Honey provides a sugar-rich food source for

Transcription

1 Honey and Contemporary Wound Care: An Overview FEATURE Keith F. Cutting, MN, RN, Cert Ed(FE) A growing body of research and empirical evidence have supported the re-discovery of medicinal-grade honey as a wound management agent. Pre-clinical study results suggest that honey has therapeutic benefit; clinical study results have shown that honey effectively addresses exudate, inflammation, devitalized tissue, and infection. Honey-containing dressings and gels have been developed to facilitate the application of medicinal-grade honey to the wound. Clinical studies to compare the safety and effectiveness of these products to other moisture-retentive dressings and treatment modalities are warranted. KEYWORDS: honey, leptospermum, Manuka, wound bed preparation Ostomy Wound Management 2007;53(11):49 54 Honey provides a sugar-rich food source for bees. They harvest honey as nectar, a sugary fluid (approximately 80% water) produced by a variety of plants in order to attract insects and su b s equ en t ly prom o te cro s s - po ll i n a ti on. The bee s transport the nectar back to the hive where the nectar is proce s s ed and tra n s form ed into hon ey (80% sugar, 17% water). The honey then is stored and sealed in the comb using beeswax. During hive processing, most of the water is removed; the binding of the remaining water molecules and the ad d i ti on of en z ymes by the bees help en su re that microbi a l growth is not supported. 1 The many different types of honey and the nuances of the finished product depend not only on the flower source, but also on a variety of factors including weather and climatic conditions. Not all honeys are the same. As flavor, consistency, and color of honey vary, so do its therapeutic purposes. These variations in characteristics led Molan 2 to the conclusion that honey should not be considered a generic term. The thera peutic properties of h on ey are va ri a bl e and depend on the type of h on ey used. Ma nuka (the Ma ori name for the New Zealand tea tree / bu s h Lepto s permum scop a rium) or Lepto s permum is h on ey derived from the tea tree ; the form er is the m ore wi dely used term. In a revi ew of the litera tu re, Moore 3 s h owed that Ma nuka hon ey has very special healing properti e s and de s c ri bed it as the be s t n a tu ral anti bi o tic in the worl d. Med i c a l - grade Ma nuka hon ey is prep a red purely for medical use and con tro ll ed by a ri gorous set of s ys tems and standard s. 4 These ex acting standard s a pp ly to the lepto s permum hon ey distri buted in the US (Med i h on ey, Derma Scien ce s, Pri n ceton, N J ). This produ ct is a bl end of L. scopa ri u m ( Ma nu k a ) and L. polyga l i fol i u m k n ow as Jelly Bu s h. The purpose of this revi ew is to accen tu a te the wi de - ra n ging thera peutic adva n t a ges that hon ey can of fer using examples from the litera tu re. Mr. Cutting is a Tissue Viability Specialist, Harefield Hospital, Middlesex, UK: and Principal Lecturer, Buckinghamshire University College, Buckinghamshire, UK. Please address correspondence to: Keith F. Cutting at info@healthdirections.co.uk. Mr. Cutting discloses that he has served as consultant to Derma Sciences, Princeton, NJ. November 2007 Vol. 53 Issue 11 49

2 History Hon ey as a thera peutic agent has a history that date s b ack thousands of ye a rs ; this fact assists in underp i n- ning its thera peutic creden ti a l s. Na m i a s 6 n o ted that h on ey is men ti on ed in rel a ti on to healing in the Bi bl e, the Kora n, and the Tora h. In ad d i ti on, the Edwin Sm i t h Pa pyrus (17th cen tu ry BC), Hi ppoc ra te s, a n d Dem oc ri tus in ancient Greece, G a l en in ancient Rom e, and Avi cenna in med i eval times all have recorded the m edical properties of h on ey. 7, 8 Until the first part of the 20th century, honey dressings were part of everyday wound care practice. With the advent of antibiotics in the 1930s and 1940s, views changed and honey was consigned to items of historical interest. Misuse of antibiotics, the emergence of resistant bacteria, and increasing interest in therapeutic honey have provided an opportunity for honey to be re-established as a broad-spectrum, antibacterial agent that is non-toxic to human tissue. Despite lack of promotional support from large corporations, interest in the use of honey in wound management has increased in recent