Effects of Photobiomodulation Therapy on the Expression of Hypoxic Inducible Factor, Vascular Endothelial Growth Factor, and Its Specific Receptor: A Randomized Control Trial in Patients with Diabetic Foot Ulcer

Background: Impaired angiogenesis is a significant factor contributing to delayed healing in diabetic foot ulcers (DFUs) due to inadequate oxygenation. Objective: This study aimed to investigate the impact of photobiomodulation (PBM) using a Ga-As laser on the release of serum hypoxia-inducible factor 1-α (HIF-1α), vascular endothelial growth factor (VEGF), vascular endothelial growth factor receptor-2, and nitric oxide (NO) in diabetic patients with DFUs. Materials and methods: In this double-blind RCT, a total of 30 patients with grade II DFUs were enrolled. The patients were randomly divided into two groups: the PBM (n = 15) and the placebo (n = 15). In the PBM group, a Ga-As laser (904 nm, 2 J/cm2, 90 W) was given for 3 days/week for 4 weeks (11 sessions). In the placebo group, the power was turned off. Both groups received similar standard wound care. Before and after interventions, the levels of serum HIF-1α, VEGF, NO, and sVEGFR-2 were measured. In addition, the percentage decrease in the wound surface area (%DWSA) was measured. Results: Following the intervention, the results revealed that the PBM group had significantly lower levels of VEGF than the placebo group (p = 0.005). The %DWSA was significantly higher in the PBM group compared to the placebo group (p = 0.003). Moreover, VEGF showed a significant negative correlation with %DWSA (p < 0.001). Conclusions: The observed decrease in serum levels of VEGF and an increase in %DWSA, compared to the placebo group, suggests that PBM effectively improves angiogenesis. Furthermore, the significant correlation found between VEGF levels and %DWSA emphasizes the importance of evaluating wound surface in patients as a dependable indicator of enhanced wound angiogenesis. Clinical Trial Registration: NCT02452086.

Diabetic foot wound ulcer management by laser therapy: A meta-analysis

A meta-analysis examination was implemented to review diabetic foot wound ulcer (DFWU) management by laser therapy (LT). A broad literature examination until May 2023 was done and 1357 interconnected examinations were revised. The 26 elected examinations, enclosed 1067 personals with DFWU were in the utilized examinations 'starting point, 540 of them were utilizing LT, and 527 were utilizing control. Odds ratio (OR) and 95% confidence intervals (CIs) were utilized to appraise the DFWUs management by LT by the dichotomous and continuous approach and a fixed or random model. LT had significantly higher ulcer size decreases (MD, 17.04; 95% CI, 12.48-21.59, p < 0.001) with high heterogeneity (I2  = 99%), and complete healing rate (OR, 2.88; 95% CI, 1.89-4.37, p < 0.001) with no heterogeneity (I2  = 0%) compared with control in personals with DFWU. LT had significantly higher ulcer size decreases, and complete healing rate compared to control in personals with DFWU. Nevertheless, exercise caution while interacting with its values since all the chosen examinations were found with a low sample size for the comparisons in the meta-analysis.

Clinical Effect of Photobiomodulation on Wound Healing of Diabetic Foot Ulcers: Does Skin Color Needs to Be Considered?

Diabetic foot ulcers (DFUs) are one of the most common complications of diabetes. DFUs impede patients' quality of life and are known to be unresponsive to conventional therapy. Photobiomodulation (PBM) is a pain-free, noninvasive treatment method that has been shown to promote chronic wound healing and has been successfully used for the treatment of DFUs. Since skin tone and color can affect the way light interacts with tissue, studies should take this into consideration when determining protocols for the use of PBM. This review is aimed at critically evaluating data of existing studies conducted to evaluate the clinical effect of PBM on DFUs, taking skin color into consideration. A literature search was conducted and resulted in articles on cell studies, animal studies, and clinical trials. Only 13 clinical trials and 2 clinical case studies were adopted and used in this review. All the clinical trials adopted for this review show evidence that PBM together with conventional treatment results in an increased healing rate of DFUs; however, only one study adjusted their protocol according to skin color. There are not enough studies conducted on people of color to determine the safety and efficacy of PBM therapy in such ethnic groups. Future randomized, placebo-controlled clinical trials are necessary on PBM and DFUs and should take skin color into consideration.

