Recurrent DFUs are a prominent and challenging issue that podiatrists encounter often. Accordingly, these panelists address patient adherence, risk factors and treatment approaches as well as emerging technology that may help prevent these complex cases.
How much of a role does patient adherence, or lack thereof, contribute toward recurrent DFUs? In your experience, what practical steps can podiatrists take to prevent adherence issues from contributing to recurrent DFUs?
All of the panelists stress the significant role patient adherence plays in the recurrence of DFUs. Kazu Suzuki, DPM, CWS feels it is the number one priority and sees a trend in repeat visits among patients who wear inappropriate footwear. Conversely, he sees patients who consistently perform daily foot checks, wear appropriate socks and shoes, and only need office visits twice a year as a result.
Andrew Meyr, DPM states, “I always tell patients that I have never actually healed a wound. I only put the patient in a better position to heal his or her own wound.”
He continues to say that he likes to see what type of partner he will have in a new patient since communication plays such an important role in adherence to a treatment plan.
Dr. Suzuki advises persistence and patience in communicating with and educating patients. Anthony Tickner, DPM agrees and states that a thorough discussion with patients and family members regarding their responsibilities to the wound care team is vital.
“Patients like to have some ‘ownership’ of their care plan. This approach has lowered our rates of non-adherence tremendously,” relates Dr. Tickner.
Alexander Reyzelman, DPM concurs that patient education is paramount and will routinely see patients one week and possibly two more weeks after their ulcer is healed to monitor their continued progress.
Aside from proper offloading of the affected area, what other factors do DPMs need to consider in patients at risk for recurrent DFUs? How do these factors affect your treatment options for these patients?
Dr. Suzuki feels that vascular status and nutrition/obesity are important factors to address. He uses a skin perfusion pressure laser Doppler in the wound clinic in order to make a prompt referral to a vascular specialist if necessary. Additionally, he relates that weight loss is a very effective method of offloading the foot and recommends the University of Southern California-developed ProLon® (L-Nutra) program. This program involves a five-day low-calorie, fasting-mimicking diet that in a clinical trial showed an average of five to eight pounds of weight loss per cycle, which consisted of a five-day fast, once a month for three consecutive months.1
Dr. Tickner agrees that vascular supply is vital, along with evaluation for and treatment of infection. He advocates for all new patients with DFUs to receive vascular studies, foot X-rays and labs, including fasting glucose and hemoglobin A1c. Dr. Tickner says these diagnostic measures assist in evaluating if the patient is ‘healthy’ enough to heal or if further intervention, such as surgery, is necessary.
He adds that, if appropriate, it may be more important to take the patient to surgery at an early stage to cut down on variables that slow wound healing. Dr. Meyr agrees, stating that abnormal biomechanics is a root cause of DFU recurrence. In these cases, he pushes for prophylactic surgery in his patients.
Dr. Reyzelman includes lifestyle, activity level, cultural beliefs and patient expectations as additional factors to consider.
“I find that most of my patients with DFUs don’t realize that their lives are going to change forever due to having had a DFU,” explains Dr. Reyzelman.
When there are recurrent DFUs, do you reassess your approach to treatment for the given patient with a recurrent DFU? Can you think of a specific recent example where a change in treatment choices significantly changed outcomes for the better?
Dr. Suzuki advocates for being flexible and thinking outside the box. He cites an example of a patient who was a “power lawyer” and refused to wear an offloading sandal. Dr. Suzuki wrote an order for the patient to work from home for four weeks.
“He reluctantly agreed and his foot wounds healed as he stopped flying for work and pacing around his large office,” explains Dr. Suzuki.
For recurrent DFUs, Dr. Tickner takes a look toward past history. Once a patient initially healed, was proactive care instituted? Were diabetic shoes discussed? Citing the lengthy process for patients to obtain some of these items, such as diabetic shoes, he says it is important to implement this proactive thinking early in the patient relationship and not just if a DFU reoccurs.
Dr. Meyr returns to the idea of addressing abnormal biomechanics surgically for recurrent DFUs. He cites that many times patients are not interested in elective surgery to address the underlying cause of a DFU. However, when the ulcer reoccurs, the need becomes more obvious.
“Patients who have had an ulceration really need a different and more reliable anatomy. That is something that we can offer with our expert knowledge in lower extremity structure and function,” relates Dr. Meyr.
Recurrent DFUs may not change his treatment approach, states Dr. Reyzelman, but they may change how aggressively he follows and monitors his patients.
In your experience, have you worked with any emerging technologies or modalities that may offer preventative benefit in patients at high risk of recrurrent DFUs?
Dr. Suzuki feels that “smart” devices such as socks or bath mats may help detect “hot spots” at risk for wounds. Although he expresses excitement over these developments, he points out that adoption of these products among elderly patients (who are possibly not as tech-savvy) may prove challenging.
Various wearable technologies being developed by researchers at Baylor University and the company Optima Molliter are cited by Dr. Tickner as examples of the bright future of this field. He also notes Herreen Technologies, a company that laser prints orthotics, shoes and inserts from 3D hologram-style images.
Dr. Reyzelman echoes optimism toward temperature-monitoring technology, specifically the Podimetrics Mat™ (Podimetrics) and Siren Socks™ (Siren), which allow providers to monitor temperature results remotely.
“This is revolutionary because we are now able to close the loop by keeping a closer eye on the patient when he or she is at home,” states Dr. Reyzelman.
Although he understands the science behind in-shoe and floor mat pressure and temperature devices, Dr. Meyr expresses that there may not be a substitute substantially better than daily foot checks, regular podiatric risk assessment and acute intervention in the setting of abnormalities.
Dr. Meyr is a Clinical Associate Professor within the Department of Surgery and the Residency Director of the Podiatric Surgical Residency Program at the Temple University School of Podiatric Medicine in Philadelphia.
Dr. Reyzelman is an Associate Professor at the California School of Podiatric Medicine at Samuel Merritt University. He is the Co-Director of the University of California San Francisco (UCSF) Center for Limb Preservation. Dr. Reyzelman has disclosed that he is a consultant for Siren.
Dr. Suzuki is the Medical Director of the Apex Wound Care Clinic in Los Angeles, CA. He is also a member of the attending staff of the Cedars-Sinai Medical Center in Los Angeles CA. He can be reached at Kazu.Suzuki@cshs.org.
Dr. Tickner is a Fellow of the American Professional Wound Care Association and a Diplomate of the American Board of Wound Management. He is in private practice in Hudson, Mass.
1. Wei M, Brandhorst S, Shelehchi M, et al. Fasting-mimicking diet and markers/risk factors for aging, diabetes, cancer and cardiovascular disease. Sci Transl Med. 2017;9(377). DOI: 10.1126/scitranslmed.aai8700.