Treatment
Hyperbaric oxygen therapy for diabetic foot ulcers: who it may help
Breathing pure oxygen in a pressurized chamber as an add-on for diabetic foot ulcers that still aren’t healing after infection, pressure and blood flow have been treated.
Medically reviewed by Dr. Efe Ozturk · Last reviewed
When a diabetic foot ulcer won’t close, we look for the reason: hidden infection, dead tissue, a bone or tendon pressing on the spot, or a narrowed artery. Hyperbaric oxygen removes none of those; it is an add-on that may help once they are treated. Dr. Efe Ozturk, a Foot and Ankle Surgeon who is board certified in wound care (FAPWH), will help you decide whether it fits. If it does, we refer you to a hyperbaric center.
How hyperbaric oxygen works
Oxygen is essential to key steps in healing: growing new blood vessels, laying down collagen and covering the wound with new skin.[1] Breathing pure oxygen at two or more atmospheres of pressure raises the oxygen level in tissue that is short of it, such as a wound with poor circulation.[1] It may not help where blood flow is very poor: in a follow-up of one trial, people with very low oxygen readings measured through the skin before treatment did not heal.[4] Other proposed effects include less swelling, better-working repair cells and, when infection is present, slower growth of bacteria, especially those that thrive without oxygen.[4]
Who it may help
The International Working Group on the Diabetic Foot (IWGDF) suggests considering hyperbaric oxygen for diabetic foot ulcers with reduced blood flow (ischemic or neuro-ischemic ulcers). This applies when standard care alone hasn’t healed them and a hyperbaric unit is already available.[1] The recommendation is conditional, and it is still unclear which patients benefit most.[1] See diabetic foot ulcers and peripheral artery disease.
The IWGDF practical guidelines add a time frame: they list it among the add-on options for an uninfected ulcer with reduced blood flow that hasn’t healed after 4–6 weeks of optimal care.[6] The two double-blind trials enrolled people with Wagner grade 2 to 4 ulcers.[2,3]
Higher Wagner grades mean more serious wounds: grade 3 includes a deep ulcer with inflammation or infection of the bone beneath it (osteitis), and grades 4 and 5 mean gangrene of part of the foot or the whole foot.[4] We can tell you your wound’s grade; see how a foot wound is evaluated.
Infection is a different question. For a diabetic foot infection, the IWGDF/IDSA guideline suggests not using hyperbaric oxygen just to treat the infection, since there is little evidence that it clears soft-tissue or bone infection.[5] See osteomyelitis.
Not everyone is a candidate. Frailty and other serious health problems can rule it out, because side effects are more likely. It is also practical only for people who live near a center and can commit to weeks of intensive treatment.[1]
Surgery and blood flow come first
Even careful wound care can’t make up for untreated infection, poor blood flow or ongoing pressure on the wound,[6] and hyperbaric oxygen doesn’t remove those causes either. So we treat them first:
- Infection and dead tissue. Dr. Ozturk drains infection, removes dead tissue and takes out infected bone. A red, hot, swollen foot should be seen the same day. See surgery for diabetic foot infection and osteomyelitis surgery.
- Pressure. When a bony prominence or a tight tendon keeps loading the ulcer, Dr. Ozturk can take that pressure off with an operation. See surgery that takes pressure off ulcers.
- Blood flow. We do noninvasive circulation testing at our practice and refer you to a vascular specialist when an artery needs opening. See restoring blood flow and the warning signs of poor circulation in the feet (external site).
When artery disease comes with foot pain at rest, gangrene (such as toes turning black) or an ulcer open for more than two weeks, it is called chronic limb-threatening ischemia. It calls for an urgent referral to a vascular specialist.[4] The global vascular guidelines say hyperbaric oxygen should not replace revascularization in these patients. They strongly advise against offering it to save a limb when severe ischemia hasn’t been corrected.[4]
For the wounds that need them, Dr. Ozturk also uses skin substitutes, negative-pressure wound therapy and skin grafts or local flaps; see limb salvage surgery for the full toolbox.
What a course of treatment is like
Treatment takes place in a one-person chamber or in a larger chamber shared by several people, who breathe the oxygen through a hood or mask.[7] In two of the main trials, the course was 30 or 40 daily sessions of about 90 minutes.[3,2]
As the pressure rises (a change similar to diving as deep as 60 feet), you may feel it in your ears.[7] Because the treatment can lower blood sugar in people with diabetes, centers check your glucose beforehand and set a minimum level.[7]
Hyperbaric oxygen is an add-on to standard wound care, not a substitute for it, so debridement, offloading and dressings continue.[1] We keep measuring your wound at each visit to see whether it is responding. See wound care visits.
Coverage depends on your plan, and some plans need prior authorization. Please call our office at 908-215-5953 to inquire about your insurance.
