Review

Treating diabetic ulcers

Francesco Tecilazich, Thanh Dinh & Aristidis Veves†
†
Beth Israel Deaconess Medical Center, Joslin-Beth Israel Deaconess Foot Center and
Microcirculation Lab, Harvard Medical School, Boston, Massachusetts, USA

1. Introduction Introduction: Diabetic foot ulceration is a serious secondary complication of

diabetes mellitus and the most common cause of hospitalization in diabetic
2. Normal aspects of wound
healing
patients. The etiology of diabetic foot ulcerations is complex due to their
multifactorial nature. Thus, addressing all of the factors involved remains
3. Development of diabetic foot
instrumental in wound healing.
ulceration
Areas covered: The first part of this review focuses on the pathophysiology of
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15

4. Current therapies diabetic foot ulceration and wound-healing impairment. The second part
5. Future therapies reviews the standard treatments, including advanced wound-care products
6. Conclusion and new therapeutic approaches currently under investigation. The reader
7. Expert opinion will understand the most up-to-date research regarding the unique patho-
physiology of diabetic foot ulceration along with the basic cornerstones of
current recommended standard therapy.
Expert opinion: Diabetic foot ulceration is a serious complication that can
lead -- potentially -- to devastating lower-extremity amputations. Proper
adherence to standard treatment strategies can potentially prevent the
need for amputation.
For personal use only.

Keywords: chronic inflammation, diabetes mellitus, diabetic foot ulcer,

endothelial dysfunction, growth factors, neuropeptides, peripheral neuropathy,
peripheral vascular disease, wound healing

Expert Opin. Pharmacother. (2011) 12(4):593-606

1. Introduction

Current statistical data from the International Diabetes Federation (IDF) and the
World Health Organization (WHO) show a dramatic worldwide increase in diabe-
tes mellitus (DM). In 2000, nearly 250 million people were affected by DM. This
corresponds with a global prevalence that is estimated to be 2.8%; a near doubling
of this number -- to 400 million (a projected prevalence of 4.4%) -- is expected in
the next two decades [1]. Because of its secondary complications, the life expectancy
of diabetic patients is on average 10 years shorter than nondiabetics [2]. Diabetic foot
ulcer (DFU) is a common secondary complication of DM, with an estimated 15%
of patients with diabetes expected to develop a foot ulcer within their lifetime [3].
More importantly, DFU us the most common cause of hospitalization in diabetic
patients [4], resulting in lower extremity amputations in about 15% of cases [3].
DFUs are the originating source of 85% of all amputations [5], representing a total
annual cost of 4 billion dollars in the United States alone [6].

2. Normal aspects of wound healing

At the host level, normal wound healing requires sufficient circulation, proper nutri-
tion, adequate immune status, and the avoidance of traumatic mechanical forces.
At the microscopic level, normal wound healing involves a complex, well-
orchestrated series of biological and molecular events consisting of cell migration,
cell proliferation, and deposition of extracellular matrix (ECM) [7]. This cascade
of wound healing can be divided into four different and overlapping
physiological phases.

10.1517/14656566.2011.530658 © 2011 Informa UK, Ltd. ISSN 1465-6566 593

All rights reserved: reproduction in whole or in part not permitted
 Treating diabetic ulcers
Article highlights.
. Diabetic foot ulceration (DFU) is the most common
cause of hospitalization in diabetic patients. Because of
the high incidence of treatment failure, DFU often leads
to amputations (in 15% of the cases).
.
Neuropathy, trauma, ischemia, and infection are the
main factors related to DFU.
. Standard care should be applied first (debridement, off
loading, restoration of blood flow, treatment
of infection).
. Advanced wound care should be applied only if the
standard care fails. It includes cell therapy, negative-
pressure therapy, hyperbaric oxygen therapy,
extracorporeal shock-wave therapy.
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15
This box summarizes key points contained in the article.
The first phase is hemostasis, which involves the forma-
tion of a fibrin plug consisting of platelets firmly enclosed
in a network of fibrin, fibronectin, vitronectin, and throm-
bospondin. Besides providing mechanical protection to the
wound from pathogenic microorganisms, the plug relea-
ses pro-inflammatory mediators, such as cytokines and
For personal use only.
growth factors. The cytokines function to recruit neutro-
phils, monocytes, and lymphocytes, which trigger the
next -- inflammatory -- phase.
In the inflammatory phase, the recruitment of neutro-
phils, monocytes, and lymphocytes serves several functions:
these cells act as a defense against contaminating microor-
ganisms by producing a wide variety of proteinases and reac-
tive oxygen species; they are involved in the phagocytosis of
cell debris; and, most importantly, they release growth fac-
tors and cytokines, which initiate the proliferative phase of
wound repair.
The proliferation phase starts with the migration and pro-
liferation of keratinocytes and of dermal fibroblasts. These
cells will later migrate into the provisional matrix and deposit
an ECM. During this phase, initiation of angiogenesis results
in the formation of new blood vessels, with nerve roots
sprouting at the wound edges. Wound contraction starts
when the deposition of ECM is coupled with angiogenesis
and re-epithelialization. As wound contraction begins, the
fourth and final phase -- remodeling -- is characterized
by ECM remodeling and formation of scar tissue, with
subsequent closure of the wound.
Much investigation has focused on defining the difference
between acute and chronic wounds. Acute wounds heal read-
ily, following the wound healing progress in an orderly pro-
cess through all of the phases. However, chronic wounds
such as DFU tend to stagnate during the healing process
and exhibit biochemical and pathophysiological abnormalities
that result in stalling of the wound in the inflammatory phase.
Thus, the path to wound closure does not follow an orderly
and reliable progression of healing [8].
594 Expert Opin. Pharmacother. (2011) 12(4)
3. Development of diabetic foot ulceration
DFUs are the result of various etiological factors and are char-
acterized by an inability to self-repair in a timely and orderly
manner [9]. DFU occurs as a consequence of the interaction of
several contributory factors, which may be divided schemati-
cally into intrinsic (neuropathy, peripheral vascular disease,
and diabetes severity) and extrinsic (wound infection, callus
formation, and excessive pressure to the site) [10].
Several studies have examined the risk factors for the devel-
opment of DFU. Most agree that a triad of factors contributes
to ulceration (Figure 1). These include the presence of periph-
eral neuropathy, foot deformities, and acute or chronic repet-
itive trauma. Peripheral neuropathy in the diabetic foot results
in loss of sensation, changes in foot structure with subsequent
deformity, and skin changes resulting in a foot more vulnera-
ble to injury with poor defenses. Peripheral sensory neuropa-
thy is responsible for the pain insensitivity, whereas
autonomic neuropathy causes impaired sweat-gland function,
resulting in dry, atrophic skin. Motor neuropathy commonly
causes intrinsic muscle wasting with a characteristic foot with
joint contractures and prominent bones to the metatarsal
plantar region with limited fat padding (Figure 2) [11]. Internal
or external traumas are generally the next key component and
these are usually related to the development of abnormally
high foot pressures during walking. Internal traumas are
typically the result of repetitive stresses from high-pressure
areas whereas external traumas derive from the environment
(ill-fitting footwear, object in the shoe, etc.).
In addition to the triad of risk factors described in the liter-
ature, impaired wound healing has been implicated as a signif-
icant cause for poor healing in the DFU. Other causes of poor
wound healing in DFU include infection and ischemia.
Recent investigation has revealed that impairments at the
microvascular level, as well as abnormal expression of growth
factors and other cytokines, may be involved in the altered
healing process.
3.1 Chronic inflammation
Over the last decade, it has steadily been recognized that DM
is a disease based fundamentally on inflammation. Both
type 1 and type 2 diabetes are characterized by the chronic
upregulation of pro-inflammatory cytokines. In type 1 DM,
cytokines like interleukin (IL)-1a, IL-4, and IL-6 are acutely
elevated during hyperglycemia and persist elevated for hours,
even after the restoration of euglycemia [12]. In type 2 DM,
the pro-inflammatory cytokines IL-1, tumor necrosis factor
(TNF)-a, IL-6, and CCL5 (RANTES) are released from var-
ious cells, such as immune cells and adipocytes, and have
been implicated together with several other mediators in the
development of insulin resistance [13,14].
In DM, a nonsequential release of pro- and anti-inflammatory
cytokines results in an imbalance that leads to impaired tissue
repair and weakened cellular and humoral immune defense
mechanisms [15,16]. Clinical investigations, both in patients

