Hypochlorous Acid: An Ideal Wound Care Agent With Powerful Microbicidal, Antibiofilm, and Wound Healing Potency

Serhan Sakarya, MD; Necati Gunay, MS; Meltem Karakulak, MS; Barcin Ozturk, MD; Bulent Ertugrul, MD

Disclosures

Wounds. 2014;26(12):342-350. 

In This Article

Abstract and Introduction

Abstract

Introduction Chronic wounds and the infections associated with them are responsible for a considerable escalation in morbidity and the cost of health care. Infection and cellular activation and the relation between cells are 2 critical factors in wound healing. Since chronic wounds offer ideal conditions for infection and biofilm production, good wound care strategies are critical for wound healing. Topical antiseptics in chronic wounds remain in widespread use today. These antiseptics are successful in microbial eradication, but their cytotoxcity is a controversial issue in wound healing.

Objective The aim of this study was to investigate the effect of stabilized hypochlorous acid solution (HOCl) on killing rate, biofilm formation, antimicrobial activity within biofilm against frequently isolated microorganisms and migration rate of wounded fibroblasts and keratinocytes.

Materials and Methods. Minimal bactericidal concentration of stabilized HOCl solution for all standard microorganisms was 1/64 dilution and for clinical isolates it ranged from 1/32 to 1/64 dilutions.

Results All microorganisms were killed within 0 minutes and accurate killing time was 12 seconds. The effective dose for biofilm impairment for standard microorganisms and clinical isolates ranged from 1/32 to 1/16. Microbicidal effects within the biofilm and antibiofilm concentration was the same for each microorganism.

Conclusion. The stabilized HOCl solution had dose-dependent favorable effects on fibroblast and keratinocyte migration compared to povidone iodine and media alone. These features lead to a stabilized HOCl solution as an ideal wound care agent.

Introduction

Wound healing is a sequence of complex and well-orchestrated events. Although the precise mechanism of wound healing is not fully understood, 3 interrelated phases—inflammation, migration, and remodeling—require coordinated activity for successful wound healing, which is a progressive series of events facilitated by platelets, leukocytes, fibroblasts, and keratinocytes. Platelets facilitate homeostasis and the release of growth factors, then leukocytes participate in the inflammatory process. Fibroblasts and keratinocytes have a critical role in wound healing by enhancing reepithelization and the remodeling of the extracellular matrix (ECM).[1–3]

Most chronic wounds are related to diabetes mellitus, venous stasis, peripheral vascular diseases, and pressure ulcerations. An open wound is a favorable niche for bacterial colonization and infection. Infection in chronic wounds starts with contamination, then colonization and critical colonization take place before an infection forms.

Biofilm formation is now recognized as a serious problem in chronic wound infections.[4] Biofilm is a complex structure of microorganisms that generate a protective shell, allowing bacteria to collect and proliferate.[5] Most of the microorganisms that form biofilms can also be found growing in microbial infections. The same species of bacteria have significant differences in existence that range either free floating and living within the biofilm. The biofilm structure of microorganisms renders phagocytosis difficult,[6] increases resistance to antibiotics,[7] and adheres to unfavorable niches such as chronic wounds.[8]

One of the remarkable features of the immune system against invading pathogens is its ability to generate an effective and rapid response by developing a group of highly reactive chemicals, such as reactive oxygen species (ROS). The mitochondrial membrane-bound enzyme nicotinamide adenine dinucleotide phosphate-oxidase (NADPH) is a primary enzyme responsible for ROS production.[9] During the activation of neutrophils, respiratory bursts generate hydrogen peroxide (H2O2) and the activated granule enzyme myeloperoxidase converts H2O2 to hypochlorous acid (HOCl) in the presence of Cl- and H+.[10] Hypochlorous acid leads to cell death by the oxidation of sulfhydryl enzymes and amino acids, ring chlorination of amino acids, loss of intracellular contents, decreased uptake of nutrients, inhibition of protein synthesis, decreased oxygen uptake, oxidation of respiratory components, decreased adenosine triphosphate production, breaks in DNA, and depressed DNA synthesis.[11–15] Hypochlorous acid is highly active against all bacterial, viral, and fungal human pathogens[16] and a small amount of HOCl can kill spore-forming and non-spore bacteria in a short time period.[17,18]

Since most of the etiologic factors in chronic wound infections are forming biofilm,[19] and most of the topical antiseptics impair wound healing with their cytotoxic effect, therapeutic strategies against biofilm with high microbial eradication and good wound healing effects will decrease the morbidity and mortality rates of patients and reduce the economic burden. The aim of this study was to investigate the effect of stabilized HOCl solution on microbial and biofilm eradication, antimicrobial activity within biofilm against frequently isolated microorganisms, and migration rate of wounded fibroblasts and keratinocytes.

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