BEST PRACTICE GUIDELINES: WOUND MANAGEMENT IN DIABETIC FOOT ULCERS - INTERNATIONAL BEST PRACTICE
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INTERNATIONAL BEST PRACTICE BEST PRACTICE GUIDELINES: WOUND MANAGEMENT IN DIABETIC FOOT ULCERS 3 BEST PRACTICE GUIDELINES FOR SKIN AND WOUND CARE IN EPIDERMOLYSIS BULLOSA
FOREWORD
Supported by an educational This document focuses on wound management best practice for diabetic
grant from B Braun
foot ulcers (DFUs). It aims to offer specialists and non-specialists everywhere
a practical, relevant clinical guide to appropriate decision making and effec-
tive wound healing in people presenting with a DFU.
The views presented in this In recognition of the gap in the literature in the field of wound manage-
document are the work of the ment, this document concentrates on the importance of wound assessment,
authors and do not necessarily
reflect the opinions of B Braun.
debridement and cleansing, recognition and treatment of infection and
appropriate dressing selection to achieve optimal healing for patients. How-
ever, it acknowledges that healing of the ulcer is only one aspect of manage-
Published by
Wounds International ment and the role of diabetic control, offloading strategies and an integrated
A division of Schofield wound care approach to DFU management (which are all covered exten-
Healthcare Media Limited sively elsewhere) are also addressed. Prevention of DFUs is not discussed in
Enterprise House
1–2 Hatfields this document.
London SE1 9PG, UK
www.woundsinternational.com
The scope of the many local and international guidelines on managing DFUs
is limited by the lack of high-quality research. This document aims to go
further than existing guidance by drawing, in addition, from the wide-ranging
experience of an extensive international panel of expert practitioners. How-
ever, it is not intended to represent a consensus, but rather a best practice
To cite this document. guide that can be tailored to the individual needs and limitations of different
International Best Practice healthcare systems and to suit regional practice.
Guidelines: Wound Manage-
ment in Diabetic Foot Ulcers.
Wounds International,
2013. Available from: www.
woundsinternational.com EXPERT WORKING GROUP
Development group
Paul Chadwick, Principal Podiatrist, Salford Royal Foundation Trust, UK
Michael Edmonds, Professor of Diabetes and Endocrinology, Diabetic Foot Clinic, King's College
Hospital, London, UK
Joanne McCardle, Advanced Clinical and Research Diabetes Podiatrist, NHS Lothian University
Hospital, Edinburgh, UK
David Armstrong, Professor of Surgery and Director, Southern Arizona Limb Salvage Alliance (SALSA),
University of Arizona College of Medicine, Arizona, USA
Review group
Jan Apelqvist, Senior Consultant, Department of Endocrinology, Skåne University Hospital, Malmo,
Sweden
Mariam Botros, Director, Diabetic Foot Canada, Canadian Wound Care Association and Clinical
Coordinator, Women's College Wound Healing Clinic, Toronto, Canada
Giacomo Clerici, Chief Diabetic Foot Clinic, IRCC Casa di Cura Multimedica, Milan, Italy
Jill Cundell, Lecturer/Practitioner, University of Ulster, Belfast Health and Social Care Trust, Northern
Ireland
Solange Ehrler, Functional Rehabilitation Department, IUR Clémenceau (Institut Universitaire de
Réadaptation Clémenceau), Strasbourg, France
Michael Hummel, MD, Diabetes Center Rosenheim & Institute of Diabetes Research, Helmholtz
Zentrum München, Germany
Benjamin A Lipsky, Emeritus Professor of Medicine, University of Washington, USA; Visiting Professor,
Infectious Diseases, University of Geneva, Switzerland; Teaching Associate, University of Oxford and
Deputy Director, Graduate Entry Course, University of Oxford Medical School, UK
José Luis Lázaro Martinez, Full Time Professor, Diabetic Foot Unit, Complutense University, Madrid,
Spain
Rosalyn Thomas, Deputy Head of Podiatry, Abertawe Bro Morgannwg University Health Board,
Swansea, Wales
Susan Tulley, Senior Podiatrist, Mafraq Hospital, Abu Dhabi, United Arab Emirates
C
3 BEST PRACTICE
BEST PRACTICE GUIDELINES:
GUIDELINES WOUND
FOR SKIN MANAGEMENT
AND WOUND CARE ININ DIABETIC FOOTBULLOSA
EPIDERMOLYSIS ULCERS
INTRODUCTION
Introduction
DFUs are complex, chronic wounds, which such as the effect on physical, psychological
have a major long-term impact on the and social wellbeing and the fact that many
morbidity, mortality and quality of patients’ patients are unable to work long term as a
lives1,2. Individuals who develop a DFU are at result of their wounds6.
greater risk of premature death, myocardial
infarction and fatal stroke than those without A DFU is a pivotal event in the life of a
a history of DFU3. Unlike other chronic person with diabetes and a marker of serious
wounds, the development and progression of disease and comorbidities. Without early
a DFU is often complicated by wide-ranging and optimal intervention, the wound can
diabetic changes, such as neuropathy and rapidly deteriorate, leading to amputation of
vascular disease. These, along with the the affected limb5,13.
altered neutrophil function, diminished tissue
perfusion and defective protein synthesis It has been estimated that every 20 seconds
that frequently accompany diabetes, present a lower limb is amputated due to complica-
practitioners with specific and unique man- tions of diabetes14.
agement challenges1.
In Europe, the annual amputation rate for
DFUs are relatively common — in the UK, people with diabetes has been cited as 0.5-
5–7% of people with diabetes currently have 0.8%1,15, and in the US it has been reported
or have had a DFU4,5. Furthermore, around that around 85% of lower-extremity
25% of people with diabetes will develop a amputations due to diabetes begin with foot
DFU during their lifetime6. Globally, around ulceration16,17.
370 million people have diabetes and this
number is increasing in every country7. Dia- Mortality following amputation increases
betes UK estimates that by 2030 some 552 with level of amputation18 and ranges from
million people worldwide will have diabetes8. 50–68% at five years, which is comparable
or worse than for most malignancies13,19
DFUs have a major economic impact. A US (Figure 1).
study in 1999 estimated the average out-
patient cost of treating one DFU episode as The statistics need not make for such grim
$28,000 USD over a two–year period9. Aver- reading. With appropriate and careful
age inpatient costs for lower limb complica- management it is possible to delay or avoid
tions in 1997 were reported as $16,580 USD most serious complications of DFUs1.
for DFUs, $25,241 USD for toe or toe plus
other distal amputations and $31,436 USD FIGURE 1: Relative five-year mortality (%) (adapted from19)
for major amputations10,11.
