Published August 17, 2018. Last updated October 5, 2018.
A 16-Part Guide by Wound Healing Doctors Julie and Rob Hamilton, MD
Diabetic Ulcers: Everything You Need to Know
If you or a loved one is suffering from diabetes, you probably have a lot of questions. You may have heard that diabetics experience compromised wound healing.This guide covers everything you need to know about diabetic ulcers and wound healing for diabetics. Here are just a few of the questions you can find answers to inside…
If you’re in need of healing—or just looking to learn how to prevent new diabetic wounds—this guide is for you.
Does Diabetes Cause Wounds?
No, diabetes does not directly cause wounds.A doctor tests for nerve damage on the bottom of a patient’s foot.
However, due to poor circulation, the ability to heal wounds is often significantly compromised in those with diabetes. The normal wounds that diabetics experience in day-to-day life can result in serious wounds that require professional medical care. That means that even a simple task like trimming your toenails can be a dangerous proposition.Furthermore, many diabetics experience peripheral neuropathy, or a lack of sensation in limbs (especially the feet) due to damage to nerve cells. Neuropathy means that many diabetics will not notice wounds until after they have begun to get much worse.Early identification is key to proper wound healing, so not noticing a wound can significantly harm your ability to heal.
What Are Diabetic Ulcers? Where Can I Get Them?
Diabetic ulcers are open wounds or sores that expose tissue underneath the skin. In some cases, diabetic ulcers can be open all the way to the bone. You may also hear the term “diabetic wound.” In most cases these are the same, though diabetic ulcers are technically a type of diabetic wound which has ulcerated (deepened). Approximately 15% of all people with diabetes will develop a foot ulcer at some point.The majority of diabetic ulcers are on the foot. Diabetic ulcers can occur elsewhere, such as on the leg, but diabetic ulcers most often occur on the bottom of the foot.Dr. Julie Hamilton discusses what counts as a diabetic ulcer.There are several reasons for this. First, your feet (andlowerlegs) are the furthest body parts from your heart. That means that poor circulation has its greatest impact in your lower extremities. Small blood vessels to the foot often become calcified (blocked) as a result of having long-standing diabetes. Poor blood flow, or ischemia, is the result of damage to the blood vessels caused by diabetes. Adequate blood flow is critical for healing when injury occurs. Normally, infection fighting white blood cells rush in to assist healing. However with diabetes, the blood supply to the legs and feet is decreased, causing slower healing and increased risk of infection and gangrene. This explains why 1 in 5 patients with a diabetic foot ulcer end up with an amputation.Second, peripheral neuropathy starts with the nerves down in the toes and then feet before progressing to the lower leg. So foot and toe injuries occur that are never even felt. Without neuropathy, you have sensation (nerves) to tell you that the new shoes you are trying on are too tight and are squeezing part of your foot. With neuropathy, you don’t know the shoes don’t fit well because you have no feeling in your feet.Wearing poor-fitting shoes can lead to serious foot wounds.Pressure is commonly the cause of a diabetic ulcer. The feet bear the weight of your body, so they tend to take more wear and tear than the rest of your body. Wearing a new pair of shoes for an hour, if ill-fitting, can cause blisters or more serious wounds.Third, if a patient with diabetes has elevated blood sugars, their immune system does not function well. White blood cells and other immune responses can’t function in a hyperglycemic environment. Patients without diabetes often experience small foot sores, such as a blister. But for patients with diabetes, those sores are anything but small. A small blister or cut on the toe of a person with diabetes can quickly lead to an infected wound that won’t heal. Diabetics have both a compromised immune system and a compromised ability to heal.
Why Do Diabetic Ulcers Happen?
Chronic ulcers are caused by diabetes for four main reasons:
Diabetes causes both macrovascular (large blood vessel) and microvascular (small blood vessel) disease. This compromises the flow of blood to your legs and feet. As a result, wounds don’t get the resources they need to heal: oxygen, healing cells, and immune boosters.
High blood sugar causes proteins to group and clog your blood vessels. Blood is essential to the healing process, and when blood can’t get to your feet (and especially your toes), wound healing is compromised.
Diabetes also impairs the body’s immune system function. Your immune system is constantly working to protect your body from a variety of bacteria, viruses, and other pathological agents. Once the immune system is impaired and the blood flow is constricted, it becomes very difficult to heal chronic wounds, particularly on the legs or feet. The skin is an important barrier against infection. Ulcerated skin and a dysfunctional immune system mean that the legs or feet of diabetics are at a tremendously high risk for infection. This infection can quickly spread to the bone, or if left unchecked, throughout the body.
Key Fact
Nueropathic foot ulcers are the most difficult to heal and the most common precursor to lower-extremity amputations.
Diabetes also causes neuropathy, a condition that diminishes nerve function. The exact mechanism is still unknown, but it is thought that the protective sheath that surrounds the nerve fibers (myelin) is disrupted by hyperglycemia. This leads to demyelinization of motor and sensory nerves, beginning at the toes and feet. As sensation declines, the patient risks foot injury. You may sustain trauma or develop an infected wound or cut but not notice it because it’s not painful. It is very important that you inspect your feet daily if you have neuropathy.
The Types of Diabetic Ulcers
The majority of diabetic ulcers fall into 3 categories.There are 3 general types of ulcers: neuropathic, ischemic, and neuroischemic.Neuropathic Ulcers are formed due to peripheral neuropathy. Lack of sensation on the foot leads to increased trauma on the foot. Patients with neuropathic wounds often aren’t aware of their ulcer until it becomes a significant issue.Ischemic Ulcers are formed due to blocked blood vessels. Diabetes compromises your circulation, especially in the small blood vessels known as the microvasculature. This is especially true in the feet. The blood can’t get to your wound to help it heal. This condition is known as peripheral artery disease. When not enough blood reaches a wound, we call it ischemic and it needs special care. It may also be very painful.Neuroischemic Ulcers display characteristics of both neuropathic and ischemic ulcers. Many wounds are attributable to both factors, and these fall into the category of neuroischemic.
