Hyperbaric Oxygen Therapy as an Adjunctive Treatment for Diabetic Foot Wounds: A Comprehensive Review With Case Studies

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Author(s): 
Michael C. Daly, MS; Justin Faul, DPM; John S. Steinberg, DPM

Abstract: Complications associated with diabetes are often expensive to treat, and commonly include foot ulceration. While most diabetic foot ulcers heal with standard treatment, when standard treatment measures fail, adjunctive therapies must be considered. We review the theory and evidence for the use of systemic Hyperbaric Oxygen Therapy (HBOT) as an adjunctive treatment for chronic lower extremity diabetic ulceration. Two clinical cases of patients treated with HBOT for refractory diabetic foot ulceration at Georgetown University Hospital are presented. A growing body of evidence suggests that oxygen plays a major role in whether wounds heal normally or remain nonhealing chronic wounds. An oxygen gradient, from high oxygen levels in the edges of the wound to hypoxic conditions in the wound center, seems to optimally stimulate wound healing. Wounds that are instead surrounded by hypoxic tissue lack this oxygen gradient and seem less likely to heal. In wounds with adequate perfusion, HBOT may overcome periwound hypoxia to create an oxygen gradient and stimulate healing of otherwise nonhealing wounds. The clinical trials assessing the effectiveness of HBOT in diabetic wound healing have been inconclusive. However, considering the evidence supporting oxygen’s role in wound healing and the potential for HBOT to decrease medical costs related to the care of chronic diabetic ulcers, there is a need for more extensive clinical trials to evaluate HBOT efficacy.



Address correspondence to:
John S. Steinberg, DPM
Georgetown University Hospital
Georgetown University School of Medicine
3800 Reservoir Rd. NW, Bles First Floor
Washington, DC 20007
Email: jss5@gunet.georgetown.edu

     Diabetes has become a global epidemic. As the prevalence of diabetes has increased, so has the burden on the healthcare system to provide treatment for the complications associated with the disease. These complications are often expensive to treat and may include foot ulceration, secondary infection, and limb amputation.1,2

     Every year, 1.9% of persons with diabetes develop foot ulcers.3 These wounds are often refractory to standard treatment, ultimately requiring amputation in 15%–20% of diabetic patients within 5 years of ulcer development.4 In the United States alone, the cost of diabetic ulcer treatment accounts for more than half of the $4.6–$13.7 billion spent each year to treat diabetic peripheral neuropathy.5 Such costs intensify the need for improved, cost-effective methods in the prevention and therapy of diabetic ulcers.

     In diabetic patients, peripheral neuropathy seems to be the most important risk factor in the development of foot ulceration.6 It has been shown that up to 80% of diabetic foot wounds are associated with diabetic peripheral neuropathy.7 Loss of innervation to sweat glands due to peripheral neuropathy may cause the skin surface to become dry and thus more prone to cracking, infection, and subsequent tissue damage and ulceration. The effects of peripheral neuropathy on protective sensation and on foot biomechanics have also been reported to drive diabetic ulcer formation.8 The loss of protective sensation due to nociceptive neuron loss can allow wounds to go unnoticed (ie, unrecognized trauma), increasing the likelihood of infection and development of a chronic, nonhealing wound. Altered foot biomechanics due to peripheral neuropathy may cause inappropriate weight distribution, which can exert high pressure on focal weight bearing areas of the foot. Ulcers may develop over time as patients apply constant micro-trauma to the skin. Tissue ischemia, uncontrolled hyperglycemia, infection, poor nutrition, and improper shoe gear also contribute to the chronic, nonhealing nature of diabetic ulcers.

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