Honey is one of the dressing choices for wound care that has been used for thousands of years because it has many characteristics that support wound healing. Honey is a liquid food made by bees from nectar or plant secretions.

Before being used for medical purposes, honey is sterilized by gamma irradiation or pasteurization to prevent bacterial spores' spread to the wound. Honey processing also aims to limit variability between specimens and reduce the potential for allergic reactions due to wax, impurities, and pollen.

One of the honey types that has been studied is Manuka honey from New Zealand. Technological developments have supported the emergence of various honey-containing dressings such as Manukaguard ®, Medihoney ®, Algivon ®, and Actilite ®. Honey is available in the form of hydrocolloids, alginates, synthetic tulle, and gels.

Application Honey bandage to treat wound
Application Honey bandage to treat a wound
source picture: https://www.naturallivingideas.com/manuka-honey-bandages

The action mechanisms of honey

Honey can help the wound healing process with a variety of mechanisms, including:

a. Triggering debridement through the osmosis process. By keeping the wound moist, honey also supports the debridement process.
b. The low pH and the high osmolarity of honey increase tissue oxygenation and draw fluid from subdermal tissue to the wound. This fluid flushes bacteria, debris, slough, and necrotic tissue from the wound as the mechanism of action of negative pressure wound therapy (NPWT).
c. Hydrogen peroxide content in honey can interfere with bacterial growth.
d. High sugar content in honey is an additional glucose source for proliferating cellular components such as fibroblasts and endothelial.
4. Anti-inflammatory effects suppress the prolonged inflammatory process to help heal chronic wounds.
5. Eliminating odors.
6. Speed ​​up the process of granulation tissue formation and wound closure
7. Not irritant, so it can be used on patients with sensitive skin.
8. Flavonoids and polyphenols content are antioxidants that protect cells from damage by free radicals caused by infection.
9. Having the ability to inhibit bacterial communication so that bacteria cannot form resistance to honey.

Therefore, honey can help eradicate bacteria with resistance to antibiotics such as methicillin-resistant Staphylococcus aureus (MRSA).

Honey Application for Various Types of Wounds

Honey is commonly used in the treatment of various types of wounds. However, there are no recommendations that can be used as definitive guidelines for using honey. The available scientific evidence is strong enough to support honey as a wound dressing in certain conditions.

The clinical application of honey in some of the conditions below is based on reviews by The Canadian Agency for Drugs and Technologies in Health (CADTH), which evaluates systematic reviews, Health Technology Assessment (HTA), and evidence-based clinical guidelines. The interventions used were topical honey and dressing honey. As a comparison, the dressings used were silver sulfadiazine and placebo.

Compared to silver sulfadiazine and other dressings, honey shows a shorter healing duration in superficial burns (on average, five days faster) and partial depth burns (on average, 4.68 days faster). Honey also has a lower infection rate, fewer complications, and a lower level of pain. Burns treated with honey are healed with lower hypertrophic scars and contractures.

Surgical Injury Infection
Moderate evidence supports the use of honey rather than antiseptic irrigation followed by gauze to treat infected surgical wounds. The honey group studied had a faster healing time, lower wound de-licensing and re-suturing rates, and a shorter eradication rate of infection. The mean time to achieve negative culture smear results was six days for honey and 14.8 days for gauze and antiseptics.

Venous ulcer
In a randomized clinical trial, patients with venous ulcers in the feet treated with honey showed faster healing, lower infection, and more effective slough breakdown than the control group.

A systematic review by Jull et al. compared honey with hydrogel to treat leg with venous ulcers. There were no clear results on whether honey increases healing or reduces infection rates. However, the honey group reported more complications, including pain and worsening of the wound, although it was unclear whether the condition was related to intervention or not. The evidence is not enough to conclude the use of honey in treating local wound infections.

Diabetic Ulcer
Some studies report that honey in diabetic ulcer patients has better effectiveness, reduced amputation rates, and better patient compliance than conventional dressings.

While another systematic review study found no significant differences between the honey and other dressing groups (saline gauze, povidone-iodine dressing) in terms of healing and rates of diabetic ulcer infections, side effects are not described clearly enough to be reported. Thus, the evidence is not enough to evaluate honey's effect on infection in patients with diabetic feet.

Although having the antimicrobial ability, methylglyoxal, mostly contained in Manuka honey, is a precursor for other molecules that play a role in the formation of diabetic ulcers.

Pressure Ulcer
Two guidelines from Scotland say that honey can be considered for pressure ulcer management. In a study with 20 samples in each group, the honey group showed more wound healing than the saline group (100% versus 70%), but the difference was not statistically significant. Side effects and infection rates were not reported.

Fournier's Gangrene
The available studies have a low quality of evidence but show that Fournier's gangrene's healing time is faster (on average eight days faster). The need for secondary suturing is lower than the antiseptic dressing group. Secondary infection rates are not reported.

Toxic Epidermal Necrolysis (TEN)
A case study reported a TEN patient suspected of having taken paracetamol or ibuprofen. The patient suffered an epithelial loss of 60% of the body surface area, including the eyes, mouth, and genitals' mucosal surface. The patient showed epithelial healing within one week after treatment with honey dressing, Revamil ®. Wound care was to be easy, with minimal wound exudate.

Chronic ulcer (not specified)
The antibacterial effect in the honey group was superior though not significant in a randomized clinical trial. Evidence of anti-inflammatory, anti-odor, debridement, and pain effects is not enough to conclude the use of honey in chronic ulcers. A guideline from the German Society for Wound Healing does not recommend honey use in chronic ulcers. However, the assessment of the evidence used to base this guideline is not described.

Acute Minor Wounds
There is no quality evidence of honey's superiority compared to conventional dressings in acute minor wounds. Mean healing time and infection rates do not show significant differences. There is no significant difference in the honey group compared to the hydrogel group related to itching, heat, and pain.

In acute and chronic mixed wounds, the rate of complications such as hyper granulation, hypertrophic scarring, contractures, and irritation in the honey group are lower than silver sulfadiazine (4% versus 28%). The wound healing time showed an average of 13 days faster in the honey group. Honey also shows a higher antibacterial effect and lower pain.

Honey Disadvantages

Studies of applying honey in other wounds cannot produce consistent conclusions and can be generalized because of the large population variations, comparative interventions, and design of study methods. The type of honey used also varies from fresh honey without processing to medical-grade honey that has been irradiated. Various factors cause honey potential differences, including geography, season, source, harvest process, processing, and storage.

Another disadvantage of honey is its tendency to become more liquid at hot temperatures. Honey also has a risk of experiencing liquefaction, making it difficult to use it in certain body areas. In some patients, the application of honey can cause a stinging sensation.