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Trophic ulcers in diabetes
Last reviewed: 07.07.2025

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The relevance of therapy of foot lesions required the identification of diabetic foot syndrome. Trophic ulcers in diabetes are a pathological condition of the feet in this pathology of the endocrine system, which occurs against the background of damage to peripheral nerves, blood vessels, skin and soft tissues, bones and joints and is manifested by acute and chronic ulcerative defects, bone and joint lesions, purulent-necrotic and gangrenous-ischemic processes.
The main components of complex treatment of trophic ulcers in diabetes:
- compensation of the disease with stabilization of blood sugar levels by prescribing insulin and other antidiabetic drugs;
- immobilization or unloading of the affected limb;
- local therapy of ulcerative-necrotic lesions using modern dressings;
- systemic targeted antibiotic therapy;
- relief of critical ischemia
- surgical treatment, including, depending on the situation, revascularization of the limb, necrectomy in the area of the ulcer defect and skin grafting.
Treatment of trophic ulcers in diabetes is the most important measure to prevent the development of severe complications that lead to loss of a limb. According to various authors, 6 to 14 weeks of outpatient treatment are necessary for complete healing of an ulcer defect. Healing of complicated ulcer defects (osteomyelitis, phlegmon, etc.) requires a longer period of time, with inpatient therapy alone lasting 30-40 days or more.
To carry out adequate therapy, it is necessary to evaluate all factors that influence the healing of ulcerative defects such as trophic ulcers in diabetes:
- neuropathies (determination of vibration sensitivity using a graduated tuning fork, pain, tactile and temperature sensitivity, tendon reflexes, electromyography);
- vascular status (arterial pulsation, ultrasound Doppler of arteries and duplex angioscanning, when planning reconstructive surgeries - angiography, including magnetic resonance angiography);
- microcirculatory disorders (transcutaneous oxygen tension, laser Doppler flowmetry, thermography, etc.);
- volume and depth of tissue damage (visual assessment and revision of the wound, photometry, ultrasound of soft tissues, radiography, CT, MRI);
- infectious factor (qualitative and quantitative determination of all types of microflora with assessment of antibacterial sensitivity).
Foot deformation and biomechanical disorders lead to abnormal redistribution of pressure on the plantar surface of the foot, in connection with which unloading the foot is the basis for both prevention and treatment of diabetic ulcerative defects. Trophic ulcers in diabetes cannot heal until the mechanical load on the foot is eliminated. This is achieved by using orthopedic insoles and shoes, foot orthoses, which are selected individually for each patient in specialized orthopedic centers. In more severe cases, as well as during inpatient treatment of the patient, bed rest, crutches and wheelchairs are used.
Uncomplicated plantar trophic ulcers in diabetes are well treated with removable boots made of lightweight synthetic materials (total contact cast). These materials (Scotchcast-3M and Cellocast-Lohmann) are not only very strong, but also lightweight, which maintains the patient's mobility. The unloading mechanism when applying this bandage consists of redistributing the load towards the heel, resulting in a decrease in pressure on the forefoot bearing the ulcer defect. When forming a bandage in the projection of a plantar trophic ulcer in diabetes, a window is made to avoid support on the ulcer defect area. The bandage is removable, which allows it to be used only while walking and facilitates care. The application of the bandage is contraindicated in case of limb ischemia, limb edema and inflammatory changes.
Trophic ulcers in diabetes are treated differently. This therapy depends on the condition, stage of the wound process. Local therapy and care themselves can compensate for long-term damage, neuropathy and ischemia, but an adequate choice of local therapy strategy allows you to speed up the reparative processes. Trophic ulcers in diabetes cannot be treated with aggressive antiseptics (hydrogen peroxide, potassium permanganate, etc.), which have an additional damaging effect on tissues due to neuropathy and ischemia. The ulcer surface must be treated with a stream of isotonic sodium chloride solution. To treat ulcerative lesions, they try to use interactive dressings that do not contain cytotoxic components. These include preparations from the group of hydrogels and hydrocolloids, alginates, biodegradable wound dressings based on collagen, mesh atraumatic wound dressings and other agents that are prescribed depending on the stage of the wound process and the characteristics of its course, in accordance with the indications and contraindications for the use of a particular dressing.
In the presence of pronounced hyperkeratosis in the circumference of a trophic ulcer in diabetes and in the formation of necrotic tissue, the generally accepted method is considered to be mechanical removal of areas of hyperkeratosis and tissue necrosis using a scalpel. Despite the fact that high-quality comparative studies of the effectiveness of excision of damaged tissue with a scalpel and autolytic or chemical cleansing have not been carried out, experts agree that the best method is surgical. In the case of complicated trophic ulcers in diabetes (phlegmon, tendinitis, osteomyelitis, etc.), surgical treatment of the purulent-necrotic focus with a wide opening of the entire pathological process and removal of non-viable tissue is indicated. Uncomplicated trophic ulcers in diabetes, occurring with severe limb ischemia, are not treated by necrectomy, since any active intervention in this situation can lead to expansion of the ulcer defect, activation of infection and development of gangrene of part of the foot.