Neuropathy
Neuropathy
Trauma
Impaired healing
Neuropathy
Neuropathy
Trauma
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15
Trauma
Ulceration
Chronic foot ulceration,
amputation
Figure 1. The pathway to foot ulceration. Sensory neuro-
pathy, associated with pain insensitivity, is the first compo-
nent of the pathway. Internal or external traumas are next
key component. Impaired wound healing is the
For personal use only.
third component.
Modified from [5].
Figure 2. Changes related to motor neuropathy. Extensive
wasting of the intrinsic muscles of the foot results in clawing
of the toes and prominent metatarsal heads.
with diabetes and in experimental animal models, demonstrate
defects of chemotactic, phagocytic and microbiocidal activities
of neutrophils that contribute to the high susceptibility and
severity of infections typical of DM [17,18].
In a prospective clinical study comparing neutrophil activ-
ity and the levels of IL-1b in patients with healing and non-
healing DFU infections, dysfunction of neutrophils and a
dysregulation of IL-1b were noted in the patients with DFU
Expert Opin. Pharmacother. (2011) 12(4)
Tecilazich, Dinh & Veves
infections. This finding could possibly indicate impaired
immunological responses in diabetic patients [19]. Decreased
immune-cell infiltration has been shown in early-stage
DFUs, and there is a persistence of neutrophils and macro-
phages in chronic nonhealing wounds. These changes in
inflammatory-cell recruitment are consistent with alterations
in growth factor expression [20].
3.2 Peripheral arterial disease
Peripheral vascular disease (PVD) in diabetes is characterized
by impairment at both the microcirculation and macrocircu-
lation levels. Macrovascular disease is morphologically similar
in diabetic and nondiabetic patients, with the only exception
of anatomic location of disease. In diabetes, there is a propen-
sity for macrovascular disease to target the infrageniculate
arteries of the calf, specifically, the posterior and anterior tib-
ial and the peroneal arteries [21]. Unlike the common macro-
vascular presentation, microcirculatory disease is unique to
DM. In microvascular disease, there is no occlusion or nar-
rowing of the capillary lumen. Instead, the fundamental struc-
tural change in the diabetic small vessels is the thickening of
the basement membrane.
These changes play a central role in the development of
DFU and their subsequent failure to heal. Over the last
decade, surgical intervention of PVD to address macrovascu-
lar disease in the patient with diabetes is commonly per-
formed to address nonhealing DFUs with good success.
However, following revascularization, cutaneous microcircu-
lation, although greatly improved, cannot be completely
restored with the revascularization of the large vessels [22]
and patients with DM complicated by neuropathy, may still
fail to heal an existing ulcer.
In addition to the structural changes in the basement mem-
brane, the microcirculation itself is dysfunctional. Capillaries
have reduced elasticity (and thereby vasodilating capacity)
and the cellular migration and nutrient exchanges that nor-
mally occur at these levels are impaired. These abnormalities
are due to endothelial dysfunction, smooth-muscle-cell dys-
function and nerve axon reflex (NARV, also known in physi-
ology as the Lewis triple-flare response; Figure 3) impairment.
The exact causes of endothelial dysfunction and of smooth-
muscle-cell dysfunction remain unknown, but it has been
shown that the microcirculation fails to react and vasodilate
appropriately in patients with diabetes compared to healthy
controls [23,24].
The functional impairment of the microcirculation has
been attributed to reduced expression of endothelial nitric
oxide synthetase (eNOS) and poly(adenosine diphosphate
(ADP)-ribose) polymerase [24,25]. Interestingly enough, the
expression of eNOS is reduced in peripheral neuropathy,
suggesting a relationship between neuropathy and endothe-
lial dysfunction. Under conditions of stress, such as pain
and trauma, the C fibers secrete peptides [e.g., substance P
(SP), neuropeptide Y (NPY), neurotensin (NT), and others]
that exert vasodilation and increase vessel permeability. This
595
 Treating diabetic ulcers
Painful stimulus
C-nociceptive fiber
stimulation
Nerve
cell
Retrograde stimulation
Vasodilatation
Substance P
CGRP
Histamine
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15
Figure 3. The nerve--axon reflex. The stimulation of the
C-nociceptive fibers causes retrograde stimulation of the
adjacent fibers, which release active vaso dilators [such as
histamine, substance P and calcitonin gene-related peptide
(CGRP)]. The final result is hyperemia during injury
or inflammation.
represents a protective mechanism, and it has been shown to
be impaired in diabetic patients with and without neuropa-
thy [26], with the largest reduction observed in neuropathic
For personal use only.
feet. This characteristic impairment at the foot level can be
considered a functional ischemia and it may be another
possible mechanism that explains poor wound healing
in DFU.
3.3 Growth factors
As previously discussed, growth factors play an enormous role
in the normal healing cascade. Growth factors influence the
wound-healing process both through inhibitory and stimula-
tory effects on the local wound environment. A multitude of
growth factors is present in wound healing. The most promi-
nent growth factors include: platelet-derived growth factor
(PDGF), fibroblast growth factor (FGF), vascular endothelial
growth factor (VEGF), epidermal growth factor (EGF), nerve
growth factor (NGF), and granulocyte/macrophage-colony
stimulating factor (GM-CSF).
PDGF plays a major role in wound healing, acting as a
mitogen on fibroblasts, vascular smooth muscle cells, endo-
thelial cells (EC), neurons, and macrophages and as a chemo-
tactic for neutrophils, macrophages, and fibroblasts. PDGF
also enhances proliferation of fibroblasts, stimulates the pro-
duction of ECM by these cells, and triggers fibroblasts to
acquire a myofibroblast phenotype [27,28]. FGF (with the
exception of FGF7) stimulate proliferation and regulate the
migration and differentiation of cells of mesodermal, ectoder-
mal, and endodermal origin. FGF are mitogenic for several
cell types present at the wound site, including fibroblasts
and keratinocytes [29]. Furthermore, FGF1 and FGF2
stimulate angiogenesis [30]. EGF [including its member
transforming growth factor (TGF)-a] play an important
role in re-epithelialization and in the formation of granulation
596 Expert Opin. Pharmacother. (2011) 12(4)
tissue. In fact, they have been shown to be mitogenic for
fibroblasts and keratinocytes. VEGF have been identified as
a major regulator of both vasculogenesis and angiogenesis [31].
Levels of VEGF increase during trauma and ischemia and
they have also been shown to stimulate wound angiogenesis
in a paracrine manner. NGF is essential for the development
and survival of certain sympathetic and sensory neurons the
central and peripheral nervous systems, as all members of
the neurotrophin family of polypeptides. GM-CSF is
involved in angiogenesis and is mitogenic for keratinocytes.
All of these growth factors have been found in wound fluid
and are known to be integral in the chemotaxis, migration,
stimulation, and proliferation of cells and matrix substances
necessary for wound healing. Therefore, changes in the
expression pattern of these growth factors in DFUs can poten-
tially diminish granulation tissue formation and maintain
chronicity of the ulcer.
3.4 Endothelial progenitor cells
Neovascularization occurs in both physiologic and pathologic
conditions and may arise both from pre-existing vessels
(angiogenesis) and from new blood vessels (vasculogenesis)
through the key contribution of bone marrow-derived endo-
thelial progenitor cells (EPCs) [32]. In 1997, Asahara et al. first
identified circulating EPCs contributing to neovasculariza-
tion [33]. This discovery led to the understanding that EPCs
play an important role in both angiogenesis and in maintain-
ing the integrity and function of vascular endothelium [34].
Recent studies have shown that the levels of circulating
EPCs are a marker for vascular function and cumulative car-
diovascular risk and that they predict the occurrence of car-
diovascular events and death from cardiovascular causes [35].
Furthermore, there is increasing evidence that that EPCs con-
tribute to neovascularization during atherosclerosis [36], post-
myocardial infarction [37], endothelialization of vascular
grafts [38], wound healing, limb ischemia [34,39,40], retinal and
lymphoid organ neovascularization [41,42], vascularization
during neonatal growth [43], and tumor growth [44].
Under normal conditions, EPC levels are relatively low; the
numbers increase in response to trauma or ischemia. The
recruitment of EPCs from the bone marrow to the systemic
circulation, and then to the homing sites of neovasculariza-
tion, is subject to regulation by many factors, including che-
mokines and growth factors; however, the exact mechanism
of EPC mobilization is not entirely elucidated and is still
under investigation. Aicher et al. demonstrated that VEGF-
A activates eNOS in bone marrow [45] and that, subsequently,
nitric oxide activates matrix metalloproteinase 9 (MMP-9).
Activated MMP-9 is responsible for the release of a stem-
cell--active cytokine (soluble Kit ligand) that shifts EPCs and
hematopoietic stem cells from a quiescent to a proliferative
niche and stimulates their mobilization to the peripheral
blood [46].
As previously discussed, restoring blood flow to the site of
injured tissue is a prerequisite for mounting a successful repair

