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The Four C’s of Diabetic Wound Management

It takes four C’s to efficiently heal diabetic wounds – HARTMANN lists these steps down. Diabetic wounds can become more complicated and aggravated if not immediately treated. Following these four C’s promotes faster wound healing for patients suffering from diabetic wounds.

The Context: Diabetes and Ulcers

According to the International Diabetes Federation, last year there were 415 million adults living with diabetes. The organisation claims that this number will increase to around 642 million, or an estimated one-in-ten adults, by 2040.

From vision loss to diabetic foot ulcers, diabetes causes many complications and damages of important body organs.

The American Podiatric Medical Association (APMA) found that diabetes is the leading cause of non-traumatic lower extremity amputations in the United States, and between 14-24 percent of patients with diabetes who develop a diabetic foot ulcer will require an amputation. Further findings from the APMA state that foot ulceration precedes 85 percent of diabetes-related amputations.

Roughly 25 percent of patients with diabetes in developing countries will develop at least one diabetic foot ulcer during their lifetime1.

Whether you are a wound specialist or a general practitioner treating the occasional diabetic wound patient, remembering these 4 C’s can help you treat your patients’ wounds efficiently.


A key to diabetic wound healing is wound cleansing.2
Research shows that the management of diabetic foot ulceration is based on:
• well-defined principles of wound debridement,
• identification and management of infection,
• use of dressings to maintain a moist healing environment;
• offloading / redistributing pressure from the wound.3
hydroclean plus
Bacteria, necrotic tissue, and fibrin hinder wound healing and act as a significant barrier to wound repair if not removed.2,4 The act of removing these factors is called debridement.

At its most basic level, debridement is defined as a natural process that occurs in all wounds. It facilitates the removal of damaged and necrotic tissue, as well as debris and bacteria from the wound. It supports the formation of healthy granulation tissue.5

Hydro-Responsive Wound Dressings (HRWD) like HARTMANN’s patented HydroClean® plus – with a unique Rinsing-Absorption Mechanism – promote autolytic debridement, a safe form of wound cleansing involving endogenous enzymes.6 A recent clinical study7,8,9,10 with more than 400 patients showed the wound cleansing properties of HRWDs in a variety of chronic wounds. Fibrin and necrotic tissue were significantly reduced following application:7
• Fifty-six percent of the wounds were coated with more than 50 percent fibrin. It was reduced to eight percent within one month of beginning treatment.7
• Thirty-two percent of the wounds were coated with necrotic tissue and this proportion reduced to five percent.7


The longer a wound remains open, the harder it is to treat. An open wound exhibits a greater risk of re-infection.

The key to proper wound healing is ensuring epithelial cells have just the right amount of moisture to jumpstart the mending process.11

HydroClean® plus is step one of HARTMANN’s two-step wound-healing technology designed to effectively clean and stimulate healthy tissue (granulation), and HydroTac® as step two facilitates wound closure (epithelialisation)…faster.

With the two-step system, clinicians have the option to speed wound healing. HydroTac technology facilitates a faster wound closure compared to inert silicones.12 As part of HARTMANN’s AquaClear technology, HydroTac contains hydrated polyurethanes that boost the concentration of growth factors and increase the activity of epithelial cells to stimulate the healing process.13,14

As medical professionals, we see it as our responsibility to ensure our patients have the best quality of life possible. Ensuring your patients’ comfort is just as important as the actual wound healing.


Hydrfilm leg
While cleansing the wound, HydroClean® plus has proven its comfort, tolerability, and reduction of pain during dressing changes.15 It is a safe, easy to apply as well as an easy-to-remove, light, and flexible5 treatment option.16

Furthermore, according to a HARTMANN observational study with more than 400 patients, 94 percent of patients who used HydroClean® plus rated the dressing overall as ‘good’ or ‘very good’.6,7,8,9,10

And when it comes to step two of wound healing, HydroTac® comfort is designed to effectively close wounds with hygiene in mind. It can be worn in the shower and applied for up to several days without a dressing change. With an adhesive border, it does not require any additional fixation to secure placement.16

The hidden C

In many countries, diabetes is a leading cause of blindness, cardiovascular disease, kidney failure, and lower-limb amputation17 (often the result of foot ulcers).
In your treatments of your diabetic wound patients, remembering the 4Cs – the context, the importance of cleaning, setting the wound up for closure, and ensuring the comfort of your patient in the process – can lead you to the most important “C” of all -- ultimate patient CARE.

To learn more about HydroClean® plus, HARTMANN’s HydroTherapy concept, and the company’s wound care history.

1Cardenas A, Mirelman A, Cooper G The cost of illness attributable to diabetic foot and cost-effectiveness
of secondary prevention in Peru. BMC Health Services Research (2015); 15:483.

Dowsett C, Claxton K. Reviewing the evidence for wound bed preparation. J Wound Care (2006); 15:439-442

3McIntosh C, Kelly L. The importance of wound debridement in management of diabetic foot ulcers. Wounds UK (2009); 4:122-129.

4Young T. Debridement — is it time to revisit clinical practice? Br J Nurs (2011); 20:24–28.

5Effective debridement in a changing NHS: a UK consensus. London: Wounds UK (2013). Available from:

6Knestele M. The treatment of problematic wounds with HydroClean plus - tried and tested over many
years in clinical practice. HARTMANN Data on file (2004).

7Ousey K, Rogers A, Rippon M. HydroClean® plus: a new perspective to wound cleansing and debridement.
Wounds UK (2016); 12(1).

8HARTMANN Effective Wound Cleansing with TenderWet Active – Observational Study with 403
patients. Available at: (accessed 11.02.2016) (2010)

9Zöllner, P. Observational study Ideal wound environment during granulation and epithelization achived
achieved with HydroTac. HARTMANN Data on file. (2010)

10Humbert P., et al. on behalf of the CLEANSITE study group. Protease-modulating polyacrylate-based hydrogel
stimulates wound bed preparation in venous leg ulcers a randomized controlled trial. Journal of the European
Academy of Dermatology and Venereology (2014); 28:12, 1742-50.

11Rook A, Wilkinson DS. Textbook of Dermatology - 4th edition. Dermatology, Blackwell Scientific Publications
(1986), 750.

12Smola H.: Stimulation of epithelial migration – novel material based approaches. Presented at EWMA Congress,
2015, London. Data on file: in-vivo study (2015), H. Smola

13Smola H, Maier G, Junginger M et al. Hydrated polyurethane polymers to increase growth factor
bioavailability in wound healing. Presented at the EORS, Congress Nantes (2014).

14Zollinger C, Schwab R, Locherer E et al HydroTherapy. Application study. HARTMANN document. Data on
file. (2014)

15Kaspar D. Therapeutic effectiveness, compatibility and handling in the daily routine of hospitals or
physicians’s practices. HARTMANN Data on file: Hydro-Responsive Wound Dressing (HRWD) and AquaClear
Technology are trademarks of HARTMANN (2011).

16Ellermann., J. HydroClean 2.0: Design validation customer/user interviews. Internal Report, International
Marketing Department (2015).

17IDF Diabetes Atlas 7th edition