Healing an ulcer is important, but it is only the first step in the treatment. It is long known that patients whose ulcer healed are at high-risk of developing a new one, but this has never been investigated in large and well-defined cohorts. New data from Sweden confirms our fears: recurrence rates after an ulcer are high, with more than 50% of patients with a new ulcer within one year.
In a longstanding cohort now including 617 patients, 262 patients (42%) developed a new ulcer within 12 months, and a further 30 patients (5%) developed a new ulcer and died within 12 months. A strength of the study was their focus on ulcer location. They showed that only 51 of the newly developed ulcers (or 17%) was found at the exact same location; 44% of the new ulcers were on the same foot but on a different location, 39% of the ulcers were located on the other foot. A limitation of the study was their lack of further analyses on predictors or risk factors. It is therefore not possible to explain who develops a new ulcer, and who can survive ulcer free.
For clinical practice, this study has important implications. A first implication concerns the focus of preventive treatment. With only 17% of ulcers developing on the same location, it is important that prevention is focused on both feet and all potential areas at higher risk within these feet. When you try to prevent a foot ulcer, you cannot focus solely on the previous ulcer location.
Potentially more important is what you tell your patient. When you tell patients their ulcer is healed, it can be expected that all they hear is “healed”, and interpret that as not having problems anymore. However, this study is another contribution to the argument of changing our language to “remission”. Even when an ulcer has healed, that person is only in remission, as their feet will likely never completely heal from diabetic foot disease. Using the word remission, similar to cancer and rheumatoid arthritis, is hoped to increase vigilance in your patients, and emphasize a focus on continuing efforts to prevent new foot ulcers.