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Medical Alliance for the Preservation of the Lower Extremity
How To Treat A Neuropathic Wound
Neuropathic wounds develop because of a combination of two factors:
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1. Sensory Loss (peripheral neuropathy)
2. Pressure / Shear (Friction)
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​As we cannot, at present, cure neuropathy, the primary goal is to deal with pressure.
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This means that assuming the patient is able to heal, with enough blood flow and sufficient nutrition and control of blood sugar and infection...​​​​​​​​​​
The most important factors in getting a wound to heal are
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Offloading (removing pressure), and Debridement (removing dead tissue).
This is backed up by key, non-profit wound organizations like the International Working Group on the Diabetic Foot, the IWGDF, and if you remember this, you'll know more than most health professionals.
The International Working Group on the Diabetic Foot (IWGDF) is an independent international panel of multidisciplinary experts that develops evidence-based guidelines for the prevention and treatment of diabetic foot disease.
The group includes a variety of different types of physicians, surgeons, podiatric surgeons, PhDs, researchers, and other specialists from many countries. Its guidelines are widely used around the world and are updated periodically after systematic reviews of the medical literature.
The goal of the IWGDF is to reduce diabetic foot complications—particularly ulcers and amputations—by providing clear, scientifically based recommendations for clinicians.
The IWGDF guidelines state that the key drivers of healing for diabetic foot ulcers are:
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Removal of pressure (offloading)
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Regular debridement
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Treatment of infection (when present)
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Ensure adequate blood supply (if insufficient)
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Citation:
Bus SA, Armstrong DG, Gooday C, et al. Guidelines on interventions to enhance healing of foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev. 2023;39(S1):e3644. doi:10.1002/dmrr.3644.
Is This How Ulcers Are Treated At Present?
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Not always.
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When a patient develops a plantar ulcer in British Columbia, he most commonly heads either to his family physician or a walk-in clinic. ​Most doctors don't treat a lot of these wounds, so the focus is often on treating presumed infection.
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A swab of the wound may or may not be taken. Then, more often that not, a light dressing is applied and a prescription for an antibiotic is usually given. ​
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Within a couple weeks of not healing, the patient is often sent to another site for wound care. There, the patient is commonly reappointed for regular dressing changes, often two to three times a week.
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More often than not, the two most important factors to heal a wound--debridement and offloading--are not addressed.
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So let's focus on the two treatments with which most patients are provided--antibiotics and dressings.
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The Problem With Focusing On Antibiotics
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It is true that about half of diabetic ulcerations will become infected and benefit from antibiotics.
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Armstrong DG, Boulton AJM, Bus SA. Diabetic Foot Ulcers: A Review.
JAMA. 2023;330(1):62-75
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And certainly, when infection is present, focusing on bacteria is extremely important. It can save your life!
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The problem with focusing treatment on killing bacteria is that many infections are not infected. And killing bacteria will not heal a wound that is caused not by infection, not by high sugar--but by a combination of neuropathy and pressure.
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To the right is a patient who presented with an ulcer on his left great toe. He had been treated with antibiotics nearly continually for 18 months. The wound would fluctuate in size a bit, antibiotics were changed, but never really get close to healing. Yet the doctor was certain the wound was infected because several swabs had been taken and something was always growing.
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Why did this not heal?
Well first, if there were infection present, putting a swab on a wound isn't particularly accurate way to diagnose an infection.
You could swab every surface on every person or item in a room and bacteria will grow. The doorframe, the wall, the chair. And every surface of the body--including the ulcer. In other words, all wounds will be colonized by bacteria because everything is colonized by bacteria.
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But bacterial presence on a wound is not the same as an infection. Infection is defined not simply by the presence of bacteria, (which are guaranteed to be present in any wound), but by the situation where the bacteria are defeating the body's defenses and spreading into the body. And the wound to the right does not exhibit the signs of an infection.
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Second, antibiotics don't heal ulcers. They kill bacteria. ​
A diabetic foot wound should be diagnosed as infected clinically, not simply because a culture grows bacteria.
The Infectious Disease Society of America (IDSA) defines infection as being present when there is pus (as seen to the right, in this example mixed with some blood) or at least two classic signs of inflammation, such as erythema (below right), warmth, swelling or discomfort. Keep in mind, discomfort is not always present with neuropathy.
Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54(12):e132-e173
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In other words, infections are diagnosed clinically--that is, how the wound looks to the eye.