What the research shows
- A positive trial. A double-blind trial included 94 people with diabetes and Wagner grade 2 to 4 ulcers open for more than three months. Within a year, 52% healed with hyperbaric oxygen, against 29% with pressurized air as a sham.[2]
- A negative trial. In another double-blind trial in people with diabetes and grade 2 to 4 ulcers, 30 sessions added nothing to thorough wound care. At 12 weeks, 11 of 49 treated and 13 of 54 sham patients met the criteria for a major amputation, and healing was similar (20% versus 22%).[3]
- Ulcers with poor circulation. In a trial of 120 people with diabetes and reduced blood flow to the leg, adding hyperbaric oxygen didn’t significantly improve healing or limb salvage at a year. With it, 53 of 60 kept the leg; without it, 47 of 60 did.[8] About a third couldn’t finish the course, mostly because of other health problems or practical reasons.[8,4] Those who finished had fewer major amputations, but people well enough to finish may differ from those who stopped.[8]
- Pooled studies. A review of studies in people with diabetic foot ulcers and artery disease found fewer major amputations with hyperbaric oxygen (10.7% versus 26.0%) but no clear effect on healing.[9] A 2025 analysis of eight randomized trials, each lasting at least 12 weeks, found better healing and fewer major amputations, though serious adverse events were more common.[10]
The IWGDF judged the evidence as conflicting: the most reliable trials suggest some benefit for healing, but good evidence that it prevents amputation is lacking.[1]
Side effects and limits
A review by hyperbaric specialists calls it among the safest therapies in use and says side effects can often be avoided with careful screening. Some are still common.[7]
- Ear and sinus pressure. Ear pressure injury is among the most common side effects; coaching helps prevent it, and most of these injuries heal on their own. Pressure injury of the sinuses is the next most common kind.[7]
- Blurred distance vision. Nearsightedness often develops after several weeks. It usually resolves within 3 to 6 weeks of finishing, sometimes longer, so wait at least 8 weeks before getting new glasses.[7]
- Feeling closed in. Coaching and, if needed, medicine help with anxiety in the chamber.[7]
- Oxygen seizures. These are rare, about 1 in 2,000 to 3,000 treatments, and stop without lasting harm when the oxygen level is lowered.[7]
Questions to ask
- Have infection, pressure and blood flow in my foot been treated?
- Has my wound stalled despite four to six weeks of good care?
- Will my plan cover it, and does it need prior authorization?
- Can I manage daily sessions for several weeks?
- If an amputation has been suggested, should I get a limb salvage second opinion first?
When to seek care
See us within a day or two for any foot wound that isn’t healing, especially if you have diabetes. To book, call 908-215-5953 or use Zocdoc.
References
- 1.Chen P, Vilorio NC, Dhatariya K, Jeffcoate W, Lobmann R, McIntosh C, et al. Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3):e3644. PubMed 37232034 (external site)
- 2.Löndahl M, Katzman P, Nilsson A, et al. Hyperbaric oxygen therapy facilitates healing of chronic foot ulcers in patients with diabetes. Diabetes Care. 2010;33(5):998-1003. PubMed 20427683 (external site)
- 3.Fedorko L, Bowen JM, Jones W, et al. Hyperbaric Oxygen Therapy Does Not Reduce Indications for Amputation in Patients With Diabetes With Nonhealing Ulcers of the Lower Limb: A Prospective, Double-Blind, Randomized Controlled Clinical Trial. Diabetes Care. 2016;39(3):392-399. PubMed 26740639 (external site)
- 4.Conte MS, Bradbury AW, Kolh P, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg. 2019;69(6S):3S-125S.e40. PubMed 31159978 (external site)
- 5.Senneville É, Albalawi Z, van Asten SA, Abbas ZG, Allison G, Aragón-Sánchez J, et al. IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023). Diabetes Metab Res Rev. 2024;40(3):e3687. PubMed 37779323 (external site)
- 6.Schaper NC, van Netten JJ, Apelqvist J, Bus SA, Fitridge R, Game F, et al. Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3):e3657. PubMed 37243927 (external site)
- 7.Heyboer M 3rd, Sharma D, Santiago W, et al. Hyperbaric Oxygen Therapy: Side Effects Defined and Quantified. Adv Wound Care (New Rochelle). 2017;6(6):210-224. PubMed 28616361 (external site)
- 8.Santema KTB, Stoekenbroek RM, Koelemay MJW, et al. Hyperbaric Oxygen Therapy in the Treatment of Ischemic Lower-Extremity Ulcers in Patients With Diabetes: Results of the DAMO2CLES Multicenter Randomized Clinical Trial. Diabetes Care. 2018;41(1):112-119. PubMed 29074815 (external site)
- 9.Brouwer RJ, Lalieu RC, Hoencamp R, et al. A systematic review and meta-analysis of hyperbaric oxygen therapy for diabetic foot ulcers with arterial insufficiency. J Vasc Surg. 2020;71(2):682-692.e1. PubMed 32040434 (external site)
- 10.Monami M, Scatena A, Ragghianti B, et al. Effectiveness of most common adjuvant wound treatments (skin substitutes, negative pressure wound therapy, hyperbaric oxygen therapy, platelet-rich plasma/fibrin, and growth factors) for the management of hard-to-heal diabetic foot ulcers: a meta-analysis of randomized controlled trials for the development of the Italian Guidelines for the Treatment of Diabetic Foot Syndrome. Acta Diabetol. 2025;62(7):1081-1095. PubMed 39724338 (external site)
This page is general health information and isn’t a substitute for advice from a clinician who knows your history. Read our medical disclaimer and how we review content.
Questions patients ask
Articles from our blog on healing a wound, protecting the foot and the surgery that saves it, with the sources listed.
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Hyperbaric Oxygen for Foot Wounds: Who Really Benefits
Who benefits from hyperbaric oxygen? Some slow-healing foot ulcers, not most. What the trials show about who gains, who doesn’t, and what has to happen first.
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Related topics
Treatment
Wound care visits
What happens at a wound care visit, how often you’re seen, what you do at home, and when wound care steps up to surgery.
Condition
Diabetic foot ulcers
Open sores on the feet of people with diabetes, and the step-by-step care, including surgery when it’s needed, that aims to heal them and keep them closed.
Condition
Peripheral artery disease
Narrowed leg arteries that starve a foot wound of blood, and the vascular procedures and foot surgery that aim to restore circulation, heal the wound and keep the foot.
Treatment
Restoring blood flow
Angioplasty, stents and bypass, performed by vascular specialists, restore blood flow to a foot wound that is starved of it; we test circulation, refer you and time foot surgery and wound care around the procedure.