Optimal medical treatment of ischemic diabetic
ulcers is multifactorial.
Infection is very common and it is necessary to distinguish between limb or life threatening
infections and non-limb-threatening
infections. The major pathogen associated with non-limb-threatening
infection is staphylococcus aureus; oral
antibiotics such as
amoxicillin/
clavulanate or
clindamycin can be used. For severe
infection, empiric
antibiotic therapy is broader-spectrum covering staphylococci, streptococci, gram-negative bacilli and enterococci;
intravenous administration is the rule. Duration of
antibiotic therapy depends on severity and depth of
infection, and on requirement of surgical debridment.
Granulocyte colony-stimulating factor is a
growth factor stimulating proliferation and function of neutrophils. As an adjunctive
therapy for limb-threatening
infections, it is associated with a lower rate of
amputation. Increasing arterial perfusion if the patient is unsuitable for reconstructive surgery or angioplasty is desirable.
Iloprost is an analogue of
epoprostenol with effects on platelet aggregability and vasodilatation. It improves
ulcer healing, decreases
pain, slightly diminishes the rate of
amputation. Systemic
hyperbaric oxygen therapy can perhaps improve clinical outcome but additional research is needed to define the specific indications and benefits of this treatment modality. Local care is not rationalized and depends on local habits. Debridment is required. Non necrotic
wounds can be covered by modern dressing (hydrophilic dressing,
alginates,
hydrocolloid). Necrotic
wounds are dryed until surgical revascularization, or excised if they are limited and superficial. Pinch grafts are very useful for arterial
ulcers. The place of topical
growth factor like PDGF (
platelet derived growth factor) and of living skin equivalents (dermagraft,
apligraf) is not defined in ischaemic diabetic
ulcers. Treatment of
edema is necessary, because it retards or complicates healing. Inelastic bandages can be useful with good tolerance if
ischemia is not critical. Pneumatic foot compression is under evaluation. Electric stimulation could be an adjuncting treatment, but with a problem of compliance. Reducing plantar pressure is always necessary.