ࡱ> y Sqbjbj .{{SiNN*=*?*?*?*?*?*?*$+h.~c*777c*x*%%%7=*%7=*%%%CW!>%)**0*%.?#n.%.%lN% Tc*c*%*7777.N n: Beneficial effects of honey dressings in wound management. Sharp, A (2009) Beneficial effects of honey dressings in wound management. Nursing Standard. 24 97) 66-74. Abstract Honey is enjoying a resurgence of popularity in wound care. There is evidence that it has beneficial action on several aspects of wound care; it has been shown to debride wounds, has antimicrobial activity and promotes healing. Many dressings we currently use have action on a single aspect of wound management, they may debride or promote granulation, or deal with infection, honey has the potential to act on more than one phase in wound healing. Perhaps it should be reached for more often. With knowledge of the honey preparations available and application techniques it is an interesting and exciting development in modern wound care. Introduction There are many dressing products now available for nurses to use in wound management. Most dressings are appropriate for one aspect of wound healing; they absorb exudate, they kill bacteria, they debride debris or dead tissue or they promote epithelialisation. There are some combination preparations available, dressings that absorb exudate and kill bacteria or absorb exudate while maintaining the moist wound environment desirable for wound healing. Selecting the appropriate dressing is based on our understanding of the condition of the wound and the patient circumstances together with our knowledge of the properties of the dressing products available to us. So why honey? Well, it is a natural product, something which patients appear to be very comfortable with and it has been used for many years. Many patients remember it being used as a home remedy. The difference now is that we, through science, understand more about how and when honey works in wounds, rather than blind faith that it will work in all wounds on all occasions. This increased knowledge base is good for staff preparing a case for the inclusion of honey products on formularies, good for patients who are looking for wound healing and good for the budget in reducing the number of wound infections that can occur along the road to healing. The antimicrobial effects of honey were first assumed to be entirely due to the osmotic effects of the high sugar concentration of honey. Honey lost favour with the emergence of antibiotics and it is interesting to see that the use of antibiotics are now resulting in renewed interest in the remedies that they replaced. Interest in honey is partly as a direct result of resistant organisms and the fight to control bacteria infections without creating more resistant organisms. Despite being an ancient remedy, honey is becoming a very exciting prospect for future wound management. Honey is described as making a difference in wound care as it has antimicrobial properties, anti-inflammatory properties, promotes debridement, deodorises wounds, maintains a moist wound environment and stimulates healing (White and Molan 2005). Historical use of honey Honey is a product that has been around for many years, long before we understood about the causes of infection and there is documentation in Egyptian papyri dating from before 2000BC that honey was used as a salve in wound care and honey has been used in wound care ever since (Zumla and Lulat 1989). It was acclaimed as a good salve for sore eyes and wounds by Aristotle (c384-322BC). Dioscorides described honey from Attica as being good for all rotten and hollow ulcers c.50AD, perhaps the first reference to recognising that different honeys have different benefits. Indeed, the ancient Greeks, Romans and Chinese have all used honey as an antiseptic in wound care. Honey is mentioned as a medicine in the Koran in a section entitled The Bee: there proceedeth from their bellies a liquor of various colour wherein is medicine for men. (Sura 16 verse 71). Reference can also be found in the Holy Bible: In the Old Testament Solomon advises My son, eat thou honey for it is good (Proverbs 24; 13). The science behind honey in wound care. There are many reasons why honey appears to have regained its popularity in wound management, see Table 1, all relate to its constituents and their action on the wound environment. Honey is a supersaturated sugar solution. It contains approximately 17% water and 80% sugars, the main sugars being fructose (38.5%) and glucose (31%). Small quantities of disaccharides, trisaccharides and