practice
A diabetic foot ulcer treated with
hydrogel and hyperbaric oxygen therapy:
a case study
Abstract: This study reports on the case of an elderly patient, with
diabetes, and a bullous wound on the left big toe that led to an
amputation of the first and second left toes. The amputation was
because of deep injury as it was not able to heal with a conventional
treatment. After completing the normal treatment and the removal of a
bacterial infection in the lesion, the patient underwent a treatment that
was based on a hydrogel gel (0.9% saline solution) and hyperbaric
diabetic foot ulcer  ● hydrogel ●  hyperbaric oxygen therapy  ●  HBOT
D
iabetic foot ulcer (DFU) is a serious
complication of diabetes and the main
reason for amputations involving the lower
limbs.1 Risk factors for a DFU include diabetes
for >10 years, male, peripheral neuropathy,
abnormal structure of the foot, peripheral arterial disease
(PAD), smoking, a history of previous ulcers or
amputations, and poor glycaemic control.2
There are a huge amount of options for the treatment
of DFUs, such as hyperbaric oxygen therapy (HBOT).
Treatment with HBOT involves an intermittent
administration of 100% oxygen, at pressures greater
than sea level, usually in daily sessions. This presents
itself to be a promising treatment for severe cases of
DFU, as well as for some difficult healing of wounds
that are resistant to other therapies.3
Difficult healing wounds can be treated with saline
solutions as it has been shown to promote autolysis
and the formation of granulation tissue.4 Hydrogel,
prepared from 0.9% saline with 1% carbomer has
been successfully used for maintaining the wound
bed and for promoting granulation tissue4 Hydrogels
consist of a matrix of insoluble polymers, with up to
96% water content, enabling them to donate water
molecules to the wound’s surface and to maintain a
moist environment at the wound bed. As the polymers
are only partially hydrated, hydrogels have the ability
P. Aguiar,1 PhD; C. Amaral,2 MD; A. Rodrigues,1 Pharmacy Technician; *A.H. de Souza,3
PhD, Lecturer
*Corresponding author email: alessandrahubnersouza@gmail.com
1  Federal University Hospital of Rio Grande, Rio Grande do Sul Brazil. 2 Hyperbaric Oxygen
Therapy Clinic of Rio Grande 3 Universidade Luterana do Brasil, Rio Grande, Rio Grande do
Sul, Brazil.
692
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 129.127.145.240 on November 14, 2017.
oxygen therapy (HBOT). After 60 sessions of the therapy, almost
complete closure of the wound was observed. There were no reports of
discomfort or infection during the treatment. After seven months of
treatment almost complete healing was observed with no infection.
This treatment appears to be effective and should be recommended for
the treatment of DFUs.
Declaration of interest: Nothing to declare.
to absorb wound exudate, the amount varying
between different brands.5 Hydrogels promote wound
debridement by the rehydration of the non-viable
tissue facilitating the process of natural autolysis.5
This study was approved by the Ethics of the Santa
Casa de Misericordia of Rio Grande Committee, RS,
Brazil, under Protocol No 021/2014.
This study demonstrates the efficacy of topical
hydrogel in conjunction with HBOT on the healing
process of a diabetic foot wound improving recovery
and quality of life (QoL).
Case report
A 71-year-old male with type 2 diabetes for 10 years
(treated with metformin 850mg) presented with a
myocardial infarction requiring angioplasty six months
before observing the wound. In December 2014, the
patient presented with a bullous wound on the left big
toe that deteriorated, until March, when amputation of
both the first and second left toes was required. The
angiotomography of the lower limbs showed a marked
atheromatous disease of the arterial vessels, with a
moderate stenosis (50–75%) in the middle third of the
left superficial femoral artery. The postoperative wound
was deep, significantly painful, had foul-smelling
serosanguinous drainage, and a necrotic area with
exposed muscle and tendon. The wound was topically
treated with sunflower oil, vitamins A and E, silicone,
Brazilian nut oil, and medium chain triglycerides, as
© 2017 MA Healthcare ltd
well as oral therapy with 500mg of ciprofloxacin twice
a day and 30mg codeine/500mg paracetamol when
there was local pain.
Since the wound did not show any sign of
improvement and the patient suffered a risk of further
JOURNAL OF WOUND CARE  VOL 26, NO 11, NOVEMBER 2017
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 practice

