Diabetic wounds are chronic, non-healing sores, frequently developing on the feet, known as diabetic foot ulcers (DFUs). High blood sugar levels damage nerves and blood vessels, leading to peripheral neuropathy (loss of sensation) and peripheral artery disease (restricted blood flow). Because the patient cannot feel the injury and the wound receives insufficient oxygen and nutrients for repair, a minor abrasion can rapidly escalate into a deep, non-healing ulcer. Aggressive treatment is necessary, as untreated DFUs precede over 80% of diabetes-related lower limb amputations.
Essential Local Wound Management
Debridement, the removal of non-viable tissue, foreign debris, and thick callus, is essential for preparing the wound bed. Sharp surgical debridement, performed by a specialist, is often preferred because it quickly converts a chronic, stalled wound into an acute wound responsive to healing signals. This procedure is repeated as necessary to ensure the wound remains free of dead tissue, which breeds bacteria and impedes new tissue growth.
Maintaining an optimal moisture balance is important for promoting cellular activity and preventing infection. Dressings are selected based on the amount of fluid (exudate) the wound produces. Highly absorbent dressings, such as alginates or foams, manage heavy drainage while maintaining a moist environment. Conversely, hydrogel dressings introduce moisture to dry wounds, facilitating the breakdown and removal of necrotic tissue through autolytic debridement.
Systemic Control of Healing Inhibitors
Systemic factors inhibiting healing must be addressed for local treatment to succeed. The most influential factor is persistent high blood glucose, measured by Hemoglobin A1c (HbA1c). Elevated glucose compromises white blood cell function, delaying pathogen defense and prolonging inflammation. For optimal wound healing, an HbA1c level below 7% is generally recommended.
Infection management requires prompt recognition and targeted therapy, as infection can rapidly destroy tissue and lead to amputation. Since neuropathy can mask classic signs like pain, a deep tissue culture is necessary to identify specific bacteria. Antibiotic therapy is then initiated based on culture results, usually for one to two weeks for soft tissue infections.
Addressing vascular health is a foundational requirement because poor blood flow prevents oxygen, immune cells, and nutrients from reaching the wound site. Peripheral artery disease (PAD) restricts circulation due to hardened arteries in the legs and feet. If blood flow is severely restricted, specialized procedures like angioplasty or surgical bypass may be necessary to restore adequate perfusion to the limb.
The Role of Pressure Relief
Relieving pressure, known as offloading, is essential for healing diabetic foot ulcers. DFUs often form on the sole of the foot due to neuropathy combined with continuous mechanical stress from walking. This repetitive pressure prevents the wound bed from forming new granulation tissue and breaks down newly formed cells, keeping the ulcer in a constant state of injury.
The gold standard for offloading plantar ulcers is the Total Contact Cast (TCC). This custom-molded, non-removable cast evenly redistributes weight and pressure across the entire surface, preventing concentration on the ulcer site. The TCC is highly effective because its non-removable nature ensures patient adherence and reduces walking activity. Other methods include specialized removable cast walkers that can be modified, and therapeutic shoes with rocker soles that reduce pressure during the gait cycle.
Advanced Therapies to Accelerate Closure
When foundational care, systemic control, and offloading fail to achieve significant healing within four to six weeks, advanced therapies are used. Negative Pressure Wound Therapy (NPWT), or vacuum-assisted closure, involves applying a specialized foam dressing connected to a pump that delivers continuous or intermittent sub-atmospheric pressure. This vacuum draws out excess fluid and edema, increases local blood flow, and mechanically stimulates the wound bed to contract and form new granulation tissue.
Bioengineered skin substitutes and growth factors are another category of advanced treatment. Skin substitutes, derived from human or animal tissue, function as a temporary scaffold that protects the wound and supports the migration of the patient’s own cells. These products often deliver growth factors, such as Vascular Endothelial Growth Factor (VEGF), directly to the wound bed, jumpstarting the proliferative phase stalled in diabetic wounds.
Hyperbaric Oxygen Therapy (HBOT) is an adjunctive treatment involving the patient breathing 100% oxygen inside a pressurized chamber, typically at two to three times normal atmospheric pressure. This process dramatically increases dissolved oxygen in the bloodstream, delivering it to the wound’s poorly perfused tissues. High oxygen levels enhance white blood cell function to fight infection, stimulate new blood vessel formation (angiogenesis), and promote fibroblast activity for collagen production.