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Hyperbaric oxygen therapy (HOT) is a treatment modality dating to 1861 in the United States.1 Today, there are 14 indications2 for HOT (Table), issued by the Undersea & Hyperbaric Medical Society, which also administers an accreditation program for facilities providing HOT.3 The 14 indications also are relevant because it is unlikely that HOT will be covered by insurance for unapproved indications.4
Although HOT is not commonly seen as a first-line intervention in dermatology, there are scenarios in which it can be used to good effect: compromised grafts and flaps; poorly healing ulceration related to vasculitis and autoimmune disorders; and possibly for vascular compromise, including cutaneous ischemia caused by fillers. We review its indications, dermatologic applications, and potential complications.
Overview of HOT
Hyperbaric oxygen therapy involves sitting or lying in a special chamber that allows for controlled levels of oxygen (O2) at increased atmospheric pressure, which specifically involves breathing near 100% O2 while inside a monoplace or multiplace chamber5 that is pressurized to greater than sea level pressure (≥1.4 atmosphere absolute).2
A monoplace chamber is designed to treat a single person (Figure 1); a multiplace chamber (Figure 2) accommodates as many as 5 to 25 patients.5,6 The chambers also accommodate hospital beds and medical attendants, if needed. Hyperbaric O2 is inhaled through a mask, a tight-fitting hood, or an endotracheal tube, depending on the patient’s status.7 Treatment ranges from only 1 or 2 iterations for acute conditions to 30 sessions or more for chronic conditions. Individual sessions last 45 minutes to 5 hours; 120 minutes is considered a safe maximum duration.7 A television often is provided to help the patient pass the time.8
Long-standing Use in Decompression Sickness
Hyperbaric oxygen therapy is best known for its effectiveness in treating decompression sickness (DCS) and carbon monoxide poisoning. Decompression sickness involves liberation of free gas from tissue, in the form of bubbles, when a person experiences a relative decrease in atmospheric pressure, which results in an imbalance in the sum of gas tensions in tissue compared to ambient pressure.
Decompression sickness has special military significance because it can affect divers and pilots, particularly those flying at high altitude. Over the course of 12 years, approximately 50 pilot trainees at an Air Force training site in Colorado required HOT when ground-level O2 failed to resolve their DCS symptoms.10
Symptoms of DCS range from musculoskeletal pain to severe neurologic and pulmonary complications. First-line therapy for DCS is 100% O2 at ground level. When symptoms are severe or persistent, HOT is the treatment of choice. It works by decreasing the volume of air bubbles (as predicted by Boyle’s Law), providing oxygenation to hypoxic tissue and mitigating inflammatory responses implicated in tissue injury9; HOT can be considered salvage treatment for rare, severe, or unresponsive complications of DCS during common activities such as diving and flying.
The emergent nature of DCS often necessitates an on-call, on-site HOT facility or contracted community services. Although DCS is a rare complication, it can be devastating, as was the case for a military pilot flying an ultrahigh altitude reconnaissance aircraft.11 He developed a near fatal case of neurologic DCS during a military mission and required treatment with emergent HOT. Although his symptoms were reduced with therapy, he has persistent cognitive deficits.11
Other Indications
Dermatologic Flaps and Grafts
Although less commonly discussed in dermatologic literature, the use of HOT in compromised grafts and flaps has been addressed in the plastic surgery literature. In a large multicenter study, researchers evaluated 20,821 Mohs micrographic surgery procedures and reported 149 adverse events, of which 20.1% were dehiscence and partial or full necrosis.12 These complications, though rare, are potentially devastating, particularly in cosmetically sensitive locations such as the face. Traditional care for compromised grafts and flaps includes local wound care, surgical debridement, and additional reconstructive procedures. These interventions can be expensive and uncomfortable for patients and carry risk for further morbidity.13
Grafts become compromised when their metabolic demand outpaces the ability of the recipient bed due to characteristics of the graft or the recipient bed or both. Flaps carry their own blood supply, which can be compromised if the flap is too long or too large for the pedicle, there is notable tension on the wound, or blood flow is mechanically obstructed by kinking or twisting. Under these conditions, HOT can be beneficial, as O2 dissolves in plasma, thus improving the O2 tissue cellular diffusion gradient.7 An increased level of systemic O2 promotes wound healing and graft or flap survival by improving fibroblast function, blood flow, and vascularity, and by mitigating ischemia-reperfusion injury.13
Radiation-Induced Ulceration
Radionecrosis, a complication of radiotherapy, is caused by progressive obliterating endarteritis with resultant vascular stenosis and fibroatrophy, which eventually cause stromal fibrosis.15 In a study that looked at 1267 nonmelanoma skin cancers that had been treated with radiotherapy, the ulceration rate was 6.3%. Most of the ulcerated lesions were treatable conservatively, but some were more treatment resistant.16 Hampson et al17 reported on 58 patients with cutaneous wounds due to soft-tissue radionecrosis who were treated with HOT as part of a larger observational case series in which investigators looked at multiple types of radionecrosis. They found that 76% of these patients improved: 26% showed complete resolution and the remaining 50% had 50% to 90% improvement.17
Vasculitis or Autoimmune Ulceration
Vasculitis and vasculopathy can occur independent of, or in association with, connective tissue disease and can result in chronic ulceration. At our institution, a patient with antimelanoma differentiation-associated protein 5 dermatomyositis who had refractory digital ulcerations despite intensive systemic therapy had an excellent response to HOT; ulcerations resolved after 37 treatments.18
Efrati et al19 reported on 35 patients who had chronic nonhealing vasculitic ulcerations despite immunosuppression medication who were treated with HOT. Twenty-eight patients completely healed, 4 had partial healing, and 3 had no improvement.
