Diabetic Foot Ulcer Treated with High-Voltage Pulsed Current Therapy: Two Case Reports

Seunghyun Hwang

doi:10.22467/jwmr.2025.03384

Abstract

Diabetic foot ulcers (DFUs) are chronic complications of diabetes mellitus that often result in delayed wound healing and in severe cases, even limb amputation. High-voltage pulsed current (HVPC) therapy has shown potential in promoting angiogenesis and cellular repair. This report describes two cases of chronic DFUs treated with adjunctive HVPC therapy. Two male patients with type 2 diabetes and chronic DFUs received HVPC therapy (3,000 V, 100 μs, 80–100 Hz) using a commercial device. Treatment was delivered every other day for 2 weeks (30 minutes per session), followed by every 3–4 days for an additional 2 weeks (20 minutes per session), alongside standard care including topical epidermal growth factor and systemic antibiotics. Wound healing was evaluated by area reduction, epithelialization time, and pain, using a visual analog scale. In Case 1 (Wagner grade 3, hemoglobin A1c [HbA1c] 6.8%), full epithelialization was achieved in 5 weeks. In Case 2 (Wagner grade 4, smoker, HbA1c 9.5%), complete healing was observed within 7 weeks after distal toe disarticulation. Both patients showed more than 75% wound reduction, pain resolution, and no adverse effects. These findings suggest that HVPC may be a useful adjunctive therapy for chronic DFUs, although controlled studies are needed to validate its clinical efficacy.

Key Words: Diabetic foot; Electric stimulation therapy; Wound healing; Epidermal growth factor; Case reports

Introduction

Diabetic foot ulcer (DFU) represents one of the most severe and prevalent complications associated with diabetes mellitus, with an estimated lifetime incidence of approximately 25% among patients with diabetes. This condition is a leading cause of lower-limb amputation worldwide, significantly impairing quality of life and imposing a substantial socioeconomic burden [1]. The chronicity and recalcitrance of DFUs are primarily attributed to peripheral neuropathy, peripheral arterial disease, and recurrent infections, all of which compromise local wound healing mechanisms [2].

Conventional management strategies, including sharp debridement, moist wound dressings, pressure offloading, and the topical application of growth factors, require protracted treatment durations—typically ranging from 12 to 20 weeks for complete epithelialization. Moreover, these approaches are frequently associated with high recurrence rates and suboptimal outcomes, especially in ulcers located at anatomically challenging sites [1].

High-voltage pulsed current (HVPC) therapy has emerged as an adjunctive modality capable of accelerating chronic wound healing. This modality involves the delivery of twin-peaked monophasic pulses at voltages of up to 3,000 V, with short pulse durations (approximately 100 μs) and frequencies between 80 and 100 Hz. HVPC is postulated to mimic endogenous injury currents, thereby stimulating angiogenesis, enhancing cellular proliferation, and reducing local bacterial bioburden [3,4]. Despite mounting evidence supporting HVPC efficacy in various chronic wounds, its clinical application in DFUs, particularly in anatomically constrained regions, remains underreported.

Herein, we present two cases of chronic DFUs successfully managed with HVPC in conjunction with standard wound care. We aim to highlight the clinical feasibility, therapeutic response, and potential mechanisms underlying HVPC-mediated healing in diabetic foot wounds.

Cases

Patient selection and clinical setting

Two male patients diagnosed with type 2 diabetes mellitus and chronic DFUs persisting for more than 6 weeks were enrolled. Inclusion criteria encompassed patients with Wagner grade 2 to 4 ulcers, an ankle–brachial index of ≥0.7, and adequate perfusion to support wound healing. Patients with cardiac pacemakers, active malignancy, or severe organ dysfunction were excluded. Written informed consent was obtained from both patients for HVPC treatment and the use of anonymized clinical information and images in this report.

Case 1

A 75-year-old male patient, a non-smoker, presented with a chronic Wagner grade 3 (deep ulcer with abscess formation and joint capsule exposure) ulcer measuring 2.1 cm² located on the lateral aspect of the right foot. His glycemic control was relatively stable (hemoglobin A1c [HbA1c] 6.8%). Empiric oral antibiotic therapy with cefaclor 250 mg three times daily was prescribed for 14 days to address local infection risk. HVPC therapy was initiated concurrently with standard wound care measures.

Case 2

A 52-year-old male patient with a significant smoking history presented with a Wagner grade 4 ulcer (4.5 cm²) on the distal phalanx of the right second toe, characterized by localized gangrene and gross osteomyelitis. The diagnosis of osteomyelitis was presumed based on clinical presentation (purulent discharge, erythema of overlying skin) and ultrasonographic evidence (irregularity or disruption of the cortical bone surface, subperiosteal fluid collection). Glycemic control was suboptimal (HbA1c 9.5%). Initial empirical therapy comprised intravenous ceftazidime and metronidazole for 5 days, followed by oral cefaclor. Due to progressive tissue necrosis, disarticulation at the distal interphalangeal joint was performed on hospital day 5. X-ray imaging was not performed due to the unavailability of radiographic equipment in the hospital (Seocho Best Surgery Clinic). Complete removal of osteomyelitic tissue was confirmed by excision of all necrotic soft tissue and bone, as evidenced by a positive paprika sign indicating viable bleeding bone. HVPC therapy was commenced postoperatively alongside routine wound management.

