6 / 44
4
VOLUME 14 NUMBER 1 • JULY 2017
REVIEW
SA JOURNAL OF DIABETES & VASCULAR DISEASE
Podiatric interventions and phototherapy in the
management of chronic diabetic foot ulceration:
a review to compare the average healing time
N SITHOLE, H ABRAHAMSE
Correspondence to: H Abrahamse
Laser Research Centre, Faculty of Health Sciences, University of Johannesburg,
Johannesburg
e-mail:
habrahamse@uj.ac.zaN Sithole
Department of Podiatry, Faculty of Health Sciences, University of
Johannesburg, Johannesburg
S Afr J Diabetes Vasc Dis
2017;
14
: 4–10
Abstract
Diabetic foot ulceration is a serious complication of
diabetes mellitus and an important risk factor for lower-
limb amputations. Diabetes is characterised by chronic
hyperglycaemia related to the resistance of target cells to
the action of insulin, which leads to degenerative disorders
caused by macro- and microangiopathy, and neuropathy.
These factors favour the occurrence of lower-limb ulcers and
delay their healing. The slow healing rate of chronic diabetic
foot ulceration has a negative impact on the patient’s quality
of life. There is a need therefore for the development of
new treatment modalities to improve the healing rate and
outcomes of diabetic ulcerations.
The management and treatment of chronic diabetic
ulcerations can last an extended period due to the lack of
response to treatment or the general nature of the ulcer.
Current podiatric protocols for the management of chronic
ulcers affecting the lower limb involve a dynamic approach,
which includes mechanical debridement of granulation and
dead tissue, antibiotics to treat infection, change of footwear,
mechanical off-loading using total-contact casts and orthotic
devices, as well as foot-care education.
Phototherapy is an alternative treatment modality that is
under investigation for the management of chronic diabetic
foot ulceration. It has been found to significantly increase
the healing rate of ulcers when used in combination with
other conventional treatments. The continuous management
and on-going surveillance and monitoring of chronic diabetic
foot ulcers with various combination therapies, including
phototherapy, may improve the healing time as so improve a
patient’s quality of life and physical activities.
The aim of this review is to compare the average
healing time of diabetic foot ulcers when treated with
standard podiatric treatment protocols and when treated in
combination with phototherapy in terms of diabetic foot-
ulcer management.
Keywords:
diabetes, foot ulcers, wound healing, laser,
phototherapy, off-loading, wound debridement.
Introduction
Diabetes mellitus is a common metabolic condition that is increasing
in prevalence worldwide. The estimates by the International
Diabetes Federation in 2009 suggested that the number of adults
with diabetes in the world will increase by 54%, from 284.6 million
in 2010 to 438.4 million in 2030.
In sub-Saharan Africa in 2010, the projected growth in incidence
of diabetes was 98%, with the prevalence of type 2 diabetes rising
quickly.
1
In South Africa in 2003, a prevalence figure was noted of
3.4% among the 24 million adults between the ages of 20 and
79 years. However in 2015, there were 2.28 million (7.0%) adult
diabetes cases noted in South Africa.
2
This drastic increase presents
a substantial public health and socio-economic burden to this
country in the face of scarce resources.
3
Type 2 diabetes is characterised by chronic hyperglycaemia related
to the resistance of target cells to the action of insulin, which leads
to degenerative disorders caused by macro- and microangiopathy,
and neuropathy.
4,5
These factors favour the occurrence of disease
complications, such as lower-limb ulcers and delayed healing.
5,6
Diabetic foot ulcers (DFUs) are estimated to occur in 15% of
all patients with diabetes and precede 84% of all diabetes-related
lower-leg amputations. These ulcers are a major cause of hospital
admissions for people with diabetes in the developed world and are
a major morbidity associated with diabetes, often leading to pain,
suffering, and an overall poor quality of life for the patient.
7
Classification of DFUs
Diabetic foot ulcers can result frommultiple factors and are therefore
classified according to the relative contribution of late diabetic
complications of peripheral neuropathy and vascular diseases.
8
Most diabetic lower-limb ulcers occur in the presence of peripheral
neuropathy, foot deformity and trauma, and these are called
neuropathic ulcers. Peripheral vascular disease, resulting in neuro-
ischaemic ulcers and infection, is believed to be the complicating
factor that prevents or delays ulcer healing.
9
The literature suggests
that the nature of chronic diabetic foot ulcerations disables
the normal stages of healing, which in turn induces a state of
pathological inflammation. This then results in the overall healing
process becoming incomplete or delayed.
10
Diabetic ulcers are also classified according to their severity or
in grades using the universally accepted validated tools such as the
Wagner andUniversity of Texas classifications.Wagner’s classification
grades 0–5 divides ulcers from superficial or deep ulcers up to
gangrene of the foot. The University of Texas classification stages
1–5 adds the presence of infection, ischaemia, or both infection
and ischaemia together.
11,12
These classifications are important as
we need to adequately describe the ulcers that we treat in order to
review a patient’s outcome.
11