Wounds – From Physiology to Wound Dressing: In Reply

by Prof. Dr. med. Peter Kujath, Dr. med. Angela Michelsen in volume 13/2008

The numerous readers' letters received in response to this article prompt a discussion of three problems which will now be briefly explained:

1. Since primeval times, humans have treated open wounds with substances to which they attributed a germicidal, disinfectant effect. The mode of action of these agents is based mainly on protein precipitation and thus on destruction or colliquation of the bacteria or fungi. According to existing knowledge, wound healing is controlled by endogenous proteins whose physiological mode of action is impaired by aggressive substances such as gentian violet, 10% sodium chloride solution or hydrogen peroxide. These toxic substances should therefore not be used. No one would instill gentian violet, silver nitrate or tincture of iodine into their eye because these substances would cause the same injuries on the fine corneal endothelium as in a wound.

The use of silver preparations is sometimes advocated by those who attribute an "oligodynamic" effect to silver. Silver has been shown to have bactericidal activity in vitro (1). Silver preparations have not been demonstrated to promote wound healing. Rather, a denaturing effect occurs which deactivates the decisive enzymes. When the principles mentioned are complied with, especially the maintenance of a moist environment, wounds heal well, if not better, even without using the often cost intensive silver preparations.

2. The use of drinking water to irrigate wounds presents no hazards. Thorough research has shown it is necessary to distinguish between drinking water and mains water. Mains water is a generic term for water supplied in water conduits (piping). This also includes industrial and process water which are not of food grade. In Germany, water from the mains system is of such high purity that it is in effect drinking water quality. Exposing a wound to drinking water, under a shower for example, results in dilution of bacteria and toxic substances. As regards the theoretical possibility that shower heads might be contaminated with Pseudomonas aeruginosa or Legionella, there is no clinical evidence of relevance for the colonization of wounds. Our own experience has shown that the use of drinking water on open wounds in many thousands of cases over 30 years has not resulted in any superinfection. As explained in our article, open wounds are never sterile but are colonized by bacteria. With the open conditions in the altered environment, however, these are not able to cause an infection.

The literature contains four studies which address the problems described (2, 3, 4, 5). An analysis of these articles came to the following conclusion: there is at present no proof of the hypothesis that the use of drinking water increases the risk of wound infection or impairs wound healing. It is known from the animal kingdom that free living animals lick and thereby cleanse their wounds. Nevertheless, the colonization of the wounds does not cause a wound healing disorder.

3. The recommendation to use sterile gloves has rightly been criticized and sets too high a standard for dressing change. The authors express their thanks for this comment, since in our own clinic wounds are dressed and cared for without problems using disposable gloves. We only use sterile gloves for wounds of particularly immunosuppressed, e.g. neutropenic patients.
DOI: 10.3238/arztebl.2008.558a


Prof. Dr. med. Peter Kujath
Universitätsklinikum Schleswig-Holstein
Campus Lübeck
Ratzeburger Allee 160
23538 Lübeck, Germany
[e-mail]

Conflict of interest statement
The author declares that no conflict of interest exists according to the Guidelines of the International Committee of Medical Journal Editors

References

1. P. Rudolph, H.-P.Werner, A. Kramer: Hygiene Medizin 25. Jahrgang 2000; 5: 184–6.

2. Angeras MH, Brandberg A, Falk A, Seeman T: Comparison between sterile saline and tap water for the cleansing of acute traumatic soft tissue wounds. Eur J Surg 1992; 158: 347–50.

3. Bansal BC, Wiebke RA, Perkins SD, Abramo TJ: Tap water for irrigation of lacerations. Am J Emerg Med 2002; 20: 469–72.

4. Fernandez R, Griffiths R, Ussia C:Water for wound cleansing. Cochrane Review Art. No.: CD003861. DOI: 10.1002/14651858.CD003861.

5. Griffiths RD, Fernandez RS, Ussia CA: Is tap water a safe alternative to normal saline for wound irrigation in the community setting? J Wound Care 2001; 10: 407–11.