years. However, a clinical profile in wound care commensurate with other modalities has not been achieved despite offering similar indications of use and an increase in research activity and clinical reports. Zumal and Lulat 7 observed, The therapeutic potential of uncontaminated, pure honey is grossly underutilized. Clinicians need reassurance that any health-related agent is safe and meets its stated therapeutic purpose. Therefore, it is important to emphasize that although natural in origin, the honey used in wound care should be of medical-grade standard and not sourced from honey destined for the supermarket shelf. Medical grade honey is filtered, gamma-irradiated, and produced under carefully controlled standards of hygiene to ensure that a standardized honey is produced. 4 Ostomy Wound Management 2007;53(11):49 54 KEY POINTS The author provides a brief ove rv i ew of the history of using honey to manage wounds and reported results of its use in pre-clinical and clinical eva l u a t i o n s. Therapeutic Benefit of Honey in Wound Care A systematic review 3 of honey as a wound dressing noting the dearth of good evidence on topical wound agents contradicts Molan s literature review 9 of the evidence (17 randomized, controlled trials involving 1,965 participants and five clinical trials involving 97 participants, plus numerous case studies), supports the use of honey as a wound dressing, and underscores clinician failure to recognize that evidence. Molan s 10 research review also addressed the range of honey s therapeutic activities (see Table 1). Wound bed preparation. Wound bed preparation may be viewed as management of the wound in order to accelerate endogenous healing. 10 The bio-activity of honey aligns closely with the concept of wound bed prep a ra ti on. The phys i o l ogy of healing in ac ute wounds is a carefully controlled series of events that en su res healing progresses in a ti m ely fashion. However, in chronic wounds this orderly sequence is disrupted and the repair process is delayed. If wound bed preparation is to be successful, the impediments to healing must be recognized and addressed, implying appropriate management of exudate, devitalized ti s su e, and assoc i a ted bi obu rden. The appropri a te application of honey dressings offers a way forward in managing potential wound-related barriers to healing. Exudate. A clinical study by Al-Waili and Saloom 12 compared honey with topical antiseptics in 50 patients with po s topera tive abdominal wound infecti on s ; Ahmed et al s 13 non-randomized study of 60 patients with chronic surgical or trauma wounds; and Betts and Molan s 14 in vivo pilot study reported that honey helps reduce the amount of wound exudate. This is most likely a consequence of honey s anti-inflammatory properties. Inflammation increased vessel permeability increases fluid movement into soft tissue, subsequently increasing surface exudate. A decrease in inflammatory cells has been found (histologically) in animal models following application of honey in fullthickness burns. 15 Similar findings have been reported in animal studies comparing ampicillin and nitrofuazone in treating infection of full-thickness wounds. 16,17 The anti-inflammatory activity of honey also has been documented in clinical studies of human burn wounds and in in vitro studies The potential con- 50 OstomyWound Management

3 TABLE 1 THE BIOACTIVITY OF HONEY Bioactivity of honey* Prevention of cross-contamination Provides a moist wound healing environment Dressings do not adhere to wound surface. Tissue does not grow into dressings Promotes drainage from wound Removes malodor Promotes autolytic debridement Stimulates healing Anti-inflammatory Suggested Rationale* Viscosity of honey provides a protective barrier Osmolarity draws fluid from underlying tissues The viscous nature of honey provides an interface between wound bed and dressing Osmotic outflow sluices the wound bed Bacterial preference for sugar instead of protein (amino acids) means lactic acid is produced in place of malodorous compounds Bioactive effect of honey Stimulation of healing has been observed together with objective measurements in animal wounds Number of inflammatory cells (histologically) found to be reduced in honey-treated wounds Managing infection *not necessarily research-based. Adapted from the literature. Antiseptic properties found to be effective against a range of microbes