oligosaccharides are also present. The remainder is made up of proteins, including the enzymes glucose oxidase and catalase, approximately 18 essential and non essential amino acids, including proline, phenylalanine, tyrosine, glutamic and aspartic acids (Molan 2005). Honey is rich in antioxidants, a major group of phytochemicals, which reduce the risk of tissue oxidative damage. Honey is capable of producing an acid environment, its pH falling in the range 3.4 6.1. Honey has a high osmotic pressure and low water activity (Murray 2004). Honey has a high sugar concentration; this osmotic pull from the honey removes the water molecules in the wound bed, removing them from bacteria that require water to grow. This reduces the ability of the bacteria to reproduce. Laboratory studies have demonstrated this antimicrobial activity of honey, showing the osmotic effect of honey on bacteria. When used in a wound the exudate dilutes the effect of honey, eventually arriving at a point where the osmolality no longer controls bacteria (Chirife et al 1983). However, Sackett (1919) noted that the antibacterial properties of honey are increased when the honey becomes dilute; this additional antimicrobial effect comes from the hydrogen peroxide production (White et al 1963). Honey produces hydrogen peroxide, which has been used in extensively in wound management. However, in contrast to the earlier use, the concentration of hydrogen peroxide produced by honey is far less than the commercially available antiseptic solutions, typically 3% solutions. The hydrogen peroxide is produced by glucose oxidase; one of the enzymes found in honey, when in contact with exudate in the wound bed. Hydrogen peroxide is recognised as an antibacterial agent; however, at concentrations required for effective bacteria control it is toxic to the tissues. The concentration produced by the action of the glucose oxidase contained within the honey when in contact with the catalase contained within the wound bed is very low, about 1000 times less than the solution used as an antiseptic. Honey appears to have additional antimicrobial effects as a direct result of the source of the nectar. Different honeys have different antimicrobial activity, not reliant on the sugar concentration or hydrogen peroxide activity, which makes the source of the honey important. The phytochemical component of honey is the additional benefit some honeys show in antimicrobial activity. When catalase has been added to the honey to remove the hydrogen peroxide activity there remains some antimicrobial activity, of which Manuka honey appears to have a significant level of non peroxide activity in honeys that have been tested (Allen et al 1991). Honey has an acidic pH; Manuka honey from New Zealand has a pH usually between 3.2 and 4.5, low enough to inhibit the growth of most micro-organisms (Molan 2001). The pH of the skins surface is usually around 4.2 to 5.6, slightly acidic (Rothman 1954). If the wound environment is more acidic, then the growth rate of pathogens is reduced. However, the pH should not be lowered too much as this can have a detrimental effect on cellular function. A slightly acidic pH has been identified as being beneficial to epithelialisation (Wiseman et al 1992). It has also been suggested that the acidic environment created by honey in the wound bed increases the rate of granulation as more oxygen is released from the haemoglobin in acidic conditions and possibly the minerals found in honey provide nutrients to the rapidly healing wound (Kaufman et al 1984, Kaufman et al 1985). Another benefit of using honey is the debriding action it has. While this may be a result of the moist wound environment it helps maintain as the wound is constantly supplied with fresh lymph fluid from deeper in the tissues this facilitates autolytic debridement. Alternatively a hypothesis put forward by Molan links the debridement activity to an enzymatic debridement process, with the hydrogen peroxide activating the proteases present in the wound tissues (Molan 1999). There are reports that metalloproteases can be activated by oxidation (Van Wart and Birkedal-Hansen 1990). This is an area that requires further work to establish the precise action of honey on the debridement of wounds. Honey has been recognised as an odour control agent. There are several methods by which honey will reduce or eliminate malodour. Malodour is frequently caused by the ammonia, amines and sulphur compounds produced by the bacteria metabolising amino