Diabetic foot ulcer: Successful healing with combination therapy, including surgical debridement, maggot therapy, and negative pressure wound therapy

Abstract

Introduction and importance

Diabetic foot ulcers (DFUs) are a common and serious complication of diabetes. A variety of treatments available to help heal diabetic foot ulcers, including sharp debridement, maggot therapy, and negative pressure wound therapy.

Case presentation

This case report presents the case study of a male patient with an 8-year history of diabetes who developed a diabetic foot ulcer. The patient was undergoing treatment with metformin and insulin. Despite the severity of the ulcer, a combination therapy approach, including surgical debridement, maggot therapy, and negative pressure wound therapy, was implemented, leading to successful healing.

Clinical discussion

DFUs are caused by various pathological mechanisms, the single therapy would lead to a very low level of recovery. Therefore, DFU management requires multimodal care and interdisciplinary treatment.

Conclusion

This case study highlights the effectiveness of a multimodal treatment strategy for diabetic foot ulcers, emphasizing the importance of individualized care and combining evidence-based practices.

Highlights

• •DFUs can lead to amputation.
• •DFUs do not respond to routine drug therapies.
• •DFUs can be managed by combination therapy.

1. Introduction

Diabetic foot ulcers are a common and serious complication of diabetes, affecting an estimated 15 % of people with diabetes at some point in their lives [1]. These ulcers can be difficult to treat and can lead to serious infections and even amputations if left untreated [2]. Fortunately, there are a variety of treatments available to help heal diabetic foot ulcers, including sharp debridement, maggot therapy, and negative pressure wound therapy [3].

Sharp debridement is a procedure in which a healthcare professional uses a scalpel or other sharp instrument to remove dead or infected tissue from the ulcer [4]. This helps to promote healing and prevent further infection [5]. While this procedure may sound painful, it is typically performed under local anesthesia and is generally well-tolerated by patients [6]. Moreover, maggot therapy, also known as larval therapy, involves the use of medical-grade maggots to clean and debride the ulcer [3]. These maggots are specially bred for medical use and are applied to the ulcer in a controlled manner [7]. The maggots feed on dead tissue, helping to remove it from the ulcer and promote healing. Maggot therapy has been shown to be effective in treating diabetic foot ulcers, and is often used in combination with other treatments. Negative Pressure Wound Therapy (NPWT) is a non-invasive therapeutic technique that involves the application of controlled negative pressure to a wound through a specialized dressing and vacuum-assisted closure system [8]. This therapy has gained recognition for its effectiveness in promoting wound healing, especially in complex and chronic wounds, such as diabetic foot ulcers [9].

The primary goal of NPWT is to create a controlled microenvironment within the wound bed, which facilitates the wound healing process through several mechanisms.

They are often used in combination with other treatments such as sharp debridement and maggot therapy [3].

When used in combination, sharp debridement, maggot therapy, and NPWT can be highly effective in treating diabetic foot ulcers. Sharp debridement removes dead tissue and prepares the ulcer for healing, maggot therapy helps to clean and debride the ulcer, and NPWT help to prevent infection and promote healing [8]. Together, these treatments can help to speed up the healing process, reduce the risk of infection, and improve outcomes for patients with diabetic foot ulcers [5].

It is important to note that these treatments are typically used in conjunction with other therapies as well, such as offloading and glycemic control, to achieve the best outcomes [7]. Additionally, patients with diabetic foot ulcers should always work closely with their healthcare providers to develop a comprehensive treatment plan that is tailored to their individual needs [10]. The work has been reported in line with the SCARE 2020 Criteria [11].

2. Presentation of case

The patient is an adult male with an 8-year history of poorly controlled diabetes, managed with a combination of metformin and insulin therapy. Despite efforts to maintain glycemic control, the patient developed a non-healing diabetic foot ulcer on the left foot (Fig. 1). The wound was identified as a Grade 3 ulcer according to the Wagner classification. Prompt and aggressive treatment was initiated due to the associated risks of infection, further tissue damage, and potential amputation. Some of the patient's laboratory data on admission were as follows:

• •1-Hemoglobin A1C = 7/5 %
• •2-Blood Sugar = 550 mg/dl
• •3-High-density lipoprotein 38 mg/dl
• •4-Low-density lipoprotein 75 mg/dl
• •5-Cholesterol 182 mg/dl
• •6-Triglycerides 79 mg/dl
• •7-Blood urea = 19.1 mg/dl
• •8-Blood creatinine = 0.83 mg/dl
• •9-Hemoglobin = 8/9 g/dl
• •10-Hematocrit = 32 %

Fig. 1.

