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Official reprint from UpToDate

www.uptodate.com2013 UpToDate

AuthorsDavid K McCulloch, MD

Richard J de Asla, MD

Section EditorsJohn F Eidt, MD

Joseph L Mills, Sr, MD

David M Nathan, MD

Deputy EditorKathryn A Collins, MD, PhD, FACS

Management of diabetic foot lesions

Disclosures

All topics are updated as new evidence becomes available and our peer review processis complete.

Literature reviewcurrent through:May 2013. | This topic last updated:mar 27, 2013.

INTRODUCTION The lifetime risk of a foot ulcer for patients with diabetes (type 1 or 2) may be as high as 25

percent [1-3]. Diabetic foot ulcers are a major cause of morbidity and mortality, accounting for approximately two-

thirds of all nontraumatic amputations performed in the United States[4,5]. This observation illustrates theimportance of prompt treatment of foot ulcers in patients with diabetes. The management of diabetic foot lesions is

provided here. Evaluation and prevention of foot ulcers and the treatment of diabetes-related foot infections (cellulitis

and osteomyelitis) are discussed separately. (See "Evaluation of the diabetic foot"and "Clinical manifestations,

diagnosis, and management of diabetic infections of the lower extremities".)

WOUND CLASSIFICATION The first step in managing diabetic foot ulcers is classifying the wound.

Classification is based upon clinical evaluation of the extent of the lesion and, in some classification systems, an

assessment of the vascular status of the foot. The intensity and duration of treatment can be determined after

clinical evaluation of the ulcer. (See "Evaluation of the diabetic foot", section on 'Wound evaluation'.)

A widely used classification of diabetic foot ulcers is that proposed by Wagner [6]:

Grade 0 No ulcer in a high-risk foot

Grade 1 Superficial ulcer involving the full skin thickness but not underlying tissues (picture 1)

Grade 2 Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess

formation (picture 2)

Grade 3 Deep ulcer with cellulitis or abscess formation, often with osteomyelitis (picture 3)

Grade 4 Localized gangrene (picture 4)

Grade 5 Extensive gangrene involving the whole foot

The Wagner classification is based upon clinical evaluation (depth of ulcer and presence of necrosis) alone and

doesnot account for the vascular status of the foot. A modified system that is frequently used by orthopedic

surgeons individually scores the components of wound depth and ischemia [7]. Other ulcer classification systemshave also been published [8-11]. The International Working Group on the Diabetic Foot proposed classifying all

ulcers according to the following categories: perfusion, extent, depth, infection, and sensation (PEDIS) [12]. The

PEDIS system is primarily used for research purposes.

The usual approach to the management of lesions of each Wagner grade is given below, followed by a discussion of

some newer approaches.

GRADE 0 LESIONS Counseling regarding preventive foot care should be given to any patient whose feet are at

risk for ulcer development, particularly patients with existing neuropathy. There are several measures that can

markedly diminish ulcer formation, such as avoiding poorly fitting shoes, walking barefoot, and smoking. This topic

is reviewed separately. (See "Evaluation of the diabetic foot", section on 'Risk factors'and "Evaluation of the
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diabetic foot", section on 'Preventive foot care'.) [1]

GRADE 1 AND 2 LESIONS Extensive debridement, good local wound care, relief of pressure on the ulcer, and

control of infection (when present) are believed to be important components of therapy for grade 1 and 2 foot ulcers

[9,13,14]. There are limited data evaluating the efficacy of this standard approach, particularly the benefits of

debridement and local wound care. In a meta-analysis of the control groups from 10 trials (622 patients) evaluating

standard treatment (debridement and local wound care) versus various new therapies, 24 and 31 percent of ulcers

healed after 12 and 20 weeks, respectively, of standard treatment [15].

