Copyright EMAP Publishing 2018

This article is not for distribution

except for journal club use

Clinical Practice Keywords Wound cleansing/Biofilm/

Cleansing/Antiseptic solutions
Review
Wound cleansing This article has been
double-blind peer reviewed

In this article...
● Circumstances in which wound cleansing is appropriate
● How to select a wound cleansing solution
● When to use topical antiseptic solutions

When is wound cleansing necessary

and what solution should be used?
Key points
Author Annemarie Brown is lecturer in nursing, University of Essex.
Wounds are often
cleansed without Abstract Routinely cleansing wounds at every dressing change can do more harm
proper consideration than good, as scrubbing the granulating wound bed with gauze swabs may disrupt
of whether this is fragile tissue growth and damage new capillaries. The body may perceive this as a
necessary new injury and re-launch an inflammatory response, which will only delay the healing
process. Cleansing wounds is, therefore, not recommended unless the wound shows
Wound cleansing signs of infection, presents with slough or is visibly contaminated with faecal material
can interrupt the or debris. This article explains the circumstances in which it is appropriate to cleanse
healing process by a wound, when it is appropriate to use tap water and when a sterile solution is
damaging new recommended. It also discusses the re-emergence of antiseptic solutions – which are
tissue or reducing becoming more popular, particularly for infected or heavily contaminated wounds –
the temperature and offers guidance on when to consider using them to cleanse wounds.
of the wound bed
Citation Brown A (2018) When is wound cleansing necessary and what solution
Potable tap water is should be used? Nursing Times [online]; 114: 9, 42-45.
as safe and effective

I
as normal saline for
wound cleansing, n the absence of slough, visible debris, ● V
 isibly contain debris, such as grit
although saline devitalised tissue or infection in the picked up in a road accident (Wolcott
should be used on wound bed, the practice of routinely and Fletcher, 2014; Flanagan, 2013).
post-operative cleansing a wound during dressing Fig 1 outlines the wound infection
wounds changes is largely ritualistic and may actu- continuum.
ally delay healing (Flanagan, 2013). Scrub-
Antiseptic solutions bing or rigorously cleaning with gauze Temperature of cleansing solution
are increasingly swabs a granulating wound bed may Lock (1979) demonstrated that cellular
used to cleanse damage newly forming capillaries and dis- activity is optimised when a stable temper-
wounds showing rupt fragile new tissue growth. The body ature of 370C is maintained in a wound.
signs of critical may perceive this as a new injury and so This seminal study also showed that, after
colonisation and re-initiate the inflammatory response, having been cleansed with a cold solution,
when the presence thereby delaying the healing process a wound could take up to 40 minutes to
of a biofilm is (Edwards-Jones and Flanagan, 2013). As reach the optimum temperature for
suspected such, it is recommended that wounds are healing (Lock, 1979).
only routinely cleansed at dressing Feinstein and Miskiewicz (2009) found
changes if they: that a reduced wound-bed temperature will
● S
 how signs of infection; result in lower oxygen levels and fewer leu-
● P
 resent with slough (which increases cocytes, which are vital for fighting infec-
the bacterial burden of the wound tion. Therefore, if a temperature of 37oC is
and makes it more vulnerable to not maintained due to frequent dressing
infection); changes and cleansing with a cold solution,
● A
 re visibly contaminated with faecal there is a risk that wound healing will be
material (which increases the risk of delayed. Health professionals, if they
infection); decide cleansing is appropriate, need to

