Overview of Basic Wound Cleansing and Debridement

Original Editor - Stacy Schiurring based on the course by Dana Palmer

Top Contributors - Stacy Schiurring and Jess Bell  

Rehabilitation Professionals as Wound Care Providers

Wound Care refers to the practice of managing and treating injuries to the skin or underlying tissues to prevent or manage infection and promote wound healing and closure. This process typically involves (1) effective wound cleansing, (2) appropriate dressing and topical medication selection, and (3) knowledgeable wound monitoring for signs of infection or other issues that could impede recovery. Wound care also encompasses the use of advanced therapies, including wound debridement and negative pressure wound therapy. Effective wound care is vital for optimal healing and can involve both medical professionals and patients in the management process.

There is a wide range of medical professionals who are well suited to be wound care providers. This list includes: medical doctors (MDs), surgeons, physician assistants (PAs), advanced practice nurses (APNs), registered nurses (RNs), licensed practical nurses (LPNs) / licensed vocational nurses (LVNs), occupational therapists (OTs) and OT assistants (OTAs), and physiotherapists (PTs) and physiotherapy assistants (PTAs).

Wound care is a speciality practice area which requires additional education and hands-on training beyond what is provided in most entry-level programmes.

Many medical professionals require or recommend advanced training and certification to practise wound care. This training involves continuing education on skin anatomy and physiology, signs and symptoms of infection, tissue identification, basic wound care techniques (such as wound cleansing and basic dressing selection), and advanced wound care techniques (such as sharp excisional debridement and negative pressure therapy).

Rehabilitation professionals are ideally set to become wound care providers. Entry-level education often includes advanced training in anatomy and physiology, and covers topics such as the effects of exercise on the body, the impact of compression, elevation, offloading / weight-bearing status and assistive devices on healing and recovery, and how activity modification can affect circulation and wound healing.These unique perspectives enhance the holistic care rehabilitation professionals bring to wound care practice.

When practising wound care, rehabilitation professionals must be aware of their scope of practice and practice rights in a given location. For example, some medical professionals, such as RNs in the United States, cannot perform sharp debridement without advanced certification and / or training, while physiotherapists in some states in the United States can with only hands-on training.

"Wound healing is a complex dynamic biomechanical process as the body attempts to restore the integrity of traumatized or devitalized tissues." - Labib and Winters, 2023

Understanding the anatomy of the skin and the phases of wound healing is vital for safe and effective wound care practice. To learn more, please review this article, Skin Anatomy, Physiology, and Healing Process.

This article has been created to supplement the hands-on learning of wound care practice and serve as a review for those considering or currently completing formal wound care training through either a wound care mentorship or certification programme.

Three Components of Wound Cleansing

For a list of wound care-related terminology and definitions, please refer to this article.

"Wound cleansing is one of the most important components of an effective wound management protocol ... In its broadest sense, wound cleansing can encompass aggressive debridement of all devitalized tissue, extensive use of fluids for cleansing, and selective use of topical antimicrobial agents to control bacterial contamination and colonization. Each of these steps is essential for obtaining a clean, vital wound that has the greatest potential for healing at an optimal rate." - Rodeheaver and Ratliff, 1997

In its most simple definition, wound cleansing is the use of fluids to remove loosely adherent contaminants and non-vitalised (also known as devitalised, non-viable) material from a wound's surface. Techniques such as debridement are indicated when foreign or non-vitalised materials cannot be easily removed with fluids alone. When creating and carrying out a wound care treatment plan, the benefits of producing a clean wound bed must be weighed against the potential trauma inflicted on the wound by any mechanical processes used during cleansing and any potential cytotoxic effects caused by selected cleansing solutions. Wound care treatment plans require ongoing assessment with each dressing change. It is not uncommon to change a wound care plan with each treatment depending on the progress or stagnation of the wound.

Wound Cleansing

Basic cleansing is an important first step in wound care. Cleansing includes cleaning both the periwound area and the wound bed itself. Periwound cleansing is the process of cleaning the intact skin around the wound bed. The simplest and most cost-effective cleanser for the periwound area is soap and water. Clean or sterile washcloths or gauze pads can be used to clean the periwound area. Wound bed cleansing is the use of fluids to remove any loosely adhered contamination (such as dirt, gravel, or fibres) and non-vitalised tissue from a wound's surface.

