Supplementary Material for: Successful Management of a Grade 4 Recalcitrant Sacral Pressure Ulcer in a Diabetic Patient with Adjunctive Ozonated Oil Therapy: A 12‑Month Case Study

Introduction: Pressure ulcers in diabetic patients represent a significant clinical challenge due to impaired wound healing mechanisms. This case demonstrates the successful use of ozonated oil as adjunctive therapy for a recalcitrant Grade 4 pressure ulcer in a complex diabetic patient with multiple comorbidities. Case Presentation: A 60-year-old male with type 2 diabetes mellitus (HbA1c 8.2%), hypertension, chronic alcoholism, and liver cirrhosis developed a Grade 4 sacral pressure ulcer (6.5×6.3×2.4 cm) during hospitalization. The wound showed positive cultures for Escherichia coli and Corynebacterium striatum and remained recalcitrant to conventional therapies including pressure offloading, surgical debridement, moisture-retentive dressings, and low-level laser therapy. Following failure of conventional treatments, adjunctive ozonated oil therapy was initiated with twice-daily applications. Over 12 months, the wound demonstrated progressive healing from Grade 4 (6.5×6.3×2.4 cm) to Grade 1 (0.2×0.2×0.2 cm) with complete re-epithelialization and minimal scarring. No adverse effects were observed during treatment. Conclusion: This case suggests ozonated oil may serve as an effective adjunctive therapy for chronic pressure ulcers in diabetic patients with multiple comorbidities when conventional treatments fail. The multifactorial therapeutic benefits include antimicrobial activity, enhanced tissue repair, and modulation of inflammatory responses. Keywords: Pressure Ulcer; Ozonated Oil; Diabetes Mellitus; Wound Healing; Adjunctive Therapy; Ozone Therapy; Chronic Wounds; Diabetic Complications