practice

Should chlorhexidine gluconate be used in wound cleansing?

The antiseptic chlorhexidine gluconate is available as a hand scrub and, in a weaker dilution, as a wound cleanser. The former is often used in wound care, although there is little evidence to support the use of either dilution as a cleanser
antiseptic; wound cleansing; toxicity; ritualistic practice; accountability
R.C. Main, RN (Adult), BSc Professional Clinical Practice (awaiting ratication), Staff Nurse, Burns Centre, Queen Victoria Hospital NHS Foundation Trust, East Grinstead. West Sussex, UK. Email: rachel.main@qvh. nhs.uk

hlorhexidine is produced in two forms: a 0.05% dilution for wound cleansing and a 4% solution for use as a surgical skin preparation and hand scrub. Chlorhexidine 4% is available in most, if not all, clinical areas, and is of particular use when hand washing in preparation for a sterile procedure. The main indication of 0.05% chlorhexidine is to irrigate wounds requiring cleansing, usually those healing by secondary intention. Anecdotal evidence from nurses in 10 acute trusts across England suggests that, in many clinical areas where wound care is performed, the 4% solution is more readily available than the 0.05% dilution, possibly because it is so widely used as a hand cleanser. Nurses involved in wound care across these trusts told me they use the 4% dilution on wounds healing by secondary intention that appear to be infected or in need of irrigation; some also reported using it as a showering agent or adding it to bath water. It is not clear whether this practice is individual to a handful of professionals or widely practised; the rationale given for using both dilutions of chlorhexidine on wounds was to remove excess wound debris and help ght and prevent localised wound infection. This paper provides an overview of the existing evidence on the use of chlorhexidine in wound care. The Athens database was accessed and search all databases requested. Use of the search terms wound cleansing, chlorhexidine and antiseptics for papers published in the past 10 years identied 20 articles. These form the basis of this overview.

amounts are present or there are clinical signs of infection.2,3 Routine unnecessary cleansing can traumatise fragile new tissue in and around the wound bed.2,4 In summary, the aims of wound cleansing are to eliminate excess exudate and debris from the wound surface,5 and initiate and aid the healing process.6 If cleansing is required, an appropriate solution should be selected to optimise the healing process and minimise the risk of damage to viable tissue. Cleansing agents include normal saline, sterile water and tap water. Antiseptic solutions can be used, although caution is advised as their toxicity might outweigh any benets.4,7 Wound cleansing solutions should: Be non-toxic to human tissues Remain effective in the presence of organic material Reduce the number of microorganisms Not cause sensitivity reactions Be widely available and cost-effective.8

Chlorhexidines value as an antiseptic

Drosou et al. suggested that microbial pathogens can delay wound healing by producing inammatory mediators, metabolic wastes and toxins, and maintaining the activated state of neutrophils.9 As part of the initial inammatory response, neutrophils emigrate to injured tissue in great numbers, and cleanse it of foreign particles. However, if large amounts of microorganisms are lodged in the wound, neutrophils will remain active as they attempt to remove the contaminants. This is likely to cause further tissue damage.10 It has been suggested that the antibacterial properties of chlorhexidine 0.05% can decrease the bacterial load in the wound, creating an environment that promotes cell migration and growth. This in turn reduces the likelihood of the prolonged presence of neutrophils in the wound bed.9 However, Lawrence proposed that it is the physical action of cleansing that removes debris or
J O U R N A L O F WO U N D C A R E V O L 1 7 , N O 3 , M A R C H 2 0 0 8

Wound cleansing
Wounds healing by secondary intention only require cleansing if there is supercial slough, excess exudate, visible debris or any matter from previous dressings present that might delay the healing process.1 Exudate may contain bactericidal properties and growth factors. These will help promote wound healing and should only be removed if copious
112