According to a 2022 Cochrane Review, while various wound cleansing solutions are available, normal saline is preferred as it does not interfere with a wound's normal healing process. However, tap water is commonly used in community settings and in low-resource areas for cleansing wounds because it is "easily accessible, efficient and cost‐effective." It is important to note that if the quality of the tap water is unreliable, it must first be boiled for a minimum of 20 minutes and allowed to cool before it is used to clean the periwound or wound bed.

Below is a list of cleansing solution options for the periwound and wound bed. These listed cleansers are considered to be non-antimicrobial and non-cytotoxic cleansing solutions:

• commercially available wound cleansers
• sterile normal saline
• sterile water
• distilled water
• potable (drinkable, tap) water

The use of an antiseptic cleanser may be indicated to manage a wound's bioburden or the formation of biofilm. Antiseptic agents are cytotoxic to healthy tissue when used at certain concentrations. It is best practice to only use one antiseptic agent at a time to prevent unwanted chemical reactions in the wound. When using an antiseptic cleanser to remove wound biofilm, it is important to follow up by rinsing the wound bed with a non-cytotoxic cleansing solution, such as saline or water. This will remove any remaining antiseptic cleanser or debris still present in the wound.

To learn more about biofilm in wounds, please review this article.

Table 1.0 Commonly used antiseptics in wound care practice

	Indications	Contraindications
Povidone-iodine (Betadine)	Betadine is broad spectrum It is effective against bacteria, fungi, protozoa, and viruses It is one of the few antimicrobial agents that can penetrate and be effective against biofilm There is no known resistance against povidone-iodine in microbes	It is contraindicated in patients with thyroid disease There is a dose-dependent cytotoxicity associated with povidone-iodine use
Chlorhexidine	Contains surfactant Allows for a good mechanical cleaning of the surface of the wound	There is no dosage control Chlorhexidine in its formulated strength is extremely cytotoxic and it needs to be diluted with water, but there is no standardised formula for dilution Must be thoroughly rinsed to remove any cytotoxic residual effect
Sodium hypochlorite (Dakin's Solution)	A super-oxidised solution Available in several different solution strengths: half-strength Dakin's to quarter-strength Dakin's (0.125% sodium hypochlorite) and a one-40th-strength Dakin's (0.0125% sodium hypochlorite) The one-40th-strength (0.0125% sodium hypochlorite) is not cytotoxic, is effective against a broad range of bacteria, and is useful in maintaining an appropriate and manageable level of bioburden on the surface of the wound	Research shows that the full-strength Dakin's, the half-strength Dakin's, and the quarter-strength Dakin's are all cytotoxic to tissues, although they are extremely antimicrobial
Octenidine dihydrochloride (OCT)	Broad-spectrum antimicrobial activity against gram-positive and negative bacteria, fungus and MRSA Effective against biofilm No known side effects
Polyhexamethylene biguanide (PHMB)	It is broad spectrum against gram-negative and gram-positive microbes as well as fungi, viruses, MRSA, and biofilms	Used as an additive to dressings, gauze dressings and foam dressings rather than as a cleansing agent
Benzalkonium chloride (BKC)	Effective against gram-positive and negative bacteria, moulds, and yeasts Solutions of 0.01 to 0.1% are typically used for cleansing skin and wounds. More dilute solutions are suitable for the irrigation of deep wounds	Can irritate the skin, eyes, mucous membranes, and upper respiratory tract
Hypochlorous acid	Has a time-dependent response against pseudomonas and Methicillin-resistant Staphylococcus aureus (MRSA) Has been found to decrease MRSA outbreaks There is no known toxicity

Wound Debridement

"Wound bed preparation is an essential process that works to optimise wound healing and reduce healing time. This includes lifestyle modification, moisture management, oedema management, perfusion optimisation, nutritional support, and removal of necrotic tissue. All of these factors will impact the prognosis for the wound, but removal of necrotic tissue is essential for healing to occur." - Dana Palmer, PT

Debridement is the process of removing non-vitalised tissue from the wound bed to promote wound healing. Non-vitalised tissue delays wound healing in the following ways:

• acts as a physical barrier to wound closure by impeding granulation formation and contraction of the wound
• serves as a source of nutrients for bacteria, which can increase infection risk
• stimulates cytokines that contribute to persistent inflammation
• masks or mimics signs of infection

Debridement is rarely a one-time event. Most often, serial debridement is required to maintain the wound in a state of readiness to heal. Deciding how often to debride and what form of debridement to utilise requires clinical reasoning and a holistic assessment of the patient.