Mirasoglu et al20 reported on a case series of 6 systemic sclerosis patients who had ulcerations that persisted despite other treatments. After initiation of HOT, 4 patients experienced complete response and 2 experienced partial response, which is notable because such ulcerations are often extremely difficult to treat and have usually failed multiple therapies before being addressed with HOT.
Cutaneous Vascular Compromise
At our institution, a 36-year-old man was referred to the dermatology clinic 2 days after undergoing embolization of a symptomatic arteriovenous malformation in the right knee (Figure 3A). The procedure was complicated by cutaneous purpura concerning for necrosis, a known complication of this procedure. We referred the patient for evaluation to consider HOT. Although he was outside the ideal window for starting treatment, HOT was initiated. With a late start in treatment, areas of skin had already progressed to full necrosis, which did not respond to treatment; however, contiguous areas that initially looked very similar clinically did respond to treatment (Figure 3B). This case suggests a penumbralike effect in which vulnerable tissue that would most likely have been lost was salvaged by HOT.
Ischemia
Hyperbaric oxygen therapy has been used to treat ischemia caused by injection of cosmetic filler. Henderson et al21 described a 37-year-old woman who experienced occlusion of the left superficial temporal artery while self-injecting a hyaluronic acid filler around the temples. The problem was complicated by left-sided hearing loss, cutaneous blanching of the left face, and pain. She was treated with enoxaparin, aspirin, dexamethasone, antibiotics, and intradermal lidocaine. Additionally, she was urgently referred to a HOT facility and was treated with 6 HOT treatments in 3 days, with the first treatment provided 15 hours after the initial insult. The patient showed a decrease in ischemic discoloration over the course of the treatment. Eventually, her hearing returned to baseline and she achieved an acceptable cosmetic outcome.21
Uittenbogaard et al22 reported the treatment of a patient who experienced dermal ischemia after receiving calcium hydroxylapatite at an aesthetic clinic. She did not improve with standard treatment but subsequently experienced resolution of symptoms after treatment with HOT. She had an excellent cosmetic outcome at 6-month follow-up.22
Complications and a Contraindication
Hyperbaric oxygen therapy generally is safe, but there is potential for complications.
Fire
This rare risk has a catastrophic outcome.23 Standards for fire prevention in hyperbaric facilities are issued by the National Fire Protection Association, covering construction and building materials, lighting, electrical wiring, exposure to flammable materials, and other possible ignition sources.24
Middle Ear Barotrauma
The incidence of the most common adverse effect of HOT is reported at 2% to 30%.7,25 Middle ear barotrauma occurs most commonly during the compression phase of treatment. It is more common in patients treated in a monoplace chamber because they are kept supine and are less able to regulate middle ear pressure.26 Symptoms of middle ear barotrauma can be relieved by teaching patients autoinflation technique, such as the Valsalva maneuver, or by placing tympanoplasty tubes.27
Reversible Myopia
Caused by direct O2 toxicity to the lens, this complication can last for weeks, though it eventually resolves spontaneously. Reversible myopia has been reported to be at least as common as middle ear barotrauma.27
Other Complications
Central nervous system complications, such as seizures, and pulmonary O2 toxicity are rare, more serious complications.27
Untreated Pneumothorax
The only absolute contraindication to HOT, pneumothorax can decompensate during HOT if left untreated. However, HOT can proceed once pneumothorax is addressed.7
Conclusion
Hyperbaric O2 therapy can make a positive contribution to the dermatologic therapeutic armamentarium, in specific patients, for impending graft or flap failure, chronic wounds and ulcerations, and cutaneous vascular compromise. Although HOT is not a commonly needed treatment in dermatology, it is important to be aware of its potential because delay in treatment can decrease its effectiveness. It is recommended that dermatologists locate the nearest HOT facility and become familiar with its capabilities.
- Carney AY. Hyperbaric oxygen therapy: an introduction. Crit Care Nurs Q. 2013;36:274-279.
- Weaver LK, ed. Hyperbaric Oxygen Therapy Indications: The Hyperbaric Oxygen Therapy Committee Report. 13th ed. Undersea and Hyperbaric Medical Society. 2014.https://www.uhms.
org/images/indications/UHMS_HBO2_Indications
_13th_Ed._Front_Matter__References.pdf. Accessed December 18, 2019. - Undersea & Hyperbaric Medical Society. UHMS Hyperbaric Facility Accreditation Program. https://www.uhms.org/about/accreditation/accreditation-for-hyperbaric-medicine.html. Accessed December 18, 2019.
- Hyperbaric oxygen (HBO) therapy. US Centers for Medicare & Medicaid Services. https://www.medicare.gov/coverage/hyperbaric-oxygen-hbo-therapy. Accessed December 18, 2019.
- Gracia L, Perez-Vidal C, de Paco JM, et al. Identification and control of a multiplace hyperbaric chamber. PLoS One. 2018;13:e0200407.
- Monoplace vs multiplace hyperbaric chamber. CutisCare. https://cutiscareusa.com/hyperbaric-oxygen-therapy/monoplace-vs-multiplace-hyperbaric-chamber/. Published August 31, 2018. Accessed December 18, 2019.
- Leach RM, Rees PJ, Wilmshurst PP. Hyperbaric oxygen therapy. BMJ. 1998;317:1140-1143.
- Health Quality Ontario. Hyperbaric oxygen therapy for the treatment of diabetic foot ulcers: a health technology assessment. Ont Health Technol Assess Ser. 2017;17:1-142.
- Vann RD, Butler FK, Mitchell SJ, et al. Decompression illness. Lancet. 2011;377:153-164.
- Rhodes WC, Hertner G, Price R, et al. Treating decompression sickness: military flight simulation site-community hospital partnership. Mil Med. 2017;182:e1718-e1721.