The EURODIALE study examined total direct
and indirect costs for one year across several
European countries. Average total costs
based on 821 patients were approximately
10,000 euros, with hospitalisation represent-
ing the highest direct cost. Based on preva-
lence data for Europe, they estimated that
costs associated with treatment of DFUs
may be as high as 10 billion euros per year12.
In England, foot complications account for
20% of the total National Health Service
spend on diabetes care, which equates to
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BEST PRACTICE GUIDELINES: WOUND MANAGEMENT IN DIABETIC FOOT ULCERS 1
INTRODUCTION
It has been suggested that up to 85% of of other aetiologies not subject to diabetic
amputations can be avoided when an effec- changes. A European-wide study found that
tive care plan is adopted20. Unfortunately, 58% of patients attending a foot clinic with a
insufficient training, suboptimal assessment new ulcer had a clinically infected wound23.
and treatment methods, failure to refer Similarly a single-centre US study found that
patients appropriately and poor access to spe- about 56% of DFUs were clinically infected24.
cialist footcare teams hinder the prospects of This study also showed the risk of hospitalisa-
achieving optimal outcomes21,22. tion and lower-extremity amputation to be
56–155 times greater for diabetes patients
Successful diagnosis and treatment of with a foot infection than those without24.
patients with DFUs involves a holistic
approach that includes: Recognising the importance of starting treat-
Q Optimal diabetes control ment early may allow practitioners to prevent
Q Effective local wound care progression to severe and limb-threatening
Q Infection control infection and potentially halt the inevitable
Q Pressure relieving strategies pathway to amputation25.
Q Restoring pulsatile blood flow.
This document offers a global wound care
Many studies have shown that planned in- plan for practitioners (page 20), which
tervention aimed at healing of DFUs is most includes a series of steps for preventing
effective in the context of a multidisciplinary complications through active management
team with the patient at the centre of this — namely prompt and appropriate treatment
care. of infection, referral to a vascular specialist to
manage ischaemia and optimal wound care.
One of the key tenets underpinning this This should be combined with appropriate
document is that infection is a major threat patient education and an integrated approach
to DFUs — much more so than to wounds to care.
2
3 BEST PRACTICE
BEST PRACTICE GUIDELINES:
GUIDELINES WOUND
FOR SKIN MANAGEMENT
AND WOUND CARE ININ DIABETIC FOOTBULLOSA
EPIDERMOLYSIS ULCERS
AETIOLOGY OF
DFUs
Aetiology of DFUs
The underlying cause(s) of DFUs will have a significant bearing on the clinical
management and must be determined before a care plan is put into place
In most patients, peripheral neuropathy and is increasing and it is reported to be a con-
peripheral arterial disease (PAD) (or both) tributory factor in the development of DFUs
play a central role and DFUs are therefore in up to 50% of patients14,28,33.
commonly classified as (Table 1)26:
Q Neuropathic It is important to remember that even in the
Q Ischaemic absence of a poor arterial supply, micro-
Q Neuroischaemic (Figures 2–4). angiopathy (small vessel dysfunction) FIGURE 2: Neuropathic DFU
contributes to poor ulcer healing in neuro-
Neuroischaemia is the combined effect ischaemic DFUs34. Decreased perfusion in
of diabetic neuropathy and ischaemia, the diabetic foot is a complex scenario and
whereby macrovascular disease and, in is characterised by various factors relating
some instances, microvascular dysfunction to microvascular dysfunction in addition to
impair perfusion in a diabetic foot26,27. PAD34.
DFUs usually result from two or more risk FIGURE 3: Ischaemic DFU
PERIPHERAL NEUROPATHY factors occurring together. Intrinsic elements
Peripheral neuropathy may predispose the such as neuropathy, PAD and foot deform-
foot to ulceration through its effects on the ity (resulting, for example, from neuropathic
sensory, motor and autonomic nerves: structural changes), accompanied by an
Q The loss of protective sensation experi- external trauma such as poorly fitting foot-
enced by patients with sensory neuropathy wear or an injury to the foot can, over time,
renders them vulnerable to physical, lead to a DFU7. FIGURE 4: Neuroischaemic
chemical and thermal trauma DFU
Q Motor neuropathy can cause foot
deformities (such as hammer toes and
claw foot), which may result in abnormal
pressures over bony prominences
TABLE 1: Typical features of DFUs according to aetiology
Q Autonomic neuropathy is typically
associated with dry skin, which can result Feature Neuropathic Ischaemic Neuroischaemic
in fissures, cracking and callus. Another Sensation Sensory loss Painful Degree of sensory
feature is bounding pulses, which is loss
often misinterpreted as indicating a good
Callus/necrosis Callus present and Necrosis common Minimal callus
circulation28. often thick Prone to necrosis
Wound bed Pink and granulat- Pale and sloughy Poor granulation
Loss of protective sensation is a major ing, surrounded by with poor
component of nearly all DFUs29,30. It is as- callus granulation
sociated with a seven–fold increase in risk
Foot temperature Warm with bound- Cool with absent Cool with absent
of ulceration6. and pulses ing pulses pulses pulses
Patients with a loss of sensation will have Other Dry skin and Delayed healing High risk of
decreased awareness of pain and other fissuring infection
symptoms of ulceration and infection31.
Typical location Weight-bearing Tips of toes, nail Margins of the
areas of the foot, edges and between foot and toes
such as metatarsal the toes and lateral
PERIPHERAL ARTERIAL DISEASE heads, the heel and borders of the foot
People with diabetes are twice as likely to over the dorsum of
have PAD as those without diabetes32. It clawed toes
is also a key risk factor for lower extremity Prevalence 35% 15% 50%
amputation30. The proportion of patients (based on35)
with an ischaemic component to their DFU
BEST PRACTICE GUIDELINES: WOUND MANAGEMENT IN DIABETIC FOOT ULCERS 3
ASSESSING DFUs
Assessing DFUs
Patients with a DFU need to be assessed holistically and intrinsic and extrinsic
factors considered
For the non-specialist practitioner, the key skill Documenting ulcer characteristics
required is knowing when and how to refer a Recording the size, depth, appearance and loca-
patient with a DFU to the multidisciplinary foot- tion of the DFU will help to establish a baseline
care team (MDFT; see page 19). Patients with for treatment, develop a treatment plan and
a DFU should be assessed by the team within monitor any response to interventions. It is
one working day of presentation — or sooner important also to assess the area around the
in the presence of severe infection22,36,37. In wound: erythema and maceration indicate
many places, however, MDFTs do not exist and additional complications that may hinder
practitioners instead work as individuals. In wound healing38.
these situations, the patient’s prognosis often
depends on a particular practitioner’s know- Digitally photographing DFUs at the first
ledge and interest in the diabetic foot. consultation and periodically thereafter
to document progress is helpful39. This is
Patients with a DFU need to be assessed holis- particularly useful for ensuring consistency
tically to identify intrinsic and extrinsic factors. of care among healthcare practitioners,
This should encompass a full patient history facilitating telehealth in remote areas and
including medication, comorbidities and diabe- illustrating improvement to the patient.
tes status38. It should also take into considera-
tion the history of the wound, previous DFUs or
amputations and any symptoms suggestive of TESTING FOR LOSS OF SENSATION
neuropathy or PAD28. Two simple and effective tests for peripheral
neuropathy are commonly used:
Q 10g (Semmes-Weinstein) monofilament
EXAMINATION OF THE ULCER Q Standard 128Hz tuning fork.
