Risk stratification and ulcer treatments
The UK National Institute for Health and Clinical Excellence (NICE) has suggested a risk stratification system for diabetic foot ulceration and appropriate follow-up (Table 21.1). Educating patients about footcare, footwear and self-inspection is essential. Early intervention at the first sign of ulceration is important, and those patients with a history of previous ulcers are at the highest risk for recurrent ulcer formation.
Off-loading refers to interventions that relieve pressure from the wound area and redistribute pressure to healthy areas of skin. The simplest method of off-loading is strict bedrest but this is impractical, difficult to enforce and associated with other complications (e.g. deep venous thrombosis). Total contact casting (TCC) is the most effective and evidence-based method for off-loading (Figure 21.10); studies have shown that TCC accelerates the healing of non-infected neuropathic ulcers. TCC is contraindicated in patients with significant peripheral arterial disease, infected ulcers or osteomyelitis. TCC facilitates mobility, but needs changing regularly, limits patients (e.g. in terms of bathing) and does not easily allow regular inspection of the ulcer. Thus, removable devices for off-loading can be used, but compliance is reduced if the patient can easily remove the boot.
Management of infected foot ulcers includes cleaning the wound and regular debridement of necrotic, unhealthy and infected material. Weekly debridement using a scalpel is associated with quicker ulcer healing. Larval therapy has also been used to promote healing; medicinal maggots secrete enzymes that digest the necrotic tissue and facilitate healing. The optimal type of dressing is unclear, and in small randomised trials simple dry dressings have been as effective as anything else. The most important pathogens causing diabetic foot infections are the aerobic gram-positive cocci (e.g. Staph. aureus, ß-haemolytic streptococcus and coagulase-negative staphylococci). Commonly used antibiotics include amoxicillin-clavulanic acid, ciprofloxacin, cephalexin and clindamycin (Figure 21.11).
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Rudy Bilous MD, FRCP, Professor of Clinical Medicine, Newcastle University, Honorary Consultant Endocrinologist, South Tees Foundation Trust, Middlesbrough, UK Richard Donnelly MD, PHD, FRCP, FRACP, Head, School of Graduate Entry Medicine and Health, University of Nottingham, Honorary Consultant Physician, Derby Hospitals NHS Foundation Trust, Derby, UK
A John Wiley & Sons, Ltd., Publication This edition first published 2010, © 2010 by Rudy Bilous and Richard Donnelly. Previous editions: 1992, 1999, 2004
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