COMPARATIVE EFFECTIVENESS OF DEBRIDEMENT MODALITIES FOR DIABETIC FOOT ULCERS: A SYSTEMATIC LITERATURE REVIEW
Indonesia Indonesia Indonesia Indonesia 
Article Sidebar
-
Clinical Outcomes, Diabetic Foot Ulcer, Debridement, Wound Healing, Systematic review
Abstract
Diabetic foot ulcers (DFUs) represent a severe complication of diabetes mellitus associated with significant risks of infection, lower-extremity amputation, and substantial healthcare burden. Although debridement is established as an essential component of DFU management, the comparative clinical effectiveness across different debridement modalities remains varied. This systematic literature review evaluated and synthesized current evidence regarding various debridement methods in DFU management following the PRISMA 2020 guidelines and SWiM framework. A structured search was performed across PubMed, ScienceDirect, SpringerLink, Wiley Online Library, MDPI, and Google Scholar for publications from 2018 to 2025. Methodological quality was appraised using the Joanna Briggs Institute (JBI) Critical Appraisal Tools. Twelve primary studies (7 RCTs, 1 quasi-experimental, 1 prospective comparative, and 3 case series) met the inclusion criteria. Current evidence suggests that enzymatic debridement and ultrasonic-assisted wound debridement (UAWD) demonstrate promising trends in accelerating tissue preparation and wound size reduction. Sharp or surgical debridement remains the primary first-line approach for immediate removal of nonviable tissue and biofilm disruption. Autolytic, biological, and hydrosurgical modalities offer potential benefits in specific clinical contexts, though available comparative data remain limited. Overall, while several advanced modalities show favorable evidence for specific parameters, no single debridement technique can be conclusively defined as universally superior across all clinical outcomes.
Full text article
References
Aditya, C., Bukke, S., Anitha, K., Meeraraje, P., Goruntla, N., Yadesa, T., & Onohuean, H. (2025). A comprehensive review on diabetic foot ulcer addressing vascular insufficiency, impaired immune response, and delayed wound healing mechanisms. Frontiers in Pharmacology, 16. https://doi.org/10.3389/fphar.2025.1622055
Armstrong, D. G., Tan, T.–W., Boulton, A. J. M., & Bus, S. A. (2023). Diabetic Foot Ulcers. JAMA, 330(1), 62–75. https://doi.org/10.1001/jama.2023.10578
Campbell, M., McKenzie, J. E., Sowden, A., Katikireddi, S. V., Brennan, S. E., Ellis, S., Hartmann–Boyce, J., Ryan, R., Shepperd, S., Thomas, J., Welch, V., & Thomson, H. (2020). Synthesis without meta-analysis (SWiM) in systematic reviews: Reporting guideline. BMJ, l6890. https://doi.org/10.1136/bmj.l6890
Chen, H., Xiao, T., Zhang, L., Liu, N., Liang, X., Li, T., Wang, J., Peng, Y., Liu, Y., & Xu, J. (2023). Effect of ultrasound?supported wound debridement in subjects with diabetic foot ulcers: A meta?analysis. International Wound Journal, 20(7), 2618–2625. https://doi.org/10.1111/iwj.14133
Chen, P., Vilorio, N. C., Dhatariya, K., Jeffcoate, W., Lobmann, R., McIntosh, C., Piaggesi, A., Steinberg, J., Vas, P., Viswanathan, V., Wu, S., & Game, F. (2024). Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews, 40(3), e3644. https://doi.org/10.1002/dmrr.3644
Dawi, J., Tumanyan, K., Tomas, K., Misakyan, Y., Gargaloyan, A., Gonzalez, E., Hammi, M., Tomas, S., & Venketaraman, V. (2025). Diabetic Foot Ulcers: Pathophysiology, Immune Dysregulation, and Emerging Therapeutic Strategies. Biomedicines, 13(5), 1076. https://doi.org/10.3390/biomedicines13051076
Dayya, D., O’Neill, O. J., Huedo–Medina, T. B., Habib, N., Moore, J., & Iyer, K. (2022). Debridement of Diabetic Foot Ulcers. Advances in Wound Care, 11(12), 666–686. https://doi.org/10.1089/wound.2021.0016