A physical examination should determine:
Q Is the wound predominantly neuropathic, The 10g monofilament is the most frequently
ischaemic or neuroischaemic? used screening tool to determine the presence
Q If ischaemic, is there critical limb ischaemia? of neuropathy in patients with diabetes28. It
Q Are there any musculoskeletal deformities? should be applied at various sites along the
Q What is the size/depth/location of the plantar aspect of the foot. Guidelines vary in the
wound? number of sites advocated, but the internation-
Q What is the colour/status of the wound al consensus is to test at three sites (see Figure
bed? 5)7. A positive result is the inability to feel the
— Black (necrosis) monofilament when it is pressed against the
— Yellow, red, pink foot with enough force to bend it40.
Q Is there any exposed bone?
Q Is there any necrosis or gangrene? Neuropathy is also demonstrated by an inability
Q Is the wound infected? If so, are there to sense vibration from a standard tuning fork.
systemic signs and symptoms of infection Other tests are available, such as the biothesi-
(such as fevers, chills, rigors, metabolic ometer and neurothesiometer, which are more
instability and confusion)? complex handheld devices for assessing the
Q Is there any malodour? perception of vibration.
Q Is there local pain?
Q Is there any exudate? What is the level of Do not test for neuropathy in areas of cal-
production (high, moderate, low, none), lus as this can mask feeling from any of the
colour and consistency of exudate, and is it neuropathy testing devices and may give a
purulent? false-positive result.
Q What is the status of the wound edge
(callus, maceration, erythema, oedema, Be aware that patients with small nerve fibre
undermining)? damage and intact sensory nerves may have
4
3 BEST PRACTICE
BEST PRACTICE GUIDELINES:
GUIDELINES WOUND
FOR SKIN MANAGEMENT
AND WOUND CARE ININ DIABETIC FOOTBULLOSA
EPIDERMOLYSIS ULCERS
ASSESSING DFUs
FIGURE 5: Procedure for carrying out the monofilament test (adapted from7)
The International Working Group on the Diabetic Foot (IWGDF) recommends the following procedure for carrying out the
monofilament test.
Q The sensory examination should be carried out in a quiet and relaxed setting
Q The patient should close their eyes so as not to see whether or where the examiner
applies the monofilament
Q The patient should sit supine with both feet level
Q First apply the monofilament on the patient’s hands or on the inside of the arm so
they know what to expect
Q Apply the monofilament perpendicular to the skin surface with sufficient force to
bend or buckle the monofilament
Q Ask the patient:
— Whether they feel the pressure applied (yes/no)
— Where they feel the pressure (left foot/right foot)
Q Apply the monofilament along the perimeter of (not on) the ulcer site
Q Do not allow the monofilament to slide across the skin or make repetitive contact at
the test site
Q The total duration of the approach (skin contact and removal of the monofilament)
should be around 2 seconds
Q Apply the monofilament to each site three times, including at least one additional
‘mock’ application in which no filament is applied
Q Encourage the patient during testing by giving positive feedback
— Protective sensation is present at each site if the patient correctly answers two
out of three applications
— Protective sensation is absent with two out of three incorrect answers
Using a monofilament to test for neuropathy
Note: The monofilament should not be used on more than 10 patients without a
recovery period of 24 hours
a painful neuropathy. They may describe there is any doubt regarding diagnosis of PAD, COMMON TERMS EXPLAINED
sharp, stabbing, burning, shooting or electric it is important to refer to a specialist for a full Critical limb ischaemia: this is
a chronic manifestation of PAD
shock type pain, which may be worse at night vascular assessment. where the arteries of the lower
and can disrupt sleep41. The absence of cold- extremities are severely blocked.
warm discrimination may help to identify Where available, Doppler ultrasound, ankle- This results in ischaemic pain
in the feet or toes even at rest.
patients with small nerve fibre damage. brachial pressure index (ABPI) and Doppler
Complications of poor circulation
waveform may be used as adjuncts to include skin ulcers or gangrene.
the clinical findings when carried out by a If left untreated it will result in
TESTING FOR VASCULAR STATUS competent practitioner. Toe pressures, and amputation of the affected limb.
Palpation of peripheral pulses should be a in some instances, transcutaneous oxygen Acute limb ischaemia: this
routine component of the physical examina- measurement (where equipment is avail- occurs when there is a sudden
tion and include assessment of the femoral, able), may be useful for measuring local lack of blood flow to a limb and
popliteal and pedal (dorsalis pedis and tissue perfusion. is due to either an embolism or
thrombosis. Without surgical
posterior tibial) pulses. Assessment of pulses revascularisation, complete
is a learned skill and has a high degree of An ischaemic foot may appear pink and rela- acute ischaemia leads to exten-
inter-observer variability, with high false- tively warm even with impaired perfusion due sive tissue necrosis within six
positive and false-negative rates. The dorsalis to arteriovenous shunting. Delayed discolour- hours.
pedis pulse is reported to be absent in 8.1% ation (rubor) or venous refilling greater than
of healthy individuals, and the posterior tibial five seconds on dependency may indicate
pulse is absent in 2.0%. Nevertheless, the poor arterial perfusion43.
absence of both pedal pulses, when assessed
by an experienced clinician, strongly suggests Other signs suggestive of ischaemia include40:
the presence of pedal vascular disease42. If Q Claudication: pain in the leg muscles and
BEST PRACTICE GUIDELINES: WOUND MANAGEMENT IN DIABETIC FOOT ULCERS 5
ASSESSING DFUs
usually exercise-induced (although this is Q A positive probe-to-bone test
often absent in people with diabetes) Q DFU present for more than 30 days
Q A temperature difference between the feet. Q A history of recurrent DFUs
Q A traumatic foot wound
If you suspect severe ischaemia in a patient Q The presence of PAD in the affected limb
with a DFU you should refer as quickly as Q A previous lower extremity amputation
possible to a MDFT with access to a vascu- Q Loss of protective sensation
lar surgeon. If the patient has critical limb Q The presence of renal insufficiency
ischaemia this should be done urgently. A Q A history of walking barefoot.