What to Look Out For: Symptoms and Signs of Diabetic Ulcers
If your wound has not healed within 3-4 weeks, this is a sign that you have a chronic wound.In most cases, using your senses is enough to tell you whether a wound is healthy. In other words, if something looks or smells “off” to you, that is a good warning sign.That being said, anyone with diabetes is at risk for infection or a severe chronic ulcer, so you should always consult a wound healing professional for any wound.Here are some of the symptoms that those with non-healing diabetic ulcers experience:
Drainage and fluid coming from the wound
Redness
Swelling
Dark or yellow scab
Blood on your sock or shoe
Something “doesn’t feel right” when you walk
Red streak moving up the foot to the ankle
Unusual hot or cold feeling
Unusual odor from your foot
Gangrene on your toe or other part of your foot
Infected diabetic ulcers often lead to further infections and even amputation.
Infection is a particularly critical concern. Infected diabetic ulcers can often lead to bone infections and amputations, so they need to be identified and treated as quickly as possible.Infected wounds are always serious. If you notice significant drainage, pain, thick pus, a strong odor, or if your wound looks deeper or larger, these may be signs of infection. Often, a person with diabetes will notice unexplained blood sugar spikes, fever, aches, hot and cold flashes, nausea, and fatigue.If you experience any of these symptoms, consult a physician immediately. Also, request to see a wound healing professional as soon as possible.
How Bad Is My Diabetic Ulcer?
While every diabetic ulcer is different, there are certain kinds of classifications that your doctor might use. These classifications allow your doctor to describe the severity of your diabetic ulcer.In general terms, diabetic ulcers can be described as either “partial” or “full thickness.” Partial thickness ulcers have breakdown of the skin only. Full thickness ulcers have trauma to deeper layers, such as the dermis, fat layer, muscle layer, and tendon or bone. Deep wounds that are open to muscles, tendons, joints, or bones may also be classified as “with exposed support structures.”The industry standard for ulcer classification, though, is the Wagner Grading System. The Wagner Grades describe the severity of an ulcer, from 0 to 5. Grade 0 means you have no ulcer but you have a high-risk foot.The Wagner Grades are used for diabetic foot ulcers in wound clinics. They help wound care specialists monitor and treat your ulcer to ensure that progress is being made.Wagner Grades 1 through 5 are as follows:
Superficial ulcer involving the full skin thickness but not the underlying tissues
Deep ulcer penetrating down to ligaments and muscle, but no abscess or bone involvement
Deep ulcer with cellulitis or abscess formation, including infection of muscle, tendon, joint or bone (osteomyelitis)
Localized gangrene (decay of body tissues -the tissue is dark, shriveled, dry, and dead) limited to the toes or forefoot
Extensive gangrene involving the whole foot
Your doctor may or may not refer to the Wagner Grades when describing your wound. The main thing to know is that the higher the grade, the faster you need to be seen and treated. Some advanced treatments for diabetic ulcers—such as hyperbaric oxygen therapy—are restricted to those with higher grade wounds.
Can My Diabetic Ulcer Be Healed? Or Do I Need to Amputate My Foot/Leg?
Diabetic ulcers are difficult to heal, but they are NOT impossible to heal. Some doctors resort to amputation of the affected site, such as your toe, part of your foot, or even below your knee. We believe in fighting to keep every part of your limb. We don’t give up unless you do.Amputation is often a bad idea for many reasons. In addition to decreasing your quality of life, amputations can lead to a new surgical wound that won’t heal. This happens when the surgeon did not check the blood flow in the leg and foot before performing the amputation. We’ve seen too many patients have multiple amputations performed after each one resulted in another non-healing wound at the site of the previous amputation. The limb just keeps getting whittled away until it finally heals (often above the knee). Quality of life plummets.Furthermore, undergoing any amputation has been shown to shorten your lifespan. An article in the Journal of AmericanPodiatry Medical Association found that nearly 3 out of every 4 patients who underwent lower-extremity amputation for a diabetic ulcer died within 5 years of the amputation.
Key Fact
Proper medical care in people with history of diabetic foot ulcer can reduce high level amputation from between 65% and 80%.
Amputation should be an absolutelast resortfor any diabetic ulcer. With proper care and treatment, and referrals to the right specialists, diabetic ulcers can be healed, even when they seem beyond hope.The following sections detail all the available treatments options. In our decades of experience helping people heal diabetic wounds, we’ve found these methods effective in finding healing for even severe and stubborn chronic wounds.
Treatment Options for Diabetic Ulcers
If you have a diabetic ulcer, you want to know: How should I treat it?There is no simple answer to this question. Every wound is unique, and every person with a wound is different. The right answer for you is likely to be a combination of the options we’re going to present—and the best way to find that combination is to consult with an experienced wound care specialist who can identify the right treatments for you.That being said, we’re going to present you with what we’ve found to be the most effective techniques and therapies for healing diabetic ulcers. Some of these are things you can do at home, while others require a visit to a specialist or clinic.They’re divided into two parts: the standard course of treatment (which the vast majority of wound care specialists will recommend in some variation) and advanced and alternative techniques we have discovered through years of practice which help to increase your overall health and speed up wound healing.First, though, let’s talk about where you should get treatment in the first place.
Where to Get Treatment for Diabetic Ulcers
When dealing with a diabetic wound, many people turn to their primary care doctor, a nearby hospital, or even the emergency room. Unfortunately, these arenotthe best place for proper wound care.Many doctors at these establishments have little to no training in chronic wound management. Medical school teaches doctors about acute wounds, sustained from an accident or injury. Medical schools do not teach chronic wound healing techniques.One of the biggest problems that arises from this lack of training is the overprescribingofantiobiotics. While antibiotics can be necessary—especially if your wound is infected— most chronic ulcers don’t need them. The problem is these wounds often look bad (scary), and doctors don’t know what else to do, so they prescribe a course of antibiotics. When you come back and the wound looks no better, they prescribe a second course of antibiotics, all the while harming your gut by eliminating the good bacteria.Specialized wound care centers provide top-of-the-line care for diabetics.
