Promising treatments for the healing of diabetic foot ulcers

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The number of Canadians with is rapidly increasing. According to the Canadian Diabetes Association, more than 20 Canadians are diagnosed with the disease every hour of every day.

(DFUs) are the most common chronic complication from diabetes, affecting four to 10 per cent of patients. DFUs can last a year or longer and can happen again in up to 70 per cent of people who have previously been affected. Patients are more likely to develop DFUs if they have had diabetes for a long time, have poorly controlled blood sugar, have foot injuries or infection, are older, or smoke. However, neuropathy, damage to the nerves, which may result in a lack of feeling in the feet, and peripheral artery disease, which reduces the blood flow to the limbs, may be the most significant causes. Because of nerve damage and numbness, an individual with diabetes may not be aware that they have a sore or wound, leading to even minor injuries getting worse or becoming infected. Decreased blood flow caused by peripheral vascular disease may prevent healing once an injury occurs.

When DFUs become infected, the bone or skin can also become infected.  This can lead to significant pain and suffering; poor quality of life for patients; amputation of a leg, foot, or toe; increased treatment and hospitalization costs ― and can even lead to death.

The good news is that many foot complications are preventable with diabetes management and proper foot care, including regular foot exams and aggressive treatment of infections. Debridement (removing dead skin and tissue), taking pressure off the foot ulcer (off-loading), infection control, and wound care with appropriate medications or dressings are some of the key aspects in the treatment of DFUs.

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— an independent, evidence-based agency that finds, assesses, and summarizes the research on drugs, medical devices, and procedures — recently looked at the evidence on two treatment approaches that are based either on off-loading or the application of controlled pressure around the wound area to stimulate DFU healing.

Off-Loading Devices

Reducing the pressure on the bottom of the foot from surfaces below (plantar pressure) can be used in the treatment and prevention of DFUs. Devices that off-load the plantar pressure include removable options such as customized footwear, cast walkers, and orthoses (sometimes called orthotics) or devices that cannot be removed by patients such as total contact casting (requiring a skilled technician) and instant total contact casting (making a removable walking cast permanent by wrapping it in casting material).

The CADTH review found that non-removable off-loading devices — total contact casting and instant total contact casting — appear to be more effective than removable devices in the treatment of DFU by providing better healing rates and healing times for ulcers. Non-removable devices may be more effective simply because patients keep the device on or because the device restricts physical activity.

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Although they may be more effective, because non-removable off-loading devices are time consuming to apply, don’t allow for regular wound assessment, and decrease patient mobility compared with removable devices, clinicians might be more likely to suggest that their patients use removable off-loading devices. Of the removable devices, cast walkers may be the most effective for the treatment of DFU; however, the evidence is limited.

Compression Therapy

While pressure off-loading is a major aspect of diabetic foot care, therapies that apply controlled pressure around or onto the wound offer a different way for promoting the healing of DFUs. One such treatment approach, compression therapy, was also reviewed by CADTH.

The goal of compression therapy for DFUs is to improve blood circulation by controlling external pressure through the application of bandages, specialized stockings, or inflatable garments. Intermittent pneumatic compression devices, which inflate and deflate to simulate the blood flow experienced while walking, and compressed air massage, in which a stream of compressed air is applied directly to the wound, are different methods of compression therapy.

The limited evidence CADTH found on these technologies suggests that intermittent compression therapy and compressed air massage may be better than standard wound treatments (such as antibiotics, insulin infusion, strict bed rest, daily cleaning of wounds with saline, and antiseptic cream dressings) for healing and reducing fluid retention. A clinical practice guideline also suggests that foot compression in addition to standard wound care may be more effective for healing infected DFUs than standard care alone.

These DFU treatment options may not be suitable for all patients with diabetes. However, knowing the evidence and taking into consideration other important factors such as patient characteristics, patient preferences, the local health care context, and costs will help to determine the best use of these promising technologies.

To learn more about CADTH, visit www.cadth.ca, follow us on Twitter: @CADTH_ACMTS, or talk to our Liaison Officer in your region: https://www.cadth.ca/contact-us/liaison-officers.