There is an ongoing debate in the healthcare profession regarding wound cleansing with common tap water: is it safe for use, or should sterile saline be the only option? The impact of poor cleansing choices by healthcare professionals can have serious consequences for those with chronic and vulnerable diabetic foot wounds. The authors review the evidence for the use of tap water to cleanse diabetic foot wounds, discuss the risks that must be assessed, and evaluate how the method of cleansing – as well as the solution that is used – plays a role in managing risk.

Healthcare professionals are indoctrinated during their training to believe that sterile is best and anything less does not have a place in wound care. Yet, a recent Cochrane review stated: "There is no evidence that using tap water to cleanse acute wounds in adults increases infection, and some evidence that it reduces it" (Fernandez and Griffiths, 2008).

Here, the authors investigate this debate as it relates to the management of diabetic foot wounds. The arguments for and against the use of tap water, rather than sterile saline, are evaluated. The use of topical antiseptics and surfactants are outside the scope of this article. To further develop this debate, water and saline are looked at in the context of how wound cleansing is delivered and the cleansing techniques used.


BACKGROUND
Cleansing involves the application of fluid to aid removal of loosely attached cellular debris and surface pathogens contained in wound exudate or residue from topically applied wound care products (e.g. hydrogels) from the wound bed (Figure 1; Towler, 2001; Williams, 1999). It is distinct from debriding, which is the removal of dead, adherent material from the wound (Stotts, 2004; Dow, 2008) by use of mechanical, sharp debridement by scalpel or hydrosurgery using a pressurised stream of fluid (e.g. Versajet, Smith & Nephew, Hull).

Figure 1. Irrigation of a diabetic foot ulcer with saline. Image courtesy of Duncan Stang.

When a wound is in the acute, proliferating stage, cleansing may not be required. Acute wound fluid differs from that of chronic wound fluid (Schultz et al, 2003). In the acute, inflammatory phase of healing, exudate is normally viewed as beneficial as it provides "essential nutrients as an energy source for actively metabolising cells, and to achieve moisture-regulation function" (Thomas, 1997). This acts as "a carrier of the cells and biochemical mediators required for tissue regeneration" (Vowden and Vowden, 2004). Thus, the removal of a nutrient rich exudate through irrigation in the acute healing cascade may be detrimental to the natural wound healing process. Furthermore, for certain therapeutic agents that promote granulation and cell proliferation (e.g. Xelma, Mölnlycke Health Care, Dunstable; Promogran, Systagenix, Gargrave), the manufactures' instructions prohibit irrigation so that the potential of the agent can be optimised.