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Mirroring Consensus Guidelines With Uniform Pure Hypochlorous Acid–based Cleansing
Peer-reviewed published data and guidelines1-5 related to the management of wound infection and chronic wounds stresses the importance of wound pH and notes the benefits associated with pure hypochlorous acid (pHA)–preserved antimicrobial cleansers as opposed to the use of cleansers that may contain sodium hypochlorite, a World War I era cleanser (Dakin's solution). This was intended for acute wounds in young soldiers to be continuously dripped through a multi-hose device due to its instability.6 Sodium hypochlorite is now known to be associated with cytotoxicity within a wound healing environment and is not considered typical standard of care by wound care guidelines (Table 1).7 Given that hypochlorite concentration at a level as low as 5 ppm has been shown to be cytotoxic, and per implications from the literature, the correct concentration of cytotoxic ingredients such as hypochlorite should be as close to zero as possible.7,7A
The material presented here addresses 3 critical components of the chronic wound milieu that are interrelated: 1) the presence or absence of biofilm, 2) necrotic tissue presence/absence, and 3) wound pH. Wound pH is a relatively recent area of focus, and it is often an underappreciated variable that can positively impact and promote wound healing if the pH is mildly acidic. Peer-reviewed literature notes that chronic wounds have a pH much higher than 7.0.8-10 Elevated chronic wound pH, cytotoxicity, biofilm presence/bacterial colonization, necrotic tissue presence, and use of cytotoxic wound cleansing agents are all factors that impair wound closure.11
Wounds progress toward closure as necrotic tissue and bioburden decreases, wound pH decreases, biofilms are removed, and pathologic bacterial colonization is reduced (<105 CFU/g of tissue is typically a problem level). A high wound pH and biofilm development by microbial pathogens are likely co-related and are critical elements that delay healing.12 Specifically, targeting wound pH and the associated biofilms could potentially provide a simplified and economically advantageous method to promote wound healing.
Wound bed moisture can be a double-edged sword; too dry or too wet an environment impairs wound healing. Uncontrolled lymphedema associated with common venous leg ulcers can result in peri-wound maceration and increased biofilm and necrotic tissue development. Appropriate compression with dressing management can improve lymphedema/interstitial edema, resulting in improved microvascular arterial delivery of oxygen and nutrients to the wound bed, enhancing healing.13 Using a pHA-based wound cleanser/dressing regimen (Vashe, Urgo Medical North America) in conjunction with compression has clinically improved granulation tissue development and biofilm management among our patients. To apply pHA, we soak gauze with pHA-based cleanser, apply the product, cover it with a petroleum jelly–based product, and replace the dressing system frequently so that the gauze never dries out. We term this way of treating wounds as “moist to moist” treatment (as opposed to moist to dry, which can lead to damage to the wound bed when the dried dressing is removed). We also typically add a peri-wound barrier to decrease maceration development. This regimen is ideal for delivering pHA-based wound care as gauze is a low-cost, safe dressing to deliver the cleanser to the wound on a regular basis (eg, daily or BID). Gauze is also relatively unreactive with HOCl and thus an ideal delivery medium for the pHA cleanser.
All the above factors, such as decreased wound pH, relative lack of cytotoxicity, and biofilm/necrotic tissue management, are interrelated and, in turn, associated with accelerated wound closure demonstrable with pHA.14,15 In our experience, the pHA wound cleanser that contains 100% hypochlorous acid (HOCl) as the antimicrobial preservative has proven to be a key component of improving chronic wound closure rates in line with other publications.16,17 It stands to reason that the pH of a chlorinated cleanser that mimics the body’s immune system via the use of HOCl must also be controlled within a very tightly controlled pH (3.5–6), which correlates with the ideal pH for wound healing.
We present a single-site series of pHA use (ie, a wound cleanser preserved with 100% pure proven antimicrobial, HOCl with near 0% cytotoxic hypochlorite). In this retrospective review, we examined patients that were treated with HOCl cleanser–soaked gauze, with BID dressing changes, in addition to our standard of care consisting of lower limb compression (typically VELCRO Brand inelastic compression over dynamic dermal microdeformation Fuzzy Wale compression tube sock (Compression Dynamics), adjunctive bionutrients (vitamins D, C, B12, B6, and folate [Juven, Abbott Nutrition]), and micronized purified flavanoid fraction (diosmin hesperidin). Duplex ultrasound for venous insufficiency was performed for patients with venous leg ulcers, and venous ablation was performed when appropriate. Ankle brachial indices and toe brachial indices were also performed to ensure adequate arterial perfusion.
METHODS
This retrospective case series evaluated the efficacy of pHA wound cleanser–soaked dressings for various wound etiologies including surgical (abdomen, orthopedic, vascular, breast), trauma, venous, and diabetic ulcers. Of the abdominal wounds, 4 originated from surgical procedures for malignant cases, 2 with chronic mesh exposure. Moist pHA–based BID dressings were initiated at consultation and continued through last follow-up (13 patients), wound closure (8 patients), or skin grafting (1 patient). Wound size was documented, and debridement was performed as indicated. No adjunctive advanced dressings were used. In-person clinic visits and telehealth care were used during the COVID-19 pandemic.
RESULTS
Eight patients had closed wounds within 3 to 5 visits (8 to 16 weeks), and 11 patients had 2 to 7 visits with 40% to 98% progression to closure as demonstrated by development of granulation tissue throughout the entire wound bed. One patient underwent skin grafting after 4 weeks. No patient experienced adverse events. Table 2 summarizes the cases. Cases 1, 10, 13, and 15 are shown in Figure 1, Figure 2, Figure 3, and Figure 4, respectively. Telehealth use came with challenges in some cases of recording wound measurements.
DISCUSSION
The pHA-based cleanser use likely results in the decrease of pathologic bacteria and biofilm and necrotic tissue, decreasing inflammation and providing an environment for accelerated angiogenesis. In this case series, pHA-soaked dressings were changed BID with the goal of reducing and maintaining wound pH in the vicinity of 5.5. This series demonstrates that a moist pure HOCl-preserved BID dressing regimen can be effective in a variety of chronic wound types and can be performed efficiently (as demonstrated by pandemic and telehealth conditions) with excellent outcomes in a patient-convenient outpatient and in-hospital settings. This strategy has the potential for a favorable economic impact because it does not involve the frequent use of costly primary dressings. A prospective study is indicated with comparative cost determinations.
REFERENCES
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SPONSORED CONTENT: Pearls for Practice is made possible through the support of Urgo Medical, Fort Worth, TX (www.urgomedical.com).
The opinions and statements of the clinicians providing Pearls for Practice are specific to the respective authors and not necessarily those of Urgo Medical, Wound Management & Prevention, or HMP Global. The authors received manuscript assistance only and no honoraria or financial incentives. This article was not subject to the Wound Management & Prevention peer-review process and is based on a poster presented at SAWC Spring 2022, Phoenix, AZ.
