Clinical usage of honey as a

wound dressing: an update

Honey is an ancient treatment that is increasingly earning its place in modern

wound care. Evidence suggests it compares with other dressings in terms of its

antibacterial properties, ease of use and ability to promote a moist environment

infection; antibacterial; anti-inflammatory; skin grafts

S
ince Molan last covered this topic in in full-strength honey, giving a more potent P. C. Molan, Bsc, PhD,
Journal of Wound C are, 1 the re antibacterial action that diffuses into the depth of Professor, Director of the
infected tissues, making it the honey chosen for sale Honey Research Unit,
have been a d v a nce s in t he Department of Biological
selection of honey for u se in for wound care.
Sciences, University of
wound care, based on its Waikato, Hamilton,
antibacterial properties, and in Dressing protocols New Zealand;
The progressive dilution of honey by exudate, J.A. Betts, RN,
c l i n i c a l protocols for its use. This paper
AdDipN, PGDipHsc,
examines wound-healing results achieved with together with the absorption of its components into
MN (Candidate), Nurse
honey in the past five years, the extent of its use the blood stream, means its osmotic and antiseptic Practitioner Wound Care,
and practical issues relating to its clinical use. effects last for only two to three days.6 Other practi- Health Waikato, Hamilton,
cal issues that need to be considered when using New Zealand.
Use of selected honey honey as a wound dressing are described below. Email: pmolan@waikato.
ac.nz
The potency of honey's antibacterial activity can
vary up to a hundred-fold.2 Honey's antibacterial The osmotic effect
activity is partly due to the high osmolarity created Honey creates a moist environment by drawing ex-
by its sugar content, although this reduces as it is udate to the wound surface, creating a non-adher-
diluted by exudate. Honey with no antibacterial ent interface between the dressing and wound bed. References
activity beyond its osmolarity ceases to be effective Lawrence6 suggested that penetrative osmosis may I Molan, P.C. The role of
honey in the management
against Staphylococcus aureus when diluted with damage wound tissue, but this does not happen as of wounds.) Wound Care
three or four times its volume of exudate.3 However, the underlying circulation provides a flow of re- 1999; 8: 8, 415-418.
honey produced specifically for wound care can still placement fluid.7 However, osmotic withdrawal of 2 Molan, P.C.The
antibacterial activity of honey:
be inhibitory if diluted to 45-60 times its volume. fluid does prevent maceration of periwound skin.
2,Yariation in the potency of the
Honey's antimicrobial activity is also due to: antibacterial activity. Bee World
Hydrogen peroxide, which is formed in a Dealing with exudate 1992; 73:2, 59-76.
3 Cooper, R.A., Molan, P.C.,
'slow-release' manner by the glucose oxidase Wound exudate can dilute a honey's antibacterial Harding, K.G,Antibacterial
added by bees during its production activity, or wash it away, so honey is best soaked activity of honey against strains
into a dressing and covered with a secondary dress- of Staphylococcus aureus from
Phytochemicals from the nectar of particular
infected
plant species. ing, rather than applied directly to the wound. wounds. J R Soc Med 1999;
Both activities can vary from sample to sample. In Due to its anti-inflammatory action, placing suf- 92:6, 283-285,
manuka honey (Leptospermum scoparium) and honey ficient honey on the wound will decrease the level of 4 Molan, P.C. Honey as a
topical antibacterial agent
from some other Leptospermum species the phyto- exudate.8 Until this decrease occurs, frequent for treatment of infected
chemical activity can be high, with a broad spec- dressing changes may be needed on exuding wounds if wounds.World Wide
trum of antimicrobial activity. (This activity, the the honey is being washed away. A new dressing,9 Wounds 2001 (www.
woridwidewounds.
Unique Manuka Factor, is rated as the UMF number comprising honey gelled with sodium alginate, com/2001/november/
on honeys on sale.) forms a rubbery sheet similar to a hydrocolloid. This Molan/honey.as-topical-
swells into a softer gel as it readily absorbs exudate, agenthtml).
Honey with a median level of hydrogen-peroxide 5 Cooper, R.A., Molan, P.C.,
activity and manuka honey with a median level of keeping honey in contact with the wound bed while Harding, K.G. Honey and
phytochemical activity are equally as potent as preventing the lateral spread of exudate. A honey G r am p os i ti v e c oc c i o f
hydrogel product (L-Mesitran Hydro, Triticum) can clinical significance in
antibacterial agents in vitro,4 although manuka wounds. J Appl Microbiol
honey is 2002; 93: 857-863.
about twice as effective against enterococci.5 6 Lawrence, J.C. Honey and
wound bacteria (editorial).
In wound care the catalase in serum and tissues J Wound Care 1999;8:4,155. 111°
decomposes to some extent the hydrogen peroxide
produced by many honeys, whereas the
phytochemical component of Leptospermum honey
maintains its activity. Also, the glucose oxidase which
produces the hydrogen peroxide in honey only
becomes active when honey is diluted, and its
acidity is neutralised by exudate. In contrast, the
phytochemical factor in Leptospermum honey is active
 absorb five times its weight of fluid, but contains only
Table I. Examples of honey dressings that have achieved 30% honey before this gets further diluted as exudate
successful results after other treatments failed is absorbed.

