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Podiatric interventions and phototherapy in the

management of chronic diabetic foot ulceration:

a review to compare the average healing time


Correspondence to: H Abrahamse

Laser Research Centre, Faculty of Health Sciences, University of Johannesburg,



N Sithole

Department of Podiatry, Faculty of Health Sciences, University of

Johannesburg, Johannesburg

S Afr J Diabetes Vasc Dis



: 4–10


Diabetic foot ulceration is a serious complication of

diabetes mellitus and an important risk factor for lower-

limb amputations. Diabetes is characterised by chronic

hyperglycaemia related to the resistance of target cells to

the action of insulin, which leads to degenerative disorders

caused by macro- and microangiopathy, and neuropathy.

These factors favour the occurrence of lower-limb ulcers and

delay their healing. The slow healing rate of chronic diabetic

foot ulceration has a negative impact on the patient’s quality

of life. There is a need therefore for the development of

new treatment modalities to improve the healing rate and

outcomes of diabetic ulcerations.

The management and treatment of chronic diabetic

ulcerations can last an extended period due to the lack of

response to treatment or the general nature of the ulcer.

Current podiatric protocols for the management of chronic

ulcers affecting the lower limb involve a dynamic approach,

which includes mechanical debridement of granulation and

dead tissue, antibiotics to treat infection, change of footwear,

mechanical off-loading using total-contact casts and orthotic

devices, as well as foot-care education.

Phototherapy is an alternative treatment modality that is

under investigation for the management of chronic diabetic

foot ulceration. It has been found to significantly increase

the healing rate of ulcers when used in combination with

other conventional treatments. The continuous management

and on-going surveillance and monitoring of chronic diabetic

foot ulcers with various combination therapies, including

phototherapy, may improve the healing time as so improve a

patient’s quality of life and physical activities.

The aim of this review is to compare the average

healing time of diabetic foot ulcers when treated with

standard podiatric treatment protocols and when treated in

combination with phototherapy in terms of diabetic foot-

ulcer management.


diabetes, foot ulcers, wound healing, laser,

phototherapy, off-loading, wound debridement.


Diabetes mellitus is a common metabolic condition that is increasing

in prevalence worldwide. The estimates by the International

Diabetes Federation in 2009 suggested that the number of adults

with diabetes in the world will increase by 54%, from 284.6 million

in 2010 to 438.4 million in 2030.

In sub-Saharan Africa in 2010, the projected growth in incidence

of diabetes was 98%, with the prevalence of type 2 diabetes rising



In South Africa in 2003, a prevalence figure was noted of

3.4% among the 24 million adults between the ages of 20 and

79 years. However in 2015, there were 2.28 million (7.0%) adult

diabetes cases noted in South Africa.


This drastic increase presents

a substantial public health and socio-economic burden to this

country in the face of scarce resources.


Type 2 diabetes is characterised by chronic hyperglycaemia related

to the resistance of target cells to the action of insulin, which leads

to degenerative disorders caused by macro- and microangiopathy,

and neuropathy.


These factors favour the occurrence of disease

complications, such as lower-limb ulcers and delayed healing.


Diabetic foot ulcers (DFUs) are estimated to occur in 15% of

all patients with diabetes and precede 84% of all diabetes-related

lower-leg amputations. These ulcers are a major cause of hospital

admissions for people with diabetes in the developed world and are

a major morbidity associated with diabetes, often leading to pain,

suffering, and an overall poor quality of life for the patient.


Classification of DFUs

Diabetic foot ulcers can result frommultiple factors and are therefore

classified according to the relative contribution of late diabetic

complications of peripheral neuropathy and vascular diseases.


Most diabetic lower-limb ulcers occur in the presence of peripheral

neuropathy, foot deformity and trauma, and these are called

neuropathic ulcers. Peripheral vascular disease, resulting in neuro-

ischaemic ulcers and infection, is believed to be the complicating

factor that prevents or delays ulcer healing.


The literature suggests

that the nature of chronic diabetic foot ulcerations disables

the normal stages of healing, which in turn induces a state of

pathological inflammation. This then results in the overall healing

process becoming incomplete or delayed.


Diabetic ulcers are also classified according to their severity or

in grades using the universally accepted validated tools such as the

Wagner andUniversity of Texas classifications.Wagner’s classification

grades 0–5 divides ulcers from superficial or deep ulcers up to

gangrene of the foot. The University of Texas classification stages

1–5 adds the presence of infection, ischaemia, or both infection

and ischaemia together.


These classifications are important as

we need to adequately describe the ulcers that we treat in order to

review a patient’s outcome.