At-Risk Patient: Diabetic Foot Ulcers

Diabetic foot ulcers (DFUs) are a significant complication of diabetes mellitus, potentially leading to substantial morbidity and healthcare costs. Understanding the risk factors, clinical presentation, underlying causes, treatment modalities, and preventive measures are crucial for clinicians managing patients with diabetes.

Risk Factors

Several factors increase the likelihood of developing DFUs:

Peripheral neuropathy. Loss of protective sensation due to nerve damage is a primary risk factor, as patients may not perceive minor lower extremity injuries.^1,2 

Peripheral arterial disease (PAD). Reduced blood flow impairs wound healing and increases infection risk.^1,2 

Foot deformities. Structural abnormalities can lead to areas of increased pressure, predisposing patients to ulceration.^1,2 

Previous ulceration or amputation. A history of foot ulcers or amputations significantly elevates the risk of future ulcers.^3,4 

Poor glycemic control. Elevated blood glucose levels contribute to neuropathy and vascular disease, increasing ulcer risk.⁵ 

Duration of diabetes. Longer disease duration correlates with higher risk due to cumulative damage.⁶ 

Symptoms

DFUs often present on weight-bearing areas like the plantar surface of the foot.¹ 

Patients with DFU may also present with infection.⁷ Signs include erythema, warmth, swelling, purulent discharge, and, in severe cases, systemic symptoms like fever. 

When present, patients may report peripheral neuropathy in the form of numbness, tingling, or burning sensations.¹ 

Etiology

The development of DFUs is multifactorial, and several of the risk factors actually play a direct role in their formation:

Neuropathy. Sensory neuropathy, as mentioned above, can lead to loss of protective sensation, while motor neuropathy may result in muscle imbalance and foot deformities.⁸ Autonomic neuropathy can manifest as decreased sweating, which can cause dry, cracked skin that is susceptible to injury. 

Ischemia. Peripheral arterial disease (PAD) reduces blood supply, impairing tissue viability and healing capacity.⁸ 

Biomechanical abnormalities. Altered foot mechanics, combined with neuropathy, can lead to abnormal pressure distribution and ulceration.⁹ Those same deformities or gait changes may pose challenges with properly fitting shoe gear, further increasing risk of friction, shear, or pressure.

Treatment

Management of DFUs requires a comprehensive approach:

Wound care. This typically consists of debridement of necrotic or nonviable tissue to promote healing, and the use of appropriate dressings to maintain a moist wound environment.¹⁰ 

Offloading. Reducing pressure on the ulcerated area through specialized footwear or devices can effectively contribute to DFU treatment.¹⁰

Infection control. In infected diabetic foot ulcers, clinicians may choose to administer antibiotics based on culture results and clinical judgment, taking antimicrobial stewardship principles into account.¹¹ 

Revascularization. For patients with significant PAD, surgical interventions to attempt to restore blood flow may be necessary.¹² 

Advanced therapies. For selected patients that meet established criteria, one may consider advanced treatments like negative pressure wound therapy, hyperbaric oxygen, cellular- and tissue-based products, or growth factors.¹³

Prevention

Preventive strategies are paramount in reducing DFU incidence:

Regular foot examinations. Routine inspections by healthcare providers can identify high-risk conditions.¹ Patients will often see a podiatrist for periodic comprehensive diabetic foot examinations to help stratify risk and identify warning signs early.

Patient education. One can prevent DFUs by teaching patients concepts such as proper foot hygiene, self-examination techniques, and the importance of appropriate footwear.¹ 

Smoking cessation. Smoking can exacerbate diabetic neuropathy and vascular problems, both factors in DFUs.¹⁴ 

Glycemic control. Tight blood glucose management can enhance healing and prevent DFU recurrence.¹⁵ 

Conclusion

Diabetic foot ulcers are a serious complication of diabetes, necessitating a multidisciplinary approach for effective management and prevention. Early identification and intervention are crucial to improving outcomes and reducing the burden of DFUs.
 

References
1. Bus SA, Sacco ICN, Monteiro-Soares M, et al. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3):e3651. doi:10.1002/dmrr.3651
2. International Working Group on the Diabetic Foot. IWGDF Guidelines. Available at https://iwgdfguidelines.org/guidelines-2023/ . Published 2023. Accessed March 11, 2025. 
3. Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med. 2017;376(24):2367-2375.
4. Guo Q, Ying G, Jing O, et al. Influencing factors for the recurrence of diabetic foot ulcers: A meta-analysis. Int Wound J. 2023;20(5):1762-1775. doi:10.1111/iwj.14017
5. Lane KL, Abusamaan MS, Voss BF, et al. Glycemic control and diabetic foot ulcer outcomes: A systematic review and meta-analysis of observational studies. J Diabetes Complications. 2020;34(10):107638. doi:10.1016/j.jdiacomp.2020.107638
6. McDermott K, Fang M, Boulton AJM, Selvin E, Hicks CW. Etiology, epidemiology, and disparities in the burden of diabetic foot ulcers. Diabetes Care. 2023;46(1):209-221. doi:10.2337/dci22-0043
7. Matheson EM, Bragg SW, Blackwelder RS. Diabetes-related foot infections: diagnosis and treatment. Am Fam Physician. 2021;104(4):386-394. 
8. McDermott K, Fang M, Boulton AJM, Selvin E, Hicks CW. Etiology, epidemiology, and disparities in the burden of diabetic foot ulcers. Diabetes Care. 2023;46(1):209-221. doi:10.2337/dci22-0043
9. Abri H, Aalaa M, Sanjari M, Amini MR, Mohajeri-Tehrani MR, Larijani B. Plantar pressure distribution in diverse stages of diabetic neuropathy. J Diabetes Metab Disord. 2019;18(1):33-39. Published 2019 May 11. doi:10.1007/s40200-019-00387-1
10. Hingorani A, LaMuraglia GM, Henke P, et al. The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg. 2016;63(2 Suppl):3S-21S
11. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis. 2012;54(12):e132-e173.
12. Beckman JA, Schneider PA, Conte MS. Advances in revascularization for peripheral artery disease: revascularization in PAD. Circ Res. 2021;128(12):1885-1912. doi:10.1161/CIRCRESAHA.121.318261
13. Boulton AJM, Armstrong DG, Löndahl M, et al. New evidence-based therapies for complex diabetic foot wounds. Arlington (VA): American Diabetes Association; 2022 May. Available from: https://www.ncbi.nlm.nih.gov/books/NBK581559/ doi: 10.2337/db2022-02
14. Xia N, Morteza A, Yang F, Cao H, Wang A. Review of the role of cigarette smoking in diabetic foot. J Diabetes Investig. 2019;10(2):202-215. doi:10.1111/jdi.12952
15. Everett E, Mathioudakis N. Update on management of diabetic foot ulcers. Ann N Y Acad Sci. 2018;1411(1):153-165. doi:10.1111/nyas.13569