Diabetic foot ulcers: patients with non-healing wounds

If your patient has a non-healing wound on their foot, it is very likely to be caused by peripheral arterial disease, which is a known complication of diabetes. 

Diabetes can also cause loss of sensation (neuropathy) so patients may not notice when they injure your feet.

Less commonly, wounds on the feet can also be caused by venous disease or rarer causes of ulceration.

Assessment of a patient with possible foot ulcers

Most people with a non-healing foot wound need to be urgently referred to a podiatrist who will act as the gatekeeper to the wider multidisciplinary team.

You should carry out an initial assessment that includes an examination of both feet to look for evidence of:

• Neuropathy – use a 10g monofilament as part of a foot sensory examination
• Limb ischaemia (see the NICE guideline on lower limb peripheral arterial disease)
• Ulceration
• Callus
• Infection and / or inflammation
• Deformity
• Gangrene
• Charcot arthropathy
• Medication such as Amlodopine, Hydroxyurea, Nicorandil
• Schleroderma
• Venous disease and Atrophie Blanche in particular

If you need to carry out further assessment, you should include:

• Doppler assessment of ankle brachial pressure index
• X-rays or other scans to determine any deep tissue (e.g. bone) involvement
• Microbial culture
• Gait analysis
• Pressure mapping

What do foot ulcers look like?

Treatment of foot ulcers

There are six main components to the treatment of any foot-related wound. Treatment should address all six to optimise the chance of wound healing:

1. Management of the underlying condition or cause e.g. control of diabetes, optimising blood flow, management of the oedema etc.
2. Debridement of the wound. This is the removal of material from within and around the wound such as slough, biofilm and callus which can impede wound healing.
3. Good management of wound symptoms through appropriate dressing selection or adjunctive therapies.
4. Managing bioburden and keeping the wound free from infection.
5. Offloading or deflecting pressure away from the wound. This may involve shoe adaptations, inserts and often casted devices are required.
6. Compression therapy where peripheral arterial disease has been excluded. This may include the need for toe garments

Diabetic foot wounds have a particularly high recurrence rate of around 40% at one year and up to 75% by year five. It is therefore more helpful to think of a diabetic foot ulcer as being in ‘remission’ rather than ‘healed’

You should place a patient who has suffered a chronic foot wound into a protective foot care programme. It’s also important that they have regular podiatry visits, footwear and orthotic reviews and that the risk factors such as diabetes are kept under control.

Patients who have diabetes or peripheral arterial disease and a foot wound are at increased risk of cardiovascular incidents such as stroke and heart attack and should have their cardio-vascular risks modified.

Clinical guidelines for foot ulcers

These guidelines give you a useful overview and more detailed information on peripheral arterial disease and diabetic feet:

• NICE Peripheral Arterial Disease Diagnosis and management (Web page)
• NICE Guidelines for the prevention and management of the Diabetic foot (Web page)
• Scottish intercollegiate guidelines on diabetes (PDF download)
• Best practice guidelines. Wound management of diabetic foot ulcers (PDF download)
• Local management of diabetic foot ulcers (PDF download)

Research surrounding foot ulcers

There is research evidence to support practice including a number of systematic reviews about diabetic foot ulceration and peripheral arterial disease.

The Cochrane Library publishes systematic reviews about the effectiveness of many treatments for diabetic foot ulcers and summarises this in a useful ‘Evidently Cochrane’ paper (Web page)

Publications & Evidence for foot ulcers

We’ve carefully curated resources to help in your everyday work.

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Patient information for foot ulcers

The patients, family and friends section has lots of useful, accessible information for your patients.

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Download a patient information leaflet as a pdf to print