Wound care
Cole, an adjunct professor at Kent State University College of Podiatric Medicine. “We lack good multimodal therapies, which act in different ways to help optimise the wound environment in these very complex and at-risk patients.”
A new hope Clearly, there is a need for better treatment options, especially in patients whose wounds aren’t responding to conventional care. One promising candidate is topical oxygen therapy, which has been associated with successful outcomes in suitable patients. Although there are around a dozen different products on the market – among them haemoglobin spray, oxygen wound spray and continuous delivery of oxygen – all work by administering some much- needed oxygen to the wound bed. “A lot of DFUs have a local hypoxia, and if it
The NHS spends almost £1bn every year on DFUs, almost 1% of its total annual budget.
tissue viability at Birmingham City University. “A lot of that is spent on treating non-healing DFUs, where the focus is on just maintaining them rather than trying to heal them.”
According to NICE guidelines, patients ought to be referred to a multidisciplinary team within 24 hours of presenting with a DFU. The sooner the better: more than half are ulcer-free at 12 weeks if they are seen within the first two days, whereas little over a third attain this outcome if they wait more than two months. Once safely in the hands of specialists, they can receive the appropriate care – offloading (a modified orthotic), cleaning, debridement (removal of dead tissue) and a dressing.
“A lot of DFUs have a local hypoxia, and if it doesn’t have oxygen, it doesn’t go through the natural process of healing.” Dr Paul Chadwick
“The standard of care is good if you can give the standard of care,” says Chadwick. “But accessing the wound care dressings can be quite difficult, and access to offloading devices can be really difficult. So access to services is a big barrier, and the services that exist are under-resourced.” In the US, the problem is starker still. Here, DFUs affect 1.6 million people every year, with advanced-stage ulcers costing upwards of $50,000 per wound. There are significant disparities in access to treatment. “Because the development of a DFU is such a complex process, and there are many underlying pathophysiological things going on in our patients, it’s important that we do a full wound assessment at every single visit,” says Dr Windy
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doesn’t have oxygen, it doesn't go through the natural process of healing,” explains Chadwick. “Quite often wounds get stalled at what we call the inflammatory stage, meaning they become chronic and much more difficult to treat.”
One trial, which looked at 72 patients with venous leg ulcers, found that their average wound size reduced by more than half at 13 weeks when treated with haemoglobin spray. Other studies have shown that twice as many chronic wounds healed by 8–16 weeks with the haemoglobin spray, compared to the standard of care.
The evidence base, as it applies to DFUs, has grown more robust in recent years with more high-quality trials in the literature. In 2023, the International Working Group of the Diabetic Foot recommended that topical oxygen therapy should be considered when caring for hard-to-heal DFUs. That’s a shift from 2019, when there wasn’t considered enough evidence to make a recommendation. “There’s a been a shift over the last five years to say that, potentially, it’s something that we should be considering in chronic wounds,” says Chadwick. “I would always argue that you need to do the standard of care first, but if the wound size hasn’t reduced by 50% in four weeks, you should be using adjunctive therapies. Topical oxygen therapy is probably one of the primary ones there.”
Help where it’s needed most Cole is especially fond of continuous topical oxygen therapy, in which oxygen is delivered 24/7 to the wound via a wearable oxygen generator. The device is small – around the size of a mobile phone – and can be strapped to the limb, allowing the patient to remain mobile. “The device takes the room air and concentrates just the oxygen through an electrochemical reaction,” she explains. “The patient can continue to work or do their daily activities while the oxygen is being delivered to the wound.”
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