An Innovative Dual‐Modality Approach Using Laser and Plasma Therapy in the Management of Chronic Diabetic Foot Ulcer With Osteomyelitis: A Case Series

ABSTRACT

Chronic diabetic foot ulcers (DFUs) complicated by osteomyelitis remain a major clinical challenge, often requiring aggressive treatments or surgical intervention. Novel non‐invasive approaches such as laser and plasma therapy have shown promise in enhancing wound healing and reducing infection. As part of a broader study involving 20 patients with chronic DFUs (14 females and 6 males), a dual‐modality treatment combining low‐level laser therapy and PRP therapy was applied. Among the participants, two representative cases are presented in detail to highlight the clinical outcomes and treatment potential of this method. The first case involves a 65‐year‐old male with a chronic heel ulcer unresponsive to conventional therapies. The second case is a 58‐year‐old female with a necrotic toe and persistent ulceration. Treatment consisted of multiple sessions of laser and plasma therapy, integrated with standard wound care protocols. Progress was monitored through wound size, tissue regeneration, infection control, and overall healing response. Both patients demonstrated substantial clinical improvement, including resolution of necrotic tissue, reduction in wound size, and formation of healthy granulation tissue. No adverse effects were observed, and neither patient required surgical amputation. Further controlled studies are recommended to validate and generalise these findings.

Key Messages

• Chronic diabetic foot ulcers with osteomyelitis present significant treatment challenges and often require multimodal strategies.

• This case series demonstrates the clinical effectiveness of a combined laser and plasma therapy approach in multiple patients.

• Across all cases, improvements were observed in granulation tissue formation, infection control and overall wound healing progression.

• The dual‐modality treatment helped avoid surgical interventions in several instances.

• This approach highlights the potential role of laser and plasma as valuable adjuncts in the multidisciplinary management of complex diabetic wounds.

1. Introduction

Diabetic foot ulcers (DFUs) complicated by osteomyelitis represent a significant clinical challenge, often leading to prolonged healing, increased risk of amputation, and high morbidity. Recent advances in regenerative medicine have highlighted the potential of platelet‐rich plasma (PRP) and low‐level laser therapy (LLLT, also known as photo biomodulation) as adjunctive treatments to enhance wound healing and infection control. While robust evidence supports the efficacy of PRP and LLLT individually in accelerating DFU healing, reducing amputation rates and improving wound closure times [1, 2, 3, 4, 5] direct studies on their combined use especially in the context of osteomyelitis are limited. However, mechanistic and clinical data suggest that both therapies may act synergistically: PRP delivers concentrated growth factors and cytokines to stimulate tissue regeneration, while LLLT modulates inflammation, promotes angiogenesis and enhances cellular repair [2, 6]. Meta‐analyses and systematic reviews consistently report that PRP improves healing rates, shortens healing time and reduces infection and amputation risk in DFUs [4, 7, 8, 9]. LLLT, though less studied, also shows promise in accelerating healing and reducing ulcer area [2, 6]. In this study, 20 patients with DFUs complicated by underlying osteomyelitis were treated using a combined approach of plasma therapy and LLLT. Their clinical outcomes were evaluated as part of a case series analysis.

2. Materials and Methods

2.1. Patient and Wound Evaluations

Patients were referred from a general hospital in Chalous, Iran, with chronic DFUs complicated by underlying osteomyelitis. Upon admission, all patients underwent initial clinical and laboratory evaluations, including complete blood count (CBC), inflammatory markers and wound culture. Wound debridement was performed as part of standard care. Based on the culture and sensitivity results, appropriate systemic antibiotic therapy was initiated to control infection.

2.2. Necrotic Tissue Management

Debridement including removal of necrotic tissue is considered a standard and often initial step in DFU management protocols [10, 11, 12, 13, 14]. However, in this study, a novel and more conservative approach was employed for all patients with necrotic tissue. Instead of immediate debridement, PRP was injected beneath the necrotic layer. This stimulation led to the formation of granulation tissue underneath the necrotic area. With repeated plasma injections over several sessions, the granulation tissue gradually elevated the necrotic layer towards the surface, facilitating a natural and atraumatic separation of devitalized tissue.