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When cultures are desired--to find the specific organism present--superficial swabs can be misleading. For example, if a wound is merely colonized by bacteria, culturing the surface may identify organisms present, but not necessarily causing the invasive infection.
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Thus, the IDSA suggests that for diabetic foot infections, the best method is to culture a wound is:
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Irrigate the wound with normal saline--not antiseptics or antimicrobial agents).
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Collect a tissue specimen via curettage or biopsy
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Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54(12):e132-e173 ​​
While antibiotics are important when infection is truly present, but they do not heal an uninfected neuropathic ulcer. Current IWGDF/IDSA guidance specifically advises not treating a clinically uninfected diabetic foot ulcer with antibiotics simply to promote healing or prevent infection as it can cause resistance in bacteria, making them more virulent.
Senneville É, Albalawi Z, van Asten SAV, et al. Guidelines
on the diagnosis and treatment of diabetes-related foot
infections. Clin Infect Dis. 2024;78(5):e178-e203).
The Problem With Focusing on Dressings
​Once the wound is labeled “infected” and the patient is often prescribed antibiotics, the patient is typically sent for repeated dressing changes, sometimes several times per week.
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Dressings can protect the wound. They can keep it clean. And they can help manage moisture. To be clear, these are important goals.
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But they do not remove the pressure and shear that caused the ulcer in the first place.
As discussed on our page about dressings, other than using them to control moisture balance (drying wounds that are too wet, applying moisture to dressings that are too dry), there seems to be little difference in closure rates when you compare dressings.
And, as discussed there, none of them appear to heal wounds as well as offloading and debridement. In fact, when dressings are the focus of wound care, less than than a third of ulcers will heal within 3 months.
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Margolis DJ, Kantor J, Berlin JA. Healing of diabetic neuropathic foot ulcers receiving standard treatment. Wound Repair Regen. 1999;7(2):106-16.
Parks VE, Crisologo PA, Lavery LA, Banks J, Liette MD, Johnson L. Progress in diabetic foot ulcer healing with standard of care therapy alone: a meta-analysis. Diabetes. 2020;69(Suppl 1):39-LB. doi:10.2337/db20-39-LB.
Driver VR, et al. Standard of care outcomes in diabetic foot ulcer trials: a meta-analysis. Wound Repair Regen. 2015.
Coye TL, Crisologo PA, Lavery LA, et al. Healing of diabetic neuropathic foot ulcers receiving standard treatment in randomized controlled trials: a random-effects meta-analysis. Wound Repair Regen. 2025.
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If the wound fails to heal, the original physician may think he's done everything right, so it must be a problem with the patient's ability to heal. The patient is commonly sent for preventable amputation.
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Certainly, this is appropriate when ischemia is suspected and essential when blood flow is inadequate. But most neuropathic patients have sufficient blood flow. The issue is we're not focusing on what needs to be done for the wound to heal.
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So what should ulcer treatment focus on?
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Assuming the patient is able to heal--that means there is sufficient blood flow to heal, there is no overlying infection, and there is sufficient nutrition...
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The most important factors in getting a wound to heal:
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Offloading (removing pressure), and
Debridement (removing dead tissue).
The most important treatment is usually offloading, because these wounds are caused by weight bearing pressure and they persist when the patient continues to walk on them. The IWGDF offloading guideline states that relief of mechanical tissue stress is arguably the most important intervention required to heal a diabetes-related foot ulcer.
Bus SA, Armstrong DG, Crews RT, et al.
Guidelines on offloading foot ulcers in persons with diabetes
IWGDF 2023 update. Diabetes Metab Res Rev. 2024;40(3):e3647).
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Diabetic foot infection and wound-care guidance also recommends that wounds with necrotic tissue or surrounding callus be debrided, and that surrounding callus be removed, because callus itself is often a marker of abnormal pressure and contributes to continued tissue injury.
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Lipsky BA, Berendt AR, Cornia PB, et al. Clin Infect Dis. 2012;54(12):e132-e173; Schaper NC, van Netten JJ, Apelqvist J, et al. Practical guidelines on the prevention and management of diabetes-related foot disease. Diabetes Metab Res Rev. 2024;40 Suppl 1:e3657
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These wounds are often treated in the wrong order. A dressing may be applied, antibiotics may be prescribed, and the patient may be told to “watch it,” while the actual cause of the wound—continued mechanical overload—remains unchanged. That is why neuropathic wounds so often become chronic. The wound may be covered, but it is still being injured every time the patient walks on it.
