When cosmetic surgery leads to unexpected complications, the results can be devastating for patients seeking aesthetic improvement. Among the most challenging post-surgical complications is pyoderma gangrenosum, a rare inflammatory skin disorder that causes painful ulcerations and can aggressively destroy tissue at surgical sites. A newly published case series from Brazil offers insight into how hyperbaric oxygen therapy is being deployed as part of multidisciplinary management for this difficult condition—though it remains well outside the FDA’s cleared indications for HBOT.
The Hidden Risk of Cosmetic Surgery
Pyoderma gangrenosum represents one of medicine’s crueler ironies. Patients undergoing elective procedures to improve their appearance can develop this neutrophilic dermatosis, which produces rapidly expanding, painful ulcers with characteristic undermined violaceous borders. The condition is not an infection—despite its name suggesting otherwise—but rather an autoinflammatory disorder where the immune system attacks the skin, often at sites of trauma including surgical incisions.
The case series, published in the Indian Journal of Plastic Surgery in April 2026, documents ten patients who developed post-surgical pyoderma gangrenosum following elective aesthetic procedures. The procedures included abdominoplasty, breast surgery, liposuction, and facial rejuvenation surgeries—all routine operations performed in plastic surgery clinics across Brazil.
Multidisciplinary Approach Shows Promise
What distinguishes this case series is its systematic documentation of a multidisciplinary treatment protocol. Rather than relying on any single intervention, the treating teams employed a comprehensive approach combining systemic corticosteroids—the cornerstone of therapy in 100% of cases—with immunosuppressants in 80% of patients. Surgical debridement, topical treatments, and careful wound care formed the foundation of management.
Hyperbaric oxygen therapy entered the treatment protocol as an adjunctive modality. Six of the ten patients received HBOT, with the authors reporting “excellent clinical response” in these cases. The therapy was typically initiated when wounds showed delayed healing despite standard interventions, or when tissue hypoxia was suspected to be compromising recovery.
The mechanism by which HBOT may benefit pyoderma gangrenosum patients involves several pathways. By delivering 100% oxygen at increased atmospheric pressure—typically 2.0 to 2.4 ATA in clinical settings—HBOT dramatically increases tissue oxygen tension. This enhanced oxygenation supports neutrophil function, promotes collagen synthesis, and stimulates angiogenesis in compromised wound beds. For pyoderma gangrenosum wounds, which often show pathergy (worsening with trauma including surgical intervention), the non-invasive nature of HBOT offers theoretical advantages over additional surgical procedures.
Evidence Assessment: Case Series Limitations
While the clinical outcomes reported are encouraging, the evidence level here is modest. Case series occupy a lower position in the hierarchy of medical evidence than randomized controlled trials. Without a control group receiving standard care alone, it is impossible to determine definitively whether HBOT provided incremental benefit beyond the aggressive immunosuppressive regimens these patients received.
The selection of patients for HBOT also introduces potential bias. Clinicians may have offered the therapy to patients with more severe or persistent wounds, or alternatively to those deemed better candidates based on overall health status. These selection factors complicate interpretation of the results.
Furthermore, the excellent response attributed to HBOT must be viewed in context. Pyoderma gangrenosum is known for its variable natural history, with some lesions healing spontaneously or responding to systemic corticosteroids alone. The contribution of HBOT specifically—as distinct from the comprehensive treatment package these patients received—remains uncertain.
FDA Position: Off-Label Use
The FDA has not cleared hyperbaric oxygen therapy for the treatment of pyoderma gangrenosum. The agency’s approved indications include specific wound types such as certain non-healing diabetic foot ulcers, compromised skin grafts and flaps, and delayed radiation injury—but pyoderma gangrenosum does not appear on this list.
This places HBOT for pyoderma gangrenosum firmly in the category of off-label use. Physicians may legally prescribe FDA-cleared devices and drugs for off-label indications based on their clinical judgment, but patients should understand that such use lacks the rigorous evaluation that precedes FDA clearance. Insurance coverage for off-label HBOT is typically limited or unavailable, potentially placing significant financial burden on patients.
The August 2025 FDA safety letter to healthcare providers emphasized the importance of following device instructions and maintaining rigorous safety protocols when administering HBOT. This communication, prompted by reports of fires, injuries, and deaths associated with hyperbaric chambers, serves as a reminder that even established medical therapies carry risks that must be carefully managed.
Implications for Plastic Surgery Practice
For plastic surgeons and wound care specialists, this case series adds to a growing body of literature exploring HBOT’s potential role in challenging dermatologic conditions. The findings suggest that HBOT may be a reasonable adjunctive therapy to consider when post-surgical pyoderma gangrenosum fails to respond adequately to corticosteroids and immunosuppressants alone.
However, the decision to pursue HBOT should involve careful patient counseling about the off-label nature of the therapy, uncertain insurance coverage, and the modest quality of supporting evidence. Patients should understand that while the case series reports positive outcomes, their individual results may vary, and HBOT represents one component of a comprehensive treatment approach rather than a standalone solution.
Research Directions
The path forward for HBOT in pyoderma gangrenosum will require more rigorous investigation. Randomized controlled trials comparing standard therapy with and without HBOT would provide clearer evidence of efficacy. Such studies would need to control for disease severity, concurrent medications, and wound characteristics to isolate the specific contribution of hyperbaric oxygen.
Until such evidence emerges, clinicians must rely on case reports and series like this one—valuable for hypothesis generation and clinical guidance, but falling short of the evidentiary standards that support FDA clearance. For patients struggling with this painful and disfiguring complication of cosmetic surgery, the promise of HBOT remains compelling but unproven.
This article reports on findings from a peer-reviewed case series. HBOT for pyoderma gangrenosum is not an FDA-cleared indication. Patients considering hyperbaric oxygen therapy should consult with qualified healthcare providers to discuss risks, benefits, and alternatives.