Volume 27 Number 1

Key messages

• A report of the first discussion of a panel of global experts on the urgent need to improve outcomes for DFU patients
• The need for innovations in DFU treatment for better infection and healing outcomes was highlighted
• Proactivity and urgency of education, including new patient metrics, and collaboration on the simplicity of guidelines and terminology, were calls to action

Introduction

Diabetic foot ulcers (DFUs) remain a devastating complication of diabetes, with unacceptably high rates of infection, hospitalisation and lower-limb amputation. Despite existing clinical guidance and a growing arsenal of treatment options, outcomes remain poor for far too many patients. To address this urgent issue, a global advisory panel of leading experts in DFU care was convened. Held in December 2024 in London, the inaugural meeting brought together eight leading international experts across diabetes care, wound care, infection, surgery and podiatry with a shared mission: to challenge the status quo and define a new path forward in DFU treatment. (The travel and consultancy was funded by Convatec).

This roundtable marked the beginning of a multi-stage dialogue to address persistent clinical gaps, refine best practices and shape the future of DFU treatment, aimed at improving outcomes. Over the course of two days, the panel shared deep clinical insights and explored strategic areas for improvement, including early intervention, diagnostic challenges, individualised and dynamic care strategies, emerging innovations and a renewed focus on education, guidance and collaboration.

The group also explored the anticipated launch of a novel multimodal, nitric oxide-generating dressing, ConvaNiox™ (Convatec, UK), highlighting its potential role in transforming the management of DFUs.¹

This report presents the key takeaways from that first meeting and signals a call to action: to elevate the urgency of DFU care and build a shared roadmap for improving outcomes through evidence-based innovation, education and collaboration.

The burden of diabetic foot ulcers and the unmet clinical need

It is estimated that DFUs affect 40–60 million people globally at any given time (Figure 1).² They are associated with devastating consequences: severe infection, extended hospital stays, diminished quality of life, and a high risk of lower limb amputation (Figure 1).^3,4 The financial burden is staggering, with costs directly associated with DFUs in the US alone an estimated $9–13 billion per year,⁵ while in England expenditure on DFUs exceeds spending on the three most common cancers combined.⁶

 

Figure 1. Diabetic foot ulcers: the silent epidemic behind diabetes.

 

More concerning, however, is the stagnation in patient outcomes. Infections—the principal cause of damage to diabetic feet—occur in 50–60% of DFUs.³ Of these, approximately 20% of moderate or severe diabetic foot infections result in lower extremity amputations.³ The 5-year mortality rate following major amputation approaches 40% (Figure 1),⁷ surpassing that of most cancers.⁸

Despite advances in skin care and wound management, healing rates for DFUs remain unacceptably low, highlighting a clear unmet need for more effective treatments. Guest et al (2020)⁹ reported healing rates as low as 40% at one year (Figure 1), while a recent meta-analysis by Coye et al (2025)¹⁰ found a pooled healing rate of just 33.15% over a 12 to 24-week period in patients receiving standard care (Figure 1), with an average healing time of 50 days (SD: 31.10 days). These data underscore the persistent challenge for healthcare professionals and the urgent need for improved therapeutic options to better support this high-risk population.

During the meeting, panellists acknowledged that despite clinical awareness, DFUs continue to be misdiagnosed, under-treated, or referred too late. They identified infection and ischemia as the two most common and challenging barriers to healing. However, many ulcers are managed with an overly generic approach, often without a clear assessment of the dominant wound pathology. Compounding this is the confusing landscape of DFU guidelines, which can be complex, fragmented, or poorly adapted to real-world settings.

The group emphasised that “disconnects between guideline theory and clinical reality” contribute to variable care quality and worse outcomes.^11,12 Furthermore, patient-related factors—such as poor glycaemic control, comorbidities, and inconsistent adherence—further complicate management and underscore the need for a proactive, patient-centred approach and innovative therapeutic options.

Key discussion points and future focus areas

1. From wound care to proactive and holistic patient management

One of the meeting’s most powerful takeaways was the shift in mindset proposed by several panellists: to stop thinking about DFU management as simply wound care and start treating it as systemic disease management. Panellists stressed that DFUs are not static—they evolve with time, patient health and environmental factors. Effective treatment must be adaptable, moving beyond a narrow focus on wound care toward a more proactive and holistic patient management approach. This means prioritising early diagnosis, ulcer-free days, hospital-free days, and preserved mobility as the true metrics of success.

