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The International Diabetes Federation (IDF) estimates that by 2024, approximately 415 million people worldwide will be living with diabetes. This number is expected to grow substantially, reaching around 642 million by 2040. Diabetes mellitus is a metabolic disorder characterized by elevated blood sugar levels.

There are primarily two types of diabetes: type 1 and type 2. Each type affects the body’s ability to regulate blood sugar levels in distinct ways. Despite their variations, both types can lead to serious complications, with Diabetic Foot Ulcers (DFUs) being among the most critical risks associated with the condition.

What Is a Diabetic Foot Ulcer?What Is a Diabetic Foot Ulcer?

Diabetic foot ulcers are a common complication in individuals with both type 1 and type 2 diabetes. These ulcers typically appear as open sores, often accompanied by pus, particularly on the soles of the feet. For people with diabetes, even minor cuts or skin abrasions can develop into chronic wounds that are difficult to heal, primarily due to an impaired healing response. If not treated promptly, these ulcers can lead to severe infections and may ultimately require amputation.

How Is a Diabetic Foot Ulcer Formed?

Diabetic foot ulcers typically develop due to a combination of several factors:

  1. Peripheral Neuropathy (Nerve Damage): Diabetes can progressively damage peripheral nerves, leading to a loss of sensation in the feet. This condition, known as “diabetic neuropathy,” causes individuals to overlook minor injuries such as small cuts, wounds, or blisters. Without pain or awareness, these seemingly minor injuries can deteriorate over time, developing into chronic wounds.
  2. Blood Circulation Disorders (Peripheral Vascular Disease): Diabetes can significantly impair blood circulation in the lower limbs, particularly in the legs. This condition, referred to as “peripheral vascular disease,” results in inadequate blood and oxygen supply to leg tissues. The reduced blood flow slows the healing process of wounds and creates a low-oxygen environment, which can lead to cell death and tissue necrosis.
  3. Immune System Weakness: Individuals with diabetes often have a compromised immune system, making it more challenging to fight off infections. Furthermore, high blood sugar levels create an environment conducive to bacterial growth, increasing the risk of infections in wounds.
  4. Abnormal Foot Mechanics: Diabetes can cause changes in foot structure, leading to increased pressure on specific areas, such as the soles. This constant pressure may contribute to ulcer formation. Additionally, diminished nerve sensitivity can prevent individuals from noticing a wound until it has progressed to a deeper, infected state.

Consequences and Risks of Diabetic Foot Ulcers

If not treated effectively, a diabetic foot ulcer can lead to severe infections that may progress to gangrene, resulting in the need for amputation. Statistics indicate that over 80% of non-traumatic amputations in individuals with diabetes are linked to diabetic foot ulcers.

 

Understanding the factors that contribute to the development of diabetic foot ulcers and implementing effective management strategies—such as diligent foot care, regular monitoring, and advanced wound care—can significantly reduce the risk of serious complications associated with this condition.

Different levels of diabetic foot ulcers. From left to right: normal foot, superficial ulcer, deep ulcer, osteitis (bone inflammation), partial gangrene, gangrene

Diabetic Foot Ulcers

Common Products for Treating Diabetic Ulcers

  • Dressings Containing Silver Nanoparticles: Silver nanoparticle-infused dressings are frequently utilized in the treatment of diabetic-related wounds.
  • Pros: They minimize side effects, enhance patient comfort, are easily accessible, and can be applied to various wound types.
  • Cons: They tend to be relatively expensive.
  • Hydrogen Peroxide: Widely recognized as a popular disinfectant, hydrogen peroxide is commonly used for cleaning wounds on diabetic feet.
  • Pros: It is readily available.
  • Cons: Hydrogen peroxide can be detrimental to epithelial layers, especially newly formed skin. It may harm fibroblasts—key cells that support skin healing and regeneration—and can also damage surrounding healthy cells near the wound.
  • Povidone-Iodine (Betadine): Betadine is a potent disinfectant suitable for sanitizing wounds.
  • Pros: It has a strong germicidal ability.
  • Cons: Its high cytotoxicity levels can impair wound healing.
  • Normal Saline (Washing Serum): Sterile normal saline is an effective wound cleanser and is often used before applying dressings.
  • Pros: It is non-cytotoxic and safe for healthy tissues.
  • Cons: It lacks disinfectant properties and is unable to eliminate pathogens.
  • Hypochlorous Acid (HOCl): Recognized as one of the most effective agents for disinfection and healing, hypochlorous acid is used in the treatment of diabetic wounds.
  • Pros:
  • Strong Antimicrobial Activity: HOCl effectively inhibits the growth and reproduction of bacteria, viruses, and fungi by draining their internal resources, limiting their oxygen and nutrient absorption, and blocking DNA, protein, and ATP production.
  • Immune System Modulator: HOCl modulates immune responses and reduces the harmful inflammation associated with diabetic ulcers.
  • Anti-Inflammatory Properties: It helps minimize swelling, inflammation, and discomfort at the wound site while accelerating the healing process.
  • Wound Healing: HOCl promotes the healing and regeneration of damaged tissues while preserving healthy tissue integrity.
  • Superiority Over Other Disinfectants: Unlike hydrogen peroxide or povidone-iodine, HOCl is non-cytotoxic, allowing it to prevent infections and facilitate wound healing without setbacks. Additionally, its ability to reduce inflammation and foster healing makes it particularly beneficial for diabetic patients, who often face challenges in wound recovery.