In clinical practice, measurements of a patient's ulcer size should be taken at every office visit so that comparisonscan be made and progress documented. The surface area of a healthy diabetic foot ulcer should decrease in size at

a rate of approximately one percent a day. Ulcers that do not improve should be evaluated for ongoing soft tissue

infection or osteomyelitis requiring antibiotics, insufficient vascular flow, or most commonly, the need for more

effective off-loading. (See 'Assessment for peripheral artery disease'below and 'Assess for osteomyelitis'below.)

Method of debridement Debridement of necrotic tissue is important for ulcer healing [16], although there are

few trials comparing the different methods of debridement (sharp, enzymatic, autolytic, mechanical, and biological).

The types of debridement are reviewed separately. (See "Treatment of pressure ulcers", section on 'Debridement'.)

Sharp debridement involves the use of a scalpel or scissors to remove necrotic tissue [ 17]. It is the most widely

used method except in certain settings, such as highly vascular ulcers or when there is significant vascular

compromise such that concerns exist as to the patient's ability to heal any new wounds created by sharp

debridement. In such settings, enzymatic debridement (topical application of proteolytic enzymes such as

collagenase) may be preferable [8]. Autolytic debridement, using a semiocclusive or occlusive (hydrogel) dressing

to cover a wound so that necrotic tissue is digested by enzymes normally present in wound tissue, may be a good

option in patients with painful ulcers.

In a systematic review of six small randomized trials, hydrogels were significantly more effective than wet to moist

saline or dry gauze in healing foot ulcers in diabetic patients [ 18]. However, a hydrogel combined with good wound

care (defined as sharp debridement, saline dressings, pressure relief, and control of infection) was not significantly

better than good wound care alone. Larval therapy (a form of biological debridement) showed no significant benefit in

small studies. Overall, the review was limited by the small number of trials and poor methodological quality.

Thus, there are few data to guide choice of debridement. When surgeons with expertise in sharp debridement are

available, we prefer this method. As an alternative, we suggest application of a hydrogel since limited data support

its efficacy in promoting ulcer healing. For patients with evidence of arterial insufficiency, we suggest referral to a

vascular specialist.

Infection control The diagnosis of infection is clinical and is likely to be present if the ulcer contains obvious

purulent material or there is redness, swelling or warmth around the ulcer [19]. Cultures of the ulcer base are taken

after debridement and prior to initiation of empiric antibiotic therapy. Tissue samples taken by curettage, rather than

wound swab or irrigation, are preferable because they provide more accurate results [20]. The most common

infecting organisms are aerobic gram-positive cocci. Other frequent pathogens are aerobic gram-negative bacilli and

anaerobes, usually as a second organism [21].

In general, the limited data on antibiotic therapy of diabetic foot infections lack standardization to allow comparison

of outcomes of different regimens. On the basis of the available studies, no single drug or combination appears to

be superior to others. Empiric antibiotic therapy should cover gram-positive cocci (table 1). Subsequent antibiotic

therapy should be tailored to culture and susceptibility results. It is not always necessary to cover all

microorganisms isolated from cultures. (See "Clinical manifestations, diagnosis, and management of diabetic

infections of the lower extremities", section on 'Antimicrobial therapy'.) [22]

Local wound care After debridement, ulcers should be kept clean and moist but free of excess fluids. Moisture

accelerates tissue healing. Dressings should be selected based upon wound characteristics, such as the extent of
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exudate, desiccation, or necrotic tissue.

Some dressings simply provide protection, whereas others promote wound hydration or prevent excessive moisture.

Wet-to-dry saline dressings are frequently used, but some ulcers may require a moister environment. In addition,

wet-to-dry dressings will remove both nonviable and viable tissues. Thus, caution is required to avoid damaging

healthy tissue.

Some dressings are impregnated with antimicrobial agents to prevent infection and enhance ulcer healing. However,

there are no clinical trial data to support their effectiveness [ 23]. (See "Treatment of pressure ulcers", section on

'Dressing choices'.)

