How to Prevent Recurrence of Diabetic Foot Ulcers: Best Practices

Diabetic foot ulcers (DFUs) are painful, costly, and—critically—likely to come back. Preventing recurrence is just as important as healing the first wound. The good news: a growing body of research and international guidelines points to practical strategies that lower recurrence risk and increase ulcer-free days. This guide summarizes best practices that clinicians and care teams can apply to protect patients after healing, using evidence-informed recommendations.

Why recurrence happens

Recurrence usually reflects ongoing mechanical, biological, or systemic risk factors that remain after a wound heals. Common drivers include:

• High plantar pressure or repetitive trauma to the same spot (often in neuropathic feet).

• Poor footwear or missing custom insoles that fail to redistribute pressure.

• Peripheral arterial disease and poor perfusion.

• Persistent neuropathy and loss of protective sensation.

• Poor glycemic control, smoking, renal disease, or other co-morbidities that impair healing.

• Insufficient follow-up or lack of patient self-management (foot checks, temperature monitoring, adherence to offloading).
  

Because multiple risk factors often co-exist, a multi-pronged prevention plan is required.

1) Risk stratification and regular screening

Start by categorizing patients into risk groups (low, moderate, high) based on neuropathy, foot deformity, prior ulcers/amputation, and peripheral arterial disease. International guidelines recommend routine screening to identify people who need more frequent follow-up and intervention. Early identification of risk allows targeted prevention and increases ulcer-free days.

Practical actions

• Screen annually for low-risk patients and more often for higher-risk patients.

• Document neuropathy (monofilament, vibration), pulses, and foot deformities.

• Record history of prior DFU or amputation; these patients need intensive prevention.
  
  

2) Offloading and therapeutic footwear: reduce mechanical stress

Mechanical stress is one of the strongest predictors of plantar ulcer recurrence. Effective pressure redistribution—through non-removable and removable offloading devices, custom therapeutic footwear, and insoles—reduces recurrence risk. Guidelines emphasize offloading as a cornerstone of DFU management and prevention.

Practical actions

• For patients with healed plantar ulcers, prescribe therapeutic footwear with validated pressure relief and custom insoles where indicated. Evidence shows pressure-based orthoses and properly designed footwear can lower recurrence.

• Consider non-removable knee-high devices when active ulceration is present; for prevention after healing, focus on footwear that patients will actually wear.

• Reassess footwear fit and plantar pressure periodically. Patient weight, activity, and foot shape change over time.
  
  

Adherence matters. Even the best shoe is ineffective if not worn. Strategies to improve adherence include patient education, prescribing comfortable and accepted designs, and follow-up checks.

3) Plantar pressure monitoring & technology

Objective monitoring of plantar pressure and foot temperature has emerged as a useful tactic to detect risk early. Devices that track pressure distribution or daily temperature asymmetry can prompt earlier action before a breakdown becomes a full ulcer. Studies suggest that targeted interventions based on pressure or temperature alerts reduce recurrence.

Practical actions

• Use temperature monitoring for patients with neuropathy and prior ulcer. Teach them to check daily and report sustained asymmetry.

• Consider referrals to centers that can provide plantar pressure mapping or smart insoles for high-risk patients.
  
  

4) Optimize medical comorbidities: glycemic control, smoking cessation, and nutrition

Systemic factors influence tissue repair and infection resistance. While preventing recurrence is multifactorial, improving metabolic control and addressing modifiable risks supports long-term tissue health.

Practical actions

• Coordinate with primary care and endocrinology to optimize HbA1c and treat dyslipidemia and hypertension.

• Support smoking cessation; smoking impairs perfusion and healing.

• Screen for and treat malnutrition or protein deficiency, which can weaken tissue integrity.
  
  

Avoid absolute claims; evidence links better metabolic control with improved healing environments, but patient-centered goals matter.

5) Vascular assessment and treating peripheral arterial disease (PAD)

Poor blood flow is a major barrier to healing and increases recurrence risk. Patients with healed ulcers should undergo vascular screening when indicated, and timely referral for vascular imaging and revascularization can be appropriate for those with significant ischemia.

Practical actions

• Palpate distal pulses and use ABI/TBI or duplex ultrasound if PAD is suspected.