acids from proteins in the serum and necrotic tissue. Firstly, the antibacterial action will destroy bacteria that typically produce the malodour. Secondly, the glucose present in honey is readily used as the energy source within the wound which will lead to production of lactic acid as opposed to forming the malodorous compounds when metabolising amino acids (Molan 2001). The anti-inflammatory action of honey has been shown in animal experiments where research found a reduction in the number of inflammatory cells in animal wound tissue treated with honey (Molan 1999). Clinical observation in human wounds confirms this. The antioxidant capacity of honey to deal with oxygen free radicals will reduce inflammation in the wound, demonstrated in burn injury (Kandil et al 1987). In one clinical trial partial thickness burn wounds were prevented from converting to full thickness wounds by the application of honey dressings (Subrahmanyam, 1998). It is suggested that honey has a barrier effect on open wounds, preventing further infection from external sources. This has been seen in burn wounds and skin graft wounds (Molan 2005). Interestingly, Molan raises the question on whether honey should be used as a prophylactic dressing on surgical wounds and at insertion sites, something which the dressings industry has acknowledged and work is underway to assess the benefits. The epithelial cells also require energy to migrate across the wound and the honey may provide a ready supply of glucose for this purpose (Silver 1980). ConstituentAction High sugar concentrationOsmotic pull debriding wound Removal of debris Reducing oedema Bactericidal Deodourising Moist wound environmentAcidic pHInhospitable to micro-organisms Hydrogen peroxide productionAnti-microbial agent Phytochemical propertiesAnti-microbial activity Antioxidant propertiesAnti-inflammatory actionTable 1: Action of honey on the wound environment Clinical experience using honey Patients generally like the idea of using natural remedies in wound care. Honey is something they can understand although may express surprise in its use in modern wound care. The author has not had any patient refuse treatment with honey, indeed quite the reverse; patients appear to feel more involved in the care of their wound when they understand the product being used. In a randomised controlled trial (in preparation for publication) patients were disappointed not to be randomised to the honey treatment group! However, honey is not always easy to use and an understanding of certain concepts makes application easier see Table 2. Wound care honey The renaissance of honey in wound care has been picked up by the media and many nurses have been presented with newspaper articles extolling the virtues of honey in wound care. Patients arrive armed with a jar of honey, sometimes very expensive honey. The healthcare practitioner then has the dilemma of whether to use the honey or not. Indeed honey has been widely used for wound care on its own or in combination with other products so not entirely an unknown concept to some nurses. If honey is going to be of any value in modern wound care, then the honey should be of a suitable quality for use in wound care. Honey for food use should not be applied to the wound bed. While honey does not allow bacterial growth it may contain fungal spores which, on dilution in the wound bed could potentially lead to a fungal infection. Honey for medical use in wound management has been gamma irradiated to kill any spores while not destroying the glucose oxidase which is responsible for the production of hydrogen peroxide when in contact with the catalase in the wound bed. The honey used in wound care is also filtered to remove any debris that may be found in the honey, reducing the risk of granulomas developing in the wound bed. New Zealand Manuka honey, well known for its antibacterial activity, is labelled with the level of antimicrobial activity given as a UMF value. This is equivalent to the phenol concentration on Staphylococcus aureus, a UMF factor of 15 is equivalent to 15% concentration of phenol. Quantity of honey The wound needs to be covered in honey for the activity of honey to be beneficial, getting the right quantity of honey onto the wound has been difficult in the past, necessitating frequent reapplication which may be more of a problem when patients are nursed at home. Honey for wound care is available as liquid honey or as dressing products which have additional properties. Alginate based