Dressings

Diabetic foot ulcers are chronic wounds and we believe that they should be kept dry. The value of moist wound healing has only been demonstrated on acute wounds. Sterile, non-adherent dressings should cover all open diabetic foot lesions at all times except when they are inspected and debrided.

The rationale for keeping ulcers covered is to:

• Protect the wound from noxious stimuli

• Prevent infestation with insects

• Protect the wound from mechanical traumas

• Reduce the likelihood of infection.

There is no robust evidence from sufficiently large controlled studies that any one dressing is better for the diabetic foot than any other. However, the following properties are useful:

• Able to accommodate pressures of walking without disintegrating

Dressings should be lifted every day for wound inspection if possible, because when patients lack protective pain sensation the only signs of infection may be visual. For this reason, dressings which need to be left on a wound for several days to achieve their best effect maybe inappropriate for diabetic feet.

In our foot clinic we frequently see the dire results of failure to detect wound deterioration early because the signs were masked by a dressing in a patient who lacked protective pain sensation. Where it is not possible to inspect the wound, any exposed adjoining areas of the foot and leg should be checked for:

• Colour change

• Change in temperature.

These can be signs either of uncontrolled infection or of worsening ischaemia which need urgent action. Fever or hyperglycaemia should also be looked for.

Types of dressings used in diabetic foot patients and their relevant features

Films

' Clear, so wound inspection can be achieved without disturbing the wound

• Cannot absorb exudate which will collect under the film and form a blister and may irritate underlying tissue. Therefore contraindicated in exuding wounds

• Should never be used on infected or necrotic wounds. When used on dry necrosis will cause maceration and possibly promote infection

• Rarely appropriate for diabetic feet.

Foams

• Very absorbent

' Cushioning effect

• Bulky—may need specially roomy shoe to accommodate

• Widely used for diabetic feet.

Hydrocolloids

' Can be used only in patients with protective pain sensation

• Patient can bathe and shower

• Designed to be left on for several days. Daily changing prevents dressing from acting optimally.

Alginates

• Only to be used on moist exuding wounds

• Daily removal is time consuming

• Drying out of dressing may prevent wound drainage

• Calcium alginate is a good haemostatic agent

• Do not use on infected or necrotic wounds.

Hydrogels

• Promote autolysis and therefore promote debridement by apparently rehydrating the wound

• As we do not favour moist wound healing in the diabetic foot we see no strong indication for hydrogel therapy.

Hydrophilic fibre dressings

• Non-adherent, absorbent, fibrous dressings

• Soft and absorbent

Other dressings

Simple non-adherent dressings may be useful. Saline soaked gauze is widely used throughout the world.

Fastening dressings

Hypoallergenic tape and tubular bandages are useful. Conventional bandaging may cause excessive tightness. Only small amounts of tape should be applied to the skin. Encircling the entire toe with tape should be avoided in case it swells. It is important to issue precise requests to patients and nurses about techniques for holding dressings in place.

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