International Wound Journal ISSN 1742-4801
LETTER TO THE EDITOR
Cleansing of wounds by tap water? An evidence-based
systemic analysis
Dear Editors,
Tap water therapy has been used for several decades (1) in
wound cleansing for the treatment of many conditions, such
as lacerations, incisions, open fractures and episiotomy (2 – 5).
The infection rate and outcome of wounds cleansed with
tap water are commonly believed to be the same as those
cleaned with normal saline solution (2 – 5). Even though this
alternative treatment is considered safe, a contrary opinion has
always existed. There is still no evidence-based consensus
on the contribution of tap water therapy to the treatment
of wound cleansing and treatment results have not always
achieved patient satisfaction. Thus, the aim of this study is to
explore the safety of tap water irrigation in wound cleansing
and to develop a specific recommendation based on the review
of medical literature.
PubMed data up to May 2013 was searched for studies in
English evaluating the outcome of tap water therapy in wound
cleansing. The words used in the search were ‘tap water’,
‘running water’, ‘normal saline solution’, ‘irrigation’ and
‘wound’. Reference lists of obtained articles were searched as
well. Studies including any laboratory values were excluded
from this data analysis. One investigator selected the articles
for inclusion. Two investigators independently extracted data
from all eligible studies using a standardised Excel file. These
authors retrieved data on study design, study period, study
size, patient demographics and treatment outcome. Relevant
studies were assigned a level of evidence according to the
Oxford Centre for Evidence-Based Medicine 2011 levels of
evidence.
The search performed in May 2013 yielded six articles
pertinent to the topic (Table 1) – five randomised controlled
trials (RCTs, level I evidence) (1 – 5), and one case series
(level IV evidence) (6). Four RCTs showed that the infection
rates and status of wound healing in tap water therapy were
similar to the normal saline solution group (P > 0·05) and the
culture results from the wounds in both groups showed no
significant finding in colony counts (P > 0·05). Furthermore,
tap water therapy may be more cost-effective (2 – 5). Only
one RCT revealed that the infection rates in tap water therapy
were significantly lower than that in normal saline solution
group (P < 0·05) and suggested that sterile saline should
be replaced by tap water in patients with acute traumatic
soft-tissue wounds (1). There was no significant difference
between the two groups in colony counts of microorganisms
in the case series, but its number of participants could not be
obtained (6).
The studies that met our inclusion criteria for eligibility
were all of evidence level I or IV. All of them used normal
saline solution as control group for evaluating the efficacy of
wound cleansing and revealed the superiority of tap water
therapy, but there was no consistency in mechanism and
degree of contamination of wounds, amount of tap water
and normal saline or pressure of irrigation. In addition, most
articles were written in developed countries such as America
and Sweden where sterilisation of tap water equipment is
well-established. Only few data could be reviewed from
other countries. Thus, further comparative studies are both
justified and necessary to provide more information on the best
technique for wound cleansing and more rigorous evidence on
effectiveness and safety are required.
Chia-Yu Huang1,2 , Mun-Yau Choong2,3 & Tzong-Shiun Li2,3
1
Department of Plastic Surgery
China Medical University Hospital
Taichung, Taiwan
2
School of Medicine
China Medical University
Taichung, Taiwan
3
Department of Plastic Surgery
Tainan Municipal An-Nan Hospital
Tainan, Taiwan
Email: li.tsa2@msa.hinet.net
Table 1 The studies with evidence levels I and IV
Studies
Number (total, intervention group, control group)
P -value
Level of evidence
Location
Angeras et al . (1)
627, 295 (tap water), 332 (normal saline solution)
<0·05
Level I
Ostra (Sweden)
Valente et al . (2)
530, 259 (tap water), 271 (normal saline solution)
>0·05
Level I
NY (America)
Bansal et al . (3)
45, 21 (tap water), 24 (normal saline solution)
>0·05
Level I
TX (America)
Griffiths et al . (4)
49, 23 (tap water), 26 (normal saline solution)
>0·05
Level I
Macarthur (Australia)
Moscati et al . (5)
634, 334 (tap water), 300 (normal saline solution)
>0·05
Level I
NY (America)
Riyat et al . (6)
*
*
Level IV
Leicester (Britain)
*, unclear data.
© 2013 The Author
International Wound Journal © 2013 John Wiley & Sons Ltd and Medicalhelplines.com Inc doi: 10.1111/iwj.12113
1
Letter to the Editor
C.-Y. Huang et al.
References
1. Angeras MH, Brandberg A, Falk A, Seeman T. Comparison between
sterile saline and tap water for the cleaning of acute traumatic soft
tissue wounds. Eur J Surg 1992;158(6 – 7):347 – 50.
2. Valente JH, Forti RJ, Freundlich LF, Zandieh SO, Crain EF. Wound
irrigation in children: saline solution or tap water? Ann Emerg Med
2003;41:609 – 16.
3. Bansal BC, Wiebe RA, Perkins SD, Abramo TJ. Tap water for
irrigation of lacerations. Am J Emerg Med 2002;20:469 – 72.
2
4. Griffiths RD, Fernandez RS, Ussia CA. Is tap water a safe alternative
to normal saline for wound irrigation in the community setting? J
Wound Care 2001;10:407 – 11.
5. Moscati RM, Mayrose J, Reardon RF, Janicke DM, Jehle DV. A
multicentre comparison of tap water versus sterile saline for wound
irrigation. Acad Emerg Med 2007;14:404 – 10.
6. Riyat MS, Quinton DN. Tap water as a wound cleansing agent in
accident and emergency. J Accid Emerg Med 1997;14:165 – 6.
© 2013 The Author
International Wound Journal © 2013 John Wiley & Sons Ltd and Medicalhelplines.com Inc