Hyperbaric oxygen therapy for necrotizing fasciitis: a narrative review of mechanisms, clinical evidence, controversies, and practical considerations.

Necrotizing fasciitis (NF) is a life-threatening infection requiring urgent, multidisciplinary care. This review examines the role of adjunctive hyperbaric oxygen therapy (HBOT), including its mechanisms and clinical evidence. HBOT increases tissue oxygen tension, thereby enhancing neutrophil bactericidal activity, inhibiting anaerobic bacteria, reducing edema, modulating inflammation, and promoting angiogenesis and wound healing. Although large-scale randomized trials are lacking, meta-analyses and cohort studies associate HBOT with reduced mortality and amputation rates, shorter hospital stays, and more efficient resource use, particularly in severe cases such as Fournier's gangrene. However, its application remains controversial due to study limitations, cost, and potential risks. This narrative review does not provide a quantitative synthesis of effect estimates, and conclusions should be interpreted with awareness of the predominantly observational nature of the available evidence. In conclusion, current evidence suggests that adjunctive HBOT may be associated with improved outcomes in NF, especially when initiated early after surgical debridement. Nevertheless, the absence of large-scale randomized controlled trials, significant heterogeneity across studies, and concerns regarding cost and logistics preclude definitive recommendations. The therapeutic role of HBOT likely depends on optimal patient selection and seamless integration within a multidisciplinary framework. Future prospective studies are essential to clarify its efficacy, cost-effectiveness, and precise indications.