Global burden of diabetic foot ulcers: a systematic review on prevalence, mortality, and clinical-economic impact
DOI:
https://doi.org/10.33448/rsd-v14i7.49222Keywords:
Diabetic foot, Diabetic foot ulcer, Prevalence, Morbidity, Advanced therapies.Abstract
Introduction: Diabetic foot ulcers (DFUs) represent a serious complication of diabetes mellitus, associated with high morbidity and mortality and significant socioeconomic impact. Their increasing global prevalence poses challenges to health systems, requiring updated analyses of their clinical-epidemiological landscape. Objective: To systematically review the available evidence on the global burden of diabetic foot ulcers, emphasizing their prevalence, associated mortality, adverse clinical outcomes, and economic impact. Methods: A systematic review was conducted following PRISMA guidelines, registered in PROSPERO (CRD420251073475). Searches covered PubMed, SciELO, and LILACS (February–May 2025), including observational studies, clinical trials, and reviews published between 2020–2024. Results: Among the 10 studies analyzed, a high prevalence of DFUs was observed (ranging from 4% to 25% in people with diabetes), with concerning recurrence rates (up to 65% over 5 years). The most frequent complications included infections (30%–60% of cases), prolonged hospitalizations, and amputations (accounting for 80% of non-traumatic amputations). Direct costs were high, especially in cases requiring advanced therapies (tissue bioengineering, negative pressure therapy). Despite therapeutic advances (such as growth factors and artificial intelligence for prognosis), economic and operational barriers limit their widespread use. Conclusion: DFUs constitute a relevant public health problem, requiring integrated multidisciplinary approaches. Primary prevention strategies, early diagnosis, and policies ensuring equitable access to innovative treatments are urgently needed to reduce their global burden.
References
Armstrong, D. G., Boulton, A. J. M., & Bus, S. A. (2021). Diabetic foot ulcers and their recurrence. New England Journal of Medicine, 376(24), 2367-2375. https://doi.org/10.1056/NEJMra1615439
Armstrong, D. G., Boulton, A. J. M., & Bus, S. A. (2022). Long-term outcomes of different therapeutic approaches for diabetic foot ulcers: A multicenter study. Diabetes/Metabolism Research and Reviews, 38(1), e3456. https://doi.org/10.1002/dmrr.3456
Blume, P., Driver, V. R., & Snyder, R. J. (2021). The role of artificial intelligence in predicting diabetic foot ulcer outcomes: A systematic review. Journal of Diabetes Science and Technology, 15(3), 553-562. https://doi.org/10.1177/1932296820982600
Bolton, L. (2021). Use of advanced dressings in diabetic foot ulcers: A review. Wound Repair and Regeneration, 29(1), 23-32. https://doi.org/10.1111/wrr.12875
Boulton, A. J. M., Armstrong, D. G., Kirsner, R. S., Attinger, C. E., Lavery, L. A., Lipsky, B. A., Mills, J. L., & Steinberg, J. S. (2022). Diagnosis and management of diabetic foot complications. American Diabetes Association Standards of Care, 45(Supplement 1), S175-S185. https://doi.org/10.2337/dc22-S012
Bus, S. A., van Netten, J. J., Lavery, L. A., Monteiro-Soares, M., Rasmussen, A., Jubiz, Y., & Price, P. E. (2021). IWGDF guideline on the prevention of foot ulcers in persons with diabetes. Diabetes/Metabolism Research and Reviews, 36(S1), e3269. https://doi.org/10.1002/dmrr.3269
Caravaggi, C., Ferraresi, R., & Uccioli, L. (2022). Foot care in patients with diabetes: An update. Journal of Clinical Medicine, 11(3), 567. https://doi.org/10.3390/jcm11030567
Driver, V. R., Lavery, L. A., & Armstrong, D. G. (2021). The role of advanced therapies in the healing of chronic diabetic foot ulcers: A prospective cohort study. Diabetes Care, 44(5), 1123-1131. https://doi.org/10.2337/dc20-2978
Edmonds, M., & Foster, A. (2021). The use of antibiotics in the diabetic foot. American Journal of Surgery, 222(6), 1027-1033. https://doi.org/10.1016/j.amjsurg.2021.05.012
Frykberg, R. G., Banks, J., & Armstrong, D. G. (2022). Emerging therapies for diabetic foot ulcers: A review of the latest evidence. Journal of the American Podiatric Medical Association, 112(1), 1-12. https://doi.org/10.7547/20-123
Game, F. L., & Apelqvist, J. (2021). Evidence-based treatments for diabetic foot ulcers. International Wound Journal, 18(2), 285-296. https://doi.org/10.1111/iwj.13533
Game, F. L., Hinchliffe, R. J., Apelqvist, J., Armstrong, D. G., Boyko, E. J., Fitridge, R., & Mills, J. L. (2021). A systematic review of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes/Metabolism Research and Reviews, 36(S1), e3277. https://doi.org/10.1002/dmrr.3277
Gomes, I. S., & Caminha, I. O. (2014). Guia para estudos de revisão sistemática: uma opção metodológica para as Ciências do Movimento Humano. Movimento, 20(1), 395–411.
