The Diabetic Foot: The Never-Ending Challenge

Diabetes, a major public health concern, is increasing in prevalence worldwide. A diabetic patient has an up to 25% lifetime risk of developing a foot ulcer condition that predisposes that patient to lower-extremity amputation. The underlying pathology is diabetic peripheral neuropathy and peripheral arterial disease (PAD) associated with deformities of foot anatomy due to motor neuropathy. Trauma, often secondary to ill-fitting shoes, precipitates skin breakdown, whereas PAD determines the prognosis for healing. Whenever optimal offloading is guaranteed, a neuropathic ulcer will heal, whereas an ulceration compromised by even a minor degree of arterial insufficiency has little chance of healing without revascularization. The population presenting with diabetic foot ulcers has shown a clear shift from neuropathic ulcers to neuro-ischaemic ulcers over the last two decades, underscoring the necessity to adapt management strategies to this condition. Cohort studies (the Eurodiale study group) teach us that the underlying problems are an absence of assessment of PAD, underuse of imaging and late referral for revascularization. Regarding reducing amputation rates in diabetes, a highly preventable complication, the situation is far from being under control. Prevention strategies targeting the high-risk population to avoid ulcer recurrence, optimized management by multidisciplinary foot care teams, integrated care with a clear definition of the patient itinerary and anticipated action to ameliorate ischaemia are promising options for the future.