What is topical oxygen therapy for diabetic wounds?

Topical Oxygen Therapy for Diabetic Wounds

Topical oxygen therapy is a conditionally recommended adjunctive treatment for diabetic foot ulcers that have failed standard care, supported by multiple high-quality randomized controlled trials showing improved healing rates at 12 weeks with minimal adverse events. 1

What Topical Oxygen Therapy Is

Topical oxygen therapy delivers oxygen directly to the wound surface through specialized devices, distinct from hyperbaric oxygen chambers. 1 Three types of topical oxygen devices exist:

• Continuous-delivery systems that provide steady oxygen flow 1
• Low-constant-pressure devices that maintain consistent pressure 1
• Cyclical-pressure modalities that alternate pressure delivery 1

The critical advantage is home-based therapy rather than requiring daily visits to specialized hyperbaric centers, making it far more practical for patients. 1

When to Use Topical Oxygen Therapy

Use topical oxygen therapy only after standard care has failed, not as first-line treatment. 1 The specific algorithm is:

1. First, optimize standard care for at least 2 weeks, which must include: 1

   • Sharp debridement of callus, slough, and necrotic tissue 1
   • Appropriate off-loading (total contact cast for plantar ulcers) 2
   • Basic moisture-retentive dressings 1
   • Vascular assessment and revascularization if indicated 2

2. If the ulcer shows insufficient reduction in area after 2 weeks of optimized standard care, then consider topical oxygen therapy as adjunctive treatment. 1

3. Ensure resources exist to support this intervention before initiating, as the devices require ongoing availability and patient compliance. 1

Evidence Supporting Topical Oxygen Therapy

The evidence base has evolved significantly between guideline iterations:

• The 2020 IWGDF guidelines recommended against topical oxygen therapy (weak recommendation; low evidence), stating it should not be used as primary or adjunctive intervention. 1

• The 2023 IWGDF guidelines reversed this position, now conditionally recommending topical oxygen therapy after standard care failure. 1 This change reflects several high-quality RCTs and at least five systematic reviews published between 2020-2023. 1

• The 2023 American Diabetes Association guidelines strongly support topical oxygen therapy, citing "several high-quality RCTs and at least five systematic reviews and meta-analyses all supporting its efficacy in healing chronic DFUs at 12 weeks." 1

• A 2023 systematic review and meta-analysis demonstrated statistical significance with a risk ratio of 1.59 (95% CI: 1.07-2.37; p = 0.021) for complete wound healing, with moderate overall quality of evidence. 3

Clinical Outcomes and Safety Profile

Very high patient participation rates with very few reported adverse events make this therapy attractive for advanced wound care. 1 The therapy demonstrates:

• Improved healing rates at 12 weeks compared to standard care alone 1, 3
• Potential to shorten healing time in nonhealing diabetic foot ulcers present for extended periods (mean 76 weeks in one study) 4
• Significant difference in healing rate between topical oxygen and standard care in controlled trials 4

Critical Distinctions from Hyperbaric Oxygen

Do not confuse topical oxygen therapy with hyperbaric oxygen therapy—they are fundamentally different interventions with different evidence bases and indications:

• Hyperbaric oxygen requires specialized chambers, daily facility visits, and is conditionally recommended only for neuro-ischemic or ischemic ulcers where standard care has failed. 1

• Topical oxygen is delivered at the wound surface, allows home-based therapy, and has broader applicability to diabetic foot ulcers without requiring ischemia. 1

• Recent evidence for hyperbaric oxygen is mixed, with only one positive RCT in the last decade and more recent studies showing no benefit in healing DFUs without ischemia and/or infection. 1

Specific Contraindications and Appropriate Patient Selection

Use topical oxygen therapy only for Wagner 1 and 2 diabetic foot ulcers in the absence of infection and ischemia. 3 Do not use for:

• Infected wounds—these require systemic antibiotics and infection control, not oxygen therapy 5, 6
• Dry, necrotic wounds—these require hydrogels to maintain moisture, not oxygen therapy 5, 2
• Post-surgical wounds—these may benefit from negative pressure wound therapy instead 2
• Wounds with active ischemia requiring revascularization—address vascular insufficiency first 2

Common Pitfalls to Avoid

Never use topical oxygen therapy as first-line treatment before optimizing standard care. 1 The most common errors include:

• Jumping to advanced therapies without adequate debridement and off-loading, which remain the cornerstone of diabetic wound care 2, 6
• Using topical oxygen on infected wounds instead of appropriate antimicrobial therapy 5, 6
• Confusing topical oxygen with hyperbaric oxygen and referring patients to hyperbaric centers unnecessarily 1
• Failing to ensure adequate resources and patient compliance before initiating therapy 1
• Using topical oxygen on wounds that haven't failed standard care, wasting resources on ulcers that would heal with basic management 1

Practical Implementation Algorithm

When a diabetic foot ulcer presents:

1. Week 0-2: Implement aggressive standard care with sharp debridement, appropriate off-loading, moisture-retentive dressings, and vascular assessment. 1, 2

2. Week 2: Reassess ulcer area—if insufficient reduction (typically <30% area reduction), the ulcer qualifies as "failed standard care." 1

3. Week 2+: Consider topical oxygen therapy if resources exist and the wound is non-infected, Wagner 1-2, without critical ischemia. 1, 3

4. Continue standard care alongside topical oxygen—debridement, off-loading, and basic wound care must continue. 1

5. Reassess at 12 weeks for healing outcomes, as this is the timeframe where evidence demonstrates efficacy. 1, 3