Nursing Times [online] September 2018 / Vol 114 Issue 9 42 www.nursingtimes.net


Clinical Practice
Review
Fig 1. The wound infection continuum
Contamination Colonisation Local infection
Vigilence required
No antimicrobials indicated Topical
antimicrobial
ensure the temperature of the solution
used will not cool the wound unnecessarily.
Normal saline or tap water?
Traditionally, sterile normal saline (0.9%)
has been used as the cleansing solution of
choice due to its isotonic qualities, which
mean it will not disrupt the normal healing
process (Flanagan, 2013). However, a sys-
tematic review found no difference in
infection rates in acute, surgical or chronic
wounds cleansed with potable tap water
compared with wounds cleansed with
sterile normal saline (Fernandez and Grif-
fiths, 2012); the authors concluded that
potable tap water is a safe and effective
alternative to sterile normal saline for
wound cleansing. Despite this robust evi-
dence, potable tap water is still not used
universally in clinical practice, and deci-
sions on whether to use it are often based
on personal experience, personal prefer-
ence, clinical setting and local protocol
(Santos et al, 2016).
Care setting
Although the evidence indicates that tap
water is a safe solution for wound
cleansing – particularly for chronic
wounds – health professionals need to be
mindful of the setting in which they are
working. In inpatient settings, swabs
cultured in the laboratory have shown
high numbers of bacteria growing in and
around washbasins (Jefferies et al, 2012;
Johnson et al, 2009; Trautmann et al, 2005).
As such, although it may be convenient
to use tap water in a patient’s home or at a
GP surgery, in an acute hospital it may be
preferable to use sachets of sterile water or
normal saline. In the acute setting, if
health professionals decide to use tap
Nursing Times [online] September 2018 / Vol 114 Issue 9
Biofilm
Increasing microbial
virulence and/or numbers
Spreading Systemic
infection infection
Intervention required
Systemic and topical
antimicrobial
water to cleanse a wound, they should
let the tap or shower head run for a few
seconds before using the water so any
impurities and bacteria are flushed away
(Flanagan, 2013).
If a patient is at home with an open
wound and cleansing is required, show-
ering is the preferred method of irrigation
– and it may also increase the patient’s
sense of wellbeing (Fernandez and Grif-
fiths, 2012). Patients whose wounds are
located in the pelvic region – such as
excised pilonidal sinuses or episiotomy
wounds – are generally encouraged to
shower daily and after every bowel move-
ment (Harris et al, 2016); this is because the
wound can be easily contaminated with
faecal material.
40 minutes
QUICK Time for a wound to reach
FACT healing temperature after
cold-solution cleansing
For patients with compromised immu-
nity, diabetic wounds, foot ulcers or
wounds where bone or tendon is exposed,
it may be more appropriate to use sterile
solutions rather than tap water as a precau-
tionary measure to reduce the risk of infec-
tion (Peate and Glencross, 2015; Cutting et
al, 2010).
Cleansing surgical wounds
The National Institute for Health and Care
Excellence recommends that sterile
normal saline is used for cleansing sur-
gical wounds during the first 48 hours
after surgery (NICE, 2013). Once the inci-
sion site has healed and the wound is no
longer open, there should be no need to
cleanse the wound.
43
Copyright EMAP Publishing 2018
This article is not for distribution
except for journal club use
Heal et al (2006) compared three groups
of patients eight days after they had under-
gone surgery to investigate whether
wound cleansing reduced infection rates.
In the groups, patients’ wounds were:
l K ept completely dry;
l C leansed using tap water only;
l C leansed using a combination of tap
water and shower gel.
No wound infection was found in any of
the groups, and the authors concluded
that most surgical wounds do not need
routine cleansing. In 2015, a Cochrane
review concurred with these findings; this
led the researchers to recommend that
dressings be removed 12 hours after sur-
gery and patients encouraged to shower as
normal (Toon et al, 2015).
However, there are occasions when it
will be necessary to cleanse surgical
wounds – for example, when there is evi-
dence of excessive bleeding on the
dressing. In that case, cleansing the wound
may be necessary not only to avoid upset-
ting patients and/or their relatives, but
also to better see the suture lines and
establish the cause of bleeding (Peate and
Glencross, 2015).
Topical antimicrobials
Topical antimicrobials are commonly used
to reduce the number of bacteria in:
l I nfected wounds;
l W ounds that may harbour a biofilm
(a colony of multiple strains of bacteria
that has a slimy protective layer around
it and is resistant to systemic
antibiotics);
l W ounds with excessive exudate,
necrotic tissue or debris in the wound
bed (Cutting et al, 2010).
Antimicrobial products can inhibit or
eradicate micro-organisms and have
broad-spectrum activity against the main
bacteria and fungi found in wounds (Wol-
cott et al, 2008).
‘Antimicrobial’ is an umbrella term for a
group of products, which have been out-
lined in Box 1.
The case for using antiseptics
Until recently, antiseptics were not
recommended for routine use in wound
care (Wounds UK, 2013). However, they are
gradually becoming a popular addition to
the wound care toolkit for managing
wounds presenting with obvious signs of
critical colonisation, including the pres-
ence of biofilm and excess exudate, necrotic
tissue or debris (Cutting et al, 2010). This
rise in popularity is due, in part, to the cur-
rent drive to reduce the prescribing of
www.nursingtimes.net
 Copyright EMAP Publishing 2018
This article is not for distribution
except for journal club use