practice
unwanted exudate from a wound bed, rather than the product used,11 although more evidence is needed to support this. It also has been reported that, in order to achieve an antimicrobial effect, antiseptics such as chlorhexidine 0.05% need to be in direct contact with bacteria for longer than is usually the case during irrigation.12,13 Holt stated that a 20-minute contact time is required.14 In my experience, leaving wounds to soak this long can macerate the surrounding skin, while it is generally thought that soaking a wound in warm water provides an optimum environment for bacteria to breed and proliferate, although no research has yet been undertaken to support this. Furthermore, it is unlikely that patients in a community or outpatient setting would be cared for effectively if the cleansing time alone took 20 minutes. Ferguson suggested that antiseptic solutions, including chlorhexidine 0.05%, are inactivated by body uids and hard tap water.13 As stated above, a key indication for cleansing is the presence of excessive exudate,1 but if it could inactivate the chlorhexidine,13 then this raises questions about its effectiveness as a wound cleanser. Anecdotal evidence suggests that many practitioners believe that both chlorhexidine 4% and 0.05% can be used to penetrate eschar and eliminate topical infection. However, the time required for the antiseptic to penetrate the eschar,12-14 as well as availability of topical antimicrobial dressings and systemic antibiotics,15 arguably make the use of chlorhexidine of either strength redundant for this purpose. Other authors have also questioned the use of chlorhexidine 0.05% in wound cleansing on the basis that its reported toxicity outweighs the benets of its antiseptic properties.17,18 Tatnall et al. compared the cytotoxic effects of different antiseptics, including chlorhexidine 0.05%, on cultured human broblasts and basal keratinocytes19 versus those on a transformed keratinocyte line. Cells were exposed to the antiseptics for 15 minutes, and cell viability was assessed 24 hours later using a colorimetric assay. All agents, which were applied at the concentration recommended for wound cleansing, killed 100% of all cell types.19 The broblasts and keratinocytes, both essential in wound healing, were equally sensitive to the chlorhexidine.19 Clearly, clinical trials would be needed to shed more light on this, particularly as wounds are unlikely to be exposed to a cleanser for 15 minutes in the clinical environment.

Adverse events
A key ingredient of chlorhexidine 4% is Ponceau 4R, a colorant that can induce an allergic reaction and cause intolerance in people who are allergic to aspirin.20-23 As it is a histamine liberator, it may intensify symptoms of asthma,20,21 and is considered carcinogenic in Norway, Finland and the US, where it is banned by Food and Drug Administration.24 Research is needed to determine its exact level of risk and thus eliminate any risk associated with the use of chlorhexidine 4% in handwashing and surgical skin preparation.

A question of accountability
Anecdotal evidence and the literature have as yet failed to explain why 4% chlorhexidine was rst incorporated into wound care, although the use of antiseptic wound cleansing products and dressings dates back many years.25 The manufacturers instructions clearly state that chlorhexidine 4% should not be applied to body cavities. Based on my observations, chlorhexidine 4% is used as a wound cleanser because of lack of awareness among practitioners of the different strengths available and the different purposes for which they are manufactured, while chlorhexidine 4% could have been used as a wound cleanser when the 0.05% solution was unavailable. Furthermore, the 4% solution is cheaper than the weaker dilution: 25 of the pre-diluted 0.05% chlorhexidine sachets cost 1.95, enough to cleanse up to 25 wounds, which is more expensive than a 500ml bottle of 4% chlorhexidine, which could be used on more wounds. Clearly, the practice of using chlorhexidine 4% as a wound cleanser is ritualistic rather than evidence-based. Practitioners must obtain informed patient consent before carrying out any procedure, including
113

Toxicity
In some cases antiseptic solutions, including chlorhexidine of all concentrations, have been found to damage newly healed tissue.2 A study investigating the effects of several antiseptic agents, including chlorhexidine 0.05%, on granulation tissue used rabbit ear chambers as the healing wound model. A laser Doppler measured changes in capillary circulation at one, ve, 30 and 60 minutes; these reected the toxic effects, seen on microscopy, on the ear chamber.16 Chlorhexidine caused a mild exudative reaction, and a few capillaries closed down, causing a redirection of the blood ow. Although no marked overall change in capillary circulation was observed, the authors concluded that the balance between killing bacteria and tissue toxicity may be a ne one,16 and suggested that caution be exercised when using antiseptic agents, including chlorhexidine 0.05%, on wounds. By implication, the potential effect of chlorhexidine 4% on the tissue would have been worse. However, it should be borne in mind that the results of this animal study are not generalisable to the clinical setting.
J O U R N A L O F WO U N D C A R E V O L 1 7 , N O 3 , M A R C H 2 0 0 8

