Treatment & Alerts

1. Assessment: neuropathy (monofilament) + vascular status (ABI / WIfI when indicated) + infection grading + suspicion of osteomyelitis
2. Offloading: total contact cast / non-removable walker boot is first-line — dressings cannot replace offloading
3. Debridement: regular removal of callus and necrotic tissue (when perfusion is adequate)
4. Infection: no antibiotics for uninfected ulcers; treat infection by mild/moderate/severe grade; if osteomyelitis is suspected, pursue further imaging / bone sampling
5. Dressings: choose basic dressings by exudate, comfort, and cost (see Dressings & Wet Gauze)
6. Advanced therapies: NPWT / oxygen therapy / cellular and matrix products — only after standard care has been optimized
7. Recurrence prevention: therapeutic footwear, regular foot examinations, patient education

1. Pressure redistribution: scheduled repositioning + appropriate support surface (high-specification foam / dynamic air mattress for high-risk patients)
2. Nutrition: screen and correct calorie / protein / micronutrient deficits
3. Debridement: remove necrotic tissue (stable dry heel eschar is the exception)
4. Infection / osteomyelitis: evaluate and treat when clinically suspected
5. Dressings: by stage and exudate (stage × dressing matrix)
6. NPWT / reconstruction: consider for large Stage 3–4 injuries once the wound bed is optimized

1. Objective perfusion assessment (ABI, toe pressure, TcPO₂…) + WIfI staging
2. Revascularization: prioritize when feasible (endovascular or bypass)
3. Necrosis management: stable dry necrosis → protect and keep dry; no aggressive debridement before perfusion is restored
4. Avoid inappropriate compression; control risk factors (smoking cessation, lipids, glycemia)
5. Dressings: choose a moist or dry strategy based on "healability"

1. Exclude arterial disease first (ABI; adjust compression strength in mixed disease)
2. Compression therapy: multilayer bandaging / compression stockings — the cornerstone of treatment
3. Exudate management and periwound skin protection
4. Venous intervention: correcting superficial venous reflux accelerates healing and reduces recurrence
5. Recurrence prevention: long-term compression stockings, activity and leg-elevation education

1. Diagnose first: biopsy + etiologic workup (Pyoderma gangrenosum, vasculitis, calciphylaxis, malignancy)
2. Disease-specific therapy: immunomodulation (Pyoderma gangrenosum/vasculitis), metabolic management (calciphylaxis), oncologic treatment
3. Avoid aggressive debridement in active Pyoderma gangrenosum (pathergy)
4. Symptom-directed dressings: exudate / odor / bleeding / pain / infection / periwound skin (palliative goals)

🔴 Tier 1: Immediate Emergency Department / Activate Trauma or Specialty Team (any single criterion triggers a red alert)

• Unstable airway, breathing, or circulation
• Uncontrollable hemorrhage or shock
• Inadequate distal perfusion: pulselessness, pallor, coldness, prolonged capillary refill
• New-onset sensory loss, motor weakness, or limb paralysis
• Open fracture or open joint injury
• Suspected compartment syndrome
• High-pressure injection injury
• Gunshot or other penetrating trauma to the torso, neck, or head
• Large-area avulsion, degloving, or crush injury
• Severe burns, inhalation injury, chemical injury, or high-voltage electrical injury
• Suspected necrotizing soft tissue infection
• Evisceration or surgical-wound fascial dehiscence

🟠 Tier 2: Same-Day Specialist Evaluation or Referral

• Suspected tendon, nerve, vascular, joint, or bone injury, but currently hemodynamically stable
• Wounds of the face, eyelid, lip, hand, foot, genitalia, perineum, or a major joint
• Deep puncture wound or foreign body that cannot be excluded
• Bite wounds involving the hand, a joint, or an immunocompromised patient
• Heavily contaminated wounds or extensive devitalized tissue
• Deeper wounds in patients with diabetes, peripheral vascular disease, immunosuppression, or anticoagulation
• Rapidly spreading infection, fever, or markedly increasing pain
• Wounds requiring complex closure, skin grafting, or flap coverage
• Tetanus or rabies prophylaxis needs that cannot be completed at the original facility

