Factors in Wound Cleansing That May Impair Healing

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by Aletha Tippett MD

Wound cleansing is an interesting dilemma. What? How can that be a dilemma? Everyone knows that you cleanse a wound before dressing it. This is what has been taught for years. Wound cleansing began in the late 19th or early 20th century once the germ theory was proposed and accepted, and hygiene was successful in reducing infections and death, and improving wound outcomes.

The whole purpose of cleansing a wound is to remove necrotic or infectious material from the wound to prevent or reduce infection. But there are several things to consider if you are going to cleanse a wound.

Assess the Wound Before Cleansing

First, is the wound dirty? Does it need to be cleansed? When a wound is sprayed with a cleanser the wound is cooled. Cooling a wound impairs and slows healing, potentially inhibiting/delaying healing for 4-8 hours.1 If the wound is not dirty, don’t clean it. There should be debris or blood in the wound that needs to be rinsed out. If you have a clean wound, consider NOT cleansing it. Another option might be to use warmed saline to cleanse wounds.

Second, how are you going to clean the wound? Just flushing with a solution should be good enough, but I have seen some nurses muck around in the wound, touching and stroking it. Even though they are wearing gloves, this increases risk of infection. Simple flushing with a loaded syringe works well, with care not to use too much pressure so tissue is not disturbed. Certainly we don’t want cleansing to infect or damage the wound.

Third, what will be used to clean the wound? We are taught to select a wound cleanser and a means to deliver that cleanser. Certainly, many things have been tried and are used. Normal saline is considered the standard, as it is physiologic. A number of commercial cleansers are actually toxic to the wound unless they are diluted 10 to 100 fold.2 Surprisingly, tap water is as useful as normal saline and has the benefit of being less expensive and overall having better patient acceptance.3

Evaluating the Impact of Cleaning a Wound

So, the point is, cleansing a wound needs careful consideration, just like other elements of wound care. Judging whether a wound actually needs to be cleansed or not is the first consideration. Certainly a draining, odorous wound with slough and necrosis would need cleansing. But what about a pink, clean, granulating wound that just had a clean, intact dressing removed? Does it really need to be cleansed, or are we actually doing harm to the wound? I think it is important that we think carefully about what we are doing in regard to wound cleansing, and why we are doing something, rather than just doing it because we think it is what is expected.

1. Large, A, Heinbecker, P. The Effect of Cooling on Wound Healing. Annals of Surgery: Nov. 1944-Vol 120-Issue 5-pp 727-741.
2. U.S. Dept. of Health and Human Services, AHCPR Publication No. 95-0652, Wound Cleansing, December 1994, pp. 50-51.
3. Beam, JW. Wound Cleansing: Water or Saline? J. Athl Train. 2006; 41(2): 196-197.

About The Author
Aletha Tippett MD is a family medicine and wound care expert, founder and president of the Hope of Healing Foundation®, family physician, and international speaker on wound care.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.


Remember that wounds are always shedding dead cells during metabolism of the healing process and this is microscopic. Therefore, we cannot know just how "dirty" or "clean" they are. Cleanse upon every dressing change for appropriate healing.

This is such an important issue. Thank you, Dr. Tippett, for the excellent summary of the disadvantages of "routine" wound cleansing at dressing changes. In addition to cooling the wound and potentially introducing microbial contamination, routine wound cleansing flushes out the nutrient-filled wound fluid and WBCs the body has sent to the wound bed to prevent infection.

Unfortunately, many clinicians believe they must cleanse the wound bed at every dressing change to meet "standard of care" and company policy requirements, and they are justifiably concerned about the possibility of microscopic contaminants building up in the wound bed if no cleansing is performed. An excellent solution is to use polymeric membrane dressings (PMDs, or PolyMem dressings), which have a complete continuous wound cleansing system built into the dressings. PMDs are activated by moisture, slowly releasing a nontoxic surfactant and glycerol into the wound bed. The surfactant loosens the bonds between contaminants, including slough and eschar, and the wound bed. The glycerol pulls fluid from the body into the wound bed, which floats the contaminants, which are then pulled into and onto the dressings by the super-absorbent starch which is locked into the dressings. The wound contaminants are thus removed and atraumatically discarded when the PMD is changed.

PolyMem is the only dressing on the market whose FDA-cleared instructions for use advise NOT to routinely cleanse the wound at dressing changes. Over twenty five years of real-world use with patients with every wound type at every stage of healing has proven that this continuously cleansing wound system is safe and effective. Avoiding harming the new granulation tissue can also dramatically speed healing. Wound Source has recently republished a White Paper, Treating Skin Traumas with PolyMem, which contains more detailed information and references. http://www.woundsource.com/white-papers

Linda Benskin, PhD, RN, SRN (Ghana), CWCN, CWS
Clinical Research and Education Liaison, and Charity Liaison
Ferris Mfg. Corp.

The white paper I referenced in my previous response is no longer available at the link I provided. However, Ostomy Wound Management has just published an article [1] that provides even more strong evidence to support avoiding additional wound cleansing when using polymeric membrane dressings (PMDs). Clinicians can be confident that they are atraumatically cleaning their patients' wounds at dressing changes if PMDs are used, because studies clearly show that continuous wound cleansing is taking place. http://www.o-wm.com/article/polymeric-membrane-dressings-topical-wound-m...
1. Benskin LL. Polymeric Membrane Dressings for topical wound management of patients with infected wounds in a challenging environment: A protocol with 3 case examples. Ostomy Wound Management 2016;62(6):42–62.

This article has outdated references, the first reference is from 1944 although the reference is listed incorrectly as year "2944." This should not be published as something new as it's most recent reference is 10 years old and this information is misleading.

I understand that academics who live under the pressure of "publish or perish" like to include only references that are recent so that they and their contemporaries can get cited more. However, in the real world, older references are often better than newer ones. Older research is sometimes less industry-driven and the designs may even be more rigorous. One of the best references on the topic of wound cleansing is Dr. Alexander Fleming's meticulous 1919 research on antiseptics and infections, produced before there were any antibiotics to compete with antiseptics (he determined that antiseptics cause more wound infections than they prevent).[1] It would be impossible to get ethics approval to conduct a study on the effect of drying out a wound because such high quality research was conducted on this topic in the 1970s and 1980s that it is clear that drying wounds is inferior in every way: they heal more slowly, are more painful, are more likely to become infected, and will ultimately develop an inferior scar.[2,3]
What a waste, in the information age, to NOT take advantage of the great works of the past! Those who refuse to study history are doomed to repeat it.

1) Fleming A. The action of chemical and physiological antiseptics in a septic wound. Br J Surg. 1919 Jan 1;7(25):99–129.
2) Hutchinson JJ, McGuckin M. Occlusive dressings: a microbiologic and clinical review. Am J Infect Control. 1990 Aug;18(4):257–68.
3) Hutchinson JJ, Lawrence JC. Wound infection under occlusive dressings. J Hosp Infect. 1991 Feb;17(2):83–94.

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