F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.148610.1 Systematic Review Articles The efficacy of combination of sodium hypochlorite (NaOCL)/hypochlorous acid (HOCL) in wound management: A systematic review and network meta-analysis

[version 1; peer review: 1 approved with reservations, 1 not approved]

 Supsamutchai Chairat Conceptualization Data Curation Investigation Supervision Visualization 1 Jirasiritham Jakrapan Writing – Review & Editing 1 Punmeechao Puvee Writing – Review & Editing 1 Pornwaragorn Chaowanun Writing – Review & Editing 1 Wilasrusmee Chumpon Conceptualization Data Curation Writing – Review & Editing 1 Poprom Napaphat Conceptualization Data Curation Formal Analysis Methodology Software Supervision Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0001-9980-038X a 2 Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Salaya, Nakhon Pathom, 10400, Thailand Faculty of Public Health, Chiang Mai University, Chiang Mai, 50200, Thailand napaphat.pro@gmail.com

No competing interests were disclosed.

 21 10 2024 2024 13 1260 26 9 2024 Copyright: © 2024 Supsamutchai C et al. 2024 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction

Antiseptic and antibacterial solutions are increasingly used in the treatment of various types of wounds. The successful stabilization of wounds using a combination Sodium Hypochlorite/Hypochlorous acid (NaOCl/HOCl) or superoxidized solution (SOS) has been reported, serving as an effective solution without irritating mammal cells and without posing a carcinogenic hazard. Presently, no systematic review or meta-analysis is available that compares the effectiveness of these antiseptic solutions. The present study aims to investigate the role of NaOCl/HOCl in the treatment of wounds.

 Methods

The systematic review with extended to network meta-analysis (NMA) was conducted using NaOCl/HOCl, povidone-iodine, octenidine dihydrochloride, polyhexamethylene biguanide, alcohol, and silver compared with normal saline. The primary outcome was wound healing. Using surface under the cumulative ranking curve (SUCRA), the direct and indirect comparisons were conducted with the probability of selecting the best treatment.

 Results

A total of 507 studies were identified from PUBMED and SCOPUS databases, and 64 articles were duplicates. Among 29 studies included, 22 randomized controlled trials (RCTs) and 7 cohort studies met our inclusion criteria. NaOCl/HOCl had a higher chance of wound healing 1.07-1.30 times compared with all the regimens. NaOCl/HOCl has the probability of providing the best treatment, followed by silver and octenidine with SUCRAs of 36.9, 23.1, and 21.8, respectively.

 Conclusions

NaOCl/HOCl ranks first and proves to have the highest efficacy, followed by silver, octenidine, and PHMB for treatment.

 sodium hypochlorite hypochlorous acid superoxidized efficacy wound healing The author(s) declared that no grants were involved in supporting this work. Introduction

Antiseptic and antibacterial solutions are increasingly being used for the treatment of traumatic wounds, chronic wounds, and infected wounds. 1, 2 Many of these agents are already launched in the market, and agents such as alcohols, phenols, iodine, and chlorine have been used for over 100 years. While most of these active agents demonstrate broad-spectrum antimicrobial activity, knowledge is lacking about their comparison and mode of action i.e., toxicity and effectiveness. Thus, a nontoxic and highly disinfected agent is crucial in the wound care setting.

Successful stabilization of the combination Sodium Hypochlorite/Hypochlorous acid (NaOCl/HOCl) or super oxidized solution (SOS) has been reported as an effective solution in the treatment of traumatic wounds, chronic wounds, infected wounds, and prevention of surgical site infection. 3, 4 NaOCl/HOCl provided an ecologically relevant novel agent because aqueous sodium chloride solution was electrochemically converted during its production. The activated solution is also called electrolyzed water. 5 The current concentration for NaOCl and HOCl amounts is 0.004% each and < 0.06% for NaOCl being a mono-substance of a physiological bactericidal mechanism. 6 Typically, NaOCl/HOCl and NaOCl are highly effective against vegetative bacteria, bacterial spores, aspergilli, cryptosporidia oocysts, and coated viruses, but they are not or barely irritating on mammal cells. Moreover, no evidence of cytotoxicity is found, and no evidence that poses a carcinogenic hazard is found. 2

No systematic review or meta-analysis is available that compares the effectiveness of these antiseptic solutions. The present study aims to investigate the role of NaOCl/HOCl when compared with other treatment regimens for traumatic wounds, chronic wounds, and infected wounds.

 Methods

The systematic review and meta-analysis (SR/MA), an extension of network meta-analysis (NMA), was conducted following the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines 7 and PROSPERO number: CRD42019120532 .

Study design and search strategy

The studies were included according to the PICO model as follows:

P: wound infection, chronic wound, surgical site infection, diabetic wound, diabetic foot ulcer, diabetic foot infection, and venous ulcer

I and C: NaOCl/HOCl, povidone-iodine (PVI), octenidine dihydrochloride, polyhexamethylene biguanide (PHMB), taurolidine, chlorhexidine, alcohol, silver, and normal saline (NSS)

O: wound healing, and wound size-reduction

A comprehensive literature search was conducted in MEDLINE and SCOPUS from their inception to March 2021, limited to literature focusing on comparative studies, written in English, and solely on humans (see supplement Table s1 [Extended Data] 63 ).

 Study selection

Randomized controlled trials (RCTs) or cohort studies published in English that met the following criteria were selected: 1) Studies in adult patients who were diagnosed as wound infection, chronic wound, surgical site infection, diabetic wound, diabetic foot ulcer, diabetic foot infection, and venous ulcer. 2) Studies that compared the effects of any pair of interventions including NaOCl/HOCl, PVI, octenidine dihydrochloride, PHMB, taurolidine, chlorhexidine, alcohol, silver, and NSS. 3) Studies that reported at least one of the following outcomes of interest: wound healing and wound size reduction.

Two reviewers were independently selected to screen titles and abstracts. If there was any disagreement, the third author resolved the disagreement by consensus.