products are available which both maintain the level of honey at the wound bed and provide an absorbent dressing for the exudate. Initially levels of exudate rise and can be difficult to manage, which is where alginate based products have an advantage. However, levels soon reduce and the dressing should maintain the moist wound environment and not dry the wound bed out. High levels of exudate from a wound have caused concern due to the dilution of the honey and therefore doubts about the antimicrobial efficacy of the honey when diluted. Cooper and Molan (1999) found honey to be effective even when diluted 10 fold by wound exudate. Further work by Murray (2004) confirms the efficacy. Minimum inhibitory concentrations (MIC), a measure of bacteriostatic action, were determined for a wide range of bacterial isolates with MIC'sranging from 1%-12% volume for volume honey with many individual species of common wound bacteria showing a narrow range of susceptibility e.g. MRSA giving MIC's of between 4% and 6% (v/v) honey. Dressings which maintain the concentration of honey at the wound bed, while absorbing excess exudate tend to be better tolerated by patients. Sinus and cavity application Sinuses and cavities should be filled with honey before a secondary dressing applied. The honey in liquid form can be inserted into sinuses using a syringe (fill by removing the plunger!) with or without a cannula to ensure honey gets to the base of the sinus. Any residual honey and exudate can be flushed out as honey is water soluble, any residue is biodegradable and should not cause a problem if honey for wound care is used as it has been filtered. Cavities should be filled with liquid honey to ensure the wound bed is covered in honey to have the beneficial effects of the honey diffusing into the wound bed. A secondary dressing is required to keep the honey in contact with the wound bed. Debriding wounds Molan (2005) describes honey as debriding wounds faster than other dressings, equating the speed of action to that of maggot therapy. Some authors have good results when using honey to debride eschar. Davies (2005) has described complete debridement from eschar to granulation tissue in 5 days. Gray and White (2005) describe a case in which a diabetic patient with a necrotic heel used honey for one week at which the eschar was ready for conservative sharp debridement. However, Robson (2005) has not found honey to be beneficial in the debridement of eschar in wounds. The author has not found honey as quick a debriding agent as other dressings on eschar, but equally as beneficial when used on wounds with slough and moist debris. As honey has a debriding action drawing lymph from deeper tissues and can debride foreign material found in the wound. This has been particularly helpful when cleaning stitch sinus wounds, particularly small sinuses. Honey will remove the grit and dirt found in some wounds without the need for painful scrubbing or leaving the cosmetically unwelcome tattooing effect on the skin. Maceration Creating and maintaining a moist wound environment has potential drawbacks. If the wound is too moist then maceration can occur and some dressings must be cut to the wound dimensions to avoid this problem. Honey dressings do not need to be cut to size as the honey will take up all free water molecules while maintaining the desirable moist environment. As honey has a high sugar concentration, whether honey dressings or free liquid honey is used, it manages the amount of free water available in the wound, reducing the risk of maceration of the surrounding peri-wound area. Honey may well reduce the pain and inflammation associated with peri-wound maceration and excoriation as a result of its anti-inflammatory activity. Creams which protect the skin and to treat excoriation are now available with honey and some benefit may be derived from these, although the quantity and type of honey used may not provide all of the benefits described in this article. Adverse effects There have been very few adverse events documented with the use of honey in wound care. Robson (2005) advises that patients who have a known sensitivity to bee stings or bee products should not use honey. It has been reported that allergy to honey is rare (Kristala et al 1995) and Molan (1999, 2001) suggests that the use of honey in wound care in unlikely to result in any undesirable effects for the patient. There are reports of honey relieving pain (Dunford et al 2000a), however, some patients have however