🟢 Tier 3: Routine Outpatient Management and Follow-up (ALL of the following conditions must be met simultaneously)

• Stable vital signs
• Bleeding controlled
• Superficial wound of limited extent
• No nerve, vascular, tendon, joint, or bone injury
• Foreign body excluded or safely removed
• Contamination can be adequately cleansed
• No systemic infection or signs of rapid deterioration
• Patient is capable of dressing changes and returning for follow-up

🚨 Any single criterion below warrants urgent / expedited referral

• Suspected sepsis or necrotizing soft tissue infection
• Cold foot, rest pain, gangrene, or absent pulses
• Infection combined with severe ischemia
• Rapidly expanding black necrosis or severe pain
• Deep abscess, joint infection, or osteomyelitis
• Massive or recurrent bleeding
• Mass, abnormal proliferation, or irregular everted edges within the wound
• Painful ulcer that rapidly enlarges after debridement (pathergy — suspect pyoderma gangrenosum)
• No reasonable improvement after 4 weeks of appropriate etiology-directed treatment
• Months of dressing changes without a confirmed etiology

Classic local signs: expanding periwound redness and swelling, increased local warmth, new or increasing pain/tenderness, induration, purulent/turbid/viscous discharge, sudden increase or change of exudate, new or marked malodour, wound dehiscence or sudden deterioration of a stable wound, periwound maceration or breakdown.

Subtle signs in chronic wounds (diabetes, ischemia, neuropathy, immunosuppression and older age may mask classic redness/heat/swelling/pain): stalled or suddenly slowed healing, increasing size or depth, edge breakdown / undermining / new sinus tracts, granulation turning dark, friable or easily bleeding, healthy granulation turning necrotic, increasing exudate/pain/odour, suddenly increased dressing-change frequency, unexplained or hard-to-control hyperglycemia, general fatigue, reduced appetite or sudden functional decline.

Signs of spread: redness extending beyond the border and enlarging, cellulitis, red streaks along lymphatics, marked induration/pain/edema of surrounding tissue, deep abscess or fluctuance, rapid enlargement or tissue necrosis, painful joint motion, exposed tendon or bone, crepitus / subcutaneous gas / bullae.

Systemic infection / sepsis warnings: fever or chills (severe cases may be hypothermic), tachycardia, tachypnea, hypotension, confusion or drowsiness, reduced urine output, marked weakness with cold clammy skin, sudden metabolic or glycemic deterioration.

Clinical diagnosis is the core: assess cause/duration/rate of change, location and dimensions with undermining and sinuses, necrosis/pus/exudate/odour/granulation, extent of redness, pain, warmth and induration, foreign bodies, implants, dead space or abscess, perfusion, sensation, edema and pressure sources, comorbidities and prior antibiotics. For lower-limb/foot wounds, infection assessment cannot replace vascular assessment — infection plus ischemia markedly increases necrosis, amputation and treatment failure.

Blood tests (by severity): CBC with differential; CRP/ESR (procalcitonin if needed); glucose, renal/liver function, electrolytes; lactate when hypoperfusion or sepsis suspected; blood cultures for fever, chills, hypotension or suspected bacteremia. Normal WBC or CRP cannot fully exclude infection, especially in older, diabetic, ischemic or immunosuppressed patients.

Suspected diabetic foot osteomyelitis: combine probe-to-bone, X-ray and inflammatory markers first; MRI when still uncertain (IWGDF/IDSA 2023).

① Source control: drain abscesses and deep collections; remove devitalised necrotic tissue; manage hematoma, dead space, sinuses and fistulae; assess and remove infected foreign bodies or implants; necrotising soft-tissue infection needs emergency surgical exploration and wide debridement; assess revascularisation concurrently when infection coexists with ischemia. Antibiotics alone usually cannot cure an undrained abscess, infected necrotic tissue or a gross foreign-body infection.