 Interventions and outcomes of interests

Interventions were NaOCl/HOCl, PVI, octenidine dihydrochloride, PHMB, taurolidine, chlorhexidine, alcohol, and silver. The patients with active wounds were treated with active wound care solution daily. NSS was the standard comparator. The patients were treated daily with saline solution. 8

Primary outcomes of interest were the effectiveness of treatment or success of treatment, defined as wound healing. Wound size reduction was defined as the percentage decrease in wound surface area, measured by a wound measurement computer software or through manual calculation. The calculation was carried out by multiplying the longest length by the widest width (length × width = cm 2) of each visit in comparison with baseline visit. 9 Category of wounds was defined as the stages of wounds and shift from high grade of the wound to the low grade of the wound of each treatment, considered as downgrading wound. 10 Reinfections were defined as the presence of local or systemic clinical signs of infection, which was confirmed by cultural examination. 11

Secondary outcomes were adverse events including disturbance of wound healing, defined as wound dehiscence, surgical wound dehiscence, or wound hernia. 12 No functional impairment of liver, kidney, other organs, or other allergic reactions was observed. 13

Data extraction and risk of bias assessments

Two reviewers (CW and NP) independently selected studies by screening titles, abstracts, and the full texts. The studies characteristics extracted, including study design, types of intervention, types of wounds, and types of outcomes. Patient characteristics extracted were the number of subjects, mean age, sex, and follow-up times (weeks). The outcomes of extraction (wound healing and adverse event) were some population, number of events, and number of no events. In addition, the quality of cohort studies was assessed based on ROBINS-I tool 14 of study attrition, representativeness of study population, outcome measure, prognostic factor measurement, statistical analysis, and presentation. For the RCTs study, the assessment was done using established tools recommended by the Cochrane library. 15

Statistical analysis

Direct meta-analysis (DMA)

The risk ratio (RR) was estimated for dichotomous outcomes (wound healing and adverse event). The pooled effect sizes of RR were pooled across studies. The heterogeneity was checked using Cochrane’s Q test and I 2 statistics. If appropriate, the model of the random-effects model or a fixed-effects was used. A meta-regression was used to explore sources of heterogeneity with sub-group analysis. Publication bias was assessed using a funnel plot and Egger test.

Network meta-analysis

The two-stage technique was performed to estimate the relative treatment effects (ln (RR)). A binary regression was used to estimate treatment effects and the variance-covariance for individual studies. Then, multivariate with random-effect meta-analysis with consistency model was used for treatment effects across the studies. The final step, which was mixed relative treatment comparisons, was estimated.

The consistency of the results was assessed using a design-by-treatment interaction inconsistency model based on a global Chi-square to explore agreement between direct and indirect comparisons. The probability of being the best treatment was assessed using surface under the cumulative ranking curve (SUCRA). The publication bias was explored using an adjusted funnel plot.

Sub-group analyses were performed according to types of wound and types of study design. All analyses were performed using STATA 16. 64 P-value less than 0.05 was set as the threshold for statistical significance, except for heterogeneity where P < 0.1 was used.

 Results

A total of 507 studies were identified from PUBMED and SCOPUS databases, and 64 articles were duplicates. Among 29 studies, 8– 13, 16– 38 included, 22 RCTs, 8– 12, 16– 31, 38 and 7 cohort studies, 13, 32– 37 met our inclusion criteria, refer to Figure 1.

Flow diagram of selection of studies. Characteristics information of eligible studies

Table 1 presented the characteristics of the 29 studies, 8– 13, 16– 38 In the 22 RCTs, 8– 12, 16– 31, 38 and 7 cohort studies, 13, 32– 37 the overall mean age was from 16.8 to 62.0, and percentages of male were from 3.2 to 94.0. Most of them had diabetic mellitus foot ulcer and followed by surgical wound, trauma, and chronic wound.

Characteristic information of included studies.
Author (year) Study design Intervention Comparator Types of wound No. subjects Mean age (year) % Male Outcomes Definition of outcomes %loss F/U Follow-up times (weeks)
Vallance (1985) RCT PHMB NSS Surgical 53 53.78 35.80 WH NR NR 4
Martinez-De (2004) RCT NaOCl/HOCl NSS DM 45 37.40 37.78 WH

WH was measured using photograph compared with based lined.

 0 20
Fabry (2006) RCT Polihexanide NSS Trauma 50 NR NR WH

WH was measured using photograph with laboratory results compared with based line.

 NR NR
Valverd (2006) RCT NaOCl/HOCl PVI Surgical 517 36.49 52.22 SSI

SSI was defined as the any SSI occurring within 30 days of post-operative.

 NR 4
Jurczak (2007) RCT Silver PVI Surgical 68 18.88 68.66 Pain, WH

Pain using visual analogue scale.

WH measured using multiplying the longest by the widest width of each other.

0.01 2
Hadi (2007) RCT NaOCl/HOCl NSS DM 100 40.00 43.00 HS, WS, WH NR NR NR
Hadi (2008) RCT NaOCl/HOCl NSS Surgical 100 45.28 68.30 HS, WS, WH NR NR NR
Suri (2008) RCT NaOCl/HOCl NSS DM 100 29.29 NR WH, SSI NR NR 16
Mohd (2010) RCT NaOCl/HOCl PVI Surgical 190 61.10 3.24 SSI NR NR 6
Miller (2010) RCT Silver PVI Chronic 266 40.48 41.35 WH, SSI

WH measured using photograph of wound area with the specific computer software.

SSI was not enough information.

0.03 12
Miller (2010) RCT Silver PVI Chronic 266 40.48 41.35 WH, SSI

WH measured using photograph of wound area with the specific computer software.

SSI was not enough information.

0.03 12
Romanelli (2010) RCT PHMB NSS Chronic 40 62.00 45.00 WS, Pain

WS measured using imaging of wound area with the specific computer software.

Pain using visual analogue scale.

NR 4
Piaggessi (2010) RCT NaOCl/HOCl PVI DM 40 33.43 NR WH, HS NR NR 24
Takesue (2011) RCT NaOCl/HOCl NSS Surgical 363 26.33 60.60 SSI, WH

WH was defined the occurrence of wound break down.

 0 12
Vanscheidt (2011) RCT Octenidine NSS Chrnic 126 32.93 56.35 WH, AE

WH was defined the complete wound closure of the target ulcer is 100%.

AE was defined any symptoms were disturbance for the patients.

NR 12
Piatkowski (2011) RCT PHMB Silver Trauma 60 38.00 39.00 WH, Pain

WH was defined the complete wound closure of the target ulcer is 100%.

Pain using visual analogue scale.

NR NR
Pandey (2011) RCT NaOCl/HOCl PVI Surgical 100 19.90 33.33 WS

WS measured using multiplying the longest by the widest width of each other.

