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Managing diabetes 2020

Diabetic foot: the cancer of diabetes

Alberto Piaggesi MD

Director, Diabetic Foot Section – Department of Medicine – University of Pisa, Italy
President of the European Wound Management Association (EWMA)

It has been estimated that a limb is lost every 30 seconds in the world because of diabetic foot. And the associated mortality is higher than that of many forms of cancer. More must be done to raise awareness of the chronic complications of diabetes.

Diabetic foot describes the complications of diabetes in the lower limb and is the most frequent cause of amputation in the lower extremity (the part of the body from the hip to the toes).

Diabetic foot affects one in three people with diabetes at least once in their life. Because of its propensity to recur, it accounts for the largest resource consumption among those related to diabetes.

The diabetic foot has a complex pathogenesis involving both peripheral neuropathy and peripheral artery disease and a chronic evolution with acute phases, characterised by ulceration and a chronic remitting period, in which deformities and possibly minor amputations limit the function of the foot and expose to relapses.2

Reducing diabetic foot related amputations

The prognosis of diabetic foot significantly improved in recent times, because of a multi-professional management strategy. This involves diabetologists, podologists, nurses, vascular surgeons, endovascular specialists and all the other specialists involved in a common therapeutic programme.

This programme aims to treat the acute phases of diabetic foot and follow up with patients in the chronic phases.

This approach aims to avoid – or at least delay – recurrences, thereby ensuring the longest possible ulcer-free and active time.3

Managing diabetic foot ulceration

Ulceration remains a pivotal event that characterises the acute phases of the disease and conditions the prognosis.

More than 85% of lower extremity amputations (LEA) in diabetic foot originate from ulcerations. Their duration is a negative prognostic marker for both healing and LEA.4

After a long time with largely observational/experimental ulceration management; new, safe and effective treatments have been approved for clinical use. This has improved healing rates and times of many types of diabetic foot ulcerations (DFU)5.

Raising awareness of diabetic foot

Despite these positive possibilities, many patients are still suffering and experiencing a worsening of their condition, due to the lack of access or too late referral to specialised care.

This is often due to the GPs lack of awareness about the pathology or due to underestimation of the severity of the clinical conditions.6

For this reason, the European Wound Management Association (EWMA), a multi-professional association in this field, developed initiatives specifically dedicated to diabetic foot and DFUs.

In 2018, EWMA promoted a joint action, together with the International Working Group on Diabetic Foot (IWGDF), to endorse the centres that implement the international diabetic foot guidelines in their practice.

The objective was to increase the quality and to standardise the care of diabetic foot in Europe.

Finally, EWMA announced the first World Diabetic Foot Day in 2020, to be held in April 2021 in Paris.

Diabetic foot is the most challenging among the chronic complications of diabetes and still accounts for a lot of suffering and death among patients.

We do, however, now have much better chances to contrast its evolution and improve the quality of life of many people living with diabetes, thereby ensuring them a brighter future.

Learn more about the European Wound Management Association at Find out more about our international residential course on the management of diabetic foot at Learn more about World Diabetic Foot Day at

[1] Jeffcoate W, Bakker K. World Diabetes Day: footing the bill. Lancet. 2005 Apr 30-May 6;365(9470). [2] Boulton AJM. The Diabetic Foot. In: De Groot LJ, Chrousos G, Dungan K, Feingold KR, Grossman A, Hershman JM, Koch C, Korbonits M, McLachlan R, New M, Purnell J, Rebar R, Singer F, Vinik A, editors. Endotext [Internet]. South Dartmouth (MA):, Inc.; 2000-2016 Oct 26. [3] Schaper NC, Van Netten JJ, Apelqvist J, Lipsky BA, Bakker K; International Working Group on the Diabetic Foot.. Prevention and management of foot problems in diabetes: a Summary Guidance for Daily Practice 2015, based on the IWGDF Guidance Documents. Diabetes Metab Res Rev. 2016 Jan;32 Suppl 1:7-15. [4] Zhang P, Lu J, Jing Y, Tang S, Zhu D, Bi Y. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. Ann Med. 2017 Mar;49(2):106-116. [5] Rayman G, Vas P, Dhatariya K, Driver V, Hartemann A, Londahl M, Piaggesi A, Apelqvist J, Attinger C, Game F; International Working Group on the Diabetic Foot (IWGDF). Guidelines on use of interventions to enhance healing of chronic foot ulcers in diabetes (IWGDF 2019 update). Diabetes Metab Res Rev. 2020 Mar;36 Suppl 1:e3283. [6] Nickinson ATO, Bridgwood B, Houghton JSM, Nduwayo S, Pepper C, Payne T, Bown MJ, Davies RSM, Sayers RD. A systematic review investigating the identification, causes, and outcomes of delays in the management of chronic limb-threatening ischemia and diabetic foot ulceration.  J Vasc Surg. 2020 Feb;71(2):669-681.e2.

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