<unk>  ulcers in diabetes require multidisciplinary assessment, usually by diabetes nurse specialist, a tissue viability nurse, podiatrists, diabetes specialists and surgeons. An aim to improve glycaemic control, if poor, forms part of the management, to slow disease progression. Individuals who have sausage shaped toes, a positive 'probe to bone' test, evidence suggesting osteomyelitis, suspected charcot neuroarthropathy, or those whose ulcers do not improve within 4 weeks of standard care and where there is evidence that exudate is of synovial membrane in origin. When osteomyelitis is suspected to be involved in the<unk>  ulcer, but not evidenced on an x-ray, an MRI scan should be obtained. With regards to infected<unk>  ulcers, the presence of microorganisms is not in itself enough to determine whether an infection is present. Signs such as inflammation and purulence are the best indicators of an active infection. The most common organism causing infection is staphylococcus. The treatment consists of debridement, appropriate bandages, managing peripheral arterial disease and appropriate use of antibiotics (against pseudomonas aeruginosa, staphylococcus, streptococcus and anaerobe strains), and arterial revascularisation. Fespixon Cream(ON101) There was a novel topical medication developed by a Taiwanese company, Oneness Biotech Co. Ltd (4743:Taipei), called ON101(officially named Fespixon cream(速必一) later), which showed promising efficacy on<unk>  healing. During a 3rd phase clinical trial of 236 patients, it showed superior complete healing rate with 60.7% in 16 weeks in average, comparing to aquacel with 35.1%. Its active components were PA-F4(from Plectranthus amboinicus) and S1(from Centella asiatica).Fespixon Cream(ON101) is a first-in-class macrophage-regulating new drug for the chronic wounds. It can effectively regulate the immune environment in the<unk>  (hyperglycemia causes dermatological immunopathy on DM patients) by suppressing M1 φ overexpression and increase M2 φ to transit the inflammation stage to proliferation stage and to resolve<unk>  chronicity. On 2021 February, it was approved by Taiwan Food and Drug Administration to be launched in Taiwan market. Antibiotics The length of antibiotic courses depend on the severity of the infection and whether bone infection is involved but can range from 1 week to 6 weeks or more. Current recommendations are that antibiotics are only used when there is evidence of infection and continued until there is evidence that the infection has cleared, instead of evidence of ulcer healing. Choice of antibiotic depends on common local bacterial strains known to infect ulcers. Microbiological swabs are believed to be of limited value in identifying causative strain. Microbiological investigation is of value in cases of osteomyelitis. Most ulcer infections involve multiple microorganisms. There is limited safety and efficacy data of topical antibiotics in treating<unk> s. Wound dressings There are many types of dressings used to treat<unk> s such as absorptive fillers, hydrogel dressings, and hydrocolloids. There is no good evidence that one type of dressing is better than another for<unk> s. In selecting dressings for chronic non healing wounds it is recommended that the cost of the product be taken into account. Hydrogel dressings may have shown a slight advantage over standard dressings, but the quality of the research is of concern. Dressings and creams containing silver have not been properly studied nor have alginate dressings. Biologically active bandages that combine hydrogel and hydrocolloid traits are available, however more research needs to be conducted as to the efficacy of this option over others. Total contact casting Total contact casting (TCC) is a specially designed cast designed to take weight of the<unk>  (off-loading) in patients with<unk> s. Reducing pressure on the wound by taking weight of the<unk>  has proven to be very effective in<unk>  treatment.