The Evidence Supporting the Use of Honey as a Wound Dressing
Identifieur interne : 000B54 ( Istex/Corpus ); précédent : 000B53; suivant : 000B55The Evidence Supporting the Use of Honey as a Wound Dressing
Auteurs : P. C. MolanSource :
- The International Journal of Lower Extremity Wounds [ 1534-7346 ] ; 2006-03.
Abstract
Some clinicians are under the impression that there is little or no evidence to support the use of honey as a wound dressing. To allow sound decisions to be made, this seminar article has covered the various reports that have been published on the clinical usage of honey. Positive findings on honey in wound care have been reported from 17 randomized controlled trials involving a total of 1965 participants, and 5 clinical trials of other forms involving 97 participants treated with honey. The effectiveness of honey in assisting wound healing has also been demonstrated in 16 trials on a total of 533 wounds on experimental animals. There is also a large amount of evidence in the form of case studies that have been reported. It has been shown to give good results on a very wide range of types of wound. It is therefore mystifying that there appears to be a lack of universal acceptance of honey as a wound dressing. It is recommended that clinicians should look for the clinical evidence that exists to support the use of other wound care products to compare with the evidence that exists for honey.
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DOI: 10.1177/1534734605286014
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ISTEX:1900C2A181E979E8CB8A92251CC51A929CC435C4Le document en format XML
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Molan</name><affiliation><mods:affiliation>Department of Biological Sciences, University of Waikato, Hamilton, New Zealand,</mods:affiliation></affiliation><affiliation><mods:affiliation>E-mail: pmolan@waikato.ac.nz</mods:affiliation></affiliation></author></analytic><monogr></monogr><series><title level="j">The International Journal of Lower Extremity Wounds</title><idno type="ISSN">1534-7346</idno><idno type="eISSN">1552-6941</idno><imprint><publisher>Sage Publications</publisher><pubPlace>Sage CA: Thousand Oaks, CA</pubPlace><date type="published" when="2006-03">2006-03</date><biblScope unit="volume">5</biblScope><biblScope unit="issue">1</biblScope><biblScope unit="page" from="40">40</biblScope><biblScope unit="page" to="54">54</biblScope></imprint><idno type="ISSN">1534-7346</idno></series><idno type="istex">1900C2A181E979E8CB8A92251CC51A929CC435C4</idno><idno type="DOI">10.1177/1534734605286014</idno><idno type="ArticleID">10.1177_1534734605286014</idno></biblStruct></sourceDesc><seriesStmt><idno type="ISSN">1534-7346</idno></seriesStmt></fileDesc><profileDesc><textClass></textClass><langUsage><language ident="en">en</language></langUsage></profileDesc></teiHeader><front><div type="abstract" xml:lang="en">Some clinicians are under the impression that there is little or no evidence to support the use of honey as a wound dressing. To allow sound decisions to be made, this seminar article has covered the various reports that have been published on the clinical usage of honey. Positive findings on honey in wound care have been reported from 17 randomized controlled trials involving a total of 1965 participants, and 5 clinical trials of other forms involving 97 participants treated with honey. The effectiveness of honey in assisting wound healing has also been demonstrated in 16 trials on a total of 533 wounds on experimental animals. There is also a large amount of evidence in the form of case studies that have been reported. It has been shown to give good results on a very wide range of types of wound. It is therefore mystifying that there appears to be a lack of universal acceptance of honey as a wound dressing. 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To allow sound decisions to be made, this seminar article has covered the various reports that have been published on the clinical usage of honey. Positive findings on honey in wound care have been reported from 17 randomized controlled trials involving a total of 1965 participants, and 5 clinical trials of other forms involving 97 participants treated with honey. The effectiveness of honey in assisting wound healing has also been demonstrated in 16 trials on a total of 533 wounds on experimental animals. There is also a large amount of evidence in the form of case studies that have been reported. It has been shown to give good results on a very wide range of types of wound. It is therefore mystifying that there appears to be a lack of universal acceptance of honey as a wound dressing. 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There is also a large amount of evidence in the form of case studies that have been reported. It has been shown to give good results on a very wide range of types of wound. It is therefore mystifying that there appears to be a lack of universal acceptance of honey as a wound dressing. It is recommended that clinicians should look for the clinical evidence that exists to support the use of other wound care products to compare with the evidence that exists for honey.</italic></p></abstract><kwd-group><kwd>evidence</kwd><kwd>honey</kwd><kwd>infected wounds</kwd><kwd>surgical wounds</kwd><kwd>burns</kwd><kwd>ulcers</kwd></kwd-group><custom-meta-wrap><custom-meta xlink:type="simple"><meta-name>sagemeta-type</meta-name><meta-value>Reviews</meta-value></custom-meta><custom-meta xlink:type="simple"><meta-name>search-text</meta-name><meta-value>
10.1177/1534734605286014MOLANHONEY AS A WOUND DRESSING
5 1
Seminar Review
The Evidence Supporting the
Use of Honey as a Wound Dressing
P. C. Molan, BSc, PhD
Department of Biological Sciences, University of Waikato, Hamilton, New Zealand
Some clinicians are under the impression that there is little or
no evidence to support the use of honey as a wound dressing.
To allow sound decisions to be made, this seminar article has
covered the various reports that have been published on the
clinical usage of honey. Positive findings on honey in wound
care have been reported from 17 randomized controlled trials
involving a total of 1965 participants, and 5 clinical trials of
other forms involving 97 participants treated with honey. The
effectiveness of honey in assisting wound healing has also
been demonstrated in 16 trials on a total of 533 wounds on
experimental animals. There is also a large amount of evi-
dence in the form of case studies that have been reported. It
has been shown to give good results on a very wide range of
types of wound. It is therefore mystifying that there appears to
be a lack of universal acceptance of honey as a wound dress-
ing. It is recommended that clinicians should look for the
clinical evidence that exists to support the use of other
wound care products to compare with the evidence that
exists for honey.
