Diabetic foot ulcers

Diabetic foot ulcers are wounds that develop on the feet of people with diabetes. They can be difficult to heal, particularly when diabetes has affected sensation, circulation, or both.

This page is written for adults with diabetes and a foot ulcer that is not healing, their families, and the clinicians treating them.

What a diabetic foot ulcer is

Diabetes can damage the nerves supplying the feet and can also affect circulation.

Reduced sensation means that pressure, rubbing or small injuries may go unnoticed. Poor circulation can make it more difficult for damaged tissue to receive the oxygen and nutrients required for healing.

In people with diabetes and neuropathy, a foot infection may be present without marked pain.

Some diabetic foot ulcers are mainly related to loss of sensation and pressure. Others are ischaemic or neuro-ischaemic, meaning that reduced blood flow is also an important part of the problem.

That distinction is particularly relevant when considering HBOT, because the international recommendations supporting its use are limited to selected ulcers where impaired circulation is involved.

Before any additional treatment is considered, the clinical team may need to assess infection, circulation, pressure on the wound, possible bone infection, acute Charcot foot and other treatable causes, and whether vascular treatment could improve blood flow.

How diabetic foot ulcers are normally treated

Good diabetic foot care always comes first.

The foundation of treatment is high-quality diabetic foot care.

Depending on the individual wound, this can include:

Offloading: reducing pressure on the affected area
Infection management: including antibiotics where appropriate
Debridement: removing dead or unhealthy tissue
Wound care and dressings
Vascular assessment: checking the blood supply to the foot
Revascularisation: improving blood flow where this is possible
Good management of diabetes and blood glucose

These treatments are normally coordinated through a multidisciplinary diabetic foot service.

HBOT does not replace any of them.

Where HBOT is considered internationally, it is used as an adjunct, an additional treatment alongside established diabetic foot care.

What UK guidance says

NICE guideline NG19, Diabetic foot problems: prevention and management, covers foot problems in people with diabetes. Its recommendation 1.5.12 is that hyperbaric oxygen therapy should not be offered to treat diabetic foot ulcers unless it is being used as part of a clinical trial. It is a recommendation about treating the ulcer. It does not address HBOT for other conditions.

The current NICE HBOT recommendation originates from its 2015 review of the evidence. At that time, the guideline development group described the quality of the evidence for HBOT as very low and raised concerns about the design of the available studies, differences between patient groups, follow-up periods and the reliability of some of the results.

The recommendation reflects the evidence available at that time, which NICE did not consider robust enough to support use outside a clinical trial.

NHS England's clinical commissioning policy for diabetic lower limb ulceration (April 2019) says: "NHS England will not routinely commission hyperbaric oxygen therapy for diabetic lower limb ulceration in accordance with the criteria outlined in this document."

How the international picture differs

The approach taken internationally is more supportive of HBOT for selected diabetic foot ulcers.

The International Working Group on the Diabetic Foot (IWGDF) reviewed the evidence again for its 2023 guidance.

It recommends considering HBOT as an additional treatment for ischaemic or neuro-ischaemic diabetic foot ulcers where appropriate standard care alone has failed and where resources already exist to support it. It does not extend to purely neuropathic ulcers.

The recommendation is conditional because the overall certainty of the evidence remains low.

However, the IWGDF also concluded that the better-quality studies suggest there may be a benefit in wound healing and reduction in ulcer size, and its expert group considered that the overall balance of effects was likely to favour HBOT over standard care alone in appropriately selected patients.

The IWGDF found that good evidence of benefit in preventing amputation is lacking, and further high-quality research is still needed.

The 2023 IWGDF/IDSA guideline on diabetic foot infection conditionally suggests against HBOT as an adjunct for the sole purpose of treating infection, on low-certainty evidence. Healing an ulcer and treating an infection are distinct questions.

The European Committee for Hyperbaric Medicine (ECHM) suggests HBOT for diabetic foot lesions only after at least four weeks of standard wound care, and never as a stand-alone therapy. It defines the ulcers concerned by the Wagner grade, a system NICE advises against using in the UK.

These professional recommendations do not establish that HBOT is effective in an individual case, and they do not change NICE guidance or NHS England commissioning.

Where it is used routinely

HBOT is already incorporated into diabetic wound-care pathways in some countries.

In the United States, for example, Medicare provides coverage for HBOT for certain more severe diabetic lower-limb wounds, a Wagner grade III or higher wound, when they have failed to show measurable improvement after at least thirty days of appropriate standard wound care.

The Undersea and Hyperbaric Medical Society in the United States and the ECHM in Europe also recognise selected diabetic wounds as an accepted indication for HBOT.

These healthcare systems use different clinical and funding criteria from the UK, so their policies cannot simply be applied to NHS care.

Where the evidence shows possible benefit

There are clinical studies suggesting that HBOT may improve healing in selected patients with diabetic foot ulcers.

A double-blind randomised trial in Sweden (Löndahl 2010, 94 people) followed patients with long-standing diabetic foot ulcers and reported complete healing after one year in 52% of patients receiving HBOT compared with 29% receiving placebo treatment. That is a single trial, and it is not a guarantee of benefit for an individual patient.

Systematic reviews have also identified evidence of improved short-term wound healing. A 2015 Cochrane review pooled five trials (205 people) with diabetic foot ulcers and reported more ulcers healed at six weeks with HBOT, a difference not evident at one year. The reviewers said the trials had flaws in design or reporting and that they were not confident in the results. In 2020 Cochrane noted that this review did not comply with its conflict of interest policy and that an update was underway.

The 2023 IWGDF review assessed 18 studies examining HBOT as an adjunct to diabetic foot ulcer treatment. Although the overall evidence was considered low certainty, its review concluded that the better-quality studies suggest a possible benefit in absolute wound healing and reduction in ulcer area.

