Diabetic foot ulcers pose a serious risk for patients with diabetes. The document discusses that diabetic patients have up to a 25% lifetime risk of developing a foot ulcer, with annual incidence rates of 3-10%. Key risk factors include neuropathy, peripheral vascular disease, foot deformities, and inappropriate footwear. Management requires a multidisciplinary approach including wound care, infection control, offloading pressure areas, and patient education on proper foot self-care. The goals are to heal ulcers, prevent amputation, and maintain foot health and function.

1. DIABETIC FOOT
ULCER
BY:
DR. MOHD HAZIM BIN ABDULLAH
MEDICAL OFFICER, WOUND TEAM
HOSPITAL DUCHESS OF KENT, SANDAKAN
Wound Care Manual, First Edition 2014

2. INTRODUCTION
• Diabetic foot is a foot that exhibits any pathology that results directly from
diabetes mellitus or any long‐term (or "chronic") complication of diabetes
mellitus (Jeffcoate & Harding, 2003).
• Diabetic foot implies that the pathophysiological process of diabetes m
ellitus does something to the foot that puts it at increased risk for “tissue d
amage” and the resultant increase in morbidity and maybe amputation
(Payne & Florkowski, 1998).

3. INCIDENCE
• Studies have indicated that diabetic patients have up to a 25%
lifetime risk of developing a foot ulcer.
• The annual incidence of diabetic foot ulcers is ~ 3% to as high
as 10%. (Armstrong and Lavery, 1998)

4. RISK FACTORS
• History of ulceration
• Presence of neuropathy
• Presence of peripheral vascular disease
• Presence of foot deformity
• Inappropriate footwear
• Skin lesion
• Nail pathology
• Duration of diabetes
• Prolonged standing or walking
• Type of occupation

5. PATHOPHYSIOLOGY
• Neuropathy‐ leads to skin dryness and cracks, foot
deformity and loss of protective sense in the foot
• Microangiopathy/vascular disease‐ lead to poor blood
supply to the toes and foot and then ulcerate easily
• Immunopathy‐ Defects in leukocyte function (leukocyte
phagocytosis, neutrophil dysfunction) and also deficient w
hite cell chemotaxis and adherence

6. CLINICAL PRESENTATION
• Soft tissue infections (superficial to deep tissue infection e.g.
cellulitis, necrotizing fasciitis, etc.)
• Osteomyelitis (bone infection)
• Septic arthritis (joint infection)
• Gangrene (dry or wet)
• Chronic non‐healing ulcer
• Combination of more than one of the above mentioned condition

7. ASSESSMENT
•History
•Examination

8. HISTORY
• Diabetic history
• Previous ulcer or amputation
• Symptoms of peripheral neuropathy
• Symptoms of peripheral vascular/ischemic problem
• Contributing factors
• Other complications of diabetes (eyes, kidney, heart etc).
• Current ulcer

9. EXAMINATION
• Previous amputation/ulcer
• Deformity and footwear
• Inspect web spaces ‐ signs of infection or wound
• Hypercallosity or nail deformity or paronychia
• Present of peripheral neuropathy with tuning folks, also mono
filament and position sense.
• Peripheral pulses ‐ peripheral vascular disease
• Ankle‐brachial index (ABSI)
• Other relevant systems (renal, eye, heart etc)
Do not forget to
examine the
other foot!

10. CLASSIFICATION OF THE DIABETIC FOOT
- WAGNER CLASSIFICATION

13. MANAGEMENT
Objectives:
1. Control infection
2. Ulcer/wound management
3. Prevent amputation
4. Maintain pre‐morbid foot/lower extremity function as much as possible
5. Prevent recurrent ulcer

15. GENERAL MANAGEMENT
• A multidisciplinary approach
• Good diabetic control
• Systemic antibiotics (according to CPG on Antibiotic Guidel
ine and also culture and sensitivity of the infected tissue)
• Optimize other co‐morbid complications.
• Advise to stop smoking

16. LOCAL MANAGEMENT
• Wound/ulcer management: depending on severity of wound; vasc
ularity and also presence of infection.
• Debride infected/necrotic tissue follow by wound management (refer
Wound care Algorithm in Chapter 17)
• Do not hesitate to perform re‐debridement if indicated.
• Amputation may be the treatment of choice.
• Minimize risk of re‐infection
• If indicated reestablished adequate blood supply (refer to chapter on a
rterial ulcer).
• Off loading with contact cast etc
• Good foot care and foot wear If no signs of healing after 2 weeks of
treatment, reevaluate and looks for the cause.

17. DIABETIC FOOT-CARE
• Foot inspection‐ minimally once a day
• Use lukewarm (air suam), not hot water to
wash feet
• Use gentle soap to bath/wash feet •
Apply moisturizer to avoid dry feet –
be careful with the web space and
not too much (causing skin maceration)
• Proper nail cutting, avoid cutting too close
/digging nail fold.
• Wear clean, dry socks (NEVER use heating
pad or hot water bottle) to keep foot
warm
• Avoid walk barefooted.
• Wear comfortable well fitting shoe (not too tight
or too loose), evening is the best time to buy sho
e.
• Shake out shoes and feel the inside before
wearing
• Never treat corns or calluses themselves
• Good diabetic control
• Stop smoking
• Periodic foot examination by relevant personals
• Keep the blood flowing to feet (elevate, wiggers to
es, moving ankle) , avoid cross‐leg or hanging leg/
feet too long

19. TAKE HOME MESSAGES
• Good glycemic control, regular foot assessment; including vascular
and neurological assessment; to prevent diabetic foot ulcer.
• The main underlying cause of diabetic foot ulcer is chronic pressure
‐ think of off loading.
• Diabetic foot ulcer needs multidisciplinary approach

20. THANK YOU