When Is Hyperbaric Oxygen Therapy Right for Wound Care?

Hyperbaric oxygen therapy (HBOT), sometimes shortened to “HBO” or “HBOT”, delivers 100% oxygen to a patient inside a pressurized chamber. In wound care, HBOT is used as an adjunctive therapy to increase tissue oxygenation, reduce hypoxia, and support processes important for healing (angiogenesis, collagen formation, infection control). But HBOT is not for every wound, and the decision to refer a patient requires weighing evidence, patient factors, logistics, and risks. This guide explains when HBOT may be helpful, which wound types are most commonly considered, practical patient-selection criteria, what the evidence actually shows, and how to combine HBOT with standard wound-care practices.

When HBOT is plausible

HBOT is most often considered for chronic, non-healing foot ulcers in people with diabetes that have not responded to optimal standard care (debridement, infection control, offloading, revascularization when indicated), especially when ischemia or severe hypoxia is present and when limb salvage is an active goal. Professional societies also recognize HBOT for certain refractory soft-tissue or bone infections (e.g., refractory osteomyelitis), radiation-induced tissue injury, and other specific indications. Evidence shows short-term benefits for some diabetic foot ulcers and possible reductions in major amputation for selected patients, but the quality and consistency of studies vary and long-term outcomes are less clear.

How HBOT might help wounds

HBOT increases the amount of dissolved oxygen in plasma by combining high inspired oxygen fraction with increased atmospheric pressure inside a chamber. Higher tissue oxygen levels can:

• Improve neutrophil and macrophage function and help fight infection.

• Promote angiogenesis (new blood vessel growth) and collagen deposition.

• Reduce tissue edema through vasoconstriction while maintaining or increasing oxygen delivery.

• Enhance the effect of some antibiotics and support graft or flap survival.
  
  

These physiologic effects help explain why HBOT can be useful for hypoxic or ischemic wounds and certain infections, but clinical benefit depends on patient selection, timing, and concurrent management.

Conditions where HBOT is commonly considered

Major professional bodies and the literature list several wound-related conditions where HBOT is an option, usually as an adjunct to standard care:

• Diabetic foot ulcers (DFUs) that are chronic, deep, or ischemic and that have not responded to several weeks of optimal therapy. Some trials show more rapid short-term healing and possible amputation reduction in selected patients. Guidelines recommend referral for HBOT after standard measures (including revascularization when needed) have been applied and healing is not progressing.

• Refractory osteomyelitis (persistent bone infection despite surgery and antibiotics). HBOT may be used adjunctively in some centers.

• Radiation-induced tissue injury (late radiation necrosis of soft tissue or bone). HBOT has a more established role for selected late radiation injuries (e.g., mandibular osteoradionecrosis).

• Compromised grafts or flaps where improved oxygenation might support tissue survival.

• Other complex or ischemic wounds where poor tissue oxygenation is a major barrier and other treatments have been optimized.
  
  

Note: UK NICE guidance and several guideline panels urge caution and selective use; HBOT is not a routine first-line therapy for all DFUs or chronic wounds.

What the evidence shows

• Systematic reviews and Cochrane analyses find that HBOT can improve short-term healing of diabetic foot ulcers and may reduce the risk of major amputation in some trials, but many studies are small, heterogeneous, and have design limitations. Consequently, confidence in long-term benefits and broad generalization is limited.

• Recent systematic reviews (2021–2025) continue to report promising signals — faster ulcer reduction and fewer amputations in selected populations — while also calling for more high-quality, adequately powered randomized trials and better reporting. Some newer analyses highlight better outcomes when HBOT is added after meticulous standard-of-care measures and when patient selection is careful.

• Guidelines (e.g., IWGDF and specialty societies) generally recommend considering HBOT for diabetic foot ulcers that fail to heal despite optimal care, rather than offering it routinely; local policies and access often shape real-world use. The Undersea and Hyperbaric Medical Society (UHMS) lists diabetic wounds among accepted indications for HBOT when criteria are met.
  
  

In plain language: HBOT may help some patients with difficult-to-heal, hypoxic wounds, especially diabetic foot ulcers after other treatments have been tried, but it is not a universal cure and the strength of evidence varies.