Mechanical off-loading Off-loading devices, including total contact casts, cast walkers, shoe modifications

and other devices to assist in ambulation are available to reduce or eliminate pressure in the region of the ulcer,

which is important for healing. The evidence supports the use of total contact casts and nonremovable cast walkers

for relief of pressure associated with diabetic ulcer healing [24]. A 2000 Cochrane database review updated in 2013

evaluated 14 trials comparing various forms of pressure-relieving treatments (nonremovable, removable) and

dressings [25,26]. In five trials, the likelihood of wound healing was significantly better at 12 weeks for

nonremovable, pressure-relieving casts compared with removable devices or dressings (relative risk [RR] 1.17, 95%

CI 1.01-1.36). In one trial, no significant differences were found between different types of nonremovable pressure-

relieving treatments [27].

Total contact cast A total contact cast is a padded fiberglass shell designed to take pressure off the heel or

elsewhere on the foot by averaging the pressure across the sole of the foot (ie, eliminates high and low pressure

regions by providing contact at all points) or to generally un-weight the entire foot through a total contact fit at the

calf. The most aggressive unloading is achieved by making the patient non-weight-bearing. Disadvantages of total

contact casting include expertise needed in applying the cast, inability to inspect the wound frequently,

inconvenience in activities of daily living (eg, bathing), and the risk of developing a secondary ulcer in an ill-fitting

cast (particularly in patients with neuropathy) [9]. Frequent cast changes may be needed to avoid complications.

Based upon randomized trials, total contact casting enhances diabetic ulcer healing and is the standard for

relieving pressure from the forefoot [25-33]. As an example, in a trial of off-loading modalities in 63 diabetic patients

with superficial, noninfected, nonischemic plantar ulcers, the proportion of ulcers that were healed at 12 weeks was

significantly higher in those randomly assigned to a total contact cast compared with a half-shoe or removable cast

walker (90 versus 58 and 65 percent, respectively) [30]. Patients with a total contact cast also had faster wound

healing. Another small trial found that a cast ing combined with Achilles tendon lengthening resulted in significantly

fewer ulcer recurrences at seven months (15 verus 59 percent) and two years (38 versus 81 percent) compared with

the casting alone [34].

Total contact casts should notbe used in patients with infected wounds, osteomyelitis, peripheral ischemia,

bilateral ulceration, lower extremity amputation or heel ulceration [35].

Cast walkers An alternative to total contact casting is a prefabricated brace called a cast walker that is

designed to maintain a total contact fit (figure 1). Several cast walkers (non-removable, removable) are commercially

available and provide capability to off-load the foot similar to contact casts. Cast walkers also appear to facilitatewound healing, but a significant disadvantage is poor patient compliance if the cast walker is removed [ 36].

Cast walkers appear to have a similar ability to off-load the foot compared with total contact casting.

One study compared plantar foot pressure metrics in a standard shoe, total contact cast and prefabricated

pneumatic walking brace [37]. Five plantar foot sensors were placed at the first, third, and fifth metatarsal

heads, fifth metatarsal base, and mid-plantar heel of 10 healthy male subjects who walked at a constant

speed over a distance of 280 meters. Peak pressures were significantly reduced in the pneumatic walking

brace compared with the standard shoe for all sensor locations to an equal or greater degree compared with

the total contact cast in all sensor locations.
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Another study measured foot pressures using an in-shoe pressure measurement system (Novel Pedar) in

18 healthy subjects while wearing a cast walker or total contact cast [38]. Peak foot pressures using the

cast walker were significantly reduced in the forefoot (12 versus 18 N/cm2) and foot as a whole (14 versus 19

N/cm2) compared with a fiberglass total contact cast, but no differences were found for the heel or midfoot.

These studies suggest these prefabricated products are at least as good as total contact casting for off-loading the

foot and equalizing foot pressures when the foot anatomy is normal, but data are not available demonstrating these

effects for patients with diabetic foot deformities.

