Diabetic foot syndrome: modern wound care in Zürich

You have diabetes. One morning, pulling on your socks, you notice a small reddened patch on the ball of your foot. It does not hurt. Perhaps it was the new shoe, perhaps a small stone you never felt. You put a plaster on it and forget it. Two weeks later, the small patch has turned into an open wound that refuses to close. This is exactly where diabetic foot syndrome begins, and exactly where it is decided whether a pressure point turns into a chronic wound or heals well.

:::answer-block{eyebrow="In short"} Diabetic foot syndrome (DFS) is one of the most common late complications of diabetes mellitus. The worldwide lifetime prevalence of a foot ulcer in people with diabetes is 19 to 34 percent [Armstrong et al., NEJM 2017]. Three factors act together: polyneuropathy removes pain as a warning signal, peripheral arterial disease throttles the blood supply, and a weakened immune defence opens the door to infection. The international IWGDF guidelines therefore recommend structured care on five pillars: pressure offloading, revascularisation, infection control, metabolic optimisation and local wound management [Schaper et al., IWGDF 2023]. With timely treatment, two out of three diabetic foot ulcers heal within twelve weeks. If treatment is delayed too long, the risk of major amputation rises to as much as 20 percent within five years of first presentation. Wound care in DFS therefore belongs in specialised hands, ideally networked with the GP, vascular medicine and diabetology. :::

Why diabetic wounds heal differently

Healthy skin heals reliably. It is well perfused, it has a working immune system, and it senses pressure before it becomes an injury. In diabetes, all three protective mechanisms typically fail at the same time.

Chronically elevated blood sugar damages fine structures throughout the body. Over time, the nerve fibres in the feet lose their function (polyneuropathy). The small and large vessels narrow (angiopathy, frequently in the form of peripheral arterial disease). And the defence cells lose function, which is why even small skin lesions can become infected. This combination is why a pressure point heals within days in a person with well-controlled diabetes, while the same pressure point can become a chronic wound in a person with poorly controlled diabetes and early neuropathy.

Polyneuropathy and blood supply: the silent risk

Diabetic polyneuropathy is insidious because it is painless. You do not notice that the shoe is rubbing. You do not notice that you have stepped on a stone. You do not notice that the bath water is too hot. Roughly half of all people with long-standing diabetes develop measurable neuropathy, and a considerable proportion are initially unaware of it [Schaper et al., IWGDF 2023].

At the same time, the blood supply changes. In many patients with DFS, clinically relevant peripheral arterial disease (PAD) can be detected [Hinchliffe et al., IWGDF 2023]. Classic warning signs such as calf pain when walking may be absent, because the neuropathy masks the pain anyway. This makes detecting PAD in people with diabetes particularly demanding and explains why the regular foot examination, with palpation of the pulses, ankle-brachial index and sensory testing, should be routine for every person with diabetes.

Wound care in stages: what modern really means

The international IWGDF guidelines describe a clear staged logic [Schaper et al., IWGDF 2023]. In our practice we follow it consistently.

First stage: precise diagnostics. This includes wound classification (depth, signs of infection, signs of ischaemia), assessing the blood supply with Doppler or duplex ultrasound, sensory testing with tuning fork and monofilament, and a microbiological swab if infection is suspected.

Second stage: pressure offloading. A foot wound that is still being walked on does not heal. The guideline names the non-removable knee-high offloading device as the gold standard for plantar neuropathic ulcers [Schaper et al., IWGDF 2023]. In practical terms, depending on the wound, we work with a total contact cast, removable orthoses, special footwear or orthopaedic insoles.

Third stage: revascularisation where needed. If the blood supply is critically reduced, no dressing, however good, helps. Here we work closely with interventional radiologists and vascular surgeons so that balloon dilatation, stent or bypass happen in good time.

Fourth stage: infection management. Local antiseptics plus, in the case of deep or systemic infection, targeted antibiotics guided by the resistance profile. If osteomyelitis is suspected, imaging is arranged.

Fifth stage: metabolic optimisation. An HbA1c above the target range slows every healing process. Here we integrate the wound clinic and diabetes care closely; more on the page on chronic diabetes care.

V.A.C. therapy and Kerecis at Dein Team

For deeper, exuding or poorly granulating wounds we use modern methods. Negative pressure wound therapy (V.A.C.) creates a controlled vacuum over the wound. This removes excess exudate, stimulates the formation of granulation tissue, improves local blood flow and lowers the risk of infection. V.A.C. therapy is an established option for deep diabetic foot ulcers and can shorten the time to wound closure [Schaper et al., IWGDF 2023].

For wounds that are particularly resistant to treatment, biological wound dressings come into play. Kerecis is a wound matrix derived from North Atlantic cod skin. The intact, omega-3-rich fish skin is applied to the wound bed and serves as a scaffold into which the body's own cells migrate. It is typically used when conventional dressings have failed to build sufficient granulation tissue after several weeks. In practice we regularly combine these procedures with debridement and pressure offloading. The team decides case by case which method is appropriate and when, always guided by the guidelines and always depending on blood supply, infection status and wound phase.

When to see a specialist and when to see your GP

A pragmatic rule of thumb for everyday life: any new foot wound in a person with diabetes is a reason to act within the coming week rather than at the next routine visit. If the wound shows no visible improvement after two weeks of ongoing care, it belongs in specialised hands [Armstrong et al., NEJM 2017]. If there is spreading redness, swelling, warmth, purulent discharge or fever, contact us the same day. Waiting is not an option here.

In concrete terms: the GP is the first point of contact for the annual foot examination, for testing sensation and pulses, for training in daily self-inspection and for the rapid initial assessment of any new skin lesion. As soon as there is an open wound, an infection threatens or the blood supply is critical, the wound clinic is brought in. This is the mechanism that makes the combination of GP and wound clinic at Dein Team fürs Leben work so well. You lose no time between the disciplines.

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How often should I check my feet myself as a person with diabetes?

Daily, ideally in the evening. Look at the soles, the spaces between the toes and the heels. If you cannot see your sole well, use a hand mirror. Watch for redness, swelling, pressure points, calluses, small cracks or blisters. A change in skin colour or a warm spot can be the first sign of a developing inflammation.

From what point is a foot wound considered chronic?

A wound that does not heal after four to six weeks of correct treatment is considered chronic. In diabetic foot syndrome, however, you should react considerably earlier. If there is no visible improvement after two weeks, the wound belongs in specialised hands.

Once a wound has healed, am I safe again?

Unfortunately not. The recurrence rate is high. Around 40 percent of patients develop a new ulcer within one year of healing, and after five years the figure is around 65 percent [Armstrong et al., NEJM 2017]. Precisely for this reason, follow-up care is part of the treatment. Structured check-ups, suitable footwear and daily inspection lower the risk noticeably.

What can I do to prevent a first ulcer?

Three levers are proven: well-controlled blood sugar, properly fitting footwear without pressure points, and regular professional foot care. The IWGDF prevention guideline also recommends annual screening examinations and, for a higher risk profile, shorter intervals [Bus et al., IWGDF 2023].

Does basic health insurance cover specialised wound care?

Yes. Specialised wound care for DFS is part of the benefits catalogue of Swiss compulsory basic health insurance (Grundversicherung) as soon as there is a medical indication. Materials such as special wound dressings and V.A.C. systems are covered when correctly indicated. For questions about billing, the practice advises you at the first consultation. :::

Author: Prof. Dr. C.K. Fritz M.Sc., Physician Associate for General Internal Medicine, Pain Medicine, Practice Lead Dein Team fürs Leben