patient with acute limb ischaemia charac-
terised by the six ‘Ps’ (pulselessness, pain, The frequent occurrence of arterial insuf-
pallor [mottled colouration], perishing cold, ficiency, an immunocompromised state and
paraesthesia and paralysis) poses a clinical loss of pain sensation means that up to half of
emergency and may be at great risk if not patients may not present with the classic signs
managed in a timely and effective way44. of infection and inflammation, such as redness,
heat and swelling47. Practitioners should there-
fore seek the presence of more subtle 'second-
IDENTIFYING INFECTION ary' signs suggestive of infection, including
Recognising infection in patients with DFUs friable granulation tissue, wound undermining,
can be challenging, but it is one of the most malodour or wound exudate47.
important steps in the assessment. It is at this
crucial early stage that practitioners have the Clinical diagnosis and cultures
potential to curb what is often progression A diagnosis of diabetic foot infection must be
from simple (mild) infection to a more severe made using clinical signs and symptoms, not
problem, with necrosis, gangrene and often just microbiological results. All open wounds
amputation45. Around 56% of DFUs become will be colonised with organisms, making
infected and overall about 20% of patients the positive culture difficult to interpret. The
with an infected foot wound will undergo a IWGDF and the Infectious Disease Society
lower extremity amputation30. of America (IDSA) have developed validated
clinical criteria for recognising and classifying
Risk factors for infection diabetic foot infection46 (Table 2).
Practitioners should be aware of the factors that
increase the likelihood of infection46: If infection is suspected, practitioners should
take appropriate cultures, preferably soft tissue
TABLE 2: Classification and severity of diabetic foot infections (adapted from46) (or bone when osteomyelitis is suspected),
or aspirations of purulent secretions46. Some
Clinical criteria Grade/severity advocate using a deep swabbing technique
No clinical signs of infection Grade 1/uninfected after the wound has been cleansed and debri-
Superficial tissue lesion with at least two of the following Grade 2/mild ded17,38. Superficial swabbing has been shown
signs: to be inaccurate as swab cultures are likely to
— Local warmth grow surface contaminants and often miss the
— Erythema >0.5–2cm around the ulcer
true pathogen(s) causing the infection38,46,48.
— Local tenderness/pain
— Local swelling/induration
— Purulent discharge Most acute infections in patients who have
Other causes of inflammation of the skin must be excluded not recently been treated with antimicrobi-
Erythema >2cm and one of the findings above or: Grade 3/moderate als are caused by aerobic Gram-positive
— Infection involving structures beneath the skin/ cocci, especially staphylococci. More chronic
subcutaneous tissues (eg deep abscess, lymphangitis, infections, or those occurring after antibiotic
osteomyelitis, septic arthritis or fascitis) treatment are often polymicrobial, with aero-
— No systemic inflammatory response (see Grade 4)
bic Gram-negative bacilli joining the aerobic
Presence of systemic signs with at least two of the following: Grade 4/severe Gram-positive cocci. Obligate anaerobes may
— Temperature >39°C or 90bpm
— Respiratory rate >20/min co-pathogens with aerobes, in ischaemic or
— PaCO2
ASSESSING DFUs
BOX 1: Signs of spreading
Cultures should not be taken from clinically The National Institute for Health and Care
infection (adapted from49) non-infected wounds as all ulcers will be con- Excellence (NICE) in the UK and IDSA
taminated; microbiological sampling cannot recommend that if initial x-rays do not confirm
Q Spreading, intense discriminate colonisation from infection. the presence of osteomyelitis and suspicion
erythema
remains high, the next advanced imaging test
Q Increasing induration
Extensive inflammation, crepitus, bullae, necro- to consider is magnetic resonance imaging
Q Lymphangitis
sis or gangrene are signs suggestive of severe (MRI)1,46. If MRI is contraindicated or unavail-
Q Regional lymphadenitis
foot infections50. Refer patients immediately able, white blood cell scanning combined with
Q Hypotension, tachy-
to an MDFT if you suspect a deep or limb- a radionuclide bone scan may be performed
pnoea, tachycardia
threatening infection. Where there is no MDFT, instead46. The most definitive way to diagnose
Q Rigors
the referral should be to the most appropriate osteomyelitis is by the combined findings of
practitioner, notably the person(s) championing culture and histology from a bone specimen.
the cause of the diabetic foot, for example an Bone may be obtained during deep debride-
experienced foot surgeon. ment or by biopsy46.
Refer patients urgently to a member of the
specialist foot care team for urgent surgical INSPECTING FEET FOR
treatment and prompt revascularisation if there DEFORMITIES
is acute spreading infection (Box 1), critical limb Excessive or abnormal plantar pressure, result-
ischaemia, wet gangrene or an unexplained hot, ing from limited joint mobility, often combined
red, swollen foot with or without the presence with foot deformities, is a common underlying
of pain37,51. These clinical signs and symptoms cause of DFUs in individuals with neuropathy6.
are potentially limb- and even life-threatening. These patients may also develop atypical
walking patterns (Figure 7). The resulting
Where necrosis occurs on the distal part of the altered biomechanical loading of the foot can
limb due to ischaemia and in the absence of result in callus, which increases the abnormal
infection (dry gangrene), mummification of the pressure and can cause subcutaneous haem-
toes and auto-amputation may occur. In most of orrhage7. Because there is commonly loss of
FIGURE 6: Necrotic toe which
these situations, surgery is not recommended. sensation, the patient continues to walk on the
has been allowed to auto- However, if the necrosis is more superficial then foot, increasing the risk of further problems.
amputate the toe can be removed with a scalpel (Figure 6).
Typical presentations resulting in high plantar
Assessing bone involvement pressure areas in patients with motor neu-
Osteomyelitis may frequently be present in ropathy are7:
RISK OF AMPUTATION
patients with moderate to severe diabetic foot Q A high-arch foot
Armstrong et al52 found that infection. If any underlying osteomyelitis is not Q Clawed lesser toes
patients were 11 times more identified and treated appropriately, the wound Q Visible muscle wasting in the plantar arch
likely to receive a midfoot is unlikely to heal17. and on the dorsum between the metatarsal
or higher level amputa- shafts (a ‘hollowed-out’ appearance)
tion if their wound had a
Osteomyelitis can be difficult to diagnose in Q Gait changes, such as the foot ‘slapping’ on
positive probe-to-bone test.