Key words: evidence, honey, infected wounds, surgical
wounds, burns, ulcers
There is a rapidly increasing interest in the use of
honey as a wound dressing, although common
clinical opinion would appear to be that there is no evi-
dence to support its use as a wound dressing. Even
where reviews of clinical evidence for the use of honey
have been published, a negative impression is often ob-
tained from consulting these, as the conclusions stated
are that the evidence is of low quality and/or that there
is a need for more evidence.1-6
But the myriad of adver-
tisements for modern wound dressings possibly blinds
people to the fact that only small, poor-quality trials ex-
ist to support the use of these products.7
For example, if
the PubMed database is searched for evidence to sup-
port the use of nanocrystalline silver dressings, it can
be seen that there is in fact very little published evi-
dence. A recent systematic review of publications on
the use of advanced dressings in the treatment of pres-
sure ulcers has found that their generalized use in the
treatment of pressure ulcers is not supported by high
quality evidence.8
In evidence-based medicine, deci-
sions should be made on the basis of the available evi-
dence: where randomized controlled trials of the high-
est quality have not been conducted, it is necessary to
consider evidence of a lower quality. It is for these rea-
sons that this perspective article has been written, to al-
low clinicians to see the large amount of evidence that
exists for the effectiveness of honey as a wound dress-
ing. By comparing this with the evidence for other
wound-care products, clinicians can then judge for
themselves the relative merits of honey as a treatment
option for wounds.
The literature cited was found by searching the
PubMed, BIOSIS, and ISI Web of Science databases for
the term honey. Literature not included in the data-
bases but found from citations in papers were included
in this search. Excluded were papers where honey was
used in a mixture with other therapeutic substances,
the 31 case studies found for single cases of wound
40 LOWER EXTREMITY WOUNDS 5(1);2006 pp. 4054
Correspondence should be sent to: Professor P. C. Molan, Department
of Biological Sciences, University of Waikato, Private Bag 3105, Hamil-
ton, New Zealand; e-mail: pmolan@waikato.ac.nz.
Conflict of interest: The author has received funding from the honey in-
dustry for research on therapeutic usage of honey and has had travel to
conferences sponsored by companies selling honey for medical
usage.
DOI: 10.1177/1534734605286014
© 2006 Sage Publications
treatment with honey, the 21 papers found giving brief
reports on the use of honey on wounds, and papers that
were expressions of opinion rather than reports of
treatment of wounds with honey. Conference presenta-
tions were also excluded from this consideration.
CLINICAL EVIDENCE
Many randomized controlled trials have been car-
ried out comparing honey with various other wound
treatments. These trials and the results obtained from
them are summarized in Table 1. Other clinical trials
have been conducted where the form of the trial has
been other than a randomized controlled trial. In some
of these, the results for the group of patients treated
with honey were compared retrospectively with those
from the control treatment. In others, the patients were
crossed over to treatment with honey after a period of
the treatment normally used for that type of wound.
The details of these trials and the results obtained from
them are summarized in Table 2. Some of the case stud-
ies reported for single cases have also involved a com-
parative study. In these, the patient has had multiple
wounds, so honey could be used to treat wounds on
one side of the body and normal wound treatment used
on those on the other side. The details of these are sum-
marized in Table 3.
There have also been many noncomparative studies
reported on the use of honey as a wound dressing. Be-
cause many of these cases were not responding to stan-
dard treatment for quite some time before dressing
with honey was commenced, these provide evidence
that is somewhat like that from a crossover trial, al-
though these studies involved no reverse change in
treatment such as would be done in a crossover trial.
Some of these studies have been with multiple cases.
The details of these are summarized in Table 4.
EVIDENCE FROM ANIMAL EXPERIMENTS
Many studies have been performed on the effective-
ness of honey in promoting the healing of standardized
wounds created on experimental animals. These ex-
periments not only have allowed there to be much
more closely comparable controls in trials but also
have allowed histological examination of the healing
wounds to provide additional data besides the usual
measurements of decrease in wound size and time to
heal. These experiments and the results obtained from
them are summarized in Table 5.
DISCUSSION
The evidence presented in this article amply dem-
onstrates that honey, the oldest wound dressing mate-
rial known to medicine, can give positive results where
the most modern products are failing. Because people
generally are unaware of the historical usage of honey
as a wound dressing, or know only of its ancient usage,
its clinical usage is presumed to be a new development
or something that has been "rediscovered."9
However,
a look at the reference list at the end of this article will
reveal reports of clinical usage published in the
1950s,10,11
1960s,12
1970s,13-16
and 1980s17-23
as well as
the rapidly increasing number since its apparent
"rediscovery."
Limitations of Evidence Presented
The evidence presented here that supports the use of
honey in wound care includes evidence from many
clinical trials. However, none of the findings from these
trials would be considered to be evidence of the very
highest level, because even though they may have been
randomized controlled trials, they have not been dou-
ble blind. It is near impossible to conduct a double-
blind trial of honey as a wound dressing, because of the
difficulty of keeping obscured from the patients that a
material as recognizable as honey is being used. Even if
honey is applied in the form of a manufactured dress-
ing, its aroma is immediately recognized, even a single-
blind randomized trial may be difficult to conduct.
