Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update)

Abstract

AimsThis is the 2023 International Working Group on the Diabetic Foot guideline on the prevention of foot ulcers in persons with diabetes, which updates the 2019 guideline. This guideline is targeted at clinicians and other healthcare professionals.Materials and MethodsWe followed the Grading of Recommendations, Assessment, Development and Evaluations methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical‐scientific literature including, where appropriate, meta‐analyses, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where (sufficient) evidence was not available, and a weighing of the desirable and undesirable effects of an intervention, as well as patient preferences, costs, equity, feasibility and applicability.ResultsWe recommend screening a person with diabetes at very low risk of foot ulceration annually for the loss of protective sensation and peripheral artery disease, and screening persons at higher risk at higher frequencies for additional risk factors. For preventing a foot ulcer, educate persons at‐risk about appropriate foot self‐care, educate not to walk without suitable foot protection, and treat any pre‐ulcerative lesion on the foot. Educate moderate‐to‐high risk people with diabetes to wear properly fitting, accommodative, therapeutic footwear, and consider coaching them to monitor foot skin temperature. Prescribe therapeutic footwear that has a demonstrated plantar pressure relieving effect during walking, to help prevent plantar foot ulcer recurrence. Consider advising people at low‐to‐moderate risk to undertake a, preferably supervised, foot‐ankle exercise programme to reduce ulcer risk factors, and consider communicating that a total increase in weight‐bearing activity of 1000 steps/day is likely safe with regards to risk of ulceration. In people with non‐rigid hammertoe with pre‐ulcerative lesion, consider flexor tendon tenotomy. We suggest not to use a nerve decompression procedure to help prevent foot ulcers. Provide integrated foot care for moderate‐to‐high‐risk people with diabetes to help prevent (recurrence of) ulceration.ConclusionsThese recommendations should help healthcare professionals to provide better care for persons with diabetes at risk of foot ulceration, to increase the number of ulcer‐free days and reduce the patient and healthcare burden of diabetes‐related foot disease.

Offloading and adherence through technological advancements: Modern approaches for better foot care in diabetes

“…1,2 International guidelines underscore the significance of offloading high plantar pressure from DFUs and high peak pressure regions as a key healing and prevention strategy. 3,4 But a good offloading device or shoe can only be effective when worn by the patient and hence adherence is also a central issue.…”

“…3 After ulcer healing, for the prevention of recurrence, appropriately offloading footwear is recommended in international guidelines. 4 Largely by definition, such footwear is removable, and adherence to treatment is always an aspect of attention in these high-risk patients. Studies have shown that custom-made footwear can be effective in reducing peak pressure at high-risk regions in the foot (where an ulcer just healed), but at the same time that adherence is low and of great concern regarding the prevention of foot ulcers in high-risk people with diabetes.…”

“…Offloading, which involves alleviating the pressure on the affected foot, is a cornerstone aspect in DFU prevention and management and minimises the risk of recurrence 1,2 . International guidelines underscore the significance of offloading high plantar pressure from DFUs and high peak pressure regions as a key healing and prevention strategy 3,4 . But a good offloading device or shoe can only be effective when worn by the patient and hence adherence is also a central issue.…”

The financial burden of diabetes‐related foot disease in Australia: a systematic review

“…Prevalence studies have shown that DFU affects 6.3% of the global diabetes population [8] and has a lifetime incidence in people with diabetes between 19 to 34% [2, 10]. DFU recurrence is also frequent, where 40% of ulcers will reoccur within one year and 65% within three years [2, 10].…”

“…Prevalence studies have shown that DFU affects 6.3% of the global diabetes population [8] and has a lifetime incidence in people with diabetes between 19 to 34% [2, 10]. DFU recurrence is also frequent, where 40% of ulcers will reoccur within one year and 65% within three years [2, 10]. In Australia, the prevalence of DFD ranges from 1.2 to 1.5%, while the incidence of diabetes‐related lower limb amputations is between 5.2 to 7.2 per 1000 person‐years.…”