The Use of Antiseptic and Antibacterial Agents on Wounds and the Skin

  • Khalad Maliyar
  • Asfandyar Mufti
  • R. Gary SibbaldEmail author
Part of the Updates in Clinical Dermatology book series (UCD)


As our global population ages, the prevalence and frequency of both acute and chronic wounds will rise, generating increased burden on patients, healthcare professionals, and healthcare systems. Wound-related bacterial damage can be situated on either the surface compartment of the wound or the deep and surrounding compartments. Wounds that are infected on the surface component are said to have local infection and should be treated topically. Wounds infected in the deep and surrounding components should be treated systemically. Topical antimicrobial and antiseptic agents are used to treat superficial critical colonization and not deep and surrounding infection. This chapter will address the use of topical antimicrobials and antiseptics for the treatment of the superficial compartment of the wound. The five broad classes of topical antimicrobial agents currently used in chronic wounds with superficial critical colonization include PHMB, ionized silver, slow-release iodine, methylene blue and gentian violet, and honey.


Chronic wounds Superficial critical colonization Bacteria Deep infection Antiseptic Antibacterial Antimicrobials Biofilms 


  1. 1.
    Singer AJ, Clark RA. Cutaneous wound healing. N Engl J Med. 1999;341(10):738–46. Scholar
  2. 2.
    Sibbald RG, Elliott JA, Verma L, Brandon A, Persaud R, Ayello EA. Update: topical antimicrobial agents for chronic wounds. Adv Skin Wound Care. 2017;30(10):438–50. Scholar
  3. 3.
    White RJ, Cutting K, Kingsley A. Topical antimicrobials in the control of wound bioburden. Ostomy Wound Manage. 2006;52(8):26–58.PubMedGoogle Scholar
  4. 4.
    Mustoe TA, O’Shaughnessy K, Kloeters O. Chronic wound pathogenesis and current treatment strategies: a unifying hypothesis. Plast Reconstr Surg. 2006;117(7 Suppl):35S–41S. Scholar
  5. 5.
    Attinger C, Wolcott R. Clinically addressing biofilm in chronic wounds. Adv Wound Care (New Rochelle). 2012;1(3):127–32. Scholar
  6. 6.
    Lewis K. Persister cells, dormancy and infectious disease. Nat Rev Microbiol. 2007;5(1):48–56. Scholar
  7. 7.
    Clinton A, Carter T. Chronic wound biofilms: pathogenesis and potential therapies. Lab Med. 2015;46(4):277–84. Scholar
  8. 8.
    Hurlow J, Bowler PG. Clinical experience with wound biofilm and management: a case series. Ostomy Wound Manage. 2009;55(4):38–49.PubMedGoogle Scholar
  9. 9.
    Ryan S, Perrier L, Sibbald RG. Searching for evidence-based medicine in wound care: an introduction. Ostomy Wound Manage. 2003;49(11):67–75.PubMedGoogle Scholar
  10. 10.
    Sibbald RG, Williamson D, Orsted HL, et al. Preparing the wound bed–debridement, bacterial balance, and moisture balance. Ostomy Wound Manage. 2000;46(11):14–22, 24–8, 30–5; quiz 36–7PubMedGoogle Scholar
  11. 11.
    Falanga V. Classifications for wound bed preparation and stimulation of chronic wounds. Wound Repair Regen. 2000;8(5):347–52.CrossRefGoogle Scholar
  12. 12.
    Sibbald RG, Woo K, Ayello EA. Increased bacterial burden and infection: the story of NERDS and STONES. Adv Skin Wound Care. 2006;19(8):447–61; quiz 461–3CrossRefGoogle Scholar
  13. 13.
    Pellizzer G, Strazzabosco M, Presi S, et al. Deep tissue biopsy vs. superficial swab culture monitoring in the microbiological assessment of limb-threatening diabetic foot infection. Diabet Med. 2001;18(10):822–7.CrossRefGoogle Scholar
  14. 14.
    Sibbald et. al. Wound bed preparation 2020 submitted for publication Advances in Skin and Wound Care.Google Scholar
  15. 15.
    Woo KY, Sibbald RG. A cross-sectional validation study of using NERDS and STONEES to assess bacterial burden. Ostomy Wound Manage. 2009;55(8):40–8.PubMedGoogle Scholar
  16. 16.
    Cutting KF, Harding KG. Criteria for identifying wound infection. J Wound Care. 1994;3(4):198–201. Scholar
  17. 17.