Furthermore, patients with
the early stages. Wounds that are chronic, the ground
infection and ischaemia large, deep or overlie a bony prominence are Q Hallux valgus, hallux rigidus and fatty pad
were nearly 90 times more at high risk for underlying bone infection, while depletion.
likely to receive a midfoot the presence of a 'sausage toe' or visible bone
or higher amputation than is suggestive of osteomyelitis. A simple clinical In people with diabetes, even minor trauma
patients with less advanced test for bone infection is detecting bone by its can precipitate a chronic ulcer7. This might
DFUs. There may also be a hard, gritty feel when gently inserting a sterile be caused by wearing poorly fitting footwear
possible correlation between blunt metal probe into the ulcer54,55. This can or walking barefoot, or from an acute injury.
location of osteomyelitis help to diagnose bone infection (when the In some cultures the frequent adoption of the
and major amputation, with likelihood is high) or exclude (when the likeli- prayer position and/or sitting cross-legged will
a higher rate of transtibial
hood is low)46. cause ulcerations on the lateral malleoli, and
amputation reported when
osteomyelitis involved the
to a lesser extent the dorsum of the foot, in
heel instead of the mid- Plain x-rays can help to confirm the diagnosis, the mid-tarsal area. The dorsal, plantar and
foot or forefoot in diabetic but they have a relatively low sensitivity (early in posterior surfaces of both feet and between
patients53. the infection) and specificity (late in the course the toes should be checked thoroughly for
of infection) for osteomyelitis46,56. breaks in the skin or newly established DFUs.
BEST PRACTICE GUIDELINES: WOUND MANAGEMENT IN DIABETIC FOOT ULCERS 7
ASSESSING DFUs
FIGURE 7: Areas at risk for DFU (adapted
Corrective foot surgery to offload pressure
from7) areas may be considered where structural
deformities cannot be accommodated by
therapeutic footwear.
CLASSIFICATION OF DFUs
Classification systems grade ulcers according
to the presence and extent of various physical
characteristics, such as size, depth, appearance
and location. They can help in the planning
and monitoring of treatment and in predicting
outcome17,58, and also for research and audit.
Classification systems should be used con-
sistently across the healthcare team and be
recorded appropriately in the patient’s records.
However, it is the assessment of the wound
that informs management.
Table 3 summarises the key features of the
systems most commonly used for DFUs.
FIGURE 8: Charcot foot. Charcot joint is a form of neuroarthropathy
Top — Charcot foot with plantar that occurs most often in the foot and in people
ulcer. Middle — Charcot foot with diabetes57. Nerve damage from diabetes
with sepsis. Bottom — Chronic causes decreased sensation, muscle atrophy
Charcot foot
and subsequent joint instability, which is made
worse by walking on an insensitive joint. In the
acute stage there is inflammation and bone
reabsorption, which weakens the bone. In later
stages, the arch falls and the foot may develop
a ‘rocker bottom’ appearance (Figure 8). Early
treatment, particularly offloading pressure,
can help stop bone destruction and promote
healing.
TABLE 3: Key features of common wound classification systems for DFUs
Classification Key points Pros/cons References
system
Wagner Assesses ulcer depth along with presence Well established58 Wagner 198159
of gangrene and loss of perfusion using six Does not fully address infection and ischaemia
grades (0-5)
University of Assesses ulcer depth, presence of infection Well established58 Lavery et al 199660
Texas and presence of signs of lower-extremity Describes the presence of infection and ischaemia Armstrong et al
(Armstrong) ischaemia using a matrix of four grades better than Wagner and may help in predicting the 199852
combined with four stages outcome of the DFU
PEDIS Assesses Perfusion, Extent (size), Depth Developed by IWGDF Lipsky et al 201246
(tissue loss), Infection and Sensation (neu- User-friendly (clear definitions, few categories) for
ropathy) using four grades (1-4) practitioners with a lower level of experience with
diabetic foot management
SINBAD Assesses Site, Ischaemia, Neuropathy, Bac- Simplified version of the S(AD)SAD classification Ince et al 200863
terial infection and Depth system61
Uses a scoring system to help predict Includes ulcer site as data suggests this might be
outcomes and enable comparisons between an important determinant of outcome62
different settings and countries
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3 BEST PRACTICE
BEST PRACTICE GUIDELINES:
GUIDELINES WOUND
FOR SKIN MANAGEMENT
AND WOUND CARE ININ DIABETIC FOOTBULLOSA
EPIDERMOLYSIS ULCERSDFU WOUND
MANAGEMENT
DFU wound management
Practitioners must strive to prevent DFUs developing elsewhere on the foot or on
the contralateral limb and to achieve limb preservation64
The principle aim of DFU management is practitioners should check other footwear
wound closure17. More specifically, the inten- worn at home and at work (eg slippers
tion should be to treat the DFU at an early and work boots).
stage to allow prompt healing65.
The essential components of management ENSURING ADEQUATE BLOOD
are: SUPPLY
Q Treating underlying disease processes A patient with acute limb ischaemia (see
Q Ensuring adequate blood supply page 5) is a clinical emergency and may be
Q Local wound care, including infection at great risk if not managed in a timely and
control effective way.
Q Pressure offloading.
It is important to appreciate that, aside from
Effective foot care should be a partnership critical limb ischaemia, decreased perfusion
between patients, carers and healthcare or impaired circulation may be an indica-
professionals1,66. This means providing tor for revascularisation in order to achieve
appropriate information to enable patients and maintain healing and to avoid or delay a
and carers to participate in decision making future amputation34.
and understand the rationale behind some
of the clinical decisions as well as supporting
good self-care. OPTIMISING LOCAL WOUND CARE
The European Wound Management Associa-
tion (EWMA) states that the emphasis in
TREATING THE UNDERLYING wound care for DFUs should be on radical and
DISEASE PROCESSES repeated debridement, frequent inspection
Practitioners should identify the underlying and bacterial control and careful moisture
cause of the DFU during the patient as- balance to prevent maceration49. Its posi-
sessment and, where possible, correct or tion document on wound bed preparation
eliminate it. suggests the following TIME framework for
Q Treating any severe ischaemia is critical managing DFUs (see also Box 2):
to wound healing, regardless of other Q Tissue debridement
interventions17. It is recommended that Q Inflammation and infection control
all patients with critical limb ischaemia, Q Moisture balance (optimal dressing BOX 2: Wound bed prepara-
including rest pain, ulceration and tissue selection) tion and TIME framework
loss, should be referred for consideration Q Epithelial edge advancement. (adapted from49)
of arterial reconstruction31. QWound bed preparation
Q Achieving optimal diabetic control. This Tissue debridement is not a static concept,
should involve tight glycaemic control and There are many methods of debridement but a dynamic and rapidly
managing risk factors such as high blood used in the management of DFUs including changing one
pressure, hyperlipidaemia and smoking67. surgical/sharp, larval, autolytic and, more QThere are four
Nutritional deficiencies should also be recently, hydrosurgery and ultrasonic68,69. components to wound
managed7. bed preparation, which
Q Addressing the physical cause of the Debridement may be a one-off procedure or address the different
pathophysiological
trauma. As well as examining the foot, it may need to be ongoing for maintenance
abnormalities underlying
practitioners should examine the patient's of the wound bed69. The requirement for chronic wounds
footwear for proper fit, wear and tear and further debridement should be determined Q The TIME framework can
the presence of any foreign bodies (such at each dressing change. If the wound is not be used to apply wound
as small stones, glass fragments, draw- progressing, practitioners should review bed preparation to
ing pins, pet hairs) that may traumatise the current treatment plan and look for an practice
the foot1. When possible and appropriate, underlying cause of delayed healing (such
BEST PRACTICE GUIDELINES: WOUND MANAGEMENT IN DIABETIC FOOT ULCERS 9DFU WOUND
MANAGEMENT
as ischaemia, infection or inflammation) an information leaflet showed that many
and consider patient concordance with patients did not understand the procedure
recommended treatment regimens (such as despite having undergone debridement on
not wearing offloading devices or not taking several previous occasions68.
antidiabetic medication)69.