Della Pepa, G., Lombardi, G., Gianfrancesco, S., Piccolo, R., Chirico, G., Pellegrino, M., Santella, L., Tecce, N., Volpicelli, A., Sollo, E., Bozzetto, L., Masulli, M., Riccardi, G., Rivellese, A. A., & Saldalamacchia, G. (2023). Triticum vulgare Extract and Polyhexanide (Fitostimoline® Hydrogel/Fitostimoline® Plus Gauze) versus Saline Gauze Dressing in Patients with Diabetic Foot Ulcers: Results of a Randomized Controlled Trial. Journal of Clinical Medicine, 12(10), 3596. https://doi.org/10.3390/jcm12103596
Flores–Escobar, S., Álvaro?Afonso, F., García–Álvarez, Y., López–Moral, M., Lázaro–Martínez, J., & García–Morales, E. (2022). Ultrasound–Assisted Wound ( UAWD) Debridement in the Treatment of Diabetic Foot Ulcer: A Systematic Review and Meta-analysis. Journal of Clinical Medicine, 11. https://doi.org/10.3390/jcm11071911
Flores–Escobar, S., García–Álvarez, Y., Álvaro–Afonso, F. J., López–Moral, M., García–Madrid, M., & Lázaro–Martínez, J. L. (2025). Clinical Effects of Weekly and Biweekly Low–Frequency Ultrasound Debridement Versus Standard of Wound Care in Patients with Diabetic Foot Ulcers: A Pilot Randomized Clinical Trial. The International Journal of Lower Extremity Wounds, 15347346251332795. https://doi.org/10.1177/15347346251332795
Gao, H., Chen, J., Zhao, Z., & Wang, G. (2022). A combination of UAWD and topical cortex phellodendri compound fluid in patients with diabetic foot ulcers. Medicine, 101(32), e29604. https://doi.org/10.1097/MD.0000000000029604
Gustinelli Barbosa, M. A., Paggiaro, A. O., Carvalho, V. F. D., Isaac, C., & Gemperli, R. (2018). Effects of Hydrogel With Enriched Sodium Alginate in Wounds of Diabetic Patients. Plastic Surgical Nursing, 38(3), 133–138. https://doi.org/10.1097/PSN.0000000000000228
JBI Critical Appraisal Tools | JBI. (n.d.). Retrieved July 29, 2026, from https://jbidevlin03.services.adelaide.edu.au/critical–appraisal–tools?utm_source=chatgpt.com
Lázaro–Martínez, J. L., Álvaro–Afonso, F. J., Sevillano–Fernández, D., García–Álvarez, Y., Sanz–Corbalan, I., & García–Morales, E. (2020). Cellular Proliferation, Dermal Repair, and Microbiological Effectiveness of UAWD ( UAWD) Versus Standard Wound Treatment in Complicated Diabetic Foot Ulcers (DFU): An Open–Label Randomized Controlled Trial. Journal of Clinical Medicine, 9(12), 4032. https://doi.org/10.3390/jcm9124032
Lazzarini, P. A., & van Netten, J. J. (2025). Best practice offloading treatments for diabetic foot ulcer healing, remission, and better plans for the healing–remission transition. Seminars in Vascular Surgery, Interdisciplinary Limb Preservation: What Every Vascular Surgeon Needs to Know, 38(1), 110–120. https://doi.org/10.1053/j.semvascsurg.2025.01.012
Liang, J., Gong, X., Hu, X., You, C., Zhou, J., Gao, Y., Zong, J., & Liu, Y. (2024). Integrated genetic analysis of diabetic complications: Bioinformatics insights into foot ulcers, neuropathy and peripheral artery disease. International Wound Journal, 21(2), e14748. https://doi.org/10.1111/iwj.14748
Lin, C., Liu, J., & Sun, H. (2020). Risk factors for lower extremity amputation in patients with diabetic foot ulcers: A meta-analysis. PLOS ONE, 15(9), e0239236. https://doi.org/10.1371/journal.pone.0239236
Lin, C.–J., Lin, C.–W., Wu, S.–H., & Cheng, H.–M. (2025). Effectiveness of Maggot Debridement Therapy for Chronic Wounds: A Systematic Review and Meta-analysis of Randomised Controlled Trials. Wound Repair and Regeneration, 33(5), e70095. https://doi.org/10.1111/wrr.70095
Lin, C.–W., Armstrong, D. G., Lin, C.–H., Liu, P.–H., Hung, S.–Y., Lee, S.–R., Huang, C.–H., & Huang, Y.–Y. (2019). Nationwide trends in the epidemiology of diabetic foot complications and lower–extremity amputation over an 8–year period. BMJ Open Diabetes Research & Care, 7(1), e000795. https://doi.org/10.1136/bmjdrc–2019–000795
Liu, E., Hu, X., Zhang, W., Xiao, W., Shen, Y., Luo, Y., Zheng, Z., Zhou, P., He, Y., & Que, H. (2024). Efficacy and safety of UAWD in the treatment of diabetic foot ulcers: A systematic review and meta-analysis of 11 randomized controlled trials. Frontiers in Endocrinology, 15, 1393251. https://doi.org/10.3389/fendo.2024.1393251
