Dressing choice is among the most frequent decisions in diabetic foot ulcer (DFU) care, and the shelves of modern wound products can suggest that a more advanced dressing must heal wounds faster. The research literature gives a more restrained picture. This article reviews what systematic reviews and guidelines show about dressings for DFUs, and where the evidence is limited.
What a Dressing Is Expected to Do
A dressing does not heal a wound on its own. In current clinical reviews of DFU care, healing depends mainly on offloading, perfusion assessment and revascularization where needed, infection control, glycemic management and repeated removal of non-viable tissue (Armstrong et al., JAMA, 2023). The dressing’s role is supportive: it manages exudate, maintains a moist but not macerated wound surface, protects the tissue and is changed without causing trauma. Dressing categories include basic non-adherent contact layers, foams, hydrogels, alginates, hydrofibres, film dressings and antimicrobial dressings such as those containing silver, iodine or honey.
What Systematic Reviews Show
The most comprehensive Cochrane overview on this question (Wu, Norman, Dumville, O’Meara and Bell-Syer, 2015) pooled evidence from 17 randomized trials across 13 systematic reviews. It covered 10 dressing types in 37 comparisons, but only 11 comparisons were supported by direct head-to-head data; the remaining 26 relied on indirect evidence. Only four directly compared dressings showed any difference in ulcer healing, and those findings were rated low or very low certainty. The authors concluded there was no robust evidence that any dressing type was superior for any outcome, and that advanced dressings had not been shown to heal DFUs better than basic wound contact dressings. They suggested that cost, ease of use and patient preference should guide selection.
This conclusion reflects the quality of the trials rather than proof that all dressings perform identically. Many trials were small, short, at risk of bias, and tested different dressings in wounds of different depth and exudate levels. Differences that may exist between products can be hard to detect under these conditions.
Guideline Position: Dressings and Healing Interventions
The International Working Group on the Diabetic Foot (IWGDF) 2023 guideline on interventions to enhance healing of foot ulcers (Chen et al., Diabetes/Metabolism Research and Reviews, 2024) addresses dressings in the context of broader healing strategies. It describes a standard of care built on offloading, debridement, infection and ischemia management, and recommends considering additional interventions only when a wound does not heal despite optimal standard care. Among topical products, it makes a conditional recommendation supporting sucrose octasulfate dressings for non-infected, neuro-ischemic ulcers that have not healed with standard care, where resources allow.
The Sucrose Octasulfate Example
The recommendation rests largely on the Explorer trial (Edmonds et al., The Lancet Diabetes & Endocrinology, 2018), a double-blind randomized trial of 240 patients with neuro-ischemic DFUs. At 20 weeks, 48% of wounds treated with a sucrose octasulfate dressing had closed compared with 30% with a neutral control dressing. This is one of the few cases in which a dressing has shown a benefit over a matched control in a rigorous trial, and it illustrates how a result depends on the wound type studied: ulcers that were neuro-ischemic and had not healed with standard care.
Practical Interpretation
Several points follow from the evidence. First, dressing selection is generally guided by the wound: exudate volume, depth, presence of infection, periwound skin condition and the patient’s ability to tolerate changes. Second, a dressing that is cheaper and easier to apply is not shown to be inferior in healing for most ulcers. Third, a wound that fails to reduce in size despite dressing changes calls for re-evaluation of offloading adherence, perfusion, infection and unrecognized osteomyelitis, rather than a switch to a different product alone. Finally, dressings are used within a multidisciplinary approach; they are not a substitute for pressure redistribution or vascular assessment.
Conclusion
Evidence does not currently support the superiority of any one general-purpose dressing for DFUs, and most comparisons are limited by low-certainty data. Sucrose octasulfate in neuro-ischemic ulcers that stall under standard care is the main exception with randomized evidence behind it. Healing continues to depend chiefly on offloading, perfusion, infection control and debridement, with dressings selected to suit the wound environment, practical needs and cost.
References
- Wu L, Norman G, Dumville JC, O’Meara S, Bell-Syer SEM. Dressings for treating foot ulcers in people with diabetes: an overview of systematic reviews. Cochrane Database of Systematic Reviews. 2015;(7):CD010471.
- 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.
- Edmonds M, Lazaro-Martinez JL, Alfayate-Garcia 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.
- Armstrong DG, Tan TW, Boulton AJM, Bus SA. Diabetic foot ulcers: a review. JAMA. 2023;330(1):62-75.
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