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Diabetic foot ulcers – prevention and treatment A Coloplast quick guide Biatain® – the simple choice
Diabetic foot ulcers have a considerable negative impact on The diabetic foot – a clinical challenge . 5 patients' lives, and are highly susceptible to infection that al too Pathway to clinical care and clinical evidence . 6 often leads to amputation. It is essential that diabetic foot ulcers How to prevent DFU's . 7 receive the best possible wound management. Successful y treating Prevention and education . 7 a diabetic foot ulcer requires a comprehensive understanding of the Prevention of ulcer formation . 8 wound: its cause, progression, risk, and treatment. But more than An interprofessional team approach . 9 this, it takes a cross functional approach, where the patient also has The patient's role . 10 an active role in the treatment process. Consider the whole patient to ensure effective care . 11How to diagnose and assess a diabetic foot ulcer . 12 The information provided here is intended as a general guideline. "The VIPS" of diabetic foot management . 12 Please consult diabetic foot ulcer guidelines applicable in your area. Local wound assessment . 13 For further study, please refer to the International Consensus on the Types of neuropathy . 14 Diabetic Foot, 2011.2 10g monofilament testing . 15Areas at risk for neuropathic, ischaemic and We hope that this quick guide wil help you diagnose, assess and neuoro-ischaemic ulcers . 16 treat diabetic foot ulcers in clinical practice, as wel as identify Clinical symptoms of neuropathic opportunities for prevention and minimising the risk of infection and and ischmaemic foot ulcers . 17 Ulcer assessment . 18Wound bed . 19 Superficial and deep infection symptoms . 20 Faculty panel: Dr. Christian Münter, Germany; Professor Patricia Wagner classification . 21 Price, UK; Wilma Ruigrok van der Werven, MA, RN, Netherlands; How to treat a diabetic foot ulcer . 22 Professor Gary Sibbald, Canada Treatment of diabetic foot ulcers . 22Local wound treatment . 23 Review panel: Patricia Coutts, RN, Canada; Mike Edmonds, Coloplast solutions for diabetic foot ulcers . 24 Consultant Diabetologist, UK; Professor Keith Harding UK; Coloplast antimicrobial dressings for infected Maria Mousley, AHP, Consultant, Podiatrist, UK diabetic foot ulcers and ulcers at risk of infection . 26 This Coloplast quick guide was updated in March 2012 in Biatain® – superior absorption for faster healing . 30 col aboration with Dr. Christian Münter.
Other Coloplast products for diabetic foot ulcers . 32 "I marvel that society The diabetic foot would pay a surgeon a – a clinical chal enge fortune to remove a person's leg – but nothing to save it!" Diabetes is a serious chronic disease that needs attention. Approximately 15% of al people with diabetes wil be affected by a foot ulcer during their lifetime.1 George Bernard Shaw Diabetic foot ulcers (DFUs) often co-exist with vascular insufficien-cy and are the major cause of gangrene and amputation in people with diabetes. Risk of developing diabetic foot ulcers is greatly in-creased by reduced sensation and blood pressure. Diabetic foot ulcers represent a huge risk to the patient's quality of life, escalating wound/infection management and costs, and account for a large proportion of al national healthcare budgets · Five-year recurrence rates of foot ulcers are 70%2 · Up to 85% of al amputations in relation to people with diabetes are preceded by a foot ulcer1-2 · People with diabetes with one lower limb amputation have a 50% risk of developing a serious lesion in the second limb within 2 years3 · People with diabetes have a 50% mortality rate in the 5 years fol owing the initial amputation4 It is possible to reduce amputation rates by 49-85% through a care strategy that combines prevention, the interprofessional diabetes care team, appropriate organisation, close monitoring and education.1 Pathway to clinical care How to prevent DFUs and clinical evidence Prevention and education "49-85% of all diabetic foot related problems are preventable." Diabetic foot ulcers Spraul, M., 2000.6 "This can be achieved through a combination of good foot care, provided by an interprofessional diabetes care team, and appropriate education for people with diabetes." Modified from Bakker, K. et al., 2005.1 "Education of patients, carers, and healthcare providers is an essential component of an effective, interprofessional team approach, …but effective systems and structures for screening, provision of chiropody and footwear, and prompt treatment when required must be in place." Modified from Spraul, M., 2000.6 "The most important aspects, for example, danger signs which require prompt action by the patient, should be summarized and repeated."Spraul, M., 2000.6 Evidence-based wound management "Successful diagnosis and treatment of patients with chronic wounds involve holistic care and a team approach. The integration of the work of an interprofessional care team that includes doctors, nurses and al ied health professionals with the Real life studies patient, family and caregivers offers an optimal formula for achieving wound resolution."Sibbald, R.G., et al, 2001.18 Prevention of ulcer formation An interprofessional team approach People with diabetes must inspect their feet regularly, or have a family member or care provider do it on their behalf. Daily inspection is the foundation of diabetic foot ulcer prevention. Al wounds and sores should be taken seriously early on.