response, and is part of the proliferative phase. When the for-
mation of new blood vessels occurs within the provisional
wound matrix, granulation tissue develops. The possible role
of EPCs in DFUs is currently under investigation, as the
role and function of EPCs has been poorly defined.
3.5 Other possible pathogenetic factors
3.5.1 Muscle metabolism
Recent studies from our unit have investigated the hypoxia of
tissue in diabetes. These studies have revealed that hypoxia is
present even in the absence of peripheral artery disease (PAD)
and may be related to impaired wound healing. In normal
physiology, the concentration of ATP in the muscle tissue is
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15
maintained at a steady-state level by the creatine kinase reac-
tion. This mechanism works as long as the supply of oxygen
and other nutrients to the cells is sufficient to maintain the
phosphocreatine (PCr) reserve [47]. When energy demand is
greater than mitochondrial capacity, or in the presence of
ischemia, the concentration of PCr drops and the phosphate
moiety for the conversion of ADP to ATP is depleted,
resulting in increased Pi concentration.
Recent findings from our unit demonstrate that muscle
metabolism and tissue hypoxia (as evidenced with an
increased Pi/PCr ratio) are present in the foot muscles of dia-
For personal use only.
betic patients with or without neuropathy in the absence of
PAD (Figure 4) [47-51]. Further investigation into these novel
techniques may help identify screening and treatment
strategies to better address DFU.
3.5.2 Skin oxygenation
Skin oxygenation of diabetic patients with neuropathy has
been shown to be reduced and has been implicated as a poten-
tial cause of impaired wound healing. In our unit, hyperspec-
tral imaging (MHSI) has helped quantify skin oxygenation by
combining the chemical specificity of spectroscopy with the
spatial resolution of imaging [48]. Initial studies in DFU
have validated this method as a valuable method of measuring
wound oxygenation; it also has the potential to predict future
areas of DFU.
Recent findings from our unit have shown that there are
changes in oxygen delivery or extraction, as manifested by
MHSI measurements of oxygen saturation in the skin of the
forearm and foot of patients with diabetes, with or without
neuropathy. Moreover, we found lower oxygen saturation lev-
els in the presence of neuropathy in the foot. These changes
are present both under resting conditions, in which no
changes are seen in skin blood flow, and after induction of
endothelium dependent vasodilation [48].
3.5.3 Neuropeptides
Neuropeptides act by binding to specific high-affinity
receptors on various cells in the skin, such as immune
cells, Langerhans cells, ECs, mast cells, fibroblasts, and
keratinocytes. The neuropeptides involved in wound healing
include SP, NPY, calcitonin gene-related peptide (CGRP),
Expert Opin. Pharmacother. (2011) 12(4)
Tecilazich, Dinh & Veves
corticotropin-releasing factor (CSF), a-melanocyte-stimulating
hormone (MSH), and NT [52-57]. The role of SP, NPY, and
CGRP in wound healing is under investigation.
SP is widely distributed in both the CNS and PNS [58-60];
in patients with diabetes, SP-positive nerve fibers [61] are
shown to be reduced. SP is released from peripheral neurons
in response to noxious stimuli. It promotes vasodilatation,
leukocyte chemotaxis, and leukocyte--endothelial-cell adhe-
sion. In this way, SP elicits the extravasation, migration, and
subsequent accumulation of leukocytes at sites of injury [62].
It is evident that dysregulation in the SP pathway in diabetes
can significantly impair the wound-repairing process.
Like SP, NPY is also important for both the inflammatory
and angiogenic phases of wound healing. Levels of NPY in the
skin are reduced in patients with diabetes [63]. The angiogenic
action of NPY consists of stimulating EC proliferation and
migration leading to angiogenesis [64]. Interestingly, the con-
tractile response of vascular smooth muscle to NPY was
shown to be reduced in rabbits with alloxan-induced diabetes
mellitus [65] and the deletion of one of its receptors (Y2) in
mice resulted in blockage of NPY-induced angiogenesis and
delayed wound healing [54].
CGRP is generated from the alternative splicing of the cal-
citonin gene, both in the CNS and the PNS. In the PNS,
CGRP is co-stored and co-released with SP [66]. CGRP is a
very potent vasodilator and also has a stimulatory effect on
angiogenesis via enhancement of VEGF release [67]. It is has
been clearly shown that, in humans, diabetes decreases its
expression, release, and action; moreover, in diabetic rats,
CGRP-mediated vasodilation is significantly reduced [68].
4. Current therapies
The cornerstones of DFU treatment have long been advo-
cated as including: regular debridement, wound-pressure
off-loading, revascularization when appropriate, adequate
treatment of infection, and wound care. In addition, advanced
wound-care therapies have been developed to the address the
biochemical inadequacies found in the chronic wound.
These advanced wound-care therapies target the deficient
cytokines and growth factors, thus providing a stimulus to
the nonhealing DFU.
A fundamental tool in the management of DFU is the
assessment of the wound area, either by measuring the maxi-
mal width and length of the ulcer [69] or through wound trac-
ings (Figure 5) [69]. By comparing the wound area at different
visits, the clinician can determine the rate of wound healing,
which is fundamental in determining the therapeutic strategy,
as described in more detail in the Expert Opinion section.
4.1 Debridement
The goal of debridement is to remove all necrotic, dysvascu-
lar, and nonviable tissue to obtain a red, granular bed
(Figure 6). Removal of all nonviable tissue allows for greater
visual assessment of the wound base and also promotes the
597
 Treating diabetic ulcers

A. 4 *
‡

2 §

0
C DM PDN
B.
40
*
*

§
20
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15

0
C DM PDN
§
C. 2

1
For personal use only.

* *

0
C DM PDN

Figure 4. Results of the PCr/Pi ratio. (A) Significant differences were found in all groups. The PCr/Pi was significantly higher in
the control group (C), followed by the non-neuropathic group (DM), and was lowest in the neuropathic group (PDN) (* vs zvs
§
p £ 0.0001). (B) Results of the total 31P concentration. The 31P concentration was similar in the control and the non-
neuropathic group and lower in the neuropathic group (*vs §p £ 0.0001). (C) Results of the foot lipid/water ratio. The ratio
was similar in the control and the non-neuropathic groups and lowest in the neuropathic group (*vs §p £ 0.0001).

release of growth factors. Several debridement techniques
have been described but the gold standard for DFU debride-
ment remains sharp debridement with a scalpel blade or a
tissue nipper [70,71].
4.2 Pressure off-loading
As ulcerations occur in high-pressure areas of the insensate foot,
the reduction of pressure is essential for achieving healing of
plantar DFUs. Different methods can be employed to obtain
a reduction in foot pressure; success rates vary. The most pop-
ular off-loading techniques are total contact casting (TCC),
half shoes, short-leg walkers, and felted foam dressings.
TCC involves the use of a well-molded, minimally padded
plaster cast to distribute pressures evenly to the entire limb,
and has been considered to be the most effective means of off-
loading diabetic foot ulcers as measured by the wound healing
rate [72]. The main advantage and likely effectiveness of the
TCC is the forced patient compliance secondary to the inability
to remove the apparatus. However, because of its significant dis-
advantages (considerable skill and time for application, possible
skin lesions, and the inability to assess the wound daily) the use
of TCC is not very common.
Although pressure reduction is significantly less than TCC,
and the patient’s compliance cannot be assured, other off-
loading devices (such as the half shoe and short-leg walker)
are more commonly used because they are easy to use, readily
accepted by patients, and relatively inexpensive. In addition to
these devices, felted foam dressings can provide adjunctive off-
loading. These dressings are fashioned from a felt-foam pad
and offer customized pressure relief with an aperture corre-
sponding to the site of the ulceration. The felted foam must
be changed every 1 -- 2 weeks to ensure integrity of the dress-
ing. Interestingly, a comparison between off-loading techni-
ques showed that felted foam dressings in combination
with a surgical shoe or half-shoe are more effective then a
short-leg walker or a half-shoe alone [73].