2. Earlier, smarter intervention

There was strong consensus that waiting to escalate care—especially in the context of infection—is counterproductive. Delayed referrals, misdiagnoses and over-reliance on visual cues often translate to missed opportunities for early intervention. They challenged the traditional notion of waiting four weeks before escalating treatment,¹³ asking, “Why wait?” when early advanced intervention could change outcomes. Experts advocated for tools and protocols that support early, targeted action, especially in wounds at risk of infection.

3. Simplifying and unifying guidelines

Despite existing clinical guidelines, real-world implementation remains inconsistent. Barriers include diagnostic ambiguity, unclear infection indicators, underdiagnosis of ischemia, and fragmented care pathways. Panellists described current DFU guidelines as “dense,” “confusing,” and often impractical for frontline clinicians. There is a pressing need for simplified, unified frameworks that help clinicians rapidly identify the dominant pathology, assess risk and select appropriate therapies without ambiguity. More intuitive tools and education are needed.

4. Bridging the knowledge gap

Patient education and health care professional (HCP) training emerged as high priority focus areas. Panellists highlighted that even advanced therapies are underutilised, largely due to lack of understanding or systemic barriers. Patient compliance remains a major barrier, particularly among those with multiple comorbidities.¹⁴ Education must be enhanced not only for HCPs but for patients and caregivers, fostering better understanding, ownership, and engagement in their care. Improving communication, addressing misconceptions and increasing knowledge transfer were deemed essential to changing the status quo.

5. Shaping the research agenda

Panellists called for greater investment in real-world evidence, randomised controlled trials and subgroup analysis to better define which patients benefit most from emerging technologies. Five key themes emerged from panellist discussion with widespread interest in collaborating on:

i   Real-world evidence generation

ii  Guideline development

iii  Providing clearer operational definitions of infection and infection risk

iv  Determining the subset of neuroischemic DFUs with potential for healing

v  Exploring outcome measures that matter most to patients

Emerging innovation: A new technology for DFU management

The panel had an in-depth discussion about a new multimodal, nitric oxide-generating dressing, (ConvaNiox^TM by Convatec, UK), which generated significant clinical interest. Designed to address the persistent issue of infection, colonisation and stagnation/recalcitrance in DFUs, it combines multiple mechanisms of action that support host healing¹ and may reduce dependence on systemic antibiotics.¹⁵ Panellists recognised its potential to play a pivotal role in early-stage management, particularly for wounds at risk of infection or with suspected biofilm.

Two clinical use scenarios were explored:

• Scenario 1: Using the multimodal dressing as standard of care from initial assessment.
• Scenario 2: Initiating use of the multimodal dressing only after four weeks of inadequate progress.

After considering the RCT data,¹ experts were unanimous in preferring Scenario 1, arguing that proactive infection control could improve healing trajectories and potentially reduce the need for systemic antibiotics.

Panellists emphasised the importance of clear communication on the multimodal dressing’s mechanisms of action, robust clinical data and a defined role within treatment algorithms. The multimodal dressing’s alignment with growing concerns around antimicrobial resistance was also seen as timely and strategically important.

Conclusion and next steps

This global advisory panel meeting delivered more than a forum for discussion—insights provide a roadmap for ongoing collaboration and change. The roundtable discussion underscored the need for:

• Earlier, more proactive intervention
• Evidence-driven personalisation of care
• Better education and integration of guidelines
• Improved collaboration between clinicians, researchers and industry

The sponsor, Convatec, UK, in collaboration with expert panels, is engaged in efforts to advance DFU care. Current initiatives are directed toward supporting improved healing, reducing infection and amputation rates, and enhancing outcomes for people living with diabetes. The expert panel will continue its work through 2025, providing insights to inform clinical practice, guide research priorities and refine the application of technologies, such as multimodal wound dressings, such as ConvaNiox^TM. These activities aim to contribute to the broader goal of improving DFU management and patient care worldwide.

Conflict of Interest

All authors serve as consultants to Convatec.

Funding

The authors’ travel and consultancy was funded by Convatec. Koodoo Health Ltd. healthcare consultants provided medical writing assistance, and Rachel Torkington-Stokes, Matthew Malone, and Daniel Metcalf (all Convatec) reviewed manuscript drafts. Their services were funded by Convatec.

