Professional Documents
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Georgina Gethin
C
hronic non-healing wounds, wounds is predominantly solution and minimising pH changes
such as leg ulcers, which affect (Solomon et al, 1990). Haemoglobin is
based on subjective
up to 2% of the population, one type of intracellular buffer. When
continue to pose a treatment challenge interpretation with little oxyhaemoglobin releases oxygen, the
to the clinician (Callam et al, 1985; recourse to objective reduced haemoglobin possesses a net
Nelzen et al, 1996; OBrien et al, 2000; analysis. Monitoring negative charge that can bind hydrogen
Moffatt, 2004). Clinical assessment surface pH may provide a ions (Solomon et al, 1990).
of the wound bed of these chronic method of measuring the
wounds is predominantly based
condition of the wound pH and wound healing
on subjective interpretation with Normal wound healing is characterised
little recourse to objective analysis. bed and ultimately aid in by the successful completion of
Monitoring surface pH may provide a determining the wounds four distinct but overlapping phases
method of measuring the condition response to treatment. haemostasis, inammation,
of the wound bed and ultimately aid proliferation, and remodelling. Altered
in determining the wounds response or impaired wound healing, as seen
to treatment. This paper will present 1990). A pH of 7 represents neutral, in chronic wounds, is marked by
a review of wound pH and the a pH below 7 is acidic representing a interruption of this process. The
physiological effects on wound healing. higher hydrogen concentration, while literature records some studies of
a pH value above 7 is termed base the affects of pH on cellular events in
What is pH? or alkaline and represents a lower wound healing and the alteration in
Regulation of hydrogen ions (H+) in hydrogen concentration. Because a surface pH of wounds when topical
the uid compartments of the body logarithmic scale is used for all pH preparations have been used.
is of critical importance to health. measurements, actual acidity increases
much faster than the numerical change The pH environment of chronic
in pH might seem to indicate (Ganong, wounds has been recorded within the
Georgina Gethin is HRB-Research Fellow, Department of 2001). A pH of 5, for example, is range of 7.158.9 (Wilson et al, 1979;
Nursing and Midwifery, RCSI, Dublin, Ireland 10 times as acidic as a pH of 6, Tsukada et al, 1992; Romanelli et al,
1997). This variability is representative et al, 1999). Every protease shows peak ulcers, the skin and local vasculature
of both healing and non-healing enzyme activity at certain pH levels, become scarred and atrophic, resulting
wounds. Both acute and chronic where the protein is broken down in permanent obstacles to the
wounds with an elevated alkaline more rapidly than at other pH values transport of oxygen (Hunt and Beckert,
pH have demonstrated lower rates (Greener et al, 2005). For example, 2005). Therefore, any factor that could
of healing than wounds in which the cathepsin G has peak activity at pH 7.0; cause even a small change in the pH of
pH is closer to neutral (Leveen et al, elastase at 8.0; plasmin at 8.0, MMP-2 the wound may appreciably alter the
1973; Roberts et al, 1997; Gethin and at 8.0 and neutrophil elastase at 8.3 available supply of oxygen to the tissues
Cowman, 2006). (Greener et al, 2005). Proteases are (Leveen et al, 1973).
not only produced by the wound itself
Importantly, as the wound but also as end-products by bacteria. In addition to the effects on
progresses towards healing, the pH Ammonia, which is liberated from urea protease activity and oxygen release,
moves to neutral and then becomes by the enzyme urease, is also produced other effects of lowering the pH to
acidic (Tsukada et al, 1992; Kaufman et a more acidic environment are to
al, 1985). This has been demonstrated reduce the toxicity of bacterial end
in one study which mapped the pH In addition to the effects products such as ammonia, enhancing
of pressure ulcers according to depth on protease activity and the destruction of abnormal collagen
and tissue type (Tsukada et al, 1992). In oxygen release, other effects in the ulcer bed, promotion of
the latter study, stage 1 pressure ulcers angiogenesis, increased macrophage
of lowering the pH to a
had a pH similar to that of intact skin and broblast activity and control
(range 5.45.6), while the pH of stage more acidic environment of enzyme activity (Thomas, 1990;
2 ulcers was 6.9. This increased to 7.6 are to reduce the toxicity of Romanelli et al, 1997; Molan, 2002;
for stage 3 ulcers. Of note in the study bacterial end products such Brett, 2003; Greener et al, 2005).
by Tsukada et al, epithelialised wounds as ammonia, enhancing the
had a mean pH of 6.0 compared with destruction of abnormal Wound dressings and wound pH
a mean of 7.8 for wounds without Efforts to decrease wound surface pH
collagen in the ulcer bed,
epithelial tissue, which was shown to using topical agents have had varying
be statistically signicant (p< 0.001) promotion of angiogenesis, degrees of efcacy. Acetic acid in 1%
(Tsukada et al, 1992). increased macrophage and and 5% solutions has been widely
broblast activity and control used in an attempt to reduce the pH.