· Family doctor/General practitioner· Orthopaedic surgeon Regular, gentle cleansing with soapy water, followed by the · Rehabilitation team: application of topical moisturizers, helps to keep the skin healthy – Occupational therapist and better able to resist breakdown and injury.
– Physiotherapist or – Specialised physician Shoes should be checked to ensure that they fit properly and offer · Interventional radiologist adequate support. Consider athletic/sports shoes and thick, · Vascular surgeon padded socks. Diabetic socks (unrestrictive on circulation) are also · Community nurse available. In the case of foot deformities or special support needs, custom shoes should be considered. · Orthotist· Footcare specialist: Podiatrist Minor foot injuries and infections, such as cuts, scrapes, blisters and tinea pedis (athletes foot), can be unintentional y worsened by home treatments that impede healing. Patients should be reminded to · Diabetes educator avoid hot soaks, heating pads and harsh topical agents such as hydrogen peroxide, iodine and astringents. A moist wound environment wil help prevent ulcer formation. Minor wounds should be gently cleansed and treated with topical antiseptics. In addition, a physician should inspect any minor wounds that do not heal quickly.
By reinforcing preventive advice and inspecting the patient's feet at routine follow-ups, the physician can help the patient develop and The involvement of the patient as maintain good foot-care practices.
a member of the healthcare team improves patient care outcomes The patient's role Consider the whole patient to ensure effective Patient self-exam needs to be part of care of the foot ulcer diabetic foot care and fol ow-up Education of patient, family and healthcare providers, such as Past history, medications Check for medications that may inhibit healing using an easy to understand patient leaflet for education, must be (i.e. steroids, immunosuppressants) Neurological, eye, heart, kidney, vascular · Any cut or open skin should be treated by a qualified healthcare Glycaemic* control Hb (Haemoglobin) A1c < 7.5% provider immediately (depending on the specific situation of the patient, e.g. medication, risk of hypoglycemia, body weight) · Inspect and examine the feet and shoes on a daily basis Hypertension* control · Appropriate footwear Clinical obesity* control BMI < 30 kg/m2 · Nails should be cared for by a qualified foot specialist (podiatrist Hyperlipidemia* control Cholesterol < 5,2 mmol/L (200 mg/dL) or related disciplines) · Dry skin should be treated with appropriate moisturizing, such as (humectant) creams containing urea or lactid acid18 *Al 4 are associated with the metabolic syndrome and type 2 onset diabetes. Optimal control of diabetes wil improve patient care outcomes.
· Fungal infections, especial y of the toe webs require topical These are general guidelines. Please check local treatment recommendations applicable for your country or healthcare institution.