Author(s)

David G Armstrong¹ DPM, MD, PhD, Vickie R Driver² DPM, MS, FACFAS, Michael E Edmonds*³ MD, FRCP, José Luis Lázaro-Martínez⁴ DPM, PhD, Chris A Manu⁵ MD, MRCP, Beate Mrozikiewicz-Rakowska⁶ MD, PhD, Alberto Piaggesi⁷ MD, Éric Senneville⁸ MD, PhD
¹Keck School of Medicine, University of Southern California, Los Angeles, California, US
²School of Medicine, Washington State University, Pullman, Washington, US
³Diabetic Foot Clinic, King’s College Hospital NHS Foundation Trust, London, UK
⁴Diabetic Foot Unit, Universidad Complutense de Madrid, Madrid, Spain
⁵Diabetic Foot Clinic, King’s College Hospital NHS Foundation Trust, London, UK
⁶Department of Endocrinology, Centre of Postgraduate Medical Education, Bielanski Hospital, Warsaw, Poland
⁷Diabetic Foot Section, Pisa University Hospital, Pisa, Italy
⁸Gustave Dron Hospital, Tourcoing, France

*Corresponding author email michael.edmonds@nhs.net

References

1. Edmonds ME, Bodansky HJ, Boulton AJM, Chadwick PJ, Dang CN, D’Costa R, et al. Multicenter, randomized controlled, observer-blinded study of a nitric oxide generating treatment in foot ulcers of patients with diabetes-ProNOx1 study. Wound Repair Regen. 2018;26(2):228–237.
2. McDermott K, Fang M, Boulton AJM, Selvin E, Hicks CW. Etiology, Epidemiology, and Disparities in the Burden of Diabetic Foot Ulcers. Diabetes Care. 2023;46(1):209–221.
3. Edmonds M, Manu C, Vas P. The current burden of diabetic foot disease. J Clin Orthop Trauma. 2021;17:88–93.
4. Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med. 2017;376:2367e2375.
5. Rice JB, Desai U, Cummings AK, Birnbaum HG, Skornicki M, Parsons NB. Burden of diabetic foot ulcers for medicare and private insurers [published correction appears in Diabetes Care. 2014;37 (9):2660]. Diabetes Care. 2014;37(3):651–658.
6. Jodheea-Jutton A, Hindocha S, Bhaw-Luximon A. Health economics of diabetic foot ulcer and recent trends to accelerate treatment. Foot. 2022;52:101909.
7. Jupiter DC, Thorud JC, Buckley CJ, Shibuya N. The impact of foot ulceration and amputation on mortality in diabetic patients. I: From ulceration to death, a systematic review. Int Wound J. 2016;13(5):892–903
8. Armstrong DG, Swerdlow MA, Armstrong AA, Conte MS, Padula WV, Bus SA. Five year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer. J Foot Ankle Res. 2020;13(1):16.
9. Guest JF, Fuller GW, Vowden P. Cohort study evaluating the burden of wounds to the UK’s National Health Service in 2017/2018: update from 2012/2013. BMJ. 2020;10:e045253.
10. Coye TL, Bargas Ochoa M, Zulbaran-Rojas A, Martinez Leal B, Quattas A, Tarricone A, et al. Healing of diabetic neuropathic foot ulcers receiving standard treatment in randomised controlled trials: A random effects meta-analysis. Wound Repair Regen. 2025;33(1):e13237.
11. Jupiter DC, Thorud JC, Buckley CJ, Shibuya N. The impact of foot ulceration and amputation on mortality in diabetic patients. I: From ulceration to death, a systematic review. Int Wound J. 2016;13(5):892–903
12. Malone M, Erasmus A, Schwarzer S, Lau NS, Ahmad M, Dickson HG. Utilisation of the 2019 IWGDF diabetic foot infection guidelines to benchmark practice and improve the delivery of care in persons with diabetic foot infections. J Foot Ankle Res. 2021;14(1):10.
13. Sheehan P, Jones P, Caselli A, Giurini JM, Veves A. Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week prospective trial. Diabetes Care. 2003;26(6):1879–1882.
14. Religioni U, Barrios-Rodríguez R, Requena P, Borowska M, Ostrowski J. Enhancing therapy adherence: impact on clinical outcomes, healthcare costs, and patient quality of life. Medicina (Kaunas). 2025;61(1):153.
15. Edmonds ME, Horner A, Manu C, Metcalf DG. The impact of nitric oxide-generating wound dressing in diabetic foot ulcers in patients receiving antibiotics: post-hoc analysis. Int Wound J. 2025;22:e70681.