598 Expert Opin. Pharmacother. (2011) 12(4)


Expert Opin. Pharmacother. Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15
Figure 5. Wound tracing may yield far more reproducible
results in measuring wound size than simply length by
width measurement.
For personal use only.
Figure 6. A diabetic foot ulcer after surgical debridement.
Adequate debridement is achieved when all callous and
necrotic tissues have been removed and a clean, red and
granular base is revealed.
4.3 Revascularization
In case of an ischemic or neuroischemic wound, restoration of
vascularization (always after resolution of eventual infection)
is fundamental to re-establish arterial flow to the foot. The
treatment of PAD consists in lifestyle changes, medical
therapy, and endovascular/open surgery. Lifestyle changes
consist of weight loss, cessation of smoking, and adherence
Expert Opin. Pharmacother. (2011) 12(4)
Tecilazich, Dinh & Veves
to a low-fat diet. Medications may include antiplatelet ther-
apy, anticoagulants, and low-density-cholesterol-lowering
drugs. The endovascular/surgical approach for PAD may be
achieved with different techniques: angioplasty (with eventual
stent positioning), endoarterectomy, grafting, or by-pass.
However, this topic is beyond the objective of this paper, we
therefore refer our readers to other more specialized
reviews [74].
4.4 Treatment of infection
Diagnosis of infection is based primarily on clinical appear-
ance, relying on the five clinical signs: erythema, edema,
pain, tenderness, and warmth (Table 1). When infection of
an ulcer is suspected, debridement of necrotic tissue, drainage
of all purulent collections, and deep culture of the wound
should be performed before starting a broad-spectrum, empir-
ical antibiotic therapy. Empiric antibiotic selection should be
based on the suspected bacterial pathogens and then modified
in accordance to the culture data. Additionally, antibiotics
selection should be optimized to minimize toxicity and to
be cost effective.
Antibiotic therapy can be discontinued when the evidence
of infection has resolved, even if the ulcer has not fully healed.
Continuation of antibiotics beyond this point has not demon-
strated any positive effect on wound healing and the
recommended guideline is 2 weeks of therapy, although recal-
citrant infections may require longer courses [75]. In such cases
of severe soft-tissue infection, the duration of antimicrobial
therapy is based on response to the antibiotics and both
patient and wound should be monitored closely.
4.5 Wound care
To ensure optimal management of DFU, the effective use of
dressings is essential to provide an appropriate wound-
healing environment. In recent years, the concept of a clean,
moist wound-healing environment has been widely accepted.
Benefits to this approach include prevention of tissue dehy-
dration and cell death, acceleration of angiogenesis, and facil-
itation of the interaction of growth factors with the target
cells [76].
Recently, the concept of wound-bed preparation has been
widely touted for wound healing. Wound-bed preparation
involves the creation of a healthy wound bed by managing
bacterial load and moisture levels within the wound. To that
end, many clinicians advocate the use of antimicrobial wound
products, such as those that contain silver or iodine. Despite
the widespread use of these dressings, no randomized, con-
trolled clinical trials have evaluated their clinical effectiveness
in preventing or eradicating infection.
4.6 Advanced wound-care products
As previously described, many growth factors are decreased in
chronic, nonhealing diabetic ulcerations. Becaplermin -- one
of the first wound-care products approved by the US Food
and Drug Administration (FDA) to treat growth-factor
599
 Treating diabetic ulcers
Table 1. Clinical manifestations of infection and
corresponding infection severity.
Clinical manifestations
of infection
Wound lacking purulence of any manifestations
of inflammation
Presence of ‡ 2 manifestations of inflammation
(purulence, or erythema, pain, tenderness, warmth,
or induration), but any cellulitis/erythema extends
£ 2 cm around the ulcer and infection is limited
to the skin or superficial subcutaneous tissues;
no other local complications or systemic illness
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15
Infection (as above) in a patient who is systemically
well and metabolically stable but which has ‡ 1 of
the following characteristics: cellulitis extending
> 2 cm, lymphangitic streaking, spread beneath the
superficial fascia, deep-tissue abscess, gangrene,
and involvement of muscle, tendon, joint or bone
Infection in a patient with systemic toxicity or
metabolic instability (e.g., fever, chills, tachycardia,
hypotension, confusion, vomiting, leukocytosis,
acidosis, severe hyperglycemia, or azotemia)
Of note, in the setting of severe ischemia all infections are considered severe
(adapted from [103]).
For personal use only.
deficiency -- addressed the decreased concentration of platelet-
derived growth factor-BB (rhPDGF-BB). As discussed above,
PDGF-BB is a mitogen and chemotactic agent for connective
tissue and stromal cells, and it increases wound vascularization
by stimulating endothelial cell proliferation and movement.
In pilot and subsequent studies, becaplermin increased the
incidence of complete wound closure and decreased the time
to achieve complete wound healing [77]. Of note, in 2008
the FDA added a black-box warning to the safety labeling
for becaplermin to warn of the increased risk for cancer mor-
tality in patients who use three or more tubes of the product;
it should therefore be used with caution in patients with
known malignancy.
Another class of advanced wound-care product is the liv-
ing skin equivalents (LSE), which includes the only two
products currently approved and available for use in diabetic
foot ulcers: Apligraf (Organogenesis, Inc., Canton, MA,
USA, distributed by Novartis Pharmaceutical Corp., East
Hanover, NJ, USA) and Dermagraft (Advanced Tissue
Sciences, Inc., La Jolla, CA, USA). LSEs offer distinct
advantages over traditional skin grafting: their use is nonin-
vasive, does not require anesthesia, can be performed in an
outpatient setting, and avoids potential donor-site complica-
tions such as infection and scarring [78]. These tissue-
engineered skins are believed to facilitate wound healing by
both filling the wound with ECM and inducing the
expression of growth factors and cytokines that contribute
to wound healing (Table 2). Although the exact mechanism
is unknown, it is speculated that the growth factors
and cytokines exert multiple positive effects on the
600 Expert Opin. Pharmacother. (2011) 12(4)
wound-healing process: they fill the wound, recruit cells,
and help lay down ECM proteins essential to wound heal-
ing. LSEs are available for epidermal, dermal, and composite
Infection (epidermal and dermal) wounds and are commercially
severity offered in both autograft and allergenic form. The latter
are produced from neonatal fibroblasts and keratinocytes
Uninfected
using tissue-engineering technology. The first LSE commer-
Mild
cially available was Apligraf a composite graft containing
both epidermal and dermal components. Apligraf has
shown to significantly increase the wound-healing rate and
to decrease the median time to complete wound closure [79].
The other commercially available LSE is Dermagraft,
which consists of a metabolically active tissue containing
Moderate
normal dermal matrix proteins and cytokines. A prospective,
randomized, multicenter study, showed that Dermagraft-
treated ulcers were associated with more complete and rapid
healing and that, moreover, they showed a reduction in
the ulcer recurrence rate compared with conventional
Severe therapy [80].
4.7 Preventive surgery
The treatment of diabetic foot ulcers may also require the use
of surgical techniques to address underlying infection or bio-
mechanical faults resulting in increased pressure points. Surgi-
cal intervention to debride infected tissue, drain purulent
collections, and resect osteomyelitis is essential for adequate
wound healing [81]. In instances where a diabetic foot ulcer is
complicated by foot deformities caused by Charcot deformity,
the biomechanical faults should be addressed through recon-
structive surgery to ameliorate the offending boney prominen-
ces [82]. Finally, the role of prophylactic surgery to correct foot
deformity prior to the development of foot ulceration has
recently been advocated as a successful preventive strategy [83].
4.8 Negative-pressure wound therapy
Negative-pressure wound therapy (NPWT) provides an envi-
ronment of subatmospheric pressure to wounds by putting a
dressing into the wound cavity, connecting the dressing to a
vacuum pump, and sealing the area with an adhesive film.
The tube is connected to a vacuum device that delivers a con-
trolled negative (i.e., suction) pressure in the range of -50 to
-125 mmHg. Negative pressure 125 mmHg is the advised
amount of negative pressure because it corresponds to the
maximum increase in blood flow of 125 mmHg [84].
NPWT has been shown to assist in wound healing by
reducing the perilesional edema that mechanically compro-
mises the microcirculation, promoting the delivery of oxygen
and nutrients to the wound bed, removing waste products,
and -- finally -- by exerting a mechanical tissue stress on the
wound bed that stimulates cellular proliferation [85]. As Arm-
strong and Lavery stated in 2005, NPWT is a safe and effec-
tive treatment for complex DFUs. In fact, their work on
surgical wounds showed that the treatment with NPWT
resulted in a higher proportion of healed wounds and
enhanced healing rates than with standard treatment [86].
 Tecilazich, Dinh & Veves