 NR 4
Garg (2013) RCT NaOCl/HOCl NSS Surgical 200 NR NR WH, SSI, HS NR NR NR
Ricci (NR) RCT NaOCl/HOCl PVI Chronic 40 40.63 NR WH, Pain NR NR NR
Djozic (2016) RCT Alcohol PVI Surgical 100 NR 94 SSI, WH, Pain

SSI was measure by occurrence of purulent, or inflammation.

WH and pain were no information.

NR 0.29
Ghafouri (2016) RCT PVI NSS Trauma 406 14.37 84.73 SSI

SSI was measure by occurrence of purulent, or inflammation.

 0 4
Watanaploy (2017) RCT PHMB Silver Trauma 46 19.36 54.35 SSI, Pain, Cost

SSI was defined as occurrence of purulent, or inflammation.

Pain was measured using Numeric rating score (NRS-11).

Cost was defined as cost of administration in the hospital.

NR 3
Paola (2005) Cohort NaOCl/HOCl PVI DM 220 NR NR WH, SSI NR NR NR
Paola (2006) Cohort NaOCl/HOCl PVI DM 218 35.83 66.51 WH, SSI NR NR 4
Goretti (2007) Cohort NaOCl/HOCl PVI DM 33 36.42 NR WH, SSI, AE NR NR 24
Anand (2007) Cohort NaOCl/HOCl PVI Surgical 50 16.86 NR WH, AE NR NR NR
Kapur (2011) Cohort NaOCl/HOCl PVI DM 200 NR NR WH, AE

WH was defined as absence odor, necrotic tissue.

AE was defined as any symptom as pain, edema, redness, dryness, or itching.

NR 4
Fanggang (NR) Cohort NaOCl/HOCl Silver Trauma 20 NR 60.00 WH

WH was measured using imaging of wound with the Mathlab compared with based line.

 NR NR
Uribe (NR) Cohort NaOCl/HOCl NSS DM 80 30.39 46.25 WH NR NR NR

AE; adverse event, CABG; coronary artery bypass grafting, DM; diabetic mellitus, HS; hospital stay, NaOCl/HOCl; hypochlorite/hypochlorous Acid, NSS; normal saline, NR; not reported, PHMB; polyhexamethylene biguanide, PVI; povidone iodine, RCT; randomized controlled trials, SOS; superoxide solution, SSI; Surgical size infection, WS; wound size, WH; wound healing.

Most RCTs compared NaOCl/HOCl vs NSS 10, 12, 17, 21, 30, 38 and NaOCl/HOCl vs PVI, 11, 19, 22, 26, 27 followed by PHMB vs NSS, 8, 9, 16 silver vs PVI, 20, 23 and others, 18, 24, 25, 28, 29, 31 Table 1 presented the cohort studies that compared NaOCl/HOCl with PVI, 32– 36 and NaOCl/HOCl, 13, 37 with others.

 Risk of bias assessment

Risk of bias assessments was performed, see supplement Figure s1a [Extended Data]. 63 Among the 22 RCTs, all studies were considered at high risk of bias for allocation concealment (selection bias), blinding of participants, blinding of outcome assessment (detection bias), and low risk of bias of random sequence generation. Nearly 68% to 90% of RCTs were at low risk of bias for selective reporting (reporting bias) and incomplete outcome data (attrition bias). All RCTs were at high risk of bias because the participants who received the treatment could be not blinded. Seven cohort studies were of low risk of bias for the study population, and most of them had a low risk of bias for study attrition and outcome measures. About three studies were of low risk of bias for prognostic factor measurement, statistical analysis, and presentation. However, all the studies suggested a high risk of bias for confounding factors. However, the overall results are considered high risk of bias, see supplement Figure s1b [Extended Data]. 63

Direct metal analysis

DMA was conducted using pooling effects of RCTs (N = 6), 10, 12, 17, 21, 30, 38 between NaOCl/HOCl and NSS on healing rate, in which pooled RRs was 1.38 (95%CI: 1.14, 1.68) with statistically significant, see supplement Figure s2a and 2b [Extended Data]. 63

Considering NaOCl/HOCl vs PVI of 4 RCTs, 11, 19, 22, 26 the pooled RR was 1.10 (95%CI: 0.96, 1.25), but the pooled RRs of 4 cohorts, 32, 34– 36 was 1.36 (95%CI: 1.11, 1.67) with statistically significant, see supplement Figure s3a and s3b [Extended Data]. 63

Among PHMB vs NSS, only 4 RCTs, 8, 9, 16, 18 were reported; the pooled RR was 1.10 (95%CI: 0.96, 1.27) with no statistically significant, see supplement Figure s4a and s4b [Extended Data]. 63

The adverse event was estimated based on the results of included RCTs, suggesting a lower adverse event rate in NaOCl/HOCl, 0.74 (95%CI: 0.19, 2.78) than NSS, with no statistically significant, see supplement Figure s5 [Extended Data]. 63 In comparison, the adverse events between NaOCl/HOCl and PVI were higher of about 1.43 (95%CI: 1.10, 1.88) with statistical significance; whereas the results of cohort studies showed a lower rate with pooled RRs of 0.28 (95%CI: 0.11, 0.69), with statistically significant, see supplement Figure s6 [Extended Data]. 63 The PHMB also suggested a lower adverse event rate of about 0.69 (95%CI: 0.14, 3.44) than NSS with no statistical significance, see supplement Figure s7 [Extended Data]. 63

Network meta-analysis

NMA was performed using data from 22 RCTs, 8– 12, 16– 31, 38 and 2,885 patients, see Figure 2. The treatment comparisons were pooled, revealing NaOCl/HOCl to have the higher success of healing rate 1.30 times of (RR; 1.30 (95%CI: 1.10, 1.54)) than NSS with statistically significant, followed by silver, PHMB, PVI, and octenidine with higher success rate than NSS excepted alcohol with pooled RRs of 1.21 (95%CI: 0.85,1.73), 1.14 (95%CI: 0.94,1.39), 1.10 (95%CI: 0.91,1.33), and 1.03 (95%CI: 0.52,2.05), respectively. Although these were not significant, see Table 2. NaOCl/HOCl had the probability of being the best treatment, followed by silver, octenidine, and PHMB with SUCRAs of 36.9, 23.1, 21.8, and 4.8 respectively, compared with all the regimens, see Table 2. The adjusted funnel plot showed symmetry, see Figure 3.

