Introduction
Neuroischemic diabetic foot ulcers — wounds in patients who have both peripheral neuropathy and peripheral arterial disease — are among the most difficult chronic wounds clinicians encounter. They make up an increasing share of diabetic foot ulcers (DFUs) and are associated with higher rates of amputation, prolonged healing times, and mortality compared with purely neuropathic ulcers. Even with optimal offloading, debridement, infection control, and revascularization, a substantial proportion of these wounds fail to close in a timely manner. In this setting, adjunctive wound dressings that target the local biology of impaired healing have become an area of intense clinical interest. One such product — the sucrose octasulfate-impregnated dressing — is now backed by randomized trial evidence and incorporated into current international wound-healing guidelines.
What Is a Sucrose Octasulfate Dressing?
Sucrose octasulfate is the potassium salt of a polysulfated sucrose molecule. Incorporated into a non-adherent lipidocolloid matrix and applied directly to the wound bed, it modulates the local biochemical environment in two principal ways. First, it inhibits matrix metalloproteinases (MMPs), the proteolytic enzymes that are pathologically elevated in chronic DFUs and that degrade extracellular matrix and growth factors. Second, it interacts with key growth factors — including vascular endothelial growth factor and fibroblast growth factor — helping to restore their biological function at the wound bed (Edmonds et al., 2018). In smaller mechanistic studies, treatment with the dressing has also been associated with measurable increases in transcutaneous oxygen pressure and improvements in microcirculation in neuroischemic ulcers.
Evidence From the EXPLORER Trial
The pivotal evidence supporting sucrose octasulfate dressings comes from EXPLORER, an international, multicenter, double-blind, randomized controlled trial published in The Lancet Diabetes & Endocrinology. The trial enrolled 240 patients with non-infected neuroischemic DFUs (University of Texas grade IC or IIC) across 43 specialized diabetic foot clinics in France, Spain, Italy, Germany, and the United Kingdom. Participants were randomized to either a sucrose octasulfate-impregnated dressing or an identical control dressing without the active agent, with both groups receiving best standard care including offloading, debridement, and infection control.
After 20 weeks of treatment, complete wound closure occurred in 48% of patients in the sucrose octasulfate group compared with 30% in the control group — an absolute difference of 18 percentage points and an adjusted odds ratio of 2.60 (95% CI 1.43–4.73; p=0.002). Estimated time to healing was also significantly shorter in the active treatment arm, and the overall safety profile was comparable between groups (Edmonds et al., 2018).
Real-World and Long-Term Outcomes
Subsequent real-world studies have extended the EXPLORER findings into more diverse clinical settings. A retrospective single-arm cohort by Meloni and colleagues reported favorable healing outcomes with sucrose octasulfate dressings in heel ulcers — historically among the most difficult anatomic locations to heal in the diabetic foot. More recently, a one-year prospective comparative study by Lázaro-Martínez and colleagues, published in the International Wound Journal in 2024, examined recurrence after healing. Among 92 patients who had healed a neuroischemic DFU, the reulceration rate at one year was 28% in those treated with the sucrose octasulfate-impregnated dressing during the index episode compared with 66.7% in those treated with conventional local therapies, suggesting potential benefits that extend beyond the initial healing event.
A 2024 Italian meta-analysis of advanced wound dressings, published in Acta Diabetologica, concluded that sucrose octasulfate — together with selected hydrogels, hyaluronic acid, and honey-based dressings — is among the advanced products with reproducible evidence for accelerating healing and shortening time-to-closure in DFUs when added to best standard care.
Where the Guidelines Place It
The 2023 update of the International Working Group on the Diabetic Foot (IWGDF) guideline on wound-healing interventions issued a conditional recommendation, supported by moderate-certainty evidence, for the use of sucrose octasulfate-impregnated dressings as an adjunctive therapy in non-infected, neuroischemic DFUs that have not shown adequate change in ulcer area after at least two weeks of best standard care, including appropriate offloading (Chen et al., 2024). The guideline emphasizes that this dressing is an adjunct — not a substitute — for the foundational pillars of DFU management: pressure offloading, sharp debridement, infection control, and revascularization where indicated.
Clinical Summary
For chronic neuroischemic DFUs that stall despite best standard care, the current body of evidence supports the use of sucrose octasulfate-impregnated dressings as an adjunctive therapy. The greatest benefit appears to be in non-infected, hard-to-heal neuroischemic wounds that have failed to show meaningful area reduction after two weeks of guideline-based care. The proposed mechanism — MMP inhibition together with preservation of growth factor activity — addresses a biologically plausible target in the pathophysiology of impaired DFU healing. Emerging data on reduced reulceration suggest that benefits may extend beyond the immediate wound episode, though additional randomized data on long-term outcomes are still needed.
References
- Edmonds M, Lázaro-Martínez JL, Alfayate-García JM, et al. Sucrose octasulfate dressing versus control dressing in patients with neuroischaemic diabetic foot ulcers (Explorer): an international, multicentre, double-blind, randomised, controlled trial. The Lancet Diabetes & Endocrinology. 2018;6(3):186–196.
- Chen P, Vilar-Compte D, Wang A, et al. Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2024;40(3):e3644.
- Lázaro-Martínez JL, García-Madrid M, Bohbot S, et al. Recurrence rates after healing in patients with neuroischemic diabetic foot ulcers healed with and without sucrose octasulfate-impregnated dressings: a 1-year comparative prospective study. International Wound Journal. 2024;21(11):e70028.
- Meloni M, Giurato L, Panunzi A, Bellia A, Bohbot S, Lauro D, Uccioli L. Effectiveness of sucrose octasulfate dressing in the treatment of neuro-ischaemic diabetic foot heel ulcers: a retrospective single-arm study. The International Journal of Lower Extremity Wounds. 2024.
- Effectiveness of different advanced wound dressings versus standard of care for the management of diabetic foot ulcers: a meta-analysis of randomized controlled trials for the development of the Italian guidelines for the treatment of diabetic foot syndrome. Acta Diabetologica. 2024.
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