Diabetes-related wounds can persist for long periods, heal slowly, and sometimes recur; presenting physicians and medical care systems with multiple challenges. These effects have significant clinical and public health ramifications. Devastating implications of diabetic foot ulcerations include amputations, a poor quality of life, and infections that pose a serious risk of complications or even fatal results. Here we take a look at five different treatment strategies and their role in the prevention and active treatment of diabetic foot ulcers.

1. Off-Loading

One of the most important strategies for managing diabetic foot ulcers is off-loading¹⁻². Bio-mechanical factors play an important role in diabetic foot disease, reducing high foot pressures is one of the main goals in healing and preventing foot ulceration². This can be done through the use of special shoes, inserts, or casts that reduce direct pressure on the affected area and is best facilitated through physician analysis of patient’s pain-levels, comfort, and lifestyle. Complete off-loading can be achieved through the use of mobility aids such as wheelchairs, walkers, crutches, or other mobile devices to remove all weight from the affected wound and limb⁵. Off-loading and pressure reduction on diabetic foot ulcers has been linked to better patient outcomes and faster healing². While off-loading can be an ulcer prevention and management strategy, it is best used in conjunction with our effective physician directed treatment.

2. Wound Debridement

Debridement is included in several guidelines for the care of patients experiencing diabetic neuropathic foot ulcers³. Debridement has continuously been indicated as an essential step in the protocol for treating diabetic foot ulcers, as removing dead and infected tissue from the wound is crucial for promoting healing³. Debridement can be achieved through a variety of methods, including surgical debridement, enzymatic debridement, and mechanical debridement. In a 1996 study, scholars concluded that extensive and more frequent wound debridement, in conjunction with other indicated therapies, resulted in higher rates of diabetic foot ulcer healing⁴.

3. Hyperbaric Oxygen Therapy

This therapy involves exposing the wound to 100% oxygen at a pressure higher than atmospheric pressure. It can help to improve oxygenation to the wound, promote healing, and reduce the risk of infection. Hyperbaric oxygen therapy may increase tissue oxygen tensions up to 15 times normal⁵. Angiogenesis and vasculogenesis may be stimulated by the using hyperbaric oxygen therapy, which can enhance the blood supply around the wound and reduce edema⁵. Antimicrobial tissue penetration and leukocyte function may be increased or strengthened by the use of hyperbaric oxygen therapy⁵. Hyperbaric oxygen therapy may be used in conjunction with wound debridement to provide an optimal environment for healing.

4. Advanced Wound Dressings

Ideally, a wound dressing should provide a moistened wound environment, offer protection from secondary infections, remove wound exudate and promote tissue regeneration, however, at this time no particular advanced wound dressing meets all of these requirements. Current advanced wound dressings such as hydrogels, hydrocolloids, and alginates may be used to keep the wound moist, which can help to promote healing. Some dressings may also contain antimicrobial agents to reduce the risk of infection. Wound dressings can even act as medication systems, when impregnated with healing enhancers or therapeutic medications such as growth factors, peptides, stem cells, or other bioactive agents⁶.

5. Hypochlorous Acid (HOCl)

When considering treatment techniques, podiatrists are increasingly opting for topical use of hypochlorous acid (HOCl). HOCl is a naturally occurring compound that can be used to clean and disinfect wounds in the treatment and management of diabetic foot ulcers. It’s a substance that is extremely effective against a wide range of microorganisms, including bacteria and fungi, and can help to reduce the risk of infection, making it an ideal wound care agent. In a 2022 academic publishing, two cases demonstrated the efficacy of HOCl in diabetic foot ulcer treatment⁷.

Case 1: A Persistent Ulcer Finally Treated With HOCl

In the first case study, a 70-year old patient had a foot ulcer that had undergone surgical debridement treatment seven months prior. The patient described following the surgery the wound area did not heal, even after topical application of povidone iodine, fucidic acid, mupirocin, and neomycin sulphate⁷. Upon presentation, the wound was 4 cm in diameter, visibly inflamed, and necrotic. The wound was thoroughly washed to remove pre-existing topical treatments, and a gauze moistened with hypochlorous acid was applied to the infected area daily. Days following this treatment protocol, necrotic tissue was visible on the gauze, signifying effective wound debridement⁷. By Day 60, the wound was fully healed and the patient instructed to develop an off-loading treatment plan as a further means of prevention.

Case 2:

In the second case, a 45-year old man with type I Diabetes presented with a seven-year old diabetic foot ulcer, measuring 5 cm x 3.5 cm⁷. The patient indicated previous surgical debridement, topical antiseptic solutions (iodine, betadine, chlorhexidine, fucidic acid) and antibiotic courses had all been unsuccessful. The wound was washed to remove previous antiseptics and treated with a gauze moistened with hypochlorous solution. Within the days following this HOCl treatment protocol, necrotic tissue was present on the gauze, indicating treatment efficacy. Within 28 days, satisfactory wound healing was present⁷.

Hypochlorous acid solutions are effective in infection and inflammation control, as well as odour reduction, and cause minimal skin reactions in comparison to traditional antiseptics, making HOCl an ideal topical antiseptic in the treatment of diabetic foot ulcers⁷. Hypochlorous acid can be utilized in conjunction with other indicated therapies, including wound debridement, wound dressing, and topical antiseptic application meaning this therapy can work in an effective multi-modal approach to diabetic foot ulcer treatment.

In Summary

It is important to note that the management of diabetic foot ulcers should be multidisciplinary and involve regular follow-up by a healthcare professional. Multiple healthcare practitioners may work collaboratively to customize a treatment plan tailored for an individual case, which may improve patient outcomes. With continuous innovation in diabetic foot ulcer treatment, wound experts should consider a multimodal approach, utilizing a number of effective strategies and treatments to improve patient outcomes and comfort.

If you are interested in learning more about hypochlorous acid in the treatment of diabetic foot ulcers, contact us director or explore our website for a number of pure HOCl products formulated specifically for wound care professionals.