Network of eligible treatment comparison mapping. Mixed treatment comparisons for RCTs.
Interventions NSS NaOCl/HOCl Octenidine PHMB Alcohol Silver PVI
NSS [0.00;0.00] 1.30 (1.10,1.54) 1.03 (0.52,2.05) 1.14 (0.94,1.39) 1.00 (0.55,1.80) 1.21 (0.85,1.73) 1.10 (0.91,1.33)
NaOCl/HOCl 0.77 (0.65,0.91) [0.80; 36.90] 0.79 (0.39,1.60) 0.88 (0.69,1.12) 0.77 (0.43,1.38) 0.93 (0.65,1.34) 0.84 (0.71,1.00)
Octenidine 0.97 (0.49,1.93) 1.26 (0.62,2.56) [0.40; 21.80] 1.11 (0.54,2.26) 0.97 (0.39,2.40) 1.18 (0.54,2.55) 1.07 (0.52,2.17)
PHMB 0.87 (0.72,1.06) 1.14 (0.90,1.45) 0.90 (0.44,1.84) [0.50; 4.80] 0.87 (0.47,1.62) 1.06 (0.75,1.51) 0.96 (0.74,1.24)
Alcohol 1.00 (0.55,1.80) 1.30 (0.73,2.34) 1.03 (0.42,2.55) 1.14 (0.62,2.11) [0.40; 13.10] 1.21 (0.63,2.35) 1.10 (0.63,1.92)
Silver 0.82 (0.58,1.18) 1.07 (0.74,1.55) 0.85 (0.39,1.84) 0.94 (0.66,1.34) 0.82 (0.43,1.59) [0.60; 23.10] 0.91 (0.64,1.29)
PVI 0.91 (0.75,1.10) 1.18 (1.00,1.41) 0.94 (0.46,1.91) 1.04 (0.80,1.34) 0.91 (0.52,1.59) 1.10 (0.78,1.57) [0.50; 0.30]

NaOCl/HOCl; hypochlorite/hypochlorous Acid, NSS; normal saline, PHMB; polyhexamethylene biguanide, PVI; povidone iodine, Value above off the diagonal cells are risk ratio with 95% confidence intervals (in round parentheses) of wound healing in the column heading compared with the reference in the left row. The values >1.00 show benefit of wound healing compared with control. Values in diagonal line in the square brackets are surface under the cumulative ranking curve area; percentage probability of being best treatment.

 Adjusted funnel plot.

NaOCl/HOCl and PVI comparison with NSS for wound healing rate were 1.47 (95%CI: 1.01, 2.15) and 0.59 (95%CI: 0.22, 1.56), respectively. NaOCl/HOCl had the probability of being the best treatment in the diabetic wound. A comparison was also conducted among NaOCl/HOCl, PHMB, Alcohol, and PVI for surgical wound with NSS, with the results of 1.32 (95%CI: 1.05, 1.67), 1.13 (95%CI: 0.70, 1.83), 1.12 (95%CI: 0.59, 2.12), and 1.23 (95%CI: 0.91, 1.67), respectively. NaOCl/HOCl offered the best treatment for the surgical wound, see Table 3. No estimation of NaOCl/HOCl comparison was observed among chronic wound and trauma wound, but the best treatment was PHMB (1.13 (95%CI: 0.91, 1.42)) with SUCRAs of 43.30, followed by Silver (1.13 (95%CI: 0.75, 1.71)), and PVI (0.98 (95%CI: 0.92, 1.03)) in a chronic wound. In addition, PHMB was suggested to be the best treatment in trauma wound with pooled RRs of 1.15 (95%CI: 0.81, 1.64), followed by silver (1.08 (95%CI: 0.00, 8.38)), octenidine (1.03 (95%CI: 0.49, 2.17)), and PVI (0.92 (95%CI: 0.00, 7.16)), see Table 3.

Mixed treatment comparisons for RCTs by types of wound.
A. Diabetes mellitus wound
Interventions NSS NaOCl/HOCl PVI
NSS [0.00;0.00] 1.47 (1.01,2.15) 0.59 (0.22,1.56)
NaOCl/HOCl 0.68 (0.47,0.99) [96.70;1.00] 0.40 (0.16,0.98)
PVI 1.70 (0.64,4.49) 2.50 (1.02,6.13) [1.70;0.10]
B. Surgical wound
Interventions NSS NaOCl/HOCl PHMB Alcohol PVI
NSS [0.00;0.00] 1.32 (1.05,1.67) 1.13 (0.70,1.83) 1.12 (0.59,2.12) 1.23 (0.91,1.67)
NaOCl/HOCl 0.76 (0.60,0.96) [41.10;0.80] 0.85 (0.50,1.46) 0.85 (0.47,1.53) 0.93 (0.77,1.13)
PHMB 0.89 (0.55,1.44) 1.17 (0.68,2.01) [21.90;0.50] 0.99 (0.45,2.21) 1.09 (0.62,1.94)
Alcohol 0.89 (0.47,1.68) 1.18 (0.65,2.13) 1.01 (0.45,2.23) [24.20;0.40] 1.10 (0.63,1.92)
PVI 0.81 (0.60,1.10) 1.07 (0.88,1.30) 0.91 (0.52,1.62) 0.91 (0.52,1.59) [12.80;0.60]
C. Chronic wound
Interventions NSS PHMB Silver PVI
NSS [0.00;0.00] 1.13 (0.91,1.42) 1.13 (0.75,1.71) 0.98 (0.92,1.03)
PHMB 0.88 (0.71,1.10) [43.30;0.80] 1.00 (0.71,1.41) 0.86 (0.68,1.08)
Alcohol 0.88 (0.59,1.33) 1.00 (0.71,1.41) [48.20;0.70] 0.86 (0.57,1.30)
PVI 1.02 (0.97,1.08) 1.16 (0.92,1.46) 1.16 (0.77,1.75) [1.70;0.20]
D. Trauma wound
Interventions NSS Octenidine PHMB Silver PVI
NSS [0.00;0.00] 1.03 (0.49,2.17) 1.15 (0.81,1.64) 1.08 (0.00,8.38) 0.92 (0.00,7.16)
Octenidine 0.97 (0.46,2.04) [19.70;0.50] 1.12 (0.49,2.54) 1.05 (0.00,8.15) 0.89 (0.00,6.96)
PHMB 0.87 (0.61,1.23) 0.90 (0.39,2.04) [0.60; 26.20] 0.94 (0.00,7.28) 0.80 (0.00,6.22)
Silver 0.93 (0.00,7.20) 0.96 (0.00,7.45) 1.07 (0.00,8.30) [34.70;0.50] 0.85 (0.50,1.47)
PVI 1.09 (0.00,8.43) 1.12 (0.00,8.72) 1.25 (0.00,9.71) 1.17 (0.68,2.02) [14.20;0.40]

NaOCl/HOCl; hypochlorite/hypochlorous Acid, NSS; normal saline, PHMB; polyhexamethylene biguanide, PVI; povidone iodine, Value above off the diagonal cells are risk ratio with 95% confidence intervals (in round parentheses) of wound healing in the column heading compared with the reference in the left row. The values >1.00 show benefit of wound healing compared with control. Values in diagonal line in the square brackets are surface under the cumulative ranking curve area; percentage probability of being best treatment.