However, there are trials and case studies in which
the honey and the comparative treatment were used si-
multaneously on the same patient thereby offering a
degree of control. These demonstrate that positive re-
sults achieved with honey are not merely a placebo ef-
fect. One of these was a prospective randomized con-
trolled trial of honey on split-thickness skin graft donor
sites24
(the last item in Table 1). On patients in this trial
who had single donor sites (3 groups of 14 patients),
half of the donor site was treated with honey and half
with the comparative treatment. On patients with 2 do-
nor sites (3 groups of 15 patients), 1 of the donor sites
was treated with honey and 1 with the comparative
treatment. (Honey was compared with 3 controls,
saline-soaked gauze, paraffin gauze, and a hydro-
colloid.) In that trial, the significantly faster healing
rates and lower pain scores achieved with honey com-
pared with saline-soaked gauze and paraffin gauze
clearly would have been due to physical effects of the
honey and not to psychosomatic effects. Further evi-
dence of a similar nature is seen in the results achieved
in the case studies summarized in Table 3,although un-
LOWER EXTREMITY WOUNDS 5(1);2006 41
HONEY AS A WOUND DRESSING
42 LOWER EXTREMITY WOUNDS 5(1);2006
MOLAN
Table 1. Randomized Controlled Trials That Have Been Carried Out on Honey as a Wound Dressing
Number Reference
Type of Wound Control Treatment in Trial Results Honey cf Control Statistics Other Findings Number
Superficial burns Silver sulfadiazine 104 Proportion of wounds becoming
sterile within 7 days: 91% cf
7%
Mean time that healthy granula-
tion tissue first observed:
means 7.4 cf 13.4 days
Proportion of wounds healing
within 15 days: 87% cf 10%
Mean healing time: 9.0 days cf
24.6 days
P < .001
Not given
Not given
P < .001
Honey gave better re-
lief of pain, less irri-
tation of the wound,
less exudation, a
lower incidence of
hypertrophic scar
and postburn
contracture, acceler-
ation of
epithelialization, a
chemical
debridement effect,
and removal of of-
fensive smell
56
Fresh partial-
thickness burns
OpSite
®
92 Mean healing time: 10.8 days cf
15.3 days
Cases infected after 8 days: 8 cf
17
P < .001
P < .001
Honey gave
debridement and
deodorization, a
soothing effect, and
ease of removal of
dressings with little
pain
57
Fresh partial-
thickness burns
Amniotic membrane 64 Mean healing time: 9.4 days cf
17.5 days
Proportion of patients with re-
sidual scars: 8% cf 16.6%
Number of cases infected after 7
days: 4 cf 11
P < .001
P < .001
P < .001
58
Partial-thickness
burns
Conventional (90 with
Vaseline gauze, 90
with OpSite, 90 with
Soframycin, 180 dry)
900 Mean healing time: 9 days cf
13.5 days
Proportion of wounds infected:
5.5% cf 12%
Proportion of cases resulting in
scars: 6.2% cf 20%
Not given
Not given
Not given
59
Fresh partial-
thickness burns
Boiled potato peel 82 Mean healing time: 10.4 days cf
16.2 days
Proportion of those with positive
swab cultures becoming sterile
within 7 days: 100% cf 0%
P < .001
P < .001
60
Superficial burns Silver sulfadiazine 50 Proportion showing
epithelialization by 7th day:
84% cf 72% by 21st day: 100%
cf 84%
Proportion showing evidence of
reparative activity (on
histological examination of bi-
opsy samples): on day 7: 80%
cf 52% on day 21: 100% cf
84%
P < .001
P < .005
Honey gave early sub-
sidence of acute in-
flammatory changes,
better control of in-
fection and quicker
wound healing.
There was eschar in
60% of the cases
treated with silver
sulfadiazine, none
with honey.
With silver
sulfadiazine, 4 of
the superficial burns
converted to deep
burns requiring skin
grafting, none with
honey.
50
(continued)
LOWER EXTREMITY WOUNDS 5(1);2006 43
HONEY AS A WOUND DRESSING
Moderate burns, half
of the total burn area
being full-thickness
Tangential excision
36 days postburn,
then skin grafting
50 Mean percentage blood volume
replaced: 21% cf 35%
Mean period antibiotics needed:
32 days cf 16 days
Proportion of swab cultures pos-
itive: 34% cf 10%
Mean length of hospital stay: 46
days cf 21 days
Proportion with excellent or
good wound appearance after 3
months: 55% cf 92%
P < .01
P < .001
P < .05
P < .001
P < .01
Skin grafting was re-
quired on only 11 of
the 25 treated with
honey cf all of the
tangentially excised
group
42
Moderate burns,
1/6th total burn area
being full-thickness
Silver sulfadiazine 100 Mean healing time: 15.4 days cf
17.2 days
Number of swab cultures posi-
tive after 7 days: 4 (from 44 at
start) cf 42 (from 42 at start)
Lipid peroxidation (a measure of
inflammation):
4.3 cf 5.3 on day 7
3.8 cf 4.4 on day 14
3.2 cf 4.1 on day 21
Mean length of hospital stay:
22.0 days cf 32.3 days
P < .001
P < .001
P < .01
P < .01
P < .005
P < .005
With honey, 4 re-
quired grafting cf 11
with silver
sulfadiazine, and
there was 1 case of
contractures cf 5
with silver
sulfadiazine
51
Pediatric burns Silver sulfadiazine 64 Mean healing time: 11.0 days cf
16.1 days
Mean time to form healthy gran-
ulation: 6.7 days cf 12.8 days
Number of swab cultures posi-
tive after 7 days: 24 (from 25 at
start) cf 21 (from 24 at start)
P < .001
Not given
P < .001
There were 2 cases of
contractures with
honey cf 5 with sil-
ver sulfadiazine.
Honey gave a de-
crease in edema and
exudate, and no
eschar.
61
Superficial burns Silver sulfadiazine 50 100% of cases healed in 10 days
cf 70% in 15 days
Not given Honey gave early sub-
sidence of acute in-
flammation, and
better control of in-
fection. Honey re-
duced the period of
hospital stay and ex-
penses by 30%.
62
Severe postoperative
wound infections
following abdomi-
nal surgery
Washing wounds with
70% ethanol then
applying povidone-
iodine
50 Mean time to get negative swab
cultures: 6 days cf 14.8 days
Mean number of days antibiotics
were required: 6.88 cf 15.4
Mean healing time: 10.73 days cf
22.04 days
Mean size of postoperative scars:
3.62 mm cf 8.62 mm
Mean period of hospitalization
required: 9.36 days cf 19.91
days
P < .05
P < .05
P < .05
P < .05
P < .05
With honey, there
was mild wound
dehiscence in 4
cases, with no need
for resuturing: in the
control group, there
was wound
dehiscence in 12
cases, 6 requiring
resuturing under
general anesthetic
63
Table 1 (continued)
Number Reference
Type of Wound Control Treatment in Trial Results Honey cf Control Statistics Other Findings Number
(continued)
like with the trial with the skin graft donor sites where
the wounds being compared were of a standard nature,
there is a possibility the wounds given different
treatment for comparison may not have been identical
when treatment was started.
