There is no single "best" formulation. Selection is based upon the location, degree of contamination/colonization/infection of the wound, size of the wound, and condition of the patient. For example, a wound on the sole of the foot, after thorough debridement, is often best treated with total contact casting, but this is not the treatment for a wound on the lower leg or dorsal surface of the foot. Some wound products absorb exudate, others moisturize: again, selection depends on the condition of the wound.

Topical silver preparations reduce colonization and are useful in infected wounds. In short, the wound has to be thoroughly assessed by a capable practitioner before a recommendation is made.

If the case is not desperate and no other formula has been effective, an experimental treatment with EGF (endothelium growth factor) may be tried. The substance is in use in Cuba though. I have no evidence about its effects in humans. Theoretically, it should improve blood perfusion.

I agree with Teresa. An oversimplification is; "if the wound is wet, dry it, if the wound is dry, moisten it." Infection is an issue that has to be addressed in addition to the local physiology.

Dragan is incorrect. He may have meant to say epidermal growth factor or vascular endothelial growth factor, both of which can be derived from a patient's own whole blood or platelet rich plasma (one early reference is by Knighton [Annals of Surgery 204:322-30, 1986] or a more recent review of EGF www.ncbi.nlm.nih.gov/pubmed/18581754). These treatments are indeed available in the US, but they have not proven to be as cost-effective as originally hoped.

The newest approaches I have heard of are:

http://idw-online.de/pages/de/news479887

http://www.eurekalert.org/pub_releases/2011-11/gumc-ril102811.php

http://www.eurekalert.org/pub_releases/2011-02/ctco-huc022211.php

http://www.eurekalert.org/pub_releases/2010-04/luhs-dch041610.php

http://www.sciencedirect.com/science/article/pii/S0168365912004403

Regards,

Joachim (not a medic)

Thanks. I meant both. The VEGF and EGFR (vascular endothelium growth factor and epidermal growth factor receptor) probably have the same pathway. Number of growth factors is certainly quite large. However, when mentioning Cuba, I meant the EGF (recombinant epidermal growth factor), which is sold in Cuba as Heberprot-P, and is reported to have important therapeutic effects in diabetic skin infections, an agent that needs investigating. That some similar agents are available in the US – I am really happy to hear. Nevertheless, experience with the activated protein C makes me have some reserves regarding the effectiveness of the agents and I have some reserves also in respect to reliability of these reports coming from the studies supported by big pharmaceutic companies. Indeed, this question about diabetic skin infection has been asked previously here and I regret for being drawn into discussion again. And if the communication style will be as it appears to be, I regret being here anyway.

Diabetic wounds are complex ulcers due to poor exrimity blood supply , neuropathy , anatomical deformities and ...There fore no topical formulation alone is enough. In my 10 years experience in managing these ulcers I use Low Level Laser Therapy which stimulates wound healing, increases blood supply, improves neuropathy and immune system. and as a systemic therapy is appropriate for such a systemic complication. I olny wash the ulcer with normal saline before Laser Therapy and use phenytoin ointment or Honey before dressing the ulcer. more than 80% of ulcer heal completely. you can see my paper s in this field too.

I think you are looking for the criteria rather than interventions themselves. Teresa has given good answers, as has Bruce. Minimizing bioburden seems to be a key to healing in these ulcers, due perhaps to the poor circulation and high blood sugar, which decreases the body's ability to fight sub-acute mixed infections. Most wound practitioners have their favorite formulations, which may do better in their climate and with their populations. I worked with a very active population in a tropical environment. In this setting, the built-in continuous wound cleansing found in PolyMem products was invaluable. A large plantar ulcer which extended into the dorsum of the foot and had destroyed several joints closed in only 8 weeks using only PolyMem Wic and PolyMem Max after thorough cleansing and debridement. Others who do not have access to modern wound dressings (in Indonesia) have used mixtures of flagyl, zinc oxide, and antifungal powder on diabetic foot wounds with excellent results.

The main way to deal with ulcers in diabetic foot care are simple actions that should involve the patient and his family, because collaboration is essential to healing. The rest of the patient is crucial in this process. Although the use of antobióticos is essential in the case of infections, the choice of technology is secondary. The most important is the care of the health team, the patient and his family.

Following to Dragan's comments and latest scientific evidence based on VEGF and EGFR I would recommend to look into the work on wound healing of Jeffrey Hubbell at EPFL. He has reached advanced clinical trial phase with his spinoff company Kuros Biosurgery on crosslinked VEGF with collagen as ECM. I met him at CLINAM this year and saw his latest results; very are impressive especially when tackling large diabetic ulcers. Let me know if you find it useful for your selection search.

There is no one right way to treat a diabetic foot ulcer. They present in many different ways.  Here are some guidelines from recent years to help:

http://www.woundsinternational.com/media/issues/673/files/content_10803.pdf

http://iwgdf.org/guidelines-2/

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0150984