Practical patient-selection checklist

Before referring a patient for HBOT, consider this checklist. HBOT is more likely to be appropriate when most or all of these things are true:

1. Diagnosis & problem: Chronic foot ulcer (often diabetic) or other wound with objective evidence of poor healing after an adequate trial (usually several weeks) of standard care (debridement, offloading, infection control, appropriate dressings).

2. Optimized systemic care: Glycemic control, nutrition, vascular status assessed and addressed (revascularization performed when indicated). HBOT is an adjunct; it works best when the root causes are managed.

3. Wound characteristics: Evidence of hypoxia/ischemia, large or deep wounds (Wagner grade 3+ in some protocols), or wounds complicated by refractory infection/osteomyelitis after surgery/antibiotics.

4. Feasibility and access: Patient can tolerate multiple daily treatments (often 20–40 sessions), has no absolute contraindication (untreated pneumothorax, some pulmonary barotrauma risks), and can attend chamber sessions.

5. Multidisciplinary agreement: Wound team, vascular surgery, infectious disease, and hyperbaric medicine specialists agree HBOT is a reasonable adjunct in this case.
   
   

If these items are not met, HBOT is less likely to be effective and other interventions should be prioritized.

Typical HBOT course and logistics

• Treatment schedule: Many protocols use daily sessions (5–7 days/week) at pressures of about 2.0–2.5 ATA for ~90 minutes (with air breaks) over 20–40 sessions, although exact regimens vary. Some centers tailor course length to clinical response.

• Monitoring and integration: HBOT is delivered alongside standard wound care — debridement, dressings, offloading, antibiotics, and revascularization as needed. Clinical response is monitored at regular intervals; if no improvement after an adequate course, clinicians reconsider the plan.

• Access: HBOT requires a dedicated chamber (monoplace or multiplace), trained staff, and safety systems; access varies by region and health system. Cost and reimbursement policies (including Medicare/LCD decisions and UHMS indications) influence availability.
  
  

Safety and contraindications

HBOT is generally well tolerated but has potential risks:

• Barotrauma to ears or sinuses (most common), and rarely middle-ear or pulmonary barotrauma.

• Oxygen toxicity leading to seizures is rare at standard therapeutic settings but possible; staff monitor oxygen exposure.

• Claustrophobia or discomfort during sessions can limit tolerance.

• Relative contraindications include untreated pneumothorax; careful assessment is needed for those with severe pulmonary disease or uncontrolled seizure disorders.
  
  

Careful patient selection, pre-treatment evaluation, and experienced HBOT centers minimize these risks.

Cost-effectiveness and health-system considerations

HBOT can be resource-intensive. Some economic analyses suggest adjunctive HBOT may be cost-effective in preventing major amputations in selected patients (because limb salvage has major downstream savings and quality-of-life benefits), but findings depend on local costs, patient selection, and the strength of clinical benefit in specific populations. Decision-makers often require strict referral criteria and multidisciplinary approval before funding HBOT.

How to discuss HBOT with patients (suggestions)

• “HBOT provides extra oxygen to the wound inside a special chamber. It may help certain hard-to-heal, low-oxygen wounds that haven’t improved with other treatments.”

• “HBOT is an add-on, not a replacement. We’ll make sure blood flow, infection, and wound care are optimized before considering it.”

• “If recommended, it involves daily sessions over weeks, some people feel ear pressure or mild discomfort, and we monitor closely for safety.”
  
  

Bottom line

• HBOT can be useful for selected patients with diabetic foot ulcers or other ischemic/refractory wounds, particularly when wounds are hypoxic, have failed optimal standard care, and limb salvage is the goal.

• HBOT should be considered after multidisciplinary review, optimization of vascular status and infection control, and when patients can tolerate the course and commute to a certified HBOT center.

• The evidence shows short-term healing benefits and possible amputation reduction in selected trials, but study quality varies and long-term benefit is less certain. Further high-quality trials are still needed.

See also

When to Use Skin Substitutes or Grafts for Non-Healing Wounds
Stem Cells, Exosomes, and Biologics: Do They Work in Wound Care?
How to Tell If a Wound Is Healing: Signs of Proper Wound Care Progress
Why Diabetic Foot Wounds Heal Slowly: Top Factors That Delay Recovery
How Often Should Wound Dressings Be Changed? Best Practices for Healing

More Information

For more information on the latest effective wound care, contact us to set up a time for a call.

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* This blog is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment.