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. 2022 Sep 14;9(9):CD003861.
doi: 10.1002/14651858.CD003861.pub4.

Water for wound cleansing

Ritin Fernandez  1   2   3 , Heidi L Green  1   3 , Rhonda Griffiths  4 , Ross A Atkinson  5 , Laura J Ellwood  1   3
Affiliations

Water for wound cleansing

Ritin Fernandez et al. Cochrane Database Syst Rev. .

Abstract

Background: Although various solutions have been recommended for cleansing wounds, normal saline is favoured as it is an isotonic solution and is not thought to interfere with the normal healing process. Tap water is commonly used in community settings for cleansing wounds because it is easily accessible, efficient and cost-effective; however, there is an unresolved debate about its use.

Objectives: To assess the effects of water for wound cleansing.

Search methods: For this fifth update, in May 2021 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

Selection criteria: We included all randomised controlled trials (RCTs) that assessed wound cleansing using different types of water (e.g. tap water, distilled, boiled) compared with no cleansing or with other solutions (e.g. normal saline). For this update, we excluded quasi-RCTs, thereby removing some studies which had been included in the previous version of the review.

Data collection and analysis: Two review authors independently carried out trial selection, data extraction and GRADE assessment of the certainty of evidence.

Main results: We included 13 trials in this update including a total of 2504 participants ranging in age from two to 95 years. Participants in the trials experienced open fractures, surgical wounds, traumatic wounds, anal fissures and chronic wounds. The trials were conducted in six different countries with the majority conducted in India and the USA. Three trials involving 148 participants compared cleansing with tap water with no cleansing. Eight trials involving 2204 participants assessed cleansing with tap water compared with cleansing with normal saline. Two trials involving 152 participants assessed cleansing with distilled water compared with cleansing with normal saline. One trial involving 51 participants also assessed cleansing with cooled boiled water compared with cleansing with normal saline, and cleansing with distilled water compared with cleansing with cooled boiled water. Wound infection: no trials reported on wound infection for the comparison cleansing with tap water versus no cleansing. For all wounds, eight trials found the effect of cleansing with tap water compared with normal saline is uncertain (risk ratio (RR) 0.84, 95% confidence interval (CI) 0.59 to 1.19); very low-certainty evidence. Two trials comparing the use of distilled water with normal saline for cleansing open fractures found that the effect on the number of fractures that were infected is uncertain (RR 0.70, 95% CI 0.45 to 1.09); very low-certainty evidence. One trial compared the use of cooled boiled water with normal saline for cleansing open fractures and found that the effect on the number of fractures infected is uncertain (RR 0.83, 95% CI 0.37 to 1.87); very low-certainty evidence. This trial also compared the use of distilled water with cooled boiled water and found that the effect on the number of fractures infected is uncertain (RR 0.59, 95% CI 0.24 to 1.47); very low-certainty evidence. Wound healing: results from three trials comparing the use of tap water with no wound cleansing demonstrated there may be little or no difference in the number of wounds that did not heal between the groups (RR 1.04, 95% CI 0.95 to 1.14); low-certainty evidence. The effect of tap water compared with normal saline is uncertain; two trials were pooled (RR 0.57, 95% CI 0.30 to 1.07) but the certainty of the evidence is very low. Results from one study comparing the use of distilled water with normal saline for cleansing open fractures found that there may be little or no difference in the number of fractures that healed (RR could not be estimated, all wounds healed); the certainty of the evidence is low. Reduction in wound size: the effect of cleansing with tap water compared with normal saline on wound size reduction is uncertain (RR 0.97, 95% CI 0.56 to 1.68); the certainty of the evidence is very low. Rate of wound healing: the effect of cleansing with tap water compared with normal saline on wound healing rate is uncertain (mean difference (MD) -3.06, 95% CI -6.70 to 0.58); the certainty of the evidence is very low.

Costs: two trials reported cost analyses but the cost-effectiveness of tap water compared with the use of normal saline is uncertain; the certainty of the evidence is very low. Pain: results from one study comparing the use of tap water with no cleansing for acute and chronic wounds showed that there may be little or no difference in pain scores. The certainty of the evidence is low. Patient satisfaction: results from one study comparing the use of tap water with no cleansing for acute and chronic wounds showed that there may be little or no difference in patient satisfaction. The certainty of evidence is low. The effect of cleansing with tap water compared with normal saline is uncertain as the certainty of the evidence is very low.

Authors' conclusions: All the evidence identified in the review was low or very low certainty. Cleansing with tap water may make little or no difference to wound healing compared with no cleansing; there are no data relating to the impact on wound infection. The effects of cleansing with tap water, cooled boiled water or distilled water compared with cleansing with saline are uncertain, as is the effect of distilled water compared with cooled boiled water. Data for other outcomes are limited across all the comparisons considered and are either uncertain or suggest that there may be little or no difference in the outcome.

Trial registration: ClinicalTrials.gov NCT01846598 NCT02820272.

PubMed Disclaimer

Conflict of interest statement

Ritin Fernandez: none known.

Heidi Green: none known.

Rhonda Griffiths: none known.

Ross Atkinson: none known.

Laura Ellwood: works as a health professional.

Ritin Fernandez and Rhonda Griffiths conducted one of the trials included in the review, however the authors did not receive from any commercial entity any payments or pecuniary, in‐kind or other professional or personal benefits that were related in any way to the subject of the work. The authors of this trial were also not involved in the data extraction or RoB assessment for this included trial. This trial was also subject to the same rigorous quality assessment as other trials included in the review.

Figures

1
1
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1: Tap water versus no cleansing, Outcome 1: Wounds healed
1.2
1.2. Analysis
Comparison 1: Tap water versus no cleansing, Outcome 2: Pain
2.1
2.1. Analysis
Comparison 2: Tap water versus normal saline, Outcome 1: Infection
2.2
2.2. Analysis
Comparison 2: Tap water versus normal saline, Outcome 2: Wounds healed
2.3
2.3. Analysis
Comparison 2: Tap water versus normal saline, Outcome 3: Reduction in wound size
2.4
2.4. Analysis
Comparison 2: Tap water versus normal saline, Outcome 4: Healing rate
3.1
3.1. Analysis
Comparison 3: Distilled water versus normal saline, Outcome 1: Infection
3.2
3.2. Analysis
Comparison 3: Distilled water versus normal saline, Outcome 2: Wounds healed
4.1
4.1. Analysis
Comparison 4: Cooled boiled water versus normal saline, Outcome 1: Infection
5.1
5.1. Analysis
Comparison 5: Distilled water versus cooled boiled water, Outcome 1: Infection
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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NCT01846598 {published data only}
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References to other published versions of this review

Fernandez 2002
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Publication types

Associated data