Due to its unique properties, hypochlorous acid has emerged as a highly regarded option for treating diabetic ulcers.

Understanding Hypochlorous Acid and Its Effects on Diabetic Foot Ulcers

Hypochlorous acid (HOCl) is a naturally occurring substance produced by white blood cells to fight infections. This remarkable compound possesses strong antimicrobial and anti-inflammatory properties, making it effective against a wide range of microorganisms, including bacteria, viruses, and fungi. One of the primary advantages of HOCl is its ability to promote wound healing while being gentle on keratinocyte and fibroblast cells. Unlike many traditional disinfectants, it is non-toxic, ensuring safety during use.

Recent research has highlighted the critical role of HOCl in the treatment of diabetic foot ulcers (DFU). These complex wounds often do not respond well to standard treatments and carry a high risk of infection and amputation. In such cases, HOCl demonstrates significant benefits by minimizing infection, reducing inflammation, and enhancing the overall healing process.

  1. Antimicrobial Effects of HOCl: This solution is highly effective at eliminating drug-resistant bacteria, including methicillin-resistant Staphylococcus aureus (MRSA), as well as fungi like Candida. Compared to standard disinfectants such as hydrogen peroxide and iodine, HOCl also offers the added benefits of reducing inflammation and alleviating patient discomfort.
  2. Improving the Healing Process in Clinical Cases: The use of dressings soaked in HOCl aids in the removal of necrotic tissue and effectively cleanses the wound, thereby reducing the need for surgical intervention.
  3. Controlling Inflammation and Reducing the Risk of Amputation: The application of HOCl helps to alleviate inflammation caused by infections, thereby decreasing the risk of amputation.

Key Mechanisms of Hypochlorous Acid (HOCl) in Wound Healing

Hypochlorous acid (HOCl) is a natural compound that plays a vital role in wound healing. As a crucial defense molecule in the body, HOCl aids in infection control, reduces inflammation, and promotes tissue regeneration in several ways, ultimately accelerating the healing process. Below, we explore the key mechanisms through which HOCl influences wound healing:

 

 

  • Strong Antimicrobial Properties

HOCl effectively eliminates a wide variety of bacteria, viruses, and fungi present in wounds. By reducing microbial load, it prevents secondary infections. Pathogenic bacteria like Staphylococcus aureus and Pseudomonas aeruginosa, often associated with wound infections, are particularly sensitive to hypochlorous acid. HOCl rapidly kills these microorganisms and inhibits the growth of others. Unlike many traditional disinfectants, HOCl minimizes the risk of developing microbial resistance or causing irritation. This quality is especially beneficial for chronic wounds such as diabetic foot ulcers, facilitating faster healing.

  • Regulation of Inflammatory Response and Prevention of Oxidative Damage

The anti-inflammatory properties of HOCl come from its ability to block the production of inflammatory mediators and suppress the activation of inflammatory cells. By reducing inflammation, HOCl promotes tissue regeneration and accelerates healing, creating an optimal environment for recovery. A study by Chopra and colleagues found that around 75% of patients with diabetic ulcers exhibited thick purulent exudate (wound secretions). After just 10 days of HOCl treatment, these secretions were completely eliminated.

  • Stimulation of Tissue Regeneration and Growth

HOCl enhances the production of essential growth factors, such as vascular endothelial growth factor (VEGF), which are crucial for angiogenesis and the formation of new blood vessels. This is particularly beneficial for chronic wounds, including diabetic foot ulcers. Additionally, HOCl promotes collagen synthesis and the development of the extracellular matrix, which facilitates rapid regeneration of skin and other tissues.

