Innovation in the world of podiatry doesn’t happen every day but from time to time things come along that have the potential to change our practice. Earlier this year, a hypochlorous solution (Clinisept+®) was launched in the UK Podiatry and as a novel product, it potentially offers new approaches in management in a range of conditions. In this blog, I will talk about how I use this product in clinic.
So, what is it?
I covered this topic in detail in a blog I made on my website a few months earlier (read here URL: https://www.foot.expert/single-post/2019/02/19/HClO) but briefly just in case you missed it, Clinisept+ is the proprietary name for a very pure form of hypochlorous solution. Not to be confused with hydrochloric acid (HCl), hypochlorous solution (HOCl) is weakly acidic but with a pH compatible with the skin making it ideal for topical use.
What makes it really useful though is that hypochlorous solution is a strong oxidiser and a powerful antimicrobial with demonstrated activity against a range of organisms including bacteria, virus and fungus (including fungal spores). All this, with no harmful effects on human tissue. So why is this, when other antiseptics show some levels of toxicity? The answer is quite straight forward. Hypochlorous acid is a substance which is produced naturally by cells of the immune system. White blood cells produce short bursts of hypochlorous acid (from an enzymatic reaction with hydrogen peroxide) when fighting infection internally, consequently the human body is very tolerant of it, hence rarely are there issues with toxicity, allergy or irritation.
That sounds just like Chlorhexidine, why change?
In many ways Clinisept+ is a great surface cleanser – ideal for pre-op and post-op skin care but even for this task it has a number of advantages over Chlorohexidine Gluconate (CHG). Firstly, Clinisept+ is water based, not alcohol based like regular CHG, so no stinging or irritating issues if the spray mist strays from the feet towards you or the patient. This gives it a different feel to regular chlorhexidine on the skin but unlike our pink friend there is no sensitivity or allergy arising out of its use. Finally unlike Chlorhexidine, it leaves no sticky residue on the skin as it just degrades to water as it dries making it more environmentally friendly too.
Its power as an antiseptic is remarkable as studies have concluded (1) it has superior spectrum and speed of activity than chlorhexidine gluconate on many organisms. In my earlier blog, I highlighted work which has shown it to be able to rapidly kill all the usual suspects including MRSA swiftly and effectively, often more quickly than chlorhexidine and povidone iodine. In addition, Hypochlorous solution destroys gram-negative organisms, against which CHG is less effective. Studies have also shown how even at very low concentrations hypochlorous solution can inhibit bacterial replication and division (2).
OK, it may be better than Chlorhexidine for skin prep – anything else?
1. Wound Care
The use of the product goes beyond skin disinfection. The product can be used as a wound cleanser as it is a powerful bactericide but just as important, it does not delay wound healing (3), whereas some evidence suggests CHG can increase healing times (4). Beyond this, there is a lot of literature around hypochlorous solution and how it can be effective against biofilms in chronic wounds (5). Have a read of Prof David Armstrong’s piece (6) on its use in diabetic foot ulceration.
To that end we have used this in our practice on ulcers on the foot. And, of course patients who are able to self-care can do this at home too, straight from the bottle. Typically, for best effect I use a clean bit of gauze or dressing, soaked in Clinisept+ and held in place for 5 minutes. This can cleanse a wound. The area can then be dressed. Best of all, it doesn’t need to be washed out afterwards as it naturally degrades to water anyway.
2. After Nail Surgery
In our practice, following nail surgery, patients can buy a bottle and safely use this at home to clean the wound between redressing. This can be carried out in two ways, firstly by spraying and cleaning the wound and leaving it wet for five minutes, the wound can then be redressed. Alternatively, a gauze can be soaked in Clnisept+ and placed on the toe for five minutes then removed. As long as the area stays damp the hypochlorous solution remains active. As patients have the Clinisept+ available in a spray bottle its more convenient for patients to store (and use) than preparing a saltwater foot bath each time.
3. Fungal Foot Infections
Its effects on fungus is impressive. Studies have confirmed its antifungal properties, but additionally HOCL has been found to be sporicidal as well. In a standardised laboratory test, Clinisept+ was used on socks infected with the dermatophyte, T. rubrum versus a control of purified water. Overnight, Clinisept+® had killed 99.99% of all the culture. Consequently, this is a solution that can be applied to socks (and shoes) which should be effective at eradicating fungal elements in shoes and hosiery (see my recent blog on how to do this: https://www.foot.expert/single-post/2019/07/24/Clinisept2). Additionally, many of my patients buy a bottle to spray their feet daily for 5 minutes and it seems to keep tinea pedis from recurring.
4. Bacterial Skin Infections
In a recent laboratory test I ran, I asked the lab to assess its ability against a common bacillus found on the foot and interdigital areas – corynebacterium sp., Using a standardised approach, the bacteria was 99.99% cleared in just 15 minutes exposure to Clinisept+. Of course, corynebacterium can be responsible for erythrasma and pitted keratolysis so having tried this clinically on patients we are getting good outcomes. Where Clinisept+ is particularly good is for web spaces. Studies have shown web spaces to be areas colonised with fungi, gram-positive and gram-negative bacteria (7-9) and infection in this area is a risk factor for the development of cellulitis (10). During treatment attention to these areas in patients with known risk factors such as diabetes with Clinisept+ is good practice to reduce bacterial and fungal loads. Once again, with a bottle at home patients can do this as part of their daily routine as well.
Additional effects – pain and itch relief
Lesions such as ulcers and fissures which are irritated by infection, can be itchy or painful for the patient. We have seen in clinic that Clinisept+, when regularly applied to these lesions can reduce the patient’s pain levels significantly with regular use. This has been documented in a study published in 2018. The authors suggest it maybe down to two mechanisms – firstly, the direct action of the hypochlorous solution on the infection thus reducing bacterial load and therefore pain. In addition, HOCl is anti-inflammatory. This is because it reduces the activities of histamine, leukotriene B4, and interleukin-2, all of which are implicated in the pathophysiology of itch (11). Consequently, it has been described as having a calming effect on the skin.
Conclusion
Clinisept+ (Hypochlorous solution) is a new innovation in podiatry which offers excellent antimicrobial properties against a range of microorganisms responsible for common foot infections. The solution is competitively priced when compared to chlorhexidine but has a better safety profile with many more applications and a long shelf life. In addition, the product can be sold to patients for home use as part of their ongoing treatment. The range of conditions it can be used for makes it ideal for the podiatry clinic.
References
1. Anagnostopoulos AG, Rong A, Miller D, Tran AQ, Head T, Lee MC, et al. 0.01% Hypochlorous Acid as an Alternative Skin Antiseptic: An In Vitro Comparison. Dermatol Surg. 2018;44(12):1489-93.
2. McKenna SM, Davies KJ. The inhibition of bacterial growth by hypochlorous acid. Possible role in the bactericidal activity of phagocytes. The Biochemical journal. 1988;254(3):685-92.
3. Robson MC, Payne WG, Ko F, Mentis M, Donati G, Shafii SM, et al. Hypochlorous Acid as a Potential Wound Care Agent: Part II. Stabilized Hypochlorous Acid: Its Role in Decreasing Tissue Bacterial Bioburden and Overcoming the Inhibition of Infection on Wound Healing. Journal of burns and wounds. 2007;6:e6.
4. Saatman RA, Carlton WW, Hubben K, Streett CS, Tuckosh JR, DeBaecke PJ. A wound healing study of chlorhexidine digluconate in guinea pigs. Fundam Appl Toxicol. 1986;6(1):1-6.
5. Sakarya S, Gunay N, Karakulak M, Ozturk B, Ertugrul B. Hypochlorous Acid: an ideal wound care agent with powerful microbicidal, antibiofilm, and wound healing potency. Wounds : a compendium of clinical research and practice. 2014;26(12):342-50.
6. Armstrong DG, Bohn G, Glat P, Kavros SJ, Kirsner R, Snyder R, et al. Expert Recommendations for the Use of Hypochlorous Solution: Science and Clinical Application. Ostomy Wound Manage. 2015;61(5):S2-s19.
7. Weidner T, Tittelbach J, Illing T, Elsner P. Gram-negative bacterial toe web infection – a systematic review. J Eur Acad Dermatol Venereol. 2018;32(1):39-47.
8. Kates SG, Nordstrom KM, McGinley KJ, Leyden JJ. Microbial ecology of interdigital infections of toe web spaces. Journal American Academy of Dermatology. 1990;22:578-82.
9. Oyeka CA, Ugwu LO. Fungal flora of human toe webs. Mycoses. 2002;45(11-12):488-91.
10. Müller D-P, Hoffmann R, Welzel J. Microorganisms of the toe web and their importance for erysipelas of the leg. JDDG: Journal der Deutschen Dermatologischen Gesellschaft. 2014;12(8):691-5.
11. Pelgrift RY, Friedman AJ. Topical Hypochlorous Acid (HOCl) as a Potential Treatment of Pruritus. Current Dermatology Reports. 2013;2(3):181-90.