Wound Outcome Reference Results observed in clinical practice

Porous non-adherent dressing Pseudomonas eliminated; Robson et al.48 In our clinical experience a variety of chronic, acute,
placed between graft and donor sites healed faster; Robson
49 infected or heavily colonised wounds that did not
honey dressing better cosmetic results respond to 'normal management' have been treated
with honey. Successful healing was achieved in all
36-month-old surgical wound Healed in I month Cooper et al.
30
patients except those with arterial insufficiency.
in the axilla However, the latter wounds remained free from
Skin lesions infected with Healed within 10 weeks Dunford et al.31 infection and did not deteriorate further. Varicose
Pseudomonas, Staphylococcus ulcers usually healed within three months, including
aureus and Enterococcus cases where compression could not be used. No
Skin-graft failure of lower leg Healed in 8 weeks: Dunford et al.28 patients required systemic antibiotics. As a result,
cavity wound; infected with elimination of wound odour community nurses in our region use honey as the
Pseudomonas, Staphylococcus standard treatment for leg ulcers infected or heavily
aureus and MRSA: donor-site colonised with Pseudomonas.
infection The most notable results have concerned honey's
Hydroxyurea-induced leg ulcer Infection cleared in 14 Natarajan et al.50 rapid (within 24 hours) cleansing and deodoris -
infected with MRSA treated days; healed in 21 days ing action, particularly on fungating (malignant)
with UMFI 2 manuka honey wounds. Honey also reduces inflammation and exu-
under DuoDERM (ConvaTec) date levels, and may suppress the growth of tumour
cells, as observed in experimental animals. 10,11
4 x 4cm non-healing traumatic Granulation and Dunford et al28 The following randomised controlled trials of
wound epithelialisation visible honey have demonstrated successful outcomes, when
within I week; complete compared with other dressing regimens:
healing in 6 weeks ●Honey versus povidone-iodine on central vein
catheter exit sites of patients on dialysisn
Ulcer from back of knee to Elimination of odour; Stewart32
●Honey versus hydrocolloid on split-thickness skin
ankle, infected with reduction in pain; reduced
Streptococcus pyogenes and bleeding at dressing
graft donor sites"
Staphylococcus aureus treated change; 80% reduction in ●Honey versus phenytoin on chronic leg ulcers14
with Medihoney size in 15 weeks ●Honey versus povidone-iodine with 70% ethanol
washes on severe postoperative wound infections.15
Bilateral leg ulcers, extending Healed in 6 weeks Richards33 Table 1 gives examples of case reports where honey
18cm up from ankle on the proved successful after other treatments failed. Many
inner and outer surfaces of an
used honey dressings we developed — Combine
88-year-old patient, treated with
Medihoney (Smith & Nephew) dressing pads impregnated with
25-35g of UMF12 or UMF13 manuka honey.
Chronic leg ulcers (20 years), Cleaner wound bed; Alcaraz and
Medihoney compared with infection and exudate Kelly45
Honey with unspecified antibacterial activity
Aquacel cleared in 10 days
The possibility that some honeys may give poor
25-year history of venous Rapid removal of odour; Kingsley51 results because they have a low level of antibacterial
ulceration and recurrent eczema cleared after 10 activity was demonstrated in a prospective ran-
infection treated with days, but infection domised controlled trial comparing honey with
UMF I0+ manuka honey returned under early tangential excision followed by autologous
compression and
skin grafting for the treatment of burns.16 Honey did
NA dressing (johnson
not provide as good infection control as early tan-
& Johnson)
gential excision, although skin grafting was required in
11
14 cases of gangrene in the Average debridement time: Anoukoum et al.24 only 11 of the group treated with honey (n=25).
genitals and perineum. Honey 5.2 days; granulation: 9.4 However, in other clinical trials, the author
was applied directly to the days; healing: 28.7 days
achieved good infection control with the same
wounds, which were covered
dressing regimen.17-22 For example, a prospective
with a honey-soaked compress
randomised controlled trial17 compared Jambhul
Fournier's gangrene, post Healing in six patients Gurdal et al.25 (Syzygium cumini) honey with silver suiphadiazine in
surgical debridement two groups of 50 patients. (One sixth of the total burn
area was full-thickness.) In the honey group the 44
positive swabs recorded at baseline reduced

