Foot ulcers in people with diabetes: evidence round-up

If you ever nurse people with diabetes (that’s most of you, I think), then keep reading!

Yesterday was World Health Day, which this year focused on diabetes, and the World Health Organization published its first global report on diabetes. It’s well worth reading and there are useful resources accompanying it. Yesterday I blogged about preventing type 2 diabetes, but here I want to share some of the Cochrane evidence on foot ulcers in people with diabetes.

About foot ulcers in people with diabetes

A male prosthesis wearer in a training situation.

Diabetes UK says 80% of foot or toe amputations are avoidable with good diabetes management and foot care

Foot ulcers in people with diabetes are commonly caused by peripheral neuropathy (nerve damage), foot deformity (associated with motor neuropathy), peripheral vascular disease, and peripheral oedema. External trauma is often the beginning of the process of ulceration. The loss of sensation associated with nerve damage (sensory neuropathy) experienced by many people with diabetes means that small injuries can go unnoticed; impaired blood supply may delay healing and infection increases the amount of damaged tissue at the site of the wound.

Being over 75 years of age increases the risk of foot ulcers, as does the use of insulin, the length of time living with diabetes, poor psychosocial status, hyperkeratosis (thickening of the outermost layer of skin) and macrovascular and microvascular complications.

Infected, non-healing foot ulcers can result in limb amputation. 85% of all non-traumatic lower limb amputations in people with diabetes are preceded by a foot ulcer.  Diabetes UK reports that there are more than 135 leg, foot or toe amputations in England alone each week and that up to 80% can be avoided with good diabetes management and foot care. Four years ago, Diabetes UK launched their Putting Feet First campaign, which includes a leaflet to help people with diabetes improve the quality of their foot checks and preventing foot ulcers in the first place is key.

Preventing foot ulcers

I went to this Cochrane review on complex interventions for preventing diabetes-related foot ulcers, published last year, full of hope, but sadly the evidence is really poor and the authors were left to conclude that “there is no high-quality research evidence evaluating complex interventions for preventing diabetic foot ulceration and insufficient evidence of benefit”.

How about patient education then? The Cochrane review on patient education for preventing diabetic foot ulceration found only short term gains in knowledge and self-care and we still don’t know if there is any benefit in terms of a reduction in ulcers and amputations.

So, what about your diabetic patients who present with foot ulcers?

Glycaemic control for treating foot ulcers

Control of hyperglycaemia may be important for ulcer healing. A new Cochrane review aimed to bring together RCTs comparing the effects of intensive glycaemic control compared with conventional control on the outcome of foot ulcers in people with type 1 or type 2 diabetes. There were no completed trials with results. The reviewers identified two ongoing trials and hope that these will have results for inclusion in a future update of the review. Meanwhile, the potential benefits and harms of intensive glycaemic control remain unclear.

Interestingly, recruitment to the trial of intensive glycaemic control was very difficult and the authors reported negative attitudes from participants, with the number of additional consultations needed and people’s ability to tolerate the potential side effects of intensive glycaemic control being contributory factors. The review includes a useful discussion of considerations for future research.

Relieving the pressure

A Cochrane review (14 studies, 709 people) found that non-removable pressure-relieving casts are more effective for healing diabetes-related plantar foot ulcers than removable casts or dressings alone. You can read more about this evidence in my earlier blog.

Growth factors

There is evidence that growth factors may be useful for increasing complete wound closure of diabetes-related foot ulcers, but the Cochrane review exploring this found only low quality studies (as assessed by GRADE), so better research is needed to strengthen or reject this finding. Let’s hope new studies address other important outcomes too, such as quality of life, time to complete healing and lower limb amputation.

Debridement

Debridement is the removal of dead, contaminated or foreign material from within or next to to a wound, until the surrounding healthy tissue is exposed.  It’s often done to promote ulcer healing. A Cochrane review on debridement of diabetes-related foot ulcers found some evidence to suggest that hydrogel speeds healing compared with gauze dressings or standard care, but hydrogel works through increasing the moisture of the wound environment and whether the effect is brought about through debridement as such is unclear.  There was very little evidence on surgical debridement or larval therapy. Once again, better quality trials are needed.

Dressings

diabetic foot ulcer

There is a lack of robust evidence on which dressings are most effective for diabetes-related foot ulcers

To help meet the need for reliable evidence to help purchasers, practitioners and patients make informed choices about which dressings to use, teams from Cochrane Wounds have carried out a number of systematic reviews on different dressings for treating foot ulcers in people with diabetes.

