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: Flow-through Instillation of Hypochlorous Acid in the Treatment of Necrotizing Fasciitis
Authors: John Crew, MD; Kerry Thibodeaux, MD; Marcus Speyrer, RN; Anibal Gauto, MD; Timothy Shiau, PhD; Lilian Pang; Keith Bley, PhD; Dmitri Debabov, PhD.
Journal name and issue: Wounds, February 2016 (pages 40-47).
Reviewed by: Payal Patel, second year podiatric medical student Temple University School of Podiatric Medicine.

This article published in 2016 in the official journal of the Association for the Advancement of Wound Care by John Crew, MD and associates describes the treatment of Necrotizing Fasciitis (NF). NF is referred to as the “flesh-eating” disease where there is a rapid involvement of superficial to deep tissue causing destruction of the tissue. The bacteria associated with this disease releases toxins that subsequently cause immune system dysfunction and local tissue necrosis. The authors of this publication used a vacuum-assisted closure, also known as negative pressure wound therapy, with 0.01% pure hypochlorous acid (HOCl) with no sodium hypochlorite impurity in saline pH 4-5.

Each patient’s wound was different in terms of location and magnitude and this was reflected in the treatment components of volume of HOCL solution and the degree of negative pressure. Before treatment, the necrotizing wounds were cleansed, debrided, and skin dried. Dressings were applied to the wound with the in-flow tubes going through or under the dressing. The negative pressure was adjusted between 50-125mmHg. The 0.01% pure HOCL was instilled via a syringe through the inlet port to the wound. This instillation was performed 4-6 times a day.

This study treated and observed 6 patients. Patient 1 had an abrupt onset of pelvic Fournier’s gangrene. After a bacterial culture revealed Serratia and Enterobacter, immediate pure HOCL with no sodium hypochlorite was introduced every 4 hours. Within 1 month of using HOCL with a negative pressure therapy, the area completely healed. Each of the remaining 5 patients had NF wounds in areas ranging from the lower abdomen to lower legs. Each patient was also treated with minimal debridement and instillation of pure HOCl and negative pressure therapy. Patients fully healed from their wound in approximately 4 weeks without any major complications.

Necrotizing Fasciitis-Causing Bacteria

A number of bacteria can cause NF, including group A Streptococcus (group A strep), group B Streptococcus, Staphylococcus aureus, Vibrio vulnificus, Clostridium perfringens, and Bacteroides fragilis with Group A Strep being the most common. Each of these types of bacteria is capable of secreting toxins that cause local destruction and immune system dysfunction and localized immunosuppression. These bacteria can also generate enzymes like hyaluronidase and collagenase that allow for horizontal extension to deep fascial planes.

For the treatment of instillation of HOCl, no diagnostic test for bacteria or bacterial toxins were required. The authors concluded that the cellular toxins released from damaged cells and the toxicity and immune dysfunction from the bacterial toxins and superantigens may be moderated by flow through instillation of pure 0.01% HOCl with no sodium hypochlorite impurity. More research with randomized controlled clinical trials with a larger sample size is needed to accept this therapy as a viable option for the treatment of necrotizing fasciitis.

About the Authors:
Payal Patel is a second year podiatric medical student at Temple University in Philadelphia, PA. Payal graduated from Temple University in 2014 with a degree in biology. Payal started podiatry school in 2014. She quickly became involved in Biomechanics Club, Student National Podiatric Medical Association (SNPMA), and American College of Foot and Ankle Surgeons (ACFAS). She became Secretary for Biomechanics Club and Activities Chair for SNPMA.

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.