Vascular status must always be determined
Sharp debridement prior to sharp debridement. Patients need-
No one debridement method has been ing revascularisation should not undergo
shown to be more effective in achieving extensive sharp debridement because of
complete ulcer healing70. However, in the risk of trauma to vascularly compro-
practice, the gold standard technique for mised tissues. However, the ‘toothpick’
tissue management in DFUs is regular, local, approach may be suitable for wounds
sharp debridement using a scalpel, scissors requiring removal of loose callus45. Seek
and/or forceps1,7,27,37,71,. The benefits of advice from a specialist if in doubt about a
debridement include72: patient’s suitability.
Q Removes necrotic/sloughy tissue and
callus Other debridement methods
Q Reduces pressure While sharp debridement is the gold
Q Allows full inspection of the underlying standard technique, other methods may be
tissues appropriate in certain situations:
Q Helps drainage of secretions or pus Q As an interim measure (eg by practition-
Q Helps optimise the effectiveness of topi- ers without the necessary skill sets to
FIGURE 9: Neuropathic ulcer cal preparations carry out sharp debridement; methods
pre- (top) and post- (bottom) Q Stimulates healing. include the use of a monofilament pad or
debridement larval therapy)
Sharp debridement should be carried out Q For patients for whom sharp debride-
by experienced practitioners (eg a spe- ment is contraindicated or unacceptably
cialist podiatrist or nurse) with specialist painful
training22,69. Q When the clinical decision is that an-
other debridement technique may be
Practitioners must be able to distinguish more beneficial for the patient
tissue types and understand anatomy to Q For patients who have expressed another
avoid damage to blood vessels, nerves and preference.
tendons69. They should also demonstrate
high-level clinical decision-making skills in Larval therapy The larvae of the greenbottle
assessing a level of debridement that is safe fly can achieve relatively rapid, atraumatic
and effective. The procedure may be carried removal of moist, slimy slough, and can
out in the clinic or at the bedside. ingest pathogenic organisms present in the
wound69. The decision to use larval debri-
Ulcers may be obscured by the presence dement must be taken by an appropriate
of callus. After discussing the plan and specialist practitioner, but the technique
expected outcome with the patient in itself may then be carried out by general-
FIGURE 10: Neuroischaemic ulcer advance, debridement should remove all ist or specialist practitioners with minimal
pre- (top) and post- (bottom) devitalised tissue, callus and foreign bodies training69.
debridement down to the level of viable bleeding tis-
sue38,69 (Figures 9 and 10). It is important Larval therapy has been shown to be safe
to debride the wound margins as well as and effective in the treatment of DFUs75.
the wound base to prevent the ‘edge effect’, However, it is not recommended as the sole
whereby epithelium fails to migrate across a method of debridement for neuropathic
firm, level granulation base73,74. DFUs as the larvae cannot remove callus76.
Sharp debridement is an invasive procedure A recent review of debridement methods
and can be quite radical. Practitioners must found some evidence to suggest that larval
explain fully to patients the risks and bene- therapy may improve outcomes when
fits of debridement in order to gain their compared to autolytic debridement with a
informed consent. One small study piloting hydrogel72.
10
3 BEST PRACTICE
BEST PRACTICE GUIDELINES:
GUIDELINES WOUND
FOR SKIN MANAGEMENT
AND WOUND CARE ININ DIABETIC FOOTBULLOSA
EPIDERMOLYSIS ULCERSDFU WOUND
MANAGEMENT
Hydrosurgical debridement This is an alterna- culture if the wound does not respond to
tive method of wound debridement, which treatment.
forces water or saline into a nozzle to create
a high-energy cutting beam. This enables Role of topical antimicrobials The increas-
precise visualisation and removal of devital- ing prevalence of antimicrobial resistance
ised tissue in the wound bed77. (eg meticillin-resistant S. aureus [MRSA]) or
other complications (eg Clostridium difficile
Autolytic debridement This is a natural infection) has led to a rise in the use of
process that uses a moist wound dressing topical antimicrobial treatments for
to soften and remove devitalised tissue. increased wound bioburden79(Box 3).
Care must be taken not to use a moisture- Antimicrobial agents that are used topically
donating dressing as this can predispose to have the advantage of not driving resistance.
maceration. In addition, the application of Such agents provide high local concentra-
moisture-retentive dressings in the pres- tions, but do not penetrate intact skin or into
ence of ischaemia and/or dry gangrene is not deeper soft tissue80.
recommended38,76.
Topical antimicrobials may be beneficial in
Not debriding a wound, not referring a certain situations79:
patient to specialist staff for debridement, or Q Where there are concerns regarding
choosing the wrong method of debridement, reduced antibiotic tissue penetration —
can cause rapid deterioration with poten- for example, where the patient has a poor
tially devastating consequences. vascular supply
Q In non-healing wounds where the classic
Inflammation and infection control signs and symptoms of infection are ab-
The high morbidity and mortality associat- sent, but where there is a clinical suspicion
ed with infection in DFUs means that early of increased bacterial bioburden.
and aggressive treatment — in the presence
of even subtle signs of infection — is more In these situations topical antimicrobials
appropriate than for wounds of other (either alone or as an adjunctive therapy
BOX 3: Common topical
aetiologies (with the exception of immuno- to systemic therapy) have the potential to
antimicrobial agents that
compromised patients) (Table 4, page reduce bacterial load and may protect the may be considered for use
12)38. In one study, nearly half of patients wound from further contamination79. In addi- as an adjunctive therapy for
admitted to a specialised foot clinic in tion, treatment at an early stage may prevent diabetic foot infections*
France with a diabetic foot infection went spread of infection to deeper tissues82.