Clinical Practice
Review

Box 1. Antimicrobial products Both antiseptics are available as irriga-

tion solutions or gels and can be applied
l Disinfectants – used to eradicate or reduce the number of microbes on objects directly from the container onto a mois-
such as dressing trolleys and surgical instruments tened wound (Fletcher and Bradbury, 2011).
l Antiseptics – used to eradicate or reduce the number of bacteria in a wound or on Alternatively, they can be applied with a
intact skin (for example, in pre-operative surgical site cleansing) soaked gauze pad (Fletcher and Bradbury,
l Antibiotics – substances that occur naturally or are manufactured and can kill 2011); however, this needs to be done at
bacteria selectively; they are given systemically but can also be applied topically, least once a day and the gauze pad needs to
although the latter is not recommended because it increases the risk of microbial be left on the wound for at least 15 minutes
resistance (Vowden et al, 2011) when using PHMB, which may not be pos-
sible in busy clinical environments
(Fletcher and Bradbury, 2011; Andriessen
systemic antibiotics due to concerns about “A systematic review found and Strohal, 2010). If using a soaked gauze
no difference in infection
drug resistance (Cooper and Kirketerp- pad is a problem, it may be preferable to
Møller, 2018). apply the antiseptic in gel form under a
Chronic wounds are prone to devel- rates in wounds that were secondary dressing at every dressing
oping a high bacterial load because they cleansed with potable tap change (Andriessen and Strohal, 2010).
remain open for a long time. If the bacte-
rial load is not reduced or managed effec-
water compared with Managing biofilms
tively, bacteria will continue to reproduce sterile normal saline” Biofilms are 10 times more likely to form in
rapidly. If this reaches a critical stage, the chronic wounds than in acute ones (Per-
wound may progress to local infection moist environment, thereby facilitating cival and Suleman, 2015; Rajpaul, 2015;
(Cutting et al, 2010) or develop a biofilm autolysis, which disrupts biofilms and James et al, 2008; European Wound Man-
(Rajpaul, 2015; Werthén et al, 2010). bacteria in the wound bed (Chamanga et agement Association, 2005). Chronic
Cutting et al (2010) argued that there is a al, 2015; Andriessen and Strohal, 2010). wounds with high bacterial loads and bio-
case for using antiseptic cleansing solu- However, octenidine dihydrochloride is films may become difficult to heal
tions – particularly in critically colonised not effective against viruses and spores. (Greener, 2011).
wounds – in the following instances: A solution of 0.01-0.2% PHMB is recom- The signs that a biofilm is present are
l W hen a localised infection has already mended for the treatment of critical colo- very subtle and often invisible to the naked
developed; nisation or local wound infection (Lind- eye. As there are currently no diagnostic
l I n patients with a history of recurrent holm, 2010) and PHMB 0.04% is tools available to detect biofilms, their
infection; recommended for heavily colonised and presence should be suspected in wounds
l W hen systematic antibiotics need to be clinically infected wounds – the recom- that are not responding as well as antici-
given to halt spreading infection such mended contact time is 15 minutes for all pated. The signs suggesting the presence
as cellulitis. strengths of solution (Andriessen and of a biofilm include:
Box 2 provides guidance on how to use Strohal, 2010). Similarly, a 100g solution of l D
 elayed or stalled healing despite
antiseptic wound-cleansing solutions. octenidine dihydrochloride contains 0.1g appropriate wound assessment and
of octenidine and the manufacturers rec- management;
Choosing the right antiseptic ommend a minimum contact time of l P
 ersistent slough that returns rapidly
solution 1 minute (Bit.ly/octenidine). after debridement (Cutting et al, 2010).
One antiseptic solution used for wound
cleansing is polyhexanide and betaine
Box 2. Guidance on using antiseptic wound-cleansing solutions
(PHMB) (Braun et al, 2014; Fletcher and
Bradbury, 2011). PHMB has been found to l Consider using a topical antiseptic solution to cleanse wounds presenting with
be less toxic and damaging to healthy cells signs and symptoms of critical colonisation or of local infection, and the wounds of
than chlorhexidine and povidone iodine patients with a history of recurrent infections
(Hübner and Kramer, 2010; Moore and l Consider using topical antiseptic solutions as an adjunct to systemic antibiotics in
Gray, 2007); it has also been shown to be patients who have signs of spreading wound infection
effective in reducing the bacterial burden l Do not use topical antiseptic solutions in patients whose wounds show none of the
in wounds (Fletcher and Bradbury, 2011). signs of critical colonisation or infection
An alternative antiseptic solution com- l Do not use more than one topical antimicrobial or antiseptic product at a time
monly used nowadays for wound cleansing l A topical antiseptic solution should be used for up to five days and for no longer
is octenidine dihydrochloride, which was than 14 days at the most. After five days of use, the wound should be re-assessed
introduced over 20 years ago as a decoloni- for signs of improvement, such as a reduction in slough or odour, which would
sation product (Greener, 2011; Siebert, indicate a reduced bacterial burden. Once the wound starts to improve, the
2010). Although this water-based solution antiseptic solution should continue to be applied for up to 14 days and then
is generally prescribed pre-operatively for discontinued (Andriessen and Strohal, 2010). If, after 14 days, the wound is found
the eradication of methicillin-resistant to have deteriorated or shows signs of spreading infection, use of systemic
Staphylococcus aureus (MRSA) (NHS antibiotics should be considered
Choices, 2017), it has broad-spectrum l Once the wound has improved, stop using the antiseptic cleaning solution
properties. It has been found to be effec- Source: Adapted from Wounds UK (2013)
tive in debriding slough, as it maintains a

