IWGDF Guideline Update on Classifying Foot Ulcers in People With Diabetes

Guidelines for diabetic foot ulcer management are crucial in assessing proper treatment for patients and establishing improved communication among health care professionals.

The International Working Group of the Diabetic Foot (IWGDF) published a 2023 update of the 2019 guidelines on the classification of foot ulcers in people with diabetes, which was published in Diabetes/Metabolism Research and Reviews.

Diabetes affects nearly 10% of the entire population, with a third being diagnosed with diabetic foot ulcers. The 2023 guidelines for patients with diabetic foot ulcers have undergone several changes since 2019. The authors determined this guideline aimed to offer recommendations on classifying foot ulcers in people with diabetes.

The recommendations are now supported by a systematic rather than a critical review. The grading methodology is more thorough with the effect sizes, and the certainty of evidence being graded with ‘very low’ as an option. The authors developed a summary of findings table and a judgment table and new important outcomes were added, such as hospitalization, health-related quality of life, diabetes-related foot ulcer and amputation-free survival, and costs. Alternative options were added for communication between health care professionals when managing complex cases, acknowledging the differences in access to equipment and detail needed according to the setting.

Communication Among Health Care Professionals

According to the IWGDF guidelines, health care professionals should use the Site, Ischaemia, Bacterial Infection, Area, and Depth (SINBAD) system as a first option to communicate characteristics of a foot ulcer in patients with diabetes.

If there are enough resources and expertise available, the guidelines recommend using the Wound, Ischaemia, foot Infection (WIfi) system to communicate ulcer characteristics among healthcare professionals. This system involves characterizing each variable that determines the ulcers makeup.

Predicting the Outcome of an Ulcer in a Specific Individual

The authors noted the IWGDF guidelines recommend against using the existing classification/scoring systems to predict the outcome of individuals with diabetes and foot ulcers. This is due to the insufficient reporting of accuracy measures and high variability, small sample sizes, and low event rates, leading to unreliable confidence intervals.

Classifying a Person With an Infected Ulcer

When classifying a person with diabetes and an infected ulcer, the guidelines recommend using the 2015 IDSA/IWGDF system. The system consists of 4 grades of diabetic foot ulcers, used to determine which patients may require hospitalization.

Based on evidence and consensus judgement using the GRADE methodology, this guideline recommends the use of SINBAD as the priority wound classification system to utilise in people with diabetes and a foot ulcer.

Additionally, the guidelines suggest utilizing the WIfI system if there are sufficient resources and expertise available, and it is deemed feasible.

Classifying a Person With an Ulcer and Peripheral Artery Disease

In a patient with diabetes, peripheral artery disease, and a foot ulcer, the guidelines recommend using the WIfI system to evaluate the chances of healing and the risk of amputation.

Alternative options for communication with health care professionals were given and there was a clear acknowledgment of the different settings and equipment needed for more complex cases.

Auditing Outcome(s) Populations

In a population of people with diabetes and foot ulcers and in which the purpose is to use for audit, the guidelines recommend using the SINBAD system to allow comparisons between institutions on outcomes. The SINBAD score is also the only system already in use to conduct audits within the United Kingdom.

Potential Limitations

The guideline authors noted that because a systematic review using the full-GRADE approach was used rather than a critical review for the evidence analysis, a change in the certainty of evidence occurred in several scenarios, and for all recommendations, the certainty of evidence was graded as low.

Despite reviewing 149 articles assessing 28 different systems used to characterize foot ulcers in people with diabetes, the currently available evidence remains limited due to a lack of articles directly comparing the systems. The authors also noted studies may be graded with a high risk of bias, and focus on healing or amputation. Only 6 out of the 28 systems were recommended.

Several members of the group had potential conflicts of interest concerning the systems, so those authors were not able to score or grade any of the items.

“Based on evidence and consensus judgement using the GRADE methodology, this guideline recommends the use of SINBAD as the priority wound classification system to utilise in people with diabetes and a foot ulcer,” the authors concluded. This includes “inter‐professional communication (describing each composite variable), clinical audits (using the full score), but the use of other more specific assessment systems for infection (IDSA/IWGDF) and peripheral artery disease (WIfI) or when resources exist in addition to an appropriate level of expertise (WIfI).”


Monteiro-Soares M, Hamilton EJ, Russell DA, et al. Guidelines on the classification of foot ulcers in people with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev. Published online May 14, 2023. doi:10.1002/dmrr.3648