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: Hypochlorous Acid: an ideal wound care agent with powerful microbicidal, antibiofilm, and wound healing potency.
Authors: Serhan Sakaryam, MD; Necati Gunay, MS; Meltem Karakulak, MS; Barcin Ozturk, MD; Bulent Ertugrul, MD.
Journal name and issue: Wounds, December 2014 (pages 342-350).
Reviewed by: Spruha Magodia, Temple University School of Podiatric Medicine

Introduction

Wound healing occurs primarily in three phases – inflammation, migration and remodeling. The article states that successful wound healing is facilitated by platelets, fibroblasts, and keratinocytes. It also states that most chronic wounds are related to diabetes mellitus, venous stasis, peripheral vascular diseases and pressure ulcerations. An open wound is favored by bacteria for biofilm formation and colonization. Biofilms make phagocytosis difficult, increase resistance to antibiotics and adhere to chronic wounds. Reactive Oxygen Species (ROS), developed by the immune system, lead to the generation of hydrogen peroxide. The activated myeloperoxidase converts the hydrogen peroxide to hypochlorous acid (HOCl), which is highly active against all bacterial, viral, and fungal human pathogens. This study investigates the effect of stabilized HOCl solution on microbial and biofilm management, antimicrobial activity within a biofilm against frequently isolated microorganisms, and migration rate of wounded fibroblasts and keratinocytes.

Materials and Methods

HOCl is generated from sodium hypochlorite and hydrogen peroxide. In this study, the concentration used was 218 ppm at pH 7,1, and the stability was 24 months. Skin fibroblast cell lines and human skin keratinocyte cell lines were grown. Staphylococcus aureus, Pseudomonas aeruginosa, and Candida albicans were isolated. Stabilized HOCl solution was inactivated with organic materials and diluted. Sterile phosphate buffered saline (PBS) solution was used as a control. HOCl dilutions and control were prepared in 10 mL tubes and inoculums were added with a density of 105 cfu/mL and incubated at 37° C for 60 minutes for minimum bacterial concentration (MBC). A 10 µL sample was removed and plated on Mueller Hinton or Sabouraud dextrose sugar plates (SDA). Skin fibroblast cells were cultured and a single wound was made across each monolayer. At 0, 4, 8, and 24 hours, images of each monolayer were captured and cell migration into the wound after 4, 8, and 24 hours was compared to the monolayer at 0 hours.

Results

According to the study, all the microorganisms were killed within 0 minutes. The accurate killing time of HOCl on green fluorescent protein (GFP) expressing P. aeruginosa was 12 seconds. The article states that treatment of microorganisms with stable HOCl solution decreased the amount of biofilm, and the amount of microorganisms within the biofilm. The effective dose of HOCl on biofilm impairment of S. aureus, P. aeruginosa, and C. albicans was 1/32, 1/16, and 1 dilution respectively. The microbicidal effects within biofilm and antibiofilm concentration was the same for each of the microorganisms. The data showed that HOCl has antibiofilm activity and actively penetrated through the biofilm and killed the microorganism within the biofilm.

Discussion

The findings in the article demonstrate that stabilized HOCl is an ideal wound care solution with a significant and rapid killing effect on different types of microorganisms, antibiofilms and microbicidal effect within the biofilm. The article states that it has a dose dependent favorable effect on fibroblast and keratinocyte migration.

About the Authors:
Spruha Magodia is a 3rd year podiatric medicine student at Temple University School of Podiatric Medicine in Philadelphia, Pennsylvania. She graduated from Rutgers University Honors Program with a degree in French Literature. She has conducted research for the Endocrine Research Center, testing beta-endorphin and its effects on hepatocellular carcinoma. She was also the president of the Bioethics Society and the Journal of Bioethics where she organized the first ever Rutgers Bioethics Symposium and oversaw the completion of the yearly publication of the academic journal.

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.