Is hypochlorous acid (HOCl) a reasonable preventative for wounds, particularly in patients with high risk of infection, including those with compromised immune systems or chronic conditions like diabetes?

Hypochlorous Acid for Wound Prevention

True - stabilized hypochlorous acid is a reasonable preventative agent for wounds, particularly for infection control and maintaining optimal wound bed pH, though it should not replace standard wound care practices. 1

Guideline-Based Support for Hypochlorous Acid Use

The most recent 2024 Clinical Infectious Diseases guideline explicitly includes stabilized hypochlorous acid in wound management protocols as part of pH management strategies (targeting pH 4-6 for healthy skin). 1 The guideline highlights three key properties that support its preventative use:

• Germicidal properties that are well-established for infection prevention 1
• Non-cytotoxic formulation with no chlorine gas or hypochlorite ion formation, making it safe for tissue contact 1
• Favorable effects on cellular migration, specifically promoting fibroblast and keratinocyte movement essential for wound healing 1

Important Limitations from Guidelines

However, major diabetes and wound care guidelines provide critical context that tempers enthusiasm:

• The 2024 IWGDF guidelines strongly recommend against using topical antimicrobial or antiseptic dressings solely for wound healing in diabetic foot ulcers, citing inconsistent evidence and small effect sizes. 1
• The 2016 IWGDF guidance found insufficient evidence to justify preferential use of any topical antiseptic preparation over standard moist wound healing. 1
• Multiple IDSA guidelines emphasize that clinically uninfected wounds should not receive antimicrobial treatment - antibiotics or antiseptics are only indicated when infection is present. 1

Research Evidence Supporting Preventative Use

Recent high-quality research demonstrates specific preventative benefits:

• A 2023 nonrandomized study of 346 chronic ulcers found that combined HOCl therapy (liquid plus gel) reduced infection risk by 70% (OR: 0.3) and increased complete healing probability nearly 5-fold (OR: 4.8). 2
• A 2022 randomized controlled trial in healthy volunteers showed HOCl increased re-epithelialization by 14% on day 4 (p=0.00051) and demonstrated immediate, durable antimicrobial action. 3
• A 2007 animal study demonstrated HOCl controls bacterial bioburden without inhibiting wound healing, unlike other antimicrobials tested. 4

Clinical Application Algorithm

When to use hypochlorous acid for prevention:

• After surgical debridement as part of wound bed preparation to prevent biofilm reformation (which occurs within 24-72 hours). 1
• In high-risk wounds with poor granulation tissue, prolonged evolution, or bad odor on admission - factors associated with infection risk. 2
• As adjunct to standard care following the TIME algorithm (Tissue management, Infection control, Moisture balance, Edge preparation), not as monotherapy. 5

When NOT to use:

• Clinically uninfected wounds in antibiotic-naive patients with mild presentations - standard moist wound healing is sufficient. 1
• As sole therapy for wound healing in diabetic foot ulcers - evidence does not support this indication. 1
• Without proper wound preparation - debridement and removal of necrotic tissue must occur first. 1, 5

Critical Application Details

The evidence suggests specific technical requirements for effectiveness:

• Brief application periods (15-30 minutes) followed by reapplication are most effective, likely due to rapid neutralization in the wound bed. 4, 5
• Combined formulations (liquid then gel) provide better outcomes than monotherapy, with liquid for immediate action and gel for residual effect. 2
• pH maintenance at 3.5-4.0 is critical for antimicrobial efficacy while remaining non-cytotoxic. 4

Common Pitfalls to Avoid

• Do not use HOCl as a substitute for adequate debridement - the most common cause of treatment failure is insufficient removal of necrotic tissue. 6
• Do not apply to actively infected wounds without systemic antibiotics - HOCl is adjunctive therapy, not definitive treatment for established infection. 1, 6
• Do not expect HOCl alone to overcome vascular insufficiency - ischemic wounds require revascularization for healing regardless of antiseptic use. 6

Evidence Quality Assessment

The strongest support comes from the 2024 CID guideline's explicit inclusion in wound management protocols 1, balanced against the 2024 IWGDF's strong recommendation against topical antimicrobials for healing purposes. 1 This apparent contradiction resolves when recognizing HOCl's role is infection prevention and wound bed optimization, not primary healing promotion. The research evidence (particularly the 2022 RCT 3 and 2023 observational study 2) supports antimicrobial and early healing benefits, but these studies had methodological limitations noted in guideline reviews. 1

The consensus position: HOCl is reasonable for infection prevention in properly prepared wound beds as part of comprehensive wound care, but should not be used as monotherapy or in place of standard wound management principles. 1, 5