Innovative approaches to diabetic foot care in Italy
09/02/10 | Diabetic foot ulcers | Alberto Piaggesi
This short report reviews recent advances in the management of the diabetic foot in Italy and the importance of an integrated approach to care. It focuses on the work of the Diabetic Foot Clinic at the University Hospital of Pisa, which has contributed to research into offloading devices and the use of antiseptics. This has led to improvements in diabetic foot management.
Page (1) Points
- The introduction in Italy of the IWGDF consensus guidelines has led to a significant decrease in the number of major amputations in patients with diabetes
- The Diabetic Foot Clinic at the University Hospital of Pisa has conducted prospective clinical trials on alternative offloading stategies, antiseptic use and application of nanotechnologies
- Superoxidised solutions may be more effective than povidone iodine in treating infections in diabetic foot ulcers
INTRODUCTION
In the past few years, management of the diabetic foot in Italy has improved significantly. This is because the national network of clinicians in charge of the management of this complex pathology has introduced the IWGDF Consensus Guidelines on the care of the diabetic foot. The incidence of major amputations has decreased significantly in the diabetic population for the first time since the St Vincent Declaration of 1989.
A key factor in achieving such a good result has been the integrated approach to the care of these patients, with extensive revascularisation, mainly endovascular, and early and aggressive surgical debridement performed by interventional diabetologists.
Our group contributed to the improvement of the management of the diabetic foot with three prospective clinical trials that produced evidence on offloading, the use of antiseptics in the infected foot and the application of nanotechnologies to help prevent ulceration.
NEW ADVANCES IN DIABETIC FOOT CARE
The trial on offloading strategies in the neuropathic foot compared the total contact cast (TCC) to the Optima Diab® (Molliter), an off-the-shelf irremovable offloading device. The study found that Optima Diab was as effective and less expensive than the TCC in treating neuropathic plantar ulceration. This finding increases the possbility of extending this offloading strategy to the many diabetic foot centres throughout Italy that cannot afford to use TCC [1].
The trial on the role of antiseptics in the management of infected diabetic foot ulcers demonstrated how Dermacyn® Wound Care (Oculus Innovative Sciences), a new super-oxidised solution, was more effective than povidone iodine in treating infections and preventing re-infections in diabetic foot ulcers, when combined with revascularisation and surgical debridement.
Super-oxidised solutions, which have been used mainly in oral surgery, combine a strong antibacterial activity with a very low toxicity for eucaryotic cells and living tissues. They should be considered as the first choice option when a local antiseptic is required in diabetic foot ulcer care [2].
Page (2) Points
- Nanotechnologies can be used as a preventative measure in both the neuropathic and ischaemic foot
- Future research needs to focus on prevention of ulcer recurrence, effective follow-up strategies and early diagnosis of Charcot foot disease
Another promising option in the prevention of the deterioration of the diabetic foot is the application of nanotechnologies to both the neuropathic and the ischaemic foot in the pre-ulceratve stage. Our experience with Difoprev® (LVM Technologies), a new device designed as a carrier for hydrating agents such as phosphatidilcoline, demonstrated how it was able to restore neuropathic dehydrated skin, preventing fissures and breaks that may lead to frank ulceration [3].
THE FUTURE
In the near future great attention will be focused on the prevention of ulcer recurrence by the implementation of effective follow-up programmes, and on the early identification and treatment of the Charcot foot, which still has a very poor prognosis both for limb preservation and for patient quality of life.
Author details:
Alberto Piaggesi, MD, Professor of Endocrinology and Metabolism and Director, Diabetic Foot Section, University Hospital of Pisa, Italy.
References
- Piaggesi A, Macchiarini S, Rizzo L, et al. An off-the-shelf instant contact casting device for the management of diabetic foot ulcers: a randomized prospective trial versus traditional fiberglass cast. Diabetes Care 2007; 30(3): 586-90.
- Piaggesi A, Goretti C, Mazzurco S, et al. Efficacy and safety of a new super-oxidized solution in managing wide post-surgical lesions of the diabetic foot. A prospective, randomized clinical trial. Int J Lower Extrem Wounds 2010; in press.
- Banchellini E, Macchiarini S, Dini V, et al. Use of nanotechnology-designed footsock in the management of preulcerative conditions in the diabetic foot: results of a single, blind randomized study. Int J Low Extrem Wounds 2008; 7(2): 82-7.
