Dear Editor,
A discharging sinus not responding to conventional therapy becomes a chronic non-
healing sinus. Conventional/traditional therapies have their own limitations in the
management of chronic discharging non-healing sinus. Thus, the treatment of such non-healing
sinus is a big worry for a clinician. We report a case of non-healing sinus, which
did not respond to conventional antimicrobial treatment and local care combined for
years, but was treated successfully by using three percent citric acid as a sole topical
antimicrobial agent.
A 22-year-old unmarried female referred to an orthopedic surgeon with a chronic discharging
sinus at the right mid-tarsal region. The case was examined thoroughly. Followings
are the details of various examinations:
Haemoglobin; 11.6 gm/dl, white blood cell count; 5400/mm3, differential leucocyte
count: neutrophils; 61%, lymphocytes; 31%, monocytes; 3%, eosinophils; 4% and basophils;
1%, peripheral blood smear; normocytic, normochromic, mildly hypochromic, and ansiocytosis,
Erythrocyte sedimentation rate (ESR); 46 mm/hr, serum uric acid; 4.8 mg/dl; C-reactive
protein; absent, rheumatoid arthritis factor (R. A factor); absent, urine analysis;
Nothing abnormal detected (NAD), anterior-posterior and oblique X-rays of right foot;
osteoporosis of lateral bones with a soft tissue swelling and chronic soft tissue
infection, enzyme linked immunosorbent assay test (ELISA) for antimycobacterium tuberculosis
antibodies: IgG; 140 units/ml and IgM; 1.0 units/ml, and weight of the patient; 50
kg.
The case was diagnosed as Koch’s mid-tarsal joints, based on the laboratory and clinical
findings. There was no osteomyelitis. The patient thereafter was subjected to Anti-Koch’s
(multidrug) therapy with a four- drug regimen involving rifampicin, pyrazinamide,
isoniazid and ethambutol for one year. The patient was considered responsive on the
basis of weight gain (55 kg) and decreased ESR level (28 mm/hr). However, the sinus
was persistent without any clinical improvement in spite of Anti-Koch’s therapy for
one year. This prompted the clinician to start antibiotic therapy. Different groups
of antibiotics were tried for two months without any changes in sinus presentation
(figure 1A). Finally the patient approached us for citric acid therapy, which she
received duly. The sinus was flushed with normal saline and was irrigated with 3 %
citric acid. Cotton swabs soaked with citric acid were placed in the sinus opening.
This modality of local application of citric acid was carried out for 11 days (one
application each day). The sinus showed signs of healing, and was closed completely
within two weeks of therapy (figure 1B). Thereafter, the patient was followed up for
six months, and no draining from sinus was observed.
Figure 1
Nonhealing tuberculous sinus in the mid-tarsal region of a 22-year-old woman (A) before
the application of citric acid, (B) after 11 daily applications of citric acid.
The effective use of citric acid in the treatment of acute and chronic wounds and
ulcers has been reported. Excellent results of citric acid therapy have been obtained
while dealing with chronic wounds.
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5
Citric acid physiologically functions as an antibacterial agent and effectively controls
the infection as indicated by microbiological studies and by rapid clearing up of
infected surfaces.
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The antiseptic property may be due to the lowering of pH of the infected surfaces,
which makes the environment unsuitable for the growth and multiplication of the bacteria.
It also enhances epithelization, which is a major factor in wound healing. Hydration,
oxygenation and removal of dead tissue ensure good epithelization.
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Histological studies showed that citric acid was found to enhance the wound healing
process by boosting fibroblastic growth and neo-vascularization, which in turn increases
microcirculation of wounds that enables the formation of healthy granulation tissue
thereby leading to faster healing of wound.
6
All of these actions increase the migration of epithelial cells from the surrounding
skin, and epithelization acts as a stimulus for laying the ground substance. Also,
the citric acid is a synergistic antioxidant,
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which may prevent free radical damage and may stabilize lysosomal enzymes needed for
collagen synthesis.
In the present study, we used citric acid for the treatment of chronic sinus successfully.
The sinus, which did not respond to anti-Koch’s treatment or loads of antibiotics,
healed completely in 11 (one application a day) applications of citric acid. Hence,
we can safely suggest the use of citric acid in the treatment of a chronic sinus when
other conventional modalities are exhausted.