December 12, 2010 journal, a cure for wounds as old as the hills is now reintroduced. Author: Peter C. Molan, BSc(Hons), PhD http://www.o-wm.com/article/1006 "Therapeutic use of honey is often referred to as "alternative" medicine. In fact, wound management using honey is an orthodox mode that has been out of common use for half a century but has been rediscovered. The oldest wound dressing known,1 honey, unlike many other ancient remedies, has not been a fashion of a period but has been in continuous use throughout time.2 Although many of the old practices in medicine are disparaged, modern research is finding rational explanations for their mode of action3; this is especially true for honey. Not only has honey been found to have various bioactivities important in the wound healing process, but also considerable evidence from clinical trials has demonstrated its worth among wound management products.4 Clinical Observations Topical application of honey has been reported to rapidly clear infection,5-10 heal deeply infected surgical wounds,6,9-15 and halt advancing necrotizing fasciitis.7,16 Honey has healed wounds not responding to conventional therapy with antibiotics and antiseptics,8,13,15,17-19 including wounds infected with antibiotic-resistant bacteria,14 such as methicillin-resistant Staphylococcus aureus.20,21 It rapidly deodorizes wounds7-9,11,16,22,23 and debrides them to facilitate the rapid development of a clean granulating wound bed.5-8,10,24 Wounds dressed with honey have a rapid rate of healing,12,16, 25,26 and honey can start the healing process in dormant wounds.8,17,18,27,28 Also, honey has been reported to stimulate the growth of epithelium over wounds,7,8,16,24,29 making plastic surgery unnecessary.6,7,11,16,24 Honey reduces inflammation,24,25 edema,7,8,16,30,31 and exudate amounts,7,8,16,25 and has a soothing effect when applied to wounds23,25,32 and burns.23,25 It also minimizes scarring.7,19,22,29 In the more than 500 reported cases of using honey on wounds and the more than 140 cases of using honey in ophthalmology, the only adverse effect reported in some patients is a stinging sensation, which appears to be due to the acidity of honey.33 In addition, honey has been used successfully on skin grafts,34 infected skin graft donor sites,19,33 infected traumatic wounds,8,11,17,35 necrotizing fasciitis (Fournier's gangrene),7,8,16 abscesses,33,36 pilonidal sinuses,33 pressure ulcers,8,26,27,33,37 leg ulcers,17,18,28,33 diabetic ulcers,8,17,33,38 tropical ulcers or Naga sores (large, open, sloughing ulcers usually at the the site of a wound or abrasion on the feet and legs, often infected with spirochetes and bacteria), sickle cell ulcers, and malignant ulcers.8 Honey is also a reliable alternative to conventional dressing for managing skin excoriation around stomas (ileostomy and colostomy), facilitating epithelialization of the raw surface.39 Comparative Effectiveness In three prospective, randomized, controlled clinical trials, honey was found to help heal superficial burns quicker than polyurethane film (OpSite(r), Smith + Nephew, Largo, Fla.), a dressing commonly used for creating a moist healing environment, or than silver sulfadiazine ointment, the "gold standard" dressing for preventing infection in burn wounds. In the study comparing honey-impregnated gauze with the polyurethane film, the mean times to healing in each group (n = 46) were 10.8 days and 15.3 days, respectively (P < 0.001). In addition, significantly fewer honey-dressed wounds became infected (P < 0.001).23 In the first of the two studies that compared honey-impregnated with silver sulfadiazine-impregnated gauze (n = 52 patients in each group), 87% of the wounds treated with honey healed within 15 days, compared with 10% of those treated with silver sulfadiazine (P < 0.001).22 A statistically significant difference (P < 0.001) also was found in the clearance of bacteria from the burns. In 43 out of 52 cases that presented positive swab cultures on admission in the group treated with honey, 91% became sterile in 7 days. In the comparison group, only 7% of 41 wounds with positive swab cultures became sterile. In the second trial, (n = 25 patients in each group), 100% of the wounds treated with honey healed within 21 days, compared to 84% of those treated with silver sulfadiazine (P < 0.001).24 Also, greater histopathological evidence of reparative activity (80% of wounds treated with honey dressing compared to 52% of the wounds treated with silver sulfadiazine, P < 0.005) was noted in biopsy samples from the wound margins after 7 days of treatment. Regarding the clearance of bacteria from burns, in 23 of the 25 cases treated with honey that had positive swab cultures on admission in the group, 65% of the wounds became sterile in 7 days and 96% in 21 days. By comparison, of the 22 wounds with positive cultures treated with silver sulfadiazine, 73% became sterile in 7 days and 86% in 21 days (P < 0.001). Although these trials showed that honey offered better control of infection than standard treatments, a trial40 on moderate burns where half of the total burn area was full-thickness showed that control of infection was better with early tangential excision followed with autologous skin grafting than with honey treatment. In two groups (n = 25) of young adults, 34% of swab cultures were positive for the group treated with honey, compared with 10% of the group treated with early tangential excision (P < 0.05). Antibiotics were