Cast walkers have been used for the treatment of neuropathic plantar ulcers but these devices, thus far, have not

been found to be superior to total contact casting in randomized trials. In one trial, the rate of ulcer healing was

significantly higher in those randomly assigned to total contact casting compared with a half-shoe or removable

cast walker [30]. Another trial that randomly assigned 48 patients to total contact casting or a removable cast

walker (ie, Stabil-D), found no difference in the number of days to achieve healing (35 versus 39 days) [ 39].

Therapeutic shoes After healing of the ulcer is achieved, extra-depth and -width shoes with orthotic inserts

are often prescribed to prevent recurrent ulceration [25]. However, in one trial, 400 diabetic patients with a history of

foot ulcer were randomly assigned to wear therapeutic shoes or their usual footwear for two years [ 40]. The risk of

re-ulceration was not found to be different between the groups. Non-prescription rocker sole shoes ( figure 2) may

also offload the foot [41,42]. In a non-randomized prospective study of 92 patients with healed diabetic foot ulcers,the first-year annual rate of foot ulcer relapse was significantly lower in patients who used stock diabetic shoes

(rocker sole) compared with those who wore their usual footwear (15 versus 60 versus percent) [ 42]. In the United

States, reimbursement from insurance carriers can be expected for at least one pair of shoes and/or shoe inserts,

provided the design of the shoe/insert meets qualifying guidelines.

Wedge shoes (eg, Darco International), also called half shoes, are available as a forefoot wedge and heel wedge

shoes to off-load the forefoot and heel, respectively (figure 3). These shoes may be useful under certain

circumstances. For example, plantar heel ulcers are particularly difficult to heel because of an inability to

adequately off-load this region; the heel wedge shoe can be useful to achieve this goal.

The disadvantage of wedge shoes is that most patients, especially elderly patients or those with proprioception

abnormalities may not be able to maintain their balance, and some patients find walking in them difficult, if not

impossible.

Knee walkers Knee walkers are ambulatory assist devices that may be indicated for anyone with a lower

extremity issue where weight bearing needs to be avoided (figure 4). These devices are becoming more popular in

the treatment of diabetic ulcer as a means to off-load the foot. There are no trials evaluating the effectiveness of

these devices in healing diabetic foot ulcers.

Summary Debridement, good local wound care, and relief of pressure on the ulcer are believed to be important

components of therapy for grade 1 and 2 foot ulcers [9]. This treatment program does not require hospitalization.

Close monitoring is required, and hospitalization for bed rest and intravenous antibiotic therapy is advisable if the

ulcer does not improve. (See "Clinical manifestations, diagnosis, and management of diabetic infections of thelower extremities".)

GRADE 3 LESIONS Before deciding upon appropriate management of deep ulcers, it is important to evaluate for

substantial peripheral vascular disease or bony involvement. A brief review is found here. These topics are

discussed in detail separately. (See "Evaluation of the diabetic foot", section on 'Physical signs of peripheral artery

disease'and "Evaluation of the diabetic foot", section on 'Signs of infection'.)

Assessment for peripheral artery disease Assessment of the adequacy of the circulation is an important

component of the evaluation of all wounds, and particularly wounds found in patients with diabetes. Symptoms of

claudication or extremity pain at rest, and physical findings of diminished or absent pulses, cool temperature, pallor

on elevation, or dependent rubor should raise suspicion about the presence of peripheral artery disease.
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Noninvasive vascular studies including ankle-brachial index, pulse volume recordings and duplex ultrasonography

should be obtained to confirm the diagnosis. (See "Evaluation of the diabetic foot", section on 'Physical signs of

peripheral artery disease'.)

The ankle-brachial index is a measurement of the ratio of blood pressure at the ankle to that in the brachial artery

that correlates with the presence and severity of arterial occlusive disease [43]. In patients with diabetes, the blood

vessels may be incompressible and ankle-brachial index values misleading. Segmental volume plethysmography

and toe-brachial index values are more reliable for determining the severity of disease. The noninvasive diagnosis of

lower extremity peripheral artery disease is reviewed in detail elsewhere. (See "Noninvasive diagnosis of arterial

disease".)

