Diabetic foot ulcers (DFUs) affect roughly one in three people with diabetes during their lifetime and are a leading precursor of lower-limb amputation. Standard care — offloading, debridement, infection control, and revascularization when needed — heals many wounds, but a substantial proportion remain open for months. This persistent gap has driven interest in adjunctive therapies, including electrical stimulation (ES), which delivers low-level current across or near the wound bed. This article reviews what systematic reviews and guidelines currently say about ES for DFUs.
Why Electrical Stimulation Is Biologically Plausible
Intact skin maintains a small endogenous electric field, and injury creates a current that guides keratinocytes, fibroblasts, and immune cells toward the wound. Laboratory work suggests that applied currents may encourage cell migration and proliferation, angiogenesis, and local perfusion. A recent narrative review by Liu and colleagues (2026) notes that diabetic fibroblasts responded favourably to low field strengths in vitro, whereas high field strengths reduced cell viability, illustrating that dose matters.
Clinical devices vary widely. The main approaches are low-intensity direct current, high-voltage pulsed current, and biphasic or monophasic pulsed currents, delivered through electrodes placed on or around the ulcer, often over several weeks. Waveform, intensity, session frequency, and electrode placement are not standardized, which complicates comparison between trials.
What the Clinical Trials Report
Individual randomized trials have generally reported favourable healing signals. In the Liu review, one trial of low-intensity direct current reported a 59.5% reduction in wound area after 12 sessions, compared with 27.1% in controls. A trial of high-voltage pulsed current reported mean area reduction of 86.2% versus 71.4% with control, with complete healing in 65% versus 35% of ulcers. Another trial found that asymmetric biphasic current more than doubled healing, whereas a symmetric biphasic waveform did not differ from control — suggesting that not all stimulation protocols behave alike.
An earlier meta-analysis by Kwan and colleagues (2012) pooled three ES trials and found higher odds of healing with ES (pooled estimate 2.8; 95% CI 1.5–5.5), yet each individual trial’s confidence interval crossed 1 and the authors still judged the evidence inadequate because the studies were small or methodologically weak.
Systematic Review Findings and Certainty of Evidence
The most rigorous recent appraisal is the systematic review by Melotto, Tunprasert, and Forss (2022, International Wound Journal). Searching eight databases, they identified 560 publications, of which seven compared ES plus standard care with standard care alone. The studies were too heterogeneous to pool statistically. Healing rates appeared higher with ES, but sample sizes were small and four of the seven studies carried a moderate or high risk of bias. The authors concluded that evidence remains insufficient to support routine use of ES in DFUs.
Liu and colleagues reached a similar conclusion in 2026, describing the overall methodological quality of the evidence as limited. Common problems include single-centre designs, inadequate blinding, retrospective designs, and inconsistent reporting of stimulation parameters. Most outcomes were surrogate measures such as wound area or perfusion, while time to closure, recurrence, amputation, and quality of life were infrequently reported. Safety reporting was also limited.
The 2023 IWGDF guideline on interventions to enhance healing of diabetes-related foot ulcers (Chen and colleagues, Diabetes/Metabolism Research and Reviews, 2024) provides context. Its 29 recommendations conditionally support several adjuncts — such as sucrose octasulfate dressings, placental-derived products, autologous leucocyte-platelet-fibrin patches, topical oxygen, and hyperbaric oxygen — only where best standard care has failed to heal the wound, and it describes the overall certainty of evidence as poor, calling for higher-quality trials and health economic analyses.
Practical Interpretation
Several points follow from the literature. First, ES is an adjunct, never a substitute for offloading, perfusion assessment, infection control, and debridement; trials tested it on top of standard care. Second, the evidence base is characterized by small samples and heterogeneous protocols, so effect sizes are uncertain and likely inflated by bias. Third, determining which waveform, dose, and patient subgroup benefit most is an open question. Finally, wireless and self-powered devices are under development but remain largely preclinical.
Key Takeaways
Electrical stimulation shows consistently positive signals for DFU healing in small trials, supported by plausible biology. However, systematic reviews rate the certainty of evidence as low and conclude that it is insufficient to support routine use. Larger, standardized, multicentre randomized trials that report complete healing, recurrence, amputation, and patient-centred outcomes are needed before ES can be considered an established component of DFU care.
References
- Melotto G, Tunprasert T, Forss R. The effects of electrical stimulation on diabetic ulcers of foot and lower limb: a systematic review. Int Wound J. 2022;19(7):1911–1933.
- Chen P, Vilorio NC, Dhatariya K, et al. Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3):e3644.
- Liu Y, Liu X, Lu J, Jiang Y, Wu J. Electrical stimulation: a novel adjunct therapy for diabetic foot ulcers. Front Clin Diabetes Healthc. 2026;6:1682871.
- Kwan RL-C, Cheing GL-Y, Vong SK-S, Lo SK. Electrophysical therapy for managing diabetic foot ulcers: a systematic review. Int Wound J. 2013;10(2):121–131.
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