No estimation was done for cohort studies, 13, 32– 37 owing to their sparse information for indirect comparison.

 Discussion

In this study, NaOCl/HOCl offered a higher rate of wound healing from 1.07 to 1.30 compared to all the regimens. The probability of NaOCl/HOCl offering the best treatment was highest, followed by silver, octenidine, and PHMB with SUCRAs of 36.9, 23.1, 21.8, and 4.8, respectively. Regarding direct and indirect comparison for types of wound, NaOCl/HOCl is recommended for diabetic and surgical wounds compared with NSS. For many years, NaOCl/HOCl has been used as an irrigation solution for cleansing and moisturizing acute, chronic, contaminated wounds, and for first and second-degree burns. 39 HOCl offers safe preservation and prevents the proliferation of gram-positive and gram-negative bacteria including Methicillin-resistant Staphylococcus aureus, Oxacillin-resistant Staphylococcus aureus, Vancomycin-resistant Staphylococcus aureus, Vancomycin-resistant enterococci, viruses, fungi, and spores. 40 In commercial products, Granudacyn, Microcyn, and Dermacyn combined of NaOCl/HOCl for wound healing, 41– 43

HOCl may be compared to sodium hypochlorite, as they are used as a bleaching agent. 40 However, they differ since HOCl is a weak acid and can be dissolved into hydrogen and hypochlorite ions (OCl -). Moreover, HOCl will convert completely to hypochlorite when pH is greater than 8.59. The antibacterial property of HOCl is much higher than that of OCl. 40, 44 Thus, the pH of the wound area is an important factor when using HOCl.

HOCl offered many mechanisms of producing positive effects for all phases of wound healing as it increases oxygenation that helps to break down biofilm at wound sites, 45, 46 The important HOCl mechanism is its ability to damage the integrity and permeability of the bacteria cell membrane. Considering HOCl toxicity, some evidence suggested that the cytotoxicity of oxidative stress of HOCl was significantly lower in human dermal fibroblast compared to hydrogen peroxide. The HOCL also failed to induce genotoxicity with an approved broad spectrum of effective agent, 46– 50

NaOCl/HOCl solution is recommended for wound irrigation, rinsing, and cleansing of moderately infected wounds and is effective in preventing wound infections. NSS removes bacteria through the mechanical effect of rinsing and does not have any antibacterial properties.

Moreover, PVI has the lowest efficacy when compared with overall treatment regimens, with a 10% higher success rate compared with NSS. PVI can kill bacteria 51 ; it also inhibits fibroblast growth. 52 One study compared the effectiveness of PVI with HOCl in terms of wound healing and found that PVI significantly delayed wound healing, while HOCl did not.

A wide range of wound dressings that contain elemental silver or a silver releasing compound has been used for hundreds of years in wound care. 53 They are easier to apply, may facilitate autolytic debridement, maintain a moist wound environment, and need less frequent dressing changes. Although silver dressings have been used extensively, some controversy still exists, regarding their wound healing rates and safety. Our study found silver dressings to be second-ranked for wound treatment.

Octenidine offered superior antiseptic efficacy in the quantitative suspension test without protein load compared with PVI, and PHMB. 54 It is available in a solution and a gel. The antiseptic activity of the rinse and the gel are well tolerated and suitable for wound cleansing, 55– 57 In this study, its success rate is ranked third for wound treatment.

PHMB has been recommended as a therapeutic option for acute traumatic wounds, chronic ulcers, and second-degree burns due to its cost-effectiveness and analgesic effect. 58 PHMB is available as a solution, hydrogel, and in wound dressings. It can also be used for wound irrigation and required an annotation on the safety of carcinogenic and anaphylactic reaction, 59, 60 PHMB is recommended to replace chlorhexidine and PVI, in case of acute bite wounds. The reasons for this are the risk of anaphylactic reactions. 61 In this study, its success is ranked fourth for wound treatment.

A few published studies explored hospital stay and the cost of treatment. However, inconsistent results are found in two RCTs, 27, 30 One study 30 concluded that NaOCl/HOCl had a shorter hospital stay of 8.2-12.3 days compared with PVI. Another study 27 suggested no difference in hospital stay when using NaOCl/HOCl and NSS. Moreover, only one study 31 compared the cost of treatment between PHMB and silver, with no statistically significant difference, but no information was found on other treatments.

Our study had some strengths. It is the first meta-analysis that has assessed the efficacy of irrigation solutions in terms of healing all types of wounds. The NMA is also covered, which identifies individual irrigation as the best compared with NSS.

 Conclusions

Our evidence suggests that NaOCl/HOCl has the highest efficacy of wound healing. NaOCl/HOCl was ranked first followed by silver, octenidine, and PHMB for treatment success. Evidence about benefits and adverse events for using these agents in wound management should be provided to patients to properly choose their optimal course of action with physicians. Further large-scale RCTs should be conducted along with the economic evaluations.

 Authors’ role

All authors included in the article contributed to the conception, design, and drafting of the article.

NP and CW developed the search strategy.

NP, CS, and CW screened studies for inclusion, extracted the data, and assessed the methodology of included studies.

NP: analyzed and interpreted the data.

NP: prepared the first draft of this paper and revised critical comments from CW, CS, JJ, PP, and CP.

All authors approved the final version of the manuscript.

 Ethics and consent

Not applicable.

 Data availability statement

No underlying data are associated with this article.

