Ischaemic diabetic foot ulcer: topical marham or urgent referral?
A 60-year-old man with type 2 diabetes for 12 years presents with a foul-smelling ulcer on the right great toe for 3 weeks. The ulcer measures 3 × 2 cm, extends into subcutaneous tissue, and has 2 cm of surrounding erythema; no bone is visible on probe. Dorsalis pedis and posterior tibial pulses are absent on the right; ankle–brachial index is 0.6. Random glucose 268 mg/dL, HbA1c 9.8%, haemoglobin 10.4 g/dL, creatinine 1.6 mg/dL. He has been applying a homemade 'marham' containing alum and copper sulphate, which stings severely. He refuses surgery and wants only Unani local treatment. The clinic has no vascular surgeon; the district hospital is 90 minutes away.
1. Classify the ulcer and decide whether sharp debridement or a Unani marham is appropriate now.
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This is a Wagner grade 2 ulcer: a deep ulcer reaching subcutaneous tissue without exposed bone, with surrounding infection. The important additional finding is ischaemia-absent foot pulses and ABI 0.6-so this is an infected neuroischaemic foot, not a simple neuropathic ulcer.
Sharp debridement should not be undertaken in the clinic without vascular assessment, because in an ischaemic foot it can enlarge the wound and precipitate gangrene. A topical Unani marham is also not the primary treatment: infection and perfusion come first. The priorities are vascular assessment, antibiotics and offloading. The reasoning is that local dressings cannot heal tissue that is not receiving blood, and caustic or astringent applications can convert a salvageable ulcer into an amputation.
2. What is the risk of the homemade marham containing alum and copper sulphate?
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The mixture is unsafe and should be stopped immediately:
- Alum is a strong astringent and can irritate and dry the wound bed.
- Copper sulphate is caustic; it can cause chemical burns, tissue necrosis and systemic copper toxicity if absorbed through broken skin.
- Severe stinging is a warning sign of chemical injury, not of the medicine 'working'.
Stop the application, irrigate gently with normal saline, and dress with a non-adherent saline dressing while arranging referral. The reasoning is that the patient's worsening pain and foul smell may reflect both infection and chemical damage; continuing the marham would obscure the true extent of tissue loss and delay correct care.
3. The patient refuses surgery and vascular referral. What minimum safe plan would you document, and what Unani systemic support is reasonable?
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Document informed refusal and the risks explained: spreading infection, gangrene, amputation and systemic sepsis.
Minimum safe plan:
- Stop the caustic marham and use saline dressings.
- Offload the foot completely; no weight-bearing on the affected foot.
- Arrange antibiotics for the infected ulcer according to local protocol.
- Improve glycaemic control with conventional medication; his HbA1c 9.8% will not be corrected by herbal remedies alone.
- Check renal function and avoid nephrotoxic or heavy-metal-containing Unani preparations because creatinine is 1.6 mg/dL.
- Review within 48 hours and give clear return criteria: fever, spreading redness, black tissue, severe pain or foul discharge.
Reasonable Unani support is limited to general muqawwi and musaffi-e-dam measures using quality-assured products that do not stress the kidney, while making clear that they are adjuncts, not alternatives to infection and vascular care.