Recommendation 1: We recommend frequent evaluation at 1- to 4-week intervals with measurements of diabetic foot wounds to monitor reduction of wound size and healing progress (Grade 1C).

Recommendation 1.1: We recommend evaluation for infection on initial presentation of all diabetic foot wounds, with initial sharp débridement of all infected diabetic ulcers, and urgent surgical intervention for foot infections involving abscess, gas, or necrotizing fasciitis (Grade 1B).

Recommendation 1.2: We suggest that treatment of DFIs should follow the most current guidelines published by the Infectious Diseases Society of America (IDSA) (Ungraded).

Recommendation 2: We recommend use of dressing products that maintain a moist wound bed, control exudate, and avoid maceration of surrounding intact skin for diabetic foot wounds (Grade 1B).

Recommendation 3: We recommend sharp débridement of all devitalized tissue and surrounding callus material from diabetic foot ulcerations at 1- to 4-week intervals (Grade 1B).

Recommendation 4: Considering lack of evidence for superiority of any given débridement technique, we suggest initial sharp débridement with subsequent choice of débridement method based on clinical context, availability of expertise and supplies, patient tolerance and preference, and cost-effectiveness (Grade 2C).

Recommendation 5: For DFUs that fail to demonstrate improvement (>50% wound area reduction) after a minimum of 4 weeks of standard wound therapy, we recommend adjunctive wound therapy options. These include negative pressure therapy, biologics (platelet-derived growth factor [PDGF], living cellular therapy, extracellular matrix products, amnionic membrane products), and hyperbaric oxygen therapy. Choice of adjuvant therapy is based on clinical findings, availability of therapy, and cost-effectiveness; there is no recommendation on ordering of therapy choice. Re-evaluation of vascular status, infection control, and off-loading is recommended to ensure optimization before initiation of adjunctive wound therapy (Grade 1B).

Recommendation 6: We suggest the use of negative pressure wound therapy for chronic diabetic foot wounds that do not demonstrate expected healing progression with standard or advanced wound dressings after 4 to 8 weeks of therapy (Grade 2B).

Recommendation 7: We suggest consideration of the use of PDGF (becaplermin) for the treatment of DFUs that are recalcitrant to standard therapy (Grade 2B).

Recommendation 8: We suggest consideration of living cellular therapy using a bilayered keratinocyte/fibroblast construct or a fibroblast-seeded matrix for treatment of DFUs when recalcitrant to standard therapy (Grade 2B).

Recommendation 9: We suggest consideration of the use of extracellular matrix products employing acellular human dermis or porcine small intestinal submucosal tissue as an adjunctive therapy for DFUs when recalcitrant to standard therapy (Grade 2C).

Recommendation 10: In patients with DFU who have adequate perfusion that fails to respond two 4 to 6 weeks of conservative management, we suggest hyperbaric oxygen therapy (Grade 2B).