Reporting guidelines

Zenodo: PRISMA_2020_checklist_hypochlorite.docx, The efficacy of combination of sodium hypochlorite (NaOCL)/hypochlorous acid (HOCL) in wound management: a systematic review and network meta-analysis, PRISMA_2020_checklist_hypochlorite.docx, DOI https://doi.org/10.5281/zenodo.13841998. 62

Extended data

Zenodo: Supplement material file, The efficacy of combination of sodium hypochlorite (NaOCL)/hypochlorous acid (HOCL) in wound management: a systematic review and network meta-analysis, Supplementary materials file 20-02-24 NP.docx, DOI https://www.doi.org/10.5281/zenodo.13831391. 63

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

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Wound Healing and Management Node Group: Evidence summary: Polyhexamethylene biguanide (PHMB) wound dressings. Wound Practice and Research. 2012;21:83–85. Kramer A Eberlein T Müller G : Re-evaluation of polihexanide use in wound antisepsis in order to clarify ambiguities of two animal studies. J. Wound Care. 2019;28(4):246–255. 30975054 10.12968/jowc.2019.28.4.246 Olivieri J Eigenmann PA Hauser C : Severe anaphylaxis to a new disinfectant: polyhexanide, a chlorhexidine polymer. Schweiz. Med. Wochenschr. 1998;128(40):1508–1511. U.S. Food & Drug Aministration: FDA Drug Safety Communication: FDA warns about rare but serious allergic reactions with the skin antiseptic chlorhexidine gluconate. Safety Announcement. 2017. Reference Source Poprom N : The efficacy of combination of sodium hypochlorite (NaOCL)/hypochlorous acid (HOCL) in wound management: a systematic review and network meta-analysis.[Dataset]. Zenodo. 2024. 10.5281/zenodo.13841998 Poprom N : The efficacy of combination of sodium hypochlorite (NaOCL)/hypochlorous acid (HOCL) in wound management: a systematic review and network meta-analysis.[Dataset]. Zenodo. 2024. 10.5281/zenodo.13831392 White IR : Network meta-analysis. Stata J. 2015;15:951–985. 10.1177/1536867X1501500403 10.5256/f1000research.162942.r366103 Reviewer response for version 1 Leavesley David 1 2 Referee https://orcid.org/0000-0002-1033-5459 The University of Newcastle School of Biomedical Sciences and Pharmacy, Callaghan, New South Wales, Australia Skin Research Institute of Singapore, Singapore, Singapore

Competing interests: No competing interests were disclosed.

 28 2 2025 Copyright: © 2025 Leavesley D 2025 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation reject

Abstract. Pg 1. Lns 19-27. The Introduction is unfortunately not up to the mark. It fails to accurately summarise the subject of main text! The subject, ‘Wound Management’ (of cutaneous lesions in humans) is not mentioned! How will you attract your target audience? (Do you have a target audience?)

Would the average (uninformed) reader understand the meaning of “ stabilization of wounds”? As a clinical expert, I am not confident I understand this means

What is the basis for the claim “ no systematic review or meta-analysis is available that compares the effectiveness of these antiseptic solutions” (sic)? Why is this an unmet need?

What does the author’ mean by “ effectiveness”?

Pg 1. Lns 29-37. It is not made clear; why, nor how “… the present study aims to investigate the role of NaOCl/HOCl in the treatment of wounds”? How will this address unmet need? …for what purpose?

This reader does not comprehend how to conduct a “systematic review with extended to network meta-analysis (NMA)… using NaOCl/HOCl…” (sic). Systematic reviews are commonly understood to be research methods that gather and evaluate all relevant studies on a specific topic. The outcome is a summary of evidence, interpretation of the evidence, and recommendation informed by the evidence. The methodology reported in the Abstract does not meet this expectation.

Pg 1. Ln 39­–Pg 2. Ln 50. It is not made clear how the authors selected “ 507 studies… from PUBMED and SCOPUS”? Please report inclusion criteria; please report exclusion criteria; please report search limits (e.g. time period, language, peer-reviewed, etc) This reader is also interested in the author’s rationale for selecting these parameters.

What is the meaning of “… 1.07-1.30 times…chance of wound healing” (sic)?

Which definition of “ wound healing” was applied by the authors. Wound healing is not a universally understood parameter.

Pg 2. Ln 54. The methodology reported in this work does not justify the claim “ NaOCl/HOCl… proves to have the highest efficacy” (sic)! Measures of “efficiency” are not reported; this is overinterpretation.

Pg 3, Ln 72. The statement “ knowledge is lacking about their comparison and mode of action…” does not justify the claim “… a nontoxic and highly disinfected agent is crucial in the wound care setting” (sic). These concepts are unrelated

Pg 3. Ln 79. It is not clear; what is the source for the statement “ The current concentration for NaOCl and HOCl amounts is 0.004% each and < 0.06% for NaOCl being a mono-substance of a physiological bactericidal mechanism” (sic)? Is this the author’s practice, or is this practice from someone else?

Pg 3. Ln 80. What is the evidence; “… NaOCl/HOCl and NaOCl are highly effective against vegetative bacteria, bacterial spores, aspergilli, cryptosporidia oocysts, and coated viruses, but they are not or barely irritating on mammal cells” (sic)? A citation is required.

Pg 3, Ln2 94-103. Study design and search strategy. The author’s applied the PICO model, defining:

“ P: wound infection, chronic wound, surgical site infection, diabetic wound, diabetic foot ulcer, diabetic foot infection, and venous ulcer.”

“ I and C: NaOCl/HOCl, povidone-iodine (PVI), octenidine dihydrochloride, polyhexamethylene biguanide (PHMB), taurolidine, chlorhexidine, alcohol, silver, and normal saline (NSS).”

“ O : wound healing, and wound size-reduction.” (sic)

While this is a sound approach, following a standard protocol (i.e. PRISMA), the criteria defined by the authors is not without problems. The chosen methodology overlooks a substantial cohort of patients suffering with chronic wounds. For example, publications that use phrases other than “ wound infection, chronic wound, surgical site infection, diabetic wound, diabetic foot ulcer, diabetic foot infection, and venous ulcer”; for example ‘lesion’, ‘hard to heal’, ‘recalcitrant’, ‘complex’, ‘delayed’, ‘stalled’, ‘leg ulcer’, ‘arterial’, ‘vascular’, pressure’ and/or ulcers having ‘mixed etiology’ are not included! These wounds represent ≥30% of clinical presentations

What methodology should have been applied?