- Jersey SL, Baril RT, McCarty RD, et al. Severe neurological decompression sickness in a U-2 pilot. Aviat Space Environ Med. 2010;81:64-68.
- Alam M, Ibrahim O, Nodzenski M, et al. Adverse events associated with Mohs micrographic surgery: multicenter prospective cohort study of 20,821 cases at 23 centers. JAMA Dermatol. 2013;149:1378-1385.
- Francis A, Baynosa RC. Hyperbaric oxygen therapy for the compromised graft or flap. Adv Wound Care (New Rochelle). 2017;6:23-32.
- Bowersox JC, Strauss MB, Hart GB. Clinical experience with hyperbaric oxygen therapy in the salvage of ischemic skin flaps and grafts. J Hyperb Med. 1986;1:141-149.
- Fernández Canedo I, Padilla España L, Francisco Millán Cayetano J, et al. Hyperbaric oxygen therapy: an alternative treatment for radiation-induced cutaneous ulcers. Australas J Dermatol. 2018;59:e203-e207.
- Schulte KW, Lippold A, Auras C, et al. Soft x-ray therapy for cutaneous basal cell and squamous cell carcinomas. J Am Acad Dermatol. 2005;53:993-1001.
- Hampson NB, Holm JR, Wreford-Brown CE, et al. Prospective assessment of outcomes in 411 patients treated with hyperbaric oxygen for chronic radiation tissue injury. Cancer. 2012;118:3860-3868.
- Jeter J, Wolf EG, Richards M, et al. Successful treatment of anti-MDA5 dermatomyositis associated cutaneous digital pulp ulcerations with hyperbaric oxygen therapy [published online August 21, 2019]. J Clin Rheumatol. doi:10.1097/RHU.0000000000001114.
- Efrati S, Bergan J, Fishlev G, et al. Hyperbaric oxygen therapy for nonhealing vasculitic ulcers. Clin Exp Dermatol. 2007;32:12-17.
- Mirasoglu B, Bagli BS, Aktas S. Hyperbaric oxygen therapy for chronic ulcers in systemic sclerosis—case series. Int J Dermatol. 2017;56:636-640.
- Henderson R, Reilly DA, Cooper JS. Hyperbaric oxygen for ischemia due to injection of cosmetic fillers: case report and issues. Plast Reconstr Surg Glob Open. 2018;6:e1618.
- Uittenbogaard D, Lansdorp CA, Bauland CG, et al. Hyperbaric oxygen therapy for dermal ischemia after dermal filler injection with calcium hydroxylapatite: a case report. Undersea Hyperb Med. 2019;46:207-210.
- Schorow S. The air in there. NFPA Journal. January 3, 2017. https://www.nfpa.org/News-and-Research/Publications-and-media/NFPA-Journal/2017/January-February-2017/Features/Hyperbaric-chambers. Accessed December 18, 2019.
- National Fire Protection Association. NFPA 99: Health Care Facilities Code 2018. https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards/detail?code=99. Accessed December 18, 2019.
- Blanshard J, Toma A, Bryson P, et al. Middle ear barotrauma in patients undergoing hyperbaric oxygen therapy. Clin Otolaryngol. 1996;21:400-403.
- Lima MA, Farage L, Cury MC, et al. Update on middle ear barotrauma after hyperbaric oxygen therapy—insights on pathophysiology. Int Arch Otorhinolaryngol. 2014;18:204-209.
- Heyboer M, Sharma D, Santiago W, et al. Hyperbaric oxygen therapy: side effects defined and quantified. Adv Wound Care (New Rochelle). 2017;6:210-224.
Hyperbaric oxygen therapy (HOT) is a treatment modality dating to 1861 in the United States.1 Today, there are 14 indications2 for HOT (Table), issued by the Undersea & Hyperbaric Medical Society, which also administers an accreditation program for facilities providing HOT.3 The 14 indications also are relevant because it is unlikely that HOT will be covered by insurance for unapproved indications.4
Although HOT is not commonly seen as a first-line intervention in dermatology, there are scenarios in which it can be used to good effect: compromised grafts and flaps; poorly healing ulceration related to vasculitis and autoimmune disorders; and possibly for vascular compromise, including cutaneous ischemia caused by fillers. We review its indications, dermatologic applications, and potential complications.
Overview of HOT
Hyperbaric oxygen therapy involves sitting or lying in a special chamber that allows for controlled levels of oxygen (O2) at increased atmospheric pressure, which specifically involves breathing near 100% O2 while inside a monoplace or multiplace chamber5 that is pressurized to greater than sea level pressure (≥1.4 atmosphere absolute).2
A monoplace chamber is designed to treat a single person (Figure 1); a multiplace chamber (Figure 2) accommodates as many as 5 to 25 patients.5,6 The chambers also accommodate hospital beds and medical attendants, if needed. Hyperbaric O2 is inhaled through a mask, a tight-fitting hood, or an endotracheal tube, depending on the patient’s status.7 Treatment ranges from only 1 or 2 iterations for acute conditions to 30 sessions or more for chronic conditions. Individual sessions last 45 minutes to 5 hours; 120 minutes is considered a safe maximum duration.7 A television often is provided to help the patient pass the time.8
Long-standing Use in Decompression Sickness
Hyperbaric oxygen therapy is best known for its effectiveness in treating decompression sickness (DCS) and carbon monoxide poisoning. Decompression sickness involves liberation of free gas from tissue, in the form of bubbles, when a person experiences a relative decrease in atmospheric pressure, which results in an imbalance in the sum of gas tensions in tissue compared to ambient pressure.