The most convincing evidence for the results with
honey not being due to a placebo effect comes from the
many studies that demonstrated the effectiveness of
honey on standard wounds inflicted on experimental
animals. Although the participants in these trials may
well have been able to detect by smell that honey was
being used, they would not have had any psychoso-
matic effects on healing resulting from beliefs that nat-
ural products would be more effective, or from hearing
via the news media of the effectiveness of honey in
wound treatment.
44 LOWER EXTREMITY WOUNDS 5(1);2006
MOLAN
Surgically drained
pyomyositis
abscesses
EUSOL-soaked gauze 32 (43
wounds)
Proportion on day 7 with clean
wounds: 100% cf 65.5%
Proportion on day 7 with granu-
lating wounds: 100% cf 50%
Proportion on day 7 with
epithelializing wounds: 86.9%
cf 35%
Proportion on day 21 with com-
plete epithelialization: 86.9% cf
55.0%
Mean length of hospital stay:
16.08 days cf 18.61 days (medi-
ans 14 days cf 22 days)
P = .007
P < .001
P = .001
P = .047
P = .019
64
Chronic leg ulcers
(mean duration of
56.5 months)
Phenytoin paste 50 Mean reduction in ulcer size:
27.0% cf 35.5%
Not
significant
65
Mean pain score (on a scale of 1
to 10): 1.8 cf 3.6
Not
significant
Pressure ulcers on or-
thopedic patients
Saline-soaked gauze 40 Proportion healed in 10 days:
100% cf 70%
P < .05 66
Mean healing time for ulcers that
healed in 10 days: 8.2 days cf
9.9 days
P < .001
Exit sites of central
venous catheters
Povidone-iodine 49 Incidences of blood-stream infec-
tions: 12 cf 19 episodes per
1000 catheter-days
Not
significant
67
Exit sites of tunneled,
cuffed central ve-
nous catheters
Mupirocin 101 Incidences of catheter-associated
bacteremias: 0.97 cf 0.85 epi-
sodes per 1000 catheter-days
Not
significant
68
Split-thickness skin
graft donor sites
Saline-soaked gauze:
also paraffin gauze:
also a hydrocolloid
(Coloplast)
87 (174
sites
treated)
Mean healing time: 9.1 days cf
13.2 days with saline
P < .05 Leakage occurred on
22 dressing changes
with the
hydrocolloid: no
fluid accumulated
under the honey
dressing. Superior
healing was shown
with honey.
24
Mean healing time: 9.4 days cf
12.4 days with paraffin
P < .001
Table 1 (continued)
Number Reference
Type of Wound Control Treatment in Trial Results Honey cf Control Statistics Other Findings Number
LOWER EXTREMITY WOUNDS 5(1);2006 45
HONEY AS A WOUND DRESSING
Table 2. Other Types of Clinical Trials That Have Been Carried Out on Honey as a Wound Dressing
Type of Number Reference
Wound Form of Trial in Trial Results Statistics Other Findings Number
Disrupted
abdominal
wounds
from
cesarean
section
Results from 15 patients
treated with honey applica-
tion and wound approxi-
mation by micropore tape
were compared retrospec-
tively with 19 similar cases
who had their dehisced
wounds cleaned with hy-
drogen peroxide and Dakin
solution and packed with
saline-soaked gauze prior to
resuturing under general
anesthesia
15 cf 19 Period of hospitalization re-
quired: 2-7 days (mean 4.5)
with honey cf 9-18 days
(mean 11.5) with control
Not given With honey, 11 healed within 7
days, the other 4 within 2 weeks.
With honey, slough and necrotic tis-
sue were replaced by granulation
and advancing epithelialization
within 2 days, wounds were made
odorless and sterile within 1 week,
and no resuturing was required.
69
Fournier's
gangrene
(necrotizing
fasciitis on
the scrotum)
20 consecutive cases of
Fournier's gangrene man-
aged conservatively with
honey plus systemic antibi-
otics (oral amoxicillin/
clavulanic acid and
metronidazole) were com-
pared with 21 cases man-
aged in the same period by
another consultant, using
surgical debridement
41 With honey, within 1 week
malodor, edema, and dis-
charge had subsided, all ne-
crotic tissues had separated,
rapid epithelialization was
occurring.
Within 1 week with honey, all
swabs were negative: there
was no need to change from
the routine antibiotics to
ones to which the bacteria
were found to be sensitive, as
was done with the surgically
debrided cases.
Not given A second operation for secondary
suturing was needed for all cases
surgically debrided, with plastic
reconstruction needed for 2 of
these. With honey, no surgery was
needed, and most healed with very
little or no scars.
Three deaths occurred in the surgi-
cally treated group, none in the
honey-treated group.
70
Large infected
surgical
wounds
on infants
Treatment was crossed over
to honey dressings after
wounds had failed to heal
with treatment of at least 14
days using intravenous an-
tibiotics (vancomycin plus
cefotaxime, subsequently
changed according to bacte-
rial sensitivity), fusidic acid
ointment, and wound
cleaning with aqueous
0.05% chlorhexidine
solution
9 After starting dressing with
honey, a marked clinical im-
provement was seen in all
cases after 5 days, and all
wounds were closed, clean,
and sterile after 21 days
Not given Six of the patients had systemic an-
tibiotic treatment discontinued
when treatment with honey started
71
Venous leg
ulcers,
nonhealing
after at least
12 weeks of
compression
Treatment was crossed over
to honey dressings used un-
der compression from stan-
dard treatment for venous
ulcers
40 Pain decreased from an aver-
age McGill score of 1.6 to
1.08 in 12 weeks
Linear decrease in pain with
time
Decrease in pain correlated
with reduction in wound
size
Decrease in pain correlated
with healing rate
The 26 malodorous wounds
decreased in odor mean
score (on a scale of 1 to 3) in
2 weeks from 1.58 to 0.69.
P < .02
P < .001
P < .05
P < .05
P < .001
In the 12-week study period, com-
plete healing occurred in 7 cases,
with a significant reduction in ul-
cer size for the rest (mean reduc-
tion 32%). There was a high level
of patient satisfaction with honey
dressings.
