Definition and Causes
Diabetic ulcers are chronic, complex, or problem wounds of the legs and feet in people with diabetes. Diabetic ulcers that
fail to heal in three months are usually considered chronic. Some take years to heal or never do. Wound care specialists classify
diabetic foot ulcers using the Wagner Grade Scale:
- Grade 0: no open lesions, but may possess preulcerative lesions, healed ulcers, presence of bone deformity
- Grade 1: superficial ulcer, not involving subcutaneous tissue
- Grade 2: deep ulcer with penetration through the subcutaneous tissue, potentially exposing bone, tendon, ligament, or joint capsule
- Grade 3: deep ulcer with osteitis (bone inflammation), abscess (pus), or osteomyelitis (bone infection)
- Grade 4: gangrene of digit (toe)
- Grade 5: gangrene of foot requiring disarticulation (amputation)
Diabetic ulcers require a healthy, oxygenated wound bed to heal. A lack of sufficient oxygen (hypoxia) in the wound bed slows
or stops the normal healing process. Wound healing in people with diabetes is often complicated by poor blood circulation in
the feet and legs. Nerve disease (neuropathy) may also cause a loss of sensation in the feet and legs, so even a small cut,
sore, or pressure ulcer may go unnoticed for some time and develop into a problem wound. Diabetic ulcers are especially prone
to serious bacterial infections that threaten life and limb.
Hyperbaric Oxygen Approval Status
Arterial Insufficiencies: Enhancement of Healing in Selected Problem Wounds
page in the Undersea and Hyperbaric Medical Society resource library to learn more about wound evaluation, hypoxia, measures of
wound oxygenation, the mechanisms and efficacy of hyperbaric oxygen, and future areas for research.
Treatment with Hyperbaric Oxygen Therapy
Hyperbaric oxygen therapy (HBOT) is an effective adjunct to traditional wound care therapies, including topical cleaning;
surgical removal (debridement) of dead skin and tissue; application of dressings, ointments, and biologics; and use of
compression boots or stockings, vacuum or negative pressure wound therapy (NPWT) pumps, ultrasound, laser, and other emerging
technologies. HBOT helps repair wounds and enhance healing by improving blood circulation, encouraging the formation of new
capillary blood vessels (angiogenesis), supplying more oxygen to tissue in the wound bed, and stimulating the growth and
distribution of stem cells. Hyperbaric oxygen also helps kill the anaerobic bacteria that cause some of the worst infections
in chronic wounds. Evidence for HBOT is especially strong in diabetic foot ulcers classified Wagner Grade 3 or higher, for
which hyperbaric oxygen is widely considered standard therapy.
Hyperbaric oxygen plays an increasingly important role in the treatment of problem wounds and limb salvage. But access to
accredited hyperbaric facilities and certified hyperbaric physicians and technicians is a public health problem. In 2004
as many as two-thirds of nursing home patients with NPUAP Stage II or worse pressure ulcers were not enrolled in wound care
In diabetes-related wounds alone, US hospitals performed 66,000 toe, foot, and leg amputations
for which health economists have estimated a cost of $3 billion per year
[ACA, 2008]. More and more
hospitals and health networks today are opening advanced wound care and hyperbaric centers to serve this unmet clinical need.
Even if chronic wounds were its only indicated use, HBOT would be assured a place in evidence-based medicine for quality and
HyperbaricLink recommends the following websites for anyone seeking authoritative information, patient advocacy, and
community support for diabetic ulcers. See also: Chronic Wounds.
A small media empire and growing diabetes community, heavily supported and monitored by drug, device, and insurance companies,
dLife has a brief Diabetes Complications: Feet page worth visiting for its extra audiovisual content. (Look for "Video: Feet".)
The leading source for diabetes information and support, the American Diabetes Association provides a short Foot Complications
page with a helpful “listen to text” button.
National Diabetes Information Clearinghouse (NDIC)
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
National Institutes of Health (NIH)
The NDIC presents of wealth of information and statistics about diabetic neuropathy, ulcers, and other complications of
diabetes, with easy-to-read educational materials focused on prevention.
A trusted online source of medical information, WebMD offers an eMedicineHealth section on Diabetic Foot Care that’s
authoritative, thorough, and plainly written for general audiences.
Start with the following resources to explore current research activities and the peer-reviewed medical literature on
hyperbaric oxygen therapy for chronic wounds.
The ACHM is a professional organization working to develop an image of hyperbaric oxygen therapy as a distinct medical
specialty, often requiring full-time practice. ACHM has a strong focus on wound care and offers a credentialing and fellowship
track for physicians, a Certified Hyperbaric and Wound Specialist (CHWS) program for hyperbaric technologists, and a Wound
Care Boot Camp online training course.
The preeminent multidisciplinary organization for wound care, AAWC is a nonprofit association open to everyone involved in
wound care. Its mission is to spread awareness by promoting excellence in education, clinical practice, public policy, and
A nonprofit organization welcoming all wound care professionals, the APWCA combines the structure of a credentialing college
and a full-service medical association. Its mission is to decrease the rate of complications from wounds all types. APWCA
provides ACHM-recognized physician and technician certification programs in conjunction with the Council for Medical Education
and Testing (CMET).
ClinicalTrials.gov keeps the official list of human clinical trials currently enrolling, in progress, and recently completed.
One may reasonably question the size and legitimacy of any study not listed here.
Search ClinicalTrials.gov for current studies of diabetic + hyperbaric oxygen therapy
An independent, international, nongovernmental organization, the Cochrane Collaboration is a powerful force in evidence-based
medicine. One may consider a Cochrane Reviews article on any HBOT topic required hyperbaric reading.
Read the Cochrane Reviews article "Hyperbaric oxygen therapy for chronic wounds"
A specialized Google search engine, Google Scholar indexes scholarly articles, patents, and legal opinions and journals.
Google Scholar may generate excessive search results, but entries provide easy access to full-text journal articles.
Search Google Scholar for "diabetic ulcer" + "hyperbaric oxygen"
HBOEvidence uses computerized tools to appraise the key randomized controlled trials (RCTs) in the hyperbaric medical
literature. One may reasonably question the overall strength of HBOT evidence for any disease or condition not covered here.
Read the HBOEvidence appraisals for treatment of nonhealing wounds with hyperbaric oxygen therapy
US National Library of Medicine
National Institutes of Health
PubMed keeps the official list of scientific papers published in reputable peer-reviewed medical journals. One may reasonably question the importance and
legitimacy of any study not listed here.
Search PubMed.gov for journal articles relating to diabetes and hyperbaric oxygen therapy
An international nonprofit organization serving some 2,400 members in 50 countries, the UHMS is the chief accrediting body
and the primary source of scientific information for diving and hyperbaric medicine physiology.
Read the UHMS statement on the Medicare Arterial Insufficiency Ulcer Issue
- Chronic wounds
- Clostridial myonecrosis
- Decubitus ulcer
- Gas gangrene
- Leg ulcer
- Limb salvage
- Necrotizing fasciitis
- Nonhealing wound
- Pressure ulcer
- Selected problem wounds
- Slow-healing wound
- Wagner ulcer grade classification scale
A Leg to Stand On
by Oliver Sacks
(Summit Books, 1984).