Diabetic Ulcers of the Lower Extremeties (DFU)

Diabetic lower extremity ulcers are among the most challenging complications of diabetes, often resulting from a combination of impaired circulation, neuropathy, infection, and delayed wound healing. Without timely and effective treatment, these wounds can become chronic, difficult to heal, and can increase the risk for serious complications, including infection and amputation.

Hyperbaric Oxygen Therapy (HBOT) is an evidence-supported intervention for selected diabetic ulcers and is recognized by the Centers for Medicare & Medicaid Services (CMS) and the Undersea & Hyperbaric Medical Society (UHMS) as an accepted therapeutic indication. By delivering high concentrations of oxygen under increased atmospheric pressure, HBOT can increase oxygen availability to compromised tissues and support the body’s natural wound-healing processes.

For referring physicians, understanding the role of HBOT in the multidisciplinary management of DFUs-including appropriate patient selection, wound classification, and referral criteria-is critical to optimizing patient outcomes. HBOT is typically considered as an adjunct to comprehensive wound care when appropriate, rather than as a standalone treatment.

Mechanism of Action: Why HBOT Works

Hyperbaric Oxygen Therapy involves inhalation of 100% oxygen at pressure two to three times normal atmospheric pressure, typically for 90-120 minutes per session.

HBOT exerts therapeutic effects through several mechanisms:

Hyperoxygenation of Hypoxic Tissue

• Elevated pressure increases plasma-dissolved oxygen, allowing oxygen to reach hypoxic tissue with compromised circulation.

Angiogenesis Stimulation

• Repeated hyperoxia exposures stimulate new blood vessel formation, improving vascular density and oxygen delivery to compromised tissue.

Fibroblast Proliferation and Collagen Synthesis

• Increased tissue oxygen levels enhance fibroblast activity and collagen production, supporting wound closure and tissue repair.

Immunomodulation and Infection Control

• HBOT enhances leukocyte oxidative killing capacity and supports the body’s ability to manage infection in oxygen-compromised diabetic wounds.

Pathophysiology of Diabetic Ulcers

Diabetic ulcers are driven by a combination of neuropathy, impaired circulation, and chronic inflammation. Diabetes can lead to:

• Peripheral neuropathy and loss of protective sensation
• Peripheral arterial disease and reduced blood flow
• Impaired immune response and increased infection risk
• Reduced fibroblast function and collagen synthesis
• Chronic tissue hypoxia
• Delayed wound healing

Minor trauma or infection can precipitate tissue breakdown and chronic ulceration. Without restoration of adequate oxygen delivery and support for tissue repair, healing is often delayed or incomplete.

Clinical Indications & Referral Criteria

HBOT is indicated for diabetic ulcers in:

• Lower-extremity diabetic ulcers with compromised healing
• Chronic, non-healing diabetic foot ulcers
• Diabetic ulcers with evidence of hypoxia or poor tissue perfusion

Consider referral when patients present with:

• Failure to demonstrate adequate healing following appropriate course of standard wound care.
• Persistent ulceration or delayed healing
• Diabetic lower extremity ulcers that are equivelent to Wagner Grade 3 (absess, osteomyelitis, tenosynovitis) or Wagner Grade 4 (gangrene)

*Early referral often improves outcomes, particularly when HBOT is initiated before extensive tissue breakdown occurs.*

Frequently Asked Patient Questions (FAQs)
Hyperbaric Oxygen Therapy for Diabetic Foot Ulcers

1. Is Hyperbaric Oxygen Therapy (HBOT) safe?
Yes, HBOT is generally safe, well tolerated and effective when performed by hyperbaric medicine professionals in a medical facility. To ensure your safety and prior to initiating any treatment, our hyperbaric physician and hyperbaric staff will review your medical history, provide you with a comprehensive medical evaluation and education, along with a tour of our chamber facility.

2. How does Hyperbaric Oxygen Therapy (HBOT) help?
Hyperbaric Oxygen Therapy helps by delivering high levels of oxygen to damaged tissue.
During treatment, you breathe 100% oxygen in a pressurized chamber. The increased pressure allows oxygen to dissolve into your bloodstream and reach areas where circulation has been reduced.

HBOT helps:

• Stimulate the growth of new blood vessels
• Support collagen production and tissue repair
• Improve wound healing
• Enhance the body’s ability to fight infection

This therapy addresses the underlying problem-lack of oxygen-rather than just treating symptoms.

HBOT is recognized by the Undersea & Hyperbaric Medical Society as an approved treatment for diabetic lower extremity ulcers.

3. What conditions related to diabetic foot ulcers can HBOT treat?
HBOT may be recommended for patients with:

• Chronic, non-healing diabetic foot ulcers
• Diabetic foot wounds with compromised tissue oxygenation
• Diabetic foot ulcers complicated by infection
• Diabetic foot ulcers with delayed or impaired healing despite standard wound care
• Selected advanced diabetic foot ulcers at risk for serious complications

4. What can I expect during treatment?
A typical HBOT course includes:

• 30-40 treatments
• One session per day, five days per week
• Each session lasting about 90-110 minutes

5. What does Hyperbaric Oxygen Therapy (HBOT) feel like?
During treatment, you relax inside a hyperbaric chamber while breathing 100% Oxygen. At the beginning of each treatment we will pressurize the chamber, most patients describe the sensation as similar to the pressure changes felt during airplane travel.

Many patients begin to notice symptomatic improvement after about 20 sessions, with continued progress over the full treatment course.