Table 1. Patient measurements over the 60 days of treatment

Session BP HR RR TC BG mg/dl Session BP HR RR TC BG mg/dl

1 130/80 120 22 36 158 31 80/50 100 20 36 116

2 110/70 105 20 36 150 32 80/60 102 20 35 145
3 150/80 108 20 36 178 33 100/60 102 25 35 138
4 120/80 96 20 36 135 34 90/60 100 16 35 134
5 140/80 88 18 35 135 35 80/50 92 18 36 90
6 110/80 100 16 35 131 36 80/50 102 22 35 126
7 120/70 104 21 35 129 37 110/80 65 16 36 102
8 140/80 96 18 35 159 38 100/70 88 18 36 145
9 130/70 100 20 36 125 39 110/70 88 18 36 119
10 130/70 104 16 36 133 40 70/45 88 16 35 147
11 110/60 96 20 36 187 41 90/60 90 20 36 146
12 120/80 92 16 36 123 42 120/80 100 20 35 96
13 120/80 100 20 36 143 43 90/60 88 20 36 149
14 120/80 84 16 36 154 44 80/60 80 20 36 146
15 90/60 104 20 36 98 45 80/60 88 20 36 177
16 100/70 84 20 36 127 46 90/60 84 18 35 108
17 110/60 76 16 35 79 47 100/60 85 20 36 116
18 100/60 76 20 36 124 48 120/80 100 21 35 132
19 80/50 76 20 36 155 49 100/70 82 20 35 108
20 100/60 96 18 35 92 50 70/40 84 18 36 118
21 150/80 84 18 35 165 51 80/60 98 20 35 160
22 100/60 104 20 35 103 52 90/60 98 18 36 152
23 110/70 107 20 35 104 53 80/50 100 18 35 134
24 80/60 89 16 35 102 54 100/70 102 18 36 141
25 100/60 104 20 36 131 55 80/50 88 20 35 141
26 120/70 97 20 36 153 56 70/50 82 18 36 118
27 120/80 82 20 36 94 57 100/60 96 16 36 171
28 90/60 87 16 36 123 58 110/70 100 18 36 112
29 120/80 100 20 35 93 59 110/80 79 16 36 108
30 90/60 80 20 36 132 60 80/60 98 20 36 108

BP—blood pressure; HR—heart rate; RR—respiratory rate; T—temperature; BG—blood glucose; days 1 to 60 of treatment in a hyperbaric oxygen therapy chamber

amputation, he sought the help of the Hyperbaric
Medical Center of Rio Grande, RS, in March 2015.
Tests were performed confirming hyperglycaemia
and wound cultures revealed the presence of Klebsiella
oxytoca. The patient received 400mg sulfamethoxazole
and 80mg trimethoprim every 12 hours for seven days.
After completing the antibiotic course, he was then
treated with HBOT and topical hydrogel.
In April 2015, the HBOT treatment began (five times
per week for 90 minutes), along with hydrogel daily
dressing changes. The wound was cleansed with 0.9%
saline, then the hydrogel layer was applied and it was
© 2017 MA Healthcare ltd
After seven days of treatment, there was reduction in
oedema, with a small amount of fibrinous material and
granulation tissue in the wound base. At session 19
(Fig  1b), intense granulation was observed. In addition,
we noted some wound contraction and epithelialisation
with continued decrease in wound bed.
At session 26 there was well-vascularised granulation
tissue, a lower amount of fibrinous material, less
surrounding oedema and an improved appearance with
regular wound edges and decreased wound size. The
hydrogel kept the moisture level in the wound stable
without causing cutaneous maceration.

covered with a gauze dressing. In addition, the patient
was instructed to protect the injury from trauma and to
rest. Diet guidelines were made in order to control the
patient’s blood glucose level (Table  1) and favour
healing (Fig 1a, day 0).
At session 46, the granulation tissue formation
remained, as well as the presence of fibrinous material
and decreasing wound depth, with continued decrease
in open area. New epithelium was covering almost the
entire surface and the edges of the wound and its crust

