A systematic review of the effectiveness of interventions to enhance the healing of chronic ulcers of the foot in diabetes

Abstract

SummaryThe outcome of management of diabetic foot ulcers is poor and there is uncertainty concerning optimal approaches to management. We have undertaken a systematic review to identify interventions for which there is evidence of effectiveness. A search was made for reports of the effectiveness of interventions assessed in terms of healing, ulcer area or amputation in controlled clinical studies published prior to December 2006. Methodological quality of selected studies was independently assessed by two reviewers using Scottish Intercollegiate Guidelines Network (SIGN) criteria. Selected studies fell into the following categories: sharp debridement and larvae; antiseptics and dressings; chronic wound resection; hyperbaric oxygen (HBO); reduction of tissue oedema; skin grafts; electrical and magnetic stimulation and ultrasound. Heterogeneity of studies prevented pooled analysis of results. Of the 2251 papers identified, 60 were selected for grading following full text review. Some evidence was found to support hydrogels as desloughing agents and to suggest that a systemic (HBO) therapy may be effective. Topical negative pressure (TNP) may promote healing of post-operative wounds, and resection of neuropathic plantar ulcers may be beneficial. More information was needed to confirm the effectiveness and cost-effectiveness of these and other interventions. No data were found to justify the use of any other topically applied product or dressing, including those with antiseptic properties. Further evidence to substantiate the effect of interventions designed to enhance the healing of chronic ulcers is urgently needed. Until such evidence is available from robust trials, there is limited justification for the use of more expensive treatments and dressings.

The molecular basis for impaired hypoxia-induced VEGF expression in diabetic tissues

“…Presently, there is little to no evidence to support the use of topically applied therapeutics in the treatment of diabetic foot ulcers (34). Consequently, our finding that topical DFO completely normalizes healing of humanized diabetic wounds has significant clinical implications.…”

Electrical Stimulation Therapy and Wound Healing: Where Are We Now?

“…However, as ES is not a new technology and numerous animal and clinical studies have been published to support its use, it is perhaps surprising that it is less widely adopted in the United States than might be expected. 6 This may in part derive from late (2002) approval by Centers for Medicare and Medicaid Services for reimbursement for ES treatment of chronic ulcers ( > 30 days) that had failed standard wound therapies for diabetic, pressure (stage III or IV), stasis, and arterial ulcers-this approval came only after a lawsuit brought by the American Physical Therapy Association. 7 Although the Food and Drug Administration (FDA) has granted premarket application for ES devices for bone, deep brain, and muscle stimulation, it has not currently approved ES for the treatment of skin wounds.…”

Relationship between ulcer healing after hyperbaric oxygen therapy and transcutaneous oximetry, toe blood pressure and ankle–brachial index in patients with diabetes and chronic foot ulcers

“…Systemic hyperbaric oxygen therapy (HBOT) has been suggested as a treatment for diabetic foot ulcers [1][2][3]. This Electronic supplementary material The online version of this article (doi:10.1007/s00125-010-1946-y) contains supplementary material, which is available to authorised users.…”