows (see the Table, below):

Dry wounds: Hydrocolloid dressings, such as DuoDERM or IntraSite Hydrocolloid, are


impermeable to oxygen, moisture, and bacteria; maintain a moist environment; and support
autolytic debridement. They are a good choice for relatively desiccated wounds.
Exudative wounds: Absorptive dressings, such as calcium alginates (eg, Kaltostat,
Curasorb), are highly absorptive and are appropriate for exudative wounds. Alginates are
available in a rope form, which is useful for packing deep wounds.
Very exudative wounds: Impregnated gauze dressings (eg, Mesalt) or hydrofiber dressings
(eg, Aquacel, Aquacel-Ag) are useful for extremely exudative wounds. In these cases, twice-
daily dressing changes may be needed.
Infected wounds: For infected superficial wounds, use Silvadene (silver sulfadiazine) if the
patient is not allergic to sulfa drugs; if a sulfa allergy exists, either bacitracin-zinc or
Neosporin ointment is a good alternative. Where heavy bacterial contamination of deeper
wounds exists, irrigation using one-fourth strength Dakin solution and 0.25% acetic acid may
be useful for a brief period of time; a hydrofiber-silver dressing (Aquacel-Ag) can help control
wounds that are both exudative and potentially colonized.
Wounds covered by dry eschar: In this case, simply protecting the wound until the eschar
dries and separates may be the best management. Occasionally, painting the eschar with
povidone iodine (Betadine) is beneficial to maintain sterility while eschar separation occurs;
an uninfected dry heel ulcer in a well-perfused foot is perhaps best managed in this fashion.
Areas that are difficult to bandage: Bandaging a challenging anatomical area, such as around
a heel ulcer, requires a highly conformable dressing, such as an extra thin hydrocolloid;
securing a dressing in a highly moist challenging site, such as around a sacrococcygeal
ulcer, requires a conformable and highly adherent dressing, such as a wafer hydrocolloid.
Fragile periwound skin: Hydrogel sheets and nonadhesive forms are useful for securing a
wound dressing when the surrounding skin is fragile.

Other topical preparations that occasionally may be useful in the management of diabetic foot
ulcers are as follows:
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2/9/2017 Diabetic Ulcers Treatment & Management: Approach Considerations, Management of Systemic and Local Factors, Wound and Foot Care

Platelet-derived growth factors (PDGF): Topically applied PDGF has a modestly beneficial
effect in promoting wound healing. Becaplermin gel 0.01% (Regranex), a recombinant human
PDGF that is produced through genetic engineering is approved by the US Food and Drug
Administration (FDA) to promote healing of diabetic foot ulcers. [32] Regranex is meant for a
healthy, granulating wound, not one with a necrotic wound base, and is contraindicated with
known skin cancers at the site of application.
Enzymatic debridement: Collagen comprises a significant fraction of the necrotic soft tissues
in chronic wounds; the enzyme collagenase, derived from fermentation of Clostridium
histolyticum, helps remove nonviable tissue from the surface of wounds. However, it is not a
substitute for an initial surgical excision of a grossly necrotic wound.
Miscellaneous topical agents: Various other topical agents that have been used for wound
management include sugar, antacids, and vitamin A and D ointment.

Cytotoxic agents, such as hydrogen peroxide, povidone iodine, acetic acid, and Dakin solution
(sodium hypochlorite), should be avoided, except as noted above under infected wounds.

Table. Characteristics and Uses of Wound Dressing Materials (Open Table in a new window)

Category Examples Description Applications

AlgiSite

Comfeel

Curasorb
This seaweed extract contains These are highly
guluronic and mannuronic acids absorbent and useful
that provide tensile strength and for wounds having
Kaltogel
calcium and sodium alginates, copious exudate.
Alginate which confer an absorptive Alginate rope is
capacity. Some of these can leave particularly useful to
fibers in the wound if they are not pack exudative wound
Kaltostat
thoroughly irrigated. These are cavities or sinus
secured with secondary coverage. tracts.

Sorbsan

Tegagel

Hydrofiber Aquacel An absorptive textile fiber pad, also These are absorbent
available as a ribbon for packing of dressings used for
deep wounds. This material is exudative wounds.
covered with a secondary dressing.
Aquacel-Ag The hydrofiber combines with
wound exudate to produce a
hydrophilic gel. Aquacel-Ag

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contains 1.2% ionic silver that has


Versiva strong antimicrobial properties
against many organisms, including
methicillin-resistant Staphylococcus
aureus and vancomycin-resistant
Enterococcus.

Hypergel
(hypertonic
saline gel)

Santyl These are useful for


Various products provide some
Debriding (collagenase) necrotic wounds as an
degree of chemical or enzymatic
agents adjunct to surgical
debridement.
debridement.

Accuzyme
(papain urea)

LYOfoam

Spyrosorb These are useful for


Polyurethane foam has some cleaning granulating
Foam
absorptive capacity. wounds having
minimal exudate.
Allevyn

Hydrocolloid Aquacel These are made of microgranular They are useful for dry
suspension of natural or synthetic necrotic wounds,
polymers, such as gelatin or pectin, wounds having
in an adhesive matrix. The granules minimal exudate, and
CombiDERM change from a semihydrated state clean granulating
to a gel as the wound exudate is wounds.
absorbed.

Comfeel

Duoderm
CGF Extra
Thin

Granuflex

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Tegasorb

Aquasorb

Duoderm

IntraSite Gel

Granugel These are water-based or glycerin-


based semipermeable hydrophilic
polymers; cooling properties may
These are useful for
decrease wound pain. These gels
Hydrogel dry, sloughy, necrotic
Normlgel can lose or absorb water
wounds (eschar).
depending upon the state of
hydration of the wound. They are
secured with secondary covering.
Nu-Gel

Purilon Gel

(KY jelly)

Mepore

These are useful for


Skintact acute minor wounds,
Low- These are various materials
such as skin tears, or
adherence designed to remove easily without
as a final dressing for
dressing damaging underlying skin.
chronic wounds that
Release have nearly healed.

Transparent OpSite These are highly conformable These are useful for
film acrylic adhesive film having no clean dry wounds
absorptive capacity and little having minimal
exudate, and they also
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Skintact hydrating ability, and they may be are used to secure an


vapor permeable or perforated. underlying absorptive
material. They are
used for protection of
Release high-friction areas and
areas that are difficult
to bandage such as
heels (also used to
Tegaderm secure IV catheters).

Bioclusive

For more information, see Diabetic Foot Infections.

Vacuum-assisted closure
Clean but nonhealing deep cavity wounds may respond to repeated treatments by application of
negative pressure under an occlusive wound dressing (vacuum-assisted closure [VAC]). [42]

Hydrotherapy

Intractable, infected, cavity wounds sometimes improve with hydrotherapy using saline pulse
lavage under pressure (PulsEvac).

Treatment of Charcot foot


Charcot foot is treated initially with immobilization using special shoes or braces but eventually
may require podiatric surgery such as ostectomy and arthrodesis.

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