When Diabetic Foot Ulcers Can Be Managed At Home
If there is no improvement within one or two weeks, and especially if pulses are absent and other signs of ischemia are present, one should obtain a peripheral vascular consultation. Angiography, angioplasty or bypass surgery may be indicated to treat ischemic ulcerations that fail to heal if the patient is a good candidate for such intervention. Keep in mind that even if the patient has adequate perfusion and the infection has been controlled, the ulcer may still fail to heal if the patient has a poor metabolic status. Anemia, poor control of diabetes and nutritional deficits contribute to faulty wound healing. To address these issues, have the patient see a primary physician, internist or endocrinologist.7 Once one has controlled the infection, obtained adequate vascular status and initiated attempts at metabolic control, the wound is ready for home care. Non-infected, neuropathic, non-ischemic ulcerations may present in this condition. Sometimes hospitalization may be required for surgical debridement, initiation of antibiotics or bypass surgery to achieve this appearance. However, once one has brought the wound to a viable appearance, the home is a very acceptable setting for further care. What One Illustrative Case Study Reveals In one case, the patient was a 60-year-old male, who had suffered from type II diabetes for over 20 years. He presented with an infected deep necrotic ulceration of the hallux, which we classified as a III-D ulcer. We performed a hallux and partial first metatarsal amputation to stabilize an acute limb-threatening infection. Our peripheral vascular consultation concurred with the diagnosis of vascular disease, but felt the patient had adequate perfusion for healing. An infectious disease consult recommended six weeks of IV antibiotic therapy based on deep cultures that were taken during surgery and were consistent with osteomyelitis. We stabilized the wound in the hospital to the appearance shown in the above photo with wet to dry saline dressings. The visiting nurse performed wound cleansing and calcium alginate dressing changes every one to two days and monitored for signs of infection. The podiatrist performed debridement every one to two weeks as necessary to maintain a viable wound. The patient used a walker and wheelchair for mobility. In the bottom right photo, one can see the patient’s wound after three weeks of home care. In the bottom left photo, one can see the almost healed wound after six weeks of home care. A Closer Look At Debridement, Dressings And Topicals In The Home Setting Debridement, dressings and offloading are well-established principles of wound healing. These latter measures may not require hospitalization and can be performed in a home care setting. Diabetic ulcerations are usually painless and one can debride these through subcutaneous tissue, tendon or muscle, and sometimes even bone without any anesthesia. There is usually an extensive keratosis that surrounds or covers the ulceration. One can usually remove this to the point where only viable, healthy tissue remains. One should proceed to clean the wound with soap and water, sterile water or saline. Debride with sterile forceps, scissors, tissue nippers or a number 15 scalpel. Once the wound bed is clean and free of any non-viable keratosis, fibrous tissue or necrotic tissue or bone, proceed to re-cleanse the foot with sterile water or saline and apply a dressing. (An exception to the need for debridement is the dry, stable, superficial eschar. If there is no evidence of underlying or ascending infection, one should leave such eschars intact to demarcate and slough as the underlying skin epithelializes. As the eschar becomes loose, it may then be appropriate to proceed with gentle debridement.) The type of dressing one uses depends on the condition of the wound. If one would like additional superficial debridement, using a wet to dry saline dressing will accomplish this. If excessive exudate is present, absorptive dressings like calcium alginate preparations are useful. This material will absorb the exudate yet maintain a physiologically moist interface between the wound itself and the dressing material. Generally speaking, dressings that promote moist environments should only cover the wound. One should avoid maceration of surrounding tissues. Topical hydrogels and gauze will also maintain a moist environment in the ulcer without causing maceration in wounds that do not have excessive exudate.