HBOT for Thermal Burns: What a New 2026 Systematic Review Reveals

Cross-section of healing skin tissue showing capillary networks and oxygen diffusion in a thermal burn wound

Thermal burns present a persistent challenge in acute care. Beyond the immediate tissue destruction lies a dynamic zone of injury—the so-called “zone of stasis”—where compromised blood flow threatens to expand the wound in the days following the initial trauma. Hyperbaric oxygen therapy (HBOT), which delivers 100% oxygen at pressures exceeding one atmosphere absolute (ATA), has been investigated for decades as a potential adjunct to standard burn care. A new systematic review published in the Journal of Burn Care & Research in 2026 offers the most comprehensive assessment to date of where the evidence stands.

The 2026 Systematic Review: Methodology and Scope

Researchers led by Molina-Vega applied PRISMA methodology to evaluate HBOT’s role in burn treatment, searching PubMed, the Cochrane Library, and Embase in September 2025. Their analysis encompassed 13 studies involving 566 patients: five randomized controlled trials, seven cohort studies, and one case-control study. This represents a significant expansion over previous reviews, incorporating data from more than five decades of experimental and clinical investigation.

The heterogeneity of the included studies presented both opportunities and limitations. Burn severity ranged from partial-thickness to full-thickness injuries. HBOT protocols varied in pressure (from 2.0 to 3.0 ATA), session duration, and treatment frequency. Outcome measures differed across studies, with some focusing on clinical endpoints like grafting requirements while others examined biomarkers or economic outcomes.

Key Findings: Signal Amid Noise

Despite these variations, several consistent patterns emerged from the review. Multiple studies reported that patients receiving HBOT alongside conventional burn care experienced a reduced need for surgical intervention and skin grafting. One 2023 prospective observational study of deep second-degree burns—conducted by a single experienced surgeon to minimize confounding—found statistically significant differences: HBOT recipients required fewer surgeries (p=0.003) and less grafting (p=0.03), with wounds epithelializing in shorter timeframes (p<0.001).

Hospital length of stay showed favorable trends in several studies, though mortality benefits remained inconsistent across the literature. The reviewers noted that while these findings point toward clinical utility, the heterogeneity of study designs and treatment protocols prevented formal meta-analysis. Their conclusion reflects this measured assessment: HBOT shows promise as an adjunct in burn care rather than an established standard of treatment.

The Pressure Question: Why Dose Matters

A 2024 review published in Undersea and Hyperbaric Medicine by Smolle and colleagues provides crucial context for interpreting these mixed results. Analyzing 47 publications containing 94 individual experiments—32 animal trials, four human volunteer studies, and 11 clinical investigations—the authors identified a striking pattern. Of the 94 experiments, 64 (67.4%) demonstrated positive outcomes, 16 (17.9%) were ambiguous, and 14 (14.7%) were negative.

The critical finding: pressure dosage emerged as the single factor independently associated with results. Sessions delivered below 3.0 ATA were significantly more likely to yield positive outcomes (p=0.0005). This suggests that the inconsistent results in burn HBOT literature may reflect not whether hyperbaric oxygen helps, but whether the specific pressure protocols employed were optimal for this particular indication.

Mechanistic Rationale: Oxygen and the Zone of Stasis

The biological basis for HBOT in burns rests on several well-established mechanisms. Hyperbaric oxygen increases tissue oxygen tension beyond what can be achieved through normobaric breathing, potentially salvaging marginally viable tissue in the zone of stasis. Enhanced oxygen delivery supports cellular metabolism in compromised tissue, reduces edema through vasoconstriction while maintaining oxygen content, and may modulate the inflammatory cascade that drives secondary injury progression.

Animal studies have consistently demonstrated reduced dermal ischemia and better preservation of the zone of stasis with HBOT application. However, as the 2026 review emphasizes, mechanistic plausibility does not automatically translate to clinical efficacy. The challenge lies in designing trials that can isolate HBOT’s contribution from the multiple variables influencing burn outcomes.

Regulatory Context: FDA Clearance and Clinical Application

The U.S. Food and Drug Administration recognizes thermal burns among its cleared indications for HBOT, specifically for “acute thermal burn injury” when the burned total body surface area exceeds specific thresholds or when burns involve critical areas. This clearance, shared by the Undersea and Hyperbaric Medical Society in its list of supported indications, provides a regulatory foundation for clinical use.

However, the FDA emphasizes that HBOT for burns should be administered within accredited facilities by trained personnel following established protocols. A 2025 safety communication specifically warned against improper use of hyperbaric devices, highlighting fire risks and the dangers of unsupervised or home-based treatments. The agency’s position remains clear: while HBOT has demonstrated benefit for specific burn presentations, it is not a first-line treatment and should complement, not replace, standard burn care including fluid resuscitation, wound debridement, and infection control.

Evidence Gaps and Future Directions

The 2026 systematic review identifies several priorities for advancing the evidence base. Well-designed randomized controlled trials conducted in burn centers with integrated hyperbaric facilities represent the most pressing need. Such studies should standardize pressure protocols—likely targeting the 2.0–2.5 ATA range suggested by current evidence—and employ consistent outcome measures including grafting requirements, healing time, functional outcomes, and cost-effectiveness.

The pressure-dose hypothesis identified by Smolle’s team offers a testable framework for protocol optimization. Future trials might directly compare different pressure levels to determine whether lower-pressure regimens indeed produce superior outcomes in thermal burns, as the retrospective analysis suggests.

Clinical Implications for Patients and Providers

For patients with significant thermal burns, the current evidence suggests that HBOT may offer meaningful adjunctive benefits when delivered in appropriate settings. The potential for reduced surgical intervention and accelerated healing carries significant implications for both clinical outcomes and healthcare costs. However, access remains uneven—hyperbaric facilities are not universally available, and insurance coverage for burn HBOT varies by jurisdiction and specific clinical circumstances.

Providers considering HBOT for burn patients should evaluate each case individually, weighing the severity and location of burns against the logistical requirements of hyperbaric treatment. Early application appears important, as the window for salvaging tissue in the zone of stasis narrows as secondary injury progresses.

Conclusion: Promise Requiring Confirmation

The 2026 systematic review positions HBOT for thermal burns at an interesting inflection point. The accumulated evidence—spanning decades of research and hundreds of patients—consistently signals potential benefit, particularly for reducing surgical requirements and accelerating healing. Yet the heterogeneity that prevents definitive conclusions also points toward actionable hypotheses, particularly regarding optimal pressure dosing.

For a field that has seen more than its share of controversy around unproven applications, burn care represents a relatively well-grounded use case with both mechanistic rationale and regulatory clearance. The task now is to build the rigorous trial infrastructure needed to transform this promise into precision protocols that can guide clinical decision-making with confidence.

HBOToday Editorial provides evidence-based reporting on hyperbaric oxygen therapy research, policy, and clinical practice. This article is for informational purposes only and does not constitute medical advice. Patients with burn injuries should consult qualified healthcare providers for individualized treatment recommendations.

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