Journal of Dermatology Study and Treatment

Research Article

Observational Study of pH and Temperature Behavior in Chronic Wounds and Its Correlation with the Bacterial Colonization Phase

Roberto H Mengarelli*and Dolores Parisi

Healing Service and Biochemistry Lab-Hospital Municipal de Tigre, Buenos Aires, Argentina

Received: 05 October 2018

Accepted: 03 January 2019

Version of Record Online: 14 January 2019

Citation

Mengarelli RH, Parisi D (2019) Observational Study of pH and Temperature Behavior in Chronic Wounds and Its Correlation with the Bacterial Colonization Phase. J Dermatol Stud Treat 2019(1): 12-18.

Correspondence should be addressed to

Roberto H Mengarelli, Argentina

E-mail: rhmengarelli@yahoo.com.ar

DOI: https://doi.org/10.33513/JDST/1801-02


Summary

A study on 28 assessment in ulcers were performed at the healing service. In the Hospital Municipal de Tigre. Basal pH and temperature measurements were also included in the procedure. After scraping the wound bed with Fluid Thioglycollate Medium (FTM), Levine EMB agar, a Gram staining and Giemsa staining was performed in order to determine the cellularity as the phase in which it is located.

Aim of the Work

The study of the correlation of pH, Temperature and Bacteriological local phase parameters, determining the influence of those determinations in the wound healing and the current phase of the beds of those wounds.

Keywords: Bacterial Colonization; Wounds; pH

Introduction

The complex evolution of chronic wounds compels us to improve their local state diagnosis before and during the treatment in order to optimise the cost.

Materials and Methods

The study on 28 assessments in ulcers were performed in the healing service of the hospital. Measurements are done to determine Basal pH and temperature randomly on chronic wounds, under all kind of conditions, with Lutron pH 206 equipment. The procedure consists in measuring the temperature immediately after the removal of the healing method in order not to alter the local conditions, and the same procedure is done with pH determinations. After that, we proceed to the scraping of the wound bed and the sample obtained is put in two glass slides without fixation in order to follow with the Gram staining and the Giemsa staining in order to determine the cellularity as the phase in which it is in. The data sheet is completed with the following parameters (The most important data is filled in tables 1 and 2).

Patient, date of taking, kind of ulcer, starting date of the lesion, treatment of the last healing previous to taking, treatment post taking and measuring, pain, smell, pH, temperature, Giemsa.

Patient

Date

Kind of Ulcer

pH

T

Giemsa

VIMA(Figure 1)

01 April 2014

VENOUS

8.1

28

C0 L3 CV1 F3 H1 G1

VE..

01 April 2014

VENOUS MIXED

8.3

24.5

C3 L2 F1 H2 G1

ACRO(Figure 2)

08 April 2014

MIXED+LYNPHATIC

8.15

25.2

C1 L3 G3

GIAY(Figure 3)

08 April 2014

TRAUMATIC

8.1

26.9

C0 L2 F0 H3 G1

TECA

08 April 2014

ON STUDY

8.06

27.06

C0 L2 F3 G1

ACRO

11 April 2014

MIXT+LYNPHATIC

7.58

24.6

C3 L2 F3 H3 G1

ACRO

15 April 2014

MIXT+LYNPHATIC

8.22

26.8

C0 L3 F2 G3

VE..

29 April 2014

VENOUS MIXED

8.22

25.5

C+ F0L3G2 CV1

ACRO

13 May 2014

VENOUS

7.48

29

C1 F1 L2 G2

VIMA

13 May 2014

MIXT

7.95

30.4

C2 L1 F1 G1

SAMU

20 May 2014

TRAUMATIC

8.56

24.9

C1 F1 L3

COAN

20 May 2014

VENOUS

8.46

25.3

C2 F2 L2

JAGR(Figure 4)

20 May 2014

RHEUMÁTIC

7.89

28.9

C2CV2L2 EOS3

BIAT

20 May 2014

TRAUMATIC

8.15

28.7

C0 L2 CV 2

OJEL

10 June 2014

ARTERIAL

8.26

24

C0 L0 F1

COAN

10 June 2014

VENOUS

8.22

25.7

C0 F2 L2

VAES

10 June 2014

VENOUS

7.02

26.9

C0 L2 G2 F1

JAGR

17 June 2014

RHEUMÁT

7.85

26.4

C1 F1 L1 E1

RU..

