Diabetic foot ulcers are serious complications frequently seen in individuals with diabetes. These wounds generally result from inadequate blood circulation. In diabetic patients, arterial narrowing and occlusions disrupt blood flow, hindering wound healing. However, with proper medical intervention, these obstacles can be overcome, and the wound healing process can be accelerated.
If an effective treatment method is not employed, gangrene in the feet becomes inevitable. This leads to the loss of feet and even more severe health risks. Therefore, the management of diabetic foot ulcers is of paramount importance to patient health.
| Condition Name | Non-Healing Diabetic Foot Ulcers |
| Definition | Chronic foot ulcers prone to infection, caused by nerve damage and circulation disorders related to diabetes, making them difficult to heal. |
| Symptoms | Pain, numbness or loss of sensation in the feet and legs, skin ulcers, infection, redness around the wound, swelling, discharge, and foul odor. |
| Causes | Peripheral nerve damage (neuropathy) due to diabetes, poor blood circulation, weakened immune system, inadequate foot care. |
| Risk Factors | Long-standing diabetes, poor blood sugar control, peripheral arterial disease, poor foot hygiene, smoking, advanced age. |
| Treatment Methods | Glycemic control, wound care (antiseptic solutions, antibiotic therapy), wound debridement, specialized footwear to reduce pressure, and in advanced cases, hyperbaric oxygen therapy or surgery. |
| Alternative Treatments | Biological wound dressings, growth factor therapies, negative pressure wound therapy, stem cell therapy, and ozone therapy. |
| Complications | Spread of infection, osteomyelitis (bone infection), gangrene, potential amputation, risk of sepsis (blood poisoning). |
| Prevention Methods | Blood sugar control, regular foot exams, careful foot hygiene, proper footwear, avoiding injuries, and smoking cessation. |
| Follow-Up and Monitoring | Regular physician visits, monitoring wound healing progression, continuously checking for infection and blood sugar levels. |
| Related Conditions | Diabetic neuropathy, peripheral arterial disease, weakened immune system, chronic wound infections. |
Prof. Dr. Özgür KILIÇKESMEZ
Interventional Radiology / Interventional Neuroradiology
Staging of Diabetic Foot Ulcers
Diabetic foot ulcers are staged using the Wagner Classification. This classification helps determine the severity of the ulcers and guide the treatment approach.
- Stage 0: Healthy skin with no sign of ulceration.
- Stage 1: Superficial ulcer; skin integrity is compromised.
- Stage 2: Deep ulcer that affects more tissue layers.
- Stage 3: Ulcer involving bone; indicates that the infection has reached bone tissue.
- Stage 4: Forefoot gangrene; toes or the front part of the foot are affected.
- Stage 5: Full foot gangrene; extensive tissue loss in the foot.
These stages are critical for safeguarding foot health in patients with diabetes and formulating appropriate treatment strategies. Early detection of diabetic foot ulcers helps prevent further complications.
This staging is particularly important for high-risk individuals. Successful treatment outcomes depend on accurately determining the ulcer’s stage. Thus, regular foot examinations and proper medical follow-up are essential for individuals with diabetes.
Symptoms of Diabetic Foot Ulcers
Diabetic foot ulcers can lead to serious health issues, particularly in those with diabetes. Characterized by hard-to-heal wounds on the foot, the condition arises when poor circulation causes vascular occlusions, leading to ulcer formation.
Non-healing ulcers elevate the risk of infection and can cause severe pain in advanced cases. Consequently, patients’ quality of life may significantly decline. Neglecting these wounds can worsen the condition further.
Signs of diabetic foot ulcers include:
- Persistent or recurring ulcers on the foot
- Redness and pain around the wound
- Swelling and warmth in the foot or ankle
- Skin color changes in the foot, particularly bruising or black discoloration
- Coldness or unusual temperature fluctuations in the foot
- Increased pain during walking or at rest
- Ingrown or deformed toenails
- Fungal infections and skin cracks on the foot
These are warning signs of progression in diabetic foot ulcers. Patients who notice such symptoms should seek medical attention immediately. Early diagnosis and treatment can prevent more serious complications and protect overall health.
Risk Factors for Diabetic and Chronic Foot Ulcers
Diabetic and chronic foot ulcers typically stem from high, uncontrolled blood sugar and lipid levels. Besides these health factors, poor dietary habits increase the risk. Patient age is also relevant; individuals over the age of seventy-five are more prone to wound formation. Additionally, existing vascular occlusions contribute to the development of foot ulcers.
