Once a diabetic foot ulcer has healed, the foot does not return to normal. Roughly four in ten people who heal an ulcer develop another one within a year, and the majority ulcerate again within five years. This pattern has pushed researchers to look for ways of detecting tissue damage before the skin breaks — and one of the most studied approaches is measuring the temperature of the skin on the sole of the foot at home, every day.
Why Skin Temperature Signals Impending Ulceration
In a foot with peripheral neuropathy, repetitive mechanical loading produces inflammation in deeper tissue long before the skin surface breaks down. Inflammation increases local blood flow, which raises skin temperature at the site. Because most people load both feet similarly, the opposite foot serves as a built-in control: a persistent temperature difference between matching sites suggests localised inflammation rather than a systemic or environmental cause.
The threshold used across nearly all clinical trials is a difference greater than 2.2°C (4°F) between corresponding sites on the two feet on two consecutive days — a “hotspot.” The intervention that follows is not a dressing or a drug: it is a temporary reduction in walking until the difference resolves, plus contact with the person’s foot care provider.
What the Trial Evidence Shows
Five randomised controlled trials, involving 772 participants classified at IWGDF risk category 2 or 3, have tested this approach. In a 2022 systematic review and meta-analysis published in Diabetes/Metabolism Research and Reviews, Golledge and colleagues pooled these trials and found that participants performing daily 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). Importantly, the authors graded the certainty of that evidence as low, since three of the five trials carried a high risk of bias. An earlier meta-analysis by Alahakoon and colleagues in Diabetic Medicine reached a similar point estimate (odds ratio 0.51) and reported comparable benefit from offloading footwear (odds ratio 0.48), while structured patient education alone did not significantly reduce ulcer incidence.
The largest and most methodologically rigorous single trial is DIATEMP, reported by Bus and colleagues in BMJ Open Diabetes Research & Care in 2021. Three hundred and four people with neuropathy and a recent ulcer history were randomised to usual care or usual care plus daily measurement at six to eight plantar sites per foot. At the pre-specified primary outcome sites, the difference was not statistically significant: 29.1% of the monitoring group re-ulcerated versus 37.3% of the usual care group. When ulcers at any foot site were counted, the reduction did reach significance (RR 0.760, 95% CI 0.579–0.997).
The Finding That Explains the Rest
DIATEMP’s most instructive result concerns what participants did after finding a hotspot. Of the 83 people in the monitoring arm who recorded one, only 24 actually reduced their walking in response. Those 24 had markedly fewer recurrences than usual care (RR 0.336, 95% CI 0.114–0.986). In other words, the measurement itself does nothing; the offloading response it is meant to trigger is what changes outcomes.
Adherence Is the Practical Limiting Factor
A secondary analysis of DIATEMP participants by Rovers and colleagues quantified this problem directly. Adherence to daily measurement (defined as recording on at least 70% of days) was 78.1% in the first three months but fell to 57.4% over months four to eighteen. Adherence to the behavioural response — reducing ambulatory activity when a hotspot appeared — was only 28.9% across the whole study. Older age and better general foot self-care behaviour were associated with better adherence to measurement.
Cost and Burden
A 2024 economic evaluation of the DIATEMP cohort by van Netten and colleagues found that monitoring reduced foot care costs (€6,067 versus €7,376) because significantly fewer participants re-ulcerated (36% versus 47%). However, quality-adjusted life years were slightly lower in the monitoring group, which the authors attributed to the burden of daily self-monitoring. Their conclusion was that the intervention is, at best, cost-neutral compared with usual care — the savings from prevented ulcers are offset by the demands placed on the person doing the measuring.
Where It Sits Among Preventive Interventions
The 2024 IWGDF-affiliated systematic review by van Netten and colleagues assessed all preventive interventions for people with diabetes at risk of ulceration. Temperature monitoring received moderate certainty evidence for reducing plantar ulcer recurrence (RR 0.51), placing it alongside pressure-optimised therapeutic footwear or insoles (RR 0.62) as one of the better-supported options. Structured education, therapeutic footwear generally, flexor tenotomy, and integrated foot care were supported by low-certainty evidence. Notably, the authors observed that very few new intervention trials have been published in recent years.
Clinical Summary
Daily at-home plantar skin temperature monitoring, using a 2.2°C left-right difference over two consecutive days as the trigger, is among the better evidence-supported strategies for preventing foot ulcer recurrence in people with diabetes and neuropathy. Pooled data suggest an approximate halving of ulcer risk, though certainty is limited by study quality. The benefit depends on acting on the result: in the largest trial, only those who reduced walking after finding a hotspot saw a clear reduction in recurrence. Adherence declines substantially after the first few months, and the approach appears roughly cost-neutral. Temperature monitoring is best understood not as a standalone technology but as an early-warning signal whose value is realised only when paired with prompt offloading and clinical follow-up.
References
- Golledge J, Fernando ME, Alahakoon C, Lazzarini PA, Aan de Stegge WB, van Netten JJ, Bus SA. 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, Busch-Westbroek TE, Nollet F, van Netten JJ. 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.
- Alahakoon C, Fernando M, Galappaththy C, Matthews EO, Lazzarini P, Moxon JV, Golledge J. Meta-analyses of randomized controlled trials reporting the effect of home foot temperature monitoring, patient education or offloading footwear on the incidence of diabetes-related foot ulcers. Diabetic Medicine. 2020;37(8):1266–1279.
- Rovers FJ, van Netten JJ, Busch-Westbroek TE, Aan de Stegge WB, Bus SA. Adherence to at-home monitoring of foot temperatures in people with diabetes at high risk of ulceration. The International Journal of Lower Extremity Wounds. 2022 (online); 2025;24(3):691–699.
- 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.
- van Netten JJ, Raspovic A, Lavery LA, Monteiro-Soares M, Paton J, Rasmussen A, Sacco ICN, Bus SA. Prevention of foot ulcers in persons with diabetes at risk of ulceration: A systematic review and meta-analysis. Diabetes/Metabolism Research and Reviews. 2024;40(3):e3652.
Source literature identified via PubMed. DOIs: 10.1002/dmrr.3549; 10.1136/bmjdrc-2021-002392; 10.1111/dme.14323; 10.1177/15347346221114565; 10.1002/dmrr.3805; 10.1002/dmrr.3652.
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