Before selecting primary debridement as a treatment, you must consider the overall condition of the patient, including any comorbidities or medical complications and their overall prognosis. Consider if there are any issues with tissue perfusion or vascular compromise. Poor perfusion results in impaired or absent blood flow to the treatment area, which impacts wound healing. Patients with these issues should be assessed by a vascular specialist for re-vascularisation options. Their care plan can include less aggressive forms of debridement such as autolytic, enzymatic, or conservative mechanical debridement. You must also consider the extent of necrotic tissue in the wound bed. Wounds that contain extensive non-vitalised tissue should be assessed by a physician or surgeon for surgical debridement.

Generally, there are two categories of debridement: selective and non-selective:

• selective debridement is specific; only non-vitalised tissue is removed
  • this category of debridement includes: (1) biological, (2) enzymatic, and (3) autolytic debridement
• non-selective debridement is non-specific; this means that viable tissue may be removed along with non-vitalised tissue
  • this category of debridement includes: (1) mechanical and (2) sharp debridement (sharp debridement can also be categorised as selective debridement when performed via surgical procedure, see Table 2.0 for details)

The five major types of debridement can be recalled using the mnemonic: BEAMS (Biological, Enzymatic, Autolytic, Mechanical, Sharp).

Table 2.0 Types of Debridement

	Category	Description	Indications	Contraindications	Clinical Applications
Biological (larval therapy, maggot debridement therapy (MDT) )	Selective	Not commonly used Involves the use of sterile medical maggots to debride non-vitalised tissue by liquefying and digesting it The medical maggots also kill and ingest bacteria while stimulating granulation tissue and wound healing		Expensive
Enzymatic	Selective	Faster method than autolytic debridement, but slower than sharp debridement Performed by applying a prescribed enzymatic topical agent that chemically liquefies non-vitalised tissues The enzymes dissolve and engulf the non-vitalised tissue within the wound matrix	Can be used in conjunction with surgical and sharp debridement, see below	Dressings containing iodine or silver, and some wound cleansers should not be used in conjunction with enzymatic debriders because they can reduce the effectiveness or inactivate the enzymes	Commonly used enzymatic agents: collagenase (Santyl, Xiaflex) bromelain (Nexobrid, Debridase) papain-urea (Accuzyme, Panafil, and Autolyse)
Autolytic	Selective	Slowest type Most common method of debridement Uses the body’s own enzymes to assist in breaking down the non-vitalised tissue Dressing selection should enhance and encourage this natural process	This method requires little skill to perform Can be employed in multiple different environments and on multiple wound types	Presence of infection Older individuals, those with compromised immune systems, or multiple co-morbidities are unlikely to mount a strong autolytic response. This includes those with arterial disease, diabetes, venous disease, or auto-immune conditions.	Examples of dressings that facilitate autolytic debridement: hydrogels hydrocolloids alginates hydrofibers foams transparent films medical grade honey polyacrylates
Mechanical	Non-selective	Second most common method of debridement Involves the use of external force to remove non-vitalised tissue, debris, and bacteria from the wound surface May be painful	Cost-effective debridement choice	Over epithelialising and granulating tissue	Mechanical debridement can be performed using various methods including: wiping with gauze or an abrasive pad low-frequency ultrasound wet-to dry dressings hydrotherapy (to include pulsed lavage and whirlpool)
Sharp	Non-selective (surgical sharp debridement) Selective (conservative sharp debridement)	Fastest method of debridement Uses instruments, such as scalpels, scissors, curettes, or forceps, to remove non-vitalised tissue through cutting or shaving Two types: (1) sharp surgical (performed by a surgeon, physician, or podiatrist) or (2) sharp conservative (performed at the bedside by a trained clinician, including rehabilitation professionals) Sharp surgical is a major procedure that sacrifices some viable tissue (non-selective) Sharp conservative is a minor procedure done at the bedside that removes only non-vitalised tissue (selective)	Removes biofilm and devitalised tissue Can be combined with autolytic or enzymatic debridement in the form of "cross-hatching" of eschar to allow for deeper penetration of the enzymatic ointment or greater surface area for the autolytic fluid Debridement of non-vitalised tissue is a painless procedure, but inflammation and high sensitivity of adjacent tissues can contribute to pain, thus patients should be medicated as needed prior to this intervention	Patients with bleeding disorders or who are on anticoagulant therapy or medication	Whenever performing sharp debridement a haemostatic agent should be on hand to stop unintended bleeding. Examples of haemostatic agents are: silver nitrate calcium alginate dressings containing chitosan