Nursing Times [online] September 2018 / Vol 114 Issue 9 44 www.nursingtimes.net


Clinical Practice
Review
This wound on an individual’s leg has become infected, as is evident by the presence of
pus and inflammation
Health professionals should be vigilant
when managing wounds displaying any of
these characteristics. If a biofilm is sus-
pected, the application of an antiseptic
solution may be appropriate. Frequent
debridement combined with the use of an
antiseptic cleansing solution has been
found to be an effective management
strategy for wounds with a biofilm
(Wounds UK, 2013).
Conclusion
The decision whether or not to cleanse a
wound depends on the type of wound and
the condition of the wound bed. If a wound
requires cleansing simply so the health
professional can better see the wound bed
or remove debris, potable tap water will be
the most appropriate solution. However, if
the health professional suspects that a bio-
film may be present or if the wound appears
Nursing Times
Self-assessment
online
Test your knowledge with Nursing
Times Self-assessment after reading
this article. If you score 80% or more,
you will receive a personalised
certificate that you can download and
store in your NT Portfolio as CPD or
revalidation evidence.
Visit nursingtimes.net/
NTSAWoundCleansing to take
the test.
SPL
Nursing Times [online] September 2018 / Vol 114 Issue 9
to have a high bacterial load, the timely
application of a topical antiseptic solution
for a limited period may prevent the wound
from developing an infection. NT
References
Andriessen A, Strohal R (2010) Understanding the
role of PHMB: a topical approach to wound
infection. Wounds International; 1: 3, 25-28.
Braun M et al (2014) An evaluation of the efficacy
and cost-effectiveness of cctenilin for chronic
wounds. Wounds UK; 10: 4, 89-96.
Chamanga ET et al (2015) Chronic wound bed
preparation using a cleansing solution. British
Journal of Nursing; 24: 12, S30-S36.
Cooper R, Kirketerp-Møller K (2018) Non-
antibiotic antimicrobial interventions and
antimicrobial stewardship in wound care. Journal
of Wound Care; 27: 6, 355-377.
Cutting KF et al (2010) Biofilms and significance
to wound healing. In: Percival S, Cutting K (eds)
Microbiology of Wounds. Boca Raton, FL:
CRC Press.
Edwards-Jones V, Flanagan M (2013) Wound
infection. In: Flanagan M (ed) Wound Healing and
Skin Integrity: Principles and Practice. Chichester:
Wiley-Blackwell.
European Wound Management Association
(2005) Identifying Criteria for Wound Infection.
London: Medical Education Partnership.
Feinstein L, Miskiewicz M (2009) Perioperative
hypothermia: review for the anaesthesia provider.
The Internet Journal of Anesthesiology; 27: 2.
Fernandez R, Griffiths R (2012) Water for wound
cleaning. Cochrane Database of Systematic
Reviews; 2: CD003861.
Flanagan M (2013) Principles of wound
management. In: Flanagan M (ed) Wound Healing
and Skin Integrity: Principles and Practice.
Chichester: Wiley-Blackwell.
Fletcher J, Bradbury S (2011) Prontosan Made
Easy. Wounds International. Bit.ly/WIProntosan
Greener M (2011) Octenidine: antimicrobial activity
and clinical efficacy. Wounds UK; 7: 3, 74-78.
Harris C et al (2016) Pilonidal sinus disease: 10
steps to optimize care. Advances in Skin and
Wound Care; 29: 10, 469-478.
Heal C et al (2006) Can sutures get wet?