Hydrogel features again in the review on hydrogel dressings, which finds that hydrogel dressings are probably more effective than basic wound contact dressings in healing foot ulcers in people with diabetes, but that it is not known how they compare with other advanced wound dressings. There is a great variety of these and so last year a Cochrane team simplified things for us by pulling together, in an overview of reviews, 13 systematic reviews (six Cochrane and seven non-Cochrane) with 17 randomized controlled trials (RCTs) on dressings for diabetes-related foot ulcers. Surely this is what you need to know to make sure your practice is evidence-informed? Well I’m afraid that, for now, we have to settle for knowing what we don’t know, as here’s the conclusion:

“There is currently no robust evidence for differences between wound dressings for any outcome in foot ulcers in people with diabetes (treated in any setting). Practitioners may want to consider the unit cost of dressings, their management properties and patient preference when choosing dressings.”

The WHO’s call to action includes addressing gaps in the diabetes knowledge base and these reviews, and the overview, have certainly revealed some important holes in the evidence base.

What do you do?

How do you care for people with diabetes-related foot ulcers in your clinical areas? Students, what are you taught about this aspect of care? I’d be interested to hear! As well as leaving comments here, you can join the conversation on Twitter, where I tweet for @ukcochranecentr and as @SarahChapman30. You can also find @CochraneWounds there. Don’t forget the #EENursing hashtag!

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Foot ulcers in people with diabetes: evidence round-up by Sarah Chapman is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.
Based on a work at http://www.cochranelibrary.com. Images have been purchased for Evidently Cochrane from stock.com and may not be reproduced.

Further reading:

World Health Organization. “World Health Day 2016: WHO calls for global action to halt rise in and improve care for people with diabetes”. [Press release]. World Health Organization, Media Centre, 6 April 2016. Web. 7 April 2016.http://www.who.int/mediacentre/news/releases/2016/world-health-day/en/

World Health Organization. Global Report on Diabetes. Geneva: World Health Organization; 2016. Available from:http://www.who.int/diabetes/global-report/en/

National Institute for Health and Care Excellence. Diabetic foot problems: prevention and management. London: National Institute for Health and Care Excellence; 2015. (NICE NG19). [Issued August 2015]. Available from:http://www.nice.org.uk/guidance/NG19/evidence

Links:

Hoogeveen RCDorresteijn JANKriegsman DMWValk GDComplex interventions for preventing diabetic foot ulcerationCochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD007610. DOI: 10.1002/14651858.CD007610.pub3.

Dorresteijn JANKriegsman DMWAssendelft WJJValk GDPatient education for preventing diabetic foot ulcerationCochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD001488. DOI: 10.1002/14651858.CD001488.pub5.

Fernando ME, Seneviratne RM, Tan YM, Lazzarini PA, Sangla KS, Cunningham M, Buttner PG, Golledge J. Intensive versus conventional glycaemic control for treating diabetic foot ulcers. Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD010764. DOI: 10.1002/14651858.CD010764.pub2.

Lewis JLipp APressure-relieving interventions for treating diabetic foot ulcers. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD002302. DOI: 10.1002/14651858.CD002302.pub2.

S. Chapman. “Non-removable casts are better than non-removable casts or dressings for helping diabetes-related foot ulcers heal.” Evidently Cochrane. 19 February 2013. Web 08 April 2016 http://www.evidentlycochrane.net/non-removable-casts-are-better-than-dressings-or-removable-casts-for-helping-diabetes-related-foot-ulcers-heal/

Martí-Carvajal AJ, Gluud C, Nicola S, Simancas-Racines D, Reveiz L, Oliva P, Cedeño-Taborda J. Growth factors for treating diabetic foot ulcers. Cochrane Database of Systematic Reviews 2015, Issue 10. Art. No.: CD008548. DOI: 10.1002/14651858.CD008548.pub2.

Edwards JStapley SDebridement of diabetic foot ulcersCochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD003556. DOI: 10.1002/14651858.CD003556.pub2.

Dumville JCO’Meara SDeshpande SSpeak KHydrogel dressings for healing diabetic foot ulcersCochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD009101. DOI: 10.1002/14651858.CD009101.pub3.

Wu LNorman GDumville JCO’Meara SBell-Syer SEMDressings for treating foot ulcers in people with diabetes: an overview of systematic reviewsCochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD010471. DOI: 10.1002/14651858.CD010471.pub2.

 

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Sarah Chapman

About Sarah Chapman

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Sarah's work as a Knowledge Broker at Cochrane UK focuses on disseminating Cochrane evidence through social media, including Evidently Cochrane blogs, blogshots and the ‘Evidence for Everyday’ series for nurses, midwives, allied health professionals and patients. A former registered general nurse, Sarah has a particular interest making evidence accessible and useful to practitioners and to others making decisions about health. Before joining Cochrane, Sarah also worked on systematic reviews for the University of Oxford and the Royal College of Nursing Institute, and obtained degrees in History from the University of Oxford and in the history of women’s health and illness in early modern England (MPhil., University of Reading).

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