DM Full Guideline (2010) - VA/DoD Clinical Practice Guidelines Home

Version 4.0
VA/DoD Clinical Practice Guideline
for the Management of Diabetes Mellitus
Puncture wound - A lesion through the epidermis, dermis, and other tissues caused by a piercing or penetrating
object. Patients with diabetes with puncture wounds can quickly develop severe limb-threatening complications.
Ingrown Toenail
Ingrown toenail - Presents as a nail plate that has pierced the surrounding periungual tissue with associated erythema
and drainage or an area of thick or discolored callus. The primary care provider should consider referral to a
podiatrist for excision of infected ingrown nails, especially in the case of high-risk patients (Giacalone, 1997).
Hemorrhagic Callus With or Without Cellulitis
The provider must determine if the cellulitis may be associated with callus tissue or necrotic tissue that may obscure
an underlying ulceration or deeper infection.
The callus tissue must be debrided to properly assess the extent of an underlying ulceration and possible deeper
more serious infection. Necrotic tissue must also be debrided to help eradicate the infection and determine the full
extent of the infection. The patient should be promptly referred to a foot care specialist for complete evaluation and
treatment.
evidence
Recommendation Sources LE QE SR
1 Assessment of peripheral vascular
disease.
2 Evaluation for acute ischemia or
rest pain.
Carrington et al., 2001
II-1 Fair B
Orchard , 1993
III
Orchard , 1993 III Poor I
3 Evaluation for foot ulceration. ADA, 2002
III Poor I
Brodsky , 1991
Caputo et al., 1994
Eckman et al., 1995
Reiber et al., 1995
4 Evaluation for ingrown toenail. Giacalone, 1997 II-1 Fair B
LE-Level of Evidence; QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A).
D. Refer to Appropriate Level of Care for Evaluation and Treatment
OBJECTIVE
Determine the appropriate intervention.
RECOMMENDATIONS
1. Patients with limb-threatening conditions should be referred to the appropriate level of care for evaluation
and treatment.
2. If the patient’s symptoms limit his/her lifestyle, a vascular specialist should determine the appropriateness
of surgical intervention on a patient-specific basis. Justification of vascular procedures should be based on
the outcomes of the vascular interventions.
Discussion
The patient with cellulitis, that is not complicated by hemorrhagic callus or necrotic tissue, and without systemic
signs of infection, should be treated with appropriate antibiotics, off-loading weight from the affected limb, and
aggressive follow-up to ensure that the condition does not become severe.
The patient should be alert to signs and symptoms of systemic infection to include fever, chills, nausea and
vomiting, and elevation in blood sugars. If the patient manifests any of these symptoms, he/she should notify the
provider immediately. If the infection has not resolved within 7 days of oral therapy or there is a worsening of the
symptoms, the patient should be admitted to a hospital for appropriate IV antibiotic therapy. Once the cellulitis has
Module F – Foot Care Page 99