Describe in detail the management of diabetic foot ulcers ?
A 1 introduction
1 requires offloading the wound by using appropriate custom made foot wear
2 requires daily saline or similar dressings to provide a moist environment
3 requires debridement when necessary and antibiotic therapy if infection or cellulitis is present
4 requires optimal.control of glucose
5 requires evaluation and correction of peripheral arterial insufficiency
Management
I - requires correction of systemic and local factors
Wound and foot care
1 the basic principle of topical wound is to provide a moist but not wet wound bed
2 requires a good wound coverage - a ) application of normal saline after debridement of wound
B ) application of moist sodium chloride dressing or isotonic sodium chloride gel ( norm gel or intrasite gel ) or hydroactive paste ( duoderm )
C ) optimal wound coverage requires wet to damp dressings which support autolytic debridement , absorbs exudate and protect the surrounding area
D ) use of a polyvinyl sterile dressing ( opsite or tegaderm ) that is semipermeable to oxygen and moisture and is impermeable to bacteria
3 types of dressings
A ) for dry wounds - hydrocolloid dressings ( duoderm ) are impermeable to oxygen , moisture and bacteria , maintains a moist environment and support autolytic debridement
B ) for exudative wounds - absorptive dressings like calcium alginates ( kaltosalt or curasorb )
C ) very exudative - impregnated gauze dressings ( mesalt ) or hydrofiber dressing ( aquacel or aquacel ag )
D ) infected wounds - silver sulfadiazine if patient is non allergic to sulfa drugs or bacitracin / neosporin ointment
If heavy - use of 1 / 4th strength if darkin solution or 0.25 % acetic acid solution
E ) in cases of eschar or wounds contaminated by eschars - use of povidone iodine ointment or lotion to paint it to maintain sterility
4 ) use of a new or recent topical preparations
A ) platelet derived growth factor ( regranex ) - becaplermin gel 0.01 % is a recombinant human pdgf that is produced thru genetic engineering to promote healing of diabetic foot ulcers , is only meant for clean and healthy granulated wound
B ) enzymatic debridement - use of collagenase isolated from clostridium histolyticum
C ) vacumm assisted closure for clean and healthy wounds ( vac )
D ) use of hydrotherapy ( pulsevac ) - saline pulse lavage under pressure
E ) extracellular matrix proteins ( hyaff ) - is a semisynthetic ester of hyaluronic acid which facilitates growth and movement of fibroblasts and controls hydration
F ) mmp modulators - ( dermax ) - contains metal ions and citric acid
Metal ion inhibits production of reactive oxygen species and citric acid acts as scavenger for superoxide ions
G ) negative pressure wound therapy - involves use of intermittent or continuous subatmospheric pressure thru a pump mechanism
It optimises blood flow , reduces edema , removes exudates
5 ) surgical care
A ) debridement - is indicated for non viable or infective tissues from the ulceration , removal of excess caluses , curretage of underlying infective bone , skin grafting and revascularisation
B ) revisional surgery - to remove pressure points
C ) vascular reconstruction - indications include a ) intractable pain at night
B ) intractable foot ulcers
C ) impending or existing gangrene
D ) intermittent claudication
D ) soft tissue coverage - indicated for clean and healthy wound after debridement usually
1 - skin graft - indicated for partial thickness wounds
2 - tissue cultured skin substitutes
A ) dermagraft - is a cryopreserved human fibroblast derived from neonatal foreskin meshing scaffold , is useful for managing full thickness wound , not appropriate for infective wounds
B ) apligraf - is a living bilayered human skin substitute
C ) xenograft - oasis is a xenogenic , acellular collagen matrix derived from porcine submucosa - contains extracellular matrix growth factors
3 ) surgical closure
6 ) use of hyperbaric oxygen therapy - 85 minutes daily 5d / wk for 8 wks
7 ) offloading or reduction of activity - by custom made shoes , bed rest , total contact casting
8 ) measures for prevention
A ) daily foot inspection
B ) gentle soap and water cleansing
C ) application of skin moisturizers
D ) inspection of shoes to ensure good cover
E ) avoidance of hot soaks , hot packs or irritating solutions
Ii - pharmacotherapy or medications used
1 ) hemarheologic agents
A ) pentoxyphilline ( trental ) - improves intermittent claudication in 60 % of cases after 3 months
B ) cilostazol ( pletal ) - is an alternative agent for those who cannot tolerate pentoxyfylline , is contraindicated in patients with congestive heart disease
Mechanism of action
Inhibits pde especially pde iii and reversible inhibition of platelet aggregation
2 ) anti platelet therapy
Use of aspirin and clopidogrel - inhibits platelet aggregation
3 ) pdgf
Use of becaplermin gel 0.01 % topically