Temple University School of Podiatric Medicine Journal Review Club

Editor's note: This post is part of the Temple University School of Podiatric Medicine (TUSPM) journal review club blog series. In each blog post, a TUSPM student will review a journal article relevant to wound management and related topics and provide their evaluation of the clinical research therein.

Article title: Effects of Hypochlorous Acid Solutions on Venous Leg Ulcers (VLU): Experience With 1249 VLUs in 897 Patients
Authors: Cheryl M. Bongiovanni, PhD, RVT, CWS, FASA, FACCWS
Journal name and issue: The Journal of The American College of Clinical Wound Specialists. December 2014. Vol. 6(3) (pages 32-37). Published online January 20, 2016.
Reviewed by: Anam Ali, Class of 2018, Temple University School of Podiatric Medicine.

Introduction

A very common wound that podiatric physicians treat is a venous leg ulcer. Venous ulcers result from increased capillary pressure and permeability that leads to water and proteins leaking into the interstitial space. The leukocytes that get leaked trigger an inflammatory response that persists and leads to tissue necrosis. The average time for venous ulcers to heal is approximately 190 days. Presence of one or more comorbidities can significantly delay wound healing times. The author of this study wanted to examine the effect that using hypochlorous acid (HCA) solutions in the treatment of venous ulcers had on the time it takes the ulcer to heal. They also examined the effect it had on the effects of the comorbidities.

Methods

This study included 897 patients who visited the Lake Wound Clinic from June 2006 to June 2014 for treatment of 1249 venous leg ulcers. The volume, color, odor, location, duration, type of exudate, and maximum depth was recorded for all ulcers. During the initial treatment of the ulcers, they were cleaned and debrided using large amounts of HCA. If abrasion was needed, the sterile gauze was wet with HCA before being used. After the treatment, the ulcers were dressed and packed using gauze with HCA. Patients were then given a compressive bandage that had the most compression at the ankle level. The bandage compression was checked and ensured not to exceed distal artery perfusion pressure.

Results

When patients had one or more comorbidities, the healing times were extended. Comorbidities that increased healing time included diabetes, peripheral artery disease, active smoking, steroid medication use, use of street drugs, and morbid obesity. Comorbidities that did not increase healing time included congestive heart failure, varicose veins, stasis dermatitis, lipodermatosclerosis, multidrug resistant infections, and immunocompromised (HIV).

The author measured transcutaneous oxygen pressure (tcpO2) to assess microcirculatory integrity. The author found that most patients had elevated transcutaneous oxygen pressure in periwound tissues 15-30 seconds after exposure to hypochlorous acid. The patients that did not have elevated tcpO2 following exposure to HCA were patients with significant PAD and/or those who smoked. The patients who had an elevated tcpO2 15-30 seconds after exposure of HCA continued to have an elevated tcpO2 72 hours after exposure. Another major concern that extends wound healing time is the development of biofilms in a wound. The author states that scraping the wound with a gauze soaked in HCA and then flushing the wound with more HCA destroys the biofilm in situ due to HCA antimicrobial properties. If this procedure is done repetitively with each treatment no longer than 36 hours apart, it also prevents the recurrence of biofilms.

Discussion

The author stated that all of the venous ulcers treated in this report completely healed. The author found that the shortest healing times were 2-5 days and the greatest were within 180 days. The group that had the longest healing times were the patients who did not receive the compression therapy because it was contraindicated for them. The shortest healing times were observed in patients who did not smoke and did not have diabetes. The HCA was beneficial because it elevated the tcpO2, which means there was increased oxygenation and perfusion to the periwound tissue. The author concludes that using HCA during the treatment of venous leg ulcers improves microcirculatory damage caused by other comorbidities and decreases healing time.

About the Authors:
Anam Ali is a second year podiatric medical student at Temple University School of Podiatric Medicine (TUSPM) in Philadelphia, Pennsylvania. She graduated from the University of Virginia in Charlottesville, Virginia in 2013 with a Bachelor of Arts in Psychology. During her time at the University of Virginia, Anam was an active member of various service oriented organizations, including the Madison house tutoring program. Through the tutoring program, she was able to tutor students who were attending various high school in the Charlottesville area.

Dr. James McGuire is the director of the Leonard S. Abrams Center for Advanced Wound Healing and an associate professor of the Department of Podiatric Medicine and Orthopedics at the Temple University School of Podiatric Medicine in Philadelphia.