72
Burns A review of all the burn cases
in a hospital over the pre-
ceding 5 years
156 90.5% of the cases were
treated with silver
sulfadiazine, 8.5% with
honey: the outcomes were
similar
Not given 73
Does honey give good results in individual cases
studied because those wounds received more atten-
tion, or the prior treatment was less than ideal? There
are cases where honey has worked even on wounds
that had received prior specialist attention. They
changed to healing from nonhealing only when treat-
ment with honey was commenced. In many of these
cases, the wounds were not responding to best practice
with modern dressings, although a recent systematic
review of the evidence for the efficacy of modern
wound dressings in the treatment of pressure ulcers
has concluded that there is no evidence that these are
any better than saline-soaked gauze.8
Supporting Evidence From In Vitro Studies
Further evidence to support the use of honey as a
wound dressing comes from laboratory studies that
have clearly demonstrated that honey has bioactivities
that would be beneficial in wound care. In work with
cultures of leukocytes, honey has been shown to stimu-
late cytokine production by monocytes.25,26
The release
of cytokines is what initiates the tissue repair process
as well as the immune response to infection. Also,
stimulation by honey of other aspects of the immune
response, the proliferation of B- and T-lymphocytes
and the activity of phagocytes, has been shown.27
Addi-
tional to this work with cells in culture, it has been
demonstrated that honey stimulates the production of
antibodies in mice in response to antigens from Esche-
richia coli.28
These findings suggest that part of the
effectiveness of honey in clearing and preventing in-
fection in wounds that is so widely seen in the clinical
evidence may be due to enhancement of the body's
own immunity as well as being due to the antibacterial
activity of honey.
The number of publications on laboratory studies
showing that honey has antibacterial activity with a
very broad spectrum is very large.29
But what is often
not taken into account is that honeys can vary as much
as 100-fold in the potency of their antibacterial activ-
ity.30
More recent publications have reported on the
sensitivity of various species of bacteria to honey, with
antibacterial potency near the median level found in
surveys of large numbers of samples. This level is a lit-
tle below that of the various honey wound-care prod-
ucts now on sale manufactured from Leptospermum
honey, but there are other wound-care products manu-
factured from honeys not selected to have high levels of
antibacterial activity (Activon Tube, Activon Tulle,
and Algivon [Advancis], Apinate [Comvita], and Medi-
honey Barrier and Medihoney Gel [Medihoney]).31
Laboratory studies with Leptospermum honey with an-
tibacterial potency near the median level have shown
the MIC (minimum inhibitory concentration, ie, the
concentration down to which honey could be diluted
by wound exudate and still prevent bacterial growth)
to be 2% to 3% for Staphylococcus aureus,32
3.3% to
46 LOWER EXTREMITY WOUNDS 5(1);2006
MOLAN
Table 3. Case Studies on the Use of Honey as a Wound Dressing Where a Comparison With Other Treatments
Was Conducted on Multiple Wounds Within Single Cases
Status of Wounds Reference
Type of Wounds Before Using Honey Comparison Results Number
Multiple chronic leg
ulcers, on both legs
20-year history of mul-
tiple ulcers on the
legs and feet resulting
from chronic venous
hypertension with
secondary
lymphedema
The ulcers on one leg were
dressed with honey, those on
the other leg with Aquacell
At the time of discharge 10 days later,
the ulcers dressed with honey had a
cleaner wound bed, signs of infection
had cleared, and the green exudate
had ceased, whereas with the
Aquacell, there was copious leakage
of green fluid
44
Multiple chronic leg
ulcers, on both legs
Ulcers had been there
for >5 years. They
had features of stasis
dermatitis. There was
no arterial disease.
The ulcers on one leg were
dressed with honey, those on
the other leg were debrided
with fibrinolysin (Elase R)
then dressed with Sorbosan R
Initially, healing was much more rapid
with honey. After 1 month, both legs
were healing well.
74
Broken-down
wound from ab-
dominal surgery
Areas of dehiscence at
each end of the
wound, of similar
appearance
The dehiscence at one end was
dressed with honey, on the
other end with Debrisan
Healing was complete in 24 days with
honey, 32 days with Debrisan
75
Third-degree burns
to both arms
Burns on one arm were dressed
with honey, the other arm
with EUSOL
Granulation was "much nicer" with
honey, reducing time to skin grafting
76
LOWER EXTREMITY WOUNDS 5(1);2006 47
HONEY AS A WOUND DRESSING
Table 4. Reports on the Use of Honey as a Wound Dressing: Studies With Multiple Cases
Status of Wounds Number Reference
Type of Wound Before Using Honey of Cases Outcome From Treatment With Honey Number
16 acute traumatic
wounds, 23 compli-
cated surgical wounds,
and 21 chronic
nonresponding wounds
The chronic
nonresponding
wounds had all been
subjected to other regi-
mens before honey
dressings were used
60 One patient withdrew from the trial because the honey was
causing pain. Two wounds did not change. The rest healed
in a mean time of 3 weeks (range 128 weeks). One patient
was treated with silver sulfadiazine and antibiotics instead
of honey for 1 week because of an infection with Staphylo-
coccus aureus.
Advanced epithelialization and a decrease in exudate,
edema, and wound odor were observed.
77
Recalcitrant wounds and
ulcers of varied etiol-
ogy, such as Fournier's
gangrene, burns,
cancrum oris, diabetic
ulcers, traumatic ul-
cers, decubitus ulcers,
sickle cell ulcers, and
tropical ulcers
47 of the patients had
been treated for 124
months with conven-
tional treatment (such
as Eusol toilet and
dressings of
Acriflavine, Sofra-
Tulle, or Cicatrin, or
systemic and topical
antibiotics) with no
signs of healing, or the
wounds were increas-
ing in size
59 The 51 wounds with bacteria present became sterile within
1 week, and the others remained sterile. In 1 of the cases, a
Buruli ulcer, treatment with honey was discontinued after
2 weeks because the ulcer was rapidly increasing in size.
The 58 other cases "showed remarkable improvement."
Sloughs, necrotic, and gangrenous tissue separated so that
they could be lifted off painlessly and were rapidly re-
placed with granulation tissue and advancing
epithelialization. Surrounding edema subsided, weeping
ulcers dehydrated, and foul-smelling wounds were ren-
dered odorless within 1 week. Burn wounds treated early
healed quickly, not becoming colonized by bacteria.
