Microenvironment of diabetic foot ulcers: Implications for healing and therapeutic strategies

Diabetic foot ulcers (DFUs) are a common yet serious complication in individuals with diabetes, often presenting as chronic, nonhealing wounds that significantly impair quality of life. The healing process of DFUs is largely influenced by the local microenvironment, which encompasses factors such as hypoxia, inflammation, and the involvement of various cell types. Poor blood circulation in the affected area results in hypoxia, compromising cellular function and restricting nutrient supply, thereby delaying wound healing. In addition, chronic inflammation disrupts immune system balance, with excessive pro-inflammatory cytokines not only failing to facilitate tissue repair but also exacerbating tissue damage. Moreover, key cell types, including fibroblasts, keratinocytes, and macrophages, play crucial roles at different stages of the healing process, contributing to collagen production and skin regeneration. A comprehensive understanding of the complex dynamics within the DFU microenvironment is essential for developing more precise therapeutic approaches, such as advanced drug delivery systems and bioactive materials, aimed at promoting wound healing and reducing the risk of recurrence.

Composite Hyaluronic Acid Gas-Entrapping Materials to Promote Wound Healing

Tissue repair is often impaired in pathological states, highlighting the need for innovative wound-healing technologies. This study introduces composite hyaluronic acid gas-entrapping materials (GEMs) delivering carbon monoxide (CO) to promote wound healing in pigs. These composite materials facilitate burst release followed by sustained release of CO over 48 h. In a porcine full-thickness wound model, CO-GEMs significantly accelerated wound closure compared to the standard-of-care dressing (Tegaderm). Wound area closure with CO-GEMs was 68.6% vs 56.8% on day 14, 41.0% vs 25.1% on day 28, and 26.9% vs 11.8% on day 42, effectively reducing healing time by 14 days. Histological analysis revealed increased epithelialization and neovascularization with reduced inflammation. These findings demonstrate the potential of CO-GEMs as a topical therapeutic to enhance tissue repair in clinically relevant models, supporting further testing for wound-healing applications.

Skin necrosis after autologous fat grafting for augmentation rhinoplasty: a case report and review of the literature

BACKGROUND

Autologous fat transplantation has gained increasing attention in the field of cosmetic surgery. However, a series of complications can occur after fat transplantation.

CASE PRESENTATION

A 24-year-old woman presented at our Hospital with nasal skin necrosis and ulceration. She had undergone autologous fat transplantation on the nose six days ago. Physical examination showed an abnormal skin range of approximately 5 × 2 cm on the left side of the nose. The initial diagnosis was "skin necrosis after autologous fat grafting for augmentation rhinoplasty." In addition to the conventional treatment, topical oxygen therapy (TOT) and platelet-rich fibrin (PRF) injection were applied to the nasal wounds area. After 16 days, the pale and dark areas of necrosis on nose were scabby, and the local skin conditions were significantly improved.

CONCLUSION

We treated a case of ischemic necrosis of the skin after autologous fat grafting for augmentation rhinoplasty. For this kind of local vascular embolism, we first proposed a comprehensive therapy of "biological + physical + drug." The therapeutic method achieved satisfactory results, providing a new strategy for the clinical treatment of vascular embolism.

Anaerobes in diabetic foot infections: pathophysiology, epidemiology, virulence, and management

