When Diabetic Foot Ulcers Can Be Managed At Home
Approximately 15 percent of all patients with diabetes can be expected to develop ulceration in their lifetime, thus putting them at risk for lower extremity amputation. Treatment for infected diabetic foot wounds accounts for one quarter of all diabetic hospital admissions in the United States and Great Britain.1-3 Patient education, proper footgear and regular foot examination can decrease the frequency and severity of ulceration. However, when ulceration does occur, home care may be a cost-effective intervention that can either avoid or shorten hospital admissions in appropriate cases. Obviously, severe, limb-threatening infection or ulceration requires hospital care. This is especially true in cases complicated by vascular disease that may require angiography and bypass surgery. However, if acute infection has been stabilized and the patient has adequate vascular perfusion (or it has been restored during hospitalization), proper wound care at home can facilitate the completion of wound closure. Such care does require administration of necessary antibiotics, debridement and dressing changes, offloading the ulcerated part, and optimal diabetes management. Evaluating Ulcerations For The Possibility Of Treatment At Home The first step in determining suitability for home care is to establish whether the ulceration is limb threatening or not. A useful system for evaluating the severity of diabetic ulcerations was developed at the University of Texas (see “University Of Texas Wound Classification System” below).4 The classification is based on the depth of the ulceration, presence of infection and degree of ischemia. One will see ischemic ulcers in pulseless feet with thin atrophic skin. These ulcers are usually fibrous or present with an eschar. Little or no granulation tissue is present. Ischemic ulcers are less common than the more typical neuropathic ulceration. Ischemic feet frequently require some form of vascular intervention such as angioplasty or bypass surgery to achieve healing. A Grade III-D ulceration is a deep, infected ischemic ulceration. This ulceration constitutes a limb threatening condition and likely requires hospitalization. Initial treatment includes surgical debridement of necrotic tissue, a bone biopsy and infectious disease consultation to initiate proper long-term antibiotic therapy. Peripheral vascular consultation for angioplasty or bypass surgery may be necessary to achieve healing. If all this is accomplished, one may manage the clean, stable, open wound with home care until closure, which may take six weeks or more. Keep in mind that not all diabetic ulcers are infected. Since most ulcerations are contaminated, cultures are likely to reveal a variety of organisms. The diagnosis of infection depends on clinical signs. These signs may include fever, redness extending from the ulcer site, surrounding edema and purulent drainage. Well-granulated ulcerations that do not probe to bone and exhibit no ascending erythema are not likely to be infected, and do not require antibiotic management. When infection does occur, one should consider the nature of the infection before initiating treatment. Superficial ulcers are typically not limb-threatening when they do not probe to bone and cellulitis is less than 2 cm from the ulceration. Patients who have these ulcers are not seriously ill and there are no signs or symptoms of significant systemic involvement. These patients may do very well with outpatient or home care and oral antibiotics. The American College of Foot and Ankle Surgeons has distinguished between non-limb-threatening infections and limb-threatening infections, advocating that patients with limb-threatening infections be hospitalized, at least initially.5 Patients who have deeper infections that probe to bone and systemic signs such as fever, leukocytosis, hyperglycemia, lymphangitis and edema may have limb-threatening disease. Gangrene, abscess, osteomyelitis and even necrotizing fasciitis may be present. Hospitalization is recommended with the following objectives. One should incise and drain deep abscesses, and debride infected bone and necrotic tissues to viable edges. One usually would do this in the operating room. Obtain deep cultures, perform a bone biopsy and proceed with appropriate antibiotic intervention. If there is an ischemic component, one should obtain a vascular consult.