Assess for osteomyelitis Osteomyelitis is likely to be present if bone can be seen at the floor of a deep ulcer,

or if it can be easily detected by probing the ulcer with a sterile, blunt stainless steel probe. Other signs that

suggest osteomyelitis are an ulcer size larger than 2 x 2 cm and an otherwise unexplained elevation in the

erythrocyte sedimentation rate. (See "Clinical manifestations, diagnosis, and management of diabetic infections of

the lower extremities", section on 'Diagnosis of underlying osteomyelitis'.)

Radiologic tests Radiologic tests may be useful if the diagnosis of osteomyelitis remains uncertain. The

diagnosis is clear if osteomyelitis is visible on plain radiographs. However, radiologic changes occur late in the

course of osteomyelitis and negative radiographs do not exclude it. Other imaging techniques that may be useful in

selective cases include radionuclide bone imaging, magnetic resonance imaging and imaging with indium-labeledleukocytes.

Bone biopsy If clinical and radiographic assessments fail to provide a diagnosis, then bone biopsy can be

considered. Bone biopsy does carry the risk of inoculating an otherwise uninfected bone if the biopsy is obtained

through an infected soft tissue bed. (See "Approach to imaging modalities in the setting of suspected

osteomyelitis".)

Treatment The treatment of grade 3 lesions includes debridement, infection control, local wound care, and relief

of pressure. The presence of osteomyelitis or peripheral artery disease warrants additional therapy [ 44].

Coordination of care among providers is important for keeping rates of amputation as low as possible. This was

illustrated in a study of 10 Department of Veterans Affairs (VA) medical centers in which increased rates of

amputation were seen in programs with the lowest scores for availability of clinical protocols, educational seminars,

discharge planning and quality of care meetings [45].

Antimicrobial therapy Whether it is important to make a definitive diagnosis of osteomyelitis and whether

patients with osteomyelitis should always be treated by hospitalization, intravenous antimicrobial drug therapy, and

surgical debridement of bone are debated [46]. Some authors have suggested that osteomyelitis is present in as

many as two-thirds of diabetic patients who have foot ulcers [47], but this figure is much higher than is generally

believed and may reflect bias in the severity of the cases studied. Surgical removal of infected bone may be

necessary if the ulcer is not healing. A short period of hospitalization, with surgical debridement, including culture of

material obtained from deep in the ulcer and bone biopsy, is often helpful in choosing antibiotic therapy [48].

Parenteral antibiotic therapy based upon the culture results has traditionally been given for four to six weeks in

patients with osteomyelitis. The optimal regimen and when to transition to oral therapy are dependent upon the

clinical features of each case. (See "Clinical manifestations, diagnosis, and management of diabetic infections of

the lower extremities", section on 'Antimicrobial therapy'.)

Mechanical off-loading Mechanical off-loading relieves pressure on the ulcer and enhances healing. Total

contact casting and cast walkers are alternatives to prolonged bed rest for the relief of pressure and allow for

continued ambulation. (See 'Mechanical off-loading'above.)

Revascularization Revascularization plays an important role in the management of diabetic foot ulcers in

patients with documented peripheral artery disease (to avoid the need for amputation) [ 9]. In patients with diabetes,

foot ulcers, and critical limb ischemia, revascularization, when possible, is associated with a lower incidence of
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amputation. As an example, in a longitudinal study of 564 patients with diabetes, foot ulcers (in 85 percent of

subjects), and critical limb ischemia (defined as ankle-pressure


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therapy in the treatment of diabetic foot ulcers may offer a benefit; however, each noted that the methodologic

quality of the included studies was poor and there was a potential for bias [ 69-73] The available trials are limited by

small sample size and heterogeneity of the wounds being treated (eg, ulcer size, ulcer depth, microbial

environment, presence of ischemia) [74-83]. No conclusions could be drawn regarding specific indications for or

timing of therapy.

