SLR - May 2022 - Einul Chowdury, DPM
References: Gunton JE, Girgis CM, Lau T, Vicaretti M, Begg L, Flood V. Vitamin C Improves Healing of Foot Ulcers: A Randomised, Double-Blind, Placebo-Controlled TrialBr J Nutr. 2021 Nov 28;126(10):1451-1458
Level of Evidence: Level II
Scientific Literature Review
Reviewed By: Einul H. Chowdhury, DPM
Residency Program: New York College of Podiatric Medicine/Metropolitan Hospital Center – New York, NY
Podiatric Relevance: In every day podiatry practice, foot ulcers are encountered on a regular basis. With foot ulcerations, many different methods of treatment are present on the market, including offloading, nutrition supplementation, skin grafting and the use of skin graft substitution, serial debridements, revascularization. Overlooked at times are basic lab values in determining a patients pre-existing vitamin deficiency which are fundamental to the healing process. This is particularly the case of vitamin C optimization which the podiatric surgeon must consider in order to provide the maximal wound healing regimen. With long-standing wounds causing serious systemic and local complications for the patient, it is critical to evaluate systemic nutritional deficiencies to aid in faster wound healing.
Methods: In this prospective double blinded randomized control trial composed of nine members in the control group and seven members (four people having known vascular disease and four members having diabetes) administered 500mg of slow release vitamin C supplementation (total of 16 patients). Half of the subjects were noted to have baseline deficiency in vitamin C levels (four members in each study arm). The study was performed at a single center, wound clinic at Westmead Hospital in Sidney, Australia. Subjects' baseline vitamin C levels were measured; one group received 500mg slow release vitamin C daily for the first 28 days, while the other received a placebo. The placebo subjects who were identified to be vitamin C deficient were supplemented during the trial's remaining 28 days. Only the pharmacist had access to the vitamin C levels of all groups throughout the study. The study does not however detail the wound care that was administered routinely to the patients while the study was carried out.
Results: After an eight-week study period, the group administered the vitamin C supplementation was noted to have significantly better healing in comparison to the control group. The rate of 50 percent tissue regeneration was marked at 20 days in the vitamin C group and 48 days in the placebo group; p=0.029. Lastly, the vitamin C supplementation group noted 100 percent wounds healed (within 77-day average) without any amputations having occurred vs. placebo group having an average wound reduction of only 14 percent.
Conclusions: There will be a requirement of further investigation to determine the role of oral vitamin C supplementation in the treatment of foot ulcers. From this study, we can appreciate that there may be potential benefit of using 500mg slow release vitamin C in the assistance of foot ulcer healing in patients, particularly those who may have pre-existing deficiencies. This article also highlights the importance of investigating baseline deficiencies in vitamin levels. There is also the discussion in the article that precludes the possibility of vitamin deficiency preluding the formation of wounds, warranting possible prophylactic vitamin supplementation to prevent foot ulcer formation. However, wound healing necessitates a multi-modal approach that includes offloading, proper wound care, adequate vascular supply, as well as medical and nutritional optimization.