A Systematic Review and Meta-Analysis of the Effects of Low-Level Laser Therapy in the Treatment of Diabetic Foot Ulcers

Diabetic foot ulcers (DFUs) are considered one of the most aggressive and expensive complications of diabetes. Low-level laser therapy (LLLT) has been highlighted as a potential modality of treatment to accelerate the healing of ulcers. This systematic review and meta-analysis aimed to investigate the efficacy of LLLT in the treatment of DFU and identify the LLLT application parameters recommended for the treatment of DFU over the past 10 years. A systematic search was conducted in PubMed, BVS, PEDro, Scopus, Web of Science, and CINAHL up to March 31, 2019. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines, randomized controlled trials (RCTs) that assessed the effect of LLLT on the treatment of DFU were included. Thirteen RCTs with a total of 361 participants were included in this review. Three RCTs reported a reduction in the percentage size of the ulcers and were included in the meta-analysis. The meta-analysis of the percentage size difference demonstrated a significant reduction in ulcer size in the LLLT group compared with controls (22.96 [95% confidence interval = 18.22-27.69; z = 9.51, P < .0001]). Treatment with 632.8 to 685 nm, 50 mW/cm2, 3 to 6 J/cm2, and irradiation for 30 to 80 seconds, 3 times weekly for a month is of benefit to patients with DFU. LLLT is effective and safe for the treatment of DFU. Additionally, well-designed, high-quality studies are needed to allow its ideal parameterization for clinical practice.

Diabetic Foot Wounds Treated With Human Amniotic Membrane and Low-level Laser Therapy: A Pilot Clinical Study

BACKGROUND

Low-level laser therapy (LLLT) and human amniotic membrane (HAM) application have been shown to be viable options for use in wound healing.

PURPOSE

This study sought to compare LLLT and HAM to a control treatment (hydrogel, saline, and gauze) in persons with diabetes mellitus (DM) and foot ulcers.

METHODS

Using a prospective pilot clinical study design, patients receiving care at a health center that specializes in the treatment of diabetic foot wounds between November 2016 and August 2017 were recruited. Eligible patients had to be 30 to 59 years of age; diagnosed with type 2 DM (postprandial capillary glucose levels between 140 and 350 mg/dL); and have uninfected, granulating stage 2 or 3 foot ulcers measuring less than 7 cm by 3 cm. Immunosuppressed and malnourished patients or those with neoplasms or in critical condition were not eligible to participate. Patients received the control treatment (2 mg hydrogel, saline, and gauze), HAM (patches of thawed HAM, applied with overlapping edges), or LLLT (phototherapy session, 2 mg hydrogel, saline, and gauze) for 28 days. Variables, wound area measurements, Pressure Ulcer Scale for Healing (PUSH) scores, and Visual Analog Scale (VAS) scores were used to assess wound improvement progress and pain on days 7, 14, 21, and 28. Descriptive statistics were used to analyze the participant anthropometric and clinical profiles. The Kolmogorov-Smirnov test was used to analyze the sample distribution. The Kruskal-Wallis test with Dunn's post-test was used to evaluate differences in PUSH and VAS scores and wound size for intergroup analysis, and the Mann-Whitney U test was used for the same outcomes in intragroup analysis. The level of significance was 5% (P < .05).

RESULTS

Twenty-seven (27) patients participated (mean age, 51.4 years; mean body mass index, 26.5 kg/m2), with 9 patients in each treatment group. No statistically significant differences were noted in clinical or anthropometric variables among the groups, but mean baseline wound areas were different (2.6 cm² for the control, 1.9 cm² for the LLLT, and 5.5 cm² for the HAM groups). Intragroup comparisons showed a significant reduction in PUSH score in the LLT group between days 0 and 21 (8.2 vs 4.9; P < .01) and days 21 to 28 (4.9 vs 3.2; P < .001). In all treatment groups the percent reduction was significantly different between days 7 and 28. No outcomes were significantly different between groups.

