Diabetes-Related Foot Ulceration as a Biological and Clinical Continuum: An Integrative Review of Risk, Chronicity, Multimodal Care, Nursing, and Recurrence Prevention

Abstract

Diabetes-related foot ulceration is a progressive and recurrent complication in which neurological, vascular, biomechanical, metabolic, inflammatory, microbial, behavioral, and health-system factors interact across time. This integrative narrative review critically synthesizes evidence on the continuum from the intact but vulnerable foot to pre-ulcerative tissue injury, active ulceration, chronic nonhealing, treatment, wound closure, remission, and recurrence prevention. Structured searches were conducted in PubMed/MEDLINE, Scopus, Web of Science, CINAHL, Embase, SciELO, and LILACS, supplemented by reference-list screening. Landmark studies were retained when they established enduring clinical concepts, while priority was assigned to evidence published from 2019 through August 2026. The synthesis indicates that loss of protective sensation, deformity, repetitive plantar loading, callus formation, unsuitable footwear, and peripheral artery disease create the principal pre-ulcerative pathway. After skin breakdown, tissue hypoxia, oxidative stress, dysregulated inflammation, impaired angiogenesis, extracellular-matrix degradation, biofilm organization, immune-cell dysfunction, and cellular senescence may sustain chronicity. Effective care therefore requires etiological diagnosis, offloading, debridement, infection control, vascular assessment and revascularization when indicated, moisture balance, metabolic and nutritional optimization, patient education, and multidisciplinary coordination. Adjunctive and regenerative interventions may benefit selected patients but should not replace optimized foundational care. Nursing practice and digital surveillance contribute across all stages through risk detection, serial wound documentation, education, adherence support, telemedicine, and post-closure monitoring. Wound closure should be interpreted as remission rather than definitive cure because the causal neuropathic, vascular, and biomechanical abnormalities frequently persist. Long-term ulcer-free survival depends on therapeutic footwear, pressure redistribution, structured surveillance, rapid recognition of pre-ulcerative signs, and timely re-entry into coordinated care.