Table 2. The cytokine expression in ApligrafTM and healing process. As a result, treatments that address the underly-
human skin. ing structural and functional impairments that contribute to
prolonged wound healing are being investigated for their diag-
Human Human dermal ApligrafTM Human nostic and therapeutic benefits. Future therapies need to rely
keratinocytes fibroblasts skin on the successful integration of mediators of different pathways
involved in wound healing, such as the impaired microvascular
FGF-1 + + + +
FGF-2 - + + + function, diminished activity of growth factors, cytokines,
FGF-7 - + + + neuropeptides, and the hypoxic tissue environment.
ECGF - + + +
IGF-1 - - + + 5.1 Cell-based therapies
IGF-2 - + + +
Cell therapy is an emerging and exciting modality for promot-
PDGF-AB + + + +
TGF-a + - + + ing wound healing. Interestingly, numerous studies have
IL-1 a + - + + investigated the potential of stem cells, keratinocytes, and
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15

IL-6 - + + + fibroblasts for the treatment of chronic wounds, but few

IL-8 - - + + studies have explored these strategies in diabetic wounds.
IL-11 - + + +
Concerns about immune rejection have increased interest
TGF-b1 - + + +
TGF-b3 - + + + in autologous cell therapy. Unfortunately, fibroblasts from
VEGF + - + + diabetic patients demonstrate an altered phenotype, including
reduced proliferation and response to growth factors. This
ECGF: Endothelial cell growth factor; FGF: Fibroblast growth factor; represents a limit in the use of autologous fibroblasts in these
IGF: Insulin-like growth factor; IL: Interleukin; PDGF: Platelet-derived growth
kinds of patient [91].
factor; TGF: Transforming growth factor; VEGF: Vascular endothelial
growth factor. To date, the use of stem cells in diabetic wound healing has
been evaluated only in animal models, but the early results are
quite encouraging. Mouse diabetic wounds injected with
For personal use only.

4.9 Hyperbaric oxygen
Hyperbaric oxygen therapy (HBOT) involves the intermittent
inhalation of 100% oxygen in chambers pressurized above
1 atmosphere absolute (ATA; 1 ATA is defined as the atmo-
spheric pressure at sea level and is equivalent to 101.3 kiloPas-
cals). The benefit of HBOT is based on the premise that
wounds often are hypoxic and that raising tissue oxygen levels
eventually improves wound healing. However, besides
increasing oxygenation of the hypoxic wound tissues and
angiogenesis, HBOT has been demonstrated to have an anti-
microbial effect, enhancing the neutrophil killing ability, as
well as a stimulatory effect on fibroblast activity and collagen
synthesis [87,88]. Generally, the chamber is pressurized to
2 -- 2.5 ATA, the patient breathes via head tent, face mask,
or endotracheal tube and the goal is to increase the arterial
PO2 to about 1500 mmHg [89]. Recently the results of a ran-
domized, placebo-controlled clinical trial on Hyperbaric
Oxygen Therapy in Diabetics with Chronic Foot Ulcers
(HODFU) were published. The results support the benefit
of adjunctive treatment with HBOT but the significance
in healing rates between the groups was obtained
9 -- 12 months after treatment completion. The fact that there
was a considerable time delay in ulcer healing raises questions
as to the therapeutic benefits of HBOT [90].
5. Future therapies
Despite this current multifaceted approach, treatment success of
DFU has demonstrated limited success. Furthermore, compel-
ling evidence suggests that DFU that fail to heal within 20 weeks
are more are likely to result in a prolonged and protracted
CD34+ cells healed much more rapidly and showed a dra-
matic acceleration in revascularization [92]. Because of their
key role in wound healing, EPCs have become an attractive
stem-cell candidate [93]; however, like fibroblasts, autologous
EPCs could be of limited use in patients with diabetes
because they have shown impaired proliferation, adhesion,
and incorporation into vascular structures [94].
5.2 Neuropeptides
As discussed above, it is becoming more and more evident
that the peripheral nerves and the cutaneous neurobiology
contribute to normal wound healing by acting through a
bidirectional connection between the nervous and immune
systems. These signaling pathways become impaired in the
presence of diabetic neuropathy, contributing to chronic
wounds and ulcers. The neuropeptides commonly implicated
in impaired diabetic wound healing are SP [56] and NPY [53].
Current research aims to reconstitute the neuropeptide--
cytokine signaling axis through neuropeptide supplementa-
tion as a future therapy to counteract wound-healing
abnormalities specific to diabetes.
5.3 Gene therapy
Gene-therapy studies for diabetic wound healing have primarily
been limited to animal models and targeted toward the delivery
of growth factors and cytokines. The use of gene therapy has not
been clinically approved for the treatment of wound healing and
several hurdles interfere with growth factor therapy: the short
half-life of growth factors (they are rapidly degraded by proteases
in the wound), the need for large amounts of purified
recombinant material, and the toxicity associated with repetitive

