Summary : This flowchart presents an algorithm for the treatment of diabetic peripheral neuropathy (DPN), guiding clinicians through decision-making steps for pain management, agent selection, and escalation of care based on symptom persistence and medication tolerance. flowchart: # Nodes : • "Is pain due to DPN?" (hexagon) • "NO or not sure" (rectangle) • "Refer to neurology or pain clinic" (rectangle) • "YES" (rectangle) • "Assess comorbidities, costs, drug-drug interactions, potential for adverse effects ➔ choose one of the following agents" (rectangle) • "ANTICONVULSANTS Pregabalin* Gabapentin" (rectangle) • "SNRIs Duloxetine* Venlafaxine" (rectangle) • "TCAs Amitriptyline, Nortriptyline" (rectangle) • "Capsaicin* 8% patch" (rectangle) • "Exercise" (rectangle) • "Persistence of symptoms" (rectangle) • "Avoid Opioids!" (rectangle, orange) • "Switch to another agent from above" (rectangle) • "Try combining agents from above" (rectangle) • "Persistent pain/medication not tolerated" (rectangle) • "Refer to pain clinic" (rectangle) # Connectors : • Arrow from "Is pain due to DPN?" to "NO or not sure" and "YES". • Arrow from "NO or not sure" to "Refer to neurology or pain clinic". • Arrow from "YES" to "Assess comorbidities..." and then to five agent options: "ANTICONVULSANTS", "SNRIs", "TCAs", "Capsaicin* 8% patch", "Exercise". • Arrows from all five agent options to "Persistence of symptoms". • Arrow from "Persistence of symptoms" to "Avoid Opioids!", "Switch to another agent from above", and "Try combining agents from above". • Arrow from "Switch to another agent from above" and "Try combining agents from above" to "Persistent pain/medication not tolerated". • Arrow from "Persistent pain/medication not tolerated" to "Refer to pain clinic". # Layout : • Top-down, stepwise progression. • Initial decision node at top, branching to referral or treatment assessment. • Five parallel agent options in the middle. • Symptom persistence leads to further branching for agent switching, combination, or referral. • Orange highlight for "Avoid Opioids!" as a warning. # Additional Information : • Footnotes: *FDA approved for treatment of DSPN. • Abbreviations: DPN = diabetic peripheral neuropathy; DSPN = distal symmetrical polyneuropathy; FDA = Food and Drug Administration; SNRI = serotonin-norepinephrine reuptake inhibitor; TCA = tricyclic antidepressant. • Source: Adapted from Pop-Busui, Boulton, et al, Diabetes Care 2017;40:136-154. # Analysis : • The algorithm prioritizes non-opioid agents for pain management in DPN, with anticonvulsants, SNRIs, TCAs, topical capsaicin, and exercise as first-line options. • If symptoms persist, clinicians are advised to avoid opioids, switch agents, or combine therapies. • Persistent pain or intolerance to medication prompts referral to a pain clinic. • The flowchart emphasizes assessment of comorbidities and adverse effects before agent selection, and provides clear escalation steps for refractory cases.

Summary : This flowchart presents a comprehensive algorithm for the prevention and care of diabetic foot, including screening, ulcer management, wound care, offloading, infection and ischemia assessment, and advanced therapies. flowchart: # Nodes : • DFU Prevention (rounded rectangle): Patient education, annual foot exam, glycemic control (A1c<7%), therapeutic footwear, Semmes-Weinstein test, ABI at age 50, vascular risk factor management. • Patient developed ulcer (rectangle). • Assess for ischemia, infection and neuropathy (rectangle): ABI + TcPO2, PTB + plain XR. • Comprehensive wound care (rectangle): Debridement and follow up q 1-4 wk, moist wound bed, control exudate, avoid maceration. • Offloading (rectangle). • Suspected soft tissue abscess or osteomyelitis (rectangle): MRI (if not possible, leukocyte or antigranulocyte scan + bone scan). • Clinically significant PAD (rectangle): Revascularization (either surgical bypass or endovascular therapy). • Healed (rectangle). • No response in 4 wks (rectangle): Adjunctive wound therapy (HBO, NPWT, cellular and extracellular agents). • plantar DFU (rectangle): Total contact cast or irremovable fixed ankle walking boot. • non-plantar (rectangle): Relieves pressure at the site of the ulcer. • Alternative for frequent dressing changes (rectangle): Removable cast. • Osteomyelitis (rectangle): Bone debridement, biopsy and culture, antibiotics, HBO. # Connectors : • Arrow from DFU Prevention to Patient developed ulcer. • Arrow from Patient developed ulcer to Assess for ischemia, infection and neuropathy. • From Assess for ischemia, infection and neuropathy, three branches: – To Comprehensive wound care. – To Offloading. – To Suspected soft tissue abscess or osteomyelitis and Clinically significant PAD. • Comprehensive wound care leads to Healed or, if no response in 4 wks, to adjunctive wound therapy. • Offloading splits into plantar DFU (total contact cast or irremovable boot) and non-plantar (relieves pressure at ulcer site), with alternative for frequent dressing changes (removable cast). • Suspected soft tissue abscess or osteomyelitis leads to Osteomyelitis (bone debridement, biopsy, antibiotics, HBO). • Clinically significant PAD leads to revascularization. • All branches ultimately aim for healing. # Layout : • Top-down flow, starting with prevention, then ulcer development, assessment, and branching into wound care, offloading, infection/ischemia management. • Multiple parallel branches for different clinical scenarios. • Merges at points where healing is achieved or advanced therapies are considered. # Analysis : • The flowchart emphasizes early prevention and regular screening to reduce diabetic foot ulcer (DFU) risk. • Once an ulcer develops, a systematic assessment for ischemia, infection, and neuropathy guides further management. • Wound care and offloading are central, with specific strategies for plantar and non-plantar ulcers. • Advanced imaging and therapies are reserved for cases with suspected infection or poor response to standard care. • The algorithm integrates vascular assessment and revascularization for patients with peripheral arterial disease (PAD). • The workflow is designed to optimize healing and minimize complications through stepwise escalation of care.