17
Wounds from radical
vulvectomy with
lymphadectomy
Wounds had broken
down
12 Wounds became free from bacteria in 36 days. Complete
healing was achieved in 38 weeks. Clean healthy granula-
tion was achieved, requiring minimal surgical
debridement. Skin grafting was unnecessary.
13
Wounds of mixed etiol-
ogy: surgical, acciden-
tal, infective, trophic,
and burns. The average
size of the wounds was
57 cm
2
.
Half of the cases had
been treated with "the
usual topical mea-
sures" (an antiseptic),
which had failed. One
third of the wounds
were purulent, the rest
were red with a whit-
ish coat.
40 Honey delimited the boundaries of the wounds and cleansed
the wounds rapidly to allow skin grafting. Of the 33 pa-
tients treated only with honey dressings, 29 were healed
successfully, with good-quality healing, in an average time
of 56 weeks. Two of the 4 who did not heal were suffering
from immunodepression, 1 was withdrawn from treatment
with honey because of a painful reaction to the honey, and
1 burn remained stationary after a good initial response.
78
Septic wounds, chronic
ulcers, burns, pyogenic
abscesses
6 patients were diabetic,
5 with a septic foot
and 1 with an abscess
11 Healing time was 715 days, apart from 1 diabetic who took
56 days and 1, who was ill, in which there was no im-
provement. Clean healthy granulation was achieved, which
allowed skin grafting in 14 days (30 for 1 diabetic), with
prompt graft taking.
18
A variety of wounds, in-
cluding ulcers of vari-
ous etiologies, pressure
ulcers, burns, skin
tears, and traumatic
wounds
20 In 80% of cases, the wound bed improved (it was cleaner,
with less slough and malodor, with movement along the
healing continuum). In 20% of cases, there was no
improvement.
65% found honey dressings easy to apply, 75% found them
easy to remove, 85% found the dressings stayed in place,
65% found them comfortable.
79
Surgical wounds, mostly
dehiscent or infected
Pediatric patients re-
ceiving chemotherapy,
making wounds hard
to heal because of pro-
found
immunosuppression
16 Wounds became sterile within 14 days. The average healing
time was 25 days. Four patients undergoing prolonged
immunosuppression healed in an average time of 27 days.
Healing occurred without complication, apart from 1 small
keloid.
38
(continued)
4% for coagulase-negative staphylococci,33
5.5% to
9% for pseudo-monads,34,35
2.7% to 3% for MRSA,36
and 3.8% to 5% for VRE.36
The effectiveness of
honey in clinical usage in clearing infection with
MRSA37,38,39,40,41
and VRE37
has been reported. The slow
clearance of infection, or failure to clear infection, in
some of the cases reported may well reflect the use of
honey with a low antibacterial potency. For example,
this may have been the case in the randomized con-
trolled trial where honey was found to be less effective
than early tangential excision followed by autologous
skin grafting in controlling infection in the treatment of
burns.42
The same author, publishing results compar-
ing the MIC values for various types of honey available
locally, reported that the MIC for the most potent honey
against S aureus was 20% to 25%,43
which means that
the honey had only about a tenth of the antibacterial
potency of the Leptospermum honey used in wound-
care products now on sale.
Dressing Techniques
Another reason for variability in results may have
been that the honey dressings were not being kept in
place on the wound in some cases. The difficulty of
achieving this was commented on.44,45
If the honey is
flushed out of the dressing by wound exudate, then its
various bioactivities cannot be having any effect on the
wound. A case that may be an example of this is where
infection in a leg ulcer was reported to recur when
compression was commenced.46
Here it was noted that
there was a problem with dressings adhering, which is
a clear indication that honey has been flushed out of
the dressing by wound exudate.47
A similar occurrence
was reported where honey-impregnated tulle dress-
ings were being used.48
These have very little absor-
bency, so honey is easily flushed from them. It was
noted in this case that the dressings became saturated
with exudate within 1 hour. In another case where poor
progress was occurring with honey, it was found that
much better progress with healing occurred when
more frequent changes of the dressings were made.49
Anti-Inflammatory Activity of Honey
It has been noted that if sufficient honey is kept in
place, by applying it by way of impregnated dressings
and changing these frequently enough, then its anti-
inflammatory activity will reduce the amount of
exudate and thus remove the need for frequent dress-
ing changes.47
There is a very large amount of evidence
for honey having significant anti-inflammatory activ-
ity. As well as the evidence that has come from the
many clinical observations summarized in this review,
48 LOWER EXTREMITY WOUNDS 5(1);2006
MOLAN
Venous leg ulcers that
had undergone split-
skin grafting
Ulcers were of 12
months or more dura-
tion and were not re-
sponding to normal
treatment such as
compression. They
were of borderline
suitability for grafts.
Five had conditions
characteristic of insuf-
ficient tissue
perfusion.
6 The mean healing time was 22 days. There were no postoper-
ative infections or other complications. No regrafting or re-
vision of grafts was needed. There was no recurrence of the
ulcers on follow-up (average of 19 months later).