needed for 32 1 18 days in the honey-treated group compared with 16 1 3 days in the excision group (P < 0.001).40 However, the mean blood volume replaced was less with the honey treatment (21% 1 15%, compared with 35% 1 12%, P < 0.01) and skin grafting was required on only 11 patients of the group treated with honey. The poor results obtained with honey in controlling infection could have been because the honey selected for use in this trial did not have a good antibacterial activity (see "Variation among honeys" in the next section). In recent reports where selected honey was used on an infected wound following surgical treatment of hidradenitis suppurativa15 and infected skin lesions from meningococcal septicemia,19 honey chosen for its good level of antibacterial activity gave rapid clearance of infection and healing of the wounds. In both studies, it had not been possible to achieve healing with the many systemic antibiotics and modern dressing materials previously tried over a long period of time. Good infection control was reported in a crossover study13 of nine infants with large infected surgical wounds. Honey was used on the wounds after they failed to heal following at least 14 days of treatments with intravenous antibiotics (a combination of vancomycin and cefotaxime, subsequently changed according to bacterial sensitivity), fusidic acid ointment, and wound cleaning with aqueous 0.05% chlorhexidine solution. Marked clinical improvement was seen in all cases after 5 days of treatment with honey; all wounds were closed, clean, and sterile after 21 days of honey application. A prospective, randomized controlled trial14 on severe postoperative wound infections following Caesarean section or abdominal hysterectomy was conducted to compare dressing with honey (n = 26) to washing wounds with 70% ethanol and applying povidone-iodine (n = 24). In the group treated with honey, infection was eradicated in less than half the time, the wounds completely healed in less than half the time, postoperative scars were less than half the size, and the period of hospitalization was less than half of that for the patients in the control group (P < 0.05). Another trial9 found that dehisced abdominal wounds following Caesarean section healed in less than half the time (mean length of stay in hospital 4.5 days, range 2 to7 days) when the wound margins were held together by micropore tape and the wounds dressed with honey, compared retrospectively with the usual treatment of wound care (cleansing with hydrogen peroxide, Dakin's solution, and packing with saline-soaked gauze) and subsequent re-suturing (mean length of stay in hospitalo11.5 days, range 9 to 18 days). Antibacterial Action Infection or a heavy bacterial burden in a wound is a major impediment to healing.41 Honey's therapeutic importance as an antibacterial has been recognized since 1892, and a large amount of laboratory research has been conducted since that time.42 Its high osmolarity, due to its sugar content, is sufficient in the undiluted product to stop the growth of all microbial species. In addition, honey contains the enzyme glucose oxidase that, when honey becomes diluted, produces low levels of hydrogen peroxide.42 Because the production is continuous, the low level is sufficient to act as an antibacterial agent, even though the concentration typically achieved in diluted honey (approximately 1 mmol/L43) is about 1,000 times less than in a commonly used 3% solution of hydrogen peroxide. In some honeys, augmentation of the antibacterial activity by phytochemicals in the nectar collected by the bees occurs.42 Usually, this is a minor factor, but in honey from Leptospermum species from Australia and New Zealand, this factor can make a major contribution to healing.42. Although the osmotic inhibition of bacterial growth is lost when honey becomes diluted by wound exudate, the antibacterial activity remains important. Also, the osmotic action on bacteria is only effective on the wound surface; whereas, the other antibacterial factors diffuse into wound tissues. Variation among honeys. The potency of the additional antibacterial factors varies as much as 100-fold between different types of honey.43 The Ancient Greeks recognized that some honeys were better than others for wound care. Dioscorides (circa 50 AD) stated that a pale yellow honey from Attica was the best.44 Aristotle (384 to 322 BC) referred to pale honey as "good as a salve for sore eyes and wounds."45 In present-day folk medicine, in practice in various parts of the world, certain local honeys are recognized for particular use.43 Discovery of the antibacterial activity over and above the osmotic effect of honey on bacteria came from research on honey as far back as 1937. A system of rating the antibacterial activity of honeys, the "inhibine number," was devised in 1955.42,43 Yet, today, almost all clinical reports of honey use show no recognition of the variance in their antibacterial activity potency. Failure to take this variance into account has complicated conclusions on the sensitivity of different species of bacteria to the antibacterial activity of honey. However, the large number of microbiological studies that have been performed demonstrate that honey has a very broad spectrum of action.42 This offers an important advantage in managing infected wounds because sensitivity testing before starting treatment is not required." This is only about one-third of the article. Refer to the website above.