<unk> s are a major factor leading to lower leg amputations among the<unk>  population in the US with 85% of amputations in<unk> s being preceded by a<unk> . Furthermore, the 5 year post-amputation mortality rate among<unk> s is estimated at around 45% for those suffering from neuropathic<unk> s. TCC has been used for off-loading<unk> s in the US since the mid-1960s and is regarded by many practitioners as the “reference standard” for off-loading the bottom surface (sole) of the<unk> . TCC helps patients to maintain their quality of life. By encasing the patient’s complete<unk>  — including the toes and lower leg — in a specialist cast to redistribute weight and pressure from the<unk>  to the lower leg during everyday movements, patients can remain mobile. The manner in which TCC redistributes pressure protects the wound, letting damaged tissue regenerate and heal. TCC also keeps the ankle from rotating during walking, which helps prevent shearing and twisting forces that can further damage the wound. Effective off loading is a key treatment modality for<unk> s, particularly those where there is damage to the nerves in the feet (peripheral neuropathy). Along with infection management and vascular assessment, TCC is vital aspect to effectively managing<unk> s. TCC is the most effective and reliable method for off-loading<unk> s. A 2013 meta-analysis by the Cochrane Collaboration compared the effectiveness of non-removable pressure relieving interventions, such as casts, with therapeutic shoes, dressings, removable pressure relieving orthotic devices, and surgical interventions. Non-removable pressure relieving interventions, including non-removable casts with an Achilles tendon lengthening component, were found to be more effective at healing<unk>  ulcers related to diabetes that therapeutic shoes and other pressure relieving approaches. TCC systems include TCC-EZ (Integra LifeSciences) and Cutimed Off-loader (BSN Medical). Hyperbaric oxygen In 2015, a Cochrane review concluded that for people with<unk> s, hyperbaric oxygen therapy reduced the risk of amputation and may improve the healing at 6 weeks. However, there was no benefit at one year and the quality of the reviewed trials was inadequate to draw strong conclusions. Negative pressure wound therapy This treatment uses vacuum to remove excess fluid and cellular waste that usually prolong the inflammatory phase of wound healing. Despite a straightforward mechanism of action, results of negative pressure wound therapy studies have been inconsistent. Research needs to be carried out to optimize the parameters of pressure intensity, treatment intervals and exact timing to start negative pressure therapy in the course of chronic wound healing. There is low-certainty evidence that negative pressure wound therapy would improve wound healing in<unk> s. Other treatments Ozone therapy – there is only limited and poor-quality information available regarding the effectiveness of ozone therapy for treating<unk>  ulcers in people with diabetes. Growth factors - there is some low-quality evidence that growth factors may increase the likelihood that<unk> s will heal completely. Continuous diffusion of oxygen (CDO) - CDO delivers continuous oxygen to an occluded, moist wound site at much lower flow rates of 3–12 mL/h for 24 h 7 days a week for up to several weeks or months, depending on the wound status. Phototherapy - there is very weak evidence to suggest that people with<unk>  ulcers due to diabetes may have improved healing. There is no evidence to suggest that phototherapy improves the quality of life for people with<unk>  ulcers caused by diabetes. Sucrose-octasulfate impregnated dressing is recommended by the International Working Group on the<unk>  (IWGDF) for the treatment of non-infected, neuro-ischaemic<unk> s that do not show an improvement with a standard of care regimen Autologous combined leucocyte, platelet and fibrin as an adjunctive treatment, in addition to best standard of care is also recommended by IWGDF However, there is only low quality evidence that such treatment is effective in treating<unk> . There is limited evidence that granulocyte colony-stimulating factor may not hasten the resolution of<unk>  infection. However, it may reduce the need for surgical interventions such as amputations and hospitalizations. It is unknown that whether intensive or conventional blood glucose control is better for<unk>  healing. A 2020 Cochrane systematic review evaluated the effects of nutritional supplements or special diets on healing<unk>  ulcers in people with diabetes. The review authors concluded that it's uncertain whether or not nutritional interventions have an effect on<unk>  ulcer healing and that more research is needed to answer this question. Skin grafting and tissue replacements can help to improve the healing of<unk> . A 2021 systematic review concluded that there was no strong evidence about the effects of psychological therapies on<unk>  healing and recurrence.
Diabetic foot ulcer
Diabetic foot infection
Diabetic sock
Arterial insufficiency ulcer
Chronic venous insufficiency
Athlete's foot
Linguatulosis
Pressure ulcer