CONCLUSION

Diabetic foot ulcer wound area as well as PUSH and VAS scores showed more improvement for patients with DM receiving LLLT or HAM than for the control group, but the differences were not significant. Larger studies are needed to compare these treatment modalities.

Treatment of diabetic foot ulcers in a frail population with severe co-morbidities using at-home photobiomodulation laser therapy: a double-blind, randomized, sham-controlled pilot clinical study

PURPOSE

To evaluate the safety and efficacy of an at-home photobiomodulation (PBM) device for the treatment of diabetic foot ulcers (DFUs) in a frail population with severe comorbidities.

METHODS

Prospective, randomized, double-blind, sham-controlled pilot study. Patients (age = 63 ± 11 years, male:female 13:7) with insulin-dependent diabetes type 2, neuropathy, peripheral artery disease, significant co-morbidities, and large osteomyelitis-associated DFUs (University of Texas grade ≥ III) were randomized to receive active (n = 10) or sham (n = 10) at-home daily PBM treatments (pulsed near-infrared 808 nm Ga-Al-As laser, 250 mW, 8.8 J/cm²) for up to 12 weeks in addition to standard care. The primary outcome was the %wound size reduction. The secondary was adverse events.

RESULTS

With the numbers available, PBM-treated group had significantly greater %reduction compared to sham (area [cm²], baseline vs endpoint: PBM 10[20.3] cm² vs 0.2[2.4] cm²; sham, 7.9 [12.0] cm² vs 4.6 [13.8] cm², p = 0.018 by Mann-Whitney U test). Wound closure > 90% occurred in 7 of 10 PBM-treated patients but in only 1 of 10 sham patients (p = 0.006). No adverse device effects were observed.

CONCLUSIONS

Photobiomodulation at home, in addition to standard care, may be effective for the treatment of severe DFUs in frail patients with co-morbidities and is particularly relevant at these times of social distancing. Our preliminary results justify the conduction of a larger clinical trial. ClinicalTrials.gov: NCT01493895.

Low-level Light Therapy for Treatment of Diabetic Foot Ulcer: A Review of Clinical Experiences

BACKGROUND

Diabetic foot ulcers (DFU) represent a significant complication of diabetes mellitus (DM). DFU affect one in four patients with DM and treatments of DFU are limited and challenging. The management of DFU remains a significant healthcare and socioeconomic burden ($245 billion). There is a wide range of advanced therapies for DFU, but these are costly and have demonstrated only minimal efficacy in limited published studies. An emerging treatment modality to improve DFU and optimize wound healing is the use of low-level light therapy (LLLT). LLLT involves the use of light in the form of low-level or low-power laser or light emitting diodes to alter biochemical pathways, which may result in changes to cell shape, cell migration, and cell signaling.<br/>

OBJECTIVE

To review published clinical experiences (case series and case reports) using LLLT for treatment of DFU, and provide evidence-based recommendations and future directions on the potential of LLLT as a therapeutic modality for DFU.<br/>

METHODS AND MATERIALS

On January 16, 2016 we searched the published literature using databases: PubMed, EMBASE, CINAHL, and Web of Science with key terms: "diabetic foot" AND ("low level laser therapy" OR "low level light therapy" OR "LLLT" OR "light emitting diode" OR "phototherapy" OR "laser").<br/>

RESULTS

After screening of titles, abstracts and/or full-text, 7 original articles were suitable in our review. Our review contains 5 case series and 2 case reports that evaluated LLLT for treatment of DFU, and all reviewed studies have shown positive improvement of DFU using LLLT with no adverse events, albeit with limitations that may be minimized with future RCTs.<br/>

CONCLUSIONS

LLLT is an emerging and promising treatment modality to current alternatives that are costly and have shown limited success. Based upon the published evidence, we envision additional research may allow for stronger recommendation with LLLT for treatment of DFU. <br /><br /> <em>J Drugs Dermatol.</em> 2016;15(7):843-848.