17 June 2014

VENOUS

7.99

28

C1 L1 F1

VIMA

17 June 2014

VENOUS

7.05

28.3

C1 L3 G3

VIMA

17 June 2014

VENOUS

8.15

26

C1 L3 G3

GB..

15 July 2014

ARTERIAL

7.6

30.1

C2 L2

GA

15 July 2014

TRAUMATIC

8.5

28

C1 CV1 L3 G3

BM

15 July 2014

VENOUS

8.7

28.8

C1 F2 L1

BM

15 July 2014

VENOUS

7.30

28.3

C1 L2 G2

OL

15 July 2014

VENOUS-RHEUMAT

7.81

27.3

C1 F2 L2

CORVA

17 July 2014

VENOUS

8.15

26.8

C1 L3 G3

VIMA

17 July 2014

MIXED

8.01

26

C1 L3 G3

Table 1: pH, Temperature and Giemsa Staining, C: Epithelial Cells, L: Lymphocytes, F: Fivers, CV: Vacuoles Cells, G: Germs.

VIMA 01 April 2014

Observational-Study-of-pH-and-Temperature-Behavior-in-Chronic-Wounds-and-Its-Correlation-with-the-Bacterial-Colonization-Phase
  • Mixed Ulcer - Starting date 2013
  • Pain ++ Smell ++
  • PH: 8.1 T: 28
  • GIEMSA: C0-L3-CVAC1-F3-H1-G1
  • GRAM: Cocci + vasilli –

Figure 1: VIMA 01 April 2014.

ACRO 08 April 2014

Observational-Study-of-pH-and-Temperature-Behavior-in-Chronic-Wounds-and-Its-Correlation-with-the-Bacterial-Colonization-Phase
  • Mixed Ulcer - Starting date 2013
  • Pain + Smell +
  • PH: 8.15 T: 25.2
  • GIEMSA: C+L+++G+++
  • GRAM: Abundant Basilli

Figure 2: A typical DSC thermogram of lysozyme.

GIAY 08 April 2014

Observational-Study-of-pH-and-Temperature-Behavior-in-Chronic-Wounds-and-Its-Correlation-with-the-Bacterial-Colonization-Phase
  • Traumatic Ulcer - Starting date 2/2014
  • Pain ++ Smell -
  • PH: 8.1 T: 26.9
  • GIEMSA: C0 L++ F0 H+++ G+
  • GRAM: Isolated cocci + gathered, isolated B-

Figure 3: GIAY 08 April 2014.

JAGR 20 May 2014

Observational-Study-of-pH-and-Temperature-Behavior-in-Chronic-Wounds-and-Its-Correlation-with-the-Bacterial-Colonization-Phase
  • Venous Ulcer - Starting date: 24 years
  • Pain XX Smell ++
  • PH: 7.89 T: 28.9
  • GIEMSA: C++ CEL VAC++L++ eosinophils +++
  • GRAM: No

Figure 4: JAGR 20 May 2014.

Patient

Date

Gram

Culture

VIMA

01 April 2014

COCCI+, BACILLUS-

S/C

VE..

01 April 2014

BACILLUS-

S/C

ACRO

08 April 2014

ABUNDANT BACILLUS-

S/C

GIAY

08 April 2014

ISOLATED COCCI + GATHERED ISOLATED B-

S/C

TECA

08 April 2014

ISOLATED COCCI + GATHERED

S/C

ACRO

11 April 2014

BACILLUS -

S/C

ACRO

15 April 2014

ABUNDANT B-

Ps. Spp R : cip, gen

VE..

29 April 2014

REGULAR B-, RARE C+, RARE B+

S/C

ACRO

13 May 2014

REGULAR B-

S/C

VIMA

13 May 2014

REGULAR B-, RARE C+

S/C

SAMU

20 May 2014

B-, C+

S/C

COAN

20 May 2014

ISOLATED C+ ,B-

S/C

JAGR

20 May 2014

No observed

No development

BIAT

20 May 2014

ISOLATED C+, B-

S/C

OJEL

10 June 2014

BACTERIA ARE NOT OBSERVED

S/C

COAN

10 June 2014

BACTERIA ARE NOT OBSERVED

S/C

VAES

10 June 2014

ABUNDANT B-, ISOLATED C+ AGRUP.

S/C

JAGR

17 June 2014

ISOLATED B-

sc

RU..