antifungal agents Patients should always remember to remove socks and shoes for regular inspection of both feet
How to diagnose and assess a diabetic foot ulcer"The VIPS"7,8 of diabetic foot Local wound assessment10 management to ensure outcomes Vascular supply is adequate · Previous ulcer(s), amputations Local skin assessment Infection control is achieved Sharp/surgical debridement has been considered Vascular examination · Check for peripheral arterial disease Symptoms are often not found, but the following signs may be present: cold feet, blanching on elevation, absent hair growth, dry, shiny and atrophic skin9 Diabetic foot ulcers typically have a thick rim · Palpate and check for dorsalis pedis, posterior tibial, of keratinized tissue surrounding the wound9 popliteal and femoral pulses9 · Measure the ankle brachial pressure index (ABPI) Toe pressure or transcutaneous oxygen may be assessed, because arterial calcification can cause falsely elevated ABPI results9 · Sensory – loss of protective sensation · Autonomic – lack of sweating that results in dry, cracked skin that bleeds and creates a portal of entry for bacteria · Muscular – loss of reflexes or atrophy of muscles that leads to foot deformities · Hammer toes, claw toes, bunions · Check the deformity and address inappropriately Blisters are associated with friction Cal us is associated with increased pressure and haemorrhage
Types of neuropathy10 10g monofilament testing The 10g monofilament testing is recommended as a screeningtool to determine the presence of protective sensation in people with · Loss of protective · Reduced sweating · Dysfunction of the motor nerves that · No perception of Places for testing shoes rubbing or · Increased blood foot. Limited joint · Plantar surface of the metatarsal heads increase plantar (min. 3 metatarsal heads)12,13 · The great toe/first toe12 · Foot deformities · The medial and lateral sides of the plantar aspect of the midfoot13 · The plantar area of the heel13 · Unaware of a foot · Dry skin with · The dorsal aspect of the midfoot13 ulcer or lack of longitudinal arch, discomfort when a · Bounding pulses metatarsal heads · Dilated dorsal The pictures show testing sites "There is no clear evidence on how many negative response sites equals an at-risk foot. Some literature shows that even one site with a negative response on each foot may indicate an at-risk foot." Baker, N. et al., 2005.12 Areas at risk for neuropathic, ischaemic Clinical symptoms of neuropathic and neuro-ischaemic ulcers and ischaemic foot ulcers14 In a cross-sectional, population-based study the proportion of the lesions were*2 Clawed toes, possible high arch, No specific deformities.
possible Charcot deformities Possible absent toes/forefoot from previous amputations Warm, palpable pulse Cold or decreased temperature, pulse may be absent or reduced Pale/bluish. Pronounced redness when lowered (dependent rubor), blanching on elevation Dry skin due to decreased Thin, fragile and dry Neuropathic ulcers 55% of total Ischaemic ulcers 10% and diabetic foot ulcers neuro-ischaemic ulcers 34% of On the plantar aspects (forefoot Distal/tips of the toes, total diabetic foot ulcers 80%) of the foot/toes heel, or margins of the foot Commonly seen on the Not usual y. If present, weight-bearing areas and is distal eschar or necrosis "Recent experience from our clinic indicates that the frequency of neuropathic ulcers has decreased, and the incidence of ischaemic Usual y painless, with a Painful, especial y with and neuro-ischaemic ulcers has increased, equaling 50-50%." "punched out" appearance necrosis or slough Mike Edmonds, 2005.
(granulation or deeper base) surrounded by cal us Reduced or absent sensation to Sensation may be present but touch, vibration, pain, and decreased if there is associated Usual y not present Present and often bounding.
Absent or markedly reduced Dilated, prominent veins *1% of the ulcers were considered not to be diabetes-related.
