1. Hess, Cathy Thomas BSN, RN, CWCN

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In my last two columns I discussed the importance of documenting the details of pressure injuries and venous ulcers using their updated classification systems. This column discusses the importance of using the proper classification system for diabetic foot ulcers (DFUs). To understand the use of the classification, let's briefly discuss the etiology, assessment, and management of DFUs.1



The financial and emotional costs and the potential complications associated with DFUs are overwhelming. Preventing amputations and the loss of function is the goal of the interprofessional team caring for patients with DFUs. To achieve this end, clinicians must understand the scope and severity of diabetes and its physiologic results. According to the CDC:2


* 34.2 million people of all ages-or 10.5% of the US population-have diabetes


* 34.1 million adults 18 years or older (13.0% of all US adults) have diabetes


* 7.3 million adults 18 years or older who meet the laboratory criteria for diabetes are not aware of or did not report having diabetes (undiagnosed diabetes). This number represents 2.8% of all US adults and 21.4% of all US adults with diabetes


* The percentage of adults with diabetes increases with age, reaching 26.8% among those 65 years or older


* In 2017, diabetes was the seventh leading cause of death in the US and 270,702 death certificates listed diabetes as the underlying or contributing cause of death.



As diabetes progresses, underlying clinical conditions, such as neuropathy, vascular disease, foot deformity, and infection, become more prevalent. These conditions may occur alone or with other factors. The pathogenesis of diabetic ulcers varies according to their etiology. A diabetic ulcer may arise from neuropathy, peripheral arterial disease, or foot structure.



Diabetic ulcers are described according to their depth and are classified using a grading system. The most common system is the Wagner Ulcer Grade Classification, developed by Wagner and Meggitt.3 According to this scale, lower-grade ulcers are less complex and may respond to medical intervention. Higher grades may need surgery or amputation. Several other classification scales have been developed including:4


* The University of Texas Staging System for Diabetic Foot Ulcers5 with Associated Interventions6


* The Diabetic Ulcer Severity Score


* Depth of the Ulcer, Extent of Bacterial Colonization, Phase of Ulcer and Association Aetiology scoring system


* Site, Ischemia, Neuropathy, Bacterial Infection and Depth score



Interesting note, authors of one study4 felt the Wagner and University of Texas classification systems, although relatively simple to assess, were better predictors of lower extremity amputations than the more complicated options. It is also important to note that there are relevant guidelines from organizations and societies.7



The key to treatment of any chronic wound is to address the underlying problem. It is important to build your initial and follow-up assessment documentation and management workflows. Consider the following approaches upon initial assessment of DFUs:


* Prepare the wound bed to convert the molecular and cellular environment of a chronic wound to that of an acute healing wound


* Relieve pressure and consider offloading devices


* Manage infection


* Consider surgical procedure based on duration of wound and patient presentation


* Debride callus and/or nonviable tissue, if present


* Optimize nutrition


* Protect surrounding tissue


* Control moisture: provide dressing products that maintain a moist wound bed, control exudate, and avoid maceration of surrounding intact skin8


* Provide patient education and continually assess patient/caregiver understanding of treatment plan


* Capture digital wound measurements using an automated mobile wound and skin imaging and predictive analytics solution



A 50% area reduction at 4 weeks is significantly associated with healing at 12 weeks.9,10 Therefore, if a DFU heals less than 50% over the first 4 weeks, providers should consider the following approaches:


* Reevaluate patient status with complete history, physical examination, and plan of care; review initial approaches for vascular status, offloading, and infection control


* Assess circulation and consider perfusion assessment testing


* Sponsor granulation and consider alternative technologies for wound management


* Introduce growth factors and/or cellular- and tissue-based products


* Improve microcirculation; consider use of hyperbaric oxygen therapy based on clinical requirements


* Provide patient education and reinforce treatment adherence


* Monitor healing and outcomes; continue to use an automated mobile wound and skin imaging and predictive analytics solution



Even among patients with diabetes, ulcers must still be differentiated between venous, arterial, and diabetic (Table).


As we close out this year, take a moment to review your clinical documentation elements, interventions, and workflows. Wishing you a safe, healthy, and happy holiday season and New Year.




1. Hess CT. Clinical Guide to Skin and Wound Care. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013. [Context Link]


2. Centers for Disease Control and Prevention. National Diabetes Statistics Report: estimates of diabetes and its burden in the United States. 2020. Last accessed October 21, 2020. [Context Link]


3. Wagner FW. The diabetic foot and amputation of the foot. In Surgery of the Foot. 5th ed. Mann RA, ed. St Louis, MO: C. V. Mosby Co; 1986. [Context Link]


4. Jeon BJ, Choi HJ, Kang JS, Tak MS, Park ES. Comparison of five systems of classification of diabetic foot ulcers and predictive factors for amputation. Int Wound J 2017;14(3):537-45. [Context Link]


5. Armstrong D, Lavery LA, Harkless LB. Validation of a diabetic wound classification system: the contribution of depth, infection and ischemia to risk of amputation. Diabetes Care 1998;21(5):855-9. [Context Link]


6. Armstrong D, Lavery LA, Harkless LB. Treatment-based classification system for assessment and care of diabetic feet. J Am Podiatric Med Assoc 1996:86(7):311-6. [Context Link]


7. American Diabetes AssociationAmerican Diabetes Association. Peripheral arterial disease in people with diabetes. Diabetes Care 2003;26(12):3333-41. [Context Link]


8. Hingorani A, Kirsner R, LaMuraglia GM, Henke P, et al. The management of diabetic foot: a clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg 2016;63(2):3S-21S. [Context Link]


9. Snyder R, Kirsner R, Warriner R, Lavery L, Hanft J, Sheehan P. Consensus recommendations on advancing the standard of care for treating neuropathic foot ulcers in patients with diabetes. Ostomy Wound Manage 2010;56(suppl4):S1-24. [Context Link]


10. Sheehan P, Jones P, Caselli A, Giurini JM, Veves A. Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week prospective trial. Diabetes Care 2003;26(6):1879-82. [Context Link]