354 JOURNAL OF WOUND CARE VOL 13, NO 9, OCTOBER 2004

to four after seven days, compared with 42 positive Table I (continued). Examples of honey dressings that have
swabs at baseline and 42 after seven days in the achieved successful results after other treatments failed
silver-sulphadiazine group. Use of honey was associ-
Wound Outcome Reference
ated with a significantly faster rate of healing. Four
of the honey-treated wounds required grafting com- Retrospective review of 50 Good response Efem26
pared with 11 treated with silver sulphadiazine. cases of lactational breast
Some cases15,23-27 in Table 1 also used honey with abscesses incised, drained and
unspecified antibacterial activity. Good results were packed daily with honey-
reported in most of these, but the three cases (out of a
27
total of 60) in the trial of Mediprof HoneySoft Skin excoriation due to Rapid epithelialisation Aminu et al.
ostomy bag leakage
dressing in which there was infection or failure to
heal may be a reflection of the fact that this honey soaked ribbon gauze Ahmed et al
23

does not have a standardised antibacterial activity. 1 6 acute traumatic, 23 two wounds did not
complicated surgical and heal but did not worsen.
Pain and honey dressings 21 chronic non-responding Others healed in a mean
wounds treated with time of 3 weeks (range:
There have been a few reports of honey causing pain
HoneySoft (Mediprof) 1-28 weeks)
when applied to wounds.14,23,28 In one study the
patient experienced pain for the first 20-30 min-
utes.28 In another case moderate pain occurred for reported any adverse effects.8 However, clinicians
15-30 minutes.29 We have observed that pain is ex- are reluctant to use non-sterile products on open
perienced only in very inflamed wounds and disap- wounds, and it is unlikely the bacterial content of 7 Chirife, J., Scarrnato, G.,
pears once the inflammation has resolved. But there Herszage, L Scientific basis
raw honey would meet regulatory requirements for for use of granulated sugar
are many reports of honey relieving pain.13,15,17,30-33 wound-management products. Although raw honey in treatment of infected
The pain experienced does not seem to be asso- does not contain disease-causing vegetative bacteria wounds. Lancet 1982;1:
ciated with damage to the wound. But there is 560-561.
(unless recently contaminated), it can contain viable B Molan, P.C. Re-
evidence that honey stimulates nociceptors.34 Inter- bacterial spores, including Clostridium species44 introducing honey In the
estingly, patients have reported a 'peppery' sensation managem ent of wounds
Several commercially available honey items pro- and ulcers: theory and practice.
when honey is applied to ulcers.14 It is possible,
duced specifically for wound care have been Ostomy/VVound Manage 2002;
therefore, that in some patients the nerve endings 48:11, 28-40.
approved by the regulatory authorities:
are sensitised and thus more responsive to the 9 Molan, P.C. Medical
● Australia, Canada and EU member states — a dressings comprising gelled
honey's acidity and/or its organic chemicals.
honey ointment (L-Mesitran, Triticum) comprises honey. European Patent
honey and Medilan, sunflower oil, cod liver oil, aloe EP 1237561, 2002.
Acceptance by the medical profession vera, calendula, vitamins A, C and E and zinc
10 Swellam,T, Miyanaga, N.,
Onozawa, M. et al.
In 2000 an answer to a reader's question in Journal of oxide; L-Mesitran Hydro (Triticum), a hydrogel Antineoplastic activity of honey
Wound Care35 commented that 'honey appears to be dressing that contains 30% honey and is also in an experimental bladder
becoming popular for the management of infected cancer implantation model: in
available as an island dressing (L-Mesitran Border) vivo and in vitro studies. Int J
wounds'. This has become even more the case, re- or incorporated into an open-weave polyester net Urol 2003; 10: 4,213-219.