So if your primary care doctor, the hospital, and the ER aren’t the right place…where should you go?You should look for a specialized wound care center. These centers are staffed with specialized doctors and nurses with experience in handling chronic wounds. They generally have the latest equipment and supplies to ensure you have the resources you need to heal your wound.Our local wound care center has seen astonishing results: more than 90% of patients who follow their course of treatment are healed within 12 weeks, with a median healing time of 30 days. Those incredible results are achieved by a combination of methods, including: treating underlying conditions, fighting infection, eliminating any pressure to the wound, improving nutrition, controlling swelling, debriding and applying appropriate dressings, balancing moisture, and protecting wounds from further damage.Wound care centers aren’t perfect, though, which is why we encourage you to read on for more treatment options. In the U.S., wound care centers are beholden to the treatment guidelines laid out by the Centers for Medicare and Medicaid Services (CMS). That means that some treatment options—such as hyperbaric oxygen therapy—that can produce great results for all diabetic ulcers are restricted to very specific patients. Medicare is currently making it almost impossible for patients to qualify for hyperbaric oxygen therapy. We may already be seeing more amputations as a result.
The “Standard” Course of Treatment for Diabetic Ulcers
The standard treatment for diabetic ulcers—the process that most wound care centers will suggest—consists of 4 main parts:
Wound centers use a 4-week benchmark for healing. If a wound doesn’t achieve a 50% area reduction at 4 weeks, it will be significantly less likely to be healed by 12 weeks.
This is an excellent foundation for healing your wound. We have found that additional steps—focused on healing your body so it can fight infection and heal the wound on its own—can make a huge difference in how quickly your wound heals. More importantly, these advanced techniques can help ulcers that have never healed over several years, a sudden shift towards healing.We’ll cover those later in this guide. First, you should learn more about these 4 steps and why they’re done. We’ll also cover what you can (and can’t) do at home.
Assessing Your Circulation
Ensuring that your wound has sufficient blood supply is critical to the healing process. Fifty percent of all patients with arterial insufficiency have no symptoms, so you can’t trust that you don’t have problems if you don’t notice them. You also cannot just feel for the pulse in your feet, since that is not a reliable method to assess circulation.While many are asymptomatic, there are some physical signs that your circulation is compromised. If you notice any of these, you may have arterial insufficiency:
Pain is severe and increases with leg elevation
Pain with walking (pain may be present at rest)
Absent or diminished pulse
Decreased skin temperature (cool to the touch)
Absence of hair on foot and leg
Thin, smooth, shiny, dry skin
Skin discoloration (pale with elevation, dark red/purple with dangling)
Thickened, brittle, yellow toenails
Gangrene
The Ankle-Brachial Index (ABI) is an excellent way to detect peripheral artery disease.
Peripheral vascular disease is four times more common in diabetics than in non-diabetics. There are a number of diagnostic tests to assess your circulation. One simple test which can easily be done at your first visit to a wound center is the Ankle-Brachial Index (ABI).This is a ratio of the blood pressure at your ankle divided by the blood pressure at your upper arm (brachial). If the result is less than 0.8, that suggests impaired circulation. If the result is less than 0.5, you have significant ischemia and need a vascular consult more urgently. It may suggest critical limb ischemia. This means you are at high risk of losing your leg.Other diagnostic tests include the Toe-Brachial Index, Aterial Duplex Scan, Arteriogram, Transcutaneous Oxygen Measurement, and Aterial Doppler.Possible treatments for impaired circulation include angioplasty, arthrectomy, stents, and bypass grafts. Blood thinners may be prescribed. Smoking contributes to impaired circulation, so you should stop immediately, especially if you have diabetes!
Debriding Your Wound to Remove Dead Tissue
Debridement is the process of removing dead tissue and debris from your wound. It can be a scary process, but it’s absolutely essential to healing chronic diabetic ulcers.Necrotic tissue hinders your body’s ability to heal properly.
If your wound is in the early stages, you may not need debridement. But if it shows any signs of dead tissue, you will absolutely need some form of debridement to heal your wound.Dead tissue—also known as necrotic tissue—has a number of negative effects on your body’s ability to heal. Wounds heal faster after dead tissue is removed, and they’re also less likely to become infected in the future. That’s why weekly debridement at a wound care center is essential to healing many diabetic ulcers.In general, there are 2 types of debridement: surgical and non-surgical.In surgical (sharp) debridement, the doctor uses a scalpel, curette, and other tools to manually remove dead tissue and debris. Surgical debridement often only removes dead skin and debris, which is known as selective debridement. When necessary, however, necrotic tissue, fat, muscle, tendon, and even bone may need to be removed from the wound. Surgical debridement is generally done under topical anaesthesia, but for those with neuropathy, anaesthesia may not be necessary.Surgical debridement should NEVER be attempted at home and should only be done by a trained medical professional. The potential for damaging healthy tissue is simply too high for proper home treatment.Non-surgical debridement, on the other hand, is a catch-all term for a number of methods of debriding a wound base. The following are methods of mechanical debridement:
Wet-to-dry dressings
Medical-grade maggots
Scrubbing the wound
We generally advise against these methods, since they are easy to do improperly, especially if you attempt to do them at home.There are, however, two non-surgical options that we have found to be successful: enzymatic and autolytic debridement.Enzymatic debridement uses a medication—we suggest Collagenase SANTYL® ointment (more on that later)—to remove dead tissue. It is often combined with sharp debridement.Autolytic debridement uses your body’s own healing process to debride the wound. We encourage autolytic debridement with medical grade honey, since it’s an entirely pain free way to debride your wound.The benefit of enzymatic and autolytic debridement is that they can be done from the comfort of your own home. In some cases, they can completely replace surgical debridement. In others, you may need to supplement them with regular surgical debridement.