This technique preserved the integrity of the newly formed granulation tissue and eliminated the need for aggressive surgical debridement. As a result, the time required for necrotic tissue clearance and granulation was significantly reduced, and critical structures such as tendons and bones were better protected during the wound healing process.

2.3. Low Level Laser Therapy and PRP Injection

LLLT significantly increases skin blood flow and perfusion, especially in areas with poor circulation or trophic abnormalities [15, 16]. Also, it reduces swelling by modulating inflammatory pathways, improving microcirculation and decreasing the expression of pro‐inflammatory markers [17, 18] Even in surgical and traumatic wounds, LLLT has been associated with faster reduction of swelling and improved healing outcomes compared to controls [17, 19].

On the other hand, as a part of treatment PRP accelerates the removal of necrotic tissue and the transition to the granulation phase, often several days earlier than standard care [20, 21, 22].

Given the documented benefits of both modalities, a combined therapeutic strategy utilising LLLT and PRP was implemented to enhance the wound healing process in the selected patients.

In these cases, LLLT was administered three times per week. The treatment protocol included application of a 6 J dose with a frequency of 3000 Hz around the wound margins, and a 4 J dose at the same frequency along the vascular pathways proximal to the wound. Additionally, red light laser with a power output of 200 mW and a dose of 2 J was applied directly over the wound surface at a distance of a few millimetres and plasma therapy was performed twice weekly, in combination with laser treatment sessions. PRP injections were delivered directly into the wound bed to enhance antimicrobial effects and promote tissue regeneration. Treatment parameters for plasma application were standardised for all patients.

Plasma was separated from the patient's blood according to the wound size and the intended injection site. A volume of 2–4 cc of venous blood was collected and transferred into vacuum‐sealed PT tubes containing 2 mL of sodium citrate as an anticoagulant. Sodium citrate is easy to use, widely available and increases the clinical versatility of PRP preparation [23].

As reported in other studies, the optimal centrifugation speed ranges between 1000 and 4000 rpm for a duration of 3–15 min [24, 25, 26, 27]. In the present study, immediately after blood collection, the tubes were centrifuged at 3000 rpm for 10 to 15 min. Following centrifugation, the separated plasma was used for injection within 15 min, as it should not be kept at room temperature for a longer period to maintain its biological activity.

Plasma injection was performed after laser therapy, the injections are performed using a 100‐unit insulin syringe, mainly in areas of the wound that are not yet granulated, in order to promote granulation through PRP injection. The injection procedure should be performed under completely sterile conditions followed by appropriate wound dressing. Patients were instructed to avoid applying any pressure to the treated area for 24 h post‐injection to minimise inflammation and ensure optimal healing.

2.4. Adjunctive Wound Care

To support the healing process between laser therapy sessions and outpatient clinic visits, advanced wound dressings were applied to all patients. These included products such as HydroClean plus (Hartmann) and MediHoney (medical‐grade honey ointment).

These dressings were selected for their ability to promote autolytic debridement, maintain a moist wound environment and accelerate granulation tissue formation. Their continued use between sessions helped enhance the therapeutic effects of plasma and laser treatments, facilitating more effective necrotic tissue resolution and overall wound healing.

3. Results

3.1. Patient Demographics

A total of 20 patients with a mean age of 60 years were included in this study. Among them, 14 were female and 6 were male. All patients presented with DFUs complicated by underlying osteomyelitis (Table 1). Of the 20 patients, 60% had Wagner Grade 5 ulcers and 40% had Wagner Grade 4. Necrotic tissue was present in 70% of the wounds at the time of initial assessment. The resolution of necrotic tissue typically required 3–5 months of treatment, following the granulation‐first plasma injection approach. Complete wound healing occurred over a period of approximately 4–6 months. After full epithelialization and closure, all patients underwent repeat laboratory testing—including CBC, erythrocyte sedimentation rate (ESR), C‐reactive protein (CRP), blood urea nitrogen (BUN) and serum creatinine (Cr)—to reassess infection status and monitor renal function (Table 2). A comprehensive overview of the treatment protocols, including laser and plasma therapy parameters and wound care procedures, is presented in Table 3.

