How to Care for Diabetic Foot Ulcers and Other Diabetic Wounds

Published on March 4, 2019 by Carole Jakucs, MSN, RN, PHN, CDCES

Whether you are new to wound care, or a seasoned veteran, you’ll most likely encounter patients with diabetes on a regular basis. And by far, the most common wounds seen in these patients are diabetic foot ulcers, said Bill Richlen, PT, WCC, DWC, clinical instructor for the Wound Care Education Institute.

According to the American Diabetes Association, diabetes has affected more than 31 million people in the U.S. since 2015.

“In addition to diabetic foot ulcers, diabetics can also get venous and pressure ulcers too,” said Richlen who also owns Infinitus LLC in Santa Claus, Ind., a wound care instruction and consulting company. “Having a diagnosis of diabetes can complicate and delay the healing process of any type of wound.”

3 types of diabetic foot ulcers

For diabetic foot ulcers to be diagnosed, they must be located below the ankle. Further, they consist of three sub-types, according to Richlen:

  1. Neuropathic: The patient lost sensation but does not have underlying arterial disease. These comprise 35% of diabetic foot ulcers.
  2. Neuroischemic: Both neuropathy and ischemia are present. This sub-type makes up 50% of diabetic foot ulcers.
  3. Ischemic: Ischemia is present, but sensation is not lost yet.

“Once wounds are diagnosed, two things need to be present for healing any type of wound,” Richlen said.

One is a healthy patient, and the other is a healthy wound environment.

“If either one of these is unhealthy, you’ll have a difficult time with healing,” he said.

6 essential steps needed for healing

Richlen said six basic steps are necessary for effective wound healing.

  1. Remove the cause of the wound

  2. Create and maintain a moist wound environment

  3. Remove any necrotic tissue and epibole

  4. Effectively manage the bioburden

  5. Adequate tissue perfusion

  6. Healthy patient nutrition


Step 1: Eliminating the cause of the wound is essential, Richlen said. “This is known as off-loading – getting the pressure off, followed by treating the wound,” he said. “Also important with diabetes is good blood glucose control to help promote healing.”

Step 2: Maintaining a moist wound environment is an evidence-based practice. “Research shows us that moist wounds heal better and faster,” he said.

Step 3: Removing any necrotic tissue and epibole is a necessary step too. “When epibole is present, it means the epithelial cells are closing the wound in an abnormal way, creating rolled edges that surround the wound. And with diabetics, callouses are typically present, which also need to be debrided, with repeated debridement performed as needed. Callus formation is a secondary effect from ongoing pressure and friction,” Richlen said.

Step 4: All wounds will have bacteria in them, Richlen said. “The questions are: How robust is the patient’s immune system and do they need antimicrobials for bacterial reduction?”

Step 5: “You’ll want to assess if the patient has adequate blood flow and is he or she getting enough oxygen to the wound,” Richlen said. “One basic intervention you may see is surgical revascularization. Some of the non-surgical interventions that could be considered are prescribed medications such as pletal, statins and/or ace inhibitors, which have been shown to improve circulation.”

Step 6: Adequate nutrition with a balance of proteins, carbs and fats, along with good blood glucose control, are imperative for diabetics, Richlen said. “They need a diet that provides the essential vitamins and nutrients, and if they’re not getting them, a good multivitamin might be considered to help fill in any gaps.”

Richlen said the above steps are vital for the care of all wounds.

“My mantra is to use evidence-based methods to treat wounds,” he said. “If someone is using outdated and unproven treatments, it’s analogous to voodoo.”

Use adjunctive treatments as needed

Always start with the basics in wound care, and if they are not working consider moving on to a more specialized treatment, Richlen said. “For example, if step 5 above is missing, and the patient does not have adequate tissue perfusion, then hyperbaric oxygen therapy is always an option.”

Products like Regranex, which is a topical treatment that consists of a platelet-derived growth factor, can help promote healing, he said. “This product goes into the wound and can yield good results if all the basics above are in place. However, if the patient is not eating a nutritious diet, or does not have good blood flow, the healing process will still be difficult.”

Stay current on evidence-based treatments

Looking at the overall picture of a patient and starting at the first step by removing the cause of the wound is imperative, Richlen said.

“Conducting effective off-loading with an item such as a total contact cast is a gold standard of treatment for off-loading diabetic foot ulcers; however, it’s rarely used,” he said. “Unfortunately, there is very little formal education in evidence-based wound care included in the basic education and training of healthcare professionals across the disciplines. Approximately 85% of amputations are preceded by a foot ulcer.”

Expanding one’s knowledge in evidence-based wound care by subscribing to wound care journals and taking continuing education units from wound care certified educators can go a long way in helping healthcare professionals stay current with research-based wound care practices that can help patients heal and improve their outcomes, Richlen said.

Learn more about diabetic wound management with our continuing education courses.

Carole Jakucs, MSN, RN, PHN, CDCES

Carole Jakucs, MSN, RN, PHN, CDCES, is a freelance writer and diabetes educator. Her background in nursing includes tenures in healthcare management and as a care provider. She has worked in med/surg/telemetry, a pediatric emergency department and college health.