Bus SA, Armstrong DG, Crews RT, et al.
Guidelines on offloading foot ulcers in persons with diabetes
IWGDF 2023 update. Diabetes Metab Res Rev. 2024;40(3):e3647​​​​​​​​​​​​​​
It's not what you put on a wound that counts
It's not dressings, and antibiotics
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It's what you take off
Removing necrotic tissue through debridement
Removing pressure through offloading
First, assess blood flow, infection, and severity
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Before focusing on dressings or advanced wound products, three issues have to be clarified: blood flow, infection, and wound severity. A wound cannot heal properly if tissue perfusion is inadequate. If there is significant arterial insufficiency, the foot may require vascular assessment and possibly revascularization before meaningful healing can occur. Likewise, if infection is present, infection becomes the immediate priority because it can spread rapidly and threaten both limb and life.
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In the office, blood flow can be assessed by checking the pulses in the foot, gently pressing on the skin until it turns white and assessing how long it takes for the color to return to it's normal color.
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A Doppler can be used to assess flow as well. They are not expensive and new models are quite portable. PPG (photoplethysmography) is a small probe that can be placed on the skin to check flow in the capillaries. ABI testing (assessments with blood pressure cuffs placed on both arms and both legs) can assess for blockages in the vessels of the leg.
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More invasive testing is performed in hospitals or specialized settings.
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Antibiotics are important when infection exists, but they do not heal an uninfected wound. Current IWGDF/IDSA guidance specifically advises not treating a clinically uninfected diabetic foot ulcer with systemic or local antibiotics simply to promote healing or prevent infection.
Senneville É, Albalawi Z, van Asten SAV, et al.
IWGDF/IDSA Guidelines on the diagnosis and
treatment of diabetes-related foot infections
(IWGDF/IDSA 2023). Clin Infect Dis. 2024;78(5):e178-e203;
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Schaper NC, van Netten JJ, Apelqvist J, et al.
Practical guidelines on the prevention and management
of diabetes-related foot disease (IWGDF 2023 update).
Diabetes Metab Res Rev. 2024;40 Suppl 1:e3657.
The most important treatment is offloading
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For a neuropathic plantar wound, the single most important treatment is usually offloading. If the patient continues to walk on the wound in ordinary shoes, healing is often slow or absent regardless of how often the dressing is changed. The 2023 IWGDF offloading guideline states that relieving mechanical tissue stress is arguably the most important intervention required to heal diabetes-related foot ulcers. For many plantar forefoot and midfoot ulcers, a non-removable knee-high offloading device is the preferred first choice when there is no contraindication.
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This point is worth emphasizing because it is so often missed. A neuropathic wound is not just an open area of skin; it is a mechanically overloaded wound. If pressure and shear are not addressed, the clinician may be providing wound care without removing the cause of the wound. Total contact casting, irremovable walkers, removable cast walkers, footwear modification, felt padding, or other site-specific offloading methods may be used depending on the case, but the principle is the same: a wound that is still being loaded is being reinjured .
Bus SA, Armstrong DG, Crews RT, et al.
Diabetes Metab Res Rev. 2024;40(3):e3647.
Debridement is usually next
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After offloading, the next major treatment is usually debridement. Neuropathic ulcers commonly develop surrounding callus, undermining, slough, or devitalized tissue. Debridement removes non-viable tissue, reduces pressure from the callus rim, improves visualization of the true wound margins and depth, and helps convert a chronic wound into one that can progress more normally through healing. The IWGDF practical guideline recommends debriding the ulcer and removing surrounding callus, preferably with sharp surgical instruments, and repeating this as needed.
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Debridement is not just cosmetic. In a neuropathic wound, a thick callus rim is often physical evidence of persistent abnormal pressure. If that callus is left in place, the local mechanics remain hostile. That said, ischemia changes the equation; aggressive sharp debridement should be approached cautiously if perfusion is poor, because tissue may not tolerate it well until the vascular situation is clarified.
Schaper NC, van Netten JJ, Apelqvist J, et al.
Diabetes Metab Res Rev. 2024;40 Suppl 1:e3657.
