A Novel Approach to Treating a Diabetic Lower Extremity Ulcer Utilizing a Combination of a Topical Dehydrating Chemical Agent & Ovine ECM Grafts containing a Layer of Hyaluronic Acid

Introduction: Lower extremity diabetic ulcers (LEDUs) are a common and highly morbid complication of diabetes. Infections in LEDUs are a leading cause of hospitalizations and emergency department visits. The aim of this case report was to observe the response of a hard-to-heal LEDU on the medial aspect of the left foot in a 57-year-old female with poorly-controlled diabetes after initiating wound bed preparation via chemical debridement with an active gel containing methane sulfonic acid, which has rapid desiccating (hygroscopic) properties followed by the routine application of a xenograft composed of a layer of glycosami- noglycans (hyaluronic acid) between sheets of ovine forestomach-derived extracellular matrix (ECM). Methods: The setting of this case report was a hospital-based outpa- tient diabetic wound care clinic at Vaiola Hospital in the Kingdom of Tonga. Her A1c was 13%. The patient’s left diabetic foot ulcer (DFU) was treated with standard dressings, including alginate dressings and hypo- chlorous acid gel, along with selective sharp debridement for 38 days. However, there was no significant improvement. On 07/19/2024, a topical dehydrating agent was applied to prepare the wound bed. On 07/21/2024, the patient developed a deep tissue injury after wearing tight-fitting shoes to church. An offloading boot was provided on 7/24/2024. On 7/25/2024, an ovine ECM graft containing a layer of hyaluronic acid was added to her treatment regimen. Results: On 7/19/2024, the patients left LEDU was treated with more aggressive sharp debridement followed by the application of a topical dehydrating agent to effectively reduce biofilm. The wound base had the expected caramelized appearance after removal of the dehydrating gel. The standard of care techniques were continued while on 7/25/2024 an ovine ECM graft containing a layer of hyaluronic acid was added to her treatment regimen. Ninety-six days after the initial chemical debridement using a topical dehydrating agent, the left LEDU reduced in area by 88%. Between 07/25/2024 to 09/21/2024, a total of five applications of the ovine ECM graft containing a layer of hyaluronic acid were applied. On average, the xenografts were placed every 12 days. Discussion: This case report introduces the use of chemical debride- ment with a topical dehydrating agent, which effectively reduces biobur- den and is subsequently followed by routine applications of an ovine ECM combined with hyaluronic acid to facilitate a trajectory toward closure. This approach resulted in a significant reduction in wound size, even in a patient with poorly controlled diabetes.