    Leekha S, Terrell CL, Edson RS. General principles of antimicrobial therapy. Mayo Clin Proc. 2011;86(2):156–67. Scholar
  18. 18.
    Antimicrobial dressings made easy – Wounds International. Accessed 3 Jan 2019.
  19. 19.
    Bernatchez SF, Menon V, Stoffel J, et al. Nitric oxide levels in wound fluid may reflect the healing trajectory. Wound Repair Regen. 2013;21(3):410–7. Scholar
  20. 20.
    Margolis DJ, Allen-Taylor L, Hoffstad O, Berlin JA. The accuracy of venous leg ulcer prognostic models in a wound care system. Wound Repair Regen. 2004;12(2):163–8. Scholar
  21. 21.
    Lipsky BA, Hoey C. Topical antimicrobial therapy for treating chronic wounds. Clin Infect Dis. 2009;49(10):1541–9. Scholar
  22. 22.
    Butcher M. PHMB: an effective antimicrobial in wound bioburden management. Br J Nurs. 2012;21(12):S16, S18–21.
  23. 23.
    Sibbald RG, Coutts P, Woo KY. Reduction of bacterial burden and pain in chronic wounds using a new polyhexamethylene biguanide antimicrobial foam dressing-clinical trial results. Adv Skin Wound Care. 2011;24(2):78–84. Scholar
  24. 24.
    To E, Dyck R, Gerber S, Kadavil S, Woo KY. The effectiveness of topical Polyhexamethylene Biguanide (PHMB) agents for the treatment of chronic wounds: a systematic review. Surg Technol Int. 2016;29:45–51.PubMedGoogle Scholar
  25. 25.
    Yin HQ, Langford R, Burrell RE. Comparative evaluation of the antimicrobial activity of ACTICOAT antimicrobial barrier dressing. J Burn Care Rehabil. 1999;20(3):195–200.CrossRefGoogle Scholar
  26. 26.
    Wright JB, Lam K, Burrell RE. Wound management in an era of increasing bacterial antibiotic resistance: a role for topical silver treatment. Am J Infect Control. 1998;26(6):572–7. Scholar
  27. 27.
    Wright JB, Lam K, Hansen D, Burrell RE. Efficacy of topical silver against fungal burn wound pathogens. Am J Infect Control. 1999;27(4):344–50.CrossRefGoogle Scholar
  28. 28.
    Sibbald RG, Browne AC, Coutts P, Queen D. Screening evaluation of an ionized nanocrystalline silver dressing in chronic wound care. Ostomy Wound Manage. 2001;47(10):38–43.PubMedGoogle Scholar
  29. 29.
    Lo S-F, Chang C-J, Hu W-Y, Hayter M, Chang Y-T. The effectiveness of silver-releasing dressings in the management of non-healing chronic wounds: a meta-analysis. J Clin Nurs. 2009;18(5):716–28. Scholar
  30. 30.
    Oliveira Ados S, VLC S. Topical iodophor use in chronic wounds: a literature review. Rev Lat Am Enfermagem. 2007;15(4):671–6.CrossRefGoogle Scholar
  31. 31.
    Sibbald RG, Elliott JA. The role of Inadine in wound care: a consensus document. Int Wound J. 2017;14(2):316–21. Scholar
  32. 32.
    Mertz PM, Oliveira-Gandia MF, Davis SC. The evaluation of a cadexomer iodine wound dressing on methicillin resistant Staphylococcus aureus (MRSA) in acute wounds. Dermatol Surg. 1999;25(2):89–93.CrossRefGoogle Scholar
  33. 33.
    Sibbald R, Leaper D, Queen D. Iodine made easy – Wounds International. Accessed 27 Dec 2018.
  34. 34.
    Burks RI. Povidone-iodine solution in wound treatment. Phys Ther. 1998;78(2):212–8.CrossRefGoogle Scholar
  35. 35.
    Drosou A, Falabella A, Kirsner R. Antiseptics on wounds: an area of controversy. Wounds. 2003;15(5):149–66.Google Scholar
  36. 36.
    Fumal I, Braham C, Paquet P, Piérard-Franchimont C, Piérard GE. The beneficial toxicity paradox of antimicrobials in leg ulcer healing impaired by a polymicrobial flora: a proof-of-concept study. Dermatology (Basel). 2002;204(Suppl 1):70–4. Scholar
  37. 37.
    Moberg S, Hoffman L, Grennert ML, Holst A. A randomized trial of cadexomer iodine in decubitus ulcers. J Am Geriatr Soc. 1983;31(8):462–5.CrossRefGoogle Scholar
  38. 38.
    Harcup JW, Saul PA. A study of the effect of cadexomer iodine in the treatment of venous leg ulcers. Br J Clin Pract. 1986;40(9):360–4.PubMedGoogle Scholar
  39. 39.
    International Wound Infection Institute (IWII)-Wound-infection-in-clinical-practice.pdf. Accessed 27 Dec 2018.
  40. 40.
    Coutts PM, Ryan J, Sibbald RG. Case series of lower-extremity chronic wounds managed with an antibacterial foam dressing bound with gentian violet and methylene blue. Adv Skin Wound Care. 2014;27(3 Suppl 1):9–13. Scholar
  41. 41.
    Hoffmann CE, Rahn O. The bactericidal and bacteriostatic action of crystal violet. J Bacteriol. 1944;47(2):177–86.CrossRefGoogle Scholar
  42. 42.
    Data on file, Hydrofera, LLC.Google Scholar
  43. 43.
    Shi L, Ermis R, Kiedaisch B, Carson D. The effect of various wound dressings on the activity of debriding enzymes. Adv Skin Wound Care. 2010;23(10):456–62. Scholar
  44. 44.
    Paddle-Ledinek JE, Nasa Z, Cleland HJ. Effect of different wound dressings on cell viability and proliferation. Plast Reconstr Surg. 2006;117(7 Suppl):110S–8S. ; discussion 119S–120S. Scholar
  45. 45.
    Woo KY, Heil J. A prospective evaluation of methylene blue and gentian violet dressing for management of chronic wounds with local infection. Int Wound J. 2017;14(6):1029–35. Scholar
  46. 46.
    Jull AB, Cullum N, Dumville JC, Westby MJ, Deshpande S, Walker N. Honey as a topical treatment for wounds. Cochrane Database Syst Rev. 2015;(3):CD005083.
  47. 47.
    Sato T, Miyata G. The nutraceutical benefit, part iii: honey. Nutrition. 2000;16(6):468–9.CrossRefGoogle Scholar
  48. 48.
    Al-Waili NS, Salom K, Butler G, Al Ghamdi AA. Honey and microbial infections: a review supporting the use of honey for microbial control. J Med Food. 2011;14(10):1079–96. Scholar
  49. 49.
    Position document Management of biofilm – Wounds UK. Accessed 3 Jan 2019.
  50. 50.
    Percival SL, Mayer D, Malone M, Swanson T, Gibson D, Schultz G. Surfactants and their role in wound cleansing and biofilm management. J Wound Care. 2017;26(11):680–90. Scholar
  51. 51.
    Burnett CL, Bergfeld WF, Belsito DV, et al. Final report of the Cosmetic Ingredient Review Expert Panel on the safety assessment of cocamidopropyl betaine (CAPB). Int J Toxicol. 2012;31(4 Suppl):77S–111S. Scholar
  52. 52.
    Sibbald RG, Elliott JA, Ayello EA, Somayaji R. Optimizing the moisture management tightrope with wound bed preparation 2015©. Adv Skin Wound Care. 2015;28(10):466–76. ; quiz 477–8. Scholar
  53. 53.
    Atiyeh BS, Ioannovich J, Al-Amm CA, El-Musa KA. Management of acute and chronic open wounds: the importance of moist environment in optimal wound healing. Curr Pharm Biotechnol. 2002;3(3):179–95.CrossRefGoogle Scholar
  54. 54.
    Norman G, Atkinson RA, Smith TA, et al. Intracavity lavage and wound irrigation for prevention of surgical site infection. Cochrane Database Syst Rev. 2017;(10):CD012234.
  55. 55.
    Salami AA, Owoeye O. A comparison of the effect of chlorhexidine, tap water, and normal saline on healing wounds. Int Morphol. 2006;4(24):673–6.Google Scholar
  56. 56.
    Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012;(2):CD003861.
  57. 57.
    Mena KD, Gerba CP. Risk assessment of Pseudomonas aeruginosa in water. Rev Environ Contam Toxicol. 2009;201:71–115. Scholar
  58. 58.
    Thomas GW, Rael LT, Bar-Or R, et al. Mechanisms of delayed wound healing by commonly used antiseptics. J Trauma. 2009;66(1):82–90. ; discussion 90–1. Scholar
  59. 59.
    Atiyeh BS, Dibo SA, Hayek SN. Wound cleansing, topical antiseptics and wound healing. Int Wound J. 2009;6(6):420–30. Scholar
  60. 60.
