Diabetic Foot Ulcer or Mal Perforans Ulcer

Diabetic foot ulcers (DFU) or mal perforans ulcers are a significant problem and cost to health care. Approximately 25% of people with diabetes will experience at least one DFU in their lifetime. DFUs proceed lower limb amputation 85% of the time. DFUs can be divided into neuropathic, ischemic, and neuroischemic foot ulcers. When ischemia is involved, the prognosis is less good. Secondary infection is common.


The typical location is an ulcer over the 1st or 5th metatarsal on the plantar aspect of the foot. The patient is often a diabetic with peripheral neuropathy. Callus formation is often an initial finding in the patient with diabetic neuropathy. An ulcer is formed after repeated trauma to the pressure areas of the sole in the setting of decreased sensation.

Microbial Analysis

One study [Wounds 2015;27;308] that cultured DFUs found Pseudomonas aeruginosa in 35% of patients followed by Staphylococcus aureus in 19%, E. coli 16%, Klebsiella 6%, MRSA 6% and Candida albicans in 3%. Age > 65, ulcer size > 2 cm2 and HbA1c > 7% were associated with a positive culture. Whether a positive culture represents merely colonization vs infection requires clinical correlation.


Diabetics should have their feet examined routinely. All calluses should be removed. Foot or gait abnormalities or poorly fitting shoes should all be considered and addressed to prevent focal pressure points that can lead to ulceration.


Assessment as to the type of ulcer, neuropathic, ischemic or both should be done. Direct pressure should be reduced or eliminated. A total contact cast may be prescribed. Optimum wound care and debridement if necessary should be prescribed. In chronic cases, one may need to rule out osteomyelitis.

Full treatment recommendations are beyond the scope of this book. See JAAD CME article Jan 2014.

Additional Pictures

Diabetic Foot Ulcer or Mal Perforans Ulcer Diabetic Foot Ulcer or Mal Perforans Ulcer

Necrosis of the toes in a diabetic.
Necrosis of the Toes in a Diabetic


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