Expert Opin. Pharmacother. (2011) 12(4) 601

 Treating diabetic ulcers
doses. One possible way of overcoming these challenges is to
reprogram somatic cells to induce the synthesis and secretion
of the growth factors. Methods commonly employed include
genetically modifying autologous cells in vitro (via viral vectors,
liposomes, or naked DNA) and transplanting them back to the
host tissue. In a diabetic wounded mouse study, PDGF lentiviral
vectors were successfully transfected into the regenerating
dermis of the wounds. The lentiviral PDGF-treated group
showed enhanced angiogenesis and collagen deposition, but
re-epithelialization did not differ among the groups [95].
In a similar diabetic wounded mouse study, a plasmid
expressing TGF-beta-1 was injected in the wound bed
followed by electroporation and electrical stimulation. Results
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15
indicated that the electrical and genetic effects worked
synergistically to promote wound healing [96].
In another diabetic wounded mouse study, an adenovirus
encoding VEGF-C was injected intradermally around the
wound. Eight days after the injection, the treated animals
showed a significantly accelerated wound healing with
enhanced angiogenesis and lymphangiogenesis compared to
the controls [97].
However, there are potential problems to use of viruses as vec-
tors; for instance, toxicity, immune and inflammatory responses,
and gene control and targeting issues. Furthermore, there is
For personal use only.
always the potential risk of viral replication. Nevertheless, viral
vectors are the first choice in most gene therapy studies.
5.4 Extracorporeal shock-wave therapy
Extracorporeal shock-wave therapy (ESWT) is a novel
biophysical treatment that consists of the application of a
mechanical stimulus in the form of shock waves. In addition
to possessing tissue-regenerative properties, ESWT exerts
anti-inflammatory and pro-angiogenic effects through the
upregulation of VEGF (via HIF-1-alfa activation) and the
down-regulation of necrosis factor kB, respectively [98].
Several studies over the last years have demonstrated the pos-
itive effects of ESWT in animal model on wound size, angiogen-
esis, and inflammation [99,100]. Moreover, a study on venous and
diabetic chronic wounds showed that ESWT determined a sig-
nificant wound size reduction, necrotic tissue decrease and blood
flow increase in the treated subjects compared to the con-
trols [101]. A recent randomized clinical trial conducted to evalu-
ate the effect of prophylactic ESWT on wound healing after vein
harvesting for coronary artery bypass graft surgery, has shown
improved healing in the treated group in comparison to the con-
trols [102]. Thus, although the precise mechanisms are only
beginning to be elucidated and further investigations are
required, these encouraging results seem to indicate that
ESWT may represent a promising future therapeutic option in
chronic non healing wounds.
6. Conclusion
DFUs are chronic wounds resulting from repetitive trauma
in an insensate foot. They represent a significant and
602 Expert Opin. Pharmacother. (2011) 12(4)
growing health problem on a global level. Aggressive treat-
ment with periodic debridement, treatment of infection,
adequate pressure offloading, use of moist wound dressings,
judicious use of advanced wound-care products, and tight
glycemic control, have been proven to be the best means
of treatment. However, as previously discussed, their
etiopathogenetic characteristics make the treatment of these
wounds difficult with a high incidence of failure and
consequent amputations.
7. Expert opinion
Currently, the cornerstones of the treatment of full-thickness
DFUs consist of adequate debridement, off-loading of pressure,
correction of ischemia, treatment of infection, and local wound
care. To address all of these issues requires the coordinated work
of a multidisciplinary team comprising a nurse with special
expertise in wound care, orthotists and prosthetists, physical
therapists, podiatrists, vascular surgeons, and diabetologists.
However, even when optimal treatment is provided, only a por-
tion of ulcers (up to 50%) will be healed after 12 -- 20 weeks [69].
To improve this outcome in a cost-effective manner, it is
strongly recommended that a standardized treatment regimen
is followed, with periodic evaluation of treatment effectiveness.
In fact, due to their significant cost, advanced wound-
care treatment should be reserved for those wounds that have
demonstrated a failure to properly progress to healing in a linear
fashion. The best way to identify which patients need advanced
wound care is through assessment of the wound-healing rate
after every 4 weeks of therapy. Patients who achieve a wound-
healing rate of 50% or more should continue receiving the stan-
dard therapy. The remaining patients with a healing rate less
than 50% should instead be selected for more aggressive thera-
pies, such as advanced-care products. This evaluation should
be performed every 4 weeks to reassess the treatment
regimen. It should be emphasized that advanced wound-
care products must always be considered an adjunct to the stan-
dard treatment of debridement, offloading, ischemia and
infection management.
The currently available advanced wound-care products
include local growth factors, LSEs, and NPWT. New thera-
peutic approaches, such as cell-based therapies, are currently
in design to produce numerous growth factors and ECM pro-
teins simultaneously. Stem cells or cell therapies are capable of
expressing a host of favorable wound modulators, thus bear
the potential of providing the chronic wound a rich supply
of growth factors and cytokines necessary for wound healing.
However, it remains unclear how effective these therapies
might be as they are currently under investigation and not
currently commercially available.
Declaration of interest
The authors state no conflict of interest and have received no
payment in preparation of this manuscript.