Interventional radiology in the diabetic lower extremity

Most of what we know today for interventional techniques for revascularization in patients with DF disease is derived from our knowledge on CLI in patients with PAD. There are today no dedicated randomized controlled trials on interventional treatment of DF. It is, however, clear that huge progress in interventional techniques has been obtained during the past decade. In most institutions, the nonsurgical option is the current first choice. As the aim of treatment is ulcer healing through temporary increase in blood flow, it is still unclear what the contribution of new stent and drug-eluting technologies will have on the clinical outcome of DF treatment. Long-term follow-up studies, dedicated to patients with an arterial DF problem, have to be performed before we can evaluate all these new technologies.

Collagen production in diabetic wounded fibroblasts in response to low-intensity laser irradiation at 660 nm

BACKGROUND

Collagen type I (Col-I) is a major component of the extracellular matrix and is important in wound healing processes. Several studies have shown that low-intensity laser irradiation (LILI) biostimulates Col-I synthesis both in vitro and in vivo. This study aimed to determine if LILI affects collagen production and related cellular responses in an in vitro diabetic wounded fibroblast model.

MATERIALS AND METHODS

This study was performed on isolated human skin fibroblasts. Different cell models (normal and diabetic wounded) were used. Cells were irradiated with 5 J/cm(2) at a wavelength of 660 nm and incubated for 48 or 72 h. Nonirradiated cells (0 J/cm(2)) were used as controls. Cellular viability (Trypan blue exclusion test), morphology (bright-field microscopy), proliferation [VisionBlue™ quick cell proliferation assay and 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay], and Col-I (enzyme-linked immunoabsorbent assay) were assessed.

RESULTS

Diabetic wounded cells irradiated with 5 J/cm(2) at 660 nm showed a significant increase in cell migration, viability, proliferation, and collagen content.

CONCLUSIONS

This study shows that LILI stimulates Col-I synthesis in diabetic wound healing in vitro at 660 nm.

[Low-level laser therapy in the treatment of diabetic ulcers: an evidence problem]

INTRODUCTION

Diabetes Mellitus is the leading cause of lower limb amputation, representing a significant economic cost for health services. The development of diabetic ulcers is a main risk factor for amputations, which have a high mortality rate at five years. The ischemia caused by macrovascular disease is a key pathophysiological factor in the development of ischemic ulcers. Existing treatments are prolonged and associated with high rates of failure and relapse, requiring the combination of multiple therapeutic modalities. Lowlevel laser therapy has been used as an adjuvant therapy for diabetic foot ulcers, since the 1960's, due to its hypothetical stimulating effects over microcirculation and tissue repair.

MATERIAL AND METHODS

Identification of published scientific studies through a literature search on PubMed, The Cochrane Library and Cochrane Controlled Trials Register.

DISCUSSION AND CONCLUSIONS

Existing evidence is favourable for in vitro cell models, but conflicting in animal models and human populations. There is significant methodological heterogeneity, which may be responsible for discordant results. Guidelines are proposed for future studies in this area, including the detailed characterization of ulcers and the parameters of laser treatment. Well-controlled studies, randomized and double-blind are needed. Accordingly to the primum non nocere, laser therapy can and should be used as adjunctive therapy in the treatment of diabetic foot, because it isn't invasive, has low costs and is a fast therapy without significant adverse effects.

Effects of monochromatic infrared energy therapy on diabetic feet with peripheral sensory neuropathy: a randomised controlled trial

INTRODUCTION

Peripheral diabetic neuropathy, which is a cause of increasing morbidity and mortality following foot ulcers and amputations, is a burden to health and the economy. Various adjunct treatments to improve neuropathy have been introduced into the market; one such treatment is monochromatic infrared energy (MIRE) therapy, which claimed to produce promising results. This study aimed to evaluate the effects of MIRE on diabetic feet with peripheral neuropathy.