80
Fournier's gangrene Honey was used follow-
ing aggressive surgical
debridement and tri-
ple antibiotic therapy
38 Honey gave rapid healing changes in an average period of 10
days
81
Gangrene in the genitals
and perineum
14 The mean time for the debriding action of the honey to
cleanse the wounds was 5.2 days, for granulation to be seen
was 9.4 days, and for complete healing was 28.7 days
82
Table 4 (continued)
Status of Wounds Number Reference
Type of Wound Before Using Honey of Cases Outcome From Treatment With Honey Number
LOWER EXTREMITY WOUNDS 5(1);2006 49
HONEY AS A WOUND DRESSING
Table 5. Animal Experiments Carried Out on the Use of Honey as a Wound Dressing
Control Species Number Other Reference
Type of Wound Treatment of Animal in Trial Results Statistics Findings Number
Deep dermal
burns (6.7 × 6.7
cm) made with a
170°C brass
block
Silver
sulfadiazine:
also sugar
Yorkshire
pigs
3 (36
wounds)
Complete epithelialization
achieved within 21 days
with both honey and
sugar, cf 28-35 days with
silver sulfadiazine
Histological examination
revealed less inflamma-
tion in wounds treated
with honey than in those
treated with sugar and
with silver sulfadiazine,
and a more advanced
stage of healing
Not given
Not given
83
Dermal burns (1.3
× 3 cm) made
with a 170°C
brass block
Silver
sulfadiazine:
also untreated
(other than a
daily saline
rinse)
Pigs 2 (27
wounds)
First granulation was ob-
served (histologically) af-
ter 5 days with honey, 10
days with the controls
Less edema and inflamma-
tion were observed
(histologically) with
honey than with the
controls
Not given
Not given
84
Third-degree der-
mal burns (made
with steam), 8.5
cm2
, inoculated
with Pseudomo-
nas aeruginosa
Silver
sulfadiazine:
also acetate
mafenid
Piglets 60 After 30 days, the mean
reduction in wound area
was 62% with honey cf
29% with silver
sulfadiazine and 22%
with acetate mafenid
After 10 days, the propor-
tion of wounds with
good granulation cover-
ing the major part, suit-
able for grafting, was
90% with honey cf 44%
with silver sulfadiazine
and 35% with acetate
mafenid
The proportion of biopsy
samples, taken after 10
days, giving positive mi-
crobial cultures was 20%
with honey cf 100%
with silver sulfadiazine
and 95% with acetate
mafenid
P = .000 for
honey cf the
other
treatments
P < .003 for
honey cf the
other
treatments
P < .00001 for
honey cf the
other
treatments
85
Superficial burns,
created on the
skin with a red-
hot pin (15 mm2
)
No treatment:
also, solution
of sugars as in
honey
Rats 60 (120
wounds)
The mean time to com-
plete healing was 20.4
days with honey cf 30.3
days with no treatment
The mean time to com-
plete healing was 20.4
days with honey cf 28.5
days with sugar
P < .01
P < .01
Healing was seen
histologically to
be more active
and advanced
with honey, and
honey was also
clearly seen to
give attenuation
of inflammation
and exudation,
and less serious
necrosis
16
(continued)
50 LOWER EXTREMITY WOUNDS 5(1);2006
MOLAN
Wounds created
by cutting away
2 × 4 cm pieces
of skin on the
back
Nitrofurazone;
also sterilized
petrolatum
Buffalo
calves
6 (24
wounds)
Granulation, scar forma-
tion, and complete heal-
ing occurred faster with
honey, with more prolif-
eration of fibroblasts and
angioblasts
Not given Attenuation of in-
flammation by
honey was also
seen (by
histological
observation)
86
Wounds created
by cutting away
2 × 4 cm pieces
of skin on the
back, infected by
subcutaneous in-
jection of Staph-
ylococcus aureus
2 days prior to
wounding
Ampicillin
ointment:
also saline
Buffalo
calves
9 (90
wounds)
Honey gave the fastest rate
of healing compared
with the other treat-
ments, also (observed
histologically) the most
rapid fibroblastic and
angioblastic activity in
the wounds and the fast-
est epithelialization
Not given Attenuation of in-
flammation by
honey was also
seen (by
histological
observation)
87
Wounds created
by excising skin
(1 × 1 cm)
Saline Mice 24 Histological examination
showed that the thick-
ness of granulation tissue
was greater with honey
Histological examination
showed that the distance
of epithelialization from
the edge of the wound
was greater with honey
P < .001
P < .001
20
Wounds created
by excising skin
(1 × 1 cm)
Saline Rats 15 (30
wounds)
The area of the wound
(mm2
) with the honey
treatment cf the area
with saline was:
after 4 days: 47.5 cf 71.4
after 8 days: 33.3 cf 52.2
after 12 days: 9.1 cf 40.5
The thickness of granula-
tion tissue (mm, as-
sessed histologically)
with the honey treat-
ment cf the thickness
with saline was:
after 4 days: 0.52 cf
0.389
after 8 days: 1.17 cf 0.53
after 12 days: 1.917 cf
0.995
P < .01
P < .01
With honey,
epithelialization
was more rapid
and there was
less edema (both
assessed
histologically)
88
Wounds created
by excising skin
(2 × 2 cm)
Saline Rats 20 The mean contraction in
size of the wounds was
80% with honey, 55%
with saline
P = .001 89
Wounds created
by excising skin
(2 × 2 cm)
Saline Rats 20 After 10 days, the mean
area of the wounds was
1.15 mm2
with honey,
2.38 mm2
with saline
P = .002 There was
histological evi-
dence of greater
granulation with
honey
90
Table 5 (continued)
Control Species Number Other Reference
Type of Wound Treatment of Animal in Trial Results Statistics Findings Number
(continued)
LOWER EXTREMITY WOUNDS 5(1);2006 51
HONEY AS A WOUND DRESSING
Wounds created
by excising skin
(2 × 2 cm)
No treatment Rats 12 The quantity of collagen
synthesized was in-
creased by honey cf the
control
The degree of cross-link-
ing of the collagen in the
granulation tissue was
increased by honey cf
the control
P < .001
P < .05
91
Wounds created
by excising skin
(2 × 2 cm)
No treatment Rats 12 The content in granula-
tion tissue of various
markers of connective
tissue metabolism in-
creased by honey cf the
control:
protein
collagen
hexosamine
uronic acid
The rate of healing was
increased by honey cf
the control:
contraction of wound
epithelialization
P < .01
P < .01
P < .01
P < .001
P < .001
P < .05
92
Incision (6 cm
long) made in
skin, then
sutured
No treatment Rats 12 The tensile strength of the
wounds was increased
by 21% with honey cf
the control
P < .05 92
Full-thickness in-
cisions (3 cm
long) made in
the skin
No treatment Rabbits 40 Honey increased the
strength of the healed
wounds compared with
the untreated control:
tensile strength
(measured after
14 days)
ultimate strength
yield strength
P < .001
P < .05
P < .02
Less edema was
observed with
the honey treat-
ment, and
histological ex-
amination re-
vealed that honey
gave less inflam-
mation and ne-
crosis and more
fibroblasts and
collagen present
93
Full-thickness in-
cisions (1.5 cm
long) made in
the skin
No treatment Rats 6 Histological examination
of biopsy samples
showed:
with honey, on day 7,
there was epithelial
bridging cf inflammatory
