When a diabetic foot ulcer closes, the next appointment, the next pair of shoes, and the next small warning sign become part of the treatment. Our colleagues in Rome have put that often-overlooked phase of care at the center of a new study.
Congratulations to Federico Rolando Bonanni, Laura Giurato, and the entire team, with a special salute to our longtime friends Marco Meloni and Luigi Uccioli. Their new paper in Nutrition, Metabolism and Cardiovascular Diseases examines an intensive, integrated approach to preventing ulcer recurrence after healing. It is a timely contribution to a question that matters every day in limb preservation: how do we help people stay in remission? [1]
What the Rome team studied
This single-center retrospective study included 331 people with healed diabetic foot ulcers. It compared 127 patients receiving standard prevention in 2015–2021 with 204 receiving an intensive protocol in 2022–2024, with outcomes assessed at one year. [1]
Standard care already included podiatry, therapeutic footwear, and education. The intensive program added dedicated prevention sessions, reinforced education, closer footwear monitoring, and broader multidisciplinary involvement, including orthopedic technicians.
The reported one-year recurrence-free survival was 86.2% with intensive prevention versus 60.6% with standard prevention (P<.0001), a 25.6-percentage-point separation. Minor amputation occurred in 0.9% versus 5.5% (P=.02). No difference in major amputation was reported.
The intensive cohort also had higher reported adherence to therapeutic footwear (95.6% versus 84.2%), skin cream (93.1% versus 71%), and podiatric care (95.6% versus 74%). These are encouraging associations from a bundled program.
Putting the findings in proportion
The calendar matters. These were historical cohorts treated in different periods, without random allocation. Changes in staffing, referral patterns, access, documentation, or other care could contribute to the difference. The intensive cohort also had more previous minor amputations and smoking, so the populations were not interchangeable. [1]
A substantial separation in outcomes deserves attention, while a causal claim requires stronger evidence. This design cannot isolate the contribution of education, footwear monitoring, podiatry, or another part of the package. Nor can an absence of a detected major-amputation difference establish equivalence.
The next useful questions concern reproducibility: which components matter most, how consistently they can be delivered, what they cost, and who has difficulty accessing them. Longer follow-up should also examine mobility, treatment burden, hospital use, and survival alongside recurrence.
From a word to a working service
When Joe Mills and I wrote about prevention as remission in 2013, the purpose was to make continuing risk visible to patients and teams. The language points toward frequent follow-up and timely intervention after an ulcer has closed. [2]
Our subsequent review with Andrew Boulton and Sicco Bus estimated recurrence at roughly 40% within one year of healing across the studies then available. That historical estimate describes the scale of the problem; it is not a matched control group for the Rome study. Neuropathy, deformity, and repetitive mechanical stress often persist after skin closure. [3]
The Rome paper helps bring this discussion into the organization of care. A footwear prescription still needs fitting, review, and support for everyday use. Education needs reinforcement. A prevention plan needs an actual appointment and a way to obtain help when something changes.
How this fits the broader evidence
The 2023 IWGDF prevention guideline recommends integrated foot care for people at moderate or high risk, combining professional foot care, adequate footwear, and structured self-care education. For high-risk people, it recommends repeating care or reassessing its need every one to three months. This is a strong recommendation supported by low-certainty evidence, an important distinction between clinical priority and certainty about effect size. [4]
In the separate DIATIME randomized trial, 148 high-risk people with a healed plantar ulcer were assigned to foot-care intervals of four, eight, or twelve weeks. The four-week group had the lowest reported one-year plantar-ulcer recurrence. We discussed that study here in August. It provides randomized evidence about visit frequency in a defined population; it does not validate every element of Rome’s combined program. [5]
Four questions for the next remission visit
The practical response is to examine whether the prevention we prescribe is reaching the person who needs it:
- Is the footwear working in daily life? Check fit, pressure relief, wear, and the barriers to using it consistently, including at home.
- Can the person inspect and protect the foot? Reinforce self-care, use teach-back, and involve a caregiver when vision or mobility makes inspection difficult.
- Are warning signs being addressed promptly? Callus, blistering, skin injury, or a new vascular concern should trigger an appropriate clinical response.
- Is the next contact real? Confirm follow-up, responsibility for ongoing care, and a clear route for urgent assessment. Transportation, affordability, and appointment availability deserve attention.
These questions follow established prevention principles. They should be individualized to the patient’s risk, function, preferences, and available support. [4]
More ulcer-free time
This is a useful contribution from our Roman colleagues because it makes the work after closure visible and measurable. The observed improvement invites prospective confirmation and careful study across other services.
Bravissimi to Federico, Laura, Marco, Luigi, and the whole team. Keeping someone in remission takes sustained attention from clinicians, patients, families, and the people who make protective care possible. The goal is more ulcer-free, hospital-free, activity-rich days.
Evidence note: This commentary is based on the publisher’s abstract and accessible article preview. The full methods, adjusted effect estimates, and confidence intervals were not available in those materials.
References
- Bonanni FR, Giurato L, Uccioli L, De Luca M, Lorusso G, Adriani E, Proietti L, Bergesi L, Zimbile A, Bellia A, Andreadi A, Lauro D, Meloni M. Intensive Integrated Prevention Protocol Reduces the Risk of Ulcer Recurrence in Patients with Previous Diabetic Foot Ulcer. Nutr Metab Cardiovasc Dis. 2026;105036. Journal pre-proof. doi:10.1016/j.numecd.2026.105036.
- Armstrong DG, Mills JL. Toward a change in syntax in diabetic foot care: prevention equals remission. J Am Podiatr Med Assoc. 2013;103(2):161–162.
- Armstrong DG, Boulton AJM, Bus SA. Diabetic Foot Ulcers and Their Recurrence. N Engl J Med. 2017;376:2367–2375.
- Bus SA, Sacco ICN, Monteiro-Soares M, et al. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40:e3651.
- López-Moral M, García-Madrid M, García-Morales E, García-Álvarez Y, Álvaro-Afonso FJ, Lázaro-Martínez JL. DIATIME: a randomized comparison of foot-care and screening intervals during remission. Diabetes Res Clin Pract. 2025;230:112962.
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