2015 International Working Group on the Diabetic Foot Guidance on the prevention and management of foot problems in diabetes

Diabetic foot ulceration (DFU) is a global health burden that has significant psycho‐social and economic ramifications. It has been estimated that the annual incidence of diabetic foot ulceration ranges between 2% and 4% in developed countries and this prevalence may be even higher in developing countries due to socio‐economic differences and variations in standards of care. In 1996, the International Working Group on the Diabetic Foot (IWGDF) was founded with a vision to reduce the global impact of diabetic foot complications. They have been publishing and revising international ‘Practical Guidelines’ with a view to improving the delivery of foot care to persons with diabetes ever since. In 2007, three working groups of independent experts in the field produced evidence‐based consensus reports on ‘footwear and offloading’, ‘wound management’ and ‘osteomyelitis’. In 2009, the IWGDF invited three working groups to produce new guidelines on peripheral arterial disease (PAD), wound healing and infection based on a series of systematic reviews. These guidelines were revised in 2011 to align with advances in research and clinical practice.

The 2015 IWGDF ‘Guidance’ documents on the prevention and management of foot problems in diabetes were recently launched at the Seventh International Symposium on the Diabetic Foot in May 2015. They present some new insights into developments in the diagnosis, prognosis and management of peripheral arterial disease in persons with diabetes, causing foot ulcers, an evidence‐based consensus on the use of interventions to enhance healing of chronic ulcers on the foot in persons with diabetes, and guidance on the diagnosis and management of foot infections in persons with diabetes. In contrast to former IWGDF ‘Practical Guidelines’ the 2015 ‘Guidance’ documents have been expanded to include an evidence‐based consensus on the prevention of foot ulcers in at‐risk persons with diabetes, and guidance on footwear and offloading to prevent and heal foot ulcers in persons with diabetes. In addition to the five documents the IWGDF Editorial Board produced a summary guidance for daily practice for health care providers around the world that are involved in the care of people with diabetes.

The 2015 updates are based on a series of systematic reviews and these recommendations were formulated using the Grading of Recommendations Assessment Development and Evaluation (GRADE) system. Table 1 outlines the recommendations on enhancing the healing of chronic DFU based on strength of evidence and the quality of evidence presented in the literature. These recommendations consist of nine interventions that are relevant to the field of wound healing. There are a number of small studies that demonstrate the efficacy of hyperbaric oxygen therapy (HBOT) and topical negative pressure wound therapy but these interventions are associated with high cost and there are very few studies confirming their effectiveness in routine clinical practice. A recent systematic review performed an analysis on the value of HBOT in healing DFU and preventing amputations. The review concluded that there was sufficient evidence to suggest that HBOT was effective in improving the healing of DFU in patients with concomitant ischaemia. However, the authors acknowledged that larger trials of higher quality were required to ascertain if implementing HBOT in routine clinical practice could be justified 1. The over use of anti‐microbial dressings to improve DFU healing times or prevent secondary infection in routine clinical practice is controversial. It has been proposed that long term use of antimicrobial dressings on colonised wounds may increase the risk of resistance and is less cost effective when compared against the cost of a conventional inert sterile dressing. Furthermore, a controversial review of the literature suggests that there is insufficient evidence to show that silver dressings improve healing rates 2 and these findings are reflected in the global consensus recommendations for a range of interventions designed to enhance the healing of chronic DFU.

Table 1.

Recommendations on the use of interventions to enhance the healing of chronic DFU

Recommendations	Strength of evidence	Quality of evidence
Clean ulcers regularly with clean water or saline, debride them when possible in order to remove debris from the wound surface and dress them with a sterile, inert dressing in order to control excessive exudate and maintain a warm, moist environment to promote healing	Strong	Low
In general remove slough, necrotic tissue and surrounding callus with sharp debridement in preference to other methods, taking relative contra‐indications such as severe ischaemia into account	Strong	Low
Select dressings principally on the basis of exudate control, comfort and cost	Strong	Low
Do not use antimicrobial dressings with the goal of improving wound healing or preventing secondary infection	Strong	Moderate
Consider the use of systemic hyperbaric oxygen therapy, even though further blinded and randomised trials are required to confirm its cost effectiveness, as well as to identify the population most likely to benefit from its use	Weak	Moderate
Topical negative pressure wound therapy may be considered in post‐operative wounds even though the effectiveness and cost‐effectiveness of the approach remains to be established	Weak	Moderate
Do not select agents reported to improve wound healing by altering the biology of the wound, including growth factors, bioengineered skin products and gases, in preference to accepted standards of good quality care	Strong	Low
Do not select agents reported to have an impact on wound healing through alteration of the physical environment, including through the use of electricity, magnetism, ultrasound and shockwaves, in preference to accepted standards of good quality care	Strong	Low
Do not select systemic treatments reported to improve wound healing, including drugs and herbal therapies, in preference to accepted standards of good quality care	Strong	Low

The recommendations outlined in the 2015 IWGDF Guidance documents demonstrate an inclusive approach to developing standards of care which can be delivered by health care providers irrespective of the socio‐economic differences that may exist between developed and developing countries around the world. They have succeeded in publishing quality standards of care for people with diabetes regardless of geographic location or social status by incorporating the five cornerstones of prevention and management of foot problems within an evidence‐based framework.