A cleanser is not a cleanser is not a cleanser
Not all such products are interchangeable
By Liza G. Ovington, PhD, CWS
President
Ovington & Associates Inc.
Fort Lauderdale, FL
There are large numbers and varieties of products available that fall into the general category of wound and skin cleansers. It is vital for the wound care clinician to discriminate among cleansers designed for wounds, those designed for general patient cleansing, and those designed for perineal or incontinent cleansing. Depending on the intended use or surface needing cleansing, these products are formulated differently, and they should not be used interchangeably.
It is important to remember that by definition cleansing is a physical process aimed at removing some foreign material from a surface or environment. Too often, cleansing is confused with disinfection, which is a chemical process aimed at killing microorganisms on a surface or in an environment.
Cleansers can contain a variety of ingredients
In general, cleansing products are designed to surround, loosen or make slippery, and assist in the physical removal of any foreign materials (such as dirt, microorganisms, or dead cells) on a surface. Cleansers accomplish these actions via the specific ingredients or chemicals they contain as well as by their method of application to the surface to be cleansed.
Examples of ingredients that may be found in cleansers include detergents, surfactants, antimicrobials, emollients, moisturizers, humectants, and preservatives. Examples of methods of application of a cleanser to a surface include direct application by spraying; pouring or irrigating at specific pressures; and application by wiping, sponging, or patting.
The greatest point of differentiation among cleansing products is whether the surface on which they are intended to be used is intact skin or compromised skin.
Skin that is intact is generally a formidable barrier to the environment and to various ingredients that may be found in cleansing products. Skin that has been broken, abraded, or otherwise compromised in integrity loses certain barrier properties and may be susceptible to harm from ingredients in certain cleansing products.
For example isopropyl alcohol may be used on intact skin with no adverse effect; however if there is even the slightest paper cut, the alcohol will sting.
Skin is made up of two major layers, the dermis and the epidermis. The epidermis is the outermost layer that comes into contact with our environment. The epidermis can be broken down further into component layers. The upper layer of the epidermis (stratum corneum) is composed of sheets of dead cells, which are called keratinocytes because they contain large amounts of a tough protein, keratin. The stratum corneum protects the living cells in the layers below by holding in moisture and keeping out foreign organisms and chemicals.
Skin cleansers
Cleansers designed for general use on intact skin may contain the following ingredients:
1. detergent and surfactant ingredients to loosen and remove foreign materials, alcohol, and other antimicrobial ingredients to kill superficial bacteria (because we often equate "clean" with "germ-free");
2. fragrances;
3. preservatives to keep the product from spoiling;
4. emollients, moisturizers, or humectants to soften, add moisture, or retain moisture to prevent the skin from drying out.
The latter ingredients (emollients, moisturizers, and humectants) are important,especially in cleansing the skin of the elderly, which tends to be dryer naturally due to decreased sebum production.
Repeated cleansing and rinsing of the skin can dry it further, and skin that is dry is more susceptible to certain types of injury (cracking, friction abrasions, and pressure ulcer formation, for example). Also, if a patient is susceptible to contact dermatitis, it should be noted that fragrances can be irritating to sensitive skin.
Perineal or incontinence cleansers
Cleansers designed for use in the perineal area may contain different ingredients than general skin cleansers because of the nature of the foreign material they are likely to encounter. Removal of urine and feces poses a different challenge because these materials are chemically active. They change the normal pH of the skin and can lead to skin breakdown if they are allowed to remain in contact with intact skin for too long.
Many perineal cleansers will contain additional emollient ingredients to soothe the skin. Because these cleansers are formulated for a specific and challenging duty, they may be inappropriate (either due to function or to cost) for use on body areas that are unaffected by incontinence.
Wound cleansers
If a cleanser is designed for use on wounds or compromised skin (where the epidermis is not intact for any reason), then it may come in contact with the living cells of the dermis, such as fibroblasts, macrophages, and lymphocytes. These living dermal cells are much more sensitive than the tough, dead keratinocytes of the epidermis and can be harmed by ingredients contained in cleansers designed for intact skin. If dermal cells are harmed, then the healing process may be delayed.
Wound cleansers typically are composed of saline and nonionic surfactants. Surfactants are chemicals that reduce surface tension and "make things slippery" so that they are easily washed away. Nonionic means that the surfactant has no electrical charge. Charged chemicals, whether positive (cationic) or negative (anionic), are usually detrimental to living cells.
The federal Agency for Health Care Policy and Research Guideline for Treatment of Pressure Ulcers recommends the use of normal saline alone for wound cleansing.
Due to the large number of cleansers on the market, a list will not be provided for this column, but readers may refer to the "1997 Buyer Guide" edition of Ostomy/Wound Management for specific examples in each category.
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