DFU before starting the combination therapy.

3. Treatment regimen

3.1. Surgical debridement

Surgical debridement, involving the removal of necrotic tissue, was performed under sterile conditions accompanied by local anesthesia. Following debridement, the wound bed was adequately prepared, facilitating the growth of healthy granulation tissue (Fig. 2).

Fig. 2.

DFU after surgical debridement.

3.2. Maggot therapy

After overcoming initial hesitations, maggot therapy was introduced to promote wound debridement, disinfection, and wound healing. Medical-grade larvae of the common green bottle fly (Lucilia sericata) were applied to the wound, along with a protective dressing, allowing them to feed on dead tissue while leaving healthy tissue unaffected (Fig. 3).

Fig. 3.

DFU after maggot therapy.

3.3. Negative pressure wound therapy (NPWT)

Negative pressure wound therapy was initiated to accelerate healing and promote wound closure. A vacuum-assisted closure system was employed, applying controlled negative pressure to the wound bed, facilitating the removal of excess fluid, improving blood flow, and promoting granulation tissue formation (Fig. 4).

Fig. 4.

NPWT applied following maggot therapy.

The combination therapy approach, consisting of surgical debridement, maggot therapy, and negative pressure wound therapy, proved effective in facilitating the healing of the diabetic foot ulcer. Over several weeks, the wound demonstrated significant progress, with reduced size, clean granulation tissue formation, decreased pain, and absence of infection signs (Fig. 5).

Fig. 5.

DFU after combination therapy.

4. Discussion

Diabetic foot ulcers (DFUs) are a common and serious complication of diabetes that can lead to significant morbidity and mortality [5]. The treatment of DFUs is complex and requires a multifaceted approach that addresses the underlying causes of the ulcer, such as peripheral neuropathy and peripheral arterial disease, as well as the wound itself. One promising treatment approach for DFUs is the combination of sharp debridement, maggot therapy, and silver bandages [6].

Sharp debridement is a well-established treatment for DFUs that involves the removal of necrotic tissue from the wound bed. This process promotes healing by removing the barrier to tissue regeneration and reducing the bacterial load in the wound. Maggot therapy, also known as larval therapy, involves the use of sterile maggots to debride the wound and promote healing [8]. The maggots secrete proteolytic enzymes that digest necrotic tissue while leaving healthy tissue intact. Maggot therapy also has antibacterial properties, which can help to reduce the risk of infection. Silver bandages are dressings that contain silver ions, which have antimicrobial properties [9].

The combination of these three therapies has been shown to be effective in treating DFUs [7]. A Research found that the use of maggot therapy in combination with other treatments, such as sharp debridement and silver dressings, was associated with a higher rate of complete healing, faster healing time, and lower risk of amputation compared to standard wound care [1].

Another study found that the combination therapy group had a significantly higher rate of complete healing compared to the standard wound care group [6].

While the evidence suggests that the combination of sharp debridement, maggot therapy, and silver bandages is effective in treating DFUs, there are some limitations to this approach [12]. For example, maggot therapy may not be well-tolerated by all patients and may cause discomfort or pain [13].

5. Conclusion

In conclusion, the combination of sharp debridement, maggot therapy, and silver bandages is a promising treatment approach for DFUs. The combination of these three therapies addresses multiple aspects of the wound healing process, including debridement, bacterial control, and wound bed preparation. While further research is needed to fully evaluate the safety and efficacy of this treatment approach, the available evidence suggests that it has the potential to improve healing rates and reduce the risk of complications in patients with DFUs. Healthcare providers should carefully evaluate the risks and benefits of this treatment approach for each individual patient and tailor the treatment plan accordingly.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethics No. IR.UMSU.REC.1402.430.

Funding

None.

Author contribution

Rasoul Goli, Navid Faraji and Kamal Rahimi: Study concept, data collection, writing the paper and making the revision of the manuscript following the reviewer's instructions. Neda Vahidi Moghaddam, Fatemeh Nikkhah and Behnam Babamiri: Study concept, reviewing and validating the manuscript's credibility.

Guarantor

Rasoul Goli

Research registration

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Provenance and peer review

Not commissioned, externally peer-reviewed.

Conflict of interest

None.