It is best practice to clean the wound and periwound prior to debridement, and to rinse the area with sterile saline or sterile water after debridement to remove any loosened debris. After cleansing or rinsing the wound, pat dry with gauze to protect wound margins and edges from excessive moisture and to improve the wound's ability to absorb any applied topical agents.

Use of Antimicrobial Topical Agents

Antimicrobials are a group of agents which reduce the possibility of infection and sepsis. In wound care, the purpose of topical antimicrobial agents is to decrease the bioburden on the surface of the wound bed. Antimicrobials can be categorised by their target organism.

Antibiotics are naturally derived from other microorganisms or they are synthetically created agents which are absorbed into the body, aiming to kill bacteria or prevent bacterial multiplication. These substances can be given parenterally (intramuscularly, intravenously), orally, or applied topically to the skin.

Antiseptics are chemical agents that slow or halt the growth of microorganisms on external body surfaces, including wounds, and aid in preventing infection. These substances are non-damaging to living tissue and skin. When applied to the skin, antiseptics are not absorbed in a significant quantity into the body.

Disinfectants destroy microorganisms on non-living objects or surfaces.

Antifungal agents slow or halt the growth of fungi, including yeasts. These substances can be given intravenously, orally or topically.

Due to the potential cytotoxic nature of topical antimicrobials, their use must justify the risk to healthy tissue in the wound bed. Research does not support the routine use of topical antimicrobials on all wounds. However, the literature does support its use in chronic wounds with persistent biofilm:

• it is estimated that 78-90% of chronic wounds contain biofilm
• biofilm is not typically visible, but can be suspected with the following wound observations: (1) wound stagnation or stalling of the healing process, (2) persistent recurrence of slough following some debridement episodes, (3) heavy exudate, (4) maceration, (5) foul odour, or (6) excessive tenderness.

Clinical Pearl: Biofilm and Wound Infection

A biofilm is a structured community of microorganisms, typically bacteria, that adhere to surfaces and are encased in a protective extracellular matrix. This matrix shields the biofilm from the immune system, which makes them significantly more resistant to antibiotics compared to planktonic (free-floating) microorganisms. Biofilms can form on a variety of surfaces in the body including on implanted medical devices, on tissues, and in wounds. Biofilms can persist for extended periods and are often associated with chronic infections.

A wound infection refers to the presence of harmful microorganisms in a wound, which leads to inflammation, tissue damage, and delayed wound healing and stagnation. Wound infections can be acute or chronic. There is an increased likelihood of biofilm formation in chronic wounds.

While a wound infection refers specifically to the presence of infection in the tissue, a biofilm is a physical and biological phenomenon that can complicate wound infections. Biofilm formation in wounds is particularly problematic in cases of chronic infection, where the protective biofilm makes it harder to fully eradicate the infection, resulting in more frequent or persistent symptoms. Thus, biofilms are an important factor to consider when addressing chronic wound infections, as they significantly hinder effective treatment and healing.

Serial debridement and the use of topical antimicrobials are indicated to manage biofilm and promote wound healing. Research shows that following wound debridement there is a 24- to 72-hour window where the remaining bacteria are especially sensitive to the antimicrobials. The use of topical antiseptics or an antiseptic cleanser will aid in disrupting the cell-to-cell interaction required to regrow biofilm in a wound.

Additional Resources

• Wound Source Product Guide: wound cleanser products
• Wound Bed Preparation paradigm 2021
• How To Cleanse, Irrigate, Debride, and Dress Wounds, Merck Manual

The following video provides a concise summary of the wound cleansing procedure and the creation of a holistic wound care plan. It also describes the difference and relationship between wound infection and biofilm. This video contains images of wounds and videos of wound debridement.