Diabetes mellitus is a chronic condition that affects millions of people worldwide. One of its most challenging complications is the development of diabetic foot ulcers (DFUs), which are not only painful but also prone to infections, particularly by multiple drug-resistant (MDR) pathogens. Effective management of DFUs is crucial to prevent further complications and improve the quality of life for individuals with diabetes. This Diabetes Awareness Month study spotlight explores a promising approach to DFU treatment using hypochlorous acid (HOCl), a pharmaceutical-grade antiseptic solution.

The Challenge: DFUs and MDR Pathogens

Individuals with diabetes are at a greater risk of developing foot ulcers, known as diabetic foot ulcers (DFU), due to the lack of neurological sensation, impaired microvascular circulation, and poor immune responses¹. These wounds are not only discomfort causing, impacting mobility and life quality, but they can be slow healing and prone to infection¹. These infections are often caused, or exacerbated by multiple-drug resistant (MDR) pathogens¹. The presence of MDR pathogens in planktonic or biofilm forms makes medical treatment even more difficult as poor circulation in the area limits oxygen, nutrient, and antibiotic supply to the wound site, while dually limiting access for phagocytic cells¹.

Effective wound care for individuals with diabetes requires an antiseptic and wound dressing regimen that not only fights infection but is also non-toxic to cells and promotes healing¹. Additionally, debridement, the removal of dead or infected tissue, is a crucial step in wound care, and the choice of dressing can play a significant role in assisting with this process¹.

The Solution: Hypochlorous Acid (HOCl)

Hypochlorous acid (HOCl) is emerging as a powerful conjuctive therapy in the treatment of diabetic foot ulcers, and related multi-drug resistant pathogens¹. HOCl is not only effective against drug-sensitive pathogens but also has anti-biofilm properties, making it a versatile antiseptic¹. Moreover, HOCl demonstrates inflammation modulation, which aids in the wound healing process¹.

HOCl solution is an effective nontoxic antiseptic agent that cleanses and disinfects the wound without damaging healthy tissue. It is useful for diminishing the pathogen burden and preventing the risk of long-term morbidity associated with amputations¹.

Case Studies: Successful DFU Treatment With HOCl

Let's delve into the case studies featured in the article, which highlight the successful treatment of DFUs using pharmaceutical-grade HOCl:

1. 70-Year-Old Female with Type 1 Diabetes Mellitus¹

This patient presented with a necrotic diabetic foot ulcer, approximately 4 cm in diameter, on the right foot that has persisted for 31 months. The DFU had been unresponsive to previous treatment measures, which included surgical debridement and the application of various topical antimicrobial agents including povidone iodine, fucidic acid, mupirocin, and neomycin sulphate intermittently before and after surgery¹. There were no detectable odors or visible discharges emanating from the wound¹. The patient expressed a preference for receiving treatment at her home due to her inability to travel to a medical facility¹.

Treatment Progression

• Day 1: The wound was cleaned with lukewarm water and soap to remove previous antiseptics. A gauze dressing soaked in hypochlorous acid was applied and secured with a crepe bandage. The patient was taught how to replace the dressing and bandage.
• Day 2 - 60: Daily dressing changes showed the removal of necrotic tissue on the gauze, indicating successful wet-to-moist wound debridement. The patient sent photos of the wound every other day for monitoring. Debridement progress continued steadily.
• Day 60: In addition to daily dressings, the patient learned about off-loading the wound. A healthcare professional visited the patient to teach her how to gently remove calloused skin around the wound. Weekly visits ensured satisfactory progress until complete healing.
• Day 65: The wound was sufficiently offloaded, and the patient was advised to visit a healthcare professional for proper padding, shoe adjustments, and daily foot injury checks.

2. 45-Year-Old Male with Type 1 Diabetes Mellitus¹

A 45-year-old male with a longstanding history of Type-1 diabetes presented with a diabetic foot ulcer (DFU) that had been persisting for 7 years¹. The ulcer measured 5 cm x 3.5 cm and was located on the medioplantar aspect of his right foot¹. Previous attempts to treat the wound with various antiseptics, including iodine, betadine, chlorhexidine, and fucidic acid, and multiple courses of antibiotics had proven unsuccessful¹. Surgical debridement, which had been employed in an effort to eliminate all necrotic tissue, was also ineffective and resulted in the enlargement of the wound, as reported by the patient¹.

Treatment Progression

The wound was initially cleaned using lukewarm water and soap to remove remnants of previous antiseptics. A gauze dressing soaked in hypochlorous acid (HOCl) was applied to the wound and secured with a crepe bandage. The patient was instructed on how to apply the dressing and bandage. Daily dressing changes revealed necrotic tissue on the gauze, indicating successful wet-to-moist wound debridement, which continued steadily throughout the treatment period. The patient provided photographs of the wound and dressing every other day, allowing the healthcare professional to monitor progress.

After 28 days of daily HOCl dressings, there was satisfactory wound improvement. Wound exudate decreased in the first four days of treatment, leading to reduced inflammation. Over the next 24 days, conservative wet-to-moist gauze debridement successfully removed all necrotic material from the wound bed, eliminating the need for surgical intervention. Unfortunately, due to the patient's relocation, further follow-up was not possible after 28 days.

Benefits of HOCl Treatment

1. Conservative Management. Both cases emphasize that satisfactory results can be obtained with conservative management of DFUs, avoiding more invasive interventions.
2. Home Treatment. Both case studies demonstrate how HOCl can be employed as a continued at-home therapy. The moistened dressing method is easily replicated at-home demonstrating how how patient compliance and general treatment outcomes can be improved through the incorporation of an HOCl based wound care solution.
3. Healthcare Provider Monitoring. Importantly, healthcare providers can monitor home treatment, ensuring that patients receive the necessary care and guidance, ultimately improving their quality of life.

Final Thoughts

The management of diabetic foot ulcers presents a significant challenge, particularly when facing multiple drug-resistant pathogens¹. The use of pharmaceutical-grade hypochlorous acid (HOCl) offers a promising solution as a conjuctive wound care strategy¹. Its effectiveness against various pathogens, anti-biofilm properties, and inflammation modulation make it an invaluable tool in wound care¹.

These case studies highlight the potential of hypochlorous acid solutions in treating DFUs effectively, while promoting stronger patient outcomes through continued at-home care and medical monitoring¹. This approach could potentially save time, cost, and most importantly, may improve patient treatment compliance and overall quality of life¹.

As research in wound care continues to evolve, treatment with pharmaceutical-grade hypochlorous stands out as a simple yet powerful ally in the fight against diabetic foot ulcers.