flecting the search for alternatives to antibiotics and (L-Mesitran Net). The Triticum products are made 1 1 Hamzaoglu, I.,
the increasing awareness of honey's effectiveness. Saribeyoglu, K., Durak, H. et al.
from honey of unspecified origin and antibacterial Protective covering of surgical
Although systematic reviews have concluded that activity wounds with honey impedes
there is a low level of evidence to support the use of ● Australia and all EU member states — Medihoney tumor implantation.Arch Surg
honey on chronic wounds,36-38 they have not 2000; 135:12, 1414-1417.
Antibacterial Wound Gel, Medihoney Antibacterial 12 Mutjaba Quadri, K.H.
acknowledged that in many published case reports it Honey Barrier (Medihoney, Australia) and (in Topical honey versus
was only used after standard treatments failed. standard povidone-iodine
Australia) Woundcare 18+ (Comvita Medical, New in the prevention of
(Most of the randomised controlled trials on honey Zealand). These honeys are harvested from Leptosper- catheter-related sepsis.) Am
have been on acute wounds.) mum species, and their standardised antibacterial Soc Nephrol 1998; 9:
Following increasing evidence from 180A-18IA.
activity stems from the unidentified phytochemical 13 Misirlioglu,A., Erog1u, S.,
laboratory-based research of honey's antimicrobial antibacterial component derived from Leptosper- Karacaoglan, N. et al. Use
properties and from clinical experience of its mum. Medihoney is funded for use in hospitals in of honey as an adjunct in
ability to promote healing, editorial comments in the healing of
Queensland and New South Wales, Australia s p l i t - thickness skin graft
medical journals are now changing from being ● All EU member states — Activon Tulle (Advancis) a donor site. Dermatol Surg
disparaging39-41 to accepting.35,42,43 triple layer of low-adherent knitted viscose primary 2003; 29; 2, 168-172.
dressing BP Type 1 impregnated with honey, and
Honeys produced specifically for Algivon dressing (Advancis), a honey-impregnated
wound care mechanically bonded calcium alginate (M type) fibre
There are over 500 reports of case studies and clinical dressing. Both are made from Leptospermum honey
trials where honey intended as a food product has with standardised antibacterial activity. Activon
been used as a wound dressing, and none have Tulle is available on the Drug Tariff in the UK
 Box I . Key issues for practice
● Australia, New Zealand and all EU member states Potency of honeys' antibacterial activity can be variable
--Apinate dressing (Comvita Medical, New Zealand), — use honey with standardised antibacterial activity
a honey-impregnated mechanically bonded calcium Only use products licensed for wound care as they
alginate (M type) fibre dressing made from Leptosper- have been finely filtered and sterilised by
mum honey with standardised antibacterial activity a gamma-irradiation to kill spores
● All EU member states — HoneySoft dressings
Ensure sufficient honey remains In contact with the
(Mediprof) are pads of polyethylenevinylacetate
wound bed by using absorbent dressings impregnated
fibre impregnated with honey of unspecified origin with honey, or honey gel dressings. Fill any cavities with
and antibacterial activity. HoneySoft is reimbursed honey
in the Netherlands, in Belgium for trauma patients,
Ensure the dressings cover any areas of inflammation
in burn centres in England that have their own
surrounding the wound. Due to honey's high osmolarity,
budgets, and in Greece. there is no risk of skin maceration
The use of honey-impregnated dressings, honey
ointments and honey gel dressings have overcome Change dressings often enough to prevent the
exudate washing the honey out of the dressing
comments that honey is messy to use and difficult
to keep in place.6,45,46