A pooled analysis found significantly improved wound healing (OR 9.99, 95% CI 3.97-25.1), and decreased risk of

amputation (OR 0.24, 95% CI 0.14-0.43) [69-72]. A later metaanalysis found similar results [73]. As an example of

these effects, in one of the larger trials that included 70 patients with severely ischemic foot ulcers (Wagner grades

3 and 4), the amputation rate was 9 percent in the treatment group and 33 percent in the control [74]. In another

trial that included 94 patients, a significantly increased incidence of complete healing (Wagner 2 though 4 ulcers)

was achieved in the hyperbaric oxygen therapy group (52 versus 29 percent) compared with a placebo group [81].

Therapies that combine hyperbaric oxygen therapy with known mediators of wound healing may augment the

effects of hyperbaric oxygen. Activation and mobilization of endothelial progenitor cells (EPCs) are impaired in

patients with diabetes. These cells are known to play an important role in wound healing by participating in the

formation of new blood vessels in areas of hypoxia [ 84-87]. Hyperoxia effectively improves EPC mobilization, but

does not specifically target to a specific site which may, in part, explain the nonuniform improvement in diabetic

foot wounds with hyperbaric oxygen therapy alone [88]. However, in a murine model of diabetes, coadministration of

the chemokine stromal cell-derived factor-1 alpha (SDF-1 alpha) resulted in homing of activated EPCs into the

wound site [89]. These data suggest that combining hyperbaric oxygen therapy with administration of SDF-1 alpha

may be synergistic. Other combination therapies (eg, fibroblast growth factor) are also being studied [ 90,91].

Other agents Small trials have shown some promise for other topical agents. In a randomized study, application

of .05 percent tretinoin solution for 10 minutes a day followed by iodine gel for four weeks resulted in complete

resolution of 46 percent of the ulcers in the treatment group (n = 13) compared with 18 percent in the control group

(n = 11) [92]. In addition, electrical stimulation near the ulcer may also help slowly healing ulcers [93,94].

INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and

Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5thto 6thgrade

reading level, and they answer the four or five key questions a patient might have about a given condition. These

articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the

Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the

10thto 12thgrade reading level and are best for patients who want in-depth information and are comfortable with

some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these

topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on

patient info and the keyword(s) of interest.)

Beyond the Basics topics (see "Patient information: Diabetes mellitus type 1: Overview (Beyond the

Basics)"and "Patient information: Diabetes mellitus type 2: Overview (Beyond the Basics)"and "Patient

information: Foot care in diabetes mellitus (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

The treatment of diabetic foot ulcers begins with a comprehensive assessment of the ulcer and the patient's

overall medical condition. Evidence of underlying neuropathy, bony deformity, and peripheral artery disease

should be actively sought. The wound is classified upon initial presentation and with each follow-up visit

using a standardized system to document the examination, plan treatment, and follow the progress of

healing. (See 'Introduction'above and 'Wound classification'above.)

Adequate debridement, proper local wound care, relief of pressure on the ulcer by mechanical off-loading,
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and control of infection (when present) are important components of therapy. Dressings are selected based

upon wound characteristics. (See 'Local wound care'above.)

Several methods are available to achieve mechanical off-loading and include total contact casts, cast

walkers, wedge shoes, and bedrest. (See 'Mechanical off-loading'above.)

Few data are available comparing methods of debridement (sharp, enzymatic, autolytic, mechanical, and

biological). In the absence of such data, we suggest surgical (sharp) debridement rather than another

method (Grade 2C). If a surgeon with clinical expertise in sharp debridement is not available, we suggest

autolytic debridement with hydrogels (Grade 2C). (See 'Method of debridement'above.) Alternatively, the

patient can be referred to a facility with appropriate surgical expertise in the management of diabetic foot

problems.

For managing extensive open wounds following debridement for infection or necrosis, or partial foot

amputation, we suggest negative pressure wound therapy (Grade 2A). All necrotic tissue or infected bone

(osteomyelitis) must be removed from the wound prior to using this device. (See 'Negative pressure wound

therapy'above and "Negative pressure wound therapy", section on 'Contraindications'.)