including multi-resistant strains s equ en ces of ef fectively managing inflammati on include rapid reduction of pain, edema, and exudate; additionally, hypertrophic scarring is minimized by avoiding protracted inflammation that may result in f i bro s i s. 21 It fo ll ows that reducing inflammati on lessens exudate production and dressing change frequency, which may conserve resources in terms of dressings used, staff time, and unnecessary disturbance of the patient and the wound bed. Devitalized tissue. It has been established that dressings that create the type of moist wound environment that honey provides facilitate the process of autolytic debridement. The osmotic pull of honey draws lymph from the deeper tissues and constantly bathes the wound bed. Lymph fluid contains proteases that contribute to the debriding activity of honey. In addition, the constant sluicing of the wound bed is believed to help remove foreign body (eg, dirt and grit) con t a m i n a ti on. 2 1 Mo l a n 2 2 has su gge s ted the most likely ex p l a n a ti on for hon ey s debriding activity the convers i on of i n active plasminogen to plasm i n, an en z yme that breaks down the fibrin that tet h ers slough and eschar to the wound bed. S teph en - Hay n e s, 2 3 who pre s en ted the re sults of t h ree p a ti ent case studies and an ad d i ti onal five pati en t s who ben ef i ted from managem ent of wound malodor, a t tests to the clinical impact of h on ey in debri dem en t. Ma l odor is known to occur in a va ri ety of wounds in con ju n cti on with slough and nec ro tic ti s- su e ; it is a particular con cern wh en managing funga t- ing lesion s. Ma l odorous su b s t a n ces su ch as ammon i a and su l phur com pounds are produ ced wh en bacteri a m et a bo l i ze pro tei n. Because hon ey provi des bacteri a an altern a tive source of en er gy (glu co s e ), these noxious com pounds are no lon ger produ ced and wo u n d m a l odor is avoi ded. November 2007 Vol. 53 Issue 11 51

4 TABLE 2 HONEY DRESSINGS AVAILABLE AND SUGGESTIONS FOR USE Application/indications Honey liquid or gel dispensed from a tube Absorbent alginate dressing with honey Honey in a hydrocolloid-like sheet Applied directly onto wound or onto appropriate dressing before application Can be applied to most acute/chronic wounds including infected or s l o u g hy wo u n d s Should be selected according to the exudate level of the wound Maceration. Macerated periwound skin can be a problem in some wounds and is often related to the dressing used. 24 The osmotic action of honey, previously mentioned, has been shown in previous reviews of the literature to reduce the risk of maceration honey draws moisture rather than donates it. 21 Thus, periwound skin is protected from overhydration. Bi obu rden. Hon ey has been shown in cl i n i c a l observations to have the ability to manage wound infection in situations where conventional antimicrobial (anti bi o ti c s / a n ti s eptics) have failed Hon ey also has been found to be effective in vitro against a range of multiresistant organisms including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), and other multi resistant Gra m - n ega tive or ganisms inclu d i n g Pseudomonas aeru gi n o s a. 28 Ot h er in vi tro s tu d i e s i nvo lving different micro - or ga n i s m s 29,30 also have demonstrated honey s effectiveness against antibioticresistant bacteria. George and Cutting 28 specifically identified honey s antibacterial activity. The binding of water can be added to these antibacterial properties: The high sugar content/low water activity provides osmotic action Acidic ph (3.2 to 4.5) inhibits bacteri a l growth G lu cose oxidase en z yme helps produ ce hydrogen peroxide Plant-derived factors (present in some honeys and not specifically identified). The antibacterial action most likely reaches below the wound surface. Although topical honey manages superficial bacteria (bactericidal in action rather than bacteriostatic) 30,31 it also has been shown in vitro to provi de prom pt cl e a ra n ce of deep - s e a ted infecti on and boils with unbro ken skin, su gge s ting that h on ey s anti b acterial activi ty may diffuse thro u gh the skin to deeper ti s su e s. Cooper et al 3 0 perform ed s en s i tivi ty te s ting of 17 strains of P. a eru gi n o s a i s o- l a ted from infected bu rns using two hon eys wi t h d i f ferent types of a n ti b acterial activi ty; Wa h d a n 3 