SUMMARYDiabetic foot infections (DFI) are a public health problem worldwide. DFI are polymicrobial, biofilm-associated infections involving complex bacterial communities organized in functional equivalent pathogroups, all including anaerobes. Indeed, multiple pathophysiological factors favor the growth of anaerobes in this context. However, the prevalence, role, and contribution of anaerobes in wound evolution remain poorly characterized due to their challenging detection. Studies based on culture reviewed herein showed a weighted average of 17% of patients with anaerobes. Comparatively, the weighted average of patients with anaerobes identified by 16S rRNA gene sequencing was 83.8%. Culture largely underestimated not only the presence but also the diversity of anaerobes compared with cultivation-independent approaches but both methods showed that anaerobic Gram-negative bacilli and Gram-positive cocci were the most commonly identified in DFI. Anaerobes were more present in deeper lesions, and their detection was associated with fever, malodorous lesions, and ulcer depth and duration. More specifically, initial abundance of Peptoniphilus spp. was associated with ulcer-impaired healing, Fusobacterium spp. detection was significantly correlated with the duration of DFI, and the presence of Bacteroides spp. was significantly associated with amputation. Antimicrobial resistance of anaerobes in DFI remains slightly studied and warrants more consideration in the context of increasing resistance of the most frequently identified anaerobes in DFI. The high rate of patients with DFI-involving anaerobes, the increased knowledge on the species identified, their virulence factors, and their potential role in wound evolution support recommendations combining debridement and antibiotic therapy effective on anaerobes in moderate and severe DFI.

Hypoxic environment of wounds and photosynthesis-based oxygen therapy

The hypoxic environment is among the most important factors that complicates the healing of chronic wounds, such as venous leg ulcers, pressure injuries and diabetic foot ulcers, which seriously affects the quality of life of patients. Various oxygen supply treatments are used in clinical practice to improve the hypoxic environment at the wound site. However, problems still occur, such as insufficient oxygen supply, short oxygen infusion time and potential biosafety risks. In recent years, artificial photosynthetic systems have become a research hotspot in the fields of materials and energy. Photosynthesis is expected to improve the oxygen level at wound sites and promote wound healing because the method provides a continuous oxygen supply and has good biosafety. In this paper, oxygen treatment methods for wounds are reviewed, and the oxygen supply principle and construction of artificial photosynthesis systems are described. Finally, research progress on the photosynthetic oxygen production system to promote wound healing is summarized.

An Observational Clinical Trial Examining the Effect of Topical Oxygen Therapy (Natrox™) on the Rates of Healing of Chronic DiAbetic Foot Ulcers (OTONAL Trial)

Natrox™ topical oxygen therapy (TOT) (Inotec AMD Ltd, Cambridgeshire, UK) employs a small battery-powered "oxygen generator" to concentrate atmospheric oxygen and feeds pure, moist, oxygen through a fine, soft tube to a dressing-like "oxygen distribution system", which is placed over the wound and is held in place by a conventional dressing. The aim was to determine the effectiveness of Natrox™ for non-healing diabetic foot ulcers (DFU) over a 3-month period.Longitudinal, single-arm, open prospective registry study using 12 weeks of TOT using a 4 week run-in period. 20 patients recruited to OTONAL had chronic DFU greater than 3 months duration or minor amputation sites with less than 50% healing in 4 weeks.There were 13 (65%) males and the mean age was 65.7 (±11.6) years. The mean glycated haemoglobin (HbA1c) was 6.9 (±1.3) mmol mol-1 and mean wound duration before TOT was 114 (±79.1) days. 18/20 (90.0%) patients had concomitant lower limb revascularization angioplasty for chronic limb threatening ischaemia. The mean size of the foot ulcer at baseline was 11.3 ± 14.8 cm2 and mean transcutaneous oxygen measurement value was 34.1 (±19.6) mm Hg. Wound closure of >75% was observed in 14/20 (70.0%) patients. There was a 91.3% (±14.9%) wound area reduction by 3 months (P = .001) and mean time for 100% closure was 77.6 ± 32.5 days. Mean pain scores reduced from 2.4 (±1.8) at baseline to .5 (±1.0) at 3 months (P = .008). All patients were very satisfied using the ambulatory device. Use of TOT in chronic diabetic foot wounds stimulates a healing state, underpinning the concept that oxygen plays a central role in wound healing. Our results are more compelling if you consider they started with relatively large-sized DFUs and majority of patients were frail with underlying peripheral artery disease. (NCT03863054).

