Pressure heel ulcers in patients with type 2 diabetes: Is it T.I.M.E. to customise wound bed preparation according to different heel areas?

The last European Pressure Ulcer Advisory Panel - National Pressure Ulcer Advisory Panel (EPUAP-NPUAP) and The National Institute for Health and Care Excellence (NICE) guidelines report the best evidence regarding the management and treatment of pressure ulcers (including those at the level of the heel) in patients with and without type 2 diabetes, providing the leading practice information and recommendations on this topic.1, 2 It is known that pressure heel ulcers are a serious complication in hospitalised patients with type 2 diabetes (with an estimated prevalence of approximately 15% to 20% and a risk of nearly 7% evolving to an amputation of the limb) and that they are strongly associated with an increased risk of limb amputation and adverse outcome.3 However, it is important to highlight that in the current guidelines,1, 2 as well as in other previous consensus documents,4 no author has paid much attention to the varying management and treatment of pressure ulcers according to their specific localisations on the heel. In fact, anatomically, it is important to remember that the heel structure is not the same in all its areas, but it could be divided into 3 main areas: medial, central-posterior, and lateral areas.5-7 Such areas support different biomechanical forces during walking and standing upright and, although minimally, differ anatomically.7 For instance, in the medial and lateral heel areas, the adipose panicle tends to be thicker than that localised in the central-posterior heel area as the Achilles's tendon and bursa take up most of the space in this area.8 Similarly, the dermis and epidermis tend to be thicker in the medial and lateral heel areas but are thinner in the central-posterior heel area.5-7 In addition, it is important to highlight that the vascularisation of the heel is provided by the posterior tibial artery and only by a small extent of the posterior branch of peroneal artery.8 Notably, if the decrease in blood flow to this area is not recognised, the healing of a heel ulcer may be delayed or impaired.8 Consistent with all these factors, it is possible to speculate that the severity of the pressure ulcers and, consequently, their chance of healing may be different according to these specific heel areas. Of note, this may be even more evident in patients with type 2 diabetes, a group of individuals who are characterised by several atypical foot anatomies (such as heavy-weight foot, sharp posterior calcaneus, and thin soft tissue padding) and in whom the wound-healing processes tend to be compromised due to some diabetes-related mechanisms, including hyperglycaemia, advanced glycosylation end products, accelerated atherosclerosis, reduction of nitric oxide synthesis, endothelial dysfunction, and alterations of extracellular matrix structure.9 Therefore, in our opinion, it is time to consider a possible customised therapeutic approach to the pressure heel ulcers in relation to specific heel areas in patients with type 2 diabetes. Based on anatomic, biomechanical, and vascular knowledge, we believe that a sharp and major debridement may be specifically reserved for the medial and lateral heel areas (except in the presence of a critical lower limb ischaemia), whereas a soft debridement may be specifically reserved for the central-posterior heel area. The sharp debridement typically includes surgical or mechanical debridement, whereas minimal and soft debridement involves enzymatic or autolytic processes. In addition, we strongly believe that the wound bed preparation should be always applied to the (pressure) heel ulcers, especially in patients with type 2 diabetes, and that the chance of healing of a heel ulcer may be very low if the direct flow based on the angiosome concept is not systematically respected. Further large and well-designed studies investigating the role of different therapeutic approaches (minimal vs major debridement) of the pressure heel ulcers according to their specific localisation are needed in patients with type 2 diabetes. Finally, the systematic application of anatomical, biomechanical, and vascular knowledge in the management and treatment of the pressure heel ulcers may highly improve the chances of healing of the heel ulcers in patients with type 2 diabetes. The authors declare no potential conflict of interests.