Decompression sickness has special military significance because it can affect divers and pilots, particularly those flying at high altitude. Over the course of 12 years, approximately 50 pilot trainees at an Air Force training site in Colorado required HOT when ground-level O2 failed to resolve their DCS symptoms.10
Symptoms of DCS range from musculoskeletal pain to severe neurologic and pulmonary complications. First-line therapy for DCS is 100% O2 at ground level. When symptoms are severe or persistent, HOT is the treatment of choice. It works by decreasing the volume of air bubbles (as predicted by Boyle’s Law), providing oxygenation to hypoxic tissue and mitigating inflammatory responses implicated in tissue injury9; HOT can be considered salvage treatment for rare, severe, or unresponsive complications of DCS during common activities such as diving and flying.
The emergent nature of DCS often necessitates an on-call, on-site HOT facility or contracted community services. Although DCS is a rare complication, it can be devastating, as was the case for a military pilot flying an ultrahigh altitude reconnaissance aircraft.11 He developed a near fatal case of neurologic DCS during a military mission and required treatment with emergent HOT. Although his symptoms were reduced with therapy, he has persistent cognitive deficits.11
Other Indications
Dermatologic Flaps and Grafts
Although less commonly discussed in dermatologic literature, the use of HOT in compromised grafts and flaps has been addressed in the plastic surgery literature. In a large multicenter study, researchers evaluated 20,821 Mohs micrographic surgery procedures and reported 149 adverse events, of which 20.1% were dehiscence and partial or full necrosis.12 These complications, though rare, are potentially devastating, particularly in cosmetically sensitive locations such as the face. Traditional care for compromised grafts and flaps includes local wound care, surgical debridement, and additional reconstructive procedures. These interventions can be expensive and uncomfortable for patients and carry risk for further morbidity.13
Grafts become compromised when their metabolic demand outpaces the ability of the recipient bed due to characteristics of the graft or the recipient bed or both. Flaps carry their own blood supply, which can be compromised if the flap is too long or too large for the pedicle, there is notable tension on the wound, or blood flow is mechanically obstructed by kinking or twisting. Under these conditions, HOT can be beneficial, as O2 dissolves in plasma, thus improving the O2 tissue cellular diffusion gradient.7 An increased level of systemic O2 promotes wound healing and graft or flap survival by improving fibroblast function, blood flow, and vascularity, and by mitigating ischemia-reperfusion injury.13
Radiation-Induced Ulceration
Radionecrosis, a complication of radiotherapy, is caused by progressive obliterating endarteritis with resultant vascular stenosis and fibroatrophy, which eventually cause stromal fibrosis.15 In a study that looked at 1267 nonmelanoma skin cancers that had been treated with radiotherapy, the ulceration rate was 6.3%. Most of the ulcerated lesions were treatable conservatively, but some were more treatment resistant.16 Hampson et al17 reported on 58 patients with cutaneous wounds due to soft-tissue radionecrosis who were treated with HOT as part of a larger observational case series in which investigators looked at multiple types of radionecrosis. They found that 76% of these patients improved: 26% showed complete resolution and the remaining 50% had 50% to 90% improvement.17
Vasculitis or Autoimmune Ulceration
Vasculitis and vasculopathy can occur independent of, or in association with, connective tissue disease and can result in chronic ulceration. At our institution, a patient with antimelanoma differentiation-associated protein 5 dermatomyositis who had refractory digital ulcerations despite intensive systemic therapy had an excellent response to HOT; ulcerations resolved after 37 treatments.18
Efrati et al19 reported on 35 patients who had chronic nonhealing vasculitic ulcerations despite immunosuppression medication who were treated with HOT. Twenty-eight patients completely healed, 4 had partial healing, and 3 had no improvement.
Mirasoglu et al20 reported on a case series of 6 systemic sclerosis patients who had ulcerations that persisted despite other treatments. After initiation of HOT, 4 patients experienced complete response and 2 experienced partial response, which is notable because such ulcerations are often extremely difficult to treat and have usually failed multiple therapies before being addressed with HOT.
Cutaneous Vascular Compromise
At our institution, a 36-year-old man was referred to the dermatology clinic 2 days after undergoing embolization of a symptomatic arteriovenous malformation in the right knee (Figure 3A). The procedure was complicated by cutaneous purpura concerning for necrosis, a known complication of this procedure. We referred the patient for evaluation to consider HOT. Although he was outside the ideal window for starting treatment, HOT was initiated. With a late start in treatment, areas of skin had already progressed to full necrosis, which did not respond to treatment; however, contiguous areas that initially looked very similar clinically did respond to treatment (Figure 3B). This case suggests a penumbralike effect in which vulnerable tissue that would most likely have been lost was salvaged by HOT.
Ischemia
Hyperbaric oxygen therapy has been used to treat ischemia caused by injection of cosmetic filler. Henderson et al21 described a 37-year-old woman who experienced occlusion of the left superficial temporal artery while self-injecting a hyaluronic acid filler around the temples. The problem was complicated by left-sided hearing loss, cutaneous blanching of the left face, and pain. She was treated with enoxaparin, aspirin, dexamethasone, antibiotics, and intradermal lidocaine. Additionally, she was urgently referred to a HOT facility and was treated with 6 HOT treatments in 3 days, with the first treatment provided 15 hours after the initial insult. The patient showed a decrease in ischemic discoloration over the course of the treatment. Eventually, her hearing returned to baseline and she achieved an acceptable cosmetic outcome.21
Uittenbogaard et al22 reported the treatment of a patient who experienced dermal ischemia after receiving calcium hydroxylapatite at an aesthetic clinic. She did not improve with standard treatment but subsequently experienced resolution of symptoms after treatment with HOT. She had an excellent cosmetic outcome at 6-month follow-up.22
Complications and a Contraindication
Hyperbaric oxygen therapy generally is safe, but there is potential for complications.