HVPC therapy protocol

High-voltage electrical stimulation was administered using the Diantte device (RegenTech), which delivers a symmetrical sinusoidal alternating current (AC) waveform. The device was configured to provide a peak voltage of 3,000 V with a maximum current of 1 mA, operating at a frequency of 60 Hz. Four carbon electrodes were placed circumferentially within 3 cm of the wound margin. Two active electrodes were positioned near the wound edge, and the other two were attached to adjacent intact skin on the dorsal and plantar aspects of the foot, serving as dispersive electrodes to ensure adequate current flow and dispersion (Fig. 1). A conductive hydrogel interface was used between the electrodes and skin to facilitate electrical transmission. Each treatment session lasted for 30 minutes. As fixed polarity control was not possible due to the AC waveform characteristics of the Diantte device, stimulation was delivered with alternating polarity throughout the session. Treatments were administered every other day during the first 2 weeks, followed by sessions every 3 to 4 days over the next 2 weeks.

Wound management and outcome measures

Conventional wound care included the application of epidermal growth factor-impregnated polyurethane foam dressings (Easyef) and appropriate systemic antibiotics. Weekly wound assessments were conducted using standardized digital photography, and wound areas were quantified with ImageJ software. Pain intensity was measured using a 0–10 visual analog scale (VAS). Complete healing was defined as full epithelialization maintained for a minimum of 14 consecutive days.

Clinical outcomes

In Case 1, the ulcer area progressively decreased from 2.1 cm² to complete epithelialization by week 5 of therapy. Pain scores decreased from VAS 6 to 0, and no adverse events were observed. Serial clinical photographs demonstrated robust granulation tissue formation and subsequent epithelial closure (Fig. 2). In Case 2, following limited disarticulation, the ulcerated region decreased from 4.5 cm² to full wound closure by week 7. Pain intensity declined from VAS 3 to 0 over the course of treatment. No secondary infections or complications were reported. Photographic documentation confirmed steady wound bed improvement and eventual re-epithelialization (Fig. 3). Table 1 provides a summary of clinical features and outcomes.

Discussion

The integration of HVPC therapy into chronic wound management is grounded in its ability to replicate bioelectric signals essential for tissue repair. The application of twin-peaked monophasic pulses at high voltages with short pulse durations facilitates the generation of a controlled electrical field that modulates key cellular behaviors involved in wound healing [3]. Specifically, HVPC induces galvanotaxis—the directional migration of fibroblasts, keratinocytes, endothelial cells, and macrophages toward the wound center, thereby enhancing granulation tissue formation and re-epithelialization [5].

HVPC further supports wound healing by enhancing angiogenesis, promoting cellular activity, and improving local perfusion. These effects are particularly beneficial in ischemic diabetic wounds, where microvascular dysfunction limits oxygen and nutrient delivery to the tissue. In addition, electrical stimulation exerts bacteriostatic effects by modulating the local wound environment, thereby reducing bacterial load and lowering the risk of infection-related complications [6,7].

From an immunomodulatory perspective, electrical stimulation therapies, including HVPC has been shown to suppress pro-inflammatory cytokines while enhancing anti-inflammatory mediators, thereby fostering a microenvironment conducive to tissue regeneration [6,8]. Clinically, alternating use of cathodal and anodal stimulation, as demonstrated in our protocol, is thought to sequentially optimize microbial clearance and cellular recruitment.

Although the total contact cast (TCC) remains the gold standard for off-loading plantar pressure in DFUs, its application is restricted in cases involving infection, exposed tendon or bone, or ulcers located in non–weight-bearing areas. In contrast, HVPC therapy provides a biologically active approach that promotes tissue repair through galvanotaxis, enhanced local perfusion, and stimulation of fibroblast and keratinocyte migration. Moreover, HVPC has shown bacteriostatic effects and can be safely combined with standard wound dressings and topical agents. From a practical perspective, HVPC is painless, noninvasive, and well-tolerated by patients, resulting in higher compliance than TCC, which often causes discomfort and restricts mobility. Several clinical trials and meta-analyses have demonstrated that HVPC significantly accelerates wound closure and reduces healing time compared with conventional care [6]. Therefore, HVPC may serve as an effective alternative or adjunctive therapy, particularly for patients in whom TCC application is contraindicated or impractical.

The two cases presented in this report underscore the potential of HVPC—a form of electrical stimulation therapy—as a safe and effective adjunct in the management of chronic DFUs. Notably, both cases involved anatomically complex wound locations—specifically the lateral plantar surface and distal toe—where offloading is particularly challenging and standard care alone often yields suboptimal results. Both patients experienced complete wound closure within 5–7 weeks of combined therapy, accompanied by significant pain reduction, likely attributable to the neuromodulatory effects of electrical stimulation [9].

These findings are in concordance with prior randomized controlled trials and meta-analyses that have demonstrated accelerated healing and greater than 75% reduction in wound area with HVPC use [4-6]. However, the generalizability of these results is constrained by the limited sample size and absence of a control arm in our report.

Despite these limitations, the current cases contribute to the growing body of literature supporting the clinical feasibility of HVPC in outpatient settings. Importantly, neither patient experienced adverse events, indicating a favorable safety profile. Future large-scale, controlled investigations are warranted to refine treatment parameters, establish optimal patient selection criteria, and elucidate long-term outcomes.