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Protecting Your Wound with Topicals and Dressings
After your wound has been debrided, you need to apply dressings to allow the wound to drain and heal properly. With so many dressings on the market, choosing the right one can be overwhelming. That’s why we’ve put together a list of the most important ones and what you need to know about them.Dressings serve three primary purposes: they control the infection, balance the level of moisture in the wound, and protect the wound from additional damage and contamination.Here are a few of the things you should look out for in dressings. If a dressing says that it has these properties, that’s a good sign that it will have a positive effect on your wound healing:
Antimicrobial Properties: Dressings that have antimicrobial properties can help control and fight infection, as well as prevent further infection from occurring.
Anti-inflammatory Properties: Dressings that have anti-inflammatory properties can help reduce swelling and pain in your wound.
Cellular Regeneration: The process of wound healing is essentially just the process of your body’s cells regenerating, and so dressings that help this growth of cells can speed up wound healing.
How should I dress my wound?
You may think of dressings as the gauze or bandages put over a wound, but dressings are actually a combination of products (including topical treatments) applied in layers to cover a wound.Dressings are applied in layers, including a topical layer, an absorbent layer, and a cover layer.
Most dressings start with a layer of topical agent (such as a cream, ointment, or salve) applied directly to the wound.Moist or draining wounds often require a layer above the topical layer that will absorb drainage from the wound. Alginate, a substance derived from seaweed, is often used in this manner.Finally, dressing your wound requires a cover layer that will protect the wound. This layer can be as simple as plain gauze (which is inexpensive and has good absorption), or it can be a more sophisticated product, such as hydrofiber dressings and foams. The cover layer is often held in place with tape, an elastic bandage, or “roll gauze.”
What should I use to dress my wound?
The answer to this question is complicated, since that depends on the severity and progress of your wound.Below are dressings to consider based on the drainage of your wound and whether or not your ulcer is in danger of infection.These are intended to teach you about what is available, not as specific medical recommendations. You should consult with a wound care specialist to determine which dressing is best for you.
Minimally Draining Wounds
Wounds with little to no drainage require simpler dressings without absorptive layers. The goal is to rehydrate the wound bed and decrease bacteria. Consider these options:
Antibiotic Ointments
Antibiotic Ointments such as gentamicin, clindamycin, and mupirocin can be powerful tools for combating wound infection. Be careful, though: don’t use standard over-the-counter antibiotic ointment such as bacitracin and neosporin on your wound. All three of the antibiotics listed above require a prescription.
Silver
Silver has been used as an antibacterial for more than 2,000 years. Silver is extremely effective after debridement or for infected wounds. It is often paired with collagen, alginate, or foam to create dressings. You can also find silver gels—such as SilvaSorb or Silvadene—over the counter (don’t worry, they’re actually inexpensive!).
Cutimed Sorbact
Cutimed® Sorbact® is a wound pad produced by BSN medical, Inc. Sorbact is non-medicated, but the structure of the pad uses a special technology to trap bacteria and fungi, so that every time you change the dressing, you’re reducing the amount of harmful substances in your wound. Sorbact uses a water-repelling layer to accomplish this. It binds pathogens to its surface so they can be removed at dressing changes. These dressings can be used long term without risk of antibiotic resistance, and they come in many forms: pads, gel, ribbons, and swabs.
Honey Gel
Honey Gel is a medical-grade wound gel made with honey from bees pollinating the medicinal Manuka bush in New Zealand. Manuka honey has been used to treat wounds for thousands of years because of the powerful antimicrobial properties of honey. Honey wound gel is also an extremely effective autolytic debriding agent: some patients who regularly use honey never need sharp debridement. Honey gel is FDA-approved, inexpensive, widely available, and completely safe. It’s hard to go wrong with using honey gel on your wound, but do be on the lookout for fake Manuka honey producers (check for the UMF Certificate). We suggest the Medihoney brand.
Hydrogel
Hydrogel is a wound gel made predominantly with water (generally 90% water). The benefit of hydrogel is that it keeps the wound environment moist. If your wound is dry enough to be in danger of forming a firm yellow scab (eschar), consider using hydrogel. You can also find hydrogel-infused bandages and gauze pads.
Hydrocolloid Dressings
Hydrocolloid Dressings are flexible, absorbent bandages made from a gel-like substance. They’re excellent for maintaining an optimal moist healing environment and protecting wounds from further contamination and trauma. They usually stick to skin without tape or cover bandages. We particularly suggest these dressings for very dry wounds over bony prominences, such as the ankle. You can even look for honey-infused hydrocolloid dressings.
Elasto-Gel Wound Dressings
Elasto-Gel Wound Dressings are made up of a resilient gel which protects skin and underlying tissues from pressure and friction. It may be cut to any shape or size to fit the wound. It provides comfort, makes dressing changes easy, and will not dry out. It can also be used for prevention of ulcers when used as padding over bony areas of the foot.
Silicone Adhesive Contact Layer
Silicone Adhesive Contact Layer helps protect, soothe, and keep wounds from drying out. Even better, you can buy a foam with a layer of silicone already overlying the foam for fragile or newly healed wounds (Mepilex Border Foam).
Moderately Draining Wounds
Wounds with some drainage generally require additional dressings, especially dressings to help absorb drainage and balance the moisture in the wound. Consider these options:
Honey Gel
Honey Gel is a medical-grade wound gel made with honey from bees pollinating the medicinal Manuka bush in New Zealand. Manuka honey has been used to treat wounds for thousands of years because of the powerful antimicrobial properties of honey. Honey wound gel is also an extremely effective autolytic debriding agent: some patients who regularly use honey never need sharp debridement. Honey gel is FDA-approved, inexpensive, widely available, and completely safe. It’s hard to go wrong with using honey gel on your wound, but do be on the lookout for fake Manuka honey producers (check for the UMF Certificate). We suggest the Medihoney brand.