Summary : This flowchart provides a comprehensive management algorithm for adults with atopic dermatitis, detailing baseline management, topical therapies, phototherapy, and systemic therapies, including FDA-approved and recommended treatments, maintenance strategies, and escalation steps for inadequate control. flowchart: # Baseline Management : • Severity Assessment: Assessment of signs of disease, severity of symptoms, comorbidities, and impact on quality of life (QOL). • Exacerbating Factor Avoidance: Identify trigger factors (allergens, irritants, etc.) and counsel patients on avoidance. • Baseline Therapy: Moisturizers/Emollients (strong recommendation), Bathing Practices (conditional recommendation). # Initial Pathways : • Mild to Severe: Proceed to Topical Therapies. • Moderate to Severe: Proceed to Phototherapy & Systemic Therapy. # Topical Therapies : ## Optimized Topical Therapy for Inflamed Areas : • TCS (Topical corticosteroids) (FDA, strong recommendation) • TCIs (Topical calcineurin inhibitors) (FDA, strong recommendation) • Crisaborole ointment (FDA, strong recommendation) • Ruxolitinib cream (FDA, strong recommendation) • Wet Dressings (strong recommendation) ## Ongoing Maintenance with Topical Therapies : • Reactive or proactive application for maintenance. • Shared decision-making for long-term treatment. • Consider patient satisfaction and adherence. ## Inadequate Control : • If topical therapy and basic management optimized, consider alternative diagnoses. • Consider additional treatment with phototherapy and/or systemic agents. # Phototherapy & Systemic Therapy : • Topical agents can be used concurrently with phototherapy or systemic agents for maintenance, rescue, or flares. # Phototherapy : • No specific agents listed; included as a treatment option for moderate to severe cases. # Systemic Therapies : ## Biologics : • Dupilumab (FDA, strong recommendation) • Tralokinumab (FDA, strong recommendation) ## JAK Inhibitors : • Upadacitinib (FDA, strong recommendation) • Abrocitinib (FDA, strong recommendation) • Baricitinib (strong recommendation) ## Immunosuppressants : • Methotrexate (strong recommendation) • Azathioprine (strong recommendation) • Cyclosporine (strong recommendation) • Mycophenolate mofetil (strong recommendation) • Systemic corticosteroids (FDA, strong recommendation against use) # Key : • Green circle: Strong recommendation in favor. • Yellow circle: Conditional recommendation in favor. • Red circle: Strong recommendation against. • Orange circle: Conditional recommendation against. • FDA: Indicated for atopic dermatitis. # Abbreviations : • QOL: Quality of Life • FDA: Food and Drug Administration • TCS: Topical corticosteroids • TCI: Topical calcineurin inhibitor # Layout : • The flowchart is organized from baseline management at the top, splitting into two main pathways (mild to severe and moderate to severe), with further branches into topical, phototherapy, and systemic therapies. • Maintenance and escalation steps are included for ongoing management and inadequate control. # Analysis : • The algorithm emphasizes starting with baseline management and topical therapies, escalating to phototherapy and systemic therapies for more severe or refractory cases. • Strong recommendations are visually highlighted for first-line agents, with systemic corticosteroids strongly discouraged. • FDA-approved options are clearly marked, supporting evidence-based decision-making. • The flowchart supports a stepwise, patient-centered approach, integrating maintenance and escalation strategies.