The authors concluded that pH is of enzyme activity. However, acetic acid lowers pH for only
related to tissue type and not the grade one hour after which it returns to pre-
of the wound. Indeed, the presence of treatment levels (Leveen et al, 1973).
necrotic tissue and devitalised tissue by bacteria and is toxic to wound tissue Efforts to manage the bacterial burden
in the wound causes an increased but importantly favours an alkaline of the wound using acetic acid has also
metabolic load on the wound resulting rather than an acid environment had limited and variable efcacy.
in tissue hypoxia (Hunt and Beckert, (Leveen et al, 1973; Thomas, 1990).
2005). These wounds have excessive This is signicant in the chronic wound In a letter to the Lancet, Milner
breakdown of the extracellular matrix which can harbour at least four (1992) reported eradication of
(ECM) and consequently the wound different types of bacteria at any one Pseudomonas aeruginosa from seven
itself as this occurs more readily in time (Trengrove et al, 1996). chronic and two acute wounds after
an alkaline environment (Greener et 27 days with once-daily soaks of
al, 2005; Gethin and Cowman, 2006). The pH environment also inuences 5% acetic acid. A further study used
There are many potentially contributing oxygen release to the tissues. Oxygen a 1% solution of distilled acetic acid
processes towards this. delivery to damaged tissue particularly diluted with equal part sterile water
in the chronic wound is dependent for management of exit site infection
One of the altered processes not only on perfusion but diffusion in 38 patients receiving continuous
is that of protease activity. Matrix (Hunt and Beckert, 2005). A lowering ambulatory peritoneal dialysis (Leung
metalloproteinases (MMPs) are a of pH by 0.6 units releases almost 50% et al, 2001). The authors reported
family of more than 20 proteases that more oxygen and a ve-fold increase eradication of Pseudomonas aeruginosa
collectively can degrade most of the in release of oxygen by a shift of 0.9 infection in 92% (n=37) of cases with
components of the ECM (Greener et al, pH units (Leveen et al, 1973). Within no relapse (Leung et al, 2001).
2005). Proteases are enzymes that have the chronic wound this is important as
the ability to cleave proteins. This ability the likelihood of healing is high if tissue However, a randomised controlled
is referred to as the activity of the oxygen tension (pO2) is >40mmHg, but trial of acetic acid compared with
proteases and is dependent on both is unlikely at levels of <20mmHg (Hunt hypochlorite showed that acetic acid
the amount of proteases present and and Hopt, 1997). Indeed in chronic had no effect on organisms other than
on the presence of inhibitors (Hoffman recurrent wounds such as venous leg P. aeruginosa and that other organisms
Hoffman R, Noble J, Eagle M (1999) The use Moffatt C (2004) Wound Bed Preparation
of proteases as prognostic markers for the in Practice. EWMA Position document: Key Points
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8 Proteases are pH dependent.
Hunt TK, Beckert S (2005) Therapeutical Molan PC (2002) Re-introducing honey in Many proteases are most active
and practical aspects of oxygen in the management of wounds and ulcers
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in an alkaline environment.
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8 Wound healing occurs as the
Hunt TK, Hopt HW (1997) Wound healing The prevalence of chronic lower-limb wound pH moves to neutral
and wound infection-what surgeons and ulceration has been underestimated: results and then acidic.
anesthesiologists can do. Surg Clin North Am of a validated population questionnaire. Br J
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Kaufman T, Eichenlaub EH, Angel MF, Levin OBrien JF, Grace PA, Perry IJ, Burke PE oxyhaemoglobin more readily
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promotes healing of experimental deep in Ireland. Ir J Med Sci 169: 1102
partial thickness skin burns: a randomised towards neutral.
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Leung D, Mok W, Yu D, Au T (2001) Use of aeruginosa. Lancet 6: 113 pH may aid objective wound
distilled white vinegar dressing supplement bed assessment.
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Compression Therapy
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