A wound practitioner's best-laid plan of care and strategy for healing an ulcerated foot is doomed to fail without a properly conceived approach based on sound off-loading principles. Wound healing that has stalled despite best-practice techniques may require reevaluation of off-loading choices. This is particularly true in the patient with abnormal foot pathologies. Special considerations are certainly required with neuropathic ulcers; however, any wound on a weight-bearing surface of the foot requires proper off-loading. This discussion explores the basic biomechanical and pathomechanical concepts that modify and influence ambulation and gait patterns. Integration of these concepts into the choices for off-loading to deter pathologic influences will alert the reader of precautionary measures and other factors for consideration. The aim of this column is to provide both an adequate working knowledge of the available off-loading devices and the necessary tools and concepts needed to stimulate wise decision protocols for wound management and healing.

The wound care provider is often faced with challenges that extend beyond wound treatment. In any chronic wound treatment scenario, often dressing choice and wound bed preparation are the focus. Habitually, blinders are donned with disregard to the surrounding skin structures. It is important to consider all factors contiguous with the healing of a wound, as well as being cognizant of the patient's surrounding skin integrity. Care of the periwound skin is mandated in successful treatment of any patient with a chronic wound. Regardless of the cause of wounds and potential secondary skin breakdown, diabetes, poor circulation, or other immunologic compromising states, treatment must always include an extensive evaluation of the patient's general health. Placing the wound and skin condition in relation to the patient's overall health helps the clinician to determine the best course toward reaching the ultimate goal of cure, closure, and or palliation. Early intervention reinforces the identification of the risk factors for developing ulcers and skin complications. Noting abnormal skin conditions immediately will hasten one's success.Many of the physiological changes that occur in the creation of the chronic wound cascade are well known. As if our dressings, application and securing methods, wraps, offloading devices, stockings, and other means by which a wound is cared for were not enough to create potential risk for surrounding skin irritation, many pathologies coexist, adding to the potential for an at-risk environment. Patients with venous insufficiency or lymphedema, for example, possess an accumulation of edema within the skin and subcutaneous tissues that stimulates production of fibroblasts, keratinocytes, and adipocytes, thus causing an increased deposition of collagen and glycosaminoglycans within the skin and subcutaneous tissues. This results in skin hypertrophy, destruction of elastic fibers, xerosis, fibrosis, and cracking of the epithelial and dermal skin layers. Further, the immune system is degraded, permitting decreased immune surveillance. 1 The result is chronic inflammation and increased susceptibility to both fungal and bacterial infections. We also see excess hyperkeratosis with diabetes patients. Additionally, neuropathic patients suffer an anhydrous state, which leads to further drying and cracking of the skin surfaces.Hygiene of the skin is the responsibility not only of the patient and caregiver but falls into the provider's realm of responsibility to guide, supervise, and educate. Having and sharing a basic knowledge will aid in this task. The importance of hygiene cannot be overstated. The skin should be cared for at regular intervals and inspected beyond the wound's borders. One should think beyond soap and water and practice use of skin cleansers that minimize the damage to skin proteins and lipids caused by surfactants. Cleansers containing phospholipids derived from vegetable oils that contain polyunsaturated fatty acids that will not strip, dehydrate, or inflame the epidermis are pre...

Patients were chosen at random by primary investigator based upon initial presentation with dry, cracked, and/or reddened skin, with underlying complications from compromised microvasculature. Intervention was conducted by using topical products designed to utilize small molecule technologies, with a molecular weight of fewer than 500 Da, to deliver, via topical diffusion, nutrients and antioxidants through the skin layers to address issues stemming from inadequate blood flow to the dermis. An ''all-in-one'' moisturizing cleansing lotion was applied to the affected areas and washed gently with a warm damp cloth. After cleansing, the skin was treated with a moisturizing skin cream or a chlorhexidine-containing skin shield on areas with redness or advanced breakdown. All products contain dimethicone as an active ingredient and are classified as OTC skin protectants per approved FDA monographs. Patients were evaluated by the primary investigator for noticeable resolution or improvements in dryness, scaling, skin cracks, and erythema.

There have been notable contributions in the literature regarding the consensus for a new standard for the treatment of diabetic foot ulcers. The more recent advances in wound care therapies, modalities, and evidence-based research have demonstrated that an advanced standard of care for wound healing should exist. Failure of treatment protocols, which center on a 50% area of wound reduction within 4 weeks as a response to standard conventional care, should indicate the use of adjuvant therapies. Negative pressure wound therapy (NPWT), hyperbaric oxygen therapy (HBOT), growth factors, human-derived bioengineered tissue, and extracellular matrix products are readily available. This commentary will explore a brief selection of the current wound care literature as it relates to the acceptance of a new advanced standard of care. Furthermore, the intention is to stimulate further discussion and thought on the relevance of this approach in the treatment of diabetic foot ulcers and chronic wounds and how it may correlate with the ultimate outcome of healing in general.