1 com p a red the anti b acterial activi ty of a su gar soluti on and hon ey on 21 types of b acteria and two types of f u n gi. Bi of i l m s. In recent ye a rs, a t ten ti on has tu rn ed to the po ten tial role of bi ofilms in wound infecti on. A bi ofilm may be de s c ri bed as a bacterial com mu n i ty l iving within a self- produ ced ex tracellular po lys acch a ri de (EPS) matri x. 3 2 The EPS pro tects the bacterial com mu n i ty from anti m i c robial and ph a goc yti c on s l a u gh t. L a tely, in vi tro evi den ce has indicated that h on ey is an ef fective agent for preven ting bi ofilm form a ti on. 3 3 In ad d i ti on, O k h i ria et al 3 4 found in an i n vi tro s tu dy that labora tory - grown Ps eu dom on a l bi ofilms were disru pted fo ll owing app l i c a ti on of Ma nuka hon ey. These findings are parti c u l a rly en co u ra ging wh en con s i dering the em er gen ce of a n ti m i c robi a l - resistant bacteri a. No evi den ce has yet been pre s en ted that bacterial re s i s t a n ce to hon ey has occ u rred it is high ly unlikely that bacteria wi ll s el ect for re s i s t a n ce to hon ey because bacteria rely on su gar as a source of food. Cro s s - con t a m i n a ti on. Use of h on ey dre s s i n gs m ay help prevent cross con t a m i n a ti on. This is and wi ll remain an important issue in healthcare. Th e vi s cous natu re of h on ey is bel i eved to provi de a physical barri er that helps safeg u a rd pati ents by preven ting cro s s - con t a m i n a ti on. 52 OstomyWound Management

5 Dressing Wounds with Honey All dressings must be used in accordance with the manufacturer s instructions. This helps endorse the maxim do no harm and ensure that the full benefit of the product is realized. Because of its fluid and viscous nature, honey can be difficult to apply. This is particularly true when profuse ex u d a te is pre s en t, d i luting the hon ey. Experience has shown that use of the appropriate honey vehicle, including a secondary dressing, can sometimes circumvent this problem (see Table 2). Allergy. Before honey is applied to a wound, the patient should be asked routinely if he/she is allergic to honey or bee products, including bee stings. It is advisable not to proceed w ith a honey-containing dressing if the answer is affirmative. D i s com fort. O cc a s i on a lly, s ome pati ents report transient stinging on application of honey. The discomfort often disappears in a short period of time or after the first few applications. Analgesia is required only in those rare circumstances when pain may persist. In a review paper, Molan 5 noted that patient re s ponse to hon ey app l i ed to open wounds was reported as soothing, pain-relieving, and non-irritating, and demonstrated no adverse effects. Conclusion The resurgence of interest in honey as a modern wound dressing offers opportunities for both patients and clinicians. Recent additions to the honey product range of dressings indicate commercial confidence in the future of therapeutic honey. The wheel has turned full circle and honey is being re-established as a valuable agent in modern wound care management. Its adva n t a ges providing a moist envi ron m en t, debriding, deodorizing, antibacterial, anti-inflammatory capabilities are factors that have been shown to facilitate healing. These advantages have been experien ced by pati ents and clinicians in Eu rope and Australia and are now available to patients in North America. Use of any medical device must be based on clinical ju s ti f i c a ti on and ava i l a ble evi den ce abo ut product safety and effectiveness. Continued research is needed to increase understanding about the role of honey in a variety of wounds and its effect on healing compared to other treatment modalities. - OWM References Molan P. Not all honeys are the same for wound healing. Eur Tissue Repair Soc Bulletin. 2002:9(1). 3. Moore OA, Smith LA, Campbell F, Seers K, McQuay HJ, Moore RA. Systematic review of the use of honey as a wound dressing. BMC Complementary and a l tern a tive med i c i n e. Ava i l a ble at Accessed July 15, Yoon YM, Newlands C. Quality standards of medical grade Manuka honey. In: White R, Cooper R, Molan P, ed s. Ho n ey: A Mod ern Wound Ma n a gem en t Produ ct. Aberdeen, U K : Wounds UK publ i s h- ing; Molan P. Honey as a topical antibacterial agent for treatment of infected wounds. World Wide Wounds. Ava i l a ble at: w w w. worl dwi dewo u n d s. com / 2001 / n ovem ber / Mo l a n / h on ey - a s - top i c a l - a gen t. h tml Acce s s ed Ju ly 15, Namias N. Honey in the management of infections. Surg Infect. 