Q Silver — dressings con-
on to have a lower-limb amputation78.
taining silver (elemental,
An initial two-week period with regular inorganic compound or
Both the IDSA46 and the International review is recommended for the use of topi- organic complex) or silver
Diabetes Federation (IDF) recommend cal antimicrobials in wounds that are mildly sulphadiazine cream/
classifying infected DFUs by severity and infected or heavily colonised. A recent dressings
using this to direct appropriate antibiotic consensus offers recommendations on ap- Q Polyhexamethylene
therapy27. Clinically uninfected wounds propriate use of silver dressings83. If after biguanide (PHMB) —
should not be treated with systemic antibi- two weeks: solution, gel or impreg-
otic therapy. However, virtually all infected Q There is improvement in the wound, but nated dressings
wounds require antibiotic therapy46. continuing signs of infection, it may be Q Iodine — povidone iodine
(impregnated dressing) or
clinically justifiable to continue the chosen
cadexomer iodine (oint-
Superficial DFUs with skin infection (mild treatment with further regular reviews
ment, beads or impreg-
infection) Q The wound has improved and the signs
nated dressings)
For mild infections in patients who have not and symptoms of wound infection are no Q Medical-grade honey —
recently received antibiotic treatment7,46: longer present, the antimicrobial should gel, ointment or impreg-
Q Start empiric oral antibiotic therapy tar- be discontinued and a non-antimicrobial nated dressings
geted at Staphylococcus aureus and dressing applied to cover the open wound
ß-haemolytic Streptococcus Q There is no improvement, consider dis- *NB: Topical antimicrobial
Q Change to an alternate antibiotic if the continuing the antimicrobial treatment agents should not be used
culture results indicate a more appropriate and re-culturing the wound and reas- alone in those with clinical
antibiotic sessing the need for surgical therapy or signs of infection
Q Obtain another optimum specimen for revascularisation.
BEST PRACTICE GUIDELINES: WOUND MANAGEMENT IN DIABETIC FOOT ULCERS 11DFU WOUND
MANAGEMENT
and switch to the oral route when the
TABLE 4: General principles of bacterial management (adapted from49)
patient is systemically well and culture
Q At initial presentation of infection it is important to assess its severity, take appropri- results are available46
ate cultures and consider need for surgical procedures Q Continue antibiotic therapy until the infec-
Q Optimal specimens for culture should be taken after initial cleansing and debride-
tion resolves, but not through to complete
ment of necrotic material
Q Patients with severe infection require empiric broad-spectrum antibiotic therapy,
healing46. In most cases 1–3 weeks of
pending culture results. Those with mild (and many with moderate) infection can be therapy is sufficient for soft tissue infections
treated with a more focused and narrow-spectrum antibiotic Q Consider giving empiric therapy directed
QPatients with diabetes have immunological disturbances; therefore even bacteria re- against MRSA46:
garded as skin commensals can cause severe tissue damage and should be regarded — in patients with a prior history of MRSA
as pathogens when isolated from correctly obtained tissue specimens infection
Q Gram-negative bacteria, especially when isolated from an ulcer swab, are often — when the local prevalence of MRSA
colonising organisms that do not require targeted therapy unless the person is at risk colonisation or infection is high
for infection with those organisms — if the infection is clinically severe.
Q Blood cultures should be sent if fever and systemic toxicity are present
Q Even with appropriate treatment, the wound should be inspected regularly for early
Note that the optimal duration of antibi-
signs of infection or spreading infection
Q Clinical microbiologists/infectious diseases specialists have a crucial role; laboratory
otic treatment is not clearly defined and
results should be used in combination with the clinical presentation and history to will depend on the severity of infection and
guide antibiotic selection response to treatment84.
Q Timely surgical intervention is crucial for deep abscesses, necrotic tissue and for
some bone infections Infection in a neuroischaemic foot is often
more serious than in a neuropathic foot
(which has a good blood supply), and this
should influence antibiotic policy49. Antibiot-
If there are clinical signs of infection at ic therapy should not be given as a preventive
dressing change, systemic antibiotic therapy measure in the absence of signs of infection
should be started. Topical antimicrobials (see Box 4). This is likely to cause infection
are not indicated as the only anti-infective with more resistant pathogens.
treatment for moderate or severe infection
of deep tissue or bone38,46. Obtain an urgent consultation with experts
(eg foot surgeon) for patients who have
Patients may also require debridement to a rapidly deteriorating wound that is not
remove infected material. In addition, in- responding to antibiotic therapy. Infections
fected wounds should be cleansed at each accompanied by a deep abscess, extensive
dressing change with saline or an appropri- bone or joint involvement, crepitus, sub-
ate antiseptic wound cleansing agent. stantial necrosis or gangrene, or necrotising
fasciitis, need prompt surgical intervention
Deep tissue infection (moderate to severe along with appropriate antibiotic therapy, to
BOX 4: Guidelines for the use
infection) reduce the risk of major amputation51,85.
of systemic antibiotic therapy
For treating deep tissue infection (cellulitis,
Antibiotics should be pre- lymphangitis, septic arthritis, fasciitis): Biofilms and chronic persistent infection
scribed using local protocols Q Start patients quickly on broad-spectrum Polymicrobial infections predominate in
and, in complex cases, the
antibiotics, commensurate with the clini- severe diabetic foot infections and this
advice of a clinical microbiol-
ogist or infectious diseases
cal history and according to local proto- diversity of bacterial populations in chronic
specialist. Avoid prescribing cols where possible37 wounds, such as DFUs, may be an important
antibiotics for uninfected Q Take deep tissue specimens or aspirates contributor to chronicity86,87. Biofilms are
ulcerations. IDSA46 offers of purulent secretions for cultures at the complex polymicrobial communities that
evidence-based suggestions, start of treatment to identify specific develop on the surface of chronic wounds,
which can be adapted to local organisms in the wound, but do not wait which may lack the overt clinical signs of infec-
needs. for results before initiating therapy1,37 tion34. They are not visible to the naked eye and
http://www.idsociety.org/ Q Change to an alternate antibiotic if: cannot be detected by routine cultures88.
uploadedFiles/IDSA/Guide- — indicated by microbiology results46
lines-Patient_Care/PDF_Li- — the signs of inflammation are not The microbes produce an extra-polymeric
brary/2012%20Diabetic%20
improving84 substance that contributes to the structure of
Foot%20Infections%20
Q Administer antibiotics parenterally for the biofilm. This matrix acts as a thick, slimy
Guideline.pdf
all severe and some moderate infections, protective barrier, making it very difficult for
12
3 BEST PRACTICE
BEST PRACTICE GUIDELINES:
GUIDELINES WOUND
FOR SKIN MANAGEMENT
AND WOUND CARE ININ DIABETIC FOOTBULLOSA
EPIDERMOLYSIS ULCERSDFU WOUND
MANAGEMENT
antimicrobial agents to penetrate it89. The should use wound dressings that best match
impact of biofilms may depend on which spe- the clinical appearance and site of the wound,
cies are present rather than the bioburden34. as well as patient preferences1. Dressing
choice must begin with a thorough patient
Treatment should aim to88: and wound assessment. Factors to consider
Q Disrupt the biofilm burden through regular, include:
repeated debridement and vigorous wound Q Location of the wound
cleansing Q Extent (size/depth) of the wound FIGURE 11: Dry necrotic wound.