Conclusion wound treatments, is taking its in place in modern

In 1999 an editorial in Advances in Wound Care com- wound care. Like modern wound dressings, it is easy
mented that there is a 'tremendous opportunity to to apply, painless and comfortable, harmless to tis-
re-examine old treatments and apply them in the sues, creates a moist healing environment, is antibac-
current environment'.47 Honey, the most ancient of terial and stimulates healing and epithelialisation.8
14 Oluwatosin, versus amniotic management. Nurs Stand infected wounds. J Wound 46 Lusby, RE., Coombes,
Olabanji, Oluwatosin, membrane in the 2000; 15: 11, 63-68. Care 2000; 9: 6, 287. A.,Wilinson, J.M. Honey: a
O.A. et aI.A comparison of treatment of burns. Burns 29 Robson,V., Dunford, 36 Namias, N. Honey in potent agent for wound
topical honey and 1994; 20:4, 331-333. C., Molan, P.C., Cooper, the management of healing? J Wound Ostomy
phenycoin in the 21 Subrahmanyam, M. R.A.The use of honey in infections. Surg Infect Continence Nurs 2002;
treatment of chronic leg Honey impregnated gauze wound management. (Larchmt) 2003; 4: 2, 29: 6, 295-300.
ulcers.Afr J Med Sci 2000; versus polyurethane film Paper presented at 219-226. 47 Salcido, R.
29:1,31-34. (OpSite) in the treatment Innovations in Wound 37 Moore, 0.A., Smith, LA., Complementary and
15 Al-Waili, N.S., Saloom, of burns — a prospective Care Conference, Cardiff, Campbell, F. et al. alternative medicine in
K.Y. Effects of topical honey randomised study. Br J UK, 2001. Systematic review of the wound healing.Adv Wound
on post-operative wound Plast Surg 1993; 46: 4, 30 Cooper, R.A., Molan, use of honey as a wound Care 1999; 12:9, 438.
infections due to Gram 322-323. RC., Krishnamoorthy, L, dressing. BMC
48 Robson,V.,Ward, R.G.,
positive and Gram 22 Subrahmanyam, M. Harding, K.G. Manuka Complement Altern Med
Molan, P.C.The use of
negative bacteria Topical application of honey honey used to heal a 2001; l: 1,2.
honey in split skin grafting.
following Caesarean in treatment of burns. Br J recalcitrant surgical 38 Fox, C. Honey as a Paper presented at the 10th
secti ons and Surg 1991;78: 4,497-498. wound. Euro J Clin dressing for chronic wounds Conference of the
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16 Subrahmanyam, M. Honey-medicated 31 Dunford, C., Cooper, R., Harrogate, UK, 2000.
39 Editorial. Honey: sweet
Early tangential excision dressing: transformation of Molan, P.C. Using honey as 49 Robson,V. University
and dangerous or a
and skin grafting of an ancient remedy into a dressing for infec ted Hospital Aintree, Liverpool,
panacea? S Afr Med I
moderate burns is superior modern therapy,Ann Plast skin lesions. Nurs Times UK. Personal
to honey dressing: a 1974; 56: 2300.
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32 Stewartd.Therapeutic 50 Natarajan, S.,
trial, Burns 1999; 25: 8, interaction of bugs and
24 Anoukoum,T.,Attipou, hon ey us e d to r ed uc e Williamson, D., Grey, J. et
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K.K.,Aylte,A. et al. Le pain and bleeding al. Healing of an MRSA.
17 Subrahmanyam, M.,
234-235.
traitment des gangrenes associated with dressing colonized, hydroxyu rea-
Sahapure,A.G., Nagane, perineales et de la sphere changes. Paper presented 41 Soffer,A. Chihuahuas
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N.S. et al. Effects of topical genitale par du miel.Tunis at the 4th Australian Wound and laetrile, chelation
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application of honey on Med 1998; 76:5, 132-135, Management Association therapy, and honey from
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25 Giirdal, M.,Yiicebas, E., 51 Kingsley,A.The use of
Burns Fire Disasters 2001; Adelaide,Australia, 2002. Med 1976; 136:865-866.
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28 Dunford, C., Cooper,
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and the management of
356 JOURNAL OF WOUND CARE VOL 13, NO 9, OCTOBER 2004