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Dressings matter, but they are not what heals the wound
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Dressings are important, but they are not the main driver of healing in a neuropathic ulcer. Their role is to protect the wound, maintain an appropriate moisture balance, manage exudate, and reduce trauma during dressing changes. The IWGDF practical guideline recommends selecting dressings to control excess exudation and maintain a moist wound environment, and the wound-healing guideline treats basic dressings as part of standard care rather than as the decisive treatment on their own.
Schaper NC, van Netten JJ, Apelqvist J, et al.
Diabetes Metab Res Rev. 2024;40 Suppl 1:e3657;
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Chen P, Asanova I, Aragón-Sánchez J, et al.
Guidelines on interventions to enhance healing of
foot ulcers in persons with diabetes (IWGDF 2023 update).
Diabetes Metab Res Rev. 2024;40 Suppl 1:e3644)
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This is where treatment is often misdirected. Repeated dressing changes may make a wound look attended to, but dressings do not unload the foot, do not remove a callus rim, and do not correct the biomechanics that caused the ulcer. They are supportive treatment, not the primary cure.
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Chen P, Asanova I, Aragón-Sánchez J, et al.
Diabetes Metab Res Rev. 2024;40 Suppl 1:e3644
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Bus SA, Armstrong DG, Crews RT, et al.
Diabetes Metab Res Rev. 2024;40(3):e3647.
Blood sugar control and general medical optimization still matter
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Although offloading and debridement are central, the wound also has to heal in a body that is medically capable of healing. The treatment of diabetic foot ulcers is most effective when it addresses glycemic control, infection, vascular status, and local wound care together with offloading.
Embil JM, Albalawi Z, Bowering K, Trepman E;
Diabetes Canada Clinical Practice Guidelines Expert Committee.
Foot Care. Can J Diabetes. 2018;42 Suppl 1:S222-S227.
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Poor glycemic control does not mechanically cause the ulcer, but it can impair host defenses, complicate infection, and contribute to poor wound progress. A systematic review found that higher A1c and fasting glucose levels were associated with worse diabetic foot ulcer outcomes, particularly lower-extremity amputation risk.
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Lane KL, Shah SK, Dennis ML, et al. Glycemic control and
diabetic foot ulcer outcomes: A systematic review and
meta-analysis of observational studies.
J Diabetes Complications. 2020;34(10):107638.
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We have a page on the effects of sugar on wound healing here, including a case presentation of fluctuating healing when the blood sugar varied.
This was a non-weight-bearing wound, so it wasn't about offloading the wound in weight bearing.
Nutrition should also be considered, especially in frail, elderly, chronically ill, or protein-calorie malnourished patients. In many patients in developed settings, as in Canada, nutrition is not the primary reason a neuropathic ulcer fails to heal, but severe undernutrition, catabolic illness, renal disease, and systemic inflammation can all hinder repair. It belongs in the background assessment, even if it is not usually the main treatment focus.
Embil JM, Albalawi Z, Bowering K, Trepman E;
Diabetes Canada Clinical Practice Guidelines Expert Committee.
Foot Care. Can J Diabetes. 2018;42 Suppl 1:S222-S227.
​Recurrence
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​​Healing is not the end, because recurrence is common. The patient still has neuropathy, and often still has deformity, abnormal pressure distribution, limited joint motion, or poor footwear. Recurrence is common. The IWGDF prevention guideline notes a recurrence rate of about 40% within one year and 65% within three years after healing, which is why prevention has to be part of treatment from the beginning.
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Bus SA, Lavery LA, Monteiro-Soares M, et al.
Guidelines on the prevention of foot ulcers
in persons with diabetes (IWGDF 2023 update).
Diabetes Metab Res Rev. 2024;40 Suppl 1:e3651).
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That means proper footwear--often custom orthotics or custom shoes--for pressure redistribution.
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It includes daily surveillance for callus and pre-ulcerative lesions, and regular foot care are not optional extras. They are what prevent the next wound. In that sense, the treatment of a neuropathic wound does not end when the skin closes; it ends when the foot is safer than it was before the ulcer developed.
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Bus SA, Lavery LA, Monteiro-Soares M, et al.
Diabetes Metab Res Rev. 2024;40 Suppl 1:e3651.
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This page written by Dr. S A Schumacher
Podiatric Surgeon
Surrey, British Columbia Canada
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Unless otherwise indicated, all clinical photographs owned and provided by
Dr. S A Schumacher. They may be reproduced for educational purposes with attribution to: Dr. S A Schumacher,
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