When Diabetic Foot Ulcers Can Be Managed At Home

By Ronald A. Sage, DPM
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. Key Insights On Offloading Most diabetic ulcers result from excessive plantar pressure. If that pressure continues after ulceration, logic suggests that the ulcer is unlikely to heal, no matter what type of topical applications one utilizes. The most effective offloading technique is non-weightbearing on the ulcerated foot. However, compliance with crutches, walkers or wheelchairs is difficult to achieve. Several alternatives to complete non-weightbearing are available, but they represent a compromise and do not fully offload the ulcerated foot. These alternatives include the total contact cast (TCC), removable cast walker and the half shoe.8 The effectiveness of these devices appears to vary inversely with the ease of application. Armstrong and his group studied the effectiveness of these devices and found the TCC promotes healing ulcers in the shortest time (4.3 weeks). This compared to 5.6 weeks for the removable cast walker and 5.5 weeks for the half shoe.8 However, the TCC is difficult and time consuming to apply. There is also a risk of cast induced ulceration with this technique. Half shoes, other healing shoes and removable cast walkers may be worn over the wound dressing, and should be used with some sort of gait assisting device, such as a cane or walker, to achieve partial weightbearing. If the patient is unsteady or unsure of how to use the offloading devices, home physical therapy for partial weightbearing gait training may be effective. Wheelchairs with leg lifts for the affected extremity allow mobility with effective offloading. One should emphasize making all efforts to facilitate as little weightbearing as possible on the ulcerated extremity. Heel ulceration is a concern with bedridden patients. One should regularly inspect the heels of both feet and make an effort to cushion or offload the heels while the patient is in bed. Major efforts to accomplish the healing of a midfoot or forefoot ulceration can be totally undone if a patient develops a decubitus ulcer. Managing The Potential Treatment Outcomes A typical plantar diabetic ulceration under home care should heal in approximately six weeks if the patient meets the following parameters: a controlled infection; adequate vascular supply; is metabolically stable with a serum albumin or 3.0 or better; has near normal hemoglobin; well-controlled diabetes; and adequate offloading of the ulcer. One should grade and measure the ulcer on a weekly basis to monitor progress. If you do not see gradual improvement, there is a likely deficiency in one of the aforementioned parameters. If the ulcer is granulated and contracting, even if slower than expected, the prognosis is good. Dysvascular, hypoalbuminemic and other compromised patients can still heal but it will likely take longer. If the wound is not deteriorating in any way, it will likely heal eventually. One can evaluate infection by monitoring white blood cell count and sedimentation rate.

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