Commentary on “Differences in Characteristics Between First-Ever Foot Ulcer and Recurrent Foot Ulcer in Patients With Diabetes: Prospective Observational Study”

We read the article “Differences in characteristics between first-ever foot ulcer and recurrent foot ulcer in patients with diabetes: Prospective observational study,” published in Health Science Reports [1]. This study makes a significant contribution by comparing the characteristics of first-ever diabetic foot ulcers (DFUs) with recurrent DFUs. The authors highlight that first-ever DFUs are associated with more serious conditions, often accompanied by infections, compared to recurrent DFUs. Trauma to the toes and plantar regions was identified as a predominant cause in both groups.

We commend the authors for their informative study and wish to offer several considerations that may further enrich the findings. This research provides a valuable opportunity to explore the factors contributing to both first-ever and recurrent DFUs and suggests ways to mitigate the recurrence of ulcers. However, several methodological limitations warrant further discussion.

The authors chose to focus on a specific set of laboratory factors, but their selection could be more extensive. Other markers, such as albumin (ALB), procalcitonin (PCT), blood urea nitrogen (BUN), creatinine (Cr), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), liver function tests, lipid markers, neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR), could provide further insights into the severity and prognosis of DFUs [2].

The study lacks a comprehensive account of underlying comorbidities, such as cardiovascular and cerebrovascular diseases, retinopathy, and nephropathy, which may impact the development and recurrence of foot ulcers. In addition, lifestyle factors like chronic alcohol use and smoking, known contributors to poor wound healing, were not discussed.

While the authors used the DMIST tool, which includes data on depth, maceration, inflammation/infection, size, tissue type, and wound edges, the study lacks a discussion of vascular factors that could affect wound healing. Scoring systems such as SINBAD, which stands for ulcer site, ischemia, neuropathy, bacterial infection, area, and depth, or PEDIS, which accounts for perfusion, extent, depth, infection, and sensation, might offer a more comprehensive assessment [3].

The study reports ankle-brachial index (ABI) values within the borderline and normal range. Still, ABI can fail to detect peripheral artery disease (PAD) in up to a third of symptomatic cases. Therefore, additional diagnostic tools, such as the toe-brachial index (TBI), should be considered to assess vascular involvement better [4].

A key omission is the lack of microbiological data, especially regarding the presence of multidrug-resistant organisms (MDROs), which are known to increase the risk of ulcer recurrence significantly [5]. Including such data would provide a clearer understanding of infection dynamics in DFUs.

In conclusion, the study offers valuable insights into the differences between first-ever and recurrent DFUs, but addressing these methodological gaps could further strengthen future research. By incorporating additional markers, risk factors, vascular assessments, and microbiological data, future studies may provide an even more comprehensive understanding of the factors contributing to DFU recurrence. We hope these suggestions inspire further research in this crucial area.

Mostafa Javanian: conceptualization, methodology. Mohammad Barary: writing–original draft, writing–review and editing. Soheil Ebrahimpour: investigation, methodology, writing–original draft.

The authors declare no conflicts of interest.