When Diabetic Foot Ulcers Can Be Managed At Home
- Volume 17 - Issue 10 - October 2004
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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. While the frequency of dressing change depends on the amount of exudate, it is usually required between two times daily to every other day. If infection is a concern, a visiting nurse should perform the dressing changes and evaluate the patient for signs of infection. If the ulcer is stable, many patients or family members can be taught to do the dressing changes.
A variety of topical products are available to facilitate wound care. One may employ topical enzymes when debridement is required beyond what sharp instrumentation can achieve. When the wound is viable and granulated, the enzymes are not helpful. Hydrogels are an economic topical treatment one can use to maintain a proper moist environment. They are easy to apply under a gauze dressing.
Platelet derived growth factors, both synthetic and autologous, have been advocated to facilitate and speed up wound healing. These may be helpful after one has achieved adequate debridement and offloading. However, platelet derived growth factors are quite costly to initiate. Some have argued this cost is offset by more rapid healing times.
A number of biological and tissue engineered preparations are also available, but may be difficult to use at home due to temperature and storage requirements. Antiseptics, like peroxide or iodophor solutions, are discouraged because their drying effects are thought to impair wound granulation.