Fire
This rare risk has a catastrophic outcome.23 Standards for fire prevention in hyperbaric facilities are issued by the National Fire Protection Association, covering construction and building materials, lighting, electrical wiring, exposure to flammable materials, and other possible ignition sources.24
Middle Ear Barotrauma
The incidence of the most common adverse effect of HOT is reported at 2% to 30%.7,25 Middle ear barotrauma occurs most commonly during the compression phase of treatment. It is more common in patients treated in a monoplace chamber because they are kept supine and are less able to regulate middle ear pressure.26 Symptoms of middle ear barotrauma can be relieved by teaching patients autoinflation technique, such as the Valsalva maneuver, or by placing tympanoplasty tubes.27
Reversible Myopia
Caused by direct O2 toxicity to the lens, this complication can last for weeks, though it eventually resolves spontaneously. Reversible myopia has been reported to be at least as common as middle ear barotrauma.27
Other Complications
Central nervous system complications, such as seizures, and pulmonary O2 toxicity are rare, more serious complications.27
Untreated Pneumothorax
The only absolute contraindication to HOT, pneumothorax can decompensate during HOT if left untreated. However, HOT can proceed once pneumothorax is addressed.7
Conclusion
Hyperbaric O2 therapy can make a positive contribution to the dermatologic therapeutic armamentarium, in specific patients, for impending graft or flap failure, chronic wounds and ulcerations, and cutaneous vascular compromise. Although HOT is not a commonly needed treatment in dermatology, it is important to be aware of its potential because delay in treatment can decrease its effectiveness. It is recommended that dermatologists locate the nearest HOT facility and become familiar with its capabilities.
Hyperbaric oxygen therapy (HOT) is a treatment modality dating to 1861 in the United States.1 Today, there are 14 indications2 for HOT (Table), issued by the Undersea & Hyperbaric Medical Society, which also administers an accreditation program for facilities providing HOT.3 The 14 indications also are relevant because it is unlikely that HOT will be covered by insurance for unapproved indications.4
Although HOT is not commonly seen as a first-line intervention in dermatology, there are scenarios in which it can be used to good effect: compromised grafts and flaps; poorly healing ulceration related to vasculitis and autoimmune disorders; and possibly for vascular compromise, including cutaneous ischemia caused by fillers. We review its indications, dermatologic applications, and potential complications.
Overview of HOT
Hyperbaric oxygen therapy involves sitting or lying in a special chamber that allows for controlled levels of oxygen (O2) at increased atmospheric pressure, which specifically involves breathing near 100% O2 while inside a monoplace or multiplace chamber5 that is pressurized to greater than sea level pressure (≥1.4 atmosphere absolute).2
A monoplace chamber is designed to treat a single person (Figure 1); a multiplace chamber (Figure 2) accommodates as many as 5 to 25 patients.5,6 The chambers also accommodate hospital beds and medical attendants, if needed. Hyperbaric O2 is inhaled through a mask, a tight-fitting hood, or an endotracheal tube, depending on the patient’s status.7 Treatment ranges from only 1 or 2 iterations for acute conditions to 30 sessions or more for chronic conditions. Individual sessions last 45 minutes to 5 hours; 120 minutes is considered a safe maximum duration.7 A television often is provided to help the patient pass the time.8
Long-standing Use in Decompression Sickness
Hyperbaric oxygen therapy is best known for its effectiveness in treating decompression sickness (DCS) and carbon monoxide poisoning. Decompression sickness involves liberation of free gas from tissue, in the form of bubbles, when a person experiences a relative decrease in atmospheric pressure, which results in an imbalance in the sum of gas tensions in tissue compared to ambient pressure.
Decompression sickness has special military significance because it can affect divers and pilots, particularly those flying at high altitude. Over the course of 12 years, approximately 50 pilot trainees at an Air Force training site in Colorado required HOT when ground-level O2 failed to resolve their DCS symptoms.10
Symptoms of DCS range from musculoskeletal pain to severe neurologic and pulmonary complications. First-line therapy for DCS is 100% O2 at ground level. When symptoms are severe or persistent, HOT is the treatment of choice. It works by decreasing the volume of air bubbles (as predicted by Boyle’s Law), providing oxygenation to hypoxic tissue and mitigating inflammatory responses implicated in tissue injury9; HOT can be considered salvage treatment for rare, severe, or unresponsive complications of DCS during common activities such as diving and flying.