Trophic ulcers in diabetes complicated by infection are a life-threatening condition, since in advanced cases or with inadequate treatment it leads to high amputation of the limb in 25-50% of cases. Whether patients are more susceptible to the development of infectious lesions than patients without the underlying disease is a controversial issue. However, there is no doubt that the consequences of infection in diabetic foot syndrome are more severe, which is most likely due to the uniqueness and complexity of the anatomical structure of the foot, as well as the peculiarities of the inflammatory response due to metabolic disorders, neuropathy and ischemia. The causative agents in superficial infection of trophic ulcers in diabetes, clinically represented by cellulitis, in typical cases are gram-positive aerobic and anaerobic cocci. Trophic ulcers in diabetes, complicated by the development of a deep foot infection with the involvement of tendons, muscles, joints and bones in the purulent-necrotic process, as well as in the case of tissue ischemia, the infection is polymicrobial in nature and usually consists of associations of gram-positive cocci, gram-negative rods and anaerobes. Antibacterial therapy in these situations has been confirmed as effective in numerous randomized studies with the level of recommendations "A". In case of cellulitis, ciprofloxacin or ofloxacin with clindamycin or metronidazole, levofloxacin or moxifloxacin in monotherapy, protected penicillins (amoxiclav, etc.) are prescribed as empirical antibacterial therapy. In addition to the above schemes, combinations of III-IV generation cephalosporins with metronidazole, sulperazone and carbapenems are used for deep foot infections.
The signs of critical ischemia are relieved by various bypass interventions, endovascular methods (subcutaneous transluminal angioplasty, arterial stenting, etc.) or a combination of both techniques. Revascularization of the limb is technically possible in most patients with the ischemic form of diabetic foot syndrome. After the elimination of limb ischemia and restoration of normal microcirculation, the course of the wound process in the ulcer defect area is the same in patients with ischemic, mixed and neuropathic forms of diabetic foot syndrome and has a favorable prognosis. If it is not possible to restore blood flow by revascularization of the limb, then trophic ulcers in diabetes are associated with a high risk of limb loss.
After reconstruction of lower extremity arteries, it is necessary to stop smoking, control hypertension and dyslipidemia, and prescribe acetylsalicylic acid and platelet disaggregants. A number of placebo-controlled studies have demonstrated that pharmacological treatment, including the administration of prostaglandin E: (alprostadil) drugs, has a positive effect on peripheral blood flow in patients with critical limb ischemia, but there is currently no convincing data on the effectiveness of such therapy for the introduction of certain drugs or treatment regimens into everyday practice.
A similar situation also occurs in the treatment of diabetic neuropathy. Of the medications used, thioctic acid preparations (thioctacid), multivitamins (milgamma, etc.), actovegin are used. The effectiveness of these drugs for the treatment of such a pathology as trophic ulcers in diabetes has not been studied from the standpoint of evidence-based medicine. However, randomized studies on the elimination of symptoms and manifestations of neuropathy with thioctic acid preparations have revealed their relatively low effectiveness both in themselves and in comparison with placebo.
In stage II of the wound process, surgical treatment of diabetic foot syndrome should be completed by reconstructive and restorative operations using various plastic surgery techniques in order to preserve the supporting function of the foot and earlier rehabilitation of patients. For surgical treatment of plantar ulcerative defects, the end area of the foot stump, and the heel area, various methods of full-layer skin grafting are used. The most commonly used technique is rotational fasciocutaneous flap grafting, in some cases, a bilobed fasciocutaneous plantar flap according to Zimani-Osborne is used, and grafting with sliding VY flaps of the foot according to Dieffenbach is used. When plantar pathologies are combined with osteomyelitis of the metatarsal head or osteoarthritis of the metatarsophalangeal joint, grafting with a dorsal skin flap of the displaced toe is used. To close large plantar ulcer defects, it is possible to use a rotational skin-fascial flap taken from the non-supporting surface of the foot. The donor wound is then closed with a split skin flap.
There have been no large multicenter randomized studies confirming the effectiveness of plastic methods for closing trophic ulcers in diabetes compared to conservative treatment methods, but experts agree that surgical treatment is a faster and more cost-effective way to eliminate these diseases.
According to some studies, the prognosis for the treatment of such a pathology as trophic ulcers in diabetes does not depend on the duration of the disease, but the elderly and senile age of the patient has a significant impact on the outcome of treatment and is associated with a high risk of limb amputation.
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