Skin substitutes and placental tissue grafts for diabetic foot ulcers

What skin substitutes are

Skin substitutes for diabetic foot ulcers are thin sheets placed on the wound bed to give it structural and biological support while it heals.⁠^[1] Some are bioengineered, some come from another person’s tissue (an allograft) and some from animal tissue (a xenograft).⁠^[2]

Guidelines sort them by whether they contain cells:⁠^[1]

• Cellular products contain human cells, such as fibroblasts or keratinocytes (skin cells).
• Acellular products are a framework with the cells removed, such as a human or bovine (cow) collagen dermal matrix.

Placental products, reviewed as their own group, come from placental membranes or umbilical cord, which hold growth factors, a collagen-rich matrix and cells. Frozen (cryopreserved) versions keep living cells; dried versions are easier to store and keep the growth factors but no living cells.⁠^[1]

When a skin substitute is considered

Before any graft, Dr. Efe Ozturk, a Foot and Ankle Surgeon who is board certified in wound care (FAPWH), makes sure the basics are in place: regular debridement, antibiotics chosen from culture results when there is infection, and noninvasive circulation testing at our practice. For an ulcer on the sole of a numb foot, the preferred offloading is a non-removable knee-high device.⁠^[3] We fit it here and teach you how to move safely in it. See wound care visits and total contact casting.

We measure your wound at every visit because early progress predicts healing: in one trial, 58% of ulcers that shrank more than the median over four weeks healed by 12 weeks, against 9% of the rest.⁠^[7]

For an uninfected ulcer that still stalls, the International Working Group on the Diabetic Foot (IWGDF) suggests considering an added treatment, such as a placental membrane graft or, for ulcers with poor circulation, hyperbaric oxygen therapy.⁠^[3] For the wounds that need it, Dr. Ozturk applies skin substitutes in the office. If hyperbaric oxygen is the better fit, we refer you for it.

Placental tissue grafts

The IWGDF gives placental-derived products a conditional recommendation, on low-certainty evidence, for diabetic foot ulcers that standard care alone hasn’t healed. Studies at low risk of bias linked them, amniotic membrane in particular, with more ulcers healed at up to 20 weeks and faster healing.⁠^[1]

A 2026 meta-analysis of nine comparisons with 944 people found the wound closed by 12 weeks in 59.0% of those given a placental product plus standard care, against 35.8% with standard care alone. Certainty was moderate, but not every product or setting may match that average.⁠^[4]

In a randomized trial of 110 people whose ulcers shrank by a quarter or less during two weeks of dressings and offloading, 70% healed by 12 weeks with a weekly dried amnion-chorion membrane added, against 50% with standard care.⁠^[8]

How it’s applied, and care between visits

After the wound is cleaned (see wound debridement), the product is laid on the wound bed and held in place with stitches, adhesive strips or a dressing on top.⁠^[1] Some products are reapplied; in the trial above, the membrane went on weekly for up to 12 weeks.⁠^[8]

Between visits, keep the dressing dry and in place unless we have shown you how to change the outer layer, and keep wearing your offloading device. Visits are usually every week or two, and each measurement shows whether the graft is helping. If a wound stops shrinking, we look again for pressure, infection or poor blood flow rather than simply adding more grafts.

Once the ulcer closes, we check your feet regularly and fit therapeutic shoes and custom inserts to help keep it closed; see keeping your foot in remission.

Skin substitutes in the operating room

Surgery to clear a deep foot infection can leave a large gap with bone, tendon or cartilage showing.⁠^[6] Once that wound is clean, it needs durable cover. A systematic review, mostly of case series, found that limited data appear to support acellular dermal matrices over exposed bone, tendon or muscle, where they may give timely, lasting cover.⁠^[5] In a series of five people with diabetes, a dermal regeneration template followed by a thin split-thickness skin graft covered exposed bone, tendon and cartilage. All five healed and walked again in extra-depth shoes.⁠^[6]

Dr. Ozturk uses amniotic and placental tissue in the operating room when a wound left open after surgery needs it, and closes a wound with a skin graft or local flap of your own tissue when that suits it better. See surgery for diabetic foot infection and partial foot amputation. Our parent practice, Ozturk Foot & Ankle, offers other regenerative treatments (external site), such as platelet-rich plasma for heel pain.

What the research shows

• A dermal template. In a trial of 307 people with slow-healing diabetic foot ulcers, a dermal regeneration template closed 51% of wounds within 16 weeks, against 32% with a saline gel dressing.⁠^[9]
• Guideline caution. The IWGDF found that cellular and acellular products may improve healing. Because the trials were at high risk of bias and the products are costly, it suggests not using them routinely.⁠^[1] So we choose them case by case, for stalled wounds.

Limits, risks and insurance

A skin substitute treats the wound’s surface, not a cause such as infection, poor circulation or ongoing pressure. For an ulcer under a metatarsal head that won’t heal with offloading, guidelines suggest considering surgery such as Achilles tendon lengthening or removing that metatarsal head.⁠^[3] Dr. Ozturk performs these operations for the wounds that need them; see surgery that takes pressure off ulcers. If circulation is the problem, we refer you to a vascular specialist; see restoring blood flow.

In the Cochrane review of 17 trials with 1,655 people, benefit varied by product, and no product clearly beat another head to head. No trial found a significant difference in side effects. Nearly all trials involved industry, long-term results are lacking and cost-effectiveness is uncertain. The only two trials that counted amputations found slightly fewer with treatment, on very low-quality evidence.⁠^[2] Placental trials were mostly short and left out people with significant artery disease, so the IWGDF found no evidence that these products lower amputation rates.⁠^[1]

Coverage for skin substitutes depends on your plan and the product, and some need prior authorization. Please call our office at 908-215-5953 to inquire about your insurance.

Questions to ask

• Have I had at least four weeks of good standard care, and how much has my wound shrunk?
• Which type of skin substitute do you suggest, and how many applications might I need?
• Is a bony prominence, a tight tendon or infected bone keeping the wound open, and would surgery fix that?

When to seek care