Wunden zu desinfizieren, lernen viele von uns schon als Kinder. Doch wie bei allen medizinischen Maßnahmen gilt: Desinfektion und Antisepsis haben klare Vorteile zur Vermeidung von Infektionen, sollten aber gezielt und mit Indikation eingesetzt werden.
Das Wort ‚Sepsis‘ stammt aus dem Altgriechischen ‚σήψις‘ (sēpsis) und bedeutet wörtlich ‚Fäulnis‘. Bereits Hippokrates (ca. 400 v. Chr.) empfahl Essig oder Wein zur Wundreinigung. Mit der Keimtheorie von Louis Pasteur (1860) wurde deutlich, dass Mikroorganismen Krankheiten verursachen. Darauf aufbauend führte Joseph Lister (1867) die antiseptische Behandlung mit Karbolsäure ein – eine Revolution in der Medizin.
Wunde reinigen oder duschen?
Weniger bekannt ist, dass Desinfektionsmittel nicht nur Bakterien abtöten, sondern auch die Hautflora (Mikrobiom) und Zellen wie Leukozyten und Fibroblasten schädigen, die für die Wundheilung wichtig sind. Deshalb gibt es bei normal heilenden Wunden keinen Grund für eine routinemäßige Desinfektion.
In Regionen wie der Gesäßfalte ist eine bakterielle Besiedlung (Kolonisation) normal und nicht schädlich. Antiseptika sind erst bei Infektionen sinnvoll, wenn sich Bakterien unkontrolliert vermehren. Welche Desinfektionsmittel und Wundspülungen geeignet sind, zeigt die folgende Übersicht.
Waschen und Duschen
"Thoroughly rinse the wound daily (several times)". - This is the most commonly reported recommendation for wound care. What does science say?
A 2012 Cochrane analysis found different types of wound irrigation (tap water vs boiled water vs saline vs no irrigation) were equivalent.
The Robert Koch Institute (RKI) nevertheless comments as follows: "Every rinsing fluid must be sterile. Tap water is not free of microorganisms. Only sterile solutions may be used to rinse wounds."
What the RKI says is the law.
Nevertheless, I feel I can comment on these opinions:
- Irrigation of the wound in the actual sense is rarely necessary after Pilonidal Sinus surgery. Wounds left open almost never become infected. In the case of a sutured wound, irrigation is not sufficient in the event of infection. The wound must usually be opened surgically.
- The recommendation refers to wound care in homes, i.e. of problem wounds in elderly and/or sick patients. The patient with Pilonidal Sinus is usually young and healthy.
- The gluteal fold never becomes permanently sterile. Neither are the patient's underpants. When it comes to the pragmatic question of whether showering, i.e. general body hygiene, is permitted after surgery, I don't think you have to be more pontifical than the Pope.
Yellow = recommended with restrictions
Waschen und Duschen – mit Leitungswassser
"Thoroughly rinse the wound daily (several times)". - This is the most commonly reported recommendation for wound care. What does science say?
A 2012 Cochrane analysis found different types of wound irrigation (tap water vs boiled water vs saline vs no irrigation) were equivalent.
The Robert Koch Institute (RKI) nevertheless comments as follows: "Every rinsing fluid must be sterile. Tap water is not free of microorganisms. Only sterile solutions may be used to rinse wounds."
What the RKI says is the law.
Nevertheless, I feel I can comment on these opinions:
- Irrigation of the wound in the actual sense is rarely necessary after Pilonidal Sinus surgery. Wounds left open almost never become infected. In the case of a sutured wound, irrigation is not sufficient in the event of infection. The wound must usually be opened surgically.
- The recommendation refers to wound care in homes, i.e. of problem wounds in elderly and/or sick patients. The patient with Pilonidal Sinus is usually young and healthy.
- The gluteal fold never becomes permanently sterile. Neither are the patient's underpants. When it comes to the pragmatic question of whether showering, i.e. general body hygiene, is permitted after surgery, I don't think you have to be more pontifical than the Pope.
Waschen und Duschen – mit Leitungswasser und Bakterienfilter
Improve water quality: The German Society for Hospital Hygiene (DGKH) says on the subject of tap water: "When using terminal sterile filters at the water outlet, drinking water ... can achieve the necessary microbiological purity. However, these filters should be changed daily...".
Suitable filters are available as disposable products or in rental systems with included reprocessing. The best solution is a terminal system as a handpiece at the shower. This seems to me to be a recommendable and practicable solution.
It is not necessary to "clean" the wound. However, once or twice a day we would recommend showering off secretion residues, loose hairs and exfoliated horny scales of the skin in the fold of the buttocks.
Green = We recommend showering with filtered water.
Disinfection
HOCl – Hypochlorige Säure
New in wound treatment are stabilized aqueous preparations of NaOCl/HOCl. They combine very good efficacy against almost all types of pathogens including resistant problem germs with very good tolerability. It is the only antiseptic permitted in the treatment of severe infections in the abdominal cavity. and central nervous system. NaOCl/HOCl is therefore already referred to as the new gold standard in wound treatment.
Representatives of this group are, for example, the products Veriforte™ med, Granudacyn®, Lavanox-Serag® and Microdacyn®, which are available as wound gel, irrigation solution and wound spray.
Pros:
- No rinsing required
- No known resistances
- Non-toxic to somatic cells
- Treatment not limited in time
- Application in body cavities possible
Green = NaOCl/HOCl is highly recommended as an effective and gentle antiseptic.
