Effects of the COVID-19 Pandemic on the Management of Diabetic Foot Ulcers

Experiences From a Dedicated Diabetic Foot Care Center

Murat Kendirci, MD; Ibrahim Tayfun Sahiner, MD; İsmail Sezikli, MD; Merve Akın, MD; Ahmet Cinar Yasti, MD


Wounds. 2022;34(5):146-150. 

In This Article


On March 16, 2020, the Turkish government began implementing strict lockdowns nationwide to minimize the spread of the COVID-19 infection. Worldwide, lockdowns have been implemented in an attempt to prevent people from convening in common and public places, with the goal of decreasing face-to-face contact and preventing the spread of airborne virus transmission.[4] Turkey is known to have a good hospital capacity to manage routine health care load; however, in Turkey as in many other countries, the pandemic substantially increased the number of patients requiring care, resulting in insufficiencies in the provision of health care services.[5,6] Thus, preventive measures and lockdowns have also aimed to decrease the workload at health care centers.

During the initial peak of the pandemic, almost all elective surgical procedures were postponed, and priority was given to emergencies and oncologic cases. Hospitalized patients had no difficulty accessing medical consultation, but the limited number of medical staff available created problems for outpatients. Most wards were converted to COVID-19 clinics, which limited bed availability, and medical staff were reassigned to the newly formed COVID-19 clinics and began to work shifts to cover all days of the week. Consequent to the decreased number of outpatients, diagnostic imaging became much easier and mostly did not require an appointment; however, patients were hesitant to undergo examination in closed spaces.

Although there was no restriction to receiving medical care in hospitals and outpatient clinics during the pandemic period, this study showed that fewer patients were admitted to the diabetic foot clinic during the pandemic. In the prepandemic period, most patients treated at the authors' clinic were referrals from distant and neighboring cities, but at the beginning of the pandemic. there was a significant decrease in the number of admissions from distant and neighboring cities (75% prepandemic to ~20% pandemic). The authors think that the fear of contracting the virus and the restrictions on intercity travel resulted in fewer patients presenting from distant cities. This finding suggests that patients refrain from referring to advanced health care facilities to receive medical support even at the risk of worsening their disease. This fear has led to detrimental consequences for patients with DFU. It has been reported that fewer patients without comorbidities have sought medical support during the COVID-19 pandemic.[3,6] In the current study, it was also determined that this hesitancy about seeking professional medical advice was more common among patients with 2 or more comorbidities than among patients with 1 comorbidity.

In this study, the results showed patients with DFUs presented to the hospital at a later stage in the wound healing process during the pandemic period compared with such patients before the pandemic period. This resulted in more acute exacerbations and more surgical interventions in the pandemic period. To prevent the delayed presentation of patients with DFU, alternative consultation methods should be offered, such as video consultations and the sharing of photographs with doctors or nurses. Such practices can help identify patients who require hospitalization. For cases suitable for outpatient treatment, home nursing should be considered. In addition, rather than prescribing modalities that require daily visits, wound care products should be provided to ensure proper wound care and decrease the frequency of dressing changes.

Lockdowns have also restricted the travel of elderly patients and decreased their daily activities.[4] Although public authorities have used televised programs to inform the public about the importance of engaging in physical exercises at home, they were not as effective as initially thought and then physical activity decreased. In the current study, patients' HbA1c level was found to be significantly higher during the pandemic period compared with the prepandemic period. Limited physical exercise and hesitancy about visiting high-volume hospitals for routine medical tests have led to higher uncontrolled blood glucose levels, resulting in worsened overall health status, including diabetes-related complications.

Another important outcome of COVID-19 is the stage of DFU among patients presenting to the hospital during the pandemic. Before the pandemic, the authors frequently treated patients with Wagner grade 2 and 3 DFU and rarely encountered patients with Wagner grade 4 DFU. Though the patients who presented to the hospital during the pandemic period had more advanced stages of the disease. As explained previously, this finding is also related to patients' attempts to manage their early-stage foot ulcers at home. This delay in seeking professional medical advice for proper treatment resulted in necrotic, gangrenous wounds with a foul odor, which eventually led patients to visit a hospital, albeit reluctantly.

Delayed presentations with advanced stages of DFU have also caused a significant increase in the rate of amputation during the pandemic.[7] In the current study, 63% of patients in the prepandemic group underwent debridement alone, compared with 23.1% of patients in the pandemic group. The rate of amputations performed in the authors' diabetic foot center significantly increased from 34.1% during the prepandemic period to 71.4% during the pandemic period (P =.005). The detrimental effects of amputation on patients and their relatives and the physical, psychological, social, medical, and economic consequences of amputation are well known.[7] When all the consequences of amputations are considered, the effects of the COVID-19 pandemic on patients with diabetes can be better understood. The findings reported in this study suggest that home restrictions resulting from lockdowns, fear of contracting the virus at high-volume hospitals with referral diabetic foot clinics in Turkey, and restrictions on intercity travel contributed to advanced stages of DFU and a higher amputation rate among patients in the pandemic period.