Burning, stinging, shooting and stabbing (non-stimulus dependent) Deep infection or Charcot joint Length, width, depth and location, preferably with clinical photograph · Black (necrosis) · Yel ow, red, pink Be aware that some signs (fever, pain, increased white blood count/ ESR) may be absent. Evaluate the ulcer for signs of infection, inflammation and oedema. For more information, please see page 20 Copious, moderate, mild, none Cal us and scale, maceration, erythema, oedema Wound undermining, deep tissue infection Unhealthy wound edge Superficial and deep infection symptoms10,15,16 Wagner classification Superficial (local) – Treat topically No open lesions; may have deformity or cel ulitis · Exuberant friable granulation tissue· Bright red discoloration of granulation tissue· Increased exudate· Malodour Superficial diabetic ulcer (partial or ful thickness) · New slough in wound base Topical antimicrobial treatment may be considered for superficial/local infection, dependent on the assessment that wil direct the Ulcer extension to ligament, tendon, joint capsule, treatment. Superficial/local infection may, however, require or deep fascia without abscess or osteomyelitis systemic antibiotics. For further details and updates, please see the International Consensus on the Diabetic Foot, 2011.2 Deep – Treat systemically Deep ulcer with abscess, osteomyelitis, or joint · Pain· Probes to bone (increased risk in the presence of osteomyelitis) · New areas of break-down Gangrene localised to portion of forefoot or heel · Warmth· Erythema, oedema Extensive gangrenous involvement of the entire Signs of local and deep infection are potential y limb and/or life threatening. These clinical signs and symptoms require Further reading: urgent medical attention International Consensus on the Diabetic Foot, The International Working Group on the Diabetic Foot, 20112, www.iwgdf.org diabetic foot ulcerTreatment of diabetic foot ulcers Local wound treatment · If inadequate circulation, refer to vascular assessment and investigations · Sharp surgery preferred · Consider angioplasty, bypass or amputation · Hydrogels, alginates and enzymes Bacterial swabs help to identify organisms and sensitivity, but do not diagnose infection in isolation from clinical features Dependent on the outcomes of the wound assessment: · Superficial/local – consider topical antimicrobial treatment (e.g. sustained silver releasing dressings). · Topical antimicrobials (e.g. sustained silver releasing dressings) However, it may need systemic antibiotic therapy. The general treatment may also include debridement of devitalized · Systemic antibiotic therapy tissue, pressure relief, optimising metabolic control and vascular · Foams, alginates · Deep – requires systemic antibiotic therapy to initial y cover Gram-positive, Gram-negative and anaerobic organisms. Subsequently, · The treatment of the edge depends on the outcomes of the systemic antibiotic therapy can be modified according to the results of assessment of the edge of the wound. In general, healthy the culture. In addition, it is essential to consider the need for surgical wounds have a pink woundbed and an advancing wound margin, debridement, drainage of infection alongside pressure relief and while un-healthy wounds have a dark and undermined wound optimising metabolic control · Topical antimicrobial (e.g. sustained silver-releasing dressings) may give Occasional y, neuropathy can be associated with pain. For people added benefit together with systemic coverage for deep infection with painful diabetic neuropathy, consider the fol owing treatment: · Appropriate offloading must be provided Tricyclic antidepressants7,17 (TCAs): · Total contact cast or pneumatic walker · Second generation TCA agents17 e.g. duloxetine · Deep toed or special shoes and orthotics · First generation TCA agent7,17: amitriptyline · Anticonvulsants: pregabalin17 Frequent (dependent on the clinical situation) Application of moisture retentive dressings in the context of ischaemia and/or dry gangrene can result in a serious life-or-limb- inspection of the diabetic foot ulcer is vital threatening infection11 due to the increased risk of infection Infection control is of paramount importance in DFU treatment because of its strong association with amputation. A study of 1,666 patients with diabetes found that foot infection increased the risk of amputation by 155 times19 Disclaimer: These are general guidelines. Please check local treatment recommendations applicable for your country or healthcare institution.
Disclaimer: These are general guidelines. Please check local treatment recommendations applicable for your country or healthcare institution.
Coloplast solutions for diabetic foot ulcers Biatain® – superior absorption for faster wound healing Biatain Soft-Hold – superior absorption for Biatain is a soft and conformable foam dressing that effectively wounds that are difficult to bandage absorbs and retains wound exudate.20,21 This ensures a moisture Biatain Soft-Hold has a gentle adherent layer balance that is optimal for healing of exuding wounds.22,23 covering less than 50% of the foam surface al ows both hands to be free during dressing application and removal Unique 3D polymer structure SeaSorb® Soft – superior absorption for slough and cavity fillingHighly absorbent alginate dressing for moderately to heavily exuding wounds of any size and shape. Faster wound healing by conforming to any wound shape and by debridement of slough Purilon® Gel – faster wound healing by effective Biatain Non-Adhesive – superior absorption and gentle debridement for wounds with extra fragile skin · Fast and effective debridement Biatain Non-Adhesive is a soft and flexible absorbent · High cohesion – the gel stays in place polyurethane foam dressing with bevelled edges Atrac-Tain® moisturizing cream Biatain Silicone – superior absorption for Atrac-Tain moisturizing cream is beneficial in the treatment of moderate-to-severe xerosis of the feet Biatain Silicone is a soft and flexible absorbent foam in patients with diabetes24 dressing with a gentle silicone adhesive only on the border leaving the foam free to absorb exudate and heal the wound Coloplast antimicrobial dressings for infected diabetic foot ulcers and ulcers at risk of infection Biatain® Ag – superior absorption for infected wounds Biatain Ag Non-Adhesive – superior absorption Sustained release of silver during the entire wear time for infected wounds with extra fragile skin Biatain Ag is a soft and conformable silver foam · Optimal healing environment26-27 dressing that is proven to help infected wounds heal · Rapid kil ing of bacteria28 · Designed to prevent wound infection Biatain Silicone Ag – superior absorption for infected woundsBiatain Silicone Ag is a soft and flexible absorbent silver foam dressing with a gentle silicone adhesive border SeaSorb® Ag – superior absorption for slough and cavity filling on infected woundsHighly absorbent antimicrobial alginate dressing for moderately to heavily exuding infected wounds or wounds at risk of infection. Faster wound healing by conforming to any wound shape and by debridement of slough.