Modulation of diabetic wound healing using carbon monoxide gas-entrapping materials

Diabetic wound healing is uniquely challenging to manage due to chronic inflammation and heightened microbial growth from elevated interstitial glucose. Carbon monoxide (CO), widely acknowledged as a toxic gas, is also known to provide unique therapeutic immune modulating effects. To facilitate delivery of CO, we have designed hyaluronic acid-based CO-gas-entrapping materials (CO-GEMs) for topical and prolonged gas delivery to the wound bed. We demonstrate that CO-GEMs promote the healing response in murine diabetic wound models (full-thickness wounds and pressure ulcers) compared to N2-GEMs and untreated controls.

Systematic review of the effects of topical oxygen therapy on wound healing

Background

Various adjunct therapies are available for wound healing in addition to standard care. Topical oxygen therapy (TCOT) is one such novel therapy. We conducted a systematic review and meta-analysis to evaluate the role of TCOT in the healing of cutaneous wounds of any etiology.

Methods

The review was conducted on articles related to wounds treated with TCOT identified through PubMed, MEDLINE/OVID, Cochrane, and Google Scholar. We included randomized controlled trials, double-arm prospective studies, single-arm prospective studies, case-control series, and case reports published on or after 2012. Only articles addressing TCOT were included; other forms of oxygen delivery were excluded. We aimed to evaluate the proportion of wounds completely healed, the percent decrease in wound area of those not completely healed, the recurrence of wounds after treatment, and effects on pain and ulcer rating scales.

Results

A total of 22 articles were included in this review. The results showed that TCOT has a significant salutary effect on complete wound healing in case-control studies (odds ratio, 4.48; 95% confidence interval, 2.05-9.77; P < .001; I 2 = 76.34%) and in single-arm studies (pooled prevalence, 0.48 [48.0%]; 95% confidence interval, 0.34-0.62; P < .001; I 2 = 86.58). However, no significant effect was observed for percent wound reduction, the difference in ulcer grade scores, or the difference in pain scores. Most of the included studies had a high risk of bias because they were not blinded, were single-arm studies, or were case reports.

Conclusions

Our findings indicate that TCOT can have a positive effect on wound healing when compared with standard care. However, owing to the lack of randomized, controlled trials or studies with comparable end points, a definitive conclusion on the full impact of TCOT on wound healing cannot be reached. More high-quality data are needed to definitively determine the effects of TCOT on wound healing, preferably from a comprehensive, randomized controlled trial.

Consenso de expertos sobre la eficacia clínica y directrices sobre la terapia de oxígeno transdérmico continuo para la cicatrización de las heridas complejas o difíciles de cicatrizar

INTRODUCTION

Oxygen is pivotal for wound healing. Its lack or hypoxia can delay this process, especially in individuals with comorbidities, potentially resulting in complex or hard-to-heal wounds. The Colombian Association of Diabetes (ACD) and the Colombian Association of Internal Medicine (ACMI) collaborated with a diverse group of experts to provide recommendations on the efficacy and best practices of continuous transdermal oxygen therapy (TOTc) in the care of such wounds.

METHOD

A modified Delphi technique was employed to obtain controlled feedback and responses. Experts from various disciplines engaged in reviewing and discussing numerous relevant scientific studies, focusing on the role of TOTc in treating chronic ulcers.

RESULTS

Continuous transdermal oxygen therapy has proven to be an effective and safe treatment for chronic and/or hard-to-heal ulcers. This therapy directly addresses the wound's oxygen deficiency, providing an environment conducive to healing. Significant benefits were observed, including the acceleration of the healing process, wound size reduction, and an enhancement in patient quality of life. Its efficacy was found across various ulcer etiologies, underscoring its therapeutic versatility.

CONCLUSIONS

Continuous transdermal oxygen therapy is effective and safe for treating chronic and hard-to-heal ulcers. It's crucial to address each case individually and through a multidisciplinary approach to maximize this therapy's benefits. Both evidence and clinical experience back its utility across a variety of ulcer etiologies.

