A diabetic foot ulcer is a frequent complication of diabetes mellitus.
Two to ten percent of diabetics have foot ulcers. The risk of developing a diabetic foot ulcer increases with in time. Blood glucose control is an important procedure. Patients with poor glucose control experience complications sooner. Unfortunately, the majority of foot and lower leg amputations are performed on patients with diabetes mellitus. The top priority in treating the diabetic foot syndrome is to avoid a major amputation.
Diabetic patients are at risk from foot ulcerations due to both peripheral and autonomic neuropathy as well as macro- and microangiopathy.
Peripheral neuropathy (sensory and motor) is the most frequent cause of foot ulceration. As many patients with sensory neuropathy suffer from altered or complete loss of sensation in the foot and leg, any cuts or trauma to the foot can go completely unnoticed for days or weeks. Motor neuropathy may prompt muscle weakness (muscle atrophy), causing foot deformities which subsequently can lead to an inappropriate weight redistribution. Tissue ischemia and necrosis may occur, causing ulcerations. Additionally, autonomic neuropathy can lead to decreased sweating due to denervation of dermal structures. This induces dry skin, causing fissures, which increase the risk of infection.
Diabetic angiopathy is another risk factor for developing diabetic foot ulcers and infections, as larger arteries calcification (macroangiopathy) and small arteries capillary basement membranes thicken (microangiopathy) this can lead to impaired microcirculation.
There are many ways to classify diabetic foot lesions. Wagner’s classification is the most widely used grading system for lesions of the diabetic foot.
Optimizing DFU Wound Management
Classification of ulcer (based on Wagner and University of Texas/ Armstrong)1-3
Classification of ulcer: 0
Description:
- Severely deformed foot at risk of ulceration
Treatment objective:
- Maintain skin integrity
Local wound treatment:
- Skin care (e.g. Trixo®/Linovera®)
Classification of ulcer:
1 - Non-infected
Description:
- Superficial ulcer, not involving tendon, capsule or bone
Wound treatment objective:
- Provide a clean wound bed for granulation tissue
Local wound treatment:
- Use antiseptic wound irrigation solution and/or gel (e.g. Prontosan® Wound Irrigation Solution, Prontosan® Wound Gel, Prontosan® Wound Gel X)
- Absorbent/low adherent moist dressing (e.g. Askina® Foam/ Askina® DresSil)
- Polyurethane film or low-adherent dressing/wound contact layer (e.g. Askina® Derm/Askina® SilNet)
Classification of ulcer:
2 - Non-infected
Description:
- Superficial ulcer, not involving tendon, capsule or bone, with signs of infection
Wound treatment objective:
- Remove slough/callus
- Reduce bacterial load
- Prevent/remove biofilm
- Manage exudate/odor
Local wound treatment:
- Use antiseptic wound irrigation solution and/or gel (e.g. Prontosan® Wound Irrigation Solution, Prontosan® Wound Gel, Prontosan® Wound Gel X)
- Antimicrobial dressing (e.g. Askina® Calgitrol® Paste)
- Polyurethane film or low-adherent dressing/wound contact layer (e.g. Askina® Derm/Askina® SilNet)
Classification of ulcer:
2 - Non-infected
Description:
- Superficial ulcer, not involving tendon, capsule or bone, with signs of infection
Wound treatment objective:
- Remove slough/callus
- Reduce bacterial load
- Prevent/remove biofilm
- Manage exudate/odor
Local wound treatment:
- Use antiseptic wound irrigation solution and/or gel (e.g. Prontosan® Wound Irrigation Solution, Prontosan® Wound Gel, Prontosan® Wound Gel X)
- Antimicrobial dressing (e.g. Askina® Calgitrol® Paste)
- Polyurethane film or low-adherent dressing/wound contact layer (e.g. Askina® Derm/Askina® SilNet)
Classification of ulcer:
2 - Infected
Description:
Deep ulcer with signs of infection
Wound treatment objective:
- Remove slough/callus
- Reduce bacterial load
- Prevent/remove biofilm
- Manage exudate/odor
Local wound treatment:
- Use antiseptic wound irrigation solution and/or gel (e.g. Prontosan® Wound Irrigation Solution, Prontosan® Wound Gel, Prontosan® Wound Gel X)
- Antimicrobial dressing
- Polyurethane film or low-adherent dressing/wound contact layer (e.g. Askina® Derm/Askina® SilNet)
Classification of ulcer:
3 - Non-infected
Description:
- Deep ulcer penetrating to bone or joint
Wound treatment objective:
- Remove slough/callus
- Provide clean wound bed for granulation tissue
- Prevent/remove biofilm
- Manage exudate
Local wound treatment:
- Caution is advised*
- Absorbent/low-adherent moist dressing (e.g. Askina® Foam/Askina® DresSil)
- Polyurethane film or low-adherent dressing/wound contact layer (e.g. Askina® Derm/Askina® SilNet)
Classification of ulcer:
3 - Infected
Description:
- Deep ulcer with evidence of osteomyelitis
Wound treatment objective:
- Remove slough
- Reduce bacterial load
- Prevent/remove biofilm
- Manage exudate/odor
Local wound treatment:
- Caution is advised*
- Antimicrobial dressing
- Polyurethane film or low-adherent dressing/wound contact layer (e.g. Askina® Derm/Askina® SilNet)
* NOTE: As Grade III DFUs may involve exposed cartilage, special caution is advised. Some products (eg Prontosan®) are contraindicated for the use on hyaline cartilage. In all cases, a careful risk:benefit assessment should be performed.
Decisions on product use must lie with the attending physician and normal saline should be used instead of Prontosan® where indicated.
(1) Wagner FW. The dysvascular foot: a system of diagnosis and treatment. Foot Ankle 1981; 2: 64-122. / (2) Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg 1996; 35: 528-31. / (3) Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care 1998; 21(5): 855-9.