Rather than phrases (text strings), searches using Medical Subject Headings (MeSH) retrieve relevant articles including those using different terms to describe the same topic. Put simply, searches based on MeSH terms are more thorough than are searches based on keywords and/or text strings

Pg 5. Ln 126. The authors state “ Primary outcomes of interest were the effectiveness of treatment or success of treatment, defined as wound healing” (sic); however, definition for “ effectiveness of treatment”, for “ success of treatment”, and “ wound healing” are not specified.

Pg 5. Ln 131. It is not made clear: what are “ local or systemic clinical signs of infection”? Please clarify.

Pg 5. Ln 134. While adverse events are defined as: " disturbance of wound healing, wound dehiscence, surgical wound dehiscence, or wound hernia”. Notably, clinical parameters not included as adverse outcomes(!) are infection, partial/incomplete wound closure, and/or changes in health-related quality of life (HRQoL) measures.

Also not reported are how (methodology) parameters “ functional impairment of liver, kidney, other organs, or other allergic reactions (sic)” were determined.

Pg 5. Ln 139. It is not made clear, what were the criteria the “ Two reviewers (CW and NP) (apply to) independently select studies”?

Pg 5. Ln 144. Please identify the “ established tools recommended by the Cochrane library… for the RCTs study” (sic)?

Pg 5. Ln 150. Only two outcomes were included in estimation of “ risk ratio (RR)… wound healing and adverse event” (sic) How were patients classified (i.e. outcome) for whom clinical wound status did not change after any paired intervention?

Pg 5. Ln 157-165. Please specify the “ binary regression”, the “ variance-covariance for individual studies”, the “ multivariate with random-effect meta-analysis”, and the “ design-by-treatment interaction inconsistency model”? This is necessary to allow others to reproduce and/or validate these analyses.

Pg 5. Ln 168. Please locate the source of “ STATA 16” (sic)?

What was the rational for choosing “ P-value less than 0.05… as the threshold for statistical significance” and the “ except(ion) for heterogeneity where P < 0.1 was used” (sic)?

Pg 5, Ln 190-199. No protocol is reported for “ Risk of bias assessments was performed, see supplement Figure s1a” (sic). Please report the method for “r isk of bias assessment”.

Pg 5. Ln 201. What is “ Direct metal analysis” (sic)? What is the relevance of DMA to wound care?

I interpret that this is a typographical error; that should read “ Direct meta-analysis”? Please correct.

What is the meaning of “ healing rate” (sic)? How is this parameter determined?

Pg 6. Ln 232. The figure legend does not report: what do the numerals, adjacent to lines, represent?

Pg 6. Ln 237-241. The sentence “ The treatment comparisons…” is excessively long, and it is data dense. To assist reader comprehension, I recommend it be broken into several sentences, each having one subject.

It is followed (Ln 241) by an incomplete sentence: “ Although these were not significant, see Table 2” (sic)

Pg 6. Ln 238. Incomplete sentence: “ NaOCl/HOCl (has) the higher success of healing rate 1.30 times of (RR; 1.30 (95%CI: 1.10, 1.54)) than NSS with statistically significant…” (sic). Please revise.

What is “ healing rate”? How does “ risk ratio” allow the ‘rate’ to be quantitated? (FYI. The definition of rate (Oxford) is ‘a measurement of the speed at which something happens.’ That is ‘rate’ has dimensions of ‘unit measure’ and ‘time’? “ Risk ratio” is dimensionless!)

Pg 7. Ln 247. What is the basis for the statement: “ NaOCl/HOCl had the probability of being the best treatment in the diabetic wound”? Please assist the reader to locate the probability data.

Pg7. Ln 250. It is somewhat antithetical, the read next “ No estimation of NaOCl/HOCl comparison was observed among chronic wound and trauma wound” Sic). Are “ diabetic wounds” not also “ chronic wounds”? I am confused.

Pg7. Ln 260. How does this parameter relate to “ success rate”?

Pg7. Ln 267. Incomplete sentence: “ In commercial products, Granudacyn, Microcyn, and Dermacyn combined of NaOCl/HOCl for wound healing,” (sic) Please revise.

Pg 7. Lns 270-273. The paragraph “ HOCl may be compared to sodium hypochlorite…” is confused and uninformative. This reader fails to understand the argument “… they differ since HOCl is a weak acid and can be dissolved into hydrogen and hypochlorite ions (OCl -)…” (sic) and “ The antibacterial property of HOCl is much higher than that of OCl” (sic). From the next sentence, I think the authors are trying to suggest wound bed pH is an important contributor to the efficacy of wound irrigation; however, this is not at all clear. Please revise.

Pg 8. Ln 288. Table 2, titled “ Mixed treatment comparisons for RCTs” reports numerical data (i.e. X. (0.00; 0.00)); representing risk ratios, ±95% CI! However, what is the meaning of “ Value above off the diagonal cell” (sic)?

Pg 8. Ln 300. Similar to Table 3, titled “ Mixed treatment comparisons for RCTs by types of wound”, what is the meaning of “ Value above off the diagonal cell” (sic)?

Pg 9. Ln 306. I do not agree, “ break down biofilm at wound sites” represents a “ mechanism of producing positive effects for all phases of wound healing”. The molecular mechanism of cutaneous wound healing is complex, involving multiple overlapping phases engaging multiple cell types (for examples see Singer AJ et al. [2022 (Ref-2)] doi: 10.1089/ten.teb.2021.0114).

What is the “ evidence suggest(ing) that the cytotoxicity of oxidative stress of HOCl was significantly lower in human dermal fibroblast compared to hydrogen peroxide”? A citation is required.

Pg 9. Ln 312. What is the evidence “ NaOCl/HOCl solution is recommended for wound irrigation, rinsing, and cleansing of moderately infected wounds and is effective in preventing wound infections”?

What is the evidence “ NSS removes bacteria through the mechanical effect of rinsing and does not have any antibacterial properties.”?

Pg 9. Ln 316. What is the evidence for “a 10% higher success rate” results from “ lower efficacy when compared with overall treatment regimens”?

Please identify the “ One study (that) compared the effectiveness of PVI with HOCl in terms of wound healing and found that PVI significantly delayed wound healing, while HOCl did not” (sic). A citation is required.

Pg 9. Ln 323. To assist the reader, please identify the evidence “ Our study found silver dressings to be second- ranked for wound treatment”. “ Wound treatment” is a gross generalization, having little meaning in clinical settings! Please revise, and include the basis used to “ rank (dressings) for wound treatment”?

