There are wide geographical variations in both the prevalence and the etiology of chronic wounds. In Europe, the prevalence ranges from 0.18 to 1 % with venous ulcers accounting for the majority of these cases followed by diabetes and arterial disease. Data from India are limited. The etiology of chronic wounds in the hospital setting is different from that seen in the community. While hospital-based studies are easier to carry out, they do not reflect the true population-based statistics. In a community-based study from Northern India, the prevalence of chronic wounds was 4.48 per 1000 population with lower-extremity involvement being much more common than the involvement of the upper extremity [1]. The most common etiology for chronic ulcers in the above study was untreated or improperly treated acute traumatic wound followed by diabetes. In contrast, most studies indicate that diabetic ulcers are the most common cause of lower-extremity ulceration in the hospital setting [2, 3].

Chronic wounds represent a heterogeneous group which shares the common characteristic of delayed wound healing due to an underlying disease. Most patients have a poor quality of life including pain, physical discomfort, functional limitations, social and economic burden, and psychological distress. The negative socioeconomic impact of chronic ulceration plays a huge strain not only on the patient and his/her family but also on the society. In the United States, chronic wounds affect around 6.5 million patients resulting in expenditure of an estimated US$ 25 billion annually on treatment. In the Scandinavian countries, the cost of treatment of chronic wounds accounts for 2–4 % of the total healthcare expenses. In developed countries approximately 1–2 % of the population will experience a chronic wound during their lifetime. The economic burden is growing rapidly across the globe due to increasing healthcare costs, an aging population, and an increasing incidence of diabetes [4–6].

According to the Center for Disease Control and Prevention, 7.8 % of the population in the United States had diabetes in 2007 which equals almost 24 million persons. In the same year, diabetes and its complications cost the exchequer $174 billion of which $116 billion were in direct costs and the rest $58 billion were indirect costs such as loss of productivity, disability, and early mortality. An analysis of Medicare claims from 1995 to 1996 showed that expenditures for diabetic foot patients were three times higher than for the general population ($15,309 vs. $5526) yielding a total Medicare cost of $1.5 billion in 1995. In a study in which patients with diabetic foot ulcers were prospectively followed up, it was shown that 54 % patients healed in 2 months, 19 % healed in 3–4 months, and 27 % healed in >5 months. Healing without amputation costs an average of $6664 against healing by amputation which averaged $44,790. The Wagner grade was also related to the cost, being $1892 for Wagner grade 1 ulcer while a Wagner grade 4/5 ulcer averaged $27,721. Presence of vascular disease and neuropathy adds to the costs of treating diabetic foot ulcers. In India, the expenditure incurred in treating diabetic foot ulcers (DFU) varied from Rs. 10,000 in patients in urban areas to Rs. 6260 in patients in rural areas. Patients in urban areas spent a significantly higher amount on medications as well as for laboratory tests and consultations than patients in rural areas. The median costs of surgical treatment were also considerably higher in urban patients (Rs. 21,000 vs. Rs. 6500). Expenditure increased with increased duration of diabetes as well as with the number of complications in both groups. In a recently published study, the cost of treating DFU in five different countries was estimated based on a hypothetical model [5]. While the cost of treatment varied from the lowest in Tanzania to the highest in the United States for two different types of diabetic foot ulcers, the burden for the patient cannot be determined by the adjusted absolute cost but by the patients’ responsibility for bearing the cost. The cost to the patient is a function of both insurance cover and annual per capita purchasing power parity (PPP) adjusted gross domestic product (GDP). The authors concluded that India is the most expensive country for treatment of DFU, where approximately 5.7 years of income are required to pay for treatment compared to only 3 months of income in Chile and in China [5]. Several investigators have reported marked differences between the costs in urban versus rural settings, being considerably higher in the latter. These differences are due to poor access to healthcare facilities and mismanagement due to lack of adequately trained healthcare providers. It is thus obvious that in countries where the cost of treatment to the patient is so high, many patients will decline treatment, while those who chose treatment will face financial ruin [6].

Diabetic neuropathy contributes to foot deformities and ulcers, which, if left untreated, increase the likelihood of lower-extremity amputations. It is estimated that up to 25 % of diabetics will develop a foot ulcer. In the United States, nearly 71,000 lower-limb amputations were performed in people with diabetes in 2004 costing approximately 3 billion dollars per year. 67 % of all lower-extremity amputations have diabetes. Majority of the amputations (nearly 80 %) are preceded by an ulcer. Every year 5 % of diabetics develop foot ulcers and 1 % will require amputation. Recurrence rate of diabetic foot ulcers is 66 %, and the amputation rate rises to 12 % with subsequent ulcerations. The age-adjusted lower-extremity amputation rate for people with diabetes (5.5 per 1000 people) was 28 times higher than in people without diabetes (0.2 per 1000 people). Amputation rates also rise with increasing age varying from 3.9 per 1000 in diabetics who are less than 65 years of age to 7.9 per 1000 in diabetics more than 75 years of age. Amputation rates are also influenced by race being 1.5 times more common in blacks than in whites. Men are twice as more likely to have a lower-extremity amputation than women. The 5-year survival rate after a major lower-extremity amputation is about 50 %. Once amputation occurs, 50 % will develop an ulcer in the contralateral limb within 5 years. According to estimates, a staggering $9 billion were spent on the treatment of diabetic foot ulcers in 2001 [4].