Revisiting the Use of Honey for Treating Chronic Wounds

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RCTs and case series to ascertain the effect of honey on chronic wounds such as lower-extremity ulcers, pressure ulcers, bums, diabetic ulcers, and slow-healing wounds in oncology. Lower-extremity Ulcers—In a comparative study, Cethin and Cowman-' used manuka honey to treat 8 patients with chronic leg ulcers that had not shown improvement with other wound care for 4 weeks. Wound odor was eliminated after the first honey application, pain duration was decreased from 2 hours to 30 minutes (per patient report), and the size of the wound was reduced by 54.8% after 4 weeks of therapy. Smith et al-'" applied Medihoney to 11 chronic lower-extremity venous ulcers that had failed to respond to various treatments, including compression, topical silver, non adherent dressings, and antibiotic therapy. All of the wounds healed after 3-6 weeks of continuous treatment. Robson et al'5 found that the average time to healing was 100 days in the Medihoney group versus 140 days in the standard-therapy (control) group for lowerextremity ulcers. In 3 case studies of patients with leg ulcerations, use of Medihoney promoted significant healing over 2-8 weeks and reduced pain (per patient report) and infection (per repeat swab cultures) in ail cases." In a study of 6 patients with non-healing wounds, use of honey produced the favorable outcomes of granulation and reduction of bacterial burden over a mean of 4 weeks. ' One patient in this study who had been experiencing severe pain was able to stop using an opioid analgesic after 17 days of honey gel treatment and no longer needed any analgesic after 6 weeks of treatment. Use of honey achieved the goals of reducing bacterial load, inflammation, and pain. By contrast, in a study conducted on patients over a 12-week time period, kill et a!-"' found that honey with compression, compared with compression alone, did not significantly increase healing of venous leg ulcers. Diabetic Ulcers—Honey was used in an elderly man with chronic diabetic heel and forefoot ulcers of 14 months' duration."' The patient had lost two toes, had undergone four surgeries, and had been hospitalized 5 times in attempts to heal the ulcers. Cultures of the wound were positive for MRSA, V'RK, and Pseudomonas, Honey was applied daily; after 2 weeks, granulation tissue was noted. The ulcers resolved over 12 months. Pressure Ulcers—Van der Weydenw used honey dressings to treat 2 patients with pressure ulcers. One patient had a stage 3 ulcer and the other patient had a stage 4 ulcer; both patients' ulcers healed after 8-11 weeks of treatment. The patient with the stage 4 sacral wound had been treated for 4 weeks with a hydrocolloid dressing, with little effect. However, after 1 week of honey treatment, the necrotic tissue began to break down and after 3 weeks, the necrotic tissue was gone. Granulation tissue was noted after 4 weeks. The other patient had been treated with a hydrocolloid dressing for 3 weeks, with no improvement. One week after starting the honey dressing, improvement was noted, and after 23 days, the wound was shallow and granulating. Acton" used honey to debride pressure ulcers, with favorable results. In one case in which a necrotic pressure ulcer had been present for ) month, the necrotic tissue was absent after 5 days of treatment. In another case, a necrotic hip wound was clean after 8 weeks of honey use. A 5-week RCT assessed the use of honey in 15 patients with 25 stage 2-3 pressure ulcers versus ethoxy-diaminoacridine/nitrofurazone in 11 patients with 25 stage 2-3 pressure ulcers.0 The honey-treated group, relative to the control group, experienced approximately 4 times the rate of pressure ulcer healing. Burns—Subrahmanyam et al treated 100 patients with burns with a honey dressing or a silver sulfadiazine dressing. At 7 and 14 days, greater healing was noted earlier in the honey group than in the silver sulfadiazine group. The silver sulfadiazine group showed persistent infection on bacterial cultures, whereas cultures in the honey group were 90% sterile. These authors reported that 50 patients with bums treated with early exci sion and skin grafting instead of honey had better functional and cosmetic results after 3 months. Wounds in Patients with Cancer—Honey has been used to treat slow-healing wounds in patients with cancer, particularly in neonate and pediatric populations. In a study by Simon et al,,: honey was found effective against nosocomial wound infections. These investigators studied wound cultures growing MRSA, VR1-, and P aeruginosa from 14 patients whose slow wound healing was related to chemotherapy and radiation toxicity, malnutrition from nausea/ vomiting, mucositis, or infection. Healing was noted after an average use of 22 days in all wounds. Patients and their parents were pleased with the results. Implications for NP Practice Assessment—The TIME frame-