Collagen
Collagen is the single most common protein in your body. It’s used by your skin, muscles, and bones to provide strength and structure. Collagen is available in a powder or gel, which works to fill wound cavities. You can also buy collagen matrix dressings, which are bandages that absorb excess wound fluid and ensure proper moisture balance. You can buy collagen with or without antimicrobial silver.
Collagenase Santyl
Collagenase Santyl® ointment is the only commercially available enzymatic debriding dressing. If your wound has a significant amount of dead tissue, this is an excellent choice. It is, however, currently on patent and only available by prescription, meaning it can be quite expensive. If you have a prescription, apply a 2mm thick layer daily after cleansing with saline, then cover the wound with gauze.
Methyl-Gentian Dressings
Methyl-Gentian Dressings are a combination dressing that pair the antibacterial properties of metyhlene blue and the antifungal properties of gentian violet. These dressings are particularly powerful for infected wounds. Look for Hydrofera BLUE® and Hydrofera BLUE® Flex, a moldable foam that works great over pressure ulcers, bony prominences, and under compression wraps.
Heavily Draining Wounds
Wounds with heavy drainage require significant steps to ensure that the wound doesn’t become too moist. Make sure you change your dressings frequently if you have heavy drainage. Typically wounds on the foot don’t drain heavily unless there is acute infection. More often these dressings would be selected for heavily drawing ulcers on the legs, especially if you have diabetes combined with leg swelling (causes including cellulitis, CHF, venous insufficiency, lymphedema). Consider these options:
Alginate
Alginate is specifically designed for heavily draining wounds, such as diabetic ulcers with higher Wagner grades. Alginate dressings are most often a combination of calcium and seaweed, and they absorb excess fluid and release a gel that speeds healing. You can also find alginate dressings combined with silver or honey, both of which help for infected wounds or ulcers in danger of becoming infected. Don’t use alginate dressings on drier wounds—doing so can dry out your wound too much.
Other Absorbent Products
Other Absorbent Products such as gel dressings (Enluxtra and Optilock), Drawtex (LevaFiber), sorbion sachet, and XTRASORB dressings are excellent for heavily draining wounds. These absorptive dressings help remove debris, control excessive drainage, and draw out bacteria and other harmful substances. Once removed, ulcers have a chance to heal.
Infected or In Danger of Infection
Wounds that are infected or in danger of infection require dressings with strong antimicrobial properties. Consider these options:
Honey Gel
Honey Gel is a medical-grade wound gel made with honey from bees pollinating the medicinal Manuka bush in New Zealand. Manuka honey has been used to treat wounds for thousands of years because of the powerful antimicrobial properties of honey. Honey wound gel is also an extremely effective autolytic debriding agent: some patients who regularly use honey never need sharp debridement. Honey gel is FDA-approved, inexpensive, widely available, and completely safe. It’s hard to go wrong with using honey gel on your wound, but do be on the lookout for fake Manuka honey producers (check for the UMF Certificate). We suggest the Medihoney brand.
Silver
Silver has been used as an antibacterial for more than 2,000 years. Silver is extremely effective after debridement or for infected wounds. It is often paired with collagen, alginate, or foam to create dressings. You can also find silver gels—such as SilvaSorb or Silvadene—over the counter (don’t worry, they’re actually inexpensive!).
Iodine
Iodine is a powerful substance. Many people try to pour iodine or Betadine onto their wounds. That’s actually detrimental to wound health. However, you can purchase iodine-impregnated gels and “putties” that safely use the disinfectant powers of iodine. These dressings are particularly effective for wounds with active infection. Look for Iodosorb (gel) or Iodoflex (putty). For tunneling wounds and abscess cavities, iodine packing gauze is a good choice if someone can help you.
Antibiotic Ointments
Antibiotic Ointments such as gentamicin, clindamycin, and mupirocin can be powerful tools for combating wound infection. Be careful, though: don’t use standard over-the-counter antibiotic ointment such as bacitracin and neosporin on your wound. All three of the antibiotics listed above require a prescription.
Cutimed Sorbact
Cutimed® Sorbact® is a wound pad produced by BSN medical, Inc. Sorbact is non-medicated, but the structure of the pad uses a special technology to trap bacteria and fungi, so that every time you change the dressing, you’re reducing the amount of harmful substances in your wound. Sorbact uses a water-repelling layer to accomplish this. It binds pathogens to its surface so they can be removed at dressing changes. These dressings can be used long term without risk of antibiotic resistance, and they come in many forms: pads, gel, ribbons, and swabs.
New Medical Advancements in Wound Dressings
Medical science is constantly evolving, and there are several areas of research that are yielding very positive results for diabetic wound healing.
Negative Pressure Wound Therapy
Negative Pressure Wound Therapy (NPWT) uses a vacuum dressing to heal your wound. V.A.C. Therapy Dressings are not new, but they continue to advance. They work by creating a wound environment which promotes healing. They reduce edema, promote perfusion, promote granulating tissue formation, and remove wound drainage and infectious materials. Advanced V.A.C. VeraFlo Instillation Therapy can now deliver topical wound solutions across the wound bed, distribute them, and then remove them with suction. This can be continuous or intermittent. Although used more commonly in surgical wounds and pressure ulcers, NPWT can be placed on diabetic foot ulcers and can be combined with offloading measures (wearing a pressure-relieving boot for example). It might be worth asking about if your wound hasn’t healed more than 50% after four weeks.
