Principles of local management of DFUs1

Indications for referral of a patient with diabetes to a specialist

foot service2,3
Priority Indications Timing of Suggested
QUICK GUIDE
Local management of
Standard local DFU management consultation or frequency of
n Debridement referral follow-up*
n Cleansing Urgent n Open wound +/- signs of Immediate As determined

diabetic foot ulcers

n Management of exudate levels (active infection consultation by specialist
n Treatment of infection pathology) n New neuropathic pain or
n Offloading/protection pain at rest
n Active Charcot deformity
(red, hot swollen midfoot or
Monitor regularly, e.g. weekly ankle)
n Is the wound making positive progress?* n Vascular compromise
(sudden absence of DP/PT
Yes pulses or gangrene)
No
High n Previous history of DFU or Immediate or Every 12 months Management of
Reassess patient and wound Continue standard (ADA risk lower extremity amputation ‘next available’
treatment diabetic foot ulcers
No category 3) n Chronic venous insufficiency outpatient
n At 4 weeks, has the consultation is complex, and
wound area reduced
by≥50%? Moderate n PAD +/- LOPS Referral within Every 2–3
requires a
Refer/amend management Yes (ADA risk n DP/PT pulse diminished 1–3 months months multi-disciplinary
as appropriate to correct category 2) or absent team approach to
problems Consider treatment n Lower limb swelling or
and reassess oedema avoid serious
n Second-line (advanced) therapies
may be indicated if wound area
regularly Low n LOPS +/- longstanding Referral within 1 Every 4–6 and expensive
reduction at 4 weeks is <50% (ADA risk non-changing foot deformity month months complications, such as
despite optimised management category 1) n Patient requires specialist
footwear infection and amputation1
of blood glucose and ischaemia, Once DFU healed
concordance with offloading/ (diabetic foot in remission) Very low n No LOPS or PAD Referral within As a minimum,
protection and exclusion of n Ongoing surveillance in remission (ADA risk n Education about foot 1–3 months annually
infection n Protective footwear category 0) care, exercise, footwear,
preventing injury, etc.
*All patients with diabetes should be seen by a foot specialist at least once per year.
*Triggers for reassessment include increasing wound size, new pain or discomfort, ADA: American Diabetic Association; DP: dorsalis pedis; LOPS: loss of protective sensation; PAD:
signs of infection peripheral arterial disease; PT: posterior tibial

© Wounds International 2017 All rights reserved. Unless otherwise designated,

References
1. WUWHS. Florence Congress, Position Document. Local
management of diabetic foot ulcers. Wounds International, 2016
2. Boulton AJM et al. Diabetes Care 2008; 31(8): 1679-85
3. Miller JD et al. J Fam Pract 2014; 63(11): 646–56 all trademarks are proprietary to KCI Licensing,
4. Chadwick P, Armstrong DG. Local management of diabetic Inc., its affiliates and/or licensors.
foot Made Easy. Wounds International, 2017 Supported by Acelity
PRA001748-R0-OUS, EN (12/17)
5. Téot L et al. Int Wound J 2017; 14(5) 842-8 www.acelity.com
 LOCAL MANAGEMENT OF DFUs1,4
Dry, black Sloughy Granulating
TIELLETM Packing Hydropolymer Foam Dressing with LIQUALOCKTM Technology; † SILVERCEL™ NON-ADHERENT hydro alginate antimicrobial dressing with EASYLIFT™
*World Union of Wound Healing Societies (WUWHS), Florence Congress, Position Document. Local management of diabetic foot ulcers. Wounds International, 2016

Mostly or completely
(due to ischaemia) Yellow, brown, grey or black Clean, red
epithelialised
Cleanse: according to local protocol. V.A.C. VERAFLO CLEANSE CHOICE™ Dressing provides a wound cleansing Red, pink
option for clinicians when surgical debridement must be delayed or is not possible or appropriate5
Debridement (as appropriate), e.g. for removal of callus and devitalised tissue

To separate toes without Dry to low exudate Moderate to high exudate Dry to low Moderate to high exudate Protect new tissue
retaining moisture or n TIELLETM Lite n BIOSORBTM Gellling Fibre Dressing exudate n BIOSORBTM Gelling Fibre Dressing growth to allow wound
Technology; SILVERCEL™ hydro alginate antimicrobial dressing

hydrating tissues: Hydropolymer Adhesive n TIELLETM Plus Hydropolymer Adhesive n ADAPTIC TOUCHTM n TIELLETM Plus Dressing maturation and prevent
ADAPTIC TOUCHTM Foam Dressing Foam Dressing with LIQUALOCKTM Dressing n TIELLETM Non Adhesive Hydropolymer from drying out
Non-Adhering Silicone with LIQUALOCKTM Technology Dressing with LIQUALOCKTM Technology n ADAPTIC TOUCHTM Dressing
Dressing Technology n TIELLETM Non Adhesive Dressing n Use low adherent contact layer with dressings n Emollient
n TIELLETM Non Adhesive n Use low adherent dressings below if above if appropriate: ADAPTIC TOUCHTM Dressing n Reassess regularly
Dressing appropriate: ADAPTIC TOUCHTM Dressing n Consider skin barrier
n Ensure ongoing surveillance
n NU-GEL™ Hydrogel with n Consider skin barrier
n Provide protective footwear
Primary dressing

Alginate n V.A.C. VERAFLO CLEANSE CHOICE™ Dressing

n NU-DERM™ Thin Hydrocolloid
Deep wounds: BIOSORBTM Dressing or TIELLETM Packing Dressing**; NPWT: V.A.C.® Therapy System (V.A.C.ULTA™ Therapy System and ACTIV.A.C.™ Therapy System) Wound Dressing
If there is a risk of infection,
consider an iodine-
Infection: SILVERCELTM Dressings†; V.A.C. VERAFLO™ Therapy in conjunction with good clinical practice such as antibiotic therapy and debridement PLEASE NOTE
impregnated dressing, e.g.
This algorithm is based on
INADINETM (PVP-I) Non
Odour: consider a dressing containing activated charcoal, e.g. ACTISORB™ Silver 220 Activated Charcoal Dressing with Silver the WUWHS DFU Position
Adherent Dressing Document* and is a guide only.

Fragile periwound skin: TIELLE ESSENTIALTM Silicone Foam Dressings or TIELLETM Non Adhesive Dressing The choice of dressings and
devices must be based on local
protocols and clinical judgement
**

Reassess the wound, periwound skin and suitability of the dressing for the patient and the wound at each review.
If area reduction is <50% at 4 weeks consider: PROMOGRANTM Protease Modulating Matrix or PROMOGRAN PRISMATM Wound Balancing Matrix

Protect/offload: Ensure dressing is compatible with mode of offloading and can be accommodated without bulk or creasing