17 June 2014

B-, C+

sc

VIMA

17 June 2014

C+ agrup Cadena

Punction: ST AUREUS METI S+ Enterococo sp

VIMA

17 June 2014

Abundances bacilos -

SWAB: Ps. Spp

GB..

15 July 2014

ISOLATED C+

sc

GA

15 July 2014

C+, B-

sc

BM

15 July 2014

C+ GATHERED

Swab: negative

BM

15 July 2014

Abund cocos + agrup

PUCION: ST AUREUS METI R

OL

15 July 2014

B-

sc

CORVA

17 July 2014

Abund basi -

SWAB: Ps. Spp

VIMA

17 July 2014

Abund basi -

SWAB: Ps. Spp

Table 2: Staining Gram and Culture.

Photographic file of the lesion is performed and also of its evolution, jointly with the results of Gram and Giemsa, putting them by the side of the wound in order to compare its state. The pH device is assessed once a month with acid and basic buffers (Figures 5 and 6).

Observational-Study-of-pH-and-Temperature-Behavior-in-Chronic-Wounds-and-Its-Correlation-with-the-Bacterial-Colonization-Phase

Figure 5: Temperature measuring device- data of ulcer PH probe and staining in one cell.

Observational-Study-of-pH-and-Temperature-Behavior-in-Chronic-Wounds-and-Its-Correlation-with-the-Bacterial-Colonization-Phase

Figure 6: Temperature measuring device- data of ulcer PH probe and staining in one cell.

Results

The assessments were performed between April and July 2014. Most of the evaluated ulcers were vascular, being the venous ulcers the most frequent, followed by the mixed, the traumatic, the arterials, by rheumatological diseases and two ulcers which are still being studied (Graphic 1). All the patients chosen for the study had an ulcer with a minimum of one year of evolution. In our study the ulcer which presented the longest time of evolution was of 10 years. Treatments performed can be found in graphic 2.

Observational-Study-of-pH-and-Temperature-Behavior-in-Chronic-Wounds-and-Its-Correlation-with-the-Bacterial-Colonization-Phase

Graphic 1: Etiology.

Observational-Study-of-pH-and-Temperature-Behavior-in-Chronic-Wounds-and-Its-Correlation-with-the-Bacterial-Colonization-Phase

Graphic 2: Treatments performed.

Nine patients had pain in their wounds and eight referred smell. The pH range of all the determinations varied between 7.02 and 8.56; and the range of temperature varied between 24 and 30.1 grades.

As regards observational conclusions we can list the following findings:

  • The patients with pain showed as a whole a minimum pH of 7.89. It could also be observed a higher quantity of leucocytes in the Giemsa smear.
  • The presence of leucocytes in the Giemsa smear was correlated with positive cocci and negative bacilli in the Gram staining; being pH higher than 8 in colonization with aeruginosa and Proteus spp, and higher than 7.5 with colonization of positive cocci.
  • The patients with cellulites 2 and 3 in the Giemsa staining developed a small quantity of germs and showed PH lower to 7.90 regardless the temperature. Only one patient does not fit this parameter, showing abundant bacilli in the Gram, which suggests a recent critical colonization that alters the wound bed with a stable healing rate.
  • It was proved that the temperature of the wound is highly changeable and volatile exposed to de environmental air, for which reason the measuring has to be taken immediately after the removal of the healing devise.
  • The PH, the Gram and the Giemsa are stable, non-invasive and fast determinations for the wound and the cell bed evaluation and enables us to determine a change in the therapeutic approach.

Discussion

A chronic wound has a different evolution than an acute one. A chronic wound is a wound that does not heal in an orderly set of stages and in a predictable amount of time the way most wounds do; wounds that do not heal within three months are often considered chronic [1]. A chronic wound shows a high number of pro-inflammatory cytokines and proteases in the exudate [2]. There are also, in those, a low cellular mitosis, low levels of growth factors and cellular senescence. However, from the stand point of medical practice, it is very difficult to make these determinations. This is not the case with measurement of parameters such as pH, temperature and exudate components from frequent stainings. The pH range handled in a chronic wound is of 7.15 to 8.9 [3]. Acute and chronic wounds that have an elevated alkaline pH, show a lower rate of healing than those with a neutral or lower pH [4]. As the ulcer advances, the pH tends to be neutral and then acid. The presence of dead and devitalized tissue causes in the wound an increase of metabolism which produces tissue hypoxia [5]. These wounds have an important destruction of the Extracellular Matrix (MEC), which occurs faster in an alkaline medium.