② Local wound management: cleanse with saline or an appropriate solution; choose surgical/sharp/mechanical/autolytic or other debridement by perfusion and etiology; control excess exudate to prevent maceration; use low-adherence dressings with adequate absorbency; antimicrobial dressings or wound antiseptics may be used short-term under professional assessment with a defined review date; do not rotate antimicrobial dressings indefinitely without improvement — re-examine for ischemia, abscess, osteomyelitis, malignancy or misdiagnosis.

③ Systemic antibiotics — indicated for: redness spreading beyond the wound, cellulitis or lymphangitis, deep soft-tissue infection, abscess/osteomyelitis/implant infection, fever/chills/hypotension or other systemic response, clinically infected diabetic foot, established infection in the immunocompromised. Selection: severity and likely pathogens, wound type and special exposures, culture and antibiotic history, MRSA/resistance risk, allergies and renal/hepatic function and interactions, local resistance data, culture and susceptibility results. Start appropriate empiric therapy, then de-escalate once cultures return; oral for mild cases, admission and IV for severe infection, sepsis or unreliable oral absorption. Duration: about 1–2 weeks for diabetic-foot soft-tissue infection (IWGDF/IDSA 2023); markedly longer for osteomyelitis, implant infection or inadequate source control — no single duration fits all wounds.

④ Treat the underlying cause: diabetic foot = offloading + glycemic control + perfusion; venous ulcer = compression after infection control once arterial supply acceptable; arterial ulcer = prioritise ischemia and revascularisation; pressure injury = immediate pressure redistribution and repositioning; edema-related wounds = manage edema and skin barrier; surgical wounds = evaluate fascia, implants, dead space and deep organ infection; malignant wounds = distinguish colonisation, local infection and tumour necrosis — goals often symptom-focused.

Assess: redness shrinking or spreading; pain, exudate, pus and odour decreasing; temperature, blood pressure, mental state and appetite improving; residual deep abscess or necrosis; culture results requiring antibiotic adjustment; need for surgical, vascular or infectious-disease consultation.

If not improving, reconsider: undrained or uncleared source, peripheral arterial ischemia, osteomyelitis, resistant or uncovered pathogens, foreign-body or implant infection, fungal/mycobacterial or other atypical infection, vasculitis, pyoderma gangrenosum or other inflammatory disease, malignant wound, contact dermatitis mistaken for infection.

Do NOT use antibiotics for: simple colonisation without clinical signs; a positive culture alone; "prophylaxis" or to promote chronic-wound healing; exudate, necrotic tissue or odour alone without other evidence of infection.

Do not self-manage: diabetic foot wounds; a cold, blackened foot, weak pulses or rest pain; deep wounds with visible tendon or bone; bites, puncture wounds or heavily contaminated wounds; dehisced surgical wounds or exposed implants; immunosuppression, chemotherapy, transplantation or long-term steroids; recurrent, refractory or unexplained infection; rapidly enlarging wounds or pain out of proportion to appearance.

Any one of the following warrants immediate ED referral or urgent surgical evaluation:

• Altered consciousness, hypotension, tachypnea or reduced urine output
• Fever and chills with rapidly deteriorating wound
• Redness spreading visibly within hours
• Severe pain — especially pain out of proportion to the visible wound
• Purple or black skin, bullae, or subcutaneous crepitus
• Copious pus, deep abscess or rapidly increasing malodour
• Infection with a cold foot, gangrene or absent pulses
• Suspected necrotising fasciitis, osteomyelitis, joint infection or sepsis

• Time and mechanism of injury
• Neurovascular and tendon function
• Foreign bodies and deep injury
• Wound contamination and infection
• Tetanus vaccine / immunoglobulin need (Tetanus Decision Tool)
• Rabies exposure assessment for bite wounds
• Pain control
• Standardized photographs and wound measurements
• Written return precautions and follow-up interval