• Collaborate with vascular surgery when revascularization may reduce future ulceration risk.
  
  

6) Infection control and wound-bed preparation (during healing and follow-up)

While this section centers on preventing recurrence after healing, infection management during the healing phase directly affects the quality of tissue repair. Avoid unnecessary systemic antibiotics for uninfected ulcers; follow diagnostic guidelines when infection is suspected. Proper debridement, managing biofilm, and ensuring an optimal wound bed lower the chance of a fragile scar that breaks down later.

Practical actions

• Use guideline-based criteria to diagnose infection; treat confirmed infections appropriately.

• Provide debridement and local wound care as needed during healing; ensure adequate documentation and clear follow-up plans at discharge.
  
  

7) Education, self-care, and behavior change

Education is central. Patients who know how to inspect their feet, choose appropriate footwear, and respond to warning signs can dramatically reduce recurrence risk. But education alone is often insufficient. Combine education with tools (temperature monitors, footwear prescriptions) and follow-up reinforcement.

Practical actions

• Teach daily foot inspection, nail/callus care basics, and the importance of avoiding barefoot walking.

• Use teach-back methods and provide written and visual materials.

• Incorporate family caregivers when appropriate.
  
  

Behavioral supports: Motivational interviewing, reminder systems, and structured follow-up improve adherence to preventive measures.

8) Multidisciplinary clinics and integrated care

Evidence suggests that care from coordinated multidisciplinary teams (podiatry, endocrinology, vascular surgery, nursing, orthotics, wound care specialists) reduces adverse outcomes including recurrence and major amputation. Integrated foot care programs can improve monitoring and deliver timely interventions when small problems arise.

Practical actions

• Refer high-risk patients to multidisciplinary diabetic foot clinics when available.

• If such a clinic is not available, create a local network of specialists to ensure rapid access to vascular, podiatry, and wound-care services.
  
  

9) Follow-up schedule and the “remission” mindset

Treat healed DFU patients as being “in remission” rather than cured. They need active surveillance to maximize ulcer-free days.

Suggested follow-up framework

• High risk (prior DFU/amputation): clinic visits every 1–3 months; footwear and insole checks; remote monitoring as needed.

• Moderate risk: visits every 3–6 months.

• Low risk: annual screening.
  
  

Document a clear plan at discharge from active wound care: who does what, when the next foot check is, and what to do if early signs appear. The goal is to detect and treat pre-ulcerative lesions early.

Practical checklist to reduce recurrence

A brief, clinician-friendly checklist that can be used at each follow-up:

• Risk stratification updated (neuropathy, PAD, prior ulcer).

• Footwear reviewed; prescription for therapeutic shoes/insoles if needed.

• Offloading adherence discussed and reinforced.

• Vascular status checked; refer if signs of ischemia.

• Glycemic control and systemic risks reviewed with primary care.

• Education reinforced (daily checks, footwear, no barefoot walking).

• Consider temperature monitoring/pressure mapping for high-risk patients.

• Plan next follow-up and who to contact for early warning signs.
  
  

Limitations and realistic expectations

Prevention reduces risk but does not eliminate it. Many interventions show benefit in trials and guideline reviews, yet patient adherence, access to specialized devices, and co-morbid disease influence outcomes. Clinicians should individualize plans, set realistic goals with patients, and document shared decision-making.

Conclusion

Preventing recurrence of diabetic foot ulcers requires a sustained, team-based effort that addresses mechanical stress, systemic health, education, and surveillance. Prioritize risk stratification, evidence-based offloading and footwear, integrated care pathways, and patient empowerment. Thinking of healed ulcers as “in remission” and maintaining active follow-up will help patients achieve more ulcer-free days and better quality of life.

See also

Best Practices for Chronic Wound Care: How to Assess Foot Ulcers Effectively
How to Tell If a Wound Is Healing: Signs of Proper Wound Care Progress
Why Diabetic Foot Wounds Heal Slowly: Top Factors That Delay Recovery
How Often Should Wound Dressings Be Changed? Best Practices for Healing
Wound Care Guide: How to Tell Colonization from True Infection

More Information

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* This blog is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment.