Wound bed preparation using appropriate cleansing products is essential for wound healing. Wounds have been cleansed with antimicrobial products such as Dakin’s solution since World War I. The main component of Dakin’s solution is sodium hypochlorite—specifically, the hypochlorite ion. This solution typically exists in a high pH that has proven to be cytotoxic to fibroblasts¹; the literature indicates cytotoxicity is noted in solutions that have 0.00005% hypochlorite (ie, as low as 0.5 ppm hypochlorite²). Like Dakin’s solution, chlorhexidine (CHG) is cytotoxic to fibroblasts and exhibits an antimicrobial effect^3,4; in addition, it may cause an allergic reaction including painful skin rash in sensitive patients.^5,6 As such, cleansing agents that are more tissue-friendly and that avoid the use of any sodium hypochlorite species should be considered.

A cleansing solution containing the antimicrobial preservative hypochlorous acid (HOCl) in its pure form (Vashe Wound Solution, Urgo Medical North America) has been used in recent years in various pediatric units as a gentle and effective wound cleanser.³ In our experience, the pH range and the additional absence of the hypochlorite species have facilitated pain-free application that requires no dilution or rinsing. 

The 3.5 to 5.5 pH range associated with wound healing⁷ of HOCl also effectively removes necrotic tissue and microbes.^8,9 This pH range allows the antimicrobial preservative to exist almost entirely as the specific, desired molecule (ie, HOCl) without contamination by undesired sodium hypochlorite. 

It is important to reiterate that, given the laws of physical chemistry, any chlorine-containing cleansing solution with a pH value greater than 5.5 will yield increasing quantities of HOCl being converted by a chemical reaction to a sodium hypochlorite species.¹⁰ 

The following 3 cases of complex skin and wound conditions in pediatric patients demonstrate successful treatment using topical HOCl as an adjunct to each patient’s treatment. 

Case 1: incontinence-associated dermatitis (IAD) management. A 10-month-old medically complex, trach/vent dependent infant with a G tube and a history of anoxic brain injury had IAD for 2 months. The IAD had not responded to many different barrier creams, both with and without zinc. The parents reported that a barrier cream with cellulose gum, petrolatum, and dimethicone mixed with Manuka honey helped, but epidermal erosion persisted to the bilateral medial buttocks even after using this mixture for 3 weeks. 

When the infant was admitted to the hospital, HOCl in a topical spray was added to this current treatment with each diaper change. The HOCl was not rinsed; if not dry in 30 to 60 seconds, it was patted dry. The parents reported they additionally placed HOCl-saturated gauze over the eroded areas after the daily bath for the first 3 days because it appeared to comfort the infant. As the skin healed, the parents subsequently just used the spray HOCl at diaper changes. 

Significant improvement was noted in 8 days (Figure 1, Figure 2, and Figure 3).

Case 2: ruptured omphalocele (stalled wound healing for 33 days). This case involved a 28-week gestational age infant with a ruptured omphalocele that was surgically repaired on day of life (DOL) 2. Prior care orders were for an umbilical area antiseptic and coverage with dry gauze, changed daily. The infant was receiving full feeds via enteral nutrition and oxygen support via continuous positive airway pressure. No other major issues existed beyond those expected with prematurity.

Figure 4, taken on DOL 33 at the time of the wound, ostomy, and continence (WOC) nurse consult, shows the omphalocele site had become moist with odor-free, cloudy drainage. The infant was afebrile and white blood cells were in the normal range. The surgical team wanted the wound left open to air, so the WOC nurse recommended 2-minute HOCl/gauze soaks, twice a day. Figure 5, taken 8 days after the initiation of new orders, shows the wound continued to progress and was completely healed 2 weeks after initiation of HOCl soaks.

Case 3: left ventricular assist device (LVAD) driveline site management (Figure 6, Figure 7, and Figure 8). A 12-year-old patient with a history of congenital heart disease was admitted for evaluation of her possibly failing Fontan procedure. Approximately 2 weeks into her stay, the patient had a cardiac arrest and was subsequently placed on extracorporeal membrane oxygenation. The  LVAD was placed 1 week later. The patient improved rapidly and was extubated within 1 week following the LVAD placement. She was alert, cooperative, and witty. The problem then became a growing wound around the driveline insertion site. 

The driveline wound deteriorated with use of the traditional topical antimicrobial agent CHG. An erythematous rash also developed under the occlusive dressing with CHG use. Betadine then was substituted, with similar negative results; the wound was not improving, and both products caused pain and a burning that increased the child’s stress during daily dressing changes. 

An alternative wound cleanser was considered due to concerns for site infection and pain. The fibroblast-sparing properties and neutral pH were factors in the decision to use an HOCl-containing solution. The LVAD driveline site wound steadily improved with daily 5-minute soaks and cleaning with HOCl over the insertion site. No dilution or rinsing was needed. The patient reported no pain when the HOCl came in contact with open or intact skin. In addition, because the patient was sensitive to CHG, her daily antimicrobial baths also utilized HOCl. At 6 months postoperatively, the LVAD site remained healed with the use of HOCl for site care. 

The experiences of a growing number of WOC nurses demonstrate the safe application of HOCl for common skin conditions in pediatric populations.^11-15 A HOCl-containing cleansing solution has consistently provided a viable answer to wound healing and skin damage problems encountered in our pediatric and neonatal intensive care units. The patients in the case examples universally experienced no measurable pain or untoward effects from the use of HOCl. Further studies on a larger cohort of patients are needed to support the expanded safe application of HOCl solution in infants and children.

Pearls for Practice is made possible through the support of Urgo Medical, Fort Worth, TX (www.urgomedical.com). The opinions and statements of the clinicians providing Pearls for Practice are specific to the respective authors and not necessarily those of Urgo Medical, Wound Management & Prevention, or HMPGlobal. This article was not subject to the Wound Management & Prevention peer-review process.