A simple and effective approach for the treatment of diabetic foot ulcers with different Wagner grades

Abstract

Diabetic foot infections are the major cause of morbidity. Infection is the common sequel of diabetic foot ulceration that leads to delayed wound healing. These infections are difficult to control. If not addressed well in time, they may lead to amputation of foot. An attempt has been made to develop simple and effective treatment modality by using citric acid as a sole antimicrobial agent to control diabetic foot infections not responding to conventional treatment. Hundred and fifteen cases of diabetic foot ulcers of different Wagner grades infected with a variety of bacteria were investigated for culture and susceptibility, and susceptibility to citric acid. Citric acid gel was applied to ulcer to determine its efficacy in the management of diabetic foot ulcers with different Wagner grades. Citric acid gel was found effective in the control of foot infections; especially in Wagner grades I and II, the success rate was found to be more than 94%. In Wagner grade III also, it was found effective in complete healing of ulcers without deep osteomyelitis. Citric acid treatment is effective in the control of diabetic foot infections and in successful management of diabetic foot ulcers with Wagner grades I and II, and even with Wagner grade III, without deep osteomyelitis.

Interventions for wound healing among diabetic patients infected with Staphylococcus aureus: a systematic review

“…Nagoba et al 13 observed that citric acid treatment promoted healing after 16-34 applications, and that this was highly effective for controlling infections and for successfully managing diabetic foot ulcers without deep osteomyelitis.…”

“…12,13 This small number of studies may be due to difficulty in monitoring diabetic patients from the onset of the infection until wound healing, thus making it complex to obtain a homogeneous sample. It is also due to difficulties in obtaining a diagnosis of infection.…”

“…Another two articles that were analyzed claimed that there was no relationship between MRSA and increased healing time 8,10 and four papers did not study this association. 9,10,12,13 Three articles 7,12 advocated that surgical debridement with removal of all the infected area was a very appropriate treatment, certainly because ulcers heal more quickly if their surfaces are clean and if sinuses are laid open. 17 Most of the studies used antibiotic therapy as the priority treatment, except for three.…”

“…In a prospective cohort study, ElMakki Ahmed et al 12 assessed the risk factors associated with hallux ulceration and the incidence of healing or amputation in 122 diabetic patients, of whom 56 were infected by S. aureus. Nagoba et al 13 investigated susceptibility to citric acid in vitro and in ulcers of different Wagner grades infected with a variety of bacteria (47 with S. aureus) from 115 diabetic patients. The Wagner grade is determined based on the depth of the skin lesion and the presence or absence of infection and gangrene, and is divided into six grades ranging from grade zero to grade five.…”

“…17 Most of the studies used antibiotic therapy as the priority treatment, except for three. Cavallini 9 used a combination of antibiotic therapy and debridement with dermal grafts using meshes of autologous fibroblasts, Kim et al 10 used the surgical technique of modified resection arthroplasty and Nagoba et al 13 used a treatment with citric acid. These articles show that alternative therapies may be an effective alternative to the indiscriminate use of antibiotics.…”