The emergent nature of DCS often necessitates an on-call, on-site HOT facility or contracted community services. Although DCS is a rare complication, it can be devastating, as was the case for a military pilot flying an ultrahigh altitude reconnaissance aircraft.11 He developed a near fatal case of neurologic DCS during a military mission and required treatment with emergent HOT. Although his symptoms were reduced with therapy, he has persistent cognitive deficits.11
Other Indications
Dermatologic Flaps and Grafts
Although less commonly discussed in dermatologic literature, the use of HOT in compromised grafts and flaps has been addressed in the plastic surgery literature. In a large multicenter study, researchers evaluated 20,821 Mohs micrographic surgery procedures and reported 149 adverse events, of which 20.1% were dehiscence and partial or full necrosis.12 These complications, though rare, are potentially devastating, particularly in cosmetically sensitive locations such as the face. Traditional care for compromised grafts and flaps includes local wound care, surgical debridement, and additional reconstructive procedures. These interventions can be expensive and uncomfortable for patients and carry risk for further morbidity.13
Grafts become compromised when their metabolic demand outpaces the ability of the recipient bed due to characteristics of the graft or the recipient bed or both. Flaps carry their own blood supply, which can be compromised if the flap is too long or too large for the pedicle, there is notable tension on the wound, or blood flow is mechanically obstructed by kinking or twisting. Under these conditions, HOT can be beneficial, as O2 dissolves in plasma, thus improving the O2 tissue cellular diffusion gradient.7 An increased level of systemic O2 promotes wound healing and graft or flap survival by improving fibroblast function, blood flow, and vascularity, and by mitigating ischemia-reperfusion injury.13
Radiation-Induced Ulceration
Radionecrosis, a complication of radiotherapy, is caused by progressive obliterating endarteritis with resultant vascular stenosis and fibroatrophy, which eventually cause stromal fibrosis.15 In a study that looked at 1267 nonmelanoma skin cancers that had been treated with radiotherapy, the ulceration rate was 6.3%. Most of the ulcerated lesions were treatable conservatively, but some were more treatment resistant.16 Hampson et al17 reported on 58 patients with cutaneous wounds due to soft-tissue radionecrosis who were treated with HOT as part of a larger observational case series in which investigators looked at multiple types of radionecrosis. They found that 76% of these patients improved: 26% showed complete resolution and the remaining 50% had 50% to 90% improvement.17
Vasculitis or Autoimmune Ulceration
Vasculitis and vasculopathy can occur independent of, or in association with, connective tissue disease and can result in chronic ulceration. At our institution, a patient with antimelanoma differentiation-associated protein 5 dermatomyositis who had refractory digital ulcerations despite intensive systemic therapy had an excellent response to HOT; ulcerations resolved after 37 treatments.18
Efrati et al19 reported on 35 patients who had chronic nonhealing vasculitic ulcerations despite immunosuppression medication who were treated with HOT. Twenty-eight patients completely healed, 4 had partial healing, and 3 had no improvement.
Mirasoglu et al20 reported on a case series of 6 systemic sclerosis patients who had ulcerations that persisted despite other treatments. After initiation of HOT, 4 patients experienced complete response and 2 experienced partial response, which is notable because such ulcerations are often extremely difficult to treat and have usually failed multiple therapies before being addressed with HOT.
Cutaneous Vascular Compromise
At our institution, a 36-year-old man was referred to the dermatology clinic 2 days after undergoing embolization of a symptomatic arteriovenous malformation in the right knee (Figure 3A). The procedure was complicated by cutaneous purpura concerning for necrosis, a known complication of this procedure. We referred the patient for evaluation to consider HOT. Although he was outside the ideal window for starting treatment, HOT was initiated. With a late start in treatment, areas of skin had already progressed to full necrosis, which did not respond to treatment; however, contiguous areas that initially looked very similar clinically did respond to treatment (Figure 3B). This case suggests a penumbralike effect in which vulnerable tissue that would most likely have been lost was salvaged by HOT.
Ischemia
Hyperbaric oxygen therapy has been used to treat ischemia caused by injection of cosmetic filler. Henderson et al21 described a 37-year-old woman who experienced occlusion of the left superficial temporal artery while self-injecting a hyaluronic acid filler around the temples. The problem was complicated by left-sided hearing loss, cutaneous blanching of the left face, and pain. She was treated with enoxaparin, aspirin, dexamethasone, antibiotics, and intradermal lidocaine. Additionally, she was urgently referred to a HOT facility and was treated with 6 HOT treatments in 3 days, with the first treatment provided 15 hours after the initial insult. The patient showed a decrease in ischemic discoloration over the course of the treatment. Eventually, her hearing returned to baseline and she achieved an acceptable cosmetic outcome.21
Uittenbogaard et al22 reported the treatment of a patient who experienced dermal ischemia after receiving calcium hydroxylapatite at an aesthetic clinic. She did not improve with standard treatment but subsequently experienced resolution of symptoms after treatment with HOT. She had an excellent cosmetic outcome at 6-month follow-up.22
Complications and a Contraindication
Hyperbaric oxygen therapy generally is safe, but there is potential for complications.
Fire
This rare risk has a catastrophic outcome.23 Standards for fire prevention in hyperbaric facilities are issued by the National Fire Protection Association, covering construction and building materials, lighting, electrical wiring, exposure to flammable materials, and other possible ignition sources.24
Middle Ear Barotrauma
The incidence of the most common adverse effect of HOT is reported at 2% to 30%.7,25 Middle ear barotrauma occurs most commonly during the compression phase of treatment. It is more common in patients treated in a monoplace chamber because they are kept supine and are less able to regulate middle ear pressure.26 Symptoms of middle ear barotrauma can be relieved by teaching patients autoinflation technique, such as the Valsalva maneuver, or by placing tympanoplasty tubes.27
Reversible Myopia
Caused by direct O2 toxicity to the lens, this complication can last for weeks, though it eventually resolves spontaneously. Reversible myopia has been reported to be at least as common as middle ear barotrauma.27
Other Complications
Central nervous system complications, such as seizures, and pulmonary O2 toxicity are rare, more serious complications.27
Untreated Pneumothorax
The only absolute contraindication to HOT, pneumothorax can decompensate during HOT if left untreated. However, HOT can proceed once pneumothorax is addressed.7
Conclusion
Hyperbaric O2 therapy can make a positive contribution to the dermatologic therapeutic armamentarium, in specific patients, for impending graft or flap failure, chronic wounds and ulcerations, and cutaneous vascular compromise. Although HOT is not a commonly needed treatment in dermatology, it is important to be aware of its potential because delay in treatment can decrease its effectiveness. It is recommended that dermatologists locate the nearest HOT facility and become familiar with its capabilities.
- Carney AY. Hyperbaric oxygen therapy: an introduction. Crit Care Nurs Q. 2013;36:274-279.
