Thursday, May 07, 2009

Honey of a Remedy for Nonhealing Wounds

Désirée Lie, MD, MSEd, Medscape, 4/30/2009

Case Presentation

A 45-year-old man has had moderately well-controlled diabetes mellitus (DM) for 5 years. He takes metformin and sulphonylurea as prescribed, but he is prone to wounds that are slow to heal. His most recent test for hemoglobin A1c (HbA1c) is 7.0%. He is overweight and has an elevated body mass index of 29 kg/m², but he says he follows an American Diabetic Association-approved 1800-kcal diet and he walks daily for at least 20 minutes. He also has an elevated low-density lipoprotein (LDL) cholesterol level (160 mg/dL), but he is not currently on statin treatment. He presents with a lower-leg venous ulcer that has not healed despite treatment that includes regular elevation of the leg, daily changes of hydrogel dressings, and medication with mupirocin ointment.

The physical examination of the lower leg reveals mild neuropathy characterized by reduced sensation for pinprick and light touch, but detects good dorsales pedis pulses. The patient has no symptoms of claudication, and his arterial-brachial index is normal at 1.1.

He recently heard about the benefits of medicinal honey and asks the physician whether he can ingest honey to better control his DM and hyperlipidemia. He is also interested in using honey topically to treat his leg ulcer. He asks what type of honey would be useful for these purposes, how much to use, and whether medicinal honey is associated with any known adverse effects...

Case Summary and Resolution

Honey is a nontoxic, inexpensive product that can be ingested for nutritional value or applied locally for treatment of nonhealing ulcers. If the patient does not have a history of bee or pollen allergy, ingestion of honey that is not from the nectar of rhododendron plants is considered safe. However, there is no evidence to support honey's efficacy in the treatment of diabetes, and little evidence from randomized clinical trials supports the use of honey in lipid management. The patient should be advised not to expect improvement in his diabetes or lipid outcomes from ingestion of honey. Rather, his diabetes should continue to be managed according to the usual practice guidelines.

Evidence for the efficacy of topical medicinal honey (ie, manuka honey) is stronger for wound management, particularly for the treatment of venous leg ulcers. Topical honey therapy can thus be recommended to the patient for his venous ulcer.

In the treatment of venous ulcers, the quantity of honey to be applied varies from study to study.[8] Generally, after cleansing the wound, honey is spread or poured thickly over the entire wound site. The frequency of application varies from twice daily for venous leg ulcers to hourly in cases of postsurgical wound management. Application frequency should be increased if the wound being managed is infected.

For this patient, honey-impregnated dressings may be recommended twice daily after his ulcers are carefully assessed for size and presence of infection. Follow-up should occur in clinic at least weekly, at which time the wound's width and depth should be measured to assess the rate of healing.

Clinical Pearls

1. Honey is 70% to 80% sugar, but it also contains water, proteins, hydrogen peroxide, and gluconic acid. Honey's antimicrobial properties are believed to derive from its high sugar and low moisture content, the acidic properties of gluconic acid, and the antiseptic properties of hydrogen peroxide.

2. As a topical agent, honey has been reported to have benefit in treating chronic, surgical, and traumatic wounds. Recently, studies have examined the benefits of honey in the treatment of burns, skin grafts, Fournier's gangrene, radiation-induced mucositis, and dermatologic conditions such as seborrhea and dermatitis. Ingested honey has been examined for its potential benefit in the treatment of DM, hypercholesterolemia, hypertension, and gastroenteritis.

3. A 2001 systematic review found topical honey to be superior to control for postoperative wound healing, maintenance of sterility, and eradication of infection. Small controlled studies have indicated that honey is beneficial wound care for cesarean section, nonhealing wounds that do not respond to other treatments, and chronic, surgical, and traumatic wounds. A Cochrane systematic review reports that the strongest evidence available supports the use of honey for venous leg ulcers. A recent randomized controlled trial confirmed the efficacy of honey in the treatment of sloughing venous ulcers. In 2007, Medihoney™ was approved by the FDA for use in wounds and burns.

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