Pg 9. Ln 336. The paragraph “ A few published studies explored hospital stay and the cost of treatment…” is outside the study boundaries established by the authors in the Introduction. These data are not relevant.

Pg 9. Ln 342. The authors claim this study is “ the first meta-analysis that has assessed the efficacy of irrigation solutions in terms of healing all types of wounds” is misleading. In the first instance, the efficacy of “ irrigation solutions” as wound healing reagents was no measured in this study. In the second instance, “ all types of wounds” have NOT been examined – see my comment addressing ‘Study design and search strategy’ (Pg 3, Ln2 94-103).

Pg 9. Ln 350. Incomplete sentence “ Further large-scale RCTs should be conducted along with the economic evaluations”. This sentence is without a subject!

Pg 15. Ref 1. Incomplete Reference: “ Stanevičiuˉtė E, Builytė IU, Ridziauskas M, et al.: Efficacy of Antiseptic Solutions in Treatment of Staphylococcus Aureus Infected Surgical Wounds with Patches of Vascular Graft:

An Experimental Study in Rats. Medicina (Kaunas). 2019; 55(4).” (sic)

Pg 15. Ref 13. Incomplete Reference: “ Fanggang N, Guoan Z: The clinical efficacy of Dermacyn on deep partial thickness burn wounds. Beijing: Burn, Jishuitan Hospital; 2021.” (sic)

Pg 15. Ref 21. Incomplete Reference: “ Suri APS: The pEffectiveness of Stable pH Neutral Super-oidized Solution for the Treatment of Infected Diabetic Foot Wounds. Diabetic Foot Global Conference. Los Angeles: 2008.” (sic)

Pg 16. Ref 27. Incomplete Reference: “ Ricci E, Astolfi S, Cassio R: Clinical results about an antimicrobial

solution (Dermacyn Wound Care) in the treatment of infected chronic wounds. Italy: San Luca Clinic.” (sic)

Pg 16. Ref 32. Incomplete Reference: “ Paola LD, Brocco E, Senesi A, et al. : Use of dermacyn, a new antiseptic agent, for the local treatment of diabetic foot ulcers. Paper presented at: ZfW Sonderheft. Italy: 2005.”

Pg 16. Ref 37. Incomplete Reference: “ Uribe F:a.c. AMdH, editor. Super-Oxidized Solution (SOS) Therapy for Diabetic Foot Ulcers. Mexico: Clinica 14 IMSS.” (sic)

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes

Is the statistical analysis and its interpretation appropriate?

Partly

If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.)

Not applicable

Are sufficient details of the methods and analysis provided to allow replication by others?

Partly

Are the conclusions drawn adequately supported by the results presented in the review?

No

Reviewer Expertise:

Skin. Epithelia, Mammalian wound healing, Tissue repair. Extracellular matrix. Cell migration

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

References : Healing Mechanisms in Cutaneous Wounds: Tipping the Balance. Tissue Eng Part B Rev .2022;28(5) : 10.1089/ten.TEB.2021.0114 1151-1167 34915757 10.1089/ten.TEB.2021.0114 10.5256/f1000research.162942.r366106 Reviewer response for version 1 Wang Xianwen 1 Referee https://orcid.org/0000-0002-6343-440X Anhui Medical University, Hefei, China

Competing interests: No competing interests were disclosed.

 13 2 2025 Copyright: © 2025 Wang X 2025 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

Here are some suggestions for major revision comments on the article "The efficacy of combination of sodium hypochlorite (NaOCL)/hypochlorous acid (HOCL) in wound management: A systematic review and network meta-analysis":

Major Revision Comments:

1. Clarification of Study Objectives and Contributions:

The abstract and introduction should more clearly state the specific objectives and contributions of the study. Clarify how this systematic review and meta-analysis will advance current knowledge and fill gaps in the literature.

2. Strengthening the Methodology Section:

Provide more details on the search strategy, including the specific databases searched, search terms used, and any limitations of the search.

Justify the inclusion and exclusion criteria used for selecting studies. Discuss potential biases that may have been introduced by these criteria.

Explain the statistical methods used in more depth, including the network meta-analysis techniques and how they were applied.

3. Data Extraction and Risk of Bias:

Discuss in more detail the process of data extraction and how inter-rater reliability was ensured. Provide any relevant statistics on agreement between reviewers.

The risk of bias assessment should be expanded. Discuss in more depth the potential biases in the included studies and how these may impact the results. Consider using standardized tools for assessing bias in both RCTs and cohort studies.

4. Results Presentation:

Present the results in a more structured and clear manner. Consider using tables and figures to summarize key findings, such as the comparison of treatment effects.

Explain the results of the direct and indirect comparisons in more detail. Discuss the implications of the SUCRA rankings and the consistency of the network meta-analysis results.

5. Discussion of Findings:

Strengthen the discussion by providing a more in-depth interpretation of the results. Discuss the strengths and limitations of the study, and how the findings compare to previous research.

Address potential sources of heterogeneity and bias in the results. Discuss the implications of these findings for clinical practice and future research.

6. Conclusion:

The conclusion should succinctly summarize the key findings and their implications. Avoid restating the objectives or methods.

7. Reporting Guidelines:

Ensure the study adheres to relevant reporting guidelines, such as PRISMA for systematic reviews and meta-analyses. Consider including a PRISMA checklist as supplementary material.

8. Ethical Considerations:

Although the study is a systematic review and does not involve human subjects research, it is good practice to discuss any ethical considerations relevant to the conduct and reporting of the study.

9. Clarity and Formatting:

Improve the overall clarity and organization of the manuscript. Ensure consistent formatting of headings, tables, and figures.

Proofread the manuscript carefully to correct any grammatical errors or typos.

10. Respond to Reviewer Comments:

Address all specific comments and concerns raised by the reviewers. Provide point-by-point responses and explain how the manuscript has been revised to incorporate these suggestions.

Overall, this is a potentially valuable study that could make an important contribution to the field. With thorough revisions addressing the points above, the manuscript has the potential to be accepted for indexing. I look forward to reviewing the revised version.

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes

Is the statistical analysis and its interpretation appropriate?

Yes

If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.)

Yes

Are sufficient details of the methods and analysis provided to allow replication by others?

Yes

Are the conclusions drawn adequately supported by the results presented in the review?

Yes

Reviewer Expertise:

wound therapy

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.