· Designed to fight cavity wound infection· Effect on a broad range of bacteria Physiotulle® AgPhysiotul e Ag is a silver-containing, non-occlusive, hydrocol oid-based wound contact layer Bakker, K. et al. The year of the diabetic foot, Diabetes Voice, March 2005, Vol. 50(1): 11-14.
17. CG96 Neuropathic pain - pharmacological management: ful guideline, NHS, National Institute for
Health and Clinical Excel ence, 27 May 2010 (http://guidance.nice.org.uk/CG96/Guidance/pdf/ International Working Group on the Diabetic Foot, International Consensus on the Diabetic Foot, 18. Sibbald, R.G. et al. Dermatological aspects of wound care, Chapter 30, In: Krasner, D.L. et al., A
Jude, E. et al. Assessment of the diabetic foot. Chronic Wound Care: Chapter 58, In: Krasner, Clinical Sourcebook for Healthcare Professionals, Third Edition, HMP Communications Inc., 2001: D.L. et al., A Clinical Sourcebook for Healthcare Professionals, Third Edition, HMP Communications Inc. 2001: 589-597.
19. Lavery et al. Diabetes Care 2006;29(6):1288–93.
Armstrong, D.G. et al. Diabetic foot infections: stepwise medical and surgical management. International Wound Journal, 2004, Vol. 1(2): 123-132.
20. Andersen et al. A randomized, control ed study to compare the ef ectiveness of two foam
dressings in the management of lower leg ulcers. Ostomy/Wound Management 2002;(48)8:34-41.
Wil iams, R. et al. The size of the problem: Epidemiological and economic aspects of foot problems in diabetes. In: Boulton, A.J.M. et al., The Foot in Diabetes, John Wiley & Sons, Ltd., 21. Thomas et al. www.dressings.org/TechnicalPublications/PDF/Coloplast-Dressings-
Spraul, M. Education – can it prevent diabetic foot ulcers and amputations? In: Boulton, A.J.M. et 22. White R and Cutting KF. Modern exudate management: a review of wound treatments.
al., The Foot in Diabetes, John Wiley & Sons, Ltd., 2000: 111-120.
Reddy, M. Wound healing: The next milennium. Diabetic Microvascular Complications Today, May/ 23. Romanel i et al. Exudate management made easy. Wounds International 2010;1(2).
June 2005: 25-27.
24. Pham et al. A prospective, randomized, control ed double-blind study of a moisturizer for xerosis
Inlow, S. et al. Best practices for the prevention, diagnosis, and treatment of diabetic foot ulcers, of the feet in patients with diabetes. OstomyWound Management 2002;48(5):30-36.
Ostomy/Wound Management 2000, Vol. 46(11): 55-68.
25. Buchholtz. An in-vitro comparison of antimicrobial activity and silver release from foam dressings.
Frykberg, R.G. et al. A summary of guidelines for managing the diabetic foot. Advances in Skin & Wounds UK 2009.
Wound Care 2005, Vol. 18(4): 209-213.