TABLE 2 FREQUENCY OF HONEY DRESSING CHANGES Type of Honey Dressing Amount of Exudate Frequency of Dressing Changes Honeycolloid Light drainage Change every 4-7 days Honey gel/ointment Light to moderate drainage Cover wi*h an occlusive dressing and change daily initially and every 2-3 days as drainage decreases Honey alginate Moderate to heavy drainage Change daily initially and then extend to 2-3 days as drainage decreases; change outer dressing pm work for wound healing, developed by Schultz et al," focuses on preparing the wound bed by modifying factors that delay or prevent healing. Wound-bed preparation includes management of 4 factors: T = nonviable or deficient tissue; I = infection or inflammation; M = moisture imbalance; and E = a non-advancing or undermined wound edge. NPs can use this framework in the office to aid in assessment of wound healing. Choosing an \npropriate Dressing —Honey dressings are available in different forms, the type used depends on the amount of wound exudate." Wounds are first cleaned using a facilityapproved wound cleanser. The outei margins are protected with skin prep. Hie dressing is applied to fit within the wound margins. For a lightly draining wound, use of a honeycolloid (non-adhesive) without a cover dressing is suggested. For a lightly to moderately draining wound, use of a honey gel/ointment and an occlusive dressing designed to maintain a moist environment is indicated. One challenge with use of a liquid/gel honey is ensuring that it stays in place; this preparation may not be optimal for a leg or abdominal wound. Frequency of dressing changes depends on the amount of drainage (Table 2). An outer dressing that becomes saturated is changed promptly to avoid maceration of the peri-wound skin and to prevent contamination. As drainage decreases, dressings are left on for longer periods of time, typically 4-7 days/1 For moderately to heavily draining wounds, another available dressing is Medihoney, a 5% calcium alginate and 95% Lepiospermum honey that is frequently used on lower-extremity ulcers under a compression wrap.5-" Although honey is generally safe when used to treat wounds, a few contraindications exist. Patients with a known history of allergy to honey or bee venom should not use honey dressings. Patients widi DM need to monitor dieir blood glucose levels more frequently because of the risk for hyperglycemia.'" Furthermore, honey should not be used on stable, dry eschar on heels, as diis is the body's natural protection, or on wounds that need surgical debridement/-' Evaluation of Therapy--As with any topical dressing, these questions must be answered when assessing the effectiveness of honey in treating a wound: (1) Have redness and swelling (ie, inflammation) decreased? (2) Has pain decreased? (3) What is the condition of the surrounding skin? Is it improving? (4) Is the number of dressing changes decreasing over time? (If not, the honey may not be effective because of the amount of drainage.) (5) Has the necrotic tissue diminished? (6) Is the wound odor decreasing? (7) Is the treatment cost-effective?1"' F.ven though honey has atuibacterial properties, systemic antibiotics may still be needed. Monitoring the wound is required. Implications for Education Nurse practitioners and wound care nurses must be educated about the use of honey and its indication for the treatment of chronic wounds. Honey dressings are easy to apply, non-adherent to the wound base, and less painful than other dressings on removal." Honey can be used in cavity wounds or a sinus tract because the residual can be cleaned out at dressing changes. 1 loney is appropriate for wounds with moderate to heavy amounts of drainage, with slough or eschar needing chemical debridement, and with an odor/'11 Honey for wound treatment must be of a medical grade that is regulated safe, effective, and cast-effective. Implications for Research Further studies specifically RCTs, are needed to assess the use of newly developed honey-impregnated dressings. According to Simon et af - many case studies, but only a few RCis, have been reported
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Revisiting the Use of Honey for Treating Chronic Wounds

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