Smart Dressings
Smart Dressings use nanotechnology by incorporating miniature electrical sensors into the dressing. These sensors can detect changes in your wound environment, then alert you or your doctor by changing the color of the dressing or sending a message via text or email.
Skin Substitutes
Skin Substitutes are also known as living cell therapies, and they provide a cellular matrix that mimics skin. Some of these are derived from biological sources, while others are synthetically produced. Skin substitutes are not always necessary, but if your wound has not healed with 4-6 weeks of standard treatment, you should talk to your doctor about the possibility.
We’ll keep updating this page with new advancements as we find them, so keep this page bookmarked in your browser.
Applying Dressings at Home
Roll gauze is an excellent covering option if you develop a reaction to adhesives.
Unless otherwise directed by a wound care specialist, daily cleansing of your wound is beneficial to healing. Wash your hands before cleaning your wound. Then, flush your wound with clean tap water or normal saline solution (tap water is generally fine). You can also use mild soap, but avoid fragrances, triclosan, or triclocarban. If the wound is extremely dirty, you should gently scrub it with a clean washcloth. Unless your wound is on the bottom of your foot, we recommend that you get in the shower and clean your wound with warm water and soap.After cleansing your wound, you should dry it with either open air exposure (preferably in sunlight) or with a clean, dry cloth. Then, apply the dressings you have chosen. Make sure your gauze or other cover layer doesn’t stick to the wound. If it does, you can rinse it with water and remove it. Tape can be used to secure dressings, but it won’t work well if there is a lot of drainage. Some people develop reactions to the adhesive, which is why we suggest roll gauze to hold the dressing in place.
Offloading Pressure to Prevent Further Damage
Walking boots, also known as total contact casts, help offload pressure and give your wound a chance to heal.
The final step of the standard procedures for chronic wound care involves taking the pressure off the wound. For diabetic ulcers, which tend to happen on the feet, that means using special equipment to reduce the burden of standing on the wound.This offloading can be done with a cast and walking boot (Total Contact Cast), custom boot, or special diabetic shoes with customized inserts. Some also choose to use crutches, a knee scooter, or a wheelchair to avoid any pressure on the bottom of their foot.Do note that pressure offloading equipment is often covered by insurance. While you can generally buy equipment over the counter or at a medical supply store, you should talk to your doctor about getting a prescription for orthotics or other special equipment.
Healing Your Wound by Restoring Overall Health
The “standard” course of treatment discussed above can be enough for many diabetic ulcers. However, in cases where your ulcer stubbornly refuses to heal, you need to take additional steps.Remember: wound healing is a process that your body naturally does on its own. It’s only when diabetes gets in the way that wound healing becomes more difficult and ulcers don’t get better on their own.To restore your wound healing, it’s important to go back to overall health. The healthier your body, the more equipped it is to heal diabetic ulcers on its own.The following treatments and techniques are ways to increase your overall health that we’ve seen make a big difference in your body’s wound healing capacity.
The Importance of Chronobiology and Circadian Biology to Wound Healing
We believe that people in poor health need to reconnect with nature to become healthy. Medical science is just beginning to understand the importance of circadian rhythms to your body’s overall health.A complex series of hormonal reactions takes place every morning when you wake up and see the first morning sunlight.
Here’s what we do know: a complex series of hormonal reactions takes place every morning when you wake up and see the first morning sunlight. For diabetics, insulin production is regulated by these circadian rhythms. These rhythms are crucial to your body’s functioning, and you should pay close attention to how your habits affect them.Here’s a few habits you can form to ensure your body is at optimal functioning:
Go outside first thing in the morning and get sun, without any lenses on your eyes.
Spend as much time outside in daytime sun as you can.
Use as little sunscreen as possible (while avoiding sunburn).
Eat only during hours when there is still sunlight.
Do not wear sunglasses while outside.
As the sun goes down and darkness falls, turn out the lights.
If you must use a screen after dark, wear blue-blocking glasses and cover as much skin as possible.
If you wear prescription glasses, get blue-blocking lenses in your glasses.
Sleep also plays a major role in your chronobiology, and thus your wound healing. Ensure you have plenty of time for quality sleep, and create an optimal sleeping environment (entirely dark). If you must get up at night, use an orange, amber, or red flashlight and don’t turn on overhead lights, which can interrupt your circadian rhythms and cause difficulties falling back asleep.
Proper Nutrition for Wound Healing: What You Should and Shouldn’t Eat
It takes a lot of energy to heal a diabetic ulcer. Proper nutrition gives your body the energy it needs to heal even incredibly stubborn non-healing wounds.A Paleo style of diet is a good start for promoting wound healing.
There are thousands of different diets, and no one “healthy” diet is going to magically heal your wounds. Instead of prescribing specific foods, we’ll suggest some general outlines for what to include in your diet (and what to avoid).In general, wound healing is aided by a diet that is high in proteins and low in carbohydrates. This aligns with the “Paleo” style of diets.Seafood should be a core component of your diet. The omega-3 fatty acid DHA is found in seafood, and it is critical for healing diabetic ulcers.Your body also needs adequate protein to heal your wounds. In general, we suggest 1.5 grams of protein per kilograms of body mass per day. If your wound is a Wagner Grade 3 or greater, we suggest upping your protein intake to 2 g/kg/day.Vegetables and fruits are also essential to healing your wound. For diabetics, though, you should be careful about your fruit intake, since fruit tends to be high in natural sugars.Diabetics should be well aware of the Glycemic Index for foods. Healing your ulcer fully often requires proper management of your diabetes. Eating low glycemic-index foods and avoiding high glycemic-index foods is an excellent step toward healing your wound.One of the questions we get a lot is “What nutritional supplements should I take?”The answer depends on your situation. If you follow all the suggestions in this guide, you may not need to take any supplements other than a general multivitamin.There are, however, a number of key substances for your wound healing (such as DHA, discussed above). If you are deficient in any of these substances, your body may need to compensate for that deficiency, harming your ability to heal chronic wounds.If you’re wondering what supplements and vitamins to take, check out our infographic, 22 Essential Supplements for Healing Your Wound.
