Diabetic foot ulceration is among the most serious complications of diabetes. Over a lifetime, an estimated 19% to 34% of people with diabetes develop a foot ulcer, and recurrence is common (Armstrong, Boulton and Bus, New England Journal of Medicine, 2017). Risk is not distributed evenly. Sex is one of the most consistently reported differences, yet it is rarely discussed outside of epidemiology papers. This article summarises what recent research shows about how men and women differ in ulcer occurrence, severity, and outcomes.
Prevalence: Men Are Affected More Often
A systematic review and meta-analysis by Zhang and colleagues (Annals of Medicine, 2017) estimated a global diabetic foot ulcer prevalence of 6.3% (95% CI 5.4–7.3%) among people with diabetes. When results were split by sex, the pooled prevalence was 4.5% (95% CI 3.7–5.2%) in men and 3.5% (95% CI 2.8–4.2%) in women. The difference is modest in absolute terms but consistent with a higher ulcer burden in men across many populations.
Several factors may contribute. Men more often smoke, more often have established peripheral artery disease, and are on average more likely to engage in work or activities that expose the feet to repetitive trauma. Reporting and care-seeking patterns may also differ, although this is harder to quantify.
Severity at Presentation
The clearest recent picture of sex-related differences in ulcer severity comes from a Belgian national prospective cohort (Vanherwegen and colleagues, IQED-Foot Study Group, PLOS ONE, 2023). The study followed 1,771 people with moderate to severe diabetic foot ulcers across 35 multidisciplinary clinics for six months; about 72% were men.
Wound Characteristics
Men presented with deeper ulcers, more probe-to-bone findings, and more deep infection. Systemic signs of infection were about twice as common in men. Plantar forefoot ulcers were more frequent in men (26.8% versus 18.0%), and women were more likely to present with small ulcers under 1 cm². Importantly, the median delay before presentation was the same in both sexes at three weeks, so delayed care-seeking did not explain the difference in severity.
Vascular and Systemic Factors
More than half of all participants had peripheral artery disease, but men had more critical limb ischaemia and more prior lower-limb revascularisation. Loss of protective sensation and smoking were also more common in men, while renal insufficiency was more common in women. The authors suggested that poorer vascular status in men, linked in part to smoking, is a likely contributor to the more severe presentation.
Amputation and Healing Outcomes
A meta-analysis of risk factors for lower-extremity amputation in people with diabetic foot ulcers (Lin, Liu and Sun, PLOS ONE, 2020) pooled 21 studies with 6,505 participants. Male sex was associated with a higher amputation risk (OR 1.30, 95% CI 1.16–1.46). This agrees with the severity data above, since deeper infection and ischaemia are the main drivers of amputation decisions.
In the Belgian cohort, crude rates of minor and major amputation did not differ significantly between the sexes, and neither did six-month mortality (6.5% in men versus 8.5% in women, p = 0.10). However, after adjustment, women had a higher likelihood of healing without a major amputation as the first event (adjusted HR 1.258, 95% CI 1.048–1.509). The authors noted that BMI, HbA1c, lipid status, and socioeconomic factors were not collected, so residual confounding cannot be excluded.
Interpreting the Evidence
Several caveats apply. Most amputation-risk data are observational, and men make up a majority of ulcer cohorts, which limits precision for women. The Belgian study included only moderate to severe ulcers, so it may not reflect the full spectrum of disease. Differences in amputation risk likely reflect differences in vascular disease, infection depth, and smoking more than sex itself. Women also face risks that are less visible in these datasets, including renal disease, which independently worsens healing and survival.
Current international guidance does not recommend different clinical pathways by sex. Risk stratification, offloading, infection and vascular assessment follow the same principles for all patients. What the sex-related data add is a reminder that the profile of risk can differ between individuals, and that vascular status and smoking history deserve particular attention in men with foot ulcers.
Key Takeaways
Men with diabetes have a somewhat higher pooled prevalence of foot ulceration than women, and they tend to present with deeper, more infected, and more ischaemic wounds. Male sex is associated with higher amputation risk in pooled analyses, although adjusted outcomes in a recent national cohort suggest that much of this relates to disease severity rather than to sex itself. Time to presentation did not differ between sexes in that cohort. Better sex-stratified reporting in future trials would help clarify whether any differences persist after accounting for vascular and renal disease.
References
- Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. New England Journal of Medicine. 2017.
- Zhang P, Lu J, Jing Y, Tang S, Zhu D, Bi Y. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. Annals of Medicine. 2017;49(2):106–116.
- Lin C, Liu J, Sun H. Risk factors for lower extremity amputation in patients with diabetic foot ulcers: a meta-analysis. PLOS ONE. 2020;15(9):e0239236.
- Vanherwegen A-S, Lauwers P, Lavens A, Doggen K, Dirinck E, et al. (IQED-Foot Study Group). Sex differences in diabetic foot ulcer severity and outcome in Belgium. PLOS ONE. 2023;18(2):e0281886.
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