Antiseptics on Wounds: An Area of Controversy (PART TWO)

Author(s): 
Anna Drosou, MD;(1) Anna Falabella, MD;(1) Robert S. Kirsner, MD(1,2)

PART TWO

Hydrogen Peroxide

A three-percent solution of hydrogen peroxide is commonly used as a wound antiseptic. The three-percent solution demonstrates in-vitro broad-spectrum efficacy. Its greatest activity is towards Gram-positive bacteria, but the presence of catalase in these bacteria makes dilutions below three percent less effective.[1] In a similar fashion, catalases present in tissues can render hydrogen peroxide even less bactericidal in vivo.[6] Although hydrogen peroxide is very commonly used, surprisingly few studies have been conducted to examine its effect on the wound healing process and its efficacy as a wound antiseptic.

Animal and human studies have shown hydrogen peroxide to have no negative effect on wound healing. Lineaweaver, et al.,[29] did not find retardation of reepithelization in a rat model after irrigation of the wound with three-percent hydrogen peroxide. However, at the in-vitro component of the same study, he found minimal bactericidal effect of hydrogen peroxide. Gruber, et al.,[52] found acceleration of reepithelization in a rat model and in a clinical trial. However, bullae were formed on or about the day of healing in most of the patients, suggesting possibly that hydrogen peroxide should not be used in newly formed epithelium.

In another study by Tur, et al.,[80] hydrogen peroxide was found to significantly increase the blood flow in ischemic ulcers in a guinea pig model. The increased blood flow may be due to new vessel formation through activation of metalloproteinases. Interestingly, the blood flow was increased even in places distant to the local application of hydrogen peroxide. No explanation was given for this finding. However, the authors found no difference in the wound-healing rate. This may be due to the limited sensitivity of the method they used to evaluate the clinical response (visual determination of the non-necrotic area).

In a clinical study evaluating the effectiveness of hydrogen peroxide on reducing the infection rate of appendectomy wounds, no toxic effects were found, but it was found to be ineffective.[81] Similarly, in another clinical study in human blister wounds contaminated with Staphylococcus aureus, hydrogen peroxide was found not to retard the healing but neither did it decrease bacterial load.[82]

In conclusion, hydrogen peroxide appears not to negatively influence wound healing, but it is also ineffective in reducing the bacterial count. However, it may be useful as a chemical debriding agent. The American Medical Association concluded that the effervescence of hydrogen peroxide might provide some mechanical benefit in loosening debris and necrotic tissue of the wound.[13]

Acetic Acid

Acetic acid is frequently used in wounds as a 0.25-percent or 0.5-percent solution. It is bactericidal against many Gram-positive and Gram-negative organisms, especially Pseudomonas aeruginosa. No delay of reepithelization has been found in animal and human models.[52] Although one study found that acetic acid initially delayed reepithelization, after the eighth day, this effect did not persist. In the same study, it was not shown to influence tensile wound strength.[29] In two human uncontrolled studies, acetic acid was found to be beneficial in wounds infected with Pseudomonas aeruginosa.[83,84] In a study with patients with venous leg ulcers,[85] gauze dressings wetted with acetic acid were shown to effectively decrease the number of Staphylococcus aureus and Gram-negative rods. Pseudomonas was not reduced significantly.

Although several in-vitro studies found acetic acid to be cytotoxic,[31,86] the in-vivo studies do not confirm these findings. The authors believe that acetic acid can continue being used topically in contaminated wounds where an agent is needed in order to eliminate the chances of infection.

Chlorhexidine

Chlorhexidine has been commonly used in disinfectant and antiseptic solutions.

References: 

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