In patients with Wagner grade 3 and higher ulcers with critical limb ischemia, we recommend

revascularization (Grade 1B). Revascularization should also be performed in patients with any degree of limb

ischemia and a nonhealing ulcer. (See 'Grade 3 lesions'above.)

Patients with Wagner grade 4 and 5 ulcers require immediate surgical consultation. (See 'Grade 4 and 5

lesions'above.)

Use of UpToDate is subject to the Subscription and License Agreement.

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GRAPHICS

Wagner grade 1 ulcer

Foot from a diabetic patient showing a superficial ulcer (Wagnergrade 1) that involves the full thickness of the skin but nounderlying tissues. This lesion healed quickly with rest and localfoot care.Courtesy of David McCulloch, MD.


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Foot from a diabetic patient with a penetrating neuropathic ulcerthat is not associated with abscess formation or boneinvolvement (Wagner grade 2). The toes have been pulledanteriorly because the anterior tibial muscles are unopposed due

to motor neuropathy-induced weakness of the intrinsic footmuscles. This promotes subluxation of the proximalinterphalangeal-metatarsal joints, resulting in a claw toeappearance (arrow) and in increased pressure on the metatarsalheads, predisposing to ulcer formation at this site.Courtesy of David McCulloch, MD.


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Wagner 3 foot ulcer

The patient presented with a fluctuant eschar on the plantarsurface of the foot. The abscess was unroofed and drained and,following debridement, exposed bone was apparent at the baseof the wound.Courtesy of Paul Thottingal, MD.


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Foot from a diabetic patient with a Wagner grade 4 ulcer thatextends to the deep layers with signs of local infection, cellulitis,

and necrosis. This lesion healed completely after an extensivehospital stay involving excision of necrotic tissue but noamputation.Courtesy of David McCulloch, MD.


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Oral agents for empiric treatment of mild to moderate diabetic footinfections

SINGLE-drug regimens with activity against streptococci and staphylococci(MSSA)

Cephalexin or

Dicloxacillin or

Amoxicillin-clavulanate or clindamycin

TWO-drug regimens with activity against streptococci and MRSA

Clindamycin* or

Linezolid or

Penicillin orcefazo lin ordicloxacillin

PLUS

Trimethoprim-sulfamethoxazole ordoxycycline

TWO-drug regimens with activity against streptococci, MRSA, aerobicgram-negative bacilli and anaerobes

Trimethoprim-sulfamethoxazole

PLUS

Amoxicillin-clavulanate

-OR-

Clindamycin

PLUS

Ciprofloxacin orlevofloxacin ormoxifloxacin

Antibiotic dosing for adults

Cephalexin 500 mg every 6 hours

Dicloxacillin 500 mg every 6 hours

Clindamycin 300 to 450 mg every 6 to 8 hours

Linezolid 600 mg every 12 hours

Penicillin V potassium 500 mg every 6 hours

Trimethoprim-sulfamethoxazole (co-trimoxazole)

2 double-strength tablets (trimethoprim 160 mgand sulfamethoxazole 800 mg per tablet) every12 hours

Doxycycline 100 mg orally every 12 hours

Amoxicillin-clavulanate 875/125 mg every 12 hours

Ciprofloxacin 750 mg every 12 hours

Levofloxacin 750 mg every 24 hours

Moxifloxacin 400 mg every 24 hours


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MSSA: methicillin-susecptible staphylococcus aureus; MRSA: methicillin-resistant staphylococcusaureus.* Check susceptibility testing. Many of these agents require adjustment of the dose in the setting of renal dysfunction.Data courtesy of authors with additional data from: Lipsky BA, et al. 2012 Infectious Diseases Societyof America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. ClinInfect Dis 2012; 54:e132.


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Removable cast walker


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Rocker sole shoe


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Wedge shoes


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Knee walker

management of diabetic foot lesions

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