One of the most common mistakes primary care providers make with diabetic patients with a foot wound is to clean the ulcer, remove all the infected tissue, bandage it and then send the patient out of the office on foot.

If it is a weight-bearing wound, it will not heal unless it is treated with a special cast or brace to allow weight bearing, said Ruth Thomas, MD, an orthopedic surgeon who is director of the University of Arkansas for Medical Sciences (UAMS) Center for Foot and Ankle Surgery.

“For weight bearing ulcers, you must to find a way to get the patient’s weight off the foot whether it is by using a cast or brace, or a wheelchair to get all of the weight off the foot,” Thomas said. “The standards have been around for years that after you clean the wound and remove the dead tissue, the ulcer on the foot can’t bear weight. Even though it is a standard of care, a lot of our general practitioners don’t realize it. They will do the wound care and turn around and let the patient walk out of the office in a shoe. When that happens, whatever they have done is essentially neutralized.”

Thomas said there is nothing extraordinarily new on the horizon for wound care. There is no drug out there to cure all wounds.

“We use a lot of topical agents to try to encourage a clean environment in the wound, but none of them have been shown to be miracle drugs,” she said. “They can assist, but they are not a sure cure.

“VAC therapy or negative pressure wound therapy can be very effective in healing wounds. It is certainly a therapy that has been shown to improve or speed up wound healing. It is basically a sponge that is applied to the wound, and then a little slit or hole is put in the covering of the sponge before applying a dressing that is not permeable. Then you cut a hole in it and attach suctions. The suction will pull all of the fluid out of the wound. It stimulates healing while drawing away unhealthy things like bacteria. So it can be effective even in wounds that are infected.”

Biological skin equivalents are skin replacements made out of viable cells taken from different sources such as pigs or humans. Biological skin substitutes can be put over clean wounds and the wound will epithelialize.

“The wound has to be healthy and the patient in good health or skin replacement therapies will not work,” Thomas said.

Researchers are finding simple soap products can cleanse wounds as well as more expensive products sold by commercial companies that have silver or other added special agents.

“No one has shown any of those are better than standard debridement and routine wound care,” Thomas said.

Thomas recommends healthcare providers take time to talk to diabetic patients about basic rules such as not walking barefoot, wearing closed shoes instead of open toe sandals, and not cutting their own toenails. See a physician at the first sign of any trouble with your feet.

“Management needs to be started quickly,” Thomas said. “You get in trouble with diabetics where there are little cuts in the skin, bacteria enters, the foot becomes infected, and can quickly deteriorate.”

Angela Driskill, MD, a wound care specialist at Baptist Health Medical Center-North Little Rock, agrees about the importance for diabetics to be instructed on foot care. As the occurrence of all diabetic associated co-morbidities rise in each individual patient, the importance of nightly self-foot examination rises.

“The patient who has retinopathy and neuropathy will have more difficulty performing a nightly foot exam, and yet the importance of the nightly exam increases exponentially as the co-morbidities take their toll,” she said. “Teaching patients to examine their feet is almost as important as teaching them to check their blood sugar.”

As diabetes soars to epidemic proportions in the U.S., diabetic foot ulcers (DFU) have increasingly become a costly problem. In 2013 the Diabetes Association reported that 25.8 million Americans have diabetes, representing nearly ten percent of the population and 25 percent of seniors.

“Patients with diabetes have a 25 percent risk of developing a DFU in their lifetime,” Driskell said. “Of those who present with a DFU, 50 percent will be infected. Of the infected ulcers, 65 percent will have underlying osteomyelitis. It is well documented that osteomyelitis carries with it a high risk for lower extremity amputation. Once the lower extremity is amputated, that patient has a five-year mortality risk of 50 percent. Those statistics show the significant economic, physical and emotional impact to patients from a single diabetic foot ulcer.”

Driskell recommends the monofilament exam for pedal neuropathy be performed.

“Your monofilament exam may save your patient’s life,” she said. “As a quick reminder, the monofilament exam is done with a 10 g filament. The great toe, and then the first, third and fifth metatarsals are tested. Enough pressure is applied to slightly bend the filament and this pressure is held for two-three seconds. The test is positive if the patient fails to detect pressure at any single point.

“Once it is established that the patient’s foot is insensate at any of these points, custom fit insoles and diabetic shoes are indicated to prevent ulceration. A diabetic shoe should be properly fit and if there is any structural abnormality a custom orthotic or insole needs to be made.”

Driskell said it is unfortunate that often patients order shoes online or purchase shoes from a retailer who does not have anyone trained in pedorthics. Typically the diabetic patient will need to have a larger toe box and adequate room for the toes, which often are deformed.

“If there is any mechanical abnormality, the insole will need to custom fit to offload this abnormality,” she said. “Someone who specializes in pedorthics should assist your patient in obtaining the appropriate shoe.

“Even with good care of their feet, more than five percent of diabetics will develop an ulcer each year. When this happens, the basics of ulcer care should be started. This entails five basic steps:

1. Removing the offending callous and any dead tissue.

2. Clean the area and get a culture.

3. Treat infection: topically if localized, systemically if there is cellulitis.

4. Offload the ulcer.

5. Maintain a clean moist wound environment to promote healing.”

If the wound has not healed by 50 percent of the surface area in four weeks, the patient may need more advanced wound care.

Healing the patient’s wound is essential to the patient’s quality of life, and greatly lessens the financial burden on the healthcare system. The average cost of healing a DFU has been estimated at $26,000 with the cost of care of a diabetic who underwent amputation was estimated to be greater than $200,000.

Driskell said another important point is that healing a DFU often means the patient can stay in his or her own home and remain independent, whereas an amputation often leads to placement in a skilled nursing facility or extensive home care.

“Financially, it is much better for the healthcare system and for the health of the individual to have advanced wound care to accomplish healing of the wound,” Driskell said.