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 practice

were covered with a yellowish colour. It was found

Fig 1. A 71-year-old male with diabetes. At presentation
that this did not interfere with the healing process. At (a); day 19 of treatment (b); day 58 of treatment (c)
session 58 (Fig  1c), there was further decrease in the
size of the open wound. The patient underwent a
a
total of 60 sessions without complications.
Data collected included clinical history and a
physical examination of the patient once a week. In
addition, there were the photographic records of the
injury. The dressings were changed daily so that the
wound was kept moist because of the regularly applied
hydrogel. There was no discomfort or complication
from the use of hydrogel, demonstrating
its tolerability.

Discussion
Open wounds heal by contraction of the edges and
migration of cells to the centre of the wound. The
wound bed is filled through fibroblast migration and b
the formation of new vessels that originate from
capillaries around the wound.6,7 Wound contraction
depends on the capacity of fibroblasts to migrate
through the extracellular matrix (ECM) and this
capacity is negatively influenced by many factors,
such as the use of steroids, a diagnosis of diabetes,
infection and vitamin deficiency.8 Our research has
found similar results from another group for a study
where hydrogel was used as control with a group of
153 patients. The healing rate, of the control group,
in that study was 32% after 16 weeks and complete
wound closure within 78 days. 11 This result
demonstrates hydrogel’s healing capacity,9 consistent
with the American Society of Plastic Surgeons’ c
recommendation that wound healing is promoted by
the maintenance of a moist environment.10
Hydrogels have been produced for use in tissue
engineering both in the pharmaceutical and
biomedical fields, due to their high capacity for water
absorption and biocompatibility.11 We chose to
combine hydrogel with HBOT, since HBOT accelerates
the tissue regeneration process of the wound and it is
a safe and effective therapy with few adverse events.12
Adverse events when they do occur include: pulmonary
toxicity, neurological toxicity, auditory discomfort
and barotraumas, facial sinus discomfort and transient
visual changes.13 HBOT accelerates the healing process
by increasing the capillary oxygenation, and thus,
promoting angiogenesis.14 Exposure to increased
barometric pressure inside a hyperbaric chamber Conclusion
increases the oxygen dissolved in the plasma. This DFUs are a major health problem and are an important
dissolved oxygen is the metabolically active fraction cause of morbidity, mortality and financial burden.19
that penetrates compromised tissues. 15 Treatment of comorbidites aids wound healing, as can
Neoangiogenesis and vasculogenesis occur due to the be seen in our study, where the blood glucose levels
stimulation of bone marrow-derived progenitor remain controlled.20
cells.16 Treatment with HBOT has antimicrobial effects The results of our case suggest that healing of DFUs
© 2017 MA Healthcare ltd

and increases intracellular leukocyte killing by the
oxygen-dependent peroxidase system.17 Wounds that
fail to progress through the normal phases of healing
demonstrate significant tissue hypoxia due to a poor
local perfusion.18,19
may be facilitated by a combination of topical hydrogel
and a higher oxygen supply as provided by using a
hyperbaric oxygen chamber. In this patient, the use of
hydrogel in conjunction with HBOT promoted healing
of a DFU.  JWC

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Use for licensed purposes only. No other uses without permission. All rights reserved.
 practice

