Antimicrobial dressings and topical antiseptics are among the most frequently used products in diabetic foot ulcer care. They are inexpensive relative to advanced biologics, easy to apply, and intuitively appealing: if infection is the pathway that leads so many diabetes-related foot ulcers to amputation, applying an antimicrobial directly to the wound seems a reasonable safeguard. The evidence, however, is more nuanced than that intuition suggests, and the last decade of systematic reviews and guideline work has clarified both what these products can be expected to do and what they cannot.
What Counts as a Topical Antimicrobial
The category is broad. It includes antiseptic-impregnated dressings — ionic and nanocrystalline silver, cadexomer iodine and povidone-iodine, polyhexamethylene biguanide (PHMB), and medical-grade honey — as well as topical antibiotic preparations, super-oxidised solutions, silver sulphadiazine cream, and dressings that bind microorganisms physically rather than chemically. These agents differ substantially in mechanism, spectrum, and the way they interact with wound exudate, so grouping them together in analysis is a persistent methodological limitation of the literature.
Their intended role also differs. Some are applied to clinically infected ulcers as an adjunct to systemic therapy; others are used on clinically uninfected ulcers with the aim of preventing infection or accelerating closure. These are different clinical questions, and the evidence supporting each is not equally strong.
What the Trial Evidence Shows About Healing
The most rigorous synthesis remains the Cochrane review by Dumville and colleagues, which identified 22 randomised trials involving more than 2,310 participants. Pooling five trials with 945 participants, the authors found that antimicrobial dressings may increase the proportion of ulcers that heal compared with non-antimicrobial dressings, with a risk ratio of 1.28 (95% CI 1.12 to 1.45) — roughly 119 additional healing events per 1,000 people treated. Critically, the review graded this as low-certainty evidence, downgraded twice for risk of bias. Most included trials were small, short (four to 24 weeks), and thirteen of the 22 did not even report whether participants’ ulcers were infected at baseline.
A more recent meta-analysis by Monami and colleagues, undertaken to inform the Italian guidelines for diabetic foot syndrome, examined 15 randomised trials of advanced wound dressings against standard care. Participants receiving advanced dressings healed significantly faster — a weighted mean difference of approximately 24 days — but the difference in the proportion of ulcers healed did not reach statistical significance (odds ratio 1.50, 95% CI 0.80 to 2.79). No significant effect was observed on major or minor amputation, pain, or mortality.
Honey Dressings
Honey has attracted particular research attention. Meta-analyses by Yildiz Karadeniz and Kaplan Serin, and by Tang and colleagues, both report shortened healing times and improved granulation with honey dressings on chronic wounds including diabetic foot ulcers. Both sets of authors also describe the underlying evidence as very low quality, citing risk of bias, inconsistency, and publication bias, and Tang’s group noted a possible increase in discomfort during application.
Topical Antimicrobials, Systemic Antibiotics, and Uninfected Ulcers
An important distinction in the Cochrane review concerns safety rather than efficacy. Comparing topical antimicrobials with systemic antibiotics across four trials and 937 participants, the risk of adverse events was essentially equivalent (RR 0.91, 95% CI 0.78 to 1.06, moderate-certainty evidence). This does not establish that topical therapy substitutes for systemic treatment in moderate or severe infection, but it does indicate that topical application is not associated with excess harm.
The more consequential point concerns uninfected wounds. The 2023 IWGDF/IDSA guidelines on diabetes-related foot infections, developed under the GRADE framework from 149 included studies, recommend against treating uninfected foot ulcers with antibiotics — whether for prophylaxis or to accelerate healing. Infection in the diabetic foot is a clinical diagnosis based on local and systemic signs, not on the growth of organisms from a swab; colonisation is expected in any open wound. Reflexive antimicrobial use in the absence of clinical infection exposes patients to adverse effects and contributes to resistance without demonstrated benefit.
Where Guidelines Place These Products
The 2023 IWGDF guideline on interventions to enhance ulcer healing, authored by Chen and colleagues, issued 29 recommendations. Conditional support was extended to sucrose octasulfate dressings, negative pressure wound therapy for post-operative wounds, placental-derived products, the autologous leucocyte/platelet/fibrin patch, topical oxygen therapy, and hyperbaric oxygen. In each case the guideline stressed that these are adjuncts for wounds that have failed to heal with best standard care, not replacements for it. Antimicrobial dressings did not receive a comparable endorsement for routine healing promotion.
Standard care remains the determinant of outcome: adequate offloading, regular sharp debridement and wound bed preparation, assessment and correction of perfusion, management of glycaemia and comorbidity, and prompt treatment of clinically diagnosed infection.
Clinical Summary
Topical antimicrobial dressings may modestly improve the likelihood of healing compared with non-antimicrobial dressings, and may shorten time to closure, but the certainty of that evidence is low and the effect on amputation has not been demonstrated. Topical antimicrobials carry no excess adverse event risk relative to systemic antibiotics. They are not a substitute for systemic therapy in established infection, and neither topical nor systemic antimicrobials are indicated for ulcers without clinical signs of infection. The research base is dominated by small, heterogeneous, and methodologically limited trials, and adequately powered studies with clinically meaningful endpoints remain a priority.
References
- Dumville JC, Lipsky BA, Hoey C, Cruciani M, Fiscon M, Xia J. Topical antimicrobial agents for treating foot ulcers in people with diabetes. Cochrane Database of Systematic Reviews, 2017;6:CD011038.
- Senneville É, Albalawi Z, van Asten SA, et al. IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023). Diabetes/Metabolism Research and Reviews, 2024;40(3):e3687.
- Chen P, Vilorio NC, Dhatariya K, 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.
- Monami M, Ragghianti B, Scatena A, et al. 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;61(12):1517–1526.
- Yildiz Karadeniz E, Kaplan Serin E. Use of honey in diabetic foot ulcer: systematic review and meta-analysis. Journal of Tissue Viability, 2023;32(2):270–278.
- Tang Y, Chen L, Ran X. Efficacy and safety of honey dressings in the management of chronic wounds: an updated systematic review and meta-analysis. Nutrients, 2024;16(15):2455.
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