Diabetes Care

Diabetic foot ulcers (DFU) represent a critical, often preventable, complication of diabetes that significantly impacts patient morbidity, mortality, and quality of life. With a lifetime risk estimated between 19% and 34%, DFU are characterized by a complex pathway involving peripheral neuropathy (PN), peripheral artery disease (PAD), and minor trauma. Despite advancements in medical care, DFU remain a major driver of hospitalizations, lower-extremity amputations, and long-term disability, with recurrence rates reaching up to 65% within 3 to 5 years.

The etiology of DFU is classified into neuropathic, ischemic, or mixed neuroischemic types. While clinical risk factors such as age, duration of diabetes, and glycemic control are well-established, this paper emphasizes that socioeconomic and structural factors are powerful mediators of risk. There is a disproportionate burden of DFU among Black, Hispanic, and socioeconomically disadvantaged populations. These disparities are compounded by unequal access to specialized care, such as podiatry and vascular surgery, and are reflected in higher rates of advanced-stage ulcer presentation and lower rates of limb-salvage procedures in these groups.

Following a long period of decline, recent data indicate a plateau or increase in lower-extremity amputation rates, particularly among younger adults and racial/ethnic minorities. This trend highlights a failure in current care delivery models to address the social determinants of health and structural biases that perpetuate inequity. Furthermore, DFU are independent predictors of mortality, with 5-year survival rates following incident ulceration comparable to those of many cancers. The economic burden is equally staggering, with advanced ulcers and amputations incurring massive direct and indirect costs.