Overview

Diabetic foot disease results in a major global burden for patients and the health care system.
The International Working Group on the Diabetic Foot (IWGDF) has been producing evidence-
based guidelines on the prevention and management of diabetic foot disease since 1999. In
2019, all IWGDF
Guidelines have been updated, based on systematic reviews of the literature and formulation
of recommendations by multidisciplinary experts from all over the world.
In this document, the IWGDF Practical Guidelines, we describe the basic principles of
prevention, classification and treatment of diabetic foot disease, based on the six IWGDF
Guideline chapters. We also describe the organizational levels to successfully prevent and treat
diabetic foot disease according to these principles and provide addenda to assist with foot
screening. The information in these practical guidelines are aimed at the global community of
healthcare professionals who are involved in the care of persons with diabetes.
What is diabetic foot disease (DFU)?
Diabetic foot disease is among the most serious complications of diabetes mellitus. It is
a source of major suffering and financial costs for the patient, and also places a considerable
burden on the patient’s family, healthcare professionals and facilities and society in general.
Strategies that include elements of prevention, patient and staff education, multi-disciplinary
treatment, and close monitoring as described in this document can reduce the burden of
diabetic foot disease.

IWGDF Guideline on the prevention of foot ulcers in persons with diabetes

There are five key elements that underpin efforts to prevent foot ulcers:
1. Identifying the at-risk foot
2. Regularly inspecting and examining the at-risk foot
3. Educating the patient, family and healthcare professionals
4. Ensuring routine wearing of appropriate footwear
5. Treating risk factors for ulceration

IDENTIFYING THE AT THE RISK FOOT

The absence of symptoms in a person with diabetes does not exclude foot disease; they may
have asymptomatic neuropathy, peripheral artery disease, pre-ulcerative signs, or even an
ulcer. Examine a person with diabetes at very low risk of foot ulceration annually for signs or
symptoms of loss of protective sensation and peripheral artery disease, to identify if they are at
risk for foot ulceration, including doing the following:
• History: Previous ulcer/lower extremity amputation, claudication
• Vascular status: palpation of pedal pulses
• Loss of protective sensation (LOPS): assess with one of the following techniques:
- Pressure perception: Semmes-Weinstein 10-gram monofilament
- Vibration perception: 128 Hz tuning fork
- When monofilament or tuning fork are not available test tactile sensation: lightly touch the
tips of the toes of the patient with the tip of your index finger for 1–2 seconds
LOPS is usually caused by diabetic polyneuropathy. If present, it is usually necessary to elicit
further history and conduct further examinations into its causes and consequences; these are
outside the scope of this guideline.

2. Regularly inspecting and examining the at-risk foot (IWGDF risk 1 or higher)
In a person with diabetes with loss of protective sensation or peripheral artery disease (IWGDF
risk 1-3) perform a more comprehensive examination, including the following:
• History: inquiring about previous ulcer/lower extremity amputation, end stage renal disease,
previous foot education, social isolation, poor access to healthcare and financial constraints,
foot pain (with walking or at rest) or numbness, claudication
• Vascular status: palpation of pedal pulses
• Skin: assessing for skin color, temperature, presence of callus or edema, pre-ulcerative signs
• Bone/joint: check for deformities (e.g., claw or hammer toes), abnormally large bony
prominences, or limited joint mobility. Examine the feet with the patient both lying down and
standing up
• Assessment for loss of protective sensation (LOPS), if on a previous examination protective
sensation was intact
• Footwear: ill-fitting, inadequate, or lack of footwear.
• Poor foot hygiene, e.g. improperly cut toenails, unwashed feet, superficial fungal infection, or
unclean socks
• Physical limitations that may hinder foot self-care (e.g. visual acuity, obesity)
• Foot care knowledge
Following examination of the foot, stratify each patient using the IWGDF risk stratification
category system shown in Table 1 to guide subsequent preventative screening frequencies and
management.
Areas of the foot most at-risk are shown in Figure 2. Any foot ulcer identified during screening
should be treated according to the principles outlined below.

Table 1: The IWGDF 2019 Risk Stratification System and corresponding foot screening frequency

CATEGORY ULCER RISK CHARACTERISTICS FREQUENCY

0 Very low No LOPS and No PAD Once a year
1 Low LOPS or PAD Once every 6-12
months
2 Moderate LOPS + PAD, or Once every 3-6
LOPS + foot months
deformity or
PAD + foot deformity
3 High LOPS or PAD, and Once every 1-3
one or more of the months
following:
- history of a foot
ulcer
- a lower-extremity
amputation (minor or
major)
- end-stage renal
disease