Optimizing Your Hormones to Heal Your Wound
Hormones are important chemical messengers in your body that control numerous systems and bodily functions. They control protein synthesis, degradation, growth, tissue repair, mood, and body composition. They tell your body when it is time to wake up and go to sleep. They control hunger and thirst, prepare you to face danger, and control attraction. Unsurprisingly, they also control the healing of diabetic ulcers.Unfortunately, even the best wound care centers tend to focus on the ulcer itself, not on the overall health of the person. It’s rare that you’ll find a wound doctor ready to dive into your hormonal milieu.Hormone management is an extremely complex topic, so we won’t dive too deep into it here. However, there are several key hormones that you should know about, since they play an important role in healing diabetic ulcers.Ask your doctor to test you for levels in these hormones:
Vitamin D (which is actually a hormone, not a vitamin)
Thyroid
Cortisol
Human Growth Hormone (HGH)
Prenenolone
Dehydroepiandrosterone (DHEA)
Testosterone (men and women)
Estrogen and Progesterone (women)
If you are deficient in any of those hormones, ask your doctor about solutions, such as hormone replacement therapy.
Healing Your Wound with Hyperbaric Oxygen Therapy
In our experience, we’ve found oxygen to be one of the most effective forms of natural therapy. One common denominator of chronic wounds is tissue hypoxia (tissue being deprived of oxygen). Identified in a variety of disease states (especially peripheral vascular disease and diabetes), hypoxia increases the risk of local infection while simultaneously slowing tissue growth.Hyperbaric Oxygen Therapy (HBOT) is a newer and incredibly effective technique for healing diabetic ulcers.
Hyperbaric oxygen therapy (HBOT) has the ability to correct local oxygen deficits and greatly improve wound healing. HBOT is a method of administering pure oxygen at greater than atmospheric pressure to a patient, which forces the oxygen into the tissues.When you undergo HBOT, you’re placed in a large, clear, acrylic chamber that is pressurized with 100% oxygen, typically at twice the ambient atmospheric pressure. You comfortably breathe this medical oxygen gas while enjoying a nap or watching television or a movie. Ninety minute sessions are most commonly provided, 5 days per week, for a total of 30-40 treatments.How does it work? HBOT increases the dissolved oxygen content in blood plasma. The combination of breathing 100% oxygen during treatment (room air has only around 21% oxygen), and pressurizing the chamber (which forces oxygen molecules to dissolve into blood plasma), makes this occur. This then translates into a systemic increase in reactive oxygen (oxygen free radicals) and reactive nitrogen species. This has many direct physiological benefits for your wound healing, including:
Increased growth factor production
Enhanced antimicrobial control
Enhanced blood vessel growth
Stem cell upregulation
Enhanced tissue growth
Enhanced post-ischemic tissue survival
Generally speaking, HBOT is both safe and well-tolerated. Occasionally patients will sense a pressure change or discomfort in the ears (as during an airplane flight). More serious complications can occur, though very rarely due to careful safety protocols employed. If you have a serious cardiopulmonary disease or COPD/emphysema, ask your doctor about the risk associated with HBOT.HBOT used to be the mainstay of therapy in most hospital-affiliated and insurance-billing wound centers. Unfortunately, most wound centers are constrained by the necessity of insurance reimbursement and will not be able to offer HBOT to patients unless they meet very specific criteria. In our experience, HBOT would be incredibly helpful to a much larger number of patients than those who qualify to have their insurance reimburse it.For more on hyperbaric oxygen therapy, read our guide, “Healing Your Wound with Oxygen”.
Advanced Alternative Therapies for Wound Healing
The longer we practice alternative therapies for wound healing, the more aware we have become of a variety of issues preventing your body from healing its own wounds. Chronic wounds often need advanced alternative therapies to supply the energy necessary for your body to heal. For some, this may be the only way to finally find healing.There are a number of different therapies that we’ve found to have a profound effect on wound healing.You could read thousands of words about each of these therapies, though, so we would encourage you to do additional research by Googling any of these therapies:
Detoxification
Light therapy (at specific frequencies for wound healing)
Microcurrent
High-intensity PEMF
PRP (platelet rich plasma)
Stem Cell Therapy
Ozone Therapy
Topical Insulin*
Topical Testosterone*
T3 Thyroid Cream*
The Quantlet
The HOCATT
*These must be prescribed by a physician and compounded by a pharmacist.The effects of these therapies will differ from person to person, so make sure you consult your wound care specialist if you are considering any advanced therapies.
Steps to Take to Prevent Diabetic Ulcers
If you’re currently healing from a diabetic ulcer, you know how trying that process can be. Luckily, there are steps you can take to prevent future diabetic ulcers from forming. With proper attention and work, you can significantly reduce your risk of diabetic ulcers and lessen their impact if they do occur.
Control your glucose carefully. In general, aim to keep you Hemoglobin A1C (HbA1C) levels less than 5.7 percent. Your body will be better able to heal minor wounds before they become ulcers.
Inspect your feet daily. This step is particularly important for those with peripheral neuropathy. Daily foot inspections—or even every time you remove your shoes—allow you to identify a wound and treat it before it spirals out of control.
Wash and dry your feet well. When you shower, soap your feet and wash with warm water. Make sure you fully dry them, even between the toes. Do NOT soak your feet, as excessive moisture can break down your skin.
Wear custom-fit shoes with socks. Shoes that fit well are critical to preventing diabetic ulcers. Ask your doctor about prescribing custom-fit shoes or orthotic inserts. Keep your foot padded by wearing soft socks at all times.
Don’t trim your own toenails. We’ve seen patients have their foot amputated after cutting themselves while trimming their toenails. A podiatrist can trim your toenails and manage calluses.