H2O2-PLA-(Alg)2Ca Hydrogel Enriched in Matrigel® Promotes Diabetic Wound Healing

Hydrogel-based dressings exhibit suitable features for successful wound healing, including flexibility, high water-vapor permeability and moisture retention, and exudate absorption capacity. Moreover, enriching the hydrogel matrix with additional therapeutic components has the potential to generate synergistic results. Thus, the present study centered on diabetic wound healing using a Matrigel-enriched alginate hydrogel embedded with polylactic acid (PLA) microspheres containing hydrogen peroxide (H2O2). The synthesis and physicochemical characterization of the samples, performed to evidence their compositional and microstructural features, swelling, and oxygen-entrapping capacity, were reported. For investigating the three-fold goal of the designed dressings (i.e., releasing oxygen at the wound site and maintaining a moist environment for faster healing, ensuring the absorption of a significant amount of exudate, and providing biocompatibility), in vivo biological tests on wounds of diabetic mice were approached. Evaluating multiple aspects during the healing process, the obtained composite material proved its efficiency for wound dressing applications by accelerating wound healing and promoting angiogenesis in diabetic skin injuries.

Cellular Therapeutics for Chronic Wound Healing: Future for Regenerative Medicine

Chronic wounds are associated with significant morbidity and mortality, which demand long-term effective treatment and represent a tremendous financial strain on the global healthcare systems. Regenerative medicines using stem cells have recently become apparent as a promising approach and are an active zone of investigation. They hold the potential to differentiate into specific types of cells and thus possess self-renewable, regenerative, and immune-modulatory effects. Furthermore, with the rise of technology, various cell therapies and cell types such as Bone Marrow and Adipose-derived Mesenchymal Cell (ADMSC), Endothelial Progenitor Cells (EPCs), Embryonic Stem Cells (ESCs), Mesenchymal Stem Cell (MSCs), and Pluripotent Stem Cells (PSCs) are studied for their therapeutic impact on reparative processes and tissue regeneration. Cell therapy has proven to have substantial control over enhancing the quality and rate of skin regeneration and wound restoration. The literature review brings to light the mechanics of wound healing, abnormalities resulting in chronic wounds, and the obstacles wound care researchers face, thus exploring the multitude of opportunities for potential improvement. Also, the review is focused on providing particulars on the possible cell-derived therapeutic choices and their associated challenges in healing, in the context of clinical trials, as solutions to these challenges will provide fresh and better future opportunities for improved study design and therefore yield a substantial amount of data for the development of more specialized treatments.

pH-switchable nanozyme cascade catalysis: a strategy for spatial-temporal modulation of pathological wound microenvironment to rescue stalled healing in diabetic ulcer

The management of diabetic ulcer (DU) to rescue stalled wound healing remains a paramount clinical challenge due to the spatially and temporally coupled pathological wound microenvironment that features hyperglycemia, biofilm infection, hypoxia and excessive oxidative stress. Here we present a pH-switchable nanozyme cascade catalysis (PNCC) strategy for spatial–temporal modulation of pathological wound microenvironment to rescue stalled healing in DU. The PNCC is demonstrated by employing the nanozyme of clinically approved iron oxide nanoparticles coated with a shell of glucose oxidase (Fe₃O₄-GOx). The Fe₃O₄-GOx possesses intrinsic glucose oxidase (GOx), catalase (CAT) and peroxidase (POD)-like activities, and can catalyze pH-switchable glucose-initiated GOx/POD and GOx/CAT cascade reaction in acidic and neutral environment, respectively. Specifically, the GOx/POD cascade reaction generating consecutive fluxes of toxic hydroxyl radical spatially targets the acidic biofilm (pH ~ 5.5), and eradicates biofilm to shorten the inflammatory phase and initiate normal wound healing processes. Furthermore, the GOx/CAT cascade reaction producing consecutive fluxes of oxygen spatially targets the neutral wound tissue, and accelerates the proliferation and remodeling phases of wound healing by addressing the issues of hyperglycemia, hypoxia, and excessive oxidative stress. The shortened inflammatory phase temporally coupled with accelerated proliferation and remodeling phases significantly speed up the normal orchestrated wound-healing cascades. Remarkably, this Fe₃O₄-GOx-instructed spatial–temporal remodeling of DU microenvironment enables complete re-epithelialization of biofilm-infected wound in diabetic mice within 15 days while minimizing toxicity to normal tissues, exerting great transformation potential in clinical DU management. The proposed PNCC concept offers a new perspective for complex pathological microenvironment remodeling, and may provide a powerful modality for the treatment of microenvironment-associated diseases.