METHODS

A randomised controlled, single-blinded study was conducted at Hospital Universiti Sains Malaysia from February 2008 to October 2008. A total of 30 feet from 24 patients were studied. Neuropathy was screened using the Michigan neuropathy scoring instrument, followed by an assessment of the current perception threshold using a neurometer at frequencies of 2,000 Hz, 250 Hz and 5 Hz. The feet were randomised to receive either daily MIRE or sham treatment for a total of 12 treatments. Each foot was then reassessed using the neurometer at six weeks and three months following treatment.

RESULTS

The data obtained was analysed using a non-parametric test to compare the pre- and post-treatment groups. No significant difference was found between the neuropathic foot of diabetic patients in both the MIRE and sham groups.

CONCLUSION

No improvement of neuropathy was observed following MIRE treatment in the neuropathic feet of diabetic patients.

[Laserotherapy of diabetic angiopathy of the lower extremities]

Low-intensity laser radiation was included in combined therapy of lower limb angiopathy in patients with diabetes mellitus. The course and results of the treatment were monitored by means of perfusion scintiography.

[Use of physical factors in the complex therapy of patients with diabetic angio- and polyneuropathies of the lower extremities]

Results are submitted of treatment of 110 patients with diabetes mellitus (61 male and 49 female subjects) presenting with angio- and polyneuropathies of the lower extremities. 70 patients, in addition to a drug therapy, were administered physiotherapeutic treatments, such as amplipulsetherapy, darsonvalization, and laserotherapy. Forty patients received medicamentous therapy only. Based on clinical findings and laboratory methods of investigation expediency has been shown of employment of physiotherapeutic methods in the treatment of the above pathology.

[Clinical efficacy of alprostan in combination with "Bioptron-II" rays and iruxol-miramistin in the treatment of the diabetic foot complicated by atherosclerosis]

Experience of clinical treatment of 9 patients with diabetes mellitus and diabetic angiopathy using alprostan in combination with rays "Bioptron-II" and iruxol-miramistinum in conditions of polyclinic was summarized. Antidiabetic preparations, mainly insulin, were administered to all patients together with abovementioned treatment. Optimal scheme of treatment constitutes daily slow (no less than 6 h) dropper intravenous infusion of alprostan in 0.1 mg dosage in 150-200 ml isotonic solution of sodium chloride during 15 days. Before and after infusion of alprostan ulcer was locally irradiated using "Bioptron-II" lamp from 5 cm distance during 6 min, bandage with iruxol-miramistinum ointment was applied in ratio 1:1. In 6 patients pain in lower extremities disappeared, ulcers epithelized, in 3--ulcers reduced by 50%.

Topical hyperbaric oxygen and low energy laser therapy for chronic diabetic foot ulcers resistant to conventional treatment

Chronic foot ulcers are common in long-standing diabetes, may herald severe complications and are often resistant to therapy. To evaluate the effects of adjunctive topical hyperbaric oxygen treatment (THBO) and low energy laser (LEL) irradiation on ulcer healing, a 100 consecutive patients with chronic diabetic foot ulcers (DFU) refractory to 4.5 +/- 1.2 months of comprehensive treatment, were enrolled in a prospective open study. While conventional treatment was continued as necessary, THBO was administered by pumping 100 percent oxygen into a disposable sealed polythylene hyperbaric chamber (150 min x 2 to 3/wk at up to 1.04 atm). Helium-neon LEL irradiation was given concurrently using a Unilaser Scan Unit at 4 J/cm2 for 20 min. Some patients continued THBO at home or their treatment was confined to THBO at home. Patients were monitored every two weeks revealing 81 percent cure after 25 +/- 13 treatments over 3.2 +/- 1.7 months. On follow-up (median 18 months), only 3/81 (4 percent) had reulceration, which responded to THBO/LEL retreatment. Nonresponders had significantly lower ankle brachial indices (ABI) than patients whose ulcers were healed (0.55 vs. 0.78, p < 0.01) and ultimately required amputation. Patient compliance was full and no adverse events occurred. In conclusion, although the study was open and uncontrolled, an 81 percent healing of DFU in patients who previously did not respond to a comprehensive treatment program, constitutes an intriguing preliminary result. Thus, THBO/LEL therapy may be a safe, simple, and inexpensive early adjunctive treatment for patients with chronic diabetic foot ulcers. Our findings should prompt its evaluation by large randomized controlled trials.

