Introduction

According to the International Diabetes Federation (IDF), the prevalence of diabetes in adults worldwide is expected to increase from 536.6 million people in 2021 to 783.2 million people in 2045. [1] People with diabetes (type 1 or 2) may have a lifetime risk of developing foot ulcers as high as 34%. Diabetic foot ulcers are the leading cause of morbidity, accounting for at least two-thirds of all nontraumatic amputations in the United States.

Standard principles for the management of diabetic foot ulcers (DFU), including debridement, infection control, pressure offloading, and revascularization. [2] However, inflammation often prevents the final step of complete healing after multiple interventions and is one of the mechanisms by which DFUs delay healing. [3] Dysregulated M1/M2-type macrophages could prolong inflammation reaction. To restore the balance between these macrophage types is deemed as a new strategy in wound healing. [4] Here, we reported a case of an adult Asian woman with type 2 diabetes who presented with a chronic right dorsal foot ulcer with exposed anterior tibial tendon, was successfully treated with macrophage modulating drugs.

Case Report

A 53-year-old woman with type 2 DM (HbA_1c 11.7%), PAD, hypertension and hyperlipidemia was sent to the emergency department of Kaohsiung Medical University Hospital due to the presence of an infected chronic ulcer with exposed anterior tibialis tendon and extensive ischemic necrosis at the edge of her right ankle wound. The ankle-brachial index of her right leg was 0.8, so a cardiac consultation was arranged for further examination. Angiography showed 100% occlusion of anterior tibial artery, 80~90% stenosis of tibioperoneal trunk and 80% stenosis of posterior tibial artery. Angioplasty was successfully completed after discussing with her family. However, 10 days after successful angioplasty, tissue proliferation was stopped by persistent inflammation and ischemia (Figure 1). After receiving angioplasty for three months and regularly following up in our plastic surgery outpatient department, there had been little improvement in the wound. To break the vicious cycle of inflammation and stimulate tissue proliferation, fat grafting was performed. We found Pseudomonas aeruginosa contamination in subsequent wound cultures due to prolonged wound care.

We applied artificial dermis for the ulcer defect after further debridement and intravenous antibiotics. However, the graft remained poorly taking. Stalled wound healing process was noted as the ulcer area measured by imitoMeasure (imito AG, Zurich, Switzerland) was 7.59 cm², which decreased to 7.23 cm² two weeks after surgery (Figure 2). The patient refused further surgical reconstruction, so a new macrophage modulating drug, ON101 (Oneness Biotech Co, Ltd, Taiwan), was instead applied topically with gauze twice daily and the wound healed completely after 16 weeks (Figure 3). According to our observation, no obvious adverse or unanticipated events were noted. At 13-month follow-up, her range for right ankle joint dorsiflexion was 11 degrees. Now she can walk without crutches or walking equipment and she is satisfied with her normal gait.

Figure 1: Although downgraded to Wagner grade II after treatment, the ulcer remained in a state of persistent inflammation and ischemia.