    Haller G, Faltin-Traub E, Faltin D, Kern C. Oxygen embolism after hydrogen peroxide irrigation of a vulvar abscess. Br J Anaesth. 2002;88(4):597–9.CrossRefGoogle Scholar
  61. 61.
    Okan D, Woo K, Ayello EA, Sibbald G. The role of moisture balance in wound healing. Adv Skin Wound Care. 2007;20(1):39–53; quiz 53–5CrossRefGoogle Scholar
  62. 62.
    Cho CY, Lo JS. Dressing the part. Dermatol Clin. 1998;16(1):25–47.CrossRefGoogle Scholar
  63. 63.
    Hampton S. A small study in healing rates and symptom control using a new sheet hydrogel dressing. J Wound Care. 2004;13(7):297–300. Scholar
  64. 64.
    Eisenbud D, Hunter H, Kessler L, Zulkowski K. Hydrogel wound dressings: where do we stand in 2003? Ostomy Wound Manage. 2003;49(10):52–7.PubMedGoogle Scholar
  65. 65.
    Hoffmann KK, Weber DJ, Samsa GP, Rutala WA. Transparent polyurethane film as an intravenous catheter dressing. A meta-analysis of the infection risks. JAMA. 1992;267(15):2072–6.CrossRefGoogle Scholar
  66. 66.
    Chang KW, Alsagoff S, Ong KT, Sim PH. Pressure ulcers–randomised controlled trial comparing hydrocolloid and saline gauze dressings. Med J Malaysia. 1998;53(4):428–31.PubMedGoogle Scholar
  67. 67.
    Kannon GA, Garrett AB. Moist wound healing with occlusive dressings. A clinical review. Dermatol Surg. 1995;21(7):583–90.CrossRefGoogle Scholar
  68. 68.
    Körber A, Kohaus S, Geisheimer M, Grabbe S, Dissemond J. Allergic contact dermatitis from a hydrocolloid dressing due to colophony sensitization. Hautarzt. 2006;57(3):242–5. Scholar
  69. 69.
    Campton-Johnston S, Wilson J. Infected wound management: advanced technologies, moisture-retentive dressings, and die-hard methods. Crit Care Nurs Q. 2001;24(2):64–77; quiz 2 p following 77CrossRefGoogle Scholar
  70. 70.
    Hilton JR, Williams DT, Beuker B, Miller DR, Harding KG. Wound dressings in diabetic foot disease. Clin Infect Dis. 2004;39(Suppl 2):S100–3. Scholar
  71. 71.
    Aparicio Gallego E, Castilla Peris C, Díez García MT, et al. Therapeutic behavior of a hydrocolloid dressing. Its evolution in the treatment of acute and chronic dermal ulcers. Rev Enferm. 2005;28(12):49–55.PubMedGoogle Scholar
  72. 72.
    Segal HC, Hunt BJ, Gilding K. The effects of alginate and non-alginate wound dressings on blood coagulation and platelet activation. J Biomater Appl. 1998;12(3):249–57. Scholar
  73. 73.
    Dabiri G, Damstetter E, Phillips T. Choosing a wound dressing based on common wound characteristics. Adv Wound Care (New Rochelle). 2016;5(1):32–41. Scholar
  74. 74.
    Cutting KF. The causes and prevention of maceration of the skin. Prof Nurse. 2001;17(3):177–8.PubMedGoogle Scholar
  75. 75.
    Faucher N, Safar H, Baret M, Philippe A, Farid R. Superabsorbent dressings for copiously exuding wounds. Br J Nurs. 2012;21(12):S22, S24, S26–28. doi:
  76. 76.
    Tadej M. The use of Flivasorb in highly exuding wounds. Br J Nurs. 2009;18(15):S38–S40–42. Scholar
  77. 77.
    Wiegand C, Abel M, Ruth P, Hipler UC. Superabsorbent polymer-containing wound dressings have a beneficial effect on wound healing by reducing PMN elastase concentration and inhibiting microbial growth. J Mater Sci Mater Med. 2011;22(11):2583–90. Scholar
  78. 78.
    Superabsorbent polymers have become an important component of diapers during the last 10 years. Accessed 28 Dec 2018.

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Khalad Maliyar
    • 1
  • Asfandyar Mufti
    • 2
  • R. Gary Sibbald
    • 3
    Email author
  1. 1.Faculty of Medicine, University of TorontoTorontoCanada
  2. 2.Women’s College Hospital, Sunnybrook Hospital, Division of Dermatology, Department of MedicineTorontoCanada
  3. 3.Public Health & Medicine, Trillium Health Partners & Womens College Hospital, University of TorontoMississaugaCanada

Personalised recommendations