Synopsis
Stratify diabetic foot risk, recognise limb- and life-threatening disease, coordinate multidisciplinary ulcer care, and avoid diagnostic or antibiotic shortcuts that delay healing.
- Every diabetes foot review should inspect skin, nails, callus, deformity and footwear, test protective sensation and assess arterial supply in both feet.
- Risk rises with neuropathy, PAD, deformity, callus, previous ulcer or amputation and renal replacement therapy; follow-up intensity follows the highest feature.
- Active problems include ulceration, infection, ischaemia, gangrene and suspected acute Charcot arthropathy and require rapid foot-service referral rather than annual review.
- Refer limb- or life-threatening problems immediately; refer other active diabetic foot problems to the multidisciplinary foot care service within one working day.
- Clinical infection is diagnosed from local or systemic inflammatory features, not from a positive swab or the mere presence of an open ulcer.
- Clean and debride before obtaining a deep tissue or bone sample when feasible; superficial swabs often describe colonisers and can misdirect antibiotics.
- For mild diabetic foot infection in adults, NICE first-choice oral flucloxacillin is 500 mg to 1 g four times daily for 7 days; use the severity table, allergies, renal function and microbiology, and review intravenous therapy by 48 hours.
- Ulcer treatment requires pressure offloading, perfusion review, debridement, appropriate dressing, infection control and glucose or nutrition optimisation as one coordinated plan.
- A normal or raised ankle pressure can mislead in calcified diabetic arteries; combine Doppler waveforms, toe measures and vascular judgement when PAD is suspected.
Key red flags
Rest pain, pallor, coolness, absent pulses, delayed capillary refill, toe necrosis or a punched-out margin suggests PAD and requires urgent vascular assessment.
Expanding erythema, warmth, swelling, tenderness, purulent discharge, systemic illness, crepitus or disproportionate pain raises deep infection and surgical urgency.
Unilateral warmth, oedema, erythema and shape change in a neuropathic foot can mimic cellulitis or gout. Normal early radiographs do not make weight-bearing safe.
Investigation priorities
Define wound severity, neuropathy, deformity, skin threat and arterial supply at the bedside.
Management branches
A person with diabetes attends routine review without a current active foot problem.
- Inspect both feet and footwear, test protective sensation, assess pulses and identify deformity, callus, previous ulcer or amputation and renal replacement therapy.
- Assign the NICE risk category, explain it in practical language and refer to foot-protection services at the required interval rather than recording risk without action.
- Teach daily inspection, safe nail and skin care, correctly fitting footwear and avoidance of barefoot walking or direct heat, with an immediate contact route for new change.