best practice guidelines: wound management in diabetic foot ulcers

DFU WOUNDMANAGEMENTBOX 5: The use of advanced therapiesDressing application and wound monitoringRegularly reviewing a patient's wound anddressing is vital. For infected or highly exudingwounds, a healthcare professional shouldinspect the wound and change the dressingdaily, and then every two or three days once theinfection is stable. A different type of dressingmay be needed as the status of the woundchanges.Some patients, especially those with mobilityissues or work commitments may prefer tochange their dressings themselves, or have arelative or carer to do it. These patients shouldbe advised about using aseptic technique andthe wound should continue to be reviewedat regular intervals by the MDFT or otherhealthcare team members. Patients should beencouraged to look out for signs of deterioration,such as increased pain, swelling, odour,purulence or septic symptoms. In some cases(eg in the first few days of antibiotic therapy) itis a good idea to mark the extent of any cellulitiswith an indelible marker and tell the patientto contact the footcare team immediately if theredness moves substantially beyond the line.When applying dressings: Avoid bandaging over toes as this maycause a tourniquet effect (instead, layergauze over the toes and secure with a bandagefrom the metatarsal heads to a suitablepoint on foot) Use appropriate techniques (eg avoidingcreases and being too bulky) and take carewhen dressing weight-bearing areas Avoid strong adhesive tapes on fragileskinAdjunctive treatments such as negative pressure wound therapy (NPWT), biologicaldressings, bioengineered skin equivalents, hyperbaric oxygen therapy, plateletrich plasma and growth factors may be considered, if appropriate and where availablefor DFUs that are not progressing 95 . These techniques require advanced clinicaldecision making and should be carried out only by practitioners with appropriateskills and anatomical knowledge 22 .However, such therapies represent considerable greater product cost than standardtherapy. These costs may be justified if they result in improved ulcer healing,reduced morbidity, fewer lower-extremity amputations and improved patientfunctional status 95 . There is a good level of evidence for some biological skinequivalents 95 as well as for the use of NPWT in DFU patients without significantinfection 96 . More recently, NPWT with instillation therapy (NPWTi) using antisepticagents (eg PHMB) has become available. Although there are limited dataon its benefits, it could be considered when there is a need for wound cleansing ortreatment with topical antimicrobials 97 . Avoid tight bandaging at the fifth toe andthe fifth metatarsal head (trim the bandageback) Ensure wound dead space is eliminated (eguse a dressing that conforms to the contoursof the wound bed) Remember that footwear needs to accommodateany dressing.Wounds should be cleansed at each dressingchange and after debridement with a woundcleansing solution or saline. Cleansing canhelp remove devitalised tissue, re-balance thebioburden and reduce exudate to help preparethe wound bed for healing 98 . It may also helpto remove biofilms 88 .Managing pain at dressing changesIt is now acknowledged that many patients —even those with neuropathy or neuroischaemia— can feel pain due to their wound or a procedure99 . It is important to incorporate strategiesto prevent trauma and minimise wound-relatedpain during dressing changes 100 . This mayinclude the use of soft silicone dressings andavoiding unnecessary manipulation of thewound 99 . Remember also that patients whohave lost the protective pain sensation are atgreater risk of trauma at dressing change 99 .When appropriate, use low- or non-adherentdressings 99 . If a dressing becomes encrustedor is difficult to remove, it is important to soakthe dressing with saline or a wound irrigationsolution and check the wound and surroundingskin for evidence of trauma and infection ondressing removal 99 .Epithelial edge advancementIt is important to debride the edges of the ulcerto remove potential physical barriers to thegrowth of the epithelium across the ulcer bed 74 .The demarcation line between any necrotictissue or gangrene and healthy tissue maybecome a site of infection 48 . Similar problemscan be seen when a gangrenous toe touches ahealthy toe 50 .Conversely, ‘die-back’ is an abnormal responseto over-aggressive sharp debridement. Itinvolves necrosis at the wound edge andextends through previously healthy tissue 50 .If the wound does not respond to standardwound management interventions despitetreatment of the underlying cause and316 BEST PRACTICEBEST PRACTICEGUIDELINESGUIDELINES:FOR SKINWOUNDAND WOUNDMANAGEMENTCARE ININEPIDERMOLYSISDIABETIC FOOTBULLOSAULCERS