Venous Stasis Ulcers

Venous Stasis Ulcers, otherwise known as venous ulcers, varicose ulcers and stasis ulcers are problem wounds that often do not respond to standard wound care. This type of problem wound is not an approved condition for hyperbaric oxygen therapy (HBOT) by the Undersea and Hyperbaric Medical Society (UHMS.) This means the Medical Services Plan (MSP) will not cover your treatment at a hospital-based hyperbaric chamber in Canada and you will need to pursue HBOT at a private facility. The only way to currently receive MSP covered HBOT for a venous stasis ulcer is to undergo a skin graft operation, and upon its failure receive HBOT to save the skin graft, which is a UHMS approved indication. 

Diabetic related problem wounds and problem wounds related to arterial insufficiency are approved by the UHMS for treatment. The effect of HBOT on approved and non-approved problem wounds is similar, and much of the logic of administering treatment overlaps but there is not yet enough evidence for the UHMS to approve HBOT for venous stasis ulcers. More research is needed.

Current treatment recommendations for venous stasis ulcers include: elevation, compression, blood thinning medication, surgical intervention and standard wound care. When this approach does not work, there is an increased risk of infection and may lead to cellulitis or gangrene and can result in amputation of the limb. 

British Article Showing 19 Cases that Responded Well to HBOT

Reports that HBOT had a positive effect on chronic wounds began in the early 1960s. In 1970, the following study was published showing dramatic improvement in 19 cases of venous stasis ulcer, then known as vericose leg ulcer. The researchers justified not having a control group because the participants would serve as their own controls, since the average time the wounds had persisted was 10 years. The treatment pressure was 2 atmospheres absolute (33 fsw) and the duration was 2 hours daily, 5 days a week. 
The findings of this article were confirmed by hyperbaric facilities in the British Royal Air Force:

Scientific Resources Supporting the use of HBOT for Venous Stasis Ulcers

Many studies have looked at the effect of HBOT on chronic wounds by looking at the effect of HBOT on a variety of problem wounds including venous stasis ulcers.


Few have looked exclusively at the effect on venous stasis ulcers. One such study was published in 1994. 16 subjects were exposed to either 2.5 atmospheres absolute (oxygen) or 2.5 atmospheres absolute (air) for 90 minutes, 5 days a week for a total of 30 sessions. Today we know that a control group of 2.5 atmospheres of air is not a suitable control, having a healing effect of its own, but none-the-less the results were dramatically better in the HBOT group.

Future studies looking at venous stasis ulcers failed to consider HBOT as a treatment option. One such study published in the British Medical Journal in 1997 elicited a letter to the editor that expressed frustration at this. Nothing has changed since.

" Hyperbaric oxygen treatment is a cost effective option

EDITOR - We were surprised at the dismissal of hyperbaric oxygen treatment by Niren Angle and John J Bergan in their clinical review article on chronic venous ulceration. They referred to a review article by Tibbles and Edelsberg, which quoted a study by Hammarlund and Sundber on the healing of chronic leg ulcers. This study found a significant improvement when chronic leg ulcers were treated with hyperbaric oxygen.

The mechanism for ulceration is described as the distal adherence, trapping, and activation of leucocytes which causes tissue destruction. In an earlier editorial Kindwall stated that hyperbaric oxygen treatment reduces white cell adhesion to capillary walls after ischaemic insult. Kinwall also described how hyperbaric oxygen stops lipid peroxidation - by sparing cell membranes; reducing oedema in post-ischaemic muscle through the preservation of adenosine triphosphate; increasing red cell flexibility and improving white cell killing of aerobic bacteria; and, probably more importantly, stimulating capillary and collagen formation. This explains the effectiveness of hyperbaric oxygen as a treatment for chronic venous ulceration.

We recognize that chronic leg ulceration has different causes and that treatment needs to be focused on the cause. However, whatever the cause, at the cellular level the mechanism of tissue damage is the same and is related to reduced oxygen delivery.

In the double blinded study by Hammarlund and Sundber, patients with chronic leg ulcers but without diabetes or large vessel arterial disease showed a 36% reduction in ulcer size at six weeks after a course of hyperbaric oxygen compared with a 3% reduction in the control group treated with hyperbaric air.

Treatment of leg ulcers is expensive. Is costs an estimated 5000 GBP per patient for three months of conventional treatment. Augmentation of conventional treatment with hyperbaric oxygen reduces ulcer healing time and should allow earlier, successful skin grafting of clean wounds. A course of 30 treatments of hyperbaric oxygen in the adjunctive management of chronic venous ulcer in the Unites States would cost about $9000. In British treatment units we estimate, using our own business plan, that these costs could be reduced by as much as half.

We believe that the use of hyperbaric oxygen treatment as an adjunct in the treatment of chronic venous ulceration is cost efficient. It is denied patients because of a lack of medical hyperbaric oxygen facilities and an ignorance of its value by medical practitioners."

Andrew W McEwen Consultant in anaesthesia
Mark B Smith Consultant in anaesthesia
Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster LA1 4RP

Biofilms in Problem Wounds

It has been reported by Wolcott et al. that problem wounds have a biofilm component. This is the main reason for the regular debridement of wounds in standard wound care. Physical removal of the infected surface of problem wounds is one of the only effective ways to remove the biofilm infection. Biofilm is a multi-kingdom form that bacteria can take in the body, that are strongly antibiotic and immune resistant. It is believed that the chronicity of many infections can be attributed to this bacterial form. HBOT has been shown to be a effective potentiator of antibiotics in many biofilm infections, it remains to be seen if HBOT has a direct anti-biofilm effect. For more information visit our biofilm page. 

Topical Oxygen Therapy

Another treatment that shows promise for venous stasis ulcer is topical oxygen. Our facility uses a product called Ozonated Olive Oil.