described a stinging or burning sensation on application of honey. This appears to be more common when the wounds are inflamed. The author has not had patients experience this, however, colleagues treated for burn injuries have described this effect, and that is does reduce within a short period of time. Dunford et al (2000b) described two patients experiencing some discomfort for the first 30 minutes after application and add that as above, this appears to be experienced more often when there is a significant amount of inflammation. The pain may be a result of the acidity of the honey coming into contact with the wound bed. Patients should be warned that this sensation is entirely normal and usually settled down within a few hours. QuestionAnswerCan any honey be used?Only honey specifically prepared for wound care use should be used. It should be filtered and gamma irradiated and CE marked.How much honey should be used?Enough to cover the wound or fill the cavity or sinus. It can overlap the wound margins.What dressings are available?Currently in the United Kingdom honey is available for wound care in liquid form, simple dressing form (tulle or pad) or alginate dressings. Select the most appropriate for the area and level of exudate. See Table 3How often should the dressing be changed?Honey needs to be in contact with the wound bed to be effective. The dressing may need daily changes initially and as the level of exudate reduces, time between dressing changes can be extended.Should honey be used alone or in combination with other dressings?Honey can be used on its own, depending on the dressing used and the wound. It may be that liquid honey is used with a suitable secondary dressing to keep it in place and absorb excess exudate.Can I use honey on a diabetic patient?There are no reports of any adverse events related to topical use of honey with diabetic patients. In practice blood sugar monitoring should continue as the diabetic patient with a wound is at high risk of infection which can affect their glycaemic control.Table 2: Frequently asked questions Summary Any product that has captured the interest of the patient population and delivers on its promises deserves the attention of healthcare practitioners involved in wound care. Honey has a number of properties that make it of great interest in modern wound care. The antimicrobial activity of honey makes it of particular interest in the current climate where infection control is paramount. The other attributes of honey are its anti-inflammatory action, deodourising ability and its potential to promote healing. None of these attributes would be considered as desirable if, in a dressing format, honey was not easy to apply and considered comfortable by patients. From ancient times honey has been used for treating wounds but lost its place in wound care, like maggot therapy, with the introduction of antibiotics half a century ago. Now, with concern about the use of antibiotics and the development of resistance to our main source of treatment for infection, alternatives are being sought to combat infection. The difference in the current climate is that wound care products which may have been used for many years are now being used only when their mode of action and properties are better understood. Without the evidence these products that may have been used for centuries are not making back into common usage. With supporting evidence we are reintroducing products in a targeted manner. Honey is one of these products. ProductFormationManufacturerActivon Tulle100% Manuka honey in a tulle dressingAdvancis MedicalActivon100% Manuka honey in a tubeAlgivon100% Manuka honey in an alginate base Actilite100% Manuka honey with Manuka oil in a low adherent dressingMedihoney Antibacterial wound gelAntibacterial wound gel with natural waxes and oilsMedihoneyMedihoney Antibacterial honeyAntibacterial wound gel withMesitranSheet hydrogel with 30% medical grade honeyMesitranMesitran MeshWound contact layer with 20% medical grade honeyMesitran BorderSheet hydrogel with 30% medical grade honey with an adhesive borderMesitran Ointment47% medical grade honey, lanolin, sunflower oil, cod liver oil, Calendula officinalis, Aloe barbadensis, vitamins C and E, zinc oxideMesitran Ointment S40% medical grade honey, lanolin, vitamins C and E, polyethylene glycolTable 3: Dressings available on the UK Drug Tariff References Allen, KL. Molan, PC. Reid, GM. (1991) A survey of antibacterial activity of some New Zealand honeys. J Pharm Pharmacol 43, 12, 817-22. Chirife, E. Herszage, L. Joseph, AL. Kohn, ES. (1983) In Vitro Study of Bacterial Growth Inhibition in Concentrated Sugar Solutions: microbiological basis for the use of sugar in treating infected wounds. Antimicrob Agents Chemother 23, 5, 766-73. Cooper, RA. Molan, PC. (1999) The Use of Honey as as Antiseptic in Managing Pseudomonas Infection. J. Wound Care. 8, 4, 161-164. Davies, P. (2005) Recent Clinical Usage of Honey in the Treatment of Wounds. Wounds-UK 3, 1, Suppl,14-22 Dunford, C. Cooper, R. Molan, PC. (2000a). Using Honey as a Dressing for Infected Skin Lesions. Nursing Times. 