26. Jørgensen et al. The silver-releasing foam dressing, Contreet Foam, promotes faster healing of
10. Edmonds, M. et al. A Practical Manual of Diabetic Foot Care, Blackwel Science, Oxford 2004.
critical y colonised venous leg ulcers: a randomised, control ed trial. International Wound Journal 2005;2(1):64-73.
11. Registered Nurses' Association of Ontario 2005. Assessment and management of foot ulcers for
people with diabetes. Toronto, Canada: Registered, Nurses' Association of Ontario.
27. Münter et al. Ef ect of a sustained silver-releasing dressing on ulcers with delayed healing: the
CONTOP study. Journal of Wound Care. 2006;15(5):199-206.
12. Baker, N. et al. A user's guide to foot screening. Part 1: Peripheral neuropathy, The Diabetic Foot
2005, Vol. 8(1): 28-37.
28. Ip et al. Antimicrobial activities of silver dressings: an in vitro comparison. Journal of Medical
13. Browne, A.C. et al. The diabetic neuropathic ulcer: An overview. Ostomy/Wound Management,
1999. Vol. 45 (No. 1A: Suppl).
14. Edmonds, M.E. et al. Managing the Diabetic Foot, Blackwel Science, Oxford 2005.
15. Sibbald, R.G. et al. Preparing the Wound Bed 2003: Focus on infection and inflammation,
Ostomy/Wound Management, November 2003, Vol. 49(1): 24-51.
16. Sibbald, R.G. et al. Cost–ef ective faster wound healing of critical y colonized wounds with a
sustained release silver foam dressing, based upon the symposium "Bacteria, sustained release of silver and improved healing", An official satel ite symposium of the WUWHS 2004. Published at www.worldwidewounds.com December 2005.
Biatain® – superior absorption for faster healing Superior absorption for Superior absorption for Superior absorption for non-infected wounds* Biatain Soft-Hold Biatain Silicone Ag Biatain Ibu Non-Adhesive Biatain Silicone Lite Biatain Ag Non-Adhesive Biatain Ibu Soft-Hold Sacral jun.
23x23 Biatain Non-Adhesive Biatain Ag Adhesive * Can be used for all types of exuding wounds.
Other Coloplast products for diabetic foot ulcers moisturizing cream After 30 years in wound care,we at Coloplast believe that absorption is the key to better healing. Our Biatain® portfolio brings superior absorption to daily wound care needs, making Biatain the simple choice for faster healing.
Coloplast develops products and services that make life easier for people with very personal and private medical conditions. Working closely with the people who use our products, we create solutions that are sensitive to their special needs. We cal this intimate healthcare. Our business includes ostomy care, urology and continence care and wound and skin care. We operate global y and employ more than 7,000 people.
The Coloplast logo is a registered trademark of Coloplast A/S. [YYYY-MM.] Al rights reserved Coloplast A/S, 3050 Humlebæk, Denmark.
Risk versus benefit of raw milk consumption Dominique Angèle VUITTON WHO Collaborating Centre; University of Franche-Comté; 25030 Besançon, France Background: the contradiction between "food safety" and biodiversity, high quality of products, sustainable development, and healthy life style. Dairy farmers and cheese producers are in the continuing process of answering the somewhat contradictory requirements of consumers for safe, high quality and diversified foods produced in sustainable conditions… at the lowest price. It has turned out that the legitimate requirements of safety from the consumer have eventually evolved in a burden of threats upon producers' activities, once they began being translated in tentative safety regulations. Within the past 10 years, the main concern of numerous producers, with little link with big dairy industry companies, has always been to provide food diversity through a traditional way of producing milk and cheese and to maintain biodiversity while reaching at the same time the very high quality and safety standards requested by the consumers. However, they now have the feeling that their way of doing is not supported in reality by the public policies and that the attitudes of experts and/or authorities may be sometimes quite contradictory.
Challenges to Protecting Species At Risk in Provincial Parks and Protected Areas in Ontario Zone Ecologist, Ontario Parks, Southeastern Zone Beechgrove Complex, 51 Heakes Lane, Kingston, ON K7M 9B1 (613) 531-5716 Fax: (613) 545-4033 Abstract Provincial parks are key landscapes for protecting populations of species at risk and their habitats, as provincial parks are of-