Of the 550 million people worldwide and 37 million people in the United States with diabetes, more than 30% will develop a diabetic foot ulcer. Patients with diabetes are at increased risk of foot ulceration due to neuropathic loss of protective sensation, muscle atrophy and repetitive stress leading to foot deformities, and vascular disease. Periodic diabetic foot examinations performed by the primary care physician can identify preulcerative conditions. If present, these should prompt interventions, such as offloading for the area of concern, patient education, prescriptions for diabetic or custom footwear, or a referral to podiatry. When an ulcer is identified, classification using the SINBAD (site, ischemia, neuropathy, bacterial infection, area [ie, size], depth) system is beneficial for triage in primary care. Initial diabetic foot wound care should begin with assessment in primary care; offloading of the ulcer; treatment of infection if present; and prompt referral to specialists in wound care, infectious disease, or vascular surgery. If signs of ischemia (eg, decreased pedal pulses or blood flow) are identified, patients should be quickly referred for arterial duplex ultrasonography; if the signs of ischemia are more marked, immediate referral for vascular surgery is indicated.

Case 1. AO, a 60-year-old patient who self-identifies as mixed African and Hispanic heritage, has type 2 diabetes with neuropathy, a 35 pack-year smoking history, and a right below-knee amputation. Her chief concern today is a sore on her left plantar foot. She ambulates with use of a prosthetic and wears off-the-shelf sneakers. An ulcer is present on the plantar surface of the left midfoot. The dorsalis pedis pulse is faint but palpable, and the plantar foot is diffusely insensate. Fluctuance, discoloration, and scant purulent discharge from the wound are consistent with infection.