Octenidine
Octenidine (Octenisept®) is effective against bacteria, fungi and, to a limited extent, viruses. It is well tolerated and does not normally sting the wound; a slight feeling of warmth occurs. It has no adverse effects on wound healing. Due to its slightly viscous consistency, it is well suited as a lubricant for shaving.
Precautions for use:
- In the case of wound irrigation, the preparation must not be introduced or injected into the tissue under pressure.
- Octenidine should not be used in body cavities or hollow organs.
- It should not be used simultaneously with PVP-iodine based antiseptics on adjacent skin areas.
Green = NaOCl/HOCl is highly recommended as an effective and gentle antiseptic.
Chlorhexidine
In Germany,chlorhexidine is mainly used in dentistry as a solution for mouth rinsing. A further, recognized application in England and the USA is the use before operations to reduce wound infections.
It has a broad spectrum of activity against gram-positive and gram-negative bacteria and yeasts. Allergic reactions and an influence on connective tissue and skin cells have been described.
I would consider the so-called decolonisation to be suitable for preventing inflammations in connection with risk situations (travel, exam preparation, etc.) at Pilonidal Sinus . Due to the approval status, the treatment would have to be classified as an off-label therapy. In case of a permanent treatment, negative effects would probably predominate.
There is currently no guideline recommendation on chlorhexidine.
Chlorhexidine wash lotion is available in Germany only to healthcare professionals as Skinsan Scrub N™. Via European distributors Desinclor Chlorhexidine Antiseptic Soap 0.8% offered. In the USA, preparations containing chlorhexidine are available without prescription. In an Australian study, decolonisation by washing with chlorhexidine was significantly more effective in preventing wound healing problems than taking antibiotics in tablet form.
As an ingredient of Bepanthen Antiseptic Wound Cream, chlorhexidine is approved for the treatment of superficial wounds. In individual cases, its use may be justified in the case of wound healing disorders that cannot be influenced in any other way.
Wound irrigation with chlorhexidine probably impedes healing more than it helps and is not recommended.
Yellow: Suitable for skin antisepsis before operations, for decolonization in case of MRSA colonization. Occasion-related use for inflammation prophylaxis of coccyx fistulas, e.g. before long journeys, seems justified. Chlorhexidine is suitable for antiseptic wound treatment with restrictions; the first choice is HOCl, polyhexanide and Octenisept.
Iodine (polyvinylpyrrolidone iodine, povidone)
PVP - Iodine is a broadly effective antiseptic against bacteria and bacterial spores, viruses and fungi, for which no significant gaps in efficacy or resistance are known (Review paper on iodine in wound treatment).
Elemental iodine is not soluble in water and is toxic to tissues. Povidone iodine (PVP iodine, polyvinylpyrrolidone iodine), on the other hand, is water-soluble and tissue-compatible and continuously releases small amounts of iodine. The substance is available over the counter as a solution and ointment.
Most surgeons report good experiences with PVP iodine ointment, also to support delayed wound healing in the area of the gluteal fold. The positive effects seem to outweigh the experimentally found inhibition of connective tissue cells (fibroblasts) and cells of the immune system. Numerous clinical studies have shown that iodine-containing antiseptics have a positive effect on the healing rate and healing time of chronic wounds.
Caution is advisable in the case of large wound areas through which large quantities of iodine could enter the organism, as well as in patients with previous heart, kidney or thyroid diseases. Allergies can also occur occasionally, very rarely reaching anaphylactic shock(1)(2).
Not every wound should be disinfected with iodine. We use PVP iodine for complex mixed colonization of delayed healing, strong smelling or exuding wounds .
Please note that the brown color stains the laundry.
Gelb – PVP Jod ist grundsätzlich zur Wundbehandlung geeignet, für nicht infizierte Wunden wahrscheinlich verzichtbar bzw. nicht erste Wahl.
Jod sollte nicht mehr als altmodisches Antiseptikum betrachtet werden…. Vielleicht ist seine größte Stärke, dass Bakterien auch nach 150 Jahren der Anwendung am Menschen keinen Weg zu einer Resistenzentwicklung gefunden haben.
Rose A. Cooper (2007), University of Wales, Centre of biomedical sciences, Cardiff
Rot – Alkoholische Desinfektionsmittel haben bei offenen Wunden keinen Stellenwert
Alkoholische Desinfektionsmittel
Alkoholische Desinfektionsmittel finden in vielen Bereichen der Hygiene ihren Platz, sind jedoch bei offenen Wunden weniger zu empfehlen. Sie verursachen starke Schmerzen bei Kontakt mit offenem Gewebe und können die natürliche Wundheilung beeinträchtigen.
Der Grund liegt in der Wirkung von Alkohol, der Proteine denaturiert. Während dies bei Keimen eine desinfizierende Wirkung hat, trifft es bei offenen Wunden auch nützliche Zellen und Gewebestrukturen. Besonders betroffen sind Fibroblasten, die essenziell für die Geweberegeneration sind. Diese Schädigung könnte die Heilung verlangsamen.
Zudem wird durch den Alkohol die natürliche Balance des Mikrobioms an der Wundoberfläche gestört, was in manchen Fällen eine übermäßige Entzündungsreaktion fördern kann. Nicht zuletzt können alkoholische Desinfektionsmittel zu einer Austrocknung der Wunde führen