exudate and no
epithelialization with
the control; with honey,
on day 14, there was
complete epithelial
bridging with honey cf
epithelium yet to cover
wound with the control
Not given 94
Table 5 (continued)
Control Species Number Other Reference
Type of Wound Treatment of Animal in Trial Results Statistics Findings Number
there is evidence from histological observation of bi-
opsy samples taken in a clinical trial of honey on
burns50
and from biochemical assays of indicators of
inflammation in other clinical trials on burns.51,52
One
of these biochemical studies was in the form of a ran-
domized controlled trial with 60 patients, comparing
honey with silver sulfadiazine, and it was demon-
strated that honey decreased oxidative stress by mop-
ping up the free radicals arising from burns.52
There is
also histological evidence for the anti-inflammatory ac-
tivity of honey from some of the studies on experimen-
tal animals summarized in Table 5. In some of the ex-
perimentally induced burns, there was no infection
evident, yet honey still brought about a decrease in in-
flammation. This indicates that the anti-inflammatory
activity of honey is a direct action and not a secondary
consequence of removal of infection through its anti-
bacterial activity. This is confirmed also by honey giv-
ing a positive result in the standard guinea pig wrist
stiffness test for anti-inflammatory activity.53
That
honey has a direct anti-inflammatory activity is also in-
dicated by the finding that honey was as effective as
prednisolone in a trial on induced colitis in rats,54
and
by its being found to give a highly significant (P < .001)
reduction in peritoneal adhesions following surgery on
the cecum and ileum in another trial on rats.55
A labora-
tory study also demonstrated a direct anti-inflamma-
tory activity in honey, as honey was shown to signifi-
cantly (P < .001) decrease the amount of reactive
oxygen intermediates released from monocytes in cul-
ture that had been stimulated with Escherichia coli
lipopolysaccharide.25
CONCLUSIONS
There is a large body of evidence to support the use
of honey as a wound dressing for a wide range of types
of wounds. Its antibacterial activity rapidly clears in-
fection and protects wounds from becoming infected,
and thus it provides a moist healing environment with-
out the risk of bacterial growth occurring. It also rap-
idly debrides wounds and removes malodor. Its anti-
inflammatory activity reduces edema and exudate and
prevents or minimizes hypertrophic scarring. It also
stimulates the growth of granulation tissue and epithe-
lial tissue so that healing is hastened. Furthermore, it
creates a nonadherent interface between the wound
and the dressing so that dressings may be easily re-
moved without pain or damage to newly regrown
tissue.
The barrier to using honey that has existed for many
clinicians who have been constrained to using only li-
censed products has been removed now that honey is
available in the form of various sterile products li-
censed for use in wound care. To practice evidence-
based medicine, clinicians involved in wound care
thus should check what evidence exists for other
wound dressing products they may be considering us-
ing and weigh this up against the evidence that exists to
support the use of honey.
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<year>2003</year>;<volume>73</volume>(<issue>6</issue>):<fpage>652</fpage>-<lpage>653</lpage>.</citation></ref></ref-list></back></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>The Evidence Supporting the Use of Honey as a Wound Dressing</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>The Evidence Supporting the Use of Honey as a Wound Dressing</title></titleInfo><name type="personal"><namePart type="given">P. C.</namePart><namePart type="family">Molan</namePart><affiliation>Department of Biological Sciences, University of Waikato, Hamilton, New Zealand,</affiliation><affiliation>E-mail: pmolan@waikato.ac.nz</affiliation></name><typeOfResource>text</typeOfResource><genre type="review-article" displayLabel="review-article"></genre><originInfo><publisher>Sage Publications</publisher><place><placeTerm type="text">Sage CA: Thousand Oaks, CA</placeTerm></place><dateIssued encoding="w3cdtf">2006-03</dateIssued><copyrightDate encoding="w3cdtf">2006</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><physicalDescription><internetMediaType>text/html</internetMediaType></physicalDescription><abstract lang="en">Some clinicians are under the impression that there is little or no evidence to support the use of honey as a wound dressing. To allow sound decisions to be made, this seminar article has covered the various reports that have been published on the clinical usage of honey. Positive findings on honey in wound care have been reported from 17 randomized controlled trials involving a total of 1965 participants, and 5 clinical trials of other forms involving 97 participants treated with honey. The effectiveness of honey in assisting wound healing has also been demonstrated in 16 trials on a total of 533 wounds on experimental animals. There is also a large amount of evidence in the form of case studies that have been reported. It has been shown to give good results on a very wide range of types of wound. It is therefore mystifying that there appears to be a lack of universal acceptance of honey as a wound dressing. It is recommended that clinicians should look for the clinical evidence that exists to support the use of other wound care products to compare with the evidence that exists for honey.</abstract><subject><genre>keywords</genre><topic>evidence</topic><topic>honey</topic><topic>infected wounds</topic><topic>surgical wounds</topic><topic>burns</topic><topic>ulcers</topic></subject><relatedItem type="host"><titleInfo><title>The International Journal of Lower Extremity Wounds</title></titleInfo><genre type="journal">journal</genre><identifier type="ISSN">1534-7346</identifier><identifier type="eISSN">1552-6941</identifier><identifier type="PublisherID">IJL</identifier><identifier type="PublisherID-hwp">spijl</identifier><part><date>2006</date><detail type="volume"><caption>vol.</caption><number>5</number></detail><detail type="issue"><caption>no.</caption><number>1</number></detail><extent unit="pages"><start>40</start><end>54</end></extent></part></relatedItem><identifier type="istex">1900C2A181E979E8CB8A92251CC51A929CC435C4</identifier><identifier type="DOI">10.1177/1534734605286014</identifier><identifier type="ArticleID">10.1177_1534734605286014</identifier><recordInfo><recordContentSource>SAGE</recordContentSource></recordInfo></mods></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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