When Diabetic Foot Ulcers Can Be Managed At Home
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. If the white blood cell count or sedimentation rate is not normal or not demonstrating decreases from the start of treatment, one should suspect osteomyelitis. If one can probe the wound to bone, osteomyelitis is likely. If one cannot probe to bone, it may be necessary to obtain an X-ray or bone scan to establish the diagnosis. If either is positive, institute treatment with bone debridement, biopsy, culture and appropriate antibiotics as previously discussed, continuing with appropriate wound care.
Other causes of wound failure include vascular disease and metabolic impairment. Usually, one would identify vascular insufficiency early in the course of care. If borderline vascular disease is present but has not been treated, and the ulcer is not healing, one should obtain a follow-up consultation with a peripheral vascular surgeon. Patients with low albumin, renal disease or poorly controlled diabetes may fail to heal. If one cannot control these processes, continue with wound care indefinitely unless one decides to consider amputation.
If there is uncontrollable infection, necrosis of bone or deep soft tissues that cannot be debrided away or intractable ischemic pain, one should consider amputation. Likewise, if the ulcer care is requiring such prolonged disability that the patient’s overall quality of life is deteriorating, amputation may be a welcome relief. Initially, many patients will resist the recommendation. However, if amputation can be viewed as a rehabilitation step to improve quality of life, the patient will eventually see the advantage of surgery over an indefinite long-term challenge of chronic wound care.
If the ulcer heals successfully, the next challenge is to return the patient to community ambulation and protect him or her from further ulceration. Anytime a patient has developed an ulceration, one should consider the patient at high risk for another ulcer. This is especially true of patients who have neuropathy with lost protective sensation, vascular disease or ulcerative deformities such as severe bunions and chronic pressure callus.
Educating the patient about risk and foot care is essential to preventing further ulceration. One should emphasize the importance of regular foot exams. Patients may need accommodative shoes. Some may have ulcerative bony deformities, which may be treated surgically if adequate blood flow is present. Other patients may need help with managing nail conditions or chronic pressure keratosis. One should also inspect a patient’s protective shoes and orthotics to ensure their effectiveness.
Also ensure the patient is aware that even minor injury can lead to ulceration and infection so he or she should not hesitate to seek medical attention any time the foot appears at risk.9
Diabetic foot ulcerations can be successfully managed in the home care setting. This is particularly true in cases where no limb threatening infection is present. In all cases, though, one should emphasize careful, long-term and regular foot examination and care as an integral part of the patient’s diabetes management.
Dr. Sage is a Professor and Chief of the Section of Podiatry within the Department of Orthopaedic Surgery at the Loyola University Stritch School of Medicine in Maywood, Ill.
Dr. Steinberg (pictured) is a faculty member of the Department of Surgery at the Georgetown University School of Medicine in Washington, D.C.