Standard, Appropriate, and Advanced Care and Medical-Legal Considerations: Part One -- Diabetic Foot Ulcerations

Gerit Mulder, DPM, MS, David Armstrong, DPM, Susie Seaman, MSN, NP, CETN

Disclosures

Wounds. 2003;15(4) 

In This Article

Dressings

Hundreds of dressings are currently on the market with more appearing each year.[48] Rather than provide an extensive discussion on available dressings, the basic concepts behind appropriate choice are presented.

Extensive literature supports the benefits of moist wound healing.[49,50,51,52,53,54,55,56] Wounds should be dressed with materials that offer protection from outside contaminants, prevent wound desiccation, and provide an environment conducive to wound closure. The degree of moisture in a wound needs to be considered when treating the diabetic ulcer.

Cellular immune response adequately addresses increased bacterial proliferation in a moist environment. Patients with compromised cellular immune responses may not be able to address high levels of bacterial proliferation in a highly exudative environment. Hutchinson, et al.,[57] studied the incidence of infection under occlusion and found it to be four times more likely to occur under dry gauze than under occlusion. This study did not, however, contain a large population of plantar, neuropathic, diabetic foot ulcers. Allowing prolonged pooling of exudate in a diabetic foot ulcer may be a potentially dangerous situation on a diabetic patient. Excessive moisture also contributes to maceration, which decreases tensile strength and, combined with pressure, shear, or friction, may lead to further wound deterioration.

A simple rule may be followed when selecting the appropriate dressing for diabetic plantar foot ulcers. High levels of exudate warrant the choice of a moisture-absorbing material, which may include alginates, foams, collagen-alginate combinations, carboxymethylcellulose materials, or gauze. Low exudate and desiccated wounds respond well to hydrogels. Occlusive hydrocolloids are not recommended over highly exuding wounds in weight-bearing areas. The dressing needs to meet the need of the wound environment and should be changed as the status of the wound evolves. Diabetic ulcers require close evaluation. Dressing changes on moderate to heavily draining wounds are best performed on a daily basis or, at most, every two days on low-risk patients. Standard dressing care for the treatment of diabetic foot ulcers in the US is still the use of wet-to-dry or wet-to-moist saline gauze dressings. While gauze dressings are appropriate when twice- or three-times-daily dressing changes are required, care must be taken to prevent strikethrough of bacteria. Gauze does not offer an effective barrier to external contaminants and bacteria. Advanced dressings are available that are more appropriate for diabetic foot ulcers than gauze.

Additional dressing choices include hydrogels, foams, calcium alginates, collagen alginates, and absorbent polymers. Choice of dressing depends on the depth, location, wound characteristics, bacterial burden, and treatment goal. The ideal dressing for the diabetic foot ulcer should prevent tissue desiccation, absorb excess fluid, and protect the wound from external contamination. Aggressive adhesives and completely occlusive dressings need to be avoided, particularly on weight-bearing surfaces or in areas of repetitive trauma. Foam dressings and alginates are effective for absorbing fluid, while hydrogels may be used on desiccated or low exudate wounds.

The clinician must be aware that dressings are constantly evolving and require the healthcare provider to be informed of their indications and contraindications. Dressings are designed to address the wound environment and are not a substitute for offloading devices or infection and diabetes control.

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