Digital Health Technologies for Diabetic Foot Ulcers: A Systematic Review of Clinical Evidence, Access Inequities, and Public Health Integration.

Diabetic foot ulcers are among the most severe complications of diabetes mellitus, disproportionately affecting populations in low- and middle-income countries. Digital health technologies have emerged as promising tools for prevention, diagnosis, and management; however, their effectiveness, usability, and applicability within public health systems remain insufficiently defined. This systematic review aimed to critically synthesize the clinical effectiveness, perceived usability, and methodological quality of digital interventions for the care of individuals with diabetes-related foot ulcers. A comprehensive search was performed in PubMed, Scopus, Web of Science, Embase, and Google Scholar for studies published between 2012 and 2024. Eighteen studies met the inclusion criteria, encompassing mobile health applications, wearable sensor devices, artificial intelligence-based tools, and telehealth platforms. Methodological quality was assessed using the Mixed Methods Appraisal Tool. Artificial intelligence-driven approaches demonstrated high diagnostic accuracy, with sensitivity and specificity above 90% for ulcer detection and classification. Mobile applications showed positive effects on self-efficacy, glycemic control, and adherence to preventive foot care, while usability scores were consistently high. Wearable sensor devices demonstrated potential for reducing ulcer recurrence, though supporting evidence remains limited. Across studies, recurrent methodological limitations included small sample sizes, absence of control groups, lack of economic evaluations, and barriers related to digital literacy and interoperability between systems. Most investigations were conducted in high-income countries, with limited consideration of public health contexts such as the Brazilian Unified Health System. In conclusion, digital health technologies show promise in improving the care of individuals with diabetes-related foot complications but face significant challenges regarding scalability, equity of access, and integration into public healthcare systems. Future research should prioritize context-adapted designs, robust clinical trials, and economic evaluations to inform health policies and support the rational adoption of these tools within universal health coverage frameworks. PROSPERO registration number: CRD420251023152.