Successful treatment of diabetic foot ulcer during COVID-19 lockdown using Cadexomer Iodine: Case report

The author coined a pneumonic — MAGIC in which M stands for metabolic control, A for aggressive debridement, G for ground clearance (offloading), I for infection control and C for compliance. These five factors are vital for the healing of diabetic foot lesions, he noted.

During the COVID-19 pandemic, clinicians have needed to adapt to new ways of delivering care. This includes treating patients using online services like video discussions and phone calls. The present case report describes a patient who presented at the author's diabetes center with a diabetic foot lesion on his left foot and was subsequently treated using video calls, due to the imposition of the lockdown.

A detailed medical history revealed the presence of family history of metabolic issues, duration of diabetes and his medication and treatments. Based on the history given by the patient, it was concluded that the lesion started as folliculitis and developed into cellulitis and ulceration. Perhaps due to underlying diabetic sensory neuropathy, the patient neglected the lesion during the earlier stages, leading to rapid spread of the bacterial infection in the great toe tissue, possibly involving the bone (osteomyelitis with septic arthritis of the joint), explained Shankhdhar.

His detailed investigations showed that his fasting blood glucose was 167mg/dl and post-prandial blood glucose 268mg/dl. His HbA1c was 9.2% and serum uric acid was 9.2mg%. His blood pressure was 140/90mmHg and his LDL cholesterol levels were high (180mg/dl).

The patient was taking 2mg of glimepiride in the morning and 1mg at night, 500mg of metformin twice daily as well as Atorvastatin (10mg) and telmisartan (20mg) at night. He was also applying an antibiotic ointment to his lesion and dressing with a simple cotton

Some adjustments were made to his regular medication regimen. Co-amoxiclav (500mg of Amoxycillin and 125mg of Clavulanic acid) was added to his prescription to be taken twice a day for 2 weeks. Surgical debridement was planned but due to the pandemic lockdown this could not be carried out.

Hence, the doctor then guided the patient to change the dressing at home adapting to the new challenge of delivering care being at home. The lesion was possibly neuropathic, which meant that the patient could clean the lesion reasonably well without much pain. The wound surface was left slightly moist, because a moist wound bed plays an important role in wound healing. Cadexomer iodine was chosen for the patient to use at home as the drug is known to remove the barrier to healing with its dual antimicrobial and desloughing properties. Certain considerations were instructed regarding the application of cadexomer iodine which were strictly followed by the patient.

These included

a) A single application of cadexomer iodine should not exceed 50 g

b) The total amount of cadexomer iodine ointment used in 1 week should not exceed 150 g

c) The duration of treatment should not exceed 3 months in any single course of treatment.

The patient applied cadexomer iodine directly to a dry, sterile non-adherent gauze. Then he moved a gloved finger lightly over the dressing to spread the ointment underneath, with a depth of 3mm.

The patient was trained to change the dressing at home and monitoring was carried out online, twice a week. With the regular application of the drug, the lesion improved remarkably within a month without any re-ulceration and long-term care was advised. Therefore, the author emphasized the fact that "one must remember that once healing is achieved, re-ulceration is always a real possibility in people with diabetes. Ulcer recurrence significantly increases the long-term costs for diabetic foot care and further increases risk of amputation, as well as deterioration of patient's health and wellbeing."

He furthermore concluded that "at the beginning of the COVID-19 lockdown, we were unable to continue with our patient's care in person. Therefore, he was taught how to care for and dress his diabetic foot ulcer at home via video call. This strategy was successful, with his wound progressing to complete epithelialization by day 30. Staff worked to educate the patient and his toe was saved."

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