Diabetic neuropathic foot ulcer: successful treatment by low-intensity laser therapy

OBJECTIVE

To evaluate the efficacy of low-intensity laser irradiation for the induction of wound healing of a diabetic neuropathic foot ulcer.

CASE

We report a case of a man with insulin-dependent diabetes mellitus, sensory neuropathy, macroangiopathy and microangiopathy who had been suffering from an ulcer of his first left toe accompanied by osteomyelitis for 6 weeks.

RESULTS

After a total of 16 sessions of low-intensity laser therapy using a 670-nm diode laser administered within a 4-week period the ulcer healed completely. During a follow-up period of 9 months, there was no recurrence of the ulcer even though the patient's metabolic condition remained unstable.

CONCLUSIONS

Although laser therapy was not applied as a monotherapy, the present observation suggests that it might constitute a useful side-effect-free alternative treatment modality for the induction of wound healing of neuropathic ulcers in diabetic patients. Therefore large properly controlled randomized studies seem justified.

Low-intensity laser irradiation improves skin circulation in patients with diabetic microangiopathy

OBJECTIVE

Diabetic foot problems due to angiopathy and neuropathy account for 50% of all nontraumatic amputations and constitute a significant economic burden to society. Low-intensity laser irradiation has been shown to induce wound healing in conditions of reduced microcirculation. We investigated the influence of low-intensity laser irradiation by means of infrared thermography on skin blood circulation in diabetic patients with diabetic microangiopathy.

RESEARCH DESIGN AND METHODS

Thirty consecutive patients with diabetic ulcers or gangrenes and elevated levels of glycosylated hemoglobin were randomized by blocks of two to receive either a single low-intensity laser irradiation with an energy density of 30 J/cm2 or a sham irradiation over both forefoot regions in a double-blind placebo-controlled clinical study. Skin blood circulation as indicated by temperature recordings over the forefoot region was detected by infrared thermography.

RESULTS

After a single transcutaneous low-intensity laser irradiation, a statistically significant rise in skin temperature was noted (P < 0.001 by ANOVA for repeated measurements), whereas in the sham-irradiated control group, a slight but significant drop in temperature (P < 0.001) was found. Subsequently performed contrasts for comparison of measurements before and after irradiation revealed significant temperature increases at 20 min of irradiation time (P < 0.001), at the end of the irradiation (P < 0.001), and 15 min after stopping the irradiation (P < 0.001). In the sham-irradiated feet, the drop in local skin temperature was not significant at 20 min (P = 0.1), but reached significance at the end of the sham-irradiation procedure (P < 0.001) and 15 min after the end of sham irradiation (P < 0.001).

CONCLUSIONS

The data from this first randomized double-blind placebo-controlled clinical trial demonstrate an increase in skin microcirculation due to athermic laser irradiation in patients with diabetic microangiopathy.

[Use of radiotherapy in the complex treatment of patients with complicated forms of diabetic angiopathy]

In 140 patients with purulent-necrotic complications of diabetic microangiopathy the results of different methods of treatment were analyzed. High efficacy of antiinflammatory X-ray therapy was confirmed. Application of X-ray therapy in combination with long lasting intraarterial infusions promoted lowering the frequency of high amputation of the extremity conduction.

[Comparative assessment of conservative therapy methods in patients with the diabetic foot syndrome]

Fifty patients with types I and II diabetes complicated by the diabetic foot syndrome were examined. The patients were divided into two groups: Group I patients were administered x-ray therapy of the feet and shins, group 2 ones were treated by angioprotectors and antiaggregants. Complaints and objective data, findings of ultrasonic examination of the lower limb vessels and biothesiometry, x-ray picture before and 6 months after the treatment were assessed. 36 normal subjects made up the control group. The authors emphasize a marked effect of x-ray therapy as against drug treatment.