Prospective randomised controlled trial of wound
45
Copyright EMAP Publishing 2018
This article is not for distribution
except for journal club use
For more articles
on wound care, go to
nursingtimes.net/woundcare
management in general practice. British Medical
Journal; 332: 7549, 1053-1056.
Hübner NO, Kramer A (2010) Review on the
efficacy, safety and clinical applications of
polihexanide, a modern wound antiseptic. Skin
Pharmacology and Physiology; 23: Suppl, 17-27.
James GA et al (2008) Biofilms in chronic wounds.
Wound Repair and Regeneration; 16: 1, 37-44.
Jefferies JM et al (2012) Pseudomonas aeruginosa
outbreaks in the neonatal intensive care unit – a
systematic review of risk factors and
environmental sources. Journal of Medical
Microbiology; 61: Pt 8, 1052-1061.
Johnson D et al (2009) Patients’ bath basins as
potential sources of infection: a multicenter
sampling study. American Journal of Critical Care;
18: 1, 31-40.
Lindholm C (2010) Expert commentary. In:
Andriessen A, Strohal R. Understanding the role of
PHMB: a topical approach to wound infection.
Wounds International; 1: 3, 25-28.
Lock PM (1979) The Effects of Temperature on
Mitotic Activity at the Edge of Experimental
Wounds. Chatham: Lock Laboratories Research.
Moore K, Gray D (2007) Using PHMB antimicrobial
to prevent wound infection. Wounds UK; 3: 2,
96-102.
National Institute for Health and Care Excellence
(2013) Surgical Site Infection. nice.org.uk/qs49
NHS Choices (2017) MRSA. nhs.uk/conditions/
mrsa
Peate I, Glencross W (2015) Principles of wound
management I. In: Wound Care at a Glance.
Chichester: John Wiley & Sons.
Percival SL, Suleman L (2015) Slough and biofilm:
removal of barriers to wound healing by
desloughing. Journal of Wound Care; 24: 11,
498-510.
Rajpaul K (2015) Biofilm in wound care. British
Journal of Community Nursing; 20: Suppl 3, S6-S11.
Santos E et al (2016) The effectiveness of
cleansing solutions for wound treatment: a
systematic review. Revista de Enfermagem
Referência; IV: 9, 130-143.
Siebert J (2010) Octenidine: a new topical
antimicrobial for wound antisepsis. Journal of
Wound Technology; 7: 66-68.
Toon CD et al (2015) Early versus delayed dressing
removal after primary closure of clean and
clean-contaminated surgical wounds. Cochrane
Database of Systematic Reviews; 9: CD010259.
Trautmann M et al (2005) Ecology of
Pseudomonas aeruginosa in the intensive care unit
and the evolving role of water outlets as a reservoir
of the organism. American Journal of Infection
Control; 33: 5 (Suppl 1), S41-S49.
Vowden P et al (2011) Antimicrobial dressings
made easy. Wounds International; 2: 1, 1-6.
Werthén M et al (2010) An in vitro model of
bacterial infections in wounds and other soft
tissues. Acta Pathologica, Microbiologica, et
Immunologica Scandinavica; 118: 2, 156-164.
Wolcott RD, Rhoads D (2008) A study of
biofilm-based wound management in subjects
with critical limb ischaemia. Journal of Wound
Care; 17: 4, 333-341.
Wolcott R, Fletcher J (2014) The role of wound
cleansing in the management of wounds. Wounds
International; 5: 3, 25-31.
Wounds UK (2013) Best Practice Statement. The
Use of Topical Antimicrobial Agents in Wound
Management. London: Wounds UK.
For more on this topic online
l Diagnosing and managing infection in
acute and chronic wounds
Bit.ly/NTInfectedWounds
www.nursingtimes.net