Using Acetic Acid in Chronic Wound Management: A Case Series Demonstrating Efficacy in a Community-based Low-resource Syringe Service Program

Introduction, Objectives, and/or Purpose: Chronic venous wound management presents a unique challenge for healthcare providers. Defined as a wound that does not heal in an expected period of time (approximately three months) nor responds to current treatment modalities, management can present additional challenges for resource-challenged care settings.
Wound treatment approaches have evolved over centuries to include systematic and topical pharmaceuticals, bandages, and barrier devices of a wide-range of materials, and mechanical devices designed to optimize the natural healing process. Acetic acid has been documented as a local wound care antiseptic since World War I, effective in treating wounds infected with gram-positive and negative microorganisms. Many of the current antiseptic solutions can damage healthy tissue, further complicating the healing process. Acetic acid, at minimum concentrations of 0.5 percent, has been shown to be effective in treating wounds infected with Pseudomonas aeruginosa. While it has been demonstrated to retard wound healing at concentrations of 0.25 percent, studies have shown it is less likely to damage healing tissue when treatment is stopped when the characteristic blue-green drainage is resolved. With monitoring, acetic acid treatment provides a low-cost, effective alternative for providers and patients.
The purpose of this chronic wound care case series is to report patient outcomes using an acetic acid wound care kit to treat chronic, injection-related wounds observed by a provider working in a community-based, low-resource syringe service program in a Midwest metropolitan setting.

Methods: A case series design was utilized. Individuals with injection-related chronic venous wounds were treated with an acetic acid wound care protocol designed for the care context of the treatment population. The provider obtained verbal consent to provide the wound care protocol. Clinical records and corresponding photographs were archived and deidentified to protect patient/participant confidentiality.
A 1-3% acetic acid solution was utilized as a wound cleanser. Dressing type progressed from wet-to-dry, to rolled, to specialty dressings (e.g., Silvercel Alginate). Dressing change kits were provided to the individuals to address unstable housing conditions. The kits included: a 1-gallon zip lock bag with hand sanitizer, sanitizing wipes, a small bottle of vinegar, dressing gauze and other appropriate dressing supplies as available, self-adhesive dressing tape (e.g., Coban) or a measure of cotton stockinette, and a printout of wound care instructions. Individuals were instructed to add vinegar to a clean, previously unopened bottle of plain drinking water (16.9 ounces) and clean the wound with this solution. Kits were supplied to individuals on a weekly basis until healing advanced to the point that utilizing the acetic acid solution was no longer indicated.

Results: Over 50 individuals consented to be treated with the acetic acid wound care protocol. In addition to wound assessment, significant lymphedema with skin thickening and discoloration was noted in several of the individuals treated with the acetic acid protocol.
Two individuals are included in this case study series. Patient demographics include: one male and one female, aged approximately 30 years, both experiencing unstable housing arrangements. The female individual was initially seen in the community care clinic on March 8, 2022. She was referred to the emergency department and refused to fulfill the referral. She had significant wounds to bilateral lower arms approximately 6 inches by 3 inches, partial to full thickness, with areas of eschar. No evidence of lymphedema was noted. She indicated that she had had these wounds for nine to 12 months and was dressing them with “makeshift” bandages. The individual was very motivated to care for the wounds, was compliant with the acetic acid protocol instructions, and returned to clinic regularly for wound care kits. Antibiotics were not prescribed. On May 3, 2022, she had experienced significant wound healing, with 70 percent or greater resolution of the wounds.
The male individual came to the clinic with large, bilateral lower extremity chronic wounds. Skin thickening and edema, consistent with lymphedema, was also noted in both extremities. He reported he had been treating these wounds for over a year. The acetic acid wound care protocol was started, and kits provided on a weekly basis. He was not consistent with implementing the wound care protocol nor clinic follow-up. He lost his dressing pack, which included alginate dressings. Despite inconsistent wound care and follow-up, approximately 35 percent resolution of the lower extremity wounds was observed.
Wound care utilizing acetic acid care kits provided to the individuals with injection-related wounds increased the rate of healing and minimized the time to complete healing for both cases. These individuals were able to successfully implement the treatment protocol at their places of residence.

Conclusion(s): Optimizing patient outcomes in managing chronic venous wounds is a constant challenge. Care follow-up was shown in these two case studies to be important to the successful application of the acetic acid protocol and ultimate wound healing. In this community care environment, inconsistent follow-up is common, with many individuals not returning for weeks at a time. Loss of supplies can also complicate the effectiveness of a wound care protocol. Many individuals refuse to return to traditional medical establishments due to stigma and shame. Opportunities to care for individuals in their community, for wound care and other issues, can be beneficial.
Acetic acid is an effective, low-cost wound care approach that meets a critical need in community-based, low-resource practice settings. This case series demonstrates successful healing of injection-related chronic wounds using an acetic acid care kit in a community acute-care setting. As lymphedema is increasingly recognized as part of the venous wound clinical presentation, including lymphedema care in the wound care protocol may positively influence patient outcomes. Future research should explore: 1) different types of wound care dressings in combination with acetic acid washes to determine an optimal low-cost protocol; 2) optimal timing and concentration of acetic acid solution for different types of wounds; and 3) the relationship between lymphedema and chronic venous wound healing, including the role of current lymphedema treatment and the collaborative roles of the lymphedema therapist, medical/advance practice nurse provider, and nurses in the management of these chronic venous wounds.