Bibliography
1. Wild S, Roglic G, Green A, et al.
Global prevalence of diabetes: estimates
for the year 2000 and projections for
2030. Diabetes Care 2004;27:1047-53
2. Gu K, Cowie CC, Harris MI. Mortality
in adults with and without diabetes in a
national cohort of the U.S. population,
1971-1993. Diabetes Care
1998;21:1138-45
3. Ramsey SD, Newton K, Blough D,
et al. Incidence, outcomes, and cost
of foot ulcers in patients with diabetes.
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15
Diabetes Care 1999;22:382-7
4. Gibbons GEG. Infection of the diabetic
foot. In: Kozak GHC, Rowbotham J,
Wheelock F, editors, Management of
diabetic foot problems. Saunders,
Philadelphia; 1984. P. 97-102
5. Pecoraro RE, Reiber GE, Burgess EM.
Pathways to diabetic limb amputation.
Basis for prevention. Diabetes Care
1990;13:513-21
6. Apelqvist J, Bakker K,
For personal use only.
van Houtum WH, et al. International
consensus and practical guidelines on
the management and the prevention of
the diabetic foot. International Working
Group on the Diabetic Foot.
Diabetes Metab Res Rev
2000;16(Suppl 1):S84-92
7. Falanga V. Wound healing and its
impairment in the diabetic foot.
Lancet 2005;366:1736-43
8. Loots MA, Lamme EN, Zeegelaar J,
et al. Differences in cellular infiltrate
and extracellular matrix of chronic
diabetic and venous ulcers versus acute
wounds. J Invest Dermatol
1998;111:850-7
9. Lazarus GS, Cooper DM, Knighton DR,
et al. Definitions and guidelines for
assessment of wounds and evaluation of
healing. Arch Dermatol 1994;130:489-93
10. Shaw JE, Boulton AJ. The pathogenesis
of diabetic foot problems: an overview.
Diabetes 1997;46(Suppl 2):S58-61
11. Boulton A. Late sequelae of diabetic
neuropathy. In: Boulton A, editor,
Diabetic neuropathy. Marius Press,
Lancaster; 1997. p. 63-76
12. Rosa JS, Flores RL, Oliver SR, et al.
Sustained IL-1alpha, IL-4, and
IL-6 elevations following correction
of hyperglycemia in children with
type 1 diabetes mellitus. Pediatr Diabetes
2008;9:9-16
13. Bogdanski P, Pupek-Musialik D,
Dytfeld J, et al. Influence of insulin
therapy on expression of chemokine
receptor CCR5 and selected
inflammatory markers in patients with
type 2 diabetes mellitus. Int J Clin
Pharmacol Ther 2007;45:563-7
14. Tilg H, Moschen AR. Inflammatory
mechanisms in the regulation of insulin
resistance. Mol Med 2008;14:222-31
15. Hatanaka E, Monteagudo PT,
Marrocos MS, Campa A. Neutrophils
and monocytes as potentially important
sources of proinflammatory cytokines in
diabetes. Clin Exp Immunol
2006;146:443-7
16. Fisman EZ, Adler Y, Tenenbaum A.
Biomarkers in cardiovascular diabetology:
interleukins and matrixins. Adv Cardiol
2008;45:44-64
17. Mastej K, Adamiec R. Neutrophil surface
expression of CD11b and CD62L in
diabetic microangiopathy. Acta Diabetol
2008;45:183-90
18. Stegenga ME, van der Crabben SN,
Dessing MC, et al. Effect of acute
hyperglycaemia and/or hyperinsulinaemia
on proinflammatory gene expression,
cytokine production and neutrophil
function in humans. Diabet Med
2008;25:157-64
19. Oncul O, Yildiz S, Gurer US, et al.
Effect of the function of
polymorphonuclear leukocytes and
interleukin-1 beta on wound healing
in patients with diabetic foot infections.
J Infect 2007;54:250-6
20. Ochoa O, Torres FM, Shireman PK.
Chemokines and diabetic wound healing.
Vascular 2007;15:350-5
21. Menzoian JO, LaMorte WW,
Paniszyn CC, et al. Symptomatology
and anatomic patterns of peripheral
vascular disease: differing impact of
smoking and diabetes. Ann Vasc Surg
1989;3:224-8
22. Arora S, Pomposelli F, LoGerfo FW,
Veves A. Cutaneous microcirculation in
the neuropathic diabetic foot improves
significantly but not completely after
successful lower extremity
revascularization. J Vasc Surg
2002;35:501-5
Expert Opin. Pharmacother. (2011) 12(4)
Tecilazich, Dinh & Veves
23. Caballero AE, Arora S, Saouaf R,
et al. Microvascular and macrovascular
reactivity is reduced in subjects at risk
for type 2 diabetes. Diabetes
1999;48:1856-62
24. Veves A, Akbari CM, Primavera J,
et al. Endothelial dysfunction and the
expression of endothelial nitric oxide
synthetase in diabetic neuropathy,
vascular disease, and foot ulceration.
Diabetes 1998;47:457-63
25. Szabo C, Zanchi A, Komjati K, et al.
Poly(ADP-Ribose) polymerase is
activated in subjects at risk of developing
type 2 diabetes and is associated with
impaired vascular reactivity. Circulation
2002;106:2680-6
26. Caselli A, Rich J, Hanane T, et al. Role
of C-nociceptive fibers in the nerve axon
reflex-related vasodilation in diabetes.
Neurology 2003;60:297-300
27. Heldin CH, Westermark B. Mechanism
of action and in vivo role of
platelet-derived growth factor.
Physiol Rev 1999;79:1283-316
28. Clark RA. Regulation of fibroplasia in
cutaneous wound repair. Am J Med Sci
1993;306:42-8
29. Abraham J, Reed T. Reshaping the
carcinogenic risk assessment of
medicines: international harmonisation
for drug safety, industry/regulator
efficiency or both? Soc Sci Med
2003;57:195-204
30. Risau W. Angiogenic growth factors.
Prog Growth Factor Res 1990;2:71-9
31. Gale NW, Yancopoulos GD. Growth
factors acting via endothelial cell-specific
receptor tyrosine kinases: VEGFs,
angiopoietins, and ephrins in vascular
development. Genes Dev
1999;13:1055-66
32. Rafii S, Meeus S, Dias S, et al.
Contribution of marrow-derived
progenitors to vascular and cardiac
regeneration. Semin Cell Dev Biol
2002;13:61-7
33. Asahara T, Murohara T, Sullivan A,
et al. Isolation of putative progenitor
endothelial cells for angiogenesis. Science
1997;275:964-7
34. Takahashi T, Kalka C, Masuda H,
et al. Ischemia- and cytokine-induced
mobilization of bone marrow-derived
endothelial progenitor cells for
603
 Treating diabetic ulcers
neovascularization. Nat Med
1999;5:434-8
35. Werner N, Kosiol S, Schiegl T, et al.
Circulating endothelial progenitor cells
and cardiovascular outcomes. N Engl
J Med 2005;353:999-1007
36. Sata M, Saiura A, Kunisato A, et al.
Hematopoietic stem cells differentiate
into vascular cells that participate in the
pathogenesis of atherosclerosis.
Nat Med 2002;8:403-9
37. Orlic D, Kajstura J, Chimenti S, et al.
Bone marrow cells regenerate infarcted
myocardium. Nature 2001;410:701-5
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15
38. Kaushal S, Amiel GE, Guleserian KJ,
et al. Functional small-diameter
neovessels created using endothelial
progenitor cells expanded ex vivo.
Nat Med 2001;7:1035-40
39. Kalka C, Masuda H, Takahashi T,
et al. Transplantation of ex vivo
expanded endothelial progenitor cells for
therapeutic neovascularization. Proc Natl
Acad Sci USA 2000;97:3422-7
40. Majka SM, Jackson KA, Kienstra KA,
For personal use only.
et al. Distinct progenitor populations in
skeletal muscle are bone marrow derived
and exhibit different cell fates during
vascular regeneration. J Clin Invest
2003;111:71-9
41. Grant MB, May WS, Caballero S, et al.
Adult hematopoietic stem cells provide
functional hemangioblast activity during
retinal neovascularization. Nat Med
2002;8:607-12
42. Otani A, Kinder K, Ewalt K, et al.
Bone marrow-derived stem cells target
retinal astrocytes and can promote or
inhibit retinal angiogenesis. Nat Med
2002;8:1004-10
43. Young PP, Hofling AA, Sands MS.
VEGF increases engraftment of bone
marrow-derived endothelial progenitor
cells (EPCs) into vasculature of newborn
murine recipients. Proc Natl Acad
Sci USA 2002;99:11951-6
44. Lyden D, Hattori K, Dias S, et al.
Impaired recruitment of
bone-marrow-derived endothelial and
hematopoietic precursor cells blocks
tumor angiogenesis and growth.
Nat Med 2001;7:1194-201
45. Aicher A, Zeiher AM, Dimmeler S.
Mobilizing endothelial progenitor cells.
Hypertension 2005;45:321-5
46. Rafii S, Avecilla S, Shmelkov S, et al.
Angiogenic factors reconstitute
604
hematopoiesis by recruiting stem cells
from bone marrow microenvironment.
Ann N Y Acad Sci 2003;996:49-60
47. Boska M. Estimating the ATP cost of
force production in the human
gastrocnemius/soleus muscle group using
31P MRS and 1H MRI. NMR Biomed
1991;4:173-81
48. Greenman RL, Panasyuk S, Wang X,
et al. Early changes in the skin
microcirculation and muscle metabolism
of the diabetic foot. Lancet
2005;366:1711-17
49. Greenman RL, Rakow-Penner R.
Evaluation of the RF field uniformity
of a double-tuned 31P/1H birdcage RF
coil for spin-echo MRI/MRS of the
diabetic foot. J Magn Reson Imaging
2005;22:427-32
50. Pomposelli FB, Kansal N, Hamdan AD,
et al. A decade of experience with
dorsalis pedis artery bypass: analysis of
outcome in more than 1000 cases.
J Vasc Surg 2003;37:307-15
51. Greenman RL. Quantification of the
31P metabolite concentration in human
skeletal muscle from RARE image
intensity. Magn Reson Med
2004;52:1036-42
52. Nakamura M, Kawahara M,
Morishige N, et al. Promotion of corneal
epithelial wound healing in diabetic rats
by the combination of a substance
P-derived peptide (FGLM-NH2) and
insulin-like growth factor-1. Diabetologia
2003;46:839-42
53. Movafagh S, Hobson JP, Spiegel S,
et al. Neuropeptide Y induces migration,
proliferation, and tube formation of
endothelial cells bimodally via Y1, Y2,
and Y5 receptors. FASEB J
2006;20:1924-6
54. Ekstrand AJ, Cao R, Bjorndahl M,
et al. Deletion of neuropeptide Y (NPY)
2 receptor in mice results in blockage of
NPY-induced angiogenesis and delayed
wound healing. Proc Natl Acad Sci USA
2003;100:6033-8
55. Kuo LE, Abe K, Zukowska Z. Stress,
NPY and vascular remodeling:
implications for stress-related diseases.
Peptides 2007;28:435-40
56. Delgado AV, McManus AT,
Chambers JP. Exogenous administration
of Substance P enhances wound healing
in a novel skin-injury model. Exp Biol
Med (Maywood) 2005;230:271-80
Expert Opin. Pharmacother. (2011) 12(4)
57. Zukowska Z, Grant DS, Lee EW.
Neuropeptide Y: a novel mechanism for
ischemic angiogenesis.
Trends Cardiovasc Med 2003;13:86-92
58. Hokfelt T, Kellerth JO, Nilsson G,
Pernow B. Substance p: localization in
the central nervous system and in some
primary sensory neurons. Science
1975;190:889-90
59. Harrison S, Geppetti P. Substance p.
Int J Biochem Cell Biol 2001;33:555-76
60. Khawaja AM, Rogers DF. Tachykinins:
receptor to effector. Int J Biochem
Cell Biol 1996;28:721-38
61. Lindberger M, Schroder HD,
Schultzberg M, et al. Nerve fibre studies
in skin biopsies in peripheral
neuropathies. I. Immunohistochemical
analysis of neuropeptides in diabetes
mellitus. J Neurol Sci 1989;93:289-96
62. Pernow B. Substance P. Pharmacol Rev
1983;35:85-141
63. Wallengren J, Badendick K, Sundler F,
et al. Innervation of the skin of the
forearm in diabetic patients: relation to
nerve function. Acta Derm Venereol
1995;75:37-42
64. Zukowska-Grojec Z,
Karwatowska-Prokopczuk E, Rose W,
et al. Neuropeptide Y: a novel angiogenic
factor from the sympathetic nerves and
endothelium. Circ Res 1998;83:187-95
65. Andersson D, Brunkwall J, Bergqvist D,
Edvinsson L. Diminished contractile
responses to neuropeptide Y of arteries
from diabetic rabbits. J Auton Nerv Syst
1992;37:215-22
66. Maggi CA. Tachykinins and calcitonin
gene-related peptide (CGRP) as
co-transmitters released from peripheral
endings of sensory nerves.
Prog Neurobiol 1995;45:1-98
67. Toda M, Suzuki T, Hosono K, et al.
Roles of calcitonin gene-related peptide
in facilitation of wound healing and
angiogenesis. Biomed Pharmacother
2008;62:352-9
68. Oltman CL, Davidson EP, Coppey LJ,
et al. Treatment of Zucker diabetic fatty
rats with AVE7688 improves vascular
and neural dysfunction.
Diabetes Obes Metab 2009;11:223-33
69. Sheehan P, Jones P, Caselli A, et al.
Percent change in wound area of
diabetic foot ulcers over a 4-week period
is a robust predictor of complete healing