Q Prevent reformation and attachment of the Q Amount and type of exudate Select dressing to rehydrate
biofilm by using antimicrobial dressings. Q The predominant tissue type on the wound and soften the eschar
surface
Appropriate wound bed preparation remains Q Condition of the periwound skin
the gold standard for biofilm removal90. Q Compatibility with other therapies (eg
contact casts)
Moisture balance: optimal dressing Q Wound bioburden and risk of infection
selection Q Avoidance of pain and trauma at dressing
Most dressings are designed to create a moist changes
wound environment and support progres- Q Quality of life and patient wellbeing.
sion towards wound healing. They are not a
substitute for sharp debridement, managing The status of the diabetic foot can change FIGURE 12: Sloughy wound bed
with areas of necrosis. Select
systemic infection, offloading devices and very quickly, especially if infection has not dressing to control moisture
diabetic control. been appropriately addressed. The need for and promote debridement of
regular inspection and assessment means devitalised tissue
Moist wound healing has the potential to that dressings designed to be left in situ for
address multiple factors that affect wound more than five days are not usually appropri-
healing. It involves maintaining a balanced ate for DFU management.
wound environment that is not too moist or
too dry. Dressings that can help to manage Practitioners should also consider the follow-
wound exudate optimally and promote a ing questions93.
balanced environment are key to improving
outcomes91. However, a dressing that may be Does the dressing:
ideal for wounds of other aetiologies may be Q Stay intact and remain in place throughout
FIGURE 13: Infected wound
entirely inappropriate for certain DFUs. The wear time?
with evidence of swelling and
dressing selected may have a considerable Q Prevent leakage between dressing exudate. Start empiric antibi-
effect on outcome and, due to the varying changes? otic therapy and take cultures.
complexities of DFUs, there is no single Q Cause maceration/allergy or sensitivity? Consider selecting an anti-
dressing to suit all scenarios. Q Reduce pain? microbial dressing to reduce
wound bioburden and manage
Q Reduce odour?
exudate
Many practitioners are confused by the great Q Retain fluid?
range of dressings available. Impressive Q Trap exudate components?
claims are rarely supported by scientific
studies and there is often a lack of high- Is the dressing:
quality evidence to support decision making. Q Comfortable, conformable, flexible and of a
One inherent problem is whether the bulk/weight that can be accommodated in
characteristics of each wound randomised to an offloading device/footwear?
a specific dressing in a trial correspond to the Q Suitable for leaving in place for the required
characteristics that the dressing was designed duration?
to manage92. Many dressings are designed Q Easy to remove (does not traumatise the
FIGURE 14: A newly epitheli-
alising DFU. It is important to
for non-foot areas of the body and may be surrounding skin or wound bed)? protect new tissue growth
difficult to apply between or over the toes or Q Easy to apply?
plantar surface. In addition, most practitioners Q Cost effective?
have historically had little specific, practical Q Likely to cause iatrogenic lesions?
guidance on selecting dressings.
Tables 5 and 6 (pages 14-15) provide advice
In the absence of strong evidence of clinical on type of dressing and how to select accord-
or cost effectiveness, healthcare professionals ing to tissue type (see also Figures 11–14).
BEST PRACTICE GUIDELINES: WOUND MANAGEMENT IN DIABETIC FOOT ULCERS 13DFU WOUND
MANAGEMENT
TABLE 5: Types of wound dressings available
Type Actions Indications/use Precautions/contraindications
Alginates/CMC* Absorb fluid Moderate to high exuding wounds Do not use on dry/necrotic wounds
Promote autolytic Special cavity presentations in the form of rope Use with caution on friable tissue (may
debridement or ribbon cause bleeding)
Moisture control Combined presentation with silver for Do not pack cavity wounds tightly
Conformability to wound bed antimicrobial activity
Foams Absorb fluid Moderate to high exuding wounds Do not use on dry/necrotic wounds or
Moisture control Special cavity presentations in the form of those with minimal exudate
Conformability to wound bed strips or ribbon
Low adherent versions available for patients
with fragile skin
Combined presentation with silver or PHMB for
antimicrobial activity
Honey Rehydrate wound bed Sloughy, low to moderate exuding wounds May cause 'drawing' pain (osmotic
Promote autolytic Critically colonised wounds or clinical signs of effect)
debridement infection Known sensitivity
Antimicrobial action
Hydrocolloids Absorb fluid Clean, low to moderate exuding wounds Do not use on dry/necrotic wounds or
Promote autolytic Combined presentation with silver for high exuding wounds
debridement antimicrobial activity May encourage overgranulation
May cause maceration
Hydrogels Rehydrate wound bed Dry/low to moderate exuding wounds Do not use on highly exuding wounds
Moisture control Combined presentation with silver for or where anaerobic infection is suspected
Promote autolytic debridement antimicrobial activity May cause maceration
Cooling
Iodine Antimicrobial action Critically colonised wounds or clinical signs of Do not use on dry necrotic
infection tissue
Low to high exuding wounds Known sensitivity to iodine
Short-term use recommended (risk of
systemic absorption)
Low-adherent Protect new tissue growth Low to high exuding wounds May dry out if left in place for too long
wound contact Atraumatic to periwound skin Use as contact layer on superficial low exuding Known sensitivity to silicone
layer (silicone) Conformable to body contours wounds
PHMB Antimicrobial action Low to high exuding wounds Do not use on dry/necrotic wounds
Critically colonised wounds or clinical signs of Known sensitivity
infection
May require secondary dressing
Odour control Odour absorption Malodorous wounds (due to excess exudate) Do not use on dry wounds
(eg activated May require antimicrobial if due to increased
charcoal) bioburden
Protease Active or passive control of Clean wounds that are not progressing despite Do not use on dry wounds or those with
modulating wound protease levels correction of underlying causes, exclusion of leathery eschar
infection and optimal wound care
Silver Antimicrobial action Critically colonised wounds or clinical signs of Some may cause discolouration
infection Known sensitivity
Low to high exuding wounds Discontinue after 2 weeks if no
Combined presentation with foam and alginates/ improvement and re-evaluate
CMC for increased absorbency. Also in paste form
Polyurethane film Moisture control Primary dressing over superficial low exuding Do not use on patients with fragile/
Breathable bacterial barrier wounds compromised periwound skin
Transparent (allow Secondary dressing over alginate or hydrogel Do not use on moderate to high exuding
visualisation of wound) for rehydration of wound bed wounds
Other more advanced dressings (eg collagen and bioengineered tissue products) may be considered for wounds that are hard to heal94.
*Wound dressings may contain alginates or CMC only; alginates may also be combined with CMC.
14
3 BEST PRACTICE
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GUIDELINES WOUND
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