TABLE 1.

Summary of patient characteristics and clinical course.

Parameter	Details
Total number of patients	20
Sex distribution	14 (70%) females 6 (30%) males
Age range	60 ± 15 years
29–50	3 (15%)
51–60	8 (40%)
61–75	9 (45%)
Ulcer location	All patients had foot ulcers
Toes	10 (50%)
Heel	3 (15%)
Fore foot	4 (20%)
Plantar	3 (15%)
Treatment duration	Between 4 and 6 months
Infection monitoring	Based on laboratory tests: CBC, ESR, CRP, BUN, and creatinine
Wound healing assessment	Based on reduction in wound size and depth

TABLE 2.

Wound characteristics and healing progression.

Wound parameter	Description
Wound severity classification (Wagner grade)	12 (60%) Grade 5 8 (40%) Grade 4
Ostelomylie with necrotic tissue	14 (70%)
Ostelomylie without necrotic tissue	6 (30%)
Necrotic tissue management	Plasma was injected directly into necrotic tissue
Time to necrotic tissue resolution (month)	4 ± 1
Time to complete wound closure(month)	5 ± 1
Post‐closure evaluation	Infection markers (CBC, ESR, CRP, BUN, Cr) were reassessed

TABLE 3.

Treatment protocol summary.

Treatment component	Description
Laser therapy frequency	Three sessions per week
Laser therapy parameters	6 J, 3000 Hz around wound margins 4 J, 3000 Hz along vascular pathways 2 J, 200 mW red light, a few mm above the wound surface
Plasma therapy frequency	Two sessions per week (combined with laser therapy)
Plasma application	Direct injection into the wound bed using non‐thermal atmospheric plasma
Wound cleansing	Performed before each session
Debridement	Performed as needed before each treatment session

4. Cases

Two cases representative of wound care in this patient population are presented below. Written informed consent was obtained from all patients included in this report for the publication of anonymised clinical information and images.

4.1. Case 1

A 65‐year‐old male patient presented with a DFU that had persisted for approximately 1 month. He had previously been hospitalised, and after 2 weeks of antibiotic therapy, which led to a reduction in the infection level, he was referred to our clinic for advanced wound care (Figure 1A). Upon admission, the following laboratory tests were conducted: CBC, ESR, CRP, BUN, Cr, wound culture, broad‐spectrum antibiotics were prescribed and laser therapy along with plasma therapy was initiated.

FIGURE 1.

Diabetic foot ulcer with osteomyelitis in the heel. (A) Wound at presentation. (B–D) Wound after 1, 2 and 3 months of laser therapy and PRP injection. (E) Wound fully healed 5 months after presentation.

The wound was cleaned before each laser session. After 1 month of combined laser and plasma therapy, the ulcer showed signs of new tissue formation and the infection significantly decreased. By the end of the first month, the wound had reduced in size and was approximately 80% granulated (Figure 1B). After 2 months of continuous plasma injections and laser therapy, the wound achieved complete granulation (Figure 1C). From the third month onward, plasma therapy was discontinued and treatment continued with laser therapy alone. Laser sessions were reduced from three times per week to twice per week, and silver dressings were applied between sessions to maintain wound hygiene and support healing (Figure 1D). Throughout the treatment period, the patient's CBC, BUN, Cr and ESR were monitored weekly, and medications were adjusted accordingly.

By the fifth month, the wound was completely healed, and all laboratory values had returned to normal levels (Figure 1E).

