2. Topical antiseptic products available for treating chronic wounds.

Product and formulations	Formulations	Bacterial spectrum	Advantages	Disadvantages	Costa	Indicationsb and comments
Acetic acid	0.25%, 0.5%, and 1% solutions	Bactericidal against most gram‐positive and gram‐negative organisms, including Pseudomonas aeruginosa	Inexpensive; shown to eliminate P aeruginosa colonisation from burn	Cytotoxic in vitro although maybe not in vivo; limited activity against biofilm	$	No longer as widely used as in the past
Cadexomer iodine	Gel,c ointment, and dressing	Polysaccharide starch lattice; active agent is slowly released free iodine; broad spectrum of activity (same as iodine)	Reduced local toxicity compared to iodine; elemental iodine released on exposure to exudate	Application may cause stinging and erythema, but less tissue damage than other iodine products; effect may not persist, and efficacy may be reduced in body fluids.	$$	Indicated for use in cleaning wet ulcers and wounds and reducing microbial load in the wound environment
Cetrimide	Solution, 40%	Active against bacteria and fungi; not active against P aeruginosa	May be less toxic to wound tissues than other antiseptics	May be corrosive and is potentially harmful if swallowed	$	Not available in the USA
Chlorhexidine gluconate	Solution, 2% and 4%; liquid, 2% and 4%; hand rinse, 0.5%; wipes, 0.5%; sponge/brush, 4%; and foam, 4%	Active against gram‐positive bacteria (e.g. Staphylococcus aureus) and gram‐negative bacteria, including P aeruginosa	Persistent activity up to 6 h after application; few adverse effects	Hypersensitivity, including anaphylaxis, generalised urticaria, bronchospasm, cough, dyspnoea, wheezing, and malaise; may cause serious injury to the eye and middle ear; avoid contact with face or head; some resistance reported	$	2% chlorhexidine indicated as surgical hand scrub, hand wash, skin and wound cleanser; polyhexanide is a similar, newer biguanide.
Hexachlorophene	Liquid, 3%; foam, 0.23% with 56% alcohol	Biguanide that is bacteriostatic against Staphylococcus species and other gram‐positive bacteria	May retain residual effect on skin for several days	Rapidly absorbed and may result in toxic blood levels; application to burns has resulted in neurotoxicity and death; may cause central nervous system stimulation and convulsions, dermatitis, and photosensitivity reactions	$$$	Not recommended for routine use on wounds due to potential toxicity
Iodine compounds and iodine tincturec	Solution (aqueous) 2% and 2.4%; and tincture (44% to 50% alcohol) 2% and 2.4%	Microbicidal against bacteria, fungi, viruses, spores, protozoa, and yeasts	Broad spectrum	Highly toxic if ingested or significantly absorbed; do not use with occlusive dressings; causes pain and stains skin and clothing; use cautiously in people with thyroid disorders	$	Iodine compounds are now rarely used for wound management; cadexomer iodine and povidone iodine products are less toxic.
Povidone iodinec	Ointment, 1%, 4.7%, 10%; solution, 1% and 10%; also wash, scrub, cleanser, gel, aerosol, gauze pad, swab, and other forms	Broad spectrum includes S aureus and enterococci; active ingredient is liberated free iodine; shares spectrum but is less potent than iodine	Less irritating to skin and allergenic than iodine. Can be covered with dressings. Clinically significant resistance very rare	Antibacterial action requires at least 2 min contact; may cause stinging and erythema; effect may not persist, and efficacy may be reduced in body fluids; prolonged use may cause metabolic acidosis; stains skin and clothing; possible interaction with starches in dressings	$	Indicated for perioperative skin cleansing and for cleansing and prevention of infection in superficial burns, incisions, and other superficial wounds
Sodium hypochlorite (Dakin’s solution and EUSOL)	Solution, 0.0125%, 0.125%, 0.25%, and 0.5%	Vegetative bacteria, viruses, and some spores and fungi	Inexpensive	No known systemic toxicity. May require prolonged contact for antibacterial action; inactivated by pus; toxic to fibroblasts and keratinocytes, and may cause pain or lyse blood clots	$	A concentration of 0.025% is both bactericidal and non‐toxic to tissues (Heggers 1991).
Hydrogen peroxidec	Solution, 1% and 3%; and cream, 1%	Oxidizing agent active against many gram‐positive and gram‐negative bacteria	Broad‐spectrum, bactericidal, inexpensive; no known 1q11	May cause some discomfort	$	Commonly used, but few clinical studies
Silver nitrate	Solution 0.5%, 10%, 25%, and 50%; ointment, 10%; and swabs, 25% to 50%	Silver ions are bactericidal against a broad spectrum of gram‐positive and gram‐negative bacteria.	Low cost; easily applied	Painful on application; stains tissues; may delay healing; concentrations 10.5% cause cauterisation; inactivated by wound exudates and chlorine	$	Previously widely used, but now largely replaced by other compounds, including newer silver dressings
Silver dressings	At least 6 approved products with different properties	Slowly released silver ions have broad spectrum, including MRSA and VRE.	Provide sustained levels of active silver ions; microbial resistance is rare; less painful and few adverse effects than silver nitrate; variety of products adaptable to different types of wounds; infrequent application required	Levels of silver ions at wound interface not well defined; may cause silver staining of tissues; may delay epithelialisation; relatively expensive; few published comparative trials	$$	Should not substitute for non‐medicated dressings for uninfected wounds; may be useful for subclinically infected, highly colonised wounds or for wounds being prepared for skin grafting

Abbreviations: EUSOL, Edinburgh University Solution of Lime; MRSA, methicillin‐resistant Staphylococcus aureus; VRE, vancomycin‐resistant enterococci.

^aCosts are approximate in USD per day for treating 100‐square centimetre wound, as follows: $, < USD 3; $$, USD 3 to 15; and $$$, > USD 15. 
 ^bUS Food and Drug Administration–approved indications. 
 ^cAvailable without prescription. Modified from Lipsky 2009.