Management of Diabetic Foot Ulcers Using Topical Oxygen Therapy: A Case Series

BACKGROUND AND AIM

Surgical and endovascular revascularization procedures along with hyperbaric oxygen therapy (HBOT) and topical oxygen therapy (TOT) for chronic oxygen-deprived wounds are standard care treatment protocols for diabetic foot ulcer (DFU). Topical developments in the delivery of topical oxygen therapy have made this a more feasible treatment in practice. The present case series highlights the efficacy of NATROX therapy as TOT in wound healing and the impact of increased oxygenation on ulcer healing in patients with diabetic foot ulcers.

METHODS

The TOT was evaluated in 6 patients with DFU who have applied NATROX topical oxygen delivery system for a period ranging from 6 weeks to 24 weeks at Kahel Specialized Centre, located in Olaya, Riyadh, Saudi Arabia.

RESULTS

The administration of TOT demonstrated complete wound healing in all the six patients who either had ulcers with minor amputation of toes/heel or had ulcers with other comorbidities in a range from 3 to 8 weeks.

CONCLUSION

NATROX therapy is an advanced topical oxygen delivery system compared to other conventional oxygen delivery systems; however, the study warrants further research to assess its potential applicability in DFU wound healing in large sample size and across the races.

Inflammatory Biomarkers as Predictors of Infected Diabetic Foot Ulcer

Diabetic foot ulcer infection is a crucial complication associated with lower-limb amputation and postoperative mortality in individuals with diabetes mellitus. Deciding if a diabetic foot ulcer is infected in a community setting is challenging without validated point-of-care tests. Early detection of infected diabetic foot ulcers can reduce the frequency of hospitalizations, the occurrence of disability, and chances of mortality. Inflammatory biomarkers are predictors of infected diabetic foot ulcers and lower-limb amputation. Procalcitonin, CRP, pentraxin-3, interleukin-6, and calprotectin may help distinguish uninfected from mildly infected diabetic foot ulcers and diagnose soft tissue infections, bone lesions, and sepsis in diabetic patients. Moreover, these biomarkers may be predictors of lower-limb amputation and postoperative mortality. The current management of infected diabetic foot ulcers is disappointing and unsatisfactory, both in preventing its development and halting and modifying its progression. The use of new (molecular) techniques for the identification of the IDFU has not yet to be proven superior to classic cultural techniques for the management of such patients. For clinicians, if the risk stratification of DFU can be obtained earlier in diabetic patients, the hospitalization, disability, and mortality rate will be reduced. For the practical application of these biomarkers, it is important to correlate these quantitative parameters with clinical symptoms. Based on clinical observations and inflammatory biomarker evaluation, it can be used to guide clinical treatment methods. This review details clinical information published during the past several decades and discusses inflammatory biomarkers that may determine the risk and level of infection of diabetic foot ulcers.

Diabetic Wound-Healing Science

Diabetes mellitus is an increasingly prevalent chronic metabolic disease characterized by prolonged hyperglycemia that leads to long-term health consequences. It is estimated that impaired healing of diabetic wounds affects approximately 25% of all patients with diabetes mellitus, often resulting in lower limb amputation, with subsequent high economic and psychosocial costs. The hyperglycemic environment promotes the formation of biofilms and makes diabetic wounds difficult to treat. In this review, we present updates regarding recent advances in our understanding of the pathophysiology of diabetic wounds focusing on impaired angiogenesis, neuropathy, sub-optimal chronic inflammatory response, barrier disruption, and subsequent polymicrobial infection, followed by current and future treatment strategies designed to tackle the various pathologies associated with diabetic wounds. Given the alarming increase in the prevalence of diabetes, and subsequently diabetic wounds, it is imperative that future treatment strategies target multiple causes of impaired healing in diabetic wounds.