The IWGDF also noted that which patients are most likely to benefit still needs to be evaluated.

Where the evidence does not support use

Not every trial has shown a benefit. A double-blind trial in Canada (Fedorko 2016, 103 people analysed) and a trial in the Netherlands (Santema 2018, DAMO2CLES, 120 people) found no significant difference in healing or amputation. Results vary with the type of ulcer, the blood supply and the treatment used, so a benefit for one patient cannot be assumed.

How we assess whether treatment is appropriate

HBOT should only ever be considered as part of a wider diabetic foot treatment pathway.

Your existing diabetic foot, vascular or wound-care team should remain responsible for the core management of your condition. Nothing here is a reason to change, pause or delay anything they have recommended, including urgent vascular care. If HBOT is considered, we work alongside them and share our assessment and treatment plan.

Before HBOT could be considered, we would want to understand:

the type and severity of the ulcer
how long it has been present
whether there is impaired circulation
what treatment has already been provided
whether pressure has been appropriately offloaded
whether infection has been adequately treated
whether vascular assessment has been completed
whether revascularisation has been considered or performed
whether the wound is improving with standard treatment

Relevant medical records and information from the clinicians already treating the ulcer may also be required, including microbiology, imaging, vascular assessment and current medicines.

Our Medical Director would consider the patient’s overall health, the available evidence, current UK and international guidance, potential risks and whether there is a reasonable clinical rationale for considering HBOT.

HBOT should not be regarded as an alternative to good diabetic foot care. Where it has a role, the evidence suggests that role is most likely to be as an additional treatment in carefully selected patients whose wounds are proving difficult to heal despite appropriate care.

We explain why HBOT is or is not appropriate, including the evidence limits, risks, alternatives and costs, before any agreement. An assessment is not a promise of treatment or benefit, and a private consultation does not change NICE's recommendation. If we do not think HBOT is appropriate, we will say so.

Common questions

Is hyperbaric oxygen available on the NHS for a diabetic foot ulcer?

Not routinely.

NHS England has said it will not routinely commission HBOT for diabetic lower limb ulceration, and NICE recommends that HBOT should not be offered for diabetic foot ulcers outside a clinical trial.

That reflects the current UK position.

Other healthcare systems and international clinical guidelines take a different approach for selected patients.

Will HBOT heal my ulcer?

No treatment can guarantee that a diabetic foot ulcer will heal.

Clinical studies have produced mixed results. Some have reported improved healing with HBOT, while others have not found a significant difference.

More recent international guidance suggests there may be a role for HBOT in selected ischaemic or neuro-ischaemic ulcers that have not responded adequately to standard care. NICE recommends that it should not be offered outside a clinical trial.

An individual medical assessment is therefore essential.

Does it replace offloading, antibiotics or vascular treatment?

No.

HBOT is an adjunctive treatment.

It does not replace offloading, wound care, antibiotics, debridement, vascular assessment or procedures designed to restore blood flow.

These remain fundamental to successful diabetic foot care.

How many sessions would be involved?

Courses reported in clinical studies commonly involve approximately 30 to 40 HBOT sessions, usually delivered on most weekdays over several weeks. This is not a standard prescription or guarantee of benefit.

There is no single course that is appropriate for every patient.

The pressure, duration and number of treatments would depend on the clinical circumstances and would only be determined after medical assessment.

Is it safe?

HBOT is generally well tolerated when patients are appropriately selected and treatment is delivered within a medically supervised hyperbaric service.

Like any medical treatment, it has risks.

The most common problems involve pressure changes affecting the ears or sinuses. Temporary changes in vision can also occur, and certain medical conditions may make HBOT unsuitable.

People with diabetes may require blood-glucose monitoring before and after treatment.

Every patient therefore requires a medical and hyperbaric safety assessment before treatment is considered.

Clinical accuracy: Approved 30 October 2026 · Dr Anil Dasineni
Content accuracy: Approved 23 October 2026 · Jonny Spodofora
Content accuracy: Approved 22 October 2026 · Tim Robins
Advertising compliance: Approved 30 October 2026 · Dr Anil Dasineni
Reviewed by: Dr Anil Dasineni, MBBS, DNB (Emergency Medicine), MRCEM. Registered with the General Medical Council with a licence to practise.
Last reviewed: 30 October 2026
Next review due: 14 October 2027
Clinical tier: Tier 1

Sources (14)

www.nice.org.uk/guidance/ng19, www.nice.org.uk/guidance/ng19/evidence/full-guideline--august-2015-pdf-15672915543, www.nhs.uk/conditions/type-1-diabetes/complications/, www.england.nhs.uk/wp-content/uploads/2018/11/Hyperbaric-oxygen-therapy-services-all-ages-Service-specification-January-2025.pdf, www.england.nhs.uk/wp-content/uploads/2019/04/Hyperbaric-oxygen-therapy-for-diabetic-lower-limb-ulceration-all-ages.pdf, iwgdfguidelines.org/wp-content/uploads/2023/07/IWGDF-2023-07-Wound-Healing-Guideline.pdf, onlinelibrary.wiley.com/doi/full/10.1002/dmrr.3687, www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004123.pub4/full, www.echm.org/documents/DHM%202017-Mathieu%20D-Tenth%20European%20Consensus%20Conference%20on%20Hyperbaric%20Medicine.pdf, uhms.org/resources/featured-resources/hbo-indications.html, www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=12, pubmed.ncbi.nlm.nih.gov/20427683/, pubmed.ncbi.nlm.nih.gov/26740639/, pubmed.ncbi.nlm.nih.gov/29074815/

How we govern clinical content

Clinically governed and CQC-aligned. Heal & Go₂ Medical is working towards CQC registration and does not describe itself as CQC registered.