Most diabetes-related foot ulcers are preceded by days of silent inflammation in tissue that has already lost its capacity to signal pain. In a foot with peripheral neuropathy, repetitive mechanical stress produces localised tissue injury and a measurable rise in skin temperature before the skin actually breaks. At-home foot skin temperature monitoring is built on that observation: if a patient can detect the “hotspot,” they may be able to offload it in time. Over the past decade this approach has moved from a promising idea to a formally graded, guideline-referenced intervention — but with important nuances about who benefits and why.
The Physiological Rationale
The premise is straightforward. Ambulatory activity concentrated on an at-risk site generates subclinical inflammation, and inflammation raises local skin temperature. Because a person’s two feet normally track closely in temperature, an asymmetry between corresponding left and right sites serves as a proxy for focal tissue stress. Across trials, the operational threshold has been consistent: a difference greater than 2.2 °C between mirror-image sites on two consecutive days, measured at six to eight plantar locations per foot with a hand-held infrared thermometer. When a hotspot appears, the instruction is to reduce weight-bearing activity until it resolves and to contact the treating clinician.
What the Randomised Evidence Shows
A 2022 systematic review and meta-analysis by Golledge and colleagues in Diabetes/Metabolism Research and Reviews pooled five randomised controlled trials involving 772 participants in IWGDF risk categories 2 or 3. Participants assigned to at-home temperature monitoring had roughly half the risk of developing a foot ulcer compared with controls (relative risk 0.51, 95% CI 0.31–0.84). Sensitivity analyses were consistent, but three of the five trials were judged at high risk of bias, and the authors graded the overall certainty of the evidence as low.
The largest and methodologically strongest trial, DIATEMP, was published by Bus and colleagues in BMJ Open Diabetes Research & Care in 2021. It randomised 304 people with neuropathy and a recent ulcer history — or Charcot neuro-osteoarthropathy — to usual care or usual care plus daily temperature measurement, with 18 months of follow-up. For the primary outcome, ulcer recurrence at or adjacent to the measurement sites, the result did not reach statistical significance (29.1% versus 37.3%; RR 0.782, 95% CI 0.566–1.080). Recurrence at any foot site was significantly reduced (RR 0.760, 95% CI 0.579–0.997).
The most clinically instructive finding was a subgroup analysis. Of the 83 participants who actually detected a hotspot, only the 24 who then reduced their ambulatory activity showed a marked benefit, with just three recurrences (RR 0.336, 95% CI 0.114–0.986). In other words, measurement alone changed little; measurement followed by offloading changed a great deal. An earlier Norwegian feasibility trial by Skafjeld and colleagues, published in BMC Endocrine Disorders in 2015, reached a similar practical conclusion — patients could sustain daily monitoring at rates comparable to routine foot inspection, but the small sample (n = 41) could not demonstrate an ulcer reduction.
Cost, Burden, and the Trade-Off
A 2024 economic analysis of the DIATEMP cohort by van Netten and colleagues found that monitoring produced lower foot care costs (€6,067 versus €7,376) driven by fewer recurrences (36% versus 47%, p = 0.045). However, quality-adjusted life years were slightly lower in the monitoring group, and the intervention was judged, at best, equally cost-effective compared with usual care. The authors attributed the QALY difference to the burden of daily self-monitoring itself — a reminder that a preventive task performed every day for years is not cost-free to the person performing it. A separate UK Health Technology Assessment by Crawford and colleagues in 2020 modelled digital infrared thermometry as potentially cost-effective, while emphasising substantial uncertainty in the underlying estimates.
Where Guidelines Have Landed
The 2023 IWGDF guideline on the prevention of foot ulcers, authored by Bus and colleagues, reflects this evidence with deliberate restraint. It suggests considering coaching moderate-to-high-risk patients to monitor foot skin temperature, positioning it as an adjunct within an integrated prevention package rather than a stand-alone measure. The stronger recommendations in that guideline remain structured screening for loss of protective sensation and peripheral artery disease, education on foot self-care and protective footwear, prompt treatment of pre-ulcerative lesions, and prescription of therapeutic footwear with a demonstrated plantar pressure-relieving effect.
Clinical Summary
At-home foot temperature monitoring has a plausible mechanism, meta-analytic support for roughly halving ulcer risk in moderate-to-high-risk patients, and low-certainty evidence overall. Its effect appears to depend almost entirely on whether a detected hotspot triggers an actual reduction in weight-bearing activity, which makes patient education and follow-up structure inseparable from the device itself. Economic data suggest cost savings offset by self-monitoring burden. It is best understood as one component of integrated preventive foot care — layered onto screening, footwear, and treatment of pre-ulcerative lesions — rather than as a substitute for any of them.
References
- Bus SA, Sacco ICN, Monteiro-Soares M, et al. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2024;40(3):e3651.
- Golledge J, Fernando ME, Alahakoon C, et al. Efficacy of at home monitoring of foot temperature for risk reduction of diabetes-related foot ulcer: a meta-analysis. Diabetes/Metabolism Research and Reviews. 2022;38(6):e3549.
- Bus SA, Aan de Stegge WB, van Baal JG, et al. Effectiveness of at-home skin temperature monitoring in reducing the incidence of foot ulcer recurrence in people with diabetes: a multicenter randomized controlled trial (DIATEMP). BMJ Open Diabetes Research & Care. 2021;9(1):e002392.
- van Netten JJ, Aan de Stegge WB, Dijkgraaf MGW, Bus SA. Cost-effectiveness of temperature monitoring to help prevent foot ulcer recurrence in people with diabetes: a multicenter randomized controlled trial. Diabetes/Metabolism Research and Reviews. 2024;40(4):e3805.
- Skafjeld A, Iversen MM, Holme I, Ribu L, Hvaal K, Kilhovd BK. A pilot study testing the feasibility of skin temperature monitoring to reduce recurrent foot ulcers in patients with diabetes — a randomized controlled trial. BMC Endocrine Disorders. 2015;15:55.
- Crawford F, Chappell FM, Lewsey J, et al. Risk assessments and structured care interventions for prevention of foot ulceration in diabetes: development and validation of a prognostic model. Health Technology Assessment. 2020;24(62):1–198.
- Schaper NC, van Netten JJ, Apelqvist J, et al. Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2024;40(3):e3657.
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