Areas of the foot at highest risk for ulceration

3. Educating patients, family and healthcare professionals about foot care
Education, presented in a structured, organized and repeated manner, is widely considered to
play an important role in the prevention of diabetic foot ulcers. The aim is to improve a
patient’s foot self-care knowledge and self-protective behavior, and to enhance their
motivation and skills to facilitate adherence to this behavior. People with diabetes, in particular
those with IWGDF risk 1 or higher, should learn how to recognize foot ulcers and pre-ulcerative
signs and be aware of the steps they need to take when problems arise. The educator should
demonstrate specific skills to the patient, such as how to cut toe nails appropriately (Figure 3).
A member of the healthcare team should provide structured education (see examples of
instructions below) individually or in small groups of people, in multiple sessions, with
periodical reinforcement, and preferably using a mixture of methods. The structured education
should be culturally appropriate, account for gender differences, and align with a patient’s
health literacy and personal circumstances. It is essential to assess whether the person with
diabetes (and, optimally, any close family member or carer) has understood the messages, is
motivated to act and adhere to the advice, to ensure sufficient self-care skills. Furthermore,
healthcare professionals providing these instructions should receive periodic education to
improve their own skills in the care for people at high-risk for foot ulceration.

The proper way to cut toe nails

Items to cover when educating the person at-risk for foot ulceration (IWGDF risk 1 or higher):
• Determine if the person is able to perform a foot inspection. If not, discuss who can assist the
person in this task. Persons who have substantial visual impairment or physical inability to
visualize their feet cannot adequately do the inspection
• Explain the need to perform daily foot inspection of the entire surface of both feet, including
areas between the toes
• Ensure the patient knows how to notify the appropriate healthcare professional if measured
foot temperature is perceptibly increased, or if a blister, cut, scratch or ulcer has developed
• Review the following practices with the patient:
- Avoid walking barefoot, in socks without footwear, or in thin-soled slippers, whether at home
or outside
- Do not wear shoes that are too tight, have rough edges or uneven seams
- Visually inspect and manually feel inside all shoes before you put them on
- Wear socks/stocking without seams (or with the seams inside out); do not wear tight or knee
high socks (compressive stocking should only be prescribed in collaboration with the foot care
team), and change socks daily
- Wash feet daily (with water temperature always below 37°C), and dry them carefully,
especially between the toes
- Do not use any kind of heater or a hot-water bottle to warm feet
- Do not use chemical agents or plasters to remove corns and calluses; see the appropriate
healthcare professional for these problems
- Use emollients to lubricate dry skin, but not between the toes
- Cut toenails straight across (see Figure )
- Have your feet examined regularly by a healthcare professional
4. Ensuring routine wearing of appropriate footwear
In persons with diabetes and insensate feet, wearing inappropriate footwear or walking
barefoot are major causes of foot trauma leading to foot ulceration. Persons with loss of
protective sensation (LOPS) must have (and may need financial assistance to acquire) and
should be encouraged to wear, appropriate footwear at all times, both indoors and outdoors.
All footwear should be adapted to conform to any alteration in foot structure or foot
biomechanics affecting the person’s foot. People without LOPS or PAD (IWGDF 0) can select
properly fitting off-the-shelf footwear. People with LOPS or PAD (IWGDF 1-3) must take extra
care when selecting, or being fitted with, footwear; this is most important when they also have
foot deformities (IWGDF 2) or have a history of a previous ulcer/amputation (IWGDF 3).
The inside length of the shoe should be 1-2 cm longer than their foot and should not be either
too tight or too loose (see Figure 4). The internal width should equal the width of the foot at
the metatarsal phalangeal joints (or the widest part of the foot), and the height should allow
enough room for all the toes. Evaluate the fit with the patient in the standing position,
preferably later in the day (when they may have foot swelling). If there is no off-the-shelf
footwear that can accommodate the foot (e.g., if the fit is poor due to foot deformity) or if
there are signs of abnormal loading of the foot (e.g., hyperemia, callus, ulceration), refer the
patient for special footwear (advice and/or construction), possibly including extra-depth shoes,
custom-made shoes, insoles, or orthoses.

Footwear should be sufficiently wide to accommodate the foot without excessive pressure on
the skin
To prevent a recurrent plantar foot ulcer, ensure that a patient’s therapeutic footwear has a
demonstrated plantar pressure relieving effect during walking. When possible, demonstrate
this plantar pressure relieving effect with appropriate equipment, as described elsewhere (1).
Instruct the patient to never again wear the same shoe that has caused an ulcer.
5. Treating risk factors for ulceration
In a patient with diabetes treat any modifiable risk factor or pre-ulcerative sign on the foot. This
includes: removing abundant callus; protecting blisters, or draining them if necessary;
appropriately treating ingrown or thickened nails; and, prescribing antifungal treatment for
fungal infections. This treatment should be repeated until these abnormalities resolve and do
not recur over time, and should be performed by an appropriately trained healthcare
professional. In patients with recurrent ulcers due to foot deformities that develop despite
optimal preventive measures as described above, consider surgical intervention.