Use lotions or creams to combat dry skin. If you see your skin cracking or drying, use lotions or creams to prevent that. Cracked skin can lead to a small wound, which can escalate into a diabetic ulcer.
Don’t get pedicures. Just as trimming your own nails can result in minor wounds; getting a pedicure at a nail salon can as well. Nail salons generally don’t follow the procedures necessary to ensure safety for those with diabetes.
Quit smoking. Neuropathy and vascular disease both significantly compromise wound healing in diabetic patients. Quitting smoking can lower your risk of developing neuropathy and vascular disease.
Get plenty of sunlight and exercise. You can improve your overall health and reduce your risk of neuropathy and vascular disease by getting ample sunlight and regular exercise.
Protect your feet from temperature extremes. Don’t do simple tasks like getting the newspaper or cooking without protecting your feet, preferably by wearing shoes. Any temperature extremes can lead to diabetic ulcers.
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Antibiotic Ointments such as gentamicin, clindamycin, and mupirocin can be powerful tools for combating wound infection. Be careful, though: don’t use standard over-the-counter antibiotic ointment such as bacitracin and neosporin on your wound. All three of the antibiotics listed above require a prescription.
Silver has been used as an antibacterial for more than 2,000 years. Silver is extremely effective after debridement or for infected wounds. It is often paired with collagen, alginate, or foam to create dressings. You can also find silver gels—such as SilvaSorb or Silvadene—over the counter (don’t worry, they’re actually inexpensive!).
Cutimed® Sorbact® is a wound pad produced by BSN medical, Inc. Sorbact is non-medicated, but the structure of the pad uses a special technology to trap bacteria and fungi, so that every time you change the dressing, you’re reducing the amount of harmful substances in your wound. Sorbact uses a water-repelling layer to accomplish this. It binds pathogens to its surface so they can be removed at dressing changes. These dressings can be used long term without risk of antibiotic resistance, and they come in many forms: pads, gel, ribbons, and swabs.
Honey Gel is a medical-grade wound gel made with honey from bees pollinating the medicinal Manuka bush in New Zealand. Manuka honey has been used to treat wounds for thousands of years because of the powerful antimicrobial properties of honey. Honey wound gel is also an extremely effective autolytic debriding agent: some patients who regularly use honey never need sharp debridement. Honey gel is FDA-approved, inexpensive, widely available, and completely safe. It’s hard to go wrong with using honey gel on your wound, but do be on the lookout for fake Manuka honey producers (check for the UMF Certificate). We suggest the Medihoney brand.
Hydrogel is a wound gel made predominantly with water (generally 90% water). The benefit of hydrogel is that it keeps the wound environment moist. If your wound is dry enough to be in danger of forming a firm yellow scab (eschar), consider using hydrogel. You can also find hydrogel-infused bandages and gauze pads.
Hydrocolloid Dressings are flexible, absorbent bandages made from a gel-like substance. They’re excellent for maintaining an optimal moist healing environment and protecting wounds from further contamination and trauma. They usually stick to skin without tape or cover bandages. We particularly suggest these dressings for very dry wounds over bony prominences, such as the ankle. You can even look for honey-infused hydrocolloid dressings.
Elasto-Gel Wound Dressings are made up of a resilient gel which protects skin and underlying tissues from pressure and friction. It may be cut to any shape or size to fit the wound. It provides comfort, makes dressing changes easy, and will not dry out. It can also be used for prevention of ulcers when used as padding over bony areas of the foot.
Silicone Adhesive Contact Layer helps protect, soothe, and keep wounds from drying out. Even better, you can buy a foam with a layer of silicone already overlying the foam for fragile or newly healed wounds (Mepilex Border Foam).
Collagen is the single most common protein in your body. It’s used by your skin, muscles, and bones to provide strength and structure. Collagen is available in a powder or gel, which works to fill wound cavities. You can also buy collagen matrix dressings, which are bandages that absorb excess wound fluid and ensure proper moisture balance. You can buy collagen with or without antimicrobial silver.
Collagenase Santyl® ointment is the only commercially available enzymatic debriding dressing. If your wound has a significant amount of dead tissue, this is an excellent choice. It is, however, currently on patent and only available by prescription, meaning it can be quite expensive. If you have a prescription, apply a 2mm thick layer daily after cleansing with saline, then cover the wound with gauze.
Methyl-Gentian Dressings are a combination dressing that pair the antibacterial properties of metyhlene blue and the antifungal properties of gentian violet. These dressings are particularly powerful for infected wounds. Look for Hydrofera BLUE® and Hydrofera BLUE® Flex, a moldable foam that works great over pressure ulcers, bony prominences, and under compression wraps.
Alginate is specifically designed for heavily draining wounds, such as diabetic ulcers with higher Wagner grades. Alginate dressings are most often a combination of calcium and seaweed, and they absorb excess fluid and release a gel that speeds healing. You can also find alginate dressings combined with silver or honey, both of which help for infected wounds or ulcers in danger of becoming infected. Don’t use alginate dressings on drier wounds—doing so can dry out your wound too much.
Other Absorbent Products such as gel dressings (Enluxtra and Optilock), Drawtex (LevaFiber), sorbion sachet, and XTRASORB dressings are excellent for heavily draining wounds. These absorptive dressings help remove debris, control excessive drainage, and draw out bacteria and other harmful substances. Once removed, ulcers have a chance to heal.
Iodine is a powerful substance. Many people try to pour iodine or Betadine onto their wounds. That’s actually detrimental to wound health. However, you can purchase iodine-impregnated gels and “putties” that safely use the disinfectant powers of iodine. These dressings are particularly effective for wounds with active infection. Look for Iodosorb (gel) or Iodoflex (putty). For tunneling wounds and abscess cavities, iodine packing gauze is a good choice if someone can help you.