- Weaver LK, ed. Hyperbaric Oxygen Therapy Indications: The Hyperbaric Oxygen Therapy Committee Report. 13th ed. Undersea and Hyperbaric Medical Society. 2014.https://www.uhms.
org/images/indications/UHMS_HBO2_Indications
_13th_Ed._Front_Matter__References.pdf. Accessed December 18, 2019. - Undersea & Hyperbaric Medical Society. UHMS Hyperbaric Facility Accreditation Program. https://www.uhms.org/about/accreditation/accreditation-for-hyperbaric-medicine.html. Accessed December 18, 2019.
- Hyperbaric oxygen (HBO) therapy. US Centers for Medicare & Medicaid Services. https://www.medicare.gov/coverage/hyperbaric-oxygen-hbo-therapy. Accessed December 18, 2019.
- Gracia L, Perez-Vidal C, de Paco JM, et al. Identification and control of a multiplace hyperbaric chamber. PLoS One. 2018;13:e0200407.
- Monoplace vs multiplace hyperbaric chamber. CutisCare. https://cutiscareusa.com/hyperbaric-oxygen-therapy/monoplace-vs-multiplace-hyperbaric-chamber/. Published August 31, 2018. Accessed December 18, 2019.
- Leach RM, Rees PJ, Wilmshurst PP. Hyperbaric oxygen therapy. BMJ. 1998;317:1140-1143.
- Health Quality Ontario. Hyperbaric oxygen therapy for the treatment of diabetic foot ulcers: a health technology assessment. Ont Health Technol Assess Ser. 2017;17:1-142.
- Vann RD, Butler FK, Mitchell SJ, et al. Decompression illness. Lancet. 2011;377:153-164.
- Rhodes WC, Hertner G, Price R, et al. Treating decompression sickness: military flight simulation site-community hospital partnership. Mil Med. 2017;182:e1718-e1721.
- Jersey SL, Baril RT, McCarty RD, et al. Severe neurological decompression sickness in a U-2 pilot. Aviat Space Environ Med. 2010;81:64-68.
- Alam M, Ibrahim O, Nodzenski M, et al. Adverse events associated with Mohs micrographic surgery: multicenter prospective cohort study of 20,821 cases at 23 centers. JAMA Dermatol. 2013;149:1378-1385.
- Francis A, Baynosa RC. Hyperbaric oxygen therapy for the compromised graft or flap. Adv Wound Care (New Rochelle). 2017;6:23-32.
- Bowersox JC, Strauss MB, Hart GB. Clinical experience with hyperbaric oxygen therapy in the salvage of ischemic skin flaps and grafts. J Hyperb Med. 1986;1:141-149.
- Fernández Canedo I, Padilla España L, Francisco Millán Cayetano J, et al. Hyperbaric oxygen therapy: an alternative treatment for radiation-induced cutaneous ulcers. Australas J Dermatol. 2018;59:e203-e207.
- Schulte KW, Lippold A, Auras C, et al. Soft x-ray therapy for cutaneous basal cell and squamous cell carcinomas. J Am Acad Dermatol. 2005;53:993-1001.
- Hampson NB, Holm JR, Wreford-Brown CE, et al. Prospective assessment of outcomes in 411 patients treated with hyperbaric oxygen for chronic radiation tissue injury. Cancer. 2012;118:3860-3868.
- Jeter J, Wolf EG, Richards M, et al. Successful treatment of anti-MDA5 dermatomyositis associated cutaneous digital pulp ulcerations with hyperbaric oxygen therapy [published online August 21, 2019]. J Clin Rheumatol. doi:10.1097/RHU.0000000000001114.
- Efrati S, Bergan J, Fishlev G, et al. Hyperbaric oxygen therapy for nonhealing vasculitic ulcers. Clin Exp Dermatol. 2007;32:12-17.
- Mirasoglu B, Bagli BS, Aktas S. Hyperbaric oxygen therapy for chronic ulcers in systemic sclerosis—case series. Int J Dermatol. 2017;56:636-640.
- Henderson R, Reilly DA, Cooper JS. Hyperbaric oxygen for ischemia due to injection of cosmetic fillers: case report and issues. Plast Reconstr Surg Glob Open. 2018;6:e1618.
- Uittenbogaard D, Lansdorp CA, Bauland CG, et al. Hyperbaric oxygen therapy for dermal ischemia after dermal filler injection with calcium hydroxylapatite: a case report. Undersea Hyperb Med. 2019;46:207-210.
- Schorow S. The air in there. NFPA Journal. January 3, 2017. https://www.nfpa.org/News-and-Research/Publications-and-media/NFPA-Journal/2017/January-February-2017/Features/Hyperbaric-chambers. Accessed December 18, 2019.
- National Fire Protection Association. NFPA 99: Health Care Facilities Code 2018. https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards/detail?code=99. Accessed December 18, 2019.
- Blanshard J, Toma A, Bryson P, et al. Middle ear barotrauma in patients undergoing hyperbaric oxygen therapy. Clin Otolaryngol. 1996;21:400-403.
- Lima MA, Farage L, Cury MC, et al. Update on middle ear barotrauma after hyperbaric oxygen therapy—insights on pathophysiology. Int Arch Otorhinolaryngol. 2014;18:204-209.
- Heyboer M, Sharma D, Santiago W, et al. Hyperbaric oxygen therapy: side effects defined and quantified. Adv Wound Care (New Rochelle). 2017;6:210-224.
- Carney AY. Hyperbaric oxygen therapy: an introduction. Crit Care Nurs Q. 2013;36:274-279.