References
1 Brem H, Sheehan P, Rosenberg HJ et al. Evidence-based protocol for
diabetic foot ulcers. Plast Reconstr Surg 2006:193S–209S. https://doi.
org/10.1097/01.prs.0000225459.93750.29
2 Centers for Disease Control and Prevention. National diabetes fact
sheet: national estimates and general information on diabetes and
prediabetes in the United States, 2011. U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention, 2011.
https://tinyurl.com/ycrabakl (accessed September 7 2017).
3 Oliveira N, Rosa P, Borges L et al. Treatment of diabetic foot
complications with hyperbaric oxygen therapy: A retrospective
experience. Foot Ankle Surg 2014; 20(2):140–143. https://doi.
org/10.1016/j.fas.2014.02.004
4 Jorge SA, Dantas RP. Abordagem Multiprofissional doTratamento de
Feridas,[Multiprofessional approach to the Wounds] [In Portuguese] Ed.
Atheneu, 2003
5 Jones V, Grey JE, Harding KG. Wound dressings. BMJ 2006;
332(7544):777–780. https://doi.org/10.1136/bmj.332.7544.777
6 Herndon DN, Hayward PG, Rutan RL, Barrow RE. Growth hormones
and factors in surgical patients. Adv Surg 1992;25:65–97
7 Gromack DT, Reyes BP, Mustoe TA. Current concepts in wound healing:
growth factor and macrophage interaction. J Trauma Inj Infect Crit Care
1990; 30(12 Suppl):129–133. https://doi.
org/10.1097/00005373-199012001-00026
8 Skalli O, Gabbiani G. 1988. The biology of the myofibroblast relationship
to wound contraction and fibrocontractive diseases. In; Clark RAF,
Henson PM. The molecular and cellular biology of wound repair; New
York: Plenum, Chap. 17, 373-402.
9 Driver VR, Lavery LA, Reyzelman AM et al. A clinical trial of Integra
Template for diabetic foot ulcer treatment. Wound Repair Regen 2015;
23(6):891–900. https://doi.org/10.1111/wrr.12357
10. American Society of Plastic Surgeons. Evidence-based Clinical
Practice Guideline: Chronic Wounds of the Lower Extremity. 2007; 1–21
11 Benamer S, Mahlous M, Boukrif A et al. Synthesis and characterisation
of hydrogels based on poly(vinyl pyrrolidone). Nucl Instrum Methods Phys
Res B 2006; 248(2):284–290. https://doi.org/10.1016/j.nimb.2006.04.072
12 Löndahl M, Katzman P, Nilsson A, Hammarlund C. Hyperbaric oxygen
therapy facilitates healing of chronic foot ulcers in patients with diabetes.
Diabetes Care 2010; 33(5):998–1003. https://doi.org/10.2337/dc09-1754
13 Junior MR, Marra AR. Quando indicar a Oxigenoterapia Hiperbárica?
[When to Indicate Hyperbaric Oxygen Therapy?] [In Portuguese] Rev
AssocMed. Bras 2004; 50:3
14 Vieira WA, Barbosa LR, Martin LM. Hyperbaric oxygen therapy as an
adjuvant treatment for pyoderma gangrenosum. An Bras Dermatol 2011;
86(6):1193–1196. https://doi.org/10.1590/S0365-05962011000600022
15 Thom SR, Bhopale VM, Velazquez OC et al. Stem cell mobilization by
hyperbaric oxygen. AJP: Heart and Circulatory Physiology 2005;
290(4):H1378–H1386. https://doi.org/10.1152/ajpheart.00888.2005
16 Almzaiel AJ, Billington R, Smerdon G, Moody AJ. Effects of hyperbaric
oxygen treatment on antimicrobial function and apoptosis of differentiated
HL-60 (neutrophil-like) cells. Life Sci 2013; 93(2-3):125–131. https://doi.
org/10.1016/j.lfs.2013.06.003
17 Hunt TK, Twomey P, Zederfeldt B, Dunphy JE. Respiratory gas
tensions and pH in healing wounds. Am J Surg 1967; 114(2):302–307.
https://doi.org/10.1016/0002-9610(67)90388-1
18 Niinikoski JH. Clinical hyperbaric oxygen therapy, wound perfusion,
and transcutaneous oximetry. World J Surg 2004; 28(3):307–311. https://
doi.org/10.1007/s00268-003-7401-1
19 Shobhana R, Rao PR, Lavanya A et al. Cost burden to diabetic
patients with foot complicationsa study from southern India. J Assoc
Physicians India 2000; 48(12):1147–1150.
20 Ruocco E, Sangiuliano S, Gravina AG et al. Pyoderma gangrenosum:
an updated review. J Eur Acad Dermatol Venereol 2009; 23(9):1008–1017.
https://doi.org/10.1111/j.1468-3083.2009.03199.x

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