Executive summary (what good looks like in primary care)
- Every person with diabetes needs regular foot checks with documented risk stratification and a clear “next review” date.
- Urgent pathways matter: suspected infection, rapidly worsening ulceration, spreading cellulitis, systemic illness, or critical ischaemia should not wait for routine podiatry.
- Charcot is the classic miss: a warm, swollen foot with relatively little pain in neuropathy should be treated as Charcot until proven otherwise → urgent specialist assessment and immobilisation.
Risk stratification (simplified practical approach)
- Low risk: intact protective sensation, palpable pulses, no deformity → routine review (often annually per local protocol).
- Moderate risk: neuropathy or absent pulses or significant deformity → more frequent review + foot protection service input.
- High risk: previous ulcer/amputation, active/recurrent ulceration, severe PAD, or advanced deformity → specialist foot protection service with close surveillance.
“Urgent” referral triggers you should not down-triage
- New foot ulcer with any signs of infection (increasing pain, erythema, purulent discharge, malodour, systemic features).
- Critical ischaemia features: rest pain, tissue loss/necrosis, pallor/cool foot, non-healing ulcer, rapidly worsening symptoms.
- Suspected Charcot: red/hot/swollen foot, temperature difference vs the other side, neuropathy, minimal pain → immobilise/offload and refer urgently.
- Systemically unwell or rapidly spreading infection → same-day acute assessment.
A GP-friendly “foot ulcer” micro-checklist
<ul>
<li><strong>Vitals:</strong> fever, tachycardia, hypotension (sepsis screen).</li>
<li><strong>Look:</strong> size/depth, surrounding cellulitis, necrosis, discharge, odour.</li>
<li><strong>Feel:</strong> pulses (DP/PT), cap refill, temperature gradient, sensation.</li>
<li><strong>Act:</strong> urgent referral if infection/ischaemia/Charcot; document safety-net and timeframe.</li>
</ul>
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.