- Weaver LK, ed. Hyperbaric Oxygen Therapy Indications: The Hyperbaric Oxygen Therapy Committee Report. 13th ed. Undersea and Hyperbaric Medical Society. 2014.https://www.uhms.
org/images/indications/UHMS_HBO2_Indications
_13th_Ed._Front_Matter__References.pdf. Accessed December 18, 2019. - Undersea & Hyperbaric Medical Society. UHMS Hyperbaric Facility Accreditation Program. https://www.uhms.org/about/accreditation/accreditation-for-hyperbaric-medicine.html. Accessed December 18, 2019.
- Hyperbaric oxygen (HBO) therapy. US Centers for Medicare & Medicaid Services. https://www.medicare.gov/coverage/hyperbaric-oxygen-hbo-therapy. Accessed December 18, 2019.
- Gracia L, Perez-Vidal C, de Paco JM, et al. Identification and control of a multiplace hyperbaric chamber. PLoS One. 2018;13:e0200407.
- Monoplace vs multiplace hyperbaric chamber. CutisCare. https://cutiscareusa.com/hyperbaric-oxygen-therapy/monoplace-vs-multiplace-hyperbaric-chamber/. Published August 31, 2018. Accessed December 18, 2019.
- Leach RM, Rees PJ, Wilmshurst PP. Hyperbaric oxygen therapy. BMJ. 1998;317:1140-1143.
- Health Quality Ontario. Hyperbaric oxygen therapy for the treatment of diabetic foot ulcers: a health technology assessment. Ont Health Technol Assess Ser. 2017;17:1-142.
- Vann RD, Butler FK, Mitchell SJ, et al. Decompression illness. Lancet. 2011;377:153-164.
- Rhodes WC, Hertner G, Price R, et al. Treating decompression sickness: military flight simulation site-community hospital partnership. Mil Med. 2017;182:e1718-e1721.
- Jersey SL, Baril RT, McCarty RD, et al. Severe neurological decompression sickness in a U-2 pilot. Aviat Space Environ Med. 2010;81:64-68.
- Alam M, Ibrahim O, Nodzenski M, et al. Adverse events associated with Mohs micrographic surgery: multicenter prospective cohort study of 20,821 cases at 23 centers. JAMA Dermatol. 2013;149:1378-1385.
- Francis A, Baynosa RC. Hyperbaric oxygen therapy for the compromised graft or flap. Adv Wound Care (New Rochelle). 2017;6:23-32.
- Bowersox JC, Strauss MB, Hart GB. Clinical experience with hyperbaric oxygen therapy in the salvage of ischemic skin flaps and grafts. J Hyperb Med. 1986;1:141-149.
- Fernández Canedo I, Padilla España L, Francisco Millán Cayetano J, et al. Hyperbaric oxygen therapy: an alternative treatment for radiation-induced cutaneous ulcers. Australas J Dermatol. 2018;59:e203-e207.
- Schulte KW, Lippold A, Auras C, et al. Soft x-ray therapy for cutaneous basal cell and squamous cell carcinomas. J Am Acad Dermatol. 2005;53:993-1001.
- Hampson NB, Holm JR, Wreford-Brown CE, et al. Prospective assessment of outcomes in 411 patients treated with hyperbaric oxygen for chronic radiation tissue injury. Cancer. 2012;118:3860-3868.
- Jeter J, Wolf EG, Richards M, et al. Successful treatment of anti-MDA5 dermatomyositis associated cutaneous digital pulp ulcerations with hyperbaric oxygen therapy [published online August 21, 2019]. J Clin Rheumatol. doi:10.1097/RHU.0000000000001114.
- Efrati S, Bergan J, Fishlev G, et al. Hyperbaric oxygen therapy for nonhealing vasculitic ulcers. Clin Exp Dermatol. 2007;32:12-17.
- Mirasoglu B, Bagli BS, Aktas S. Hyperbaric oxygen therapy for chronic ulcers in systemic sclerosis—case series. Int J Dermatol. 2017;56:636-640.
- Henderson R, Reilly DA, Cooper JS. Hyperbaric oxygen for ischemia due to injection of cosmetic fillers: case report and issues. Plast Reconstr Surg Glob Open. 2018;6:e1618.
- Uittenbogaard D, Lansdorp CA, Bauland CG, et al. Hyperbaric oxygen therapy for dermal ischemia after dermal filler injection with calcium hydroxylapatite: a case report. Undersea Hyperb Med. 2019;46:207-210.
- Schorow S. The air in there. NFPA Journal. January 3, 2017. https://www.nfpa.org/News-and-Research/Publications-and-media/NFPA-Journal/2017/January-February-2017/Features/Hyperbaric-chambers. Accessed December 18, 2019.
- National Fire Protection Association. NFPA 99: Health Care Facilities Code 2018. https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards/detail?code=99. Accessed December 18, 2019.
- Blanshard J, Toma A, Bryson P, et al. Middle ear barotrauma in patients undergoing hyperbaric oxygen therapy. Clin Otolaryngol. 1996;21:400-403.
- Lima MA, Farage L, Cury MC, et al. Update on middle ear barotrauma after hyperbaric oxygen therapy—insights on pathophysiology. Int Arch Otorhinolaryngol. 2014;18:204-209.
- Heyboer M, Sharma D, Santiago W, et al. Hyperbaric oxygen therapy: side effects defined and quantified. Adv Wound Care (New Rochelle). 2017;6:210-224.
Practice Points
- Hyperbaric oxygen therapy can be considered for the treatment of failing cutaneous grafts and flaps, chronic ulcerations caused by vasculitis or autoimmune disorders, and vascular compromise, including cutaneous ischemia caused by fillers.
- Hyperbaric oxygen therapy involves 1- to 2-hour treatments, 5 days a week, for as long as 1 month.
- Hyperbaric oxygen therapy is safe and well-tolerated, with few contraindications. The sooner therapy is started, the greater the potential for benefit.