The PH medium also influences the oxygen liberation to the tissues. The oxygen delivery to the damaged tissues, particularly in chronic wounds, not only depends on the perfusion but also on the dissemination. A pH decrease of 0,6 units liberates almost 50% more oxygen [6], as it is the case observed during the second and third determination pre and post hyper pressure treatment in a mixed ulcer (Table 1). Any factor that could provoke a small change in the wound pH, can alter the oxygen intake of the tissues. This condition has frequently observed during this study, on the infected patients with increased pH.

The pH reduction to a more acid medium reduces the final toxicity of the bacteria products, such as ammonia; it stimulates angiogenesis, increases fiver blasts and macrophages activity with control of the enzymatic activity. We have evidence of this activity in the present study with the low pH in Giemsa richer in epithelial cells and fibers, and lesser cells of the white progenie. This comes along with negative Gram culture in these samples.

A study of Gethin and Cowman reported that the wounds that presented a PH lower to 7,6 showed a 30% reduction in the size of the wound after two weeks. On the other hand, those with a pH of 8.0 or more, increased their size [4]. The same tendency was evidenced in our sample.

As regards the treatment and the pH and temperature variations, with the occlusive treatment and the use of bandages, the Winter investigations are respected, in which the concept of cure in a humid environment is developed, showing in an experimental way that skin lesions covered by a laminate of impermeable film, heals twice faster than those exposed to the air [7]. This is shown with an increase of the temperature of the wound bed, avoiding the cooling which causes a decrease of the cellular mitosis and a slowing of the granulation. Moreover, importance has to be given to certain antibacterial topics that can change dramatically the wound pH.

It has been demonstrated that a low temperature of the tissue of the wound bed delays the healing, mainly because of a reduction of the liberation of oxygen. The temperature of the wound bed, in chronic ulcers of the leg, ranges between 24°C and 26°C when the ulcer is not occluded [8]. The use of a hydrocolloid occlusive dressing makes the temperature rise, enhancing the healing process. This phenomenon could not be demonstrated is our case study because of the volatility shown by the temperature at the moment of its measuring. For this reason, we consider it a non-reliable parameter taken as an isolated data in wounds measuring, short after the removal of the dressing.

Conclusion

The local conditions of the wound bed are fundamental in chronic wounds to increase their healing. Trying to keep stable and favorable in pH and temperature conditions enhances the patient’s prognosis. Using as parameter of evolution the pH, the Giemsa and the Gram on a daily basis, evolution of the chronic wounds can be followed and modified easily and economically. The temperature appears as a very volatile factor to accompany the other three.

References

  1. Jones K, FennieK, Lenihan A (2007) Evidence based-management of chronic wounds. Adv skin wound care 20: 591-600.
  2. Fan L, Rashid M, Enoch S (2010) Current advances in modern wound healing. Wounds UK 6: 22-36.
  3. Romanelli M, Schipani E, Piaggesi A, Barachini P (1997) Evaluation of surface pH on Venous Leg Ulcers under Allevyn Dressings. London The Royal Society of Medicine Press. Evidence based wound care Pg no: 57-63.
  4. Gethin G, Cowman S (2006) Changes in Surface pH of Chronic Wounds When a Honey Dressing was Used. Wounds UK Conference Proceedings, 13-15 November 2006. Wounds UK, Aberdeen.
  5. Hunt TK, Beckert S (2005) Therapeutical and practical aspects of oxygen in wound healing. In: Lee B (ed.). The Wound Management Manual, McGraw-Hill Medical, New York, USA.
  6. Leveen H, Falk G, Borek B, Diaz C, Lynfield Y, et al. (1973) Chemical acidification of wounds. An adjuvant to healing and the unfavourable action of alkalinity and ammonia. Ann Surg 178: 745-753.
  7. Winter GD (1962) Formation of the scab and the rate of epithelization of superficial wounds in the skin of the Young domestic pig. Nature 193: 293-294.
  8. Romanelli M, Gaggio G, Coluccia M, Rizzello F, Piaggesi A (2002) Technological Advances in Wound Bed Measurements. Wounds 14: 58-66.
Ocimum Scientific Publishers

This work is licensed under a Creative Commons Attribution 4.0 International License.  Creative Commons License

Copyright © 2019 - All Rights Reserved - ocimumpublishers.com