Healing of skin lesions in diabetic foot syndrome during hospitalization

Czech version

Authors: A. Jirkovská
Authors‘ workplace: Centrum diabetologie IKEM, Praha, přednostka prof. MUDr. Terezie Pelikánová, DrSc.
Published in: Vnitř Lék 2006; 52(5): 459-464
Category: Diabetes and other subjects (infection, dermatovenerology and rheumatology) Hradec Králové 3 to 4 June 2005

Overview

Wound healing during the diabetic foot disease is indicated to in-patient treatment in case of non-healing wound, in case of serious infection and/or critical ischemia and in case of necessity of surgical treatment. Diabetic foot disease is the main reason for in-patient treatment of people with diabetes, which our experience confirms. Chronic wound is characterised by non-healing for at least 4 weeks. Ischemia and recurrent trauma caused by incomplete off-loading, prolong inflammation and infection are the main reasons for difficult healing of chronic wound. Infection is also leading cause for prolonged hospitalisation of patients with diabetic foot disease. Local decrease of grow factors and increase of tissue protease are characteristics of chronic wound. The process of wound healing is characterized by a cascade of interrelated events involving infection and inflammatory factors. The results of these investigations led to the moist wound healing concept and use of growth factors and bioengineered skin substitutes. We have good experience with the use of xenotransplant skin substitues in the treatment of diabetic foot. Off loading techniques including total contact casting, local therapy by debridement and skin substitutes had the best evidence based efficacy. We are introducing new method of the treatment of diabetic foot – VAC – vacuum assisted closure. The fundamental principle in the therapy during in-patient period, is comprehensive approach; the omitting of any of the principle of the therapy – e.g. the off-loading of the ulcers, the infection and ischemia control, may contribute to its failure.

Key words:
diabetic foot disease - chronic wound treatment - foot infection

Sources

1. Eneroth M, Larsson J, Apelqvist J. Deep foot infections in patients with diabetes and foot ulcer: an entity with different characteristics, treatments, and prognosis. J Diab Comp 1999; 13: 254-263.

2. Caputo G, Cavanagh PR, Ulbrecht JS et al. Assessment and management of foot disease in patients with diabetes. N Engl J Med 1994; 331: 854-860.

3. Caputo GM. The rationale use of antimicrobial agents in diabetic foot infection.. In: Boulton AJM, Connor H, Cavanagh PR (eds). The foot in diabetes. Chichester: John Wiley and sons, LTD 2000: 143-151.

4. Mason J, Keeffet CO, Hutchinson A et al. A systematic review of foot ulcer in patients with type 2 diabetes mellitus. II: Treatment. Diabet Med 1999; 16: 889-909.

5. Chantelau E, Tanudjaja T, Altenhofer F et al. Antibiotic treatment for uncomplicated forefoot ulcers in diabetes: a controlled trial. Diabet Med 1996; 13: 156-159.

6. Jeffcoat WJ, Price P, Harding KG. Wound healing and treatments for people with diabetic foot ulcers. Diabetes Metab Res Rev 2004; 20(Suppl 1): S78-S89.

7. Steed DL. Role of growth factors in the treatment of diabetic foot ulceration. In: Veves A, Giurini JM, LoGerfo FW (eds). The diabetic foot. Totowa: Human Press 2002: 385-395.

8. Katz MH, Alvarez AF, Kirsner RS et al. Human wound fluid from acute wounds stimulates fibroblasts and endotelial cell growth. J Am Acad dermatol 1991; 25: 1054-1058.

9. Bucalo B, Eaglstein WH, Falanga V. Inhibition of cell proliferation by chronic wound fluid. Wound Rep Regen 1993; 1: 181-186.

10. Grey JE, Jones V, Harding KG. Principles of treatment of chronic wound. In: Veves A, Giurini JM, LoGerfo FW (eds). The diabetic foot. Totowa: Human Press 2002: 247- 278.

11. Eldor R, Raz I, Ben Yehudat A et al. New and experimental approaches to treatment of diabetic foot ulcers: a comprehensive review of emerging treatment strategies. Diabet Med 2004; 21: 1161-1173.

12. Courtney M. The use of larval therapy in wound management in the UK. J Wound Care 1999; 8: 177-179.

13. Armstrong DG, Salas P, Short B et al. Maggot therapy in „lower- extremity hospice“ wound care: fewer amputations and more antibiotic-free days. J Am Podiatr Med Assoc 2005; 95: 254-257.

14. Kalani M, Brismar K, Fagrell B et al. Transcutaneous oxygen tension and toe blood pressure as predictors for outcome of diabetic foot ulcers. Diabetes Care 1999; 22: 147-151.

15. Fife CE, Buyukcakir C, Otto GH et al. The predictive value of transcutaneous oxygen tension measurement in diabetic lower extremity ulcers treated with hyperbaric oxygen therapy: a retrospecitve analysis of 1 144 patients. Wound Repair Regen 2002; 10: 198-207.

16. Falanga V, Oian SV, Danielpour D et al. Hypoxia upregulates synthesis of TGF β 1 by human fibroblasts. J Invest Dermatol 1991; 97: 634-637.

17. Jirkovská A. Aktuální problematika syndromu diabetické nohy. In: Perušičová J (ed). Trendy soudobé diabetologie. Praha: Galén 2001: 51-87.

18. Piaggesi A, Viacava P, Rizzo L et al. Semiquantitative analysis of the histopathological features of the neuropathic foot ulcers. Diabetes Care 2003; 26: 3123-3128.

19. Steed DL. Clinical evaluation of recombinant human platelet-derived growth factor for the treatment of lower extremity diabetic ulcers. The diabetic ulcer study group. J Vasc Surg 1995; 21: 71-78.

20. Smiell JM, Wieman TJ, Steed DL et al. Efficacy and safety of becaplermin (recombinant human platelet-derived growth factor BB) in patients with nonhealing, lower extremity diabetic ulcers: a combined analysis of four randomized studies. Wound repair regen 1999; 7: 335-346.

21. Veves A, Sheehan P, Pham HT. A randomized, controlled trial of Promogran (a collagen/oxidized regenerated cellulose dressing) vs standard treatment in the management of diabetic foot ulcers. Arch Surg 2002; 137: 822-827.

22. Badiavas EV, Falanga V. Treatment of chronic wounds with bone-marrow derived cells. Arch Dermatol 2003; 139: 510-516.

23. Falanga V, Isaacs C, Paquette D et al. Wounding of bioengineered skin: cellular and molecular aspects after injury. J Invest Dermatol 2002; 119: 653-660.

24. Armstrong DG, Lavery LA, Abu-Rumman P et al. Outcomes of sub-athmospheric pressure dressing therapy on wounds of the diabetic foot. Ostotomy Wound management 2002; 48: 64-68.

25. Armstrong DG, Boulton AJM, Banwell PE. Topical negative pressure: management of complex diabetic foot wounds. Oxford: The Oxford Wound Healing Society 2004.