McDermott, K., Fang, M., Boulton, A. J. M., Selvin, E., & Hicks, C. W. (2023). Etiology, Epidemiology, and Disparities in the Burden of Diabetic Foot Ulcers. Diabetes Care, 46(1), 209–221. https://doi.org/10.2337/dci22–0043
Nair, H. K., Ahmad, N. W., Ismail, A. A., Alabed, A. A. A., Zheming, B. O., Kaur, G., Hassan, H., & Supaat, N. I. (2021). Maggot debridement therapy to treat hard–to–heal diabetic foot ulcers: A single–centre study. Journal of Wound Care, 30(Sup12), S30–S36. https://doi.org/10.12968/jowc.2021.30.Sup12.S30
Ning, P., Liu, Y., Kang, J., Cao, H., & Zhang, J. (2023). Comparison of healing effectiveness of different debridement approaches for diabetic foot ulcers: A network meta-analysis of randomized controlled trials. Frontiers in Public Health, 11. https://doi.org/10.3389/fpubh.2023.1271706
Nube, V. L., Alison, J. A., & Twigg, S. M. (2021). Frequency of sharp wound debridement in the management of diabetes–related foot ulcers: Exploring current practice. Journal of Foot and Ankle Research, 14, 52. https://doi.org/10.1186/s13047–021–00489–1
Olamoyegun, M. A., Afolabi, S. A., Alare, K., Olamoyegun, O. D., Adeyemi, T., & Olopade, O. B. (2026). Epidemiology and Outcome of Diabetic Foot Ulcers in Nigeria: A Systematic Review and meta-analysis of 2 Decades: 2005???2024. Journal of Epidemiology and Global Health, 16(1), 19. https://doi.org/10.1007/s44197–025–00509–4
Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo–Wilson, E., McDonald, S., … Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, n71. https://doi.org/10.1136/bmj.n71
Schardt, C., Adams, M. B., Owens, T., Keitz, S., & Fontelo, P. (2007). Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Medical Informatics and Decision Making, 7(1), 16. https://doi.org/10.1186/1472–6947–7–16
Sharma, D. J., Singh, R., Bahl, I., & Singh, G. (2024). Role of hydrosurgery in the management of diabetic foot disease– new application of an age–old technique. International Surgery Journal, 11(7), 1103–1111. https://doi.org/10.18203/2349–2902.isj20241737
Silva, M. A., Hamilton, E. J., Russell, D. A., Game, F., Wang, S. C., Baptista, S., & Monteiro–Soares, M. (2025). Diabetic Foot Ulcer Classification Models Using Artificial Intelligence and Machine Learning Techniques: Systematic Review. Journal of Medical Internet Research, 27(1), e69408. https://doi.org/10.2196/69408
Syam, K., Joiya, S. A., Khan, S., & Unnikrishnan, P. N. (2021). Maggot Debridement Therapy for Chronic Leg and Foot Ulcers: A Review of Randomized Controlled Trials. Advances in Skin & Wound Care, 34(11), 603–607. https://doi.org/10.1097/01.ASW.0000792928.08722.ae
Tonaco, L. A. B., Gomes, F. L., Velasquez–Melendez, G., Lopes, M. T. P., & Salas, C. E. (2018). The Proteolytic Fraction from Latex of Vasconcellea cundinamarcensis (P1G10) Enhances Wound Healing of Diabetic Foot Ulcers: A Double–Blind Randomized Pilot Study. Advances in Therapy, 35(4), 494–502. https://doi.org/10.1007/s12325–018–0684–2
Wernecke, J., Wernecke, M., Ebenau, O., Spruth, B., Krämer, M., Vogelmann, T., & Zöllner, Y. (2025). Epidemiology and the Medical Burden of Diabetic Foot Ulcers Especially in Patients With Infection A Population?Based Analysis From Germany. International Wound Journal, 22(4), e70157. https://doi.org/10.1111/iwj.70157
Zhao, H., Wu, Y., Xie, Y., Li, Y., Chen, C., Li, C., Yang, F., Zhang, D., Wang, Y., & Yuan, J. (2024). Hydrogel dressings for diabetic foot ulcer: A systematic review and meta-analysis. Diabetes, Obesity and Metabolism, 26(6), 2305–2317. https://doi.org/10.1111/dom.15544
Zhou, X., Chen, S., Savitz, B., Yu, N., Perdikis, G., Duckworth, K., Dean, Y., Long, X., & Lineaweaver, W. (2025). Comparative efficacy of different functional hydrogel dressings in healing diabetic foot ulcer: A systematic review and network meta-analysis. Diabetes, Obesity and Metabolism, 27(6), 3431–3441. https://doi.org/10.1111/dom.16367
Authors
Copyright (c) 2026 Bunga Arinda Dwi Sabrina, Rudi Hamarno, Supono Supono, Taufan Arif
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
