Diabetic foot ulcers: A devastating complication of diabetes mellitus continues non-stop in spite of new medical treatment modalities

Abstract

Diabetic foot ulcer is a devastating complication of diabetes mellitus and significant cause of mortality and morbidity all over the world and can be complex and costly. The development of foot ulcer in a diabetic patient has been estimated to be 19%-34% through their lifetime. The pathophysiology of diabetic foot ulcer consist of neuropathy, trauma and, in many patients, additional peripheral arterial disease. In particular, diabetic neuropathy leads to foot deformity, callus formation, and insensitivity to trauma or pressure. The standard algorithms in diabetic foot ulcer management include assessing the ulcer grade classification, surgical debridement, dressing to facilitate wound healing, off-loading, vascular assessment (status and presence of a chance for interventional vascular correction), and infection and glycemic control. Although especially surgical procedures are sometimes inevitable, they are poor predictive factors for the prognosis of diabetic foot ulcer. Different novel treatment modalities such as nonsurgical debridement agents, oxygen therapies, and negative pressure wound therapy, topical drugs, cellular bioproducts, human growth factors, energy-based therapies, and systematic therapies have been available for patients with diabetic foot ulcer. However, it is uncertain whether they are effective in terms of promoting wound healing related with a limited number of randomized controlled trials. This review aims at evaluating diabetic foot ulcer with regard to all aspects. We will also focus on conventional and novel adjunctive therapy in diabetic foot management.

Keywords: Diabetic foot ulcer; Intralesionar growth factor treatment; Macrovascular complications; Neuropathy; Peripheric artery disease; Wagner classification.

Figure 1

Ethiopathogenesis of diabetic foot leading to vascular complications.

Figure 2

Monofilament test is a diagnostic tool to detect diabetic peripheral neuropathy. When the nylon line bends, the force is 10 grams. It is used for diabetic foot contact and stress testing.

Figure 3

Callus formation as a presentation of diabetic neuropathy.

Figure 4

Charcot neuroarthropathy is a chronic devastating and destructive disease of bone structure and joint in patients with neuropathy. A and B: Rocker-bottom foot deformity to charcot process.

Figure 5

Radiographic findings. A and B: Radiographic findings of charcot neuroarthropathy.

Figure 6

Negative pressure wound therapy is considered as a better alternative therapy for the management of diabetic foot ulcer. A-E: This patient was treated with negative pressure wound therapy therapy after surgical therapy.

Figure 7

Epidermal growth factor is perhaps the most widely used method in diabetic foot. A-D: Intralesional epidermal growth factor therapy into the wound bottom and contours encourages granulation tissue growth and wound closure; E-H: Before and after intralesional epidermal growth factor therapy.