in a 12-week prospective trial.
Diabetes Care 2003;26:1879-82
70. Steed DL, Donohoe D, Webster MW,
Lindsley L. Effect of extensive
debridement and treatment on the
healing of diabetic foot ulcers. Diabetic
Ulcer Study Group. J Am Coll Surg
1996;183:61-4
71. Falanga V, Sabolinski M. A bilayered
living skin construct (APLIGRAF)
accelerates complete closure of
hard-to-heal venous ulcers.
Wound Repair Regen 1999;7:201-7
72. Armstrong DG, Nguyen HC, Lavery LA,
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15
et al. Off-loading the diabetic foot
wound: a randomized clinical trial.
Diabetes Care 2001;24:1019-22
73. Birke JA, Fred B, Krieger LA, Sliman K.
The effectiveness of an accommodative
dressing in offloading pressure over areas
of previous metatarsal head ulceration.
Wounds 2003;15:33-9
74. Faries PL, Teodorescu VJ, Morrissey NJ,
et al. The role of surgical
revascularization in the management of
For personal use only.
diabetic foot wounds. Am J Surg
2004;187:34S-37S
75. Lipsky BA, Berendt AR, Deery HG,
et al. Diagnosis and treatment of diabetic
foot infections. Plast Reconstr Surg
2006;117:212S-38S
76. Field FK, Kerstein MD. Overview of
wound healing in a moist environment.
Am J Surg 1994;167:2S-6S
77. Wieman TJ, Smiell JM, Su Y.
Efficacy and safety of a topical gel
formulation of recombinant human
platelet-derived growth factor-BB
(becaplermin) in patients with chronic
neuropathic diabetic ulcers. A phase III
randomized placebo-controlled
double-blind study. Diabetes Care
1998;21:822-7
78. Muhart M, McFalls S, Kirsner RS, et al.
Behavior of tissue-engineered skin:
a comparison of a living skin equivalent,
autograft, and occlusive dressing in
human donor sites. Arch Dermatol
1999;135:913-18
79. Veves A, Falanga V, Armstrong DG,
Sabolinski ML. Graftskin, a human skin
equivalent, is effective in the
management of noninfected neuropathic
diabetic foot ulcers: a prospective
randomized multicenter clinical trial.
Diabetes Care 2001;24:290-5
80. Gentzkow GD, Iwasaki SD,
Hershon KS, et al. Use of dermagraft, a
cultured human dermis, to treat diabetic
foot ulcers. Diabetes Care 1996;19:350-4
81. Faglia E, Clerici G, Caminiti M, et al.
The role of early surgical debridement
and revascularization in patients with
diabetes and deep foot space abscess:
retrospective review of 106 patients with
diabetes. J Foot Ankle Surg
2006;45:220-6
82. Pinzur MS. Circular fixation for the
nonplantigrade Charcot foot.
Hosp Pract (Minneap) 2010;38:56-62
83. Mueller MJ, Sinacore DR, Hastings MK,
et al. Effect of Achilles tendon
lengthening on neuropathic plantar
ulcers. A randomized clinical trial.
J Bone Joint Surg Am
2003;85-A:1436-45
84. Morykwas MJ, Faler BJ, Pearce DJ,
Argenta LC. Effects of varying levels
of subatmospheric pressure on the rate
of granulation tissue formation in
experimental wounds in swine.
Ann Plast Surg 2001;47:547-51
85. Ubbink DT, Westerbos SJ, Evans D,
et al. Topical negative pressure for
treating chronic wounds.
Cochrane Database Syst Rev
2008;3:CD001898
86. Armstrong DG, Lavery LA. Negative
pressure wound therapy after partial
diabetic foot amputation: a multicentre,
randomised controlled trial. Lancet
2005;366:1704-10
87. Knighton DR, Halliday B, Hunt TK.
Oxygen as an antibiotic. A comparison
of the effects of inspired oxygen
concentration and antibiotic
administration on in vivo bacterial
clearance. Arch Surg 1986;121:191-5
88. Hunt TK, Pai MP. The effect of
varying ambient oxygen tensions on
wound metabolism and collagen
synthesis. Surg Gynecol Obstet
1972;135:561-7
89. Wang C, Schwaitzberg S, Berliner E,
et al. Hyperbaric oxygen for treating
wounds: a systematic review of the
literature. Arch Surg
2003;138:272-9; discussion 80
90. Londahl M, Katzman P, Nilsson A,
Hammarlund C. Hyperbaric oxygen
therapy facilitates healing of chronic foot
ulcers in patients with diabetes.
Diabetes Care 2010;33:998-1003
Expert Opin. Pharmacother. (2011) 12(4)
Tecilazich, Dinh & Veves
91. Loots MA, Lamme EN, Mekkes JR,
et al. Cultured fibroblasts from chronic
diabetic wounds on the lower extremity
(non-insulin-dependent diabetes mellitus)
show disturbed proliferation.
Arch Dermatol Res 1999;291:93-9
92. Sivan-Loukianova E, Awad OA,
Stepanovic V, et al. CD34+ blood cells
accelerate vascularization and healing of
diabetic mouse skin wounds. J Vasc Res
2003;40:368-77
93. Bauer SM, Goldstein LJ, Bauer RJ, et al.
The bone marrow-derived endothelial
progenitor cell response is impaired in
delayed wound healing from ischemia.
J Vasc Surg 2006;43:134-41
94. Tepper OM, Galiano RD, Capla JM,
et al. Human endothelial progenitor cells
from type II diabetics exhibit impaired
proliferation, adhesion, and incorporation
into vascular structures. Circulation
2002;106:2781-6
95. Lee JA, Conejero JA, Mason JM, et al.
Lentiviral transfection with the PDGF-B
gene improves diabetic wound healing.
Plast Reconstr Surg 2005;116:532-8
96. Lee PY, Chesnoy S, Huang L.
Electroporatic delivery of TGF-beta 1
gene works synergistically with electric
therapy to enhance diabetic wound
healing in db/db mice. J Invest Dermatol
2004;123:791-8
97. Saaristo A, Tammela T, Farkkila A, et al.
Vascular endothelial growth factor-C
accelerates diabetic wound healing.
Am J Pathol 2006;169:1080-7
98. Wang FS, Wang CJ, Chen YJ, et al. Ras
induction of superoxide activates
ERK-dependent angiogenic transcription
factor HIF-1alpha and
VEGF-A expression in shock
wave-stimulated osteoblasts. J Biol Chem
2004;279:10331-7
99. Stojadinovic A, Elster EA, Anam K, et al.
Angiogenic response to extracorporeal
shock wave treatment in murine skin
isografts. Angiogenesis 2008;11:369-80
100. Oi K, Fukumoto Y, Ito K, et al.
Extracorporeal shock wave therapy
ameliorates hindlimb ischemia in rabbits.
Tohoku J Exp Med 2008;214:151-8
101. Saggini R, Figus A, Troccola A, et al.
Extracorporeal shock wave therapy for
management of chronic ulcers in the
lower extremities. Ultrasound Med Biol
2008;34:1261-71
605
 Treating diabetic ulcers

102. Dumfarth J, Zimpfer D,

Vogele-Kadletz M, et al. Prophylactic
low-energy shock wave therapy improves
wound healing after vein harvesting for
coronary artery bypass graft surgery:
a prospective, randomized trial.
Ann Thorac Surg 2008;86:1909-13
103. Lipsky BA, Berendt AR, Deery HG,
et al. Diagnosis and treatment of
diabetic foot infections. Clin Infect Dis
2004;39:885-910

Affiliation
Francesco Tecilazich MD, Thanh Dinh DPM &
Expert Opin. Pharmacother. Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15

Aristidis Veves† MD DSc

†
Author for correspondence
Beth Israel Deaconess Medical Center
Joslin-Beth Israel Deaconess Foot Center and
Microcirculation Lab,
Harvard Medical School,
330 Brookline Avenue,
Boston, Massachusetts 02215, USA
E-mail: aveves@bidmc.harvard.edu
For personal use only.

606 Expert Opin. Pharmacother. (2011) 12(4)