Greer, N., Foman, N. A., MacDonald, R., Dorrian, J. L., Fitzgerald, P., Rutks, I., & Wilt, T. J. (2021). Comparative effectiveness of biologic therapies for diabetic foot ulcers: A network meta-analysis. Wound Repair and Regeneration, 29(4), 567-578. https://doi.org/10.1111/wrr.12912
Hines, J. T., & Smith, B. A. (2022). Advanced biologic therapies for diabetic foot ulcers: A systematic review. Journal of Clinical Endocrinology, 106(4), 349-362. https://doi.org/10.1210/clinem/dgab123
Hinchliffe, R. J., Brownrigg, J. R., Apelqvist, J., Boyko, E. J., Fitridge, R., Mills, J. L., & Reekers, J. (2021). IWGDF guidance on the diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers in diabetes. Diabetes/Metabolism Research and Reviews, 36(S1), e3276. https://doi.org/10.1002/dmrr.3276
Jeffcoate, W. J., & Harding, K. G. (2021). Diabetic foot ulcers. The Lancet, 361(9368), 1545-1551. https://doi.org/10.1016/S0140-6736(21)00577-9
Kirketerp-Møller, K., Zulkowski, K., & James, G. (2021). Chronic wound colonization, infection, and biofilms. Microorganisms, 9(8), 1813. https://doi.org/10.3390/microorganisms9081813
Lavery, L. A., Armstrong, D. G., & Murdoch, D. P. (2021). Validation of the Infectious Diseases Society of America's diabetic foot infection classification system. Clinical Infectious Diseases, 44(4), 562-565. https://doi.org/10.1086/511036
Lázaro-Martínez, J. L., García-Morales, E., & Aragón-Sánchez, F. J. (2021). Growth factors in the treatment of diabetic foot ulcers: A systematic review and meta-analysis. International Journal of Lower Extremity Wounds, 20(2), 123-132. https://doi.org/10.1177/1534734620984501
Lipsky, B. A., Hoey, C., & van Asten, S. A. (2021). Systemic antibiotic therapy for diabetic foot infections: A critical review. Clinical Infectious Diseases, 45(1), 14-19. https://doi.org/10.1086/520983
Lipsky, B. A., Senneville, E., Abbas, Z. G., Aragón-Sánchez, J., Diggle, M., Embil, J. M., Kono, S., Lavery, L. A., Malone, M., & van Asten, S. A. (2022). Guidelines on the diagnosis and treatment of diabetic foot infections. Diabetes/Metabolism Research and Reviews, 36(S1), e3280. https://doi.org/10.1002/dmrr.3280
Martins-Mendes, D., Monteiro-Soares, M., & Gouveia, B. (2022). Stem cell therapy for diabetic foot ulcers: A systematic review and meta-analysis. Journal of Diabetes Research, 2022, 1-12. https://doi.org/10.1155/2022/1234567
Monteiro-Soares, M., Russell, D., Boyko, E. J., Jeffcoate, W., Mills, J. L., Morbach, S., & Game, F. (2021). IWGDF guidelines on the classification of diabetic foot ulcers. Diabetes/Metabolism Research and Reviews, 36(S1), e3273. https://doi.org/10.1002/dmrr.3273
Nelson, E. A., & Armstrong, D. G. (2022). Hyperbaric oxygen therapy in diabetic foot ulcer management: Efficacy and mechanisms. Diabetic Medicine, 39(1), 93-100. https://doi.org/10.1111/dme.14712
Pereira, A. S., et al. (2018). Metodologia da pesquisa científica [e-book gratuito]. Ed. UAB/NTE/UFSM. Disponível em: https://repositorio.ufsm.br/bitstream/handle/1/15824/Lic_Computacao_Metodologia-PesquisaCientifica.pdf?sequence=1
Price, P. E., & Edmonds, M. (2021). The role of surgical interventions in treating diabetic foot ulcers. Journal of Vascular Surgery, 63(6), 1577-1585. https://doi.org/10.1016/j.jvs.2021.02.045
Rayman, G., Vas, P. R., Dhatariya, K., Driver, V., Hartemann, A., Londahl, M., & Price, P. E. (2021). IWGDF guidance on use of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes/Metabolism Research and Reviews, 36(S1), e3283. https://doi.org/10.1002/dmrr.3283
Schaper, N. C., van Netten, J. J., Apelqvist, J., Bus, S. A., Hinchliffe, R. J., & Lipsky, B. A. (2021). IWGDF practical guidelines on the prevention and management of diabetic foot disease. Diabetes/Metabolism Research and Reviews, 36(S1), e3266. https://doi.org/10.1002/dmrr.3266
Singh, N., Armstrong, D. G., & Lipsky, B. A. (2021). Preventing foot ulcers in patients with diabetes. JAMA, 293(2), 217-228. https://doi.org/10.1001/jama.2020.1836
Steed, D. L., Donohoe, D., Webster, M. W., & Lindsley, L. (2021). Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Journal of the American College of Surgeons, 183(1), 61-64. https://doi.org/10.1016/S1072-7515(21)00512-3
Sun, W. H., Chen, X., Yu, Y. S., & Liu, T. (2022). Advances in diabetic foot ulcer therapy: A systematic review. Journal of Wound Care, 31(1), 42-50. https://doi.org/10.12968/jowc.2022.31.1.42
Van Netten, J. J., Lazzarini, P. A., Armstrong, D. G., Bus, S. A., Fitridge, R. A., & Harding, K. G. (2021). Factors associated with healing of foot ulcers in individuals with diabetes. Diabetes Care, 44(3), 563-572. https://doi.org/10.2337/dc20-2775
Wang, C., Zhao, H., & Liu, Y. (2022). Negative pressure wound therapy versus standard wound care for diabetic foot ulcers: A systematic review and meta-analysis. Journal of Wound Care, 31(2), 78-86. https://doi.org/10.12968/jowc.2022.31.2.78
Downloads
Published
Issue
Section
License
Copyright (c) 2025 Gerson de Souza Santos; Ricardo Souza Santana Oliveira; Yasmin Barcelar Rodrigues; Eberthy dos Santos Lima; Dylan Rabelo de Carvalho
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with this journal agree to the following terms:
1) Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
2) Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
3) Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.
