Three-pronged approach stops foot ulcers

New York - Uniform treatment consisting of a three-pronged approach can help patients with foot ulcers heal more effectively and prevent chronic ulceration and the need for amputations, according to Peter Sheehan, M.D., director of the Diabetic Foot and Ankle Center for Joint Diseases, Orthopaedic Institute in New York, N.Y.

He notes that proper treatment improves function and quality of life. It also controls infection, maintains health status, prevents amputation and reduces associated costs.

"Diabetic foot ulcers are a major public health problem," Dr. Sheehan explains. "About 15 percent of people with diabetes get foot ulcers at one point in their lifetime, and about 15 percent of ulcers develop a bone infection, or osteomyelitis, and about 15 percent of ulcers result in amputation," he says.

The aging baby boomer population is another contributing factor.

Currently, foot ulcers are not a uniformly addressed complication.

Foot ulcers occur in patients with neuropathy. In diabetes, nerve damage is typically in the feet.

"Patients don't perceive trauma, which is usually recurrent mechanical injury seen with daily ambulation," he explains.

First, calluses and blisters appear and then the ulcerations form.

"The ulcers become chronic when they exhibit faulty healing," says Dr. Sheehan. "This can, unfortunately, lead to infection, osteomyelitis and amputation."

The biology of wound healing consists of acute wounds, which have a succession of four distinct phases, and chronic wounds.

With chronic wounds, the wound is "stuck" in the inflammatory/proliferative process. Established treatments for foot ulcers, after treating infection and poor circulation, include off-loading, debridement and then moist wound healing.

Off-loading is a process of removing repetitive pressure of ambulation. This can be done several ways, including a total contact cast, removable walkers, surgical felt or healing sandals.

Dr. Sheehan notes that research over the years has shown that moist wound healing provides enhanced keratinocyte migration. It also prevents trauma and minimizes the risk of infection.

Numerous advanced wound care products are on the market to establish and ensure moist wound healing.

In addition, there are three U.S. Food and Drug Administration (FDA)-approved products for foot ulcerations: becaplermin (Regranex, Ortho-McNeil) or platelet derived growth factor-BB; Apligraf-(Graftskin), (Organogenesis, Inc.) a living bi-layer skin construct; and Dermagraft (Smith and Nephew) a human dermal-replacement construct.

"These products have been shown to accelerate healing in difficult to heal wounds," Dr. Sheehan says .

"The patient should be seen initially to exclude ischemia or infection and then treated with off-loading, debridement and moist wound healing," he says.

"The ulcers should be reassessed after a period of three to four weeks. If there is not significant improvement in the wound area, then advanced FDA-approved treatments should be considered."

Disclosure: Dr. Sheehan reports no financial interest in any of the products mentioned.