Impact of topical oxygen therapy on diabetic foot ulcer healing rates: a systematic review

OBJECTIVE

The aim of this systematic review was to determine the impact of topical oxygen therapy (TOT) on diabetic foot ulcer (DFU) healing.

METHOD

Using systematic review methodology, we considered randomised controlled trials (RCTs), controlled trials, pilot studies and observational studies. The search was conducted in January 2019, using PubMed, CINAHL, Ovid, Cochrane, Web of Science and EMBASE databases. Data analysis was undertaken using RevMan and a narrative synthesis. The article titles were assessed by two authors independently, and the abstracts (when available) of the studies identified by the search strategy were screened for their eligibility, according to the inclusion and exclusion criteria. The full-text version of potentially relevant studies was obtained and two authors independently screened this against the inclusion criteria. Data were extracted using a predesigned extraction tool and all included studies were quality appraised using the Evidence-Based Librarianship checklist.

RESULTS

The search returned 565 records of which eight met the inclusion criteria. Of the included studies, three were set in single centre outpatient wound clinics, two studies were set in an outpatient wound care research clinic and three studies were multisite. Meta-analysis of four studies was undertaken. DFUs are >2 times more likely to heal with TOT than with standard care alone. The odds ratio (OR)=2.49 (95% confidence interval (CI): 1.59-3.90, p=0.00001). The remaining four studies also showed that using TOT increased healing rates. An included study reported that time to 50% DFU closure was significantly shorter in participants who received the TOT, mean 18.4 days versus 28.9 days in the sham therapy group (p=0.001). However, the validity of 65.5% of the eight studies was assessed as low.

CONCLUSION

The findings suggest that TOT enhances healing for patients with hard-to-heal DFUs when used with standard care. The results from the trials reviewed also indicate a benefit for patients over standard care alone. However, the sample sizes in the studies were generally small, thus, more RCTs are warranted to further validate these findings.

DECLARATION OF INTEREST

The authors have no conflicts of interest to declare.

Topical oxygen treatment relieves pain from hard-to-heal leg ulcers and improves healing: a case report

Pain from hard-to-heal wounds is common and challenging to manage with current therapies. Most hard-to-heal wounds show some degree of hypoxia that impairs healing and contributes to pain. Regular oxygen therapy is given in hyperbaric oxygen chambers and is costly, time-consuming and cannot be offered to most patients. Moreover, hyperbaric oxygen therapy (HBOT) only increases tissue oxygen for a short time and is given only for a few hours per week. Topical oxygen therapy (TOT) was introduced as an alternative and in this report we focus on topical continuous oxygen therapy (TCOT), which has been shown to be associated with healing of hard-to-heal ulcers. We report on a patient with type 1 diabetes with a painful hard-to-heal lower leg ulcer that failed to heal with standard wound dressings and that had insufficient response to pharmacological analgesia. The patient was on three different analgesics before treating the wound with TCOT. As the wound was considered hypoxic, due to longstanding diabetes and probable microangiopathy, TCOT was commenced. Within one week of treatment starting, the patient spontaneously ceased all his analgesics as he was free of pain; and after 2.5 months, the ulcer healed. The patient reported no adverse effects. In addition to promoting healing, TCOT may also be considered for its potential analgesic effects in hard-to-heal wound management.

Topical oxygen therapy in the treatment of diabetic foot ulcers: a multicentre, open, randomised controlled clinical trial

OBJECTIVES

Perfusion and blood oxygen levels are frequently insufficient in patients with hard-to-heal wounds due to poor circulation, vascular disruption and vasoconstriction, reducing the wound's capacity to heal. This study aimed to investigate the effect of topical oxygen on healing rates in patients with hard-to-heal diabetic foot ulcers (DFUs) (i.e., non-responsive over four weeks).

METHOD

This multicentre, open-label, community-based randomised clinical trial compared standard care (SOC) with or without continuous topical oxygen therapy (TOT) for 12 weeks in patients with DFUs or minor amputation wounds. SOC included debridement, offloading with total contact casting (TCC) and appropriate moisture balance. Primary endpoints were the number of patients to achieve complete wound closure and percentage change in ulcer size. Secondary endpoints were pain levels and adverse events.