  • Facilitating Debridement (Wound Cleaning)

HOCl plays an essential role in removing necrotic tissue, keeping wounds clean and aiding in the debridement process. This action significantly decreases the risk of infection and enhances effective healing. When present in high concentrations, HOCl promotes the movement of fibroblasts and keratinocytes to the wound site while simultaneously inhibiting matrix metalloproteinases (MMPs) such as MMP-7 and MMP-9, as well as collagenases. This results in a reduction of MMP-9 activity, which is a critical indicator of healing speed in diabetic wounds, thereby accelerating the healing process.

  • Stabilizing the pH of the Wound Environment

Maintaining an appropriate pH level is crucial for the healing process of wounds. HOCl plays a significant role in managing wound acidity, which in turn stimulates the activity of repair enzymes and encourages new cell growth. Additionally, maintaining a balanced pH is essential to inhibit the proliferation of resistant microorganisms.

Clinical Research Findings on the Use of Hypochlorous Acid (HOCl) for Treating Diabetic Foot Ulcers

Recent clinical research has revealed a significant breakthrough in treating diabetic foot ulcers (DFUs) through the application of hypochlorous acid (HOCl) solution. This powerful compound has demonstrated impressive efficacy against both sensitive and drug-resistant pathogens, effectively inhibiting biofilm development and reducing inflammation associated with these challenging wounds.

In this innovative treatment approach, patients applied surgical gauze soaked in hypochlorous acid daily, securely fastening it with a bandage to ensure optimal results. This method not only promotes wound healing but also enhances the overall patient experience by minimizing discomfort and reducing the risk of infection.

The findings highlight the potential of HOCl as a valuable therapeutic option for managing diabetic foot ulcers, offering hope for improved outcomes in patients facing this complex and often debilitating condition.

Figure 3: The diabetic foot ulcer was initially resistant to multiple disinfectants and antibacterial treatments. However, the application of hypochlorous acid dressing proved to be a game changer. By using moistened gauze soaked in hypochlorous acid for daily dressing and then securing it with a bandage, significant progress was made in eliminating necrotic tissue and promoting healing. The right side of the image displays the remarkable healing achieved after 65 days.

Treatment of diabetic foot ulcer using dressing containing hypochlorous

Research indicates that hypochlorous acid (HOCl) offers multiple benefits in wound care, including softening the wound surface and maintaining moisture in grafted skin areas. Additionally, HOCl effectively minimizes unpleasant odors associated with wounds while providing a soothing, cooling sensation. These findings highlight HOCl as a valuable tool for alleviating various symptoms during the wound care process, enhancing patient comfort and promoting a more effective healing environment.

Figure A) An abscess has developed in the left leg following a surgical incision and debridement, with wound care beginning through the application of negative pressure therapy combined with hypochlorous acid. 

Figure B) Four weeks post-surgery and two weeks after transitioning from negative pressure treatment to a collagen dermal matrix dressing infused with hypochlorous acid.

A: A leg wound resulting from a dog bite, followed by cutting and debridement

B: Three weeks later, after cleansing and hydrating with hypochlorous acid, the wound was dressed with collagen skin matrices also moistened with hypochlorous acid

Conclusion

Hypochlorous acid (HOCl) has emerged as a promising antimicrobial and wound healing agent, particularly in managing diabetic foot ulcers. As a naturally occurring compound produced by white blood cells, HOCl effectively targets and eliminates bacteria, viruses, and fungi, thereby reducing microbial burden in wounds. Research indicates that HOCl not only accelerates the wound healing process by promoting collagen and growth factor production but also aids in the removal of necrotic tissue.

Additionally, hypochlorous acid creates an optimal healing environment by modulating inflammatory responses and maintaining a balanced pH level in the affected area. Compared to traditional treatment methods, dressings infused with HOCl demonstrate remarkable efficacy, especially in cases where standard treatments may be inadequate. Regular application of gauze soaked in hypochlorous acid, combined with appropriate dressings, can significantly accelerate the healing of diabetic foot ulcers while minimizing the risk of secondary infections. This approach also alleviates pain and inflammation, resulting in a more comfortable recovery experience for patients.

In summary, hypochlorous acid represents an innovative therapeutic option for diabetic foot ulcers, enhancing patients’ quality of life and expediting the healing journey.