To the Editor,
We read the article “Differences in characteristics between first‐ever foot ulcer and recurrent foot ulcer in patients with diabetes: Prospective observational study,” published in Health Science Reports [1]. This study makes a significant contribution by comparing the characteristics of first‐ever diabetic foot ulcers (DFUs) with recurrent DFUs. The authors highlight that first‐ever DFUs are associated with more serious conditions, often accompanied by infections, compared to recurrent DFUs. Trauma to the toes and plantar regions was identified as a predominant cause in both groups.
We commend the authors for their informative study and wish to offer several considerations that may further enrich the findings. This research provides a valuable opportunity to explore the factors contributing to both first‐ever and recurrent DFUs and suggests ways to mitigate the recurrence of ulcers. However, several methodological limitations warrant further discussion.
1. Inclusion of Additional Laboratory Markers
The authors chose to focus on a specific set of laboratory factors, but their selection could be more extensive. Other markers, such as albumin (ALB), procalcitonin (PCT), blood urea nitrogen (BUN), creatinine (Cr), erythrocyte sedimentation rate (ESR), C‐reactive protein (CRP), liver function tests, lipid markers, neutrophil‐to‐lymphocyte ratio (NLR), and platelet‐to‐lymphocyte ratio (PLR), could provide further insights into the severity and prognosis of DFUs [2].
2. Comorbidities and Risk Factors
The study lacks a comprehensive account of underlying comorbidities, such as cardiovascular and cerebrovascular diseases, retinopathy, and nephropathy, which may impact the development and recurrence of foot ulcers. In addition, lifestyle factors like chronic alcohol use and smoking, known contributors to poor wound healing, were not discussed.
3. Wound Classification Systems
While the authors used the DMIST tool, which includes data on depth, maceration, inflammation/infection, size, tissue type, and wound edges, the study lacks a discussion of vascular factors that could affect wound healing. Scoring systems such as SINBAD, which stands for ulcer site, ischemia, neuropathy, bacterial infection, area, and depth, or PEDIS, which accounts for perfusion, extent, depth, infection, and sensation, might offer a more comprehensive assessment [3].
4. Vascular Assessments
The study reports ankle‐brachial index (ABI) values within the borderline and normal range. Still, ABI can fail to detect peripheral artery disease (PAD) in up to a third of symptomatic cases. Therefore, additional diagnostic tools, such as the toe‐brachial index (TBI), should be considered to assess vascular involvement better [4].
5. Multidrug‐Resistant Organisms
A key omission is the lack of microbiological data, especially regarding the presence of multidrug‐resistant organisms (MDROs), which are known to increase the risk of ulcer recurrence significantly [5]. Including such data would provide a clearer understanding of infection dynamics in DFUs.
In conclusion, the study offers valuable insights into the differences between first‐ever and recurrent DFUs, but addressing these methodological gaps could further strengthen future research. By incorporating additional markers, risk factors, vascular assessments, and microbiological data, future studies may provide an even more comprehensive understanding of the factors contributing to DFU recurrence. We hope these suggestions inspire further research in this crucial area.
Author Contributions
Mostafa Javanian: conceptualization, methodology. Mohammad Barary: writing–original draft, writing–review and editing. Soheil Ebrahimpour: investigation, methodology, writing–original draft.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
The authors thank the Infectious Diseases and Tropical Medicine Research Center of Babol University of Medical Sciences.
Data Availability Statement
Data sharing is not applicable to this article as no new data were created or analyzed in this study.
References
- 1. Oe M., Saad S. S., Jais S., and Sugama J., “Differences in Characteristics Between First‐Ever Foot Ulcer and Recurrent Foot Ulcer in Patients With Diabetes: Prospective Observational Study,” Health Science Reports 7, no. 4 (2024): e2018. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Serban D., Papanas N., Dascalu A. M., et al., “Significance of Neutrophil to Lymphocyte Ratio (NLR) and Platelet Lymphocyte Ratio (PLR) in Diabetic Foot Ulcer and Potential New Therapeutic Targets,” International Journal of Lower Extremity Wounds 23, no. 2 (2024): 205–216. [DOI] [PubMed] [Google Scholar]
- 3. Game F., “Classification of Diabetic Foot Ulcers,” supplement, Diabetes/Metabolism Research and Reviews 32, no. S1 (2016): 186–194. [DOI] [PubMed] [Google Scholar]
- 4. Mahé G., Lanéelle D., and Le Faucheur A., “Postexercise Ankle‐Brachial Index Testing to Diagnose Peripheral Artery Disease,” Journal of the American Medical Association 325, no. 1 (2021): 89. [DOI] [PubMed] [Google Scholar]
- 5. Liu X., Ren Q., Zhai Y., Kong Y., Chen D., and Chang B., “Risk Factors for Multidrug‐Resistant Organisms Infection in Diabetic Foot Ulcer,” Infection and Drug Resistance 15 (2022): 1627–1635. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data sharing is not applicable to this article as no new data were created or analyzed in this study.