- Uncontrolled glucose and lipid levels
- Improper dietary habits
- Excess body weight and obesity
- Advanced age
- Vascular occlusion
- Diabetes-related eye and kidney problems
- Past history of foot ulcers
- Loss of sensation in the feet
- Foot deformities, inadequate foot care, and wearing unsuitable shoes
These risk factors, especially common in individuals with diabetes, substantially raise the likelihood of ulcer formation. Identifying and managing these risks is crucial for preventing ulcers. Patients should undergo regular health check-ups and adhere to conservative treatments.
Diagnosis of Diabetic and Chronic Foot Ulcers
The initial step involves a physical examination of the patient. Detailed vascular imaging is then recommended for a more in-depth assessment. Various imaging techniques may be used, including:
- Vascular Ultrasound-Doppler: provides a detailed examination of arterial and venous systems.
- Angiographic Methods: helpful for identifying advanced vascular problems. Different angiography techniques include:
- CT Angiography (CTA)
- Magnetic Resonance Angiography (MRA)
- Conventional Angiography (DSA)
Each imaging method offers unique advantages for mapping vascular health. These techniques help doctors accurately identify arterial occlusions and stenoses, facilitating a more effective treatment plan. This comprehensive diagnostic process is vital for preventing further health complications.
Treatment Approaches: Advanced Methods for Diabetic Foot Ulcers
Various methods are adopted in treating diabetic foot ulcers. Wound cleaning and antibiotic therapy are initial steps, followed by relieving vascular occlusions. Interventional radiology is one option for clearing these blockages. Through a procedure starting at the groin, occlusions can be opened. These interventions include:
- Balloon angioplasty
- Drug-coated balloon angioplasty
- Stent placement
- Atherectomy (plaque removal)
These methods help normalize blood flow and speed up healing. In more advanced cases, further interventions may be necessary. During this stage, interventional radiology can reduce the risk of amputation and improve the patient’s quality of life. Small interventions can yield significant benefits for patients on the brink of amputation. Treatment protocols must be effectively managed to benefit the patient.
Prevention of Diabetic Foot Ulcers
To protect foot health in individuals with diabetes, the following precautions are recommended:
- Wash feet daily, paying special attention to water temperature, and dry them thoroughly.
- Use moisturizer to prevent cracks caused by dry skin, but avoid applying it between toes.
- Never walk barefoot; wear cotton socks and proper sandals or shoes.
- When choosing footwear, avoid tight and rigid designs. Select soft-soled, leather shoes that fit the foot structure.
- Use soft insoles in shoes to reduce pressure points.
- Cut toenails straight across and avoid ingrown toenails or cuts.
Smoking impairs blood circulation and should be avoided. Regular exercise can enhance blood flow in the legs and feet, reducing the incidence of diabetic foot ulcers. Corns must be addressed by professionals.
Sharp tools or medicated corn removers should not be used. Professional diabetic foot care centers should handle the cleaning of corns. Regular maintenance can reduce the risk of ulcer formation.
Angioplasty Treatment for Non-Healing Diabetic Foot Ulcers
In treating diabetic foot ulcers, angiography involves endovascular revascularization procedures. These minimally invasive techniques aim to restore blood flow to the affected area and promote wound healing. Key steps in the procedure include:
- Angiogram: A contrast dye is injected into the blood vessels, enabling visualization of occlusions and narrowed areas via X-ray imaging.
- Balloon Angioplasty: A small catheter with a balloon tip is guided to the occluded area and inflated. This dilates the narrowed artery and improves blood flow.
- Stent Placement (if necessary): In cases of severe occlusion or weakened artery walls, a small mesh tube called a stent may be inserted to keep the artery open and maintain blood flow.
- Atherectomy (if necessary): In some situations, plaque removal devices are used to clear arterial build-up.
Before treatment, the patient’s overall health and location of the occlusion are evaluated — critical to forming a treatment plan. Post-procedure, patients must practice rigorous wound care and attend regular medical check-ups. The goal is to reduce infection risk and support wound healing.
Moreover, lifestyle modifications made by the patient can positively influence treatment outcomes. Healthy eating, regular exercise, and smoking cessation improve blood circulation and facilitate faster wound healing. Consequently, a multidisciplinary approach can achieve success in managing diabetic foot ulcers. Patient education and motivation also play a vital role in the treatment process.
Frequently Asked Questions
Daily cleaning is vital for foot ulcers resulting from diabetes. The ulcer should be gently cleaned with soap and water. Keeping the wound dry and bandaged lowers the infection risk. Hydrogen peroxide and similar products should be avoided as they can damage tissue. Specialized footwear or orthotic supports help relieve pressure on the foot. As prescribed by a doctor, topical treatments such as saline solutions or growth factors may accelerate wound healing. Optimized blood sugar levels enhance the body’s ability to heal. If there are any signs of infection, immediate medical consultation is necessary.