96, 14, Suppl, 7-9. Dunford, C. Cooper, R. Molan, PC. White, R. (2000b). The Use of Honey in Wound Management. Nursing Standard. 15, 11, 63-68. Gray, D. White, R. (2005) Mesitran Ointment Case Studies. Wounds-UK 3, 1, Suppl, 32-35. Kandil, A. El-Banby, M. Abdel-Wahed, K. Abou-Sehly, G. Ezzat, N. (1987) Healing Effect of True Floral and False Non-Floral Honey on Medical Wounds. J Drug Res (Cairo) 17, 1-2, 71-5. Kaufman, T. Eichenlaub, EH. Angel, MF. Levin, M. Futrell, JW. (1985) Topical Acidification Promotes Healing of Experimental Deep Partial Thickness Skin Burns: a randomised double-blind preliminary study. Burns 12, 84-9. Kaufman, T. Levin, M. Hurwitz, DJ. (1984) The Effect of Topical Hyperalimentation on Wound Healing Rate and Granulation Tissue Formation of Experimental Deep Second Degree Burns in Guinea-pigs. Burns 10, 4, 252-6. Kristala,R. Hannuksela, M. Makinen-Kiljunen, S. Ninimaki, A. Haahtela, T. (1995) Honey Allergy is Rare in Patients Sensitive to Pollen. Allergy. 50, 844-7. Molan, PC. (1999) The Role of Honey in the Management of Wounds. J. Wound Care. 8, 415-418. Molan, PC. (2001) Honey as a Topical Antibacterial Agent for Treatment of Infected Wounds.  HYPERLINK "http://www.worldwidewounds.com/2001/november/Molan/honey-as-topical-agent.html" http://www.worldwidewounds.com/2001/november/Molan/honey-as-topical-agent.html. Accessed 14 April 2008. Molan, PC. (2005) Mode of Action. In White, R. Cooper, R, Molan, P. (Eds) Honey: a modern wound management product . Wounds-UK, Aberdeen, 1-24. Murray, M. (2004) Action of honey on bacteria from infected surgical wounds. MSc Project. Glasgow Caledonian University. Robson, V. (2005) Guidelines for the use of Honey in Wound Management. In White, R. Cooper, R, Molan, P. (Eds) Honey: a modern wound management product . Wounds-UK, Aberdeen, 149-155. Rothman, S. (1954) pH of Sweat and Skin Surface. In Rothman, S. (ed) Physiology and Biochemistry of the Skin. University of Chicago Press, Chicago. Sackett, WG. (1919) Honey as a Carrier of Intestinal Diseases. Bull Collo Agric Exp Stn No 252, 18. Silver, IA. (1980) The Physiology of Wound Healing. In: TK Hunt, (ed) Wound Healing and Wound Infection: theory and surgical practice. Appleton-Century-Croft, New York, 11-28. Subrahmanyam, M. (1998) A Prospective Randomised Clinical and Histological Study of Superficial Burn Wound Healing with Honey and Silver Sulfadiazine. Burns 24, 2, 157-61. Van Wart, HE. Birkedal-Hansen, H. (1990) The Cystein Switch: a principle of regulation of metalloproteinase activity with the potential applicability to the entire matrix metalloproteinase gene family. Proc Nat Acad Sci USA 87, 14, 5578-82. White, JW. Subers, MH. Shepartz, AI. (1963) The Identification of Inhibine, the Antibacterial Factor in Honey as Hydrogen Peroxide and its Origin in a Honey Glucose-Oxidase System. Biochem Biophys Acta, 73, 557-70. White, R. Molan, PC. (2005) A Summary of Published Clinical Research on Honey in Wound Management. In White, R. Cooper, R, Molan, P. (Eds) Honey: a modern wound management product . Wounds-UK, Aberdeen, 130-143. White, JW. Subers, MH. Schepartz, AI. (1963) The Identification of Inhibine, the Antibacterial Factor in Honey, as Hydrogen Peroxide and its Origin in a Honey Glucose-oxidase System. Biochim Biophys Acta 73, 57-70. Wiseman, D. Rovee, D. Alvarez, O. (1992) Wound Dressings: design and use. In Cohen, IK. Diegelmann, RF. Lindblad, WJ (eds), Wound Healing: biochemical and clinical aspects. WB Saunders, Philadelphia. Zumla A, Lulat A (1989) Honey a Remedy Rediscovered. J. Royal Soc. Med. 82, 384-385. :;   ? @ A 1 2 3 ? @ q`N#hZ=h/5OJQJ^JmH sH  hZ=h\XOJQJ^JmH sH  hZ=hoGOJQJ^JmH sH  hZ=hOJQJ^JmH sH  hZ=hF OJQJ^JmH sH #hZ=h\X5OJQJ^JmH sH  hZ=hZ,OJQJ^JmH sH &hZ=hZ=56OJQJ^JmH sH #hZ=hZ,5OJQJ^JmH sH #hZ=hZ=5OJQJ^JmH sH ;<2 3 @ kd! $t'.*^gdli^gdo^gdoG^gd1^gdZ=^gdD%  ! 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