The global burden of diabetes mellitus has increased beyond the projected rates given by the World Health Organization. According to the statistics published by the CDC, the estimated prevalence of diabetes mellitus is around 10.5% of the total US population. [1] Diabetes mellitus is a leading risk factor for an impaired wound healing process. Consequently, the burden of diabetes-related complications has also increased. 

Why Are Diabetic Patients Prone To Chronic Wounds?

Diabetic patients are at an increased risk of chronic wounds due to multiple diabetes-related complications that impair the normal wound healing process. As a result of low tissue perfusion which affects nutrient supply to the wound site, the wound healing is suboptimal. Moreover, neuropathic changes predispose diabetic individuals to an increased risk of unnoticed trauma, especially in the foot and ankle region. To put the risk in perspective, diabetic foot ulcers account for 25% of all diabetes-related hospitalizations in the United States and Great Britain. [2]

The following risk factors have been identified for the development of ulcers in diabetic patients:

• Diabetic neuropathic changes
• Previous history of ulcers or amputations 
• Trauma
• Foot deformity
• Infection 
• Chronic ischemic changes [3]

Wound Care Principles For Diabetic Wounds

Following wound care principles should be observed during the treatment of diabetic wounds:

• Blood Sugar Control: Elevated blood sugar levels are associated with poor healing outcomes. Therefore, HbA1c levels should be kept at an optimum range for a better prognosis. 
• Infection Control: Immunity is compromised in diabetic individuals which predisposes them to infections. Therefore, diabetic wounds should be regularly screened for bacterial colonization and infection. Topical or oral antibiotics should be used in case microbiological investigation yields bacterial growth. It should be kept in mind that antibiotics should only be prescribed according to the culture report as indiscriminate use of antibiotics is associated with the development of antibiotic-resistant bacteria.
• Patient Education: Patients should be educated about the risk and complications of diabetic foot ulcers. Advice should be given regarding appropriate footwear and regular screening with a podiatrist should be scheduled. [4]
• Foot Care: Diabetic patients have a 34% risk of developing diabetic foot ulcers at any point in their life. [5] Given the high-risk status of these individuals, appropriate risk stratification should be done by podiatrists. Regular foot inspections for calluses and trauma can help prevent impending complications. Podiatrists should also inform patients about the importance of protective footwear. Foot sensations should be assessed using a monofilament to detect early neuropathic changes.

Local Wound Care Solutions

Following wound care solutions are available for the management of diabetic wounds. 

• Debridement: Debridement or removal of dead, necrotic tissue is critical in promoting wound healing. A study carried out to assess the effectiveness of debridement for diabetic wounds found that healing rates increased up to 2.5 folds with debridement. There are different methods of debridement available: surgical, biological, and enzymatic but healing rates do not significantly differ between the type of debridement used per se. [6] The most widely used method however is the "sharp debridement" which involves the surgical removal of necrotic tissue. Maggot or "larval therapy" has also been tried for the treatment of diabetic foot ulcers. This can be used along with conventional debridement techniques. [7]
• Dressing: The wound should be kept clean and exudate-free. This goal can be achieved with the use of dressings. Various types of dressings are available, and the choice depends on the characteristics of the wound. For diabetic wounds, hydrogel, hydrocolloid, alginate, foams, and silver-impregnated dressings are used. There isn't any good quality evidence available to prefer one dressing type over the other. [8]
• Negative Pressure Wound Therapy (NPWT): Negative pressure wound therapy has been found to decrease hospital stay and complications associated with diabetic wounds. It also has a faster healing time and is superior to dressings in efficacy. [9] It improves wound healing through increased tissue perfusion, reduced edema, and stimulation of granulation tissue formation.
• Offloading: To reduce pressure at the wound site, "offloading" is used to equally distribute pressure over the foot. As repeated pressure can aggravate the wound, offloading is a commonly used technique in the treatment of diabetic foot ulcers. [10] A plastic or fiberglass cast is used to protect the ulcer from further damage.

Preventing Recurrence - How Telehealth Can Help?

Unfortunately, diabetic foot ulcers have a high rate of recurrence so patients should be closely followed and monitored in the community. [11] Patients should be told to regularly visit a podiatrist for inspection. They should also be advised to avoid smoking, walking barefoot, and wearing uncomfortable, ill-fitted shoes. As foot ulcers are the cause of 70% of diabetes-related amputations, there is a need for a surveillance system that can effectively prevent amputations. [12] 

Diabetic ulcer screening requires regular visits to a podiatrist and wound care facilities. However, many rural residents are unable to access these advanced healthcare services due to geographical and financial restrictions. Telehealth consultations can help serve these communities at a reduced cost. A study carried out to determine the effectiveness of telehealth consultation for diabetic foot ulcers found no statistical difference compared to physical consultation. [13] Telehealth has the potential to revolutionize the way healthcare is delivered and can help bridge the barriers to healthcare equity. 

References

1. National Diabetes Statistics Report, 2020 [Internet]. Cdc.gov. 2020 [cited 2021 Nov 5]. Available from: https://www.cdc.gov/diabetes/data/statistics-report/index.html
2. Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med. 2017;376(24):2367–75.
3. Boulton AJM, Armstrong DG, Albert SF, Frykberg RG, Hellman R, Kirkman MS, et al. Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care. 2008;31(8):1679–85.
4. Rekha P-D, Rao SS, Sahana TG, Prabhu A. Diabetic wound management. Br J Community Nurs. 2018;23(Sup9):S16–22.
5. Ibrahim A. IDF Clinical Practice Recommendation on the Diabetic Foot: A guide for healthcare professionals. Diabetes Res Clin Pract. 2017;127:285–7.
6. Karavan M, Olerud J, Bouldin E, Taylor L, Reiber GE. Evidence-based chronic ulcer care and lower limb outcomes among Pacific Northwest veterans: Evidence-based chronic ulcer care and outcomes. Wound Repair Regen. 2015;23(5):745–52.
7. Opletalová K, Blaizot X, Mourgeon B, Chêne Y, Creveuil C, Combemale P, et al. Maggot therapy for wound debridement: a randomized multicenter trial: A randomized multicenter trial. Arch Dermatol. 2012;148(4):432–8.
8. Wu L, Norman G, Dumville JC, O’Meara S, Bell-Syer SEM. Dressings for treating foot ulcers in people with diabetes: an overview of systematic reviews. Cochrane Database Syst Rev. 2015;(7):CD010471.
9. Armstrong DG, Lavery LA, Abu-Rumman P, Espensen EH, Vazquez JR, Nixon BP, et al. Outcomes of subatmospheric pressure dressing therapy on wounds of the diabetic foot. Ostomy Wound Manage. 2002;48(4):64–8.
10. Piaggesi A, Goretti C, Iacopi E, Clerici G, Romagnoli F, Toscanella F, et al. Comparison of removable and irremovable walking boot to total contact casting in offloading the neuropathic diabetic foot ulceration. Foot Ankle Int. 2016;37(8):855–61.
11. Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med. 2017;376(24):2367–75.
12. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care. 1990;13(5):513–21.
13. Wilbright WA, Birke JA, Patout CA, Varnado M, Horswell R. The use of telemedicine in the management of diabetes-related foot ulceration: A pilot study. Adv Skin Wound Care. 2004;17(5):232–8.

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