A 69-year-old man with a 10-year history of type 2 diabetes, who was undergoing routine care for diabetes in the authors’ clinic, developed a DFU of his right foot of 4 years duration. During the 10-year history, his diabetes was controlled with metformin and acarbose.
At first, an ulcer of 15 mm × 10 mm developed in the mid plantar surface (midfoot) of the right foot along the first metatarsal bone without exudate and inflammation. There was no significant vascular or neuropathic defect, no history of foot trauma, no overt infection, and no atypical changes. The wound surface was small but too deep; the wound surface was dry and clean with no sign of infection and discharge. There were a few granulation tissues in the wound margin. Due to the size and dryness of the DFU, it was followed by observation without treatment for 3 years.
After 3 years without any change, the wound became symptomatic with inflammation and infectious discharge. Following these symptoms, a triphasic bone scan was performed and revealed osteomyelitis in the proximal end of the right first metatarsal bone. As of result of this finding, he was admitted to the hospital and received parenteral antibiotics, including ciprofloxacin and clindamycin, for 3 weeks. At the same time, a magnetic resonance imaging (MRI) of his right foot was performed and was unremarkable without any lesion. Wound biopsy also was normal.
After hospital discharge, oral antibiotics continued for 1 year. After 1 year of antibiotic treatment started, the wound did not heal though the wound discharge reduced slightly. After 9 months from the first MRI, a second MRI of the right foot was performed and, again, was unremarkable. In addition, wound culture showed normal skin flora.
Three months following the second MRI and 12 months from initial biopsy, a second wound biopsy of the right foot was performed and, again, was negative for malignancy. As the chronic, nonhealing wound persisted, general surgeons recommended to excise the wound. Local excision was performed, and the foot was repaired. About 12 weeks postoperatively, the wound closed completely without event. Pathologic examination of the lesion showed invasive, moderately differentiated SCC without any vascular or perineural invasion; it was an in-situ carcinoma (Figures 1, 2A, 2B).
At 6-month follow-up, there was no recurrence of the DFU, and the patient was followed-up every 3 months for any reulceration or recurrence in regular intervals.