RESULTS

For the study, 145 patients were randomised with index ulcers graded Infectious Diseases Society of America (IDSA) 1 or 2, or Wagner 1 or 2. In the intention-to-treat analysis, 18/64 (28.1%) patients healed in the SOC group at 12 weeks compared with 36/81 (44.4%) in the SOC plus TOT group (p=0.044). There was a statistically significant reduction in wound area between the groups: SOC group mean reduction: 40% (standard deviation (SD) 72.1); SOC plus TOT group mean reduction: 70% (SD 45.5); per protocol p=0.005). There were no significant differences in changes to pain levels or adverse events.

CONCLUSION

This study suggests that the addition of TOT to SOC facilitates wound closure in patients with hard-to-heal DFUs.

Therapeutic effect of continuous diffusion of oxygen therapy combined with traditional moist wound dressing therapy in the treatment of diabetic foot ulcers

AIMS

To investigate the therapeutic effect of continuous diffusion of oxygen (CDO) combined with traditional moist wound dressing (MWD) on the diabetic foot ulcers (DFUs) inpatients.

METHODS

The inpatients from May 2016 to April 2018 were enrolled and randomly divided into MWD, CDO and combination treatment groups (n = 40 each group). The moist dressing was used in the MWD group while a micro-oxygen supply device was used in the CDO group. The combination treatment group was given both MWD and CDO. All patients were treated for 8 weeks. The wound healing, amputation rate, and inflammatory control were evaluated.

RESULTS

Compared with MWD and CDO groups, the combination group showed a higher wound healing rate (P < 0.05), lower white blood cell count (P < 0.05) and lower high-sensitivity C-reactive protein level (P < 0.05). During 1-year follow-up, the amputation rate was 0% in combination group, which was significantly lower than that in other two groups (P < 0.05).

CONCLUSIONS

The combination of MWD and CDO was effective in promoting healing and preventing infection of DFUs, which holds a potential to be a new strategy for the treatment of this critical clinical condition.

Autologous non-cultured keratinocyte cell suspension in non-healing diabetic ulcers: A preliminary study

Background:

Diabetic ulcers are a common morbidity associated with poorly controlled glycemic status. Most patients often have neuropathy and vasculopathy as the etiology behind such ulcers. These factors not only lead to poor wound healing but also nonhealing ulcers. Nonhealing ulcers pose therapeutic challenges as they are usually not amenable to be treated with simple wound care and hence require newer modalities to effectively cure this condition that leads to a plethora of poor health outcomes. This study was conducted to see the effect of autologous noncultured keratinocyte cell suspension in chronic nonhealing diabetic ulcers that failed to normal wound care.

Material and Methods:

It was an observational pilot study. A total of 05 patients with nonhealing ulcers, attending the tertiary care teaching hospital in North India, were included in the study. Inclusion criteria was type 2 DM with more than 5 years duration of diabetes mellitus and glycated hemoglobin (HbA1c) <9 g%. History was taken in detail; name, age, sex, address, duration of disease and various other treatments taken from outside were noted; and size of ulcer was recorded as per Proforma.

Results:

A total of 5 patients were enrolled in the study, three (60%) and two (40%) patients were male and female, respectively. Three (60%) patients were habitual for tobacco use. Mean age of patients was 45 ± 6.51 years. Mean duration of ulcers was 4.8 ± 1.48 months. Area of ulcers ranged from 31.2 to 122.2 cm². Majority of cases, three (60%) of diabetic foot ulcers, were improved at 9–12 weeks and remaining two cases with large size of ulcer were healed at 13–16 weeks and 17–20 weeks, respectively. Majority (80%) of patients revealed >50% reduction in the size of ulcer within 2 weeks.

Conclusion:

Noncultured keratinocytes are useful in healing of nonhealing diabetic ulcer.

