A Narrative Review of Local Therapies in Diabetic Foot Ulcers: Promises, Limitations and Unmet Needs.

BACKGROUND: Diabetic foot ulcers (DFUs) frequently remain open despite multidisciplinary standard care. Local therapies target different components of the wound microenvironment, but their comparative value and generalisability are uncertain. OBJECTIVE: To critically summarise evidence for seven local approaches-autologous leucocyte-platelet-fibrin patches, placenta-derived products, sucrose octasulfate dressings, fish skin matrices, hyperbaric oxygen therapy (HBOT), topical oxygen therapy (TOT) and negative pressure wound therapy (NPWT)-and to identify limitations and research priorities. METHODS: PubMed and the Cochrane Library were searched through 31 July 2026, supplemented by citation tracking. Randomised and prospective comparative studies, systematic reviews or meta-analyses, guidelines and economic analyses were eligible. The narrative synthesis followed SANRA-informed principles. Forty-one publications were included, among them 18 randomised trial reports. RESULTS: An international trial of the leucocyte-platelet-fibrin patch reported healing at 20 weeks in 34% versus 22% with standard care. A meta-analysis of 11 placental-product trials reported complete healing in 66.9% versus 34.1% (risk ratio 2.00). EXPLORER reported 48% versus 30% closure with sucrose octasulfate at 20 weeks. In deep ulcers, ODIN reported 44% versus 26% healing with intact fish skin at 16 weeks. TOT meta-analysis suggested benefit (risk ratio 1.59), whereas HBOT trials were discordant and NPWT evidence was clinically supportive but low certainty. Severe infection, osteomyelitis and critical ischaemia were commonly excluded. CONCLUSIONS: Several local therapies improve healing in selected DFUs, but none replaces debridement, offloading, infection control and vascular care. Product-specific selection, durable outcomes, head-to-head pragmatic trials, complex-ulcer populations and independent economic evaluation are priority needs.