4.2. Case 2

A 58‐year‐old female patient presented with a severe DFU accompanied by necrosis of one toe. Upon admission, baseline laboratory investigations were performed, including, CBC, ESR, CRP, BUN, Cr and wound culture. Following the availability of laboratory results, antibiotic therapy was initiated according to the culture sensitivity (Figure 2A). After 1 month of treatment with laser therapy and sub‐necrotic tissue plasma injections a technique we employ to target and resorb necrotic tissue in chronic wounds the wound demonstrated approximately 70% granulation. However, the necrotic tissue was still partially present (Figure 2B). After 2 months of continuous plasma and laser therapy, the necrotic tissue was fully eliminated without the need for amputation (Figure 2C). The wound achieved full granulation, and plasma injections were discontinued. Laser therapy was continued as the sole modality. From this point, laser sessions were reduced from three times per week to twice weekly, and during the intervals between sessions, the patient applied Medihoney wound gel to maintain a moist and antimicrobial environment (Figure 2D). By the end of the fifth month, the wound had completely healed, with full epithelialization and restoration of tissue integrity (Figure 2E).

FIGURE 2.

Diabetic foot ulcer with necrotic toe. (A) Wound at presentation. (B–D) Healing process by laser therapy and PRP injections. (E) Wound fully healed.

Throughout the treatment course, weekly monitoring of CBC, ESR, CRP, BUN and Cr was conducted, and medications were adjusted accordingly. Upon completion of treatment, all laboratory parameters had returned to normal levels.

5. Discussion

The management of chronic DFUs, particularly those complicated by suspected osteomyelitis, remains a persistent clinical challenge. Conventional approaches often fail to achieve satisfactory outcomes, leading to prolonged healing time, recurrent infections or even limb amputation.

In recent studies aiming to discover novel approaches for the treatment of severe DFUs, several advanced modalities have been introduced, including hyperbaric oxygen therapy (HBOT), heberprot‐P supplementation, SCIP free flap and various grafting techniques [28, 29, 30, 31]. While some of these methods have shown promise in preventing major amputations, often limiting the need to minor amputations [31, 32], others still carry a high risk of complete limb loss, especially in cases complicated by infection or poor vascularisation [13, 29, 33].

This study also aims to serve the same purpose; technologies such as laser and plasma therapy may represent a valuable adjunct to standard wound care. Remarkably, all 20 patients in this article experienced full wound healing following the application of this dual therapy, with no adverse effects or need for surgical intervention. This outcome strongly suggests that the synergy between laser and plasma therapy may provide a highly effective and safe alternative for managing chronic DFUs.

Early published articles using LLLT individually, confirm that LLLT can significantly increase healing rates, reduce ulcer size and shorten healing time in DFUs compared to standard care alone [2, 34, 35] however studies on healing time in DFUs with osteomyelitis focus on surgical, antibiotic or combined treatments, not LLLT [36, 37].

This study demonstrates that the simultaneous application of laser and plasma therapy is not only safe but also synergistic, enhancing overall therapeutic outcomes in the management of chronic DFUs.

One of the main limitations of this study is the absence of a control group. This is due to the difficulty of finding wounds with identical clinical characteristics, including severity, infection level, vascular status and patient comorbidities. Moreover, withholding or delaying effective treatment in such severe cases would pose an ethical risk and potentially cause harm to the patient.

Further clinical trials with larger patient populations are needed to validate the efficacy and reproducibility of this combined therapeutic approach also, either modality—laser or plasma therapy—may be synergistically combined with additional treatment strategies to optimise wound healing in complex DFUs.

Considering the distinct advantages of this approach compared to conventional methods such as the lack of need for early‐stage necrotic tissue debridement, the elimination of costly and rare materials, and the avoidance of extensive surgical procedures the results obtained in this study were both highly satisfactory and clinically effective. This innovative method may represent a significant advancement in the management of DFUs. However, further research involving a larger number of patients is recommended to confirm its efficacy and establish it as a reliable and standardised therapeutic option.

Funding

The authors have nothing to report.

Ethics Statement

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Sani F. H. and Sani H. H., “An Innovative Dual‐Modality Approach Using Laser and Plasma Therapy in the Management of Chronic Diabetic Foot Ulcer With Osteomyelitis: A Case Series,” International Wound Journal 22, no. 12 (2025): e70796, 10.1111/iwj.70796.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.