practice
wound cleansing.26,27 Any practitioner who chooses to cleanse a wound with chlorhexidine 4% has a responsibility to inform the patient of the potential risks involved. It is unlikely patients would give informed consent knowing that it is not indicated for this purpose. any antimicrobial effects,11 then water alone would be sufcient and far more cost effective The active agents of chlorhexidine appear to be inactivated by body uids and hard tap water13 Furthermore, an in vitro study found that chlorhexidine 0.05% killed all cell types tested,19 although an in vivo study would be needed to ascertain if its use in the clinical environment would have a similar effect. Much of the existing evidence on the use of chlorhexidine 0.05% in wound care dates from the 1990s, and more up-to-date studies are required. Nevertheless, there is a strong argument that the existing evidence highlights the need for practitioners to reconsider the ritualistic use of chlorhexidine of any concentration on open wounds unless further evidence can prove that its benets outweigh any ill effects.
16 Brennan, S., Leaper, D. The effect of antiseptics on the healing wound: a study using the rabbit ear chamber. Br J Surg 1985; 72: 10, 780-782. 17 Brennan, S.S., Foster, M.E., Leaper, D. Antiseptic toxicity in wounds healing by secondary intention. J Hosp Infect 1986; 8: 3, 263-267. 18 Deas, J.P., Billings, Brennan, S. et al. The toxicity of commonly used antiseptics on broblasts in tissue culture. Phlebology 1986; 1: 205-209. 19 Tatnall, F.M., Leigh, I.M., Gibson, J.R. Comparative study of antiseptic toxicity on basal keratinocytes, transformed human keratinocytes and broblasts. Skin Pharmacol. 1990; 3: 3, 157-163. 20 Ponceau 4R. www.chm.bris. ac.uk/webprojects2001/anderson/ colourings.htm#e123. Accessed 10 November 2006. 21 Ponceau 4R. www.eatwell.gov. uk/healthissues/foodintolerance/ foodintolerancetypes/foodadditiv. Accessed 14 February 2008. 22 Ponceau 4R. www.food-info. net/uk/e/e124.htm. Accessed 13 February 2008. 23 Ponceau 4R. www. ukfoodguide.net/e124.htm. Accessed 13 February 2008. 24 US Food and Drug Administration. Food GMP Modernization Working Group: Report Summarizing Food Recalls. 19992003. www.cfsan.fda. gov/~dms/cgmps2.html. Accessed 14 February 2008. 25 Forrest, R.D. Early history of wound treatment. J R Soc Med 1982; 75: 3, 198-205. 26 Nursing and Midwifery Council. Code of Professional Conduct, 2002 27 Department of Health. Reference Guide to Consent for Examination or Treatment. DH, 2000.

Conclusion
In summary, chlorhexidine gluconate 4% should only be used as indicated by the manufacturer as an antiseptic hand wash, a pre-operative hand scrub and to prepare skin for surgery. Chlorhexidine 0.05%, however, has been used as a wound cleanser for many years, although the evidence in the literature raises questions about its suitability for this purpose: If removal of bacteria from a wound is likely to be due to the physical action of cleansing rather than References
1 Miller, M., Dyson, M. Principles of Wound Care. Professional Nurse/Emap Healthcare, 1996. 2 Mulder, M., Small, N., Botma, Y. et al. Basic Principles of Wound Care. Pearson Education, 2002. 3 Oliver, L. Wound cleansing. Nurs Stand 1997; 11: 20, 47-51. 4 Morison, M. A Colour Guide to the Nursing Management of Wounds. Wolfe Publishing, 1992. 5 Sibbald, R.G., Williamson, D., Orsted, H.L. et al. Preparing the wound bed: debridement, bacterial balance and moisture balance. Ostomy Wound Manage 2000; 46: 11, 14-35. 6 Towler, J. Cleansing traumatic wounds with swabs, water or saline. J Wound Care 2001; 10: 6, 231-234. 7 Cunliffe, P., Tonks, N. Wound Cleansing: The evidence for the techniques and solutions used. Prof Nurs 2002; 18: 2, 95-99. 8 Flanagan, M. Wound cleansing. In: Morison, M., Moffat, C., BridelNixon, J., Bale, S. (eds). Nursing Management of Chronic Wounds. Mosby, 1997. 9 Drosou, A., Falabella, A., Kirsner, R.S. Antiseptics on wounds: an area of controversy. Wounds 2003; 15: 5, 149-166. 10 Clark, R. (ed). The Molecular and Cellular Biology of Wound Repair (2nd edn). Plenum Press, 1996. 11 Lawrence, J. Wound irrigation. J Wound Care 1997; 6: 1, 23-26. 12 Dealey, C. The Care of Wounds: A guide for nurses (2nd edn). Blackwell Science, 1999. 13 Ferguson, A. Best performer. Nurs Times 1988; 84: 14, 52-55. 14 Holt, L. Wound Care. Accident and Emergency Theory into Practice. Bailliere Tindall, 2000. 15 Young, T. Common problems in wound care: wound cleansing. Br J Nurs 1995; 4: 5, 286-289.

interface

Bulletin board
Resin salve for pressure care
traditional Finnish folk medicine, made from the resin of Norwegian spruce tree and butter, has been found to be effective in treating severe pressure ulcers, according to a paper in British Journal of Dermatology. The investigators compared
114

the resin salve with a hydrocolloid control in 22 patients with 29 ulcers over a six-month treatment period. Ninety-two per cent of patients in the study group healed compared with 44% of the controls. Healing rates were significantly faster in the study group. However, the superior effect of the resin solve

only became apparent after three months of treatment. The investigators speculate the salve may have antimicrobial qualities.
Sipponen, A., Jokinen, J.J., Sipponen, P. et al. Benecial effect of resin salve in treatment of severe pressure ulcers: a prospective randomised and controlled multicentre trial. Br J Dermatol 2008 (to be published in March).

J O U R N A L O F WO U N D C A R E V O L 1 7 , N O 3 , M A R C H 2 0 0 8