Diabetic foot ulcers do not heal spontaneously. Because patients with diabetes have a weakened immune system, their healing process is slow. Additionally, a weaker immune system can rapidly exacerbate infections. Thus, foot ulcers in diabetic patients require specialized care and treatment. Without proper intervention, ulcers can worsen and lead to serious health complications. In summary, diabetic foot ulcers do not heal without professional medical intervention.
In diabetic foot treatment, Internal Medicine and Endocrinology manage overall health problems. Interventional Radiology and Cardiovascular Surgery address vascular circulation issues. Dermatology focuses on skin health, while Infectious Diseases controls infection risk. Plastic and Reconstructive Surgery repairs damaged tissues. Orthopedics manages skeletal structure and mobility, and Interventional Radiology provides imaging-based interventions (balloon, stent, atherectomy, etc.).
Diabetic foot ulcer (DFU) healing is often prolonged due to several factors: About 50–70% of DFUs are associated with peripheral artery disease (PAD), which impairs blood flow and thus delays healing. Neuropathy, common in diabetic patients, causes loss of sensation, allowing unnoticed injuries to worsen. Chronic inflammation and weakened immunity also hamper the body’s capacity to repair ulcers. Nutritional deficiencies (albumin, hemoglobin, iron, zinc) are found in many diabetic foot patients, hindering healing. Consequently, DFU recovery times range from 3 to 12 months, depending on ulcer characteristics and overall health status.
Diabetic foot ulcers occur in up to 34% of patients with diabetes, 50–89% of which can become infected, substantially increasing the risk of amputation. To prevent infection, stringent blood sugar control is crucial for strengthening the immune system and supporting healing. Daily foot checks help identify cuts or blisters early for immediate treatment. Proper footwear avoids pressure points and injuries, and patients should never walk barefoot. Regular foot care, including nail trimming and callus removal, should be performed by health professionals. Quitting smoking enhances circulation, and patient education regarding foot hygiene further decreases infection risk. These strategies significantly reduce infection and complication rates in diabetic foot ulcers.
Hyperbaric oxygen therapy (HBOT) is considered effective for diabetic foot ulcers. One study reported that 52% of patients receiving HBOT experienced complete ulcer healing within a year, versus 29% in the placebo group. Additionally, in patients receiving local HBOT, the wound surface area declined from 8.54 cm² to 4.23 cm², while pain levels on the Visual Analog Scale dropped from 4.64 to 1.51. However, systematic reviews assessing HBOT’s efficacy highlight variability in evidence quality, indicating the need for further high‑quality research.
Surgical intervention in diabetic foot therapy is generally required for severe infections like abscess, gas formation, or necrotizing fasciitis. In cases of diabetic foot osteomyelitis, combining surgical and medical treatment yields a success rate of approximately 85.7%, compared to 68.2% when using medical treatment alone. Patients with peripheral artery disease who develop foot ulcers or gangrene are advised to rapidly consult surgical and vascular specialists for drainage or revascularization.
Moist wound dressings can shorten healing time by an average of 2.5 days compared to traditional gauze, accelerating diabetic foot ulcer recovery. They also reduce infection rates by around 70% and decrease dressing changes by roughly 3.6 times. Silver‑based dressings can shorten healing time by up to 95% compared to iodine-based dressings. Polyurethane dressings create a moist environment conducive to healing. Emerging “smart” dressings allow real‑time monitoring of wound healing.
In diabetic foot ulcers, angioplasty is often needed to restore blood flow and support effective wound healing. Studies show that angioplasty is feasible in a large proportion of diabetic patients with peripheral occlusive artery disease and foot ulcers, significantly improving limb perfusion parameters. Additionally, using an angiosome-based model for targeted angioplasty raises primary wound healing rates, shortens the time to complete healing, and reduces major amputations in patients with resistant diabetic foot ulcers. Thus, angioplasty plays a critical role by increasing blood flow and aiding the healing process in diabetic foot ulcer treatment.
Prof. Dr. Özgür Kılıçkesmez graduated from Cerrahpaşa Medical Faculty in 1997. He completed his specialization at Istanbul Education and Research Hospital. He received training in interventional radiology and oncology in London. He founded the interventional radiology department at Istanbul Çam and Sakura City Hospital and became a professor in 2020. He holds many international awards and certificates, has over 150 scientific publications, and has been cited more than 1500 times. He is currently working at Medicana Ataköy Hospital.
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