2003;4(2): Zumla A, Lulat A. Honey: a remedy rediscovered. J Royal Society of Med. 1989;82: Jones R. Honey and healing through the ages. In: Munn P, Jones R eds. Honey and Healing. Cardiff, U K. In tern a ti onal Bee Re s e a rch As s oc i a ti on. 2001: Molan PC. The evi den ce su pporting the use of honey as a wound dressing. Lower Extremity Wounds. 2006;5(1): Molan PC. Why honey is effective as a medicine 2. The scientific explanation of its effects. Bee World. 2001;82(1): Dowsett C, Ayello E. TIME principles of chronic wound bed preparation and treatment In: Cutting KF ed. Trends in Wound Care IV. London, UK: MA Healthcare Ltd. 12. Al-Waili NS, Saloom KY. Effects of topical honey on post-operative wound infections due to Gram-positive and Gram-negative bacteria following Caesarean s ecti ons and hys terectom i e s. Eur J Med Re s. 1999;4: Betts JA, Molan PC. A pilot trial of honey as a wound dressing has shown the importance of the way that honey is applied to wounds. Presented at the 11th European Wound Management Association conference. Dublin, Ireland. May 17 19, Ahmed AK, Hoekstra MJ, Hage JJ, Karim RB. Honeymedicated dressing: transformation of an ancient rem edy into modern thera py. Ann Plast Su rg. 2003;50(2): Postmes T, Vandeputte J. Recombinant growth fac- November 2007 Vol. 53 Issue 11 53

6 tors of honey. Burns. 1999;25: Kumar A, Sharma VK, Singh HO, Prakash O, Singh SP. Efficacy of some indigenous drugs in tissue repair in buffaloes. Indian Vet J. 1993;70(1): Oryan A, Zaker SR. Effects of topical application of honey on cutaneous wound healing in rabbits. J Vet Med. 1998;Series A45(3): Subrahmanyam M. A prospective randomized clinical and histological study of superficial burn wound healing with honey and silver sulfadiazine. Burns. 1998;24(2): Subrahmanyam M, Sahapure AG, Nagane NS, et al. Effects of topical application of honey on burn wound healing. Ann Burns Fi re Di s a s ters. 2001;14(3): Subrahmanyam M, Sahapure AG, Nagane NS, et al. Free radical control the main mechanism of the action of honey in burns. Ann Burns Fire Disasters. 2003;16(3): Molan PC. Re-introducing honey in the management of wounds and ulcers theory and practice. Ostomy Wound Manage. 2002;48(11): Molan PC. Mode of action. In: White R, Cooper R, Molan P, eds. Honey: A Modern Wound Management Produ ct. Aberdeen, U K : Wounds UK Publishing; Stephen-Haynes J. Evaluation of honey impregnated tulle dressing in primary care. Brit J Community Nurs. 2004:June(wound care Suppl):S21 S Cutting K, White R. Maceration of the skin: 1. The nature and causes of skin maceration. J Wound Care. 2002;11(7): Efem SEE. Recent advances in the management of Fo u rn i er s ga n gren e : prel i m i n a ry ob s erva ti on s. Surgery. 1993;113(2): Wood B, Rademaker M, Molan PC. Manuka honey, a low cost leg ulcer dressing. New Zealand Med J. 1997;110: Dunford C, Cooper R, Molan PC. Using honey as a d ressing for infected skin lesion s. Nu rs Ti m e s. 2000;96(14 NT-Plus): George NM, Cutting KF. Medihoney Antibacterial honey in vitro activity against clinical isolates of MRSA, VRE and other multi-resistant Gram-negative organisms including Pseudomonas aeruginosa. WOUNDS In press. 29. Karayil S, Deshpande SD, Koppikar GV. Effect of honey on multidrug resistant organisms and its synergistic action with three common antibiotics. J Postgrad Med. 1998;44: Cooper RA, Halas E. Molan PC. The efficacy of honey in inhibiting strains of Pseudomonas aeruginosa from infecte d burns. J Burn Care Rehabil. 2002;23: Wahdan HA. Causes of the antimicrobial activity of honey. Infection. 1998;26(1): Cut ting KF. Wound In fecti on unders t a n d i n g, assessment and control. Wound Care Society educational booklet Wound Care Society, UK. 33. Irish J, Carter D, Blair S. Honey prevents biofilm formation in Staphylococcus aureus. Poster presentation 8th Asian Ap i c u l tu ral As s oc i a ti on Con feren ce. Perth, Australia. March 20 24, Okhiria O, Henriques A, Burton N, Peters A, Cooper RA. The potential of Manuka honey for the disruption of biofilms produced by strains of Pseudomonas aeruginosa isolated from wounds. Poster presentation at the 155th Meeting of the Society for General Microbiology. Dublin, Ireland. September 6 9, OstomyWound Management