Oxygen therapy: evidence base

The evidence base for the different methods of oxygen therapy ranges from systematic reviews and meta-analyses to case series evaluations. A common thread running through the assorted evidence is that oxygen therapy accelerates healing and reduces healing times. This article summarises the clinical evidence produced on this therapy.

Therapeutic Effects of Hyperbaric Oxygen in the Process of Wound Healing

Chronic and non-healing wounds, especially diabetic foot ulcers and radiation injuries, imply remarkable morbidity with a significant effect on the quality of life and a high sanitary cost. The management of these wounds requires complex actions such as surgical debris, antibiotic treatment, dressings and even revascularization. These wounds are characterized by poor oxygen supply resulting in inadequate oxygenation of the affected tissue. The adjuvant treatment with hyperbaric oxygen therapy (HBOT) may increase tissue oxygenation favoring the healing of wounds which do not respond to the usual clinical care. The increase in the partial pressure of oxygen contributes to cover the energy demands necessary for the healing process and reduces the incidence of infections. Moreover, the increase in oxygen leads to the production of reactive species with hormetic activity, acting on signaling pathways that modulate the synthesis of inflammation mediators, antioxidants and growth factors which can contribute to the healing process. Studies performed with cell cultures and in animal models seem to demonstrate the beneficial effects of HBOT. However, clinical trials do not show such conclusive results; thus, additional randomized placebo-controlled studies are necessary to determine the real efficacy of HBOT and the mechanism of action for various types of wounds.

Application of Topical Oxygen Therapy in Healing Dynamics of Diabetic Foot Ulcers - A Systematic Review

BACKGROUND

Individuals with diabetes may develop diabetic foot ulcers due to diabetic peripheral neuropathy. Multiple factors influence the ulcer healing process; oxygen helps in facilitating the different stages of wound healing.

OBJECTIVE

The objective of this systematic review was to analyze the different levels of evidence available in the application of topical oxygen therapy, warm oxygen therapy, or other modes of topical oxygen delivery in the healing dynamics of diabetic foot ulcers.

METHODS

Databases searched included Pubmed/Medline, Science Direct, Web of Science, Scopus, Cochrane, and CINAHL. The eligibility criteria of studies included participants ≥18 years with chronic non-healing diabetic foot ulcer (duration ≥3 months) receiving warm oxygen or topical oxygen therapy (TOT), and other modes of topical oxygen administration, which were compared with standard care group. Randomized and non-randomized studies were included. The primary outcome measure assessed was the rate of wound healing or wound closure.

RESULTS

The review included 5 studies which used different modes of topical oxygen administration. The healing trajectory of the wounds was completely achieved in low-grade ulcers (grade 1), whereas all high-grade ulcers (grades 2, 3, and above) showed either 100% or 50% healing with a reduction in ulcer size and ulcer tissue depth.

CONCLUSION

Topical oxygen therapy facilitates wound healing dynamics among individuals with chronic diabetic foot ulcers.

Topical oxygen therapy stimulates healing in difficult, chronic wounds: a tertiary centre experience

OBJECTIVE

Oxygen plays a central role in wound healing. Recent technological advances have miniaturised oxygen delivery systems, with novel topical oxygen therapy allowing patients to receive oxygen therapy 24 hours a day while remaining completely mobile. Here we aim to examine the efficacy and safety of continuous topical oxygen diffusion in a 'real-world' setting.

METHODS

Topical oxygen therapy (TOT) was evaluated in patients with chronic, non-healing wounds in a tertiary referral specialist clinic.

RESULTS

The mean wound duration before TOT was 15 months. Regardless of treatment duration, in this previously non-healing group complete wound closure was observed in 32% of the total patients treated with the TOT device. However, optimal wound healing occurred when the device was used for >25 days, with an 83% wound area reduction and 47% wound closure rate seen in venous leg ulcers (VLUs) and a 74% reduction and a 57% wound closure rate in arterial foot ulcers.

CONCLUSION

Use of TOT in chronic wounds stimulates a healing state. In our study, almost half of the previously non-healing wounds closed.