The use of medical grade honey in clinical practice

AbstractIn the current healthcare environment, clinicians are increasingly under pressure to use wound care products that are cost-effective. This includes products that can be used in a variety of wounds to achieve different outcomes, depending on the wound-bed requirements. Medical grade honey has emerged as a product that can achieve a variety of outcomes within the wound and is safe and easy to use. This article reviews the use of a medical grade honey (Medihoney™) in various clinical applications, with a view to placement on the wound care formulary in both primary and secondary care. It provides an in-depth account of case studies featured in a poster presentation at the 2008 European Wound Management Association meeting in Lisbon, Portugal.

Key words: Formulary n Honey n Medical grade n Tissue viabilityn Wound care

In recent years, honey has re-emerged as a wound care product that can be used on a variety of wounds. Honey is produced by bees as their food store for the hive during winter. Honey consists of 20% water and

80% sugar (Molan, 2005) and contains enzymes added by the bee. In more recent years, honey products have become available as a sterile, regulated medical device and are often referred to as ‘medical grade honey’. These products have been shown to be effective in treating a variety of wound types, including venous leg ulcers, pressure ulcers, burns, surgical wounds, necrotizing fasciitis, diabetic foot wounds, grafts and various oncological wounds (White and Molan, 2005; Molan, 2006; White and Acton, 2006; Emsen, 2007; Gethin and Cowman, 2008).

Currently there is a need to source wound care products that are safe, effective and easy to obtain in both primary and secondary care, to enable continuity of care and reduce the need for many different products throughout the wound-healing process. Not all medical grade honeys work in the same way, so they should not be referred to collectively

Claire Acton, Gillian Dunwoody

(Molan, 2002). Clinicians need to be aware of how individual honey products work within the wound environment before using them in practice.

This article provides an in-depth account of the case histories featured in a poster presentation to the 2008 European Wound Management Association meeting in Lisbon, Portugal. The poster used case studies to illustrate the effects of a medical grade honey in clinical practice in both primary and secondary care settings; the aim was to show that medical grade honey is an effective product, and should be included in a wound care formulary.

Medical grade honeyThere are many medical grade honey products available for use in wound management; Medihoney™ (Medihoney, Slough) is one example. However, not all honey products are the same: for example, they have differing antibacterial potencies, which affects the efficacy of the mode of action (Molan, 2002).

Medihoney™ consists of a blend of Leptospermum honeys. The genus Leptospermum comprises more than 80 species of plants, including two Australian species (L. semibaccatum and L. polygalifolium), also known as jelly bush, and a New Zealand species (L. scoparium), also known as manuka. Only honey from these specific Leptospermum species have been shown to have exceptional antibacterial activity (Cooper, 2005; 2008).

Medical grade honey has been identified as having five key modes of action: antimicrobial; anti-inflammatory; promotes debridement in sloughy and necrotic wounds; provides a moist, wound environment; and reduces wound malodour. Antimicrobial: The high-sugar, low-water content of medical grade honey means that bacteria within a wound dressed with a honey product have insufficient water to support their growth (Molan, 2002), while the low pH of 3.9 inhibits their growth (White, 1979; Dissemond et al, 2003). The low levels of hydrogen peroxide produced by the dilution of honey in wound exudate also have an antibacterial action (Molan, 2005), as do the naturally occurring phytochemicals found only in Leptospermum honey (Simon et al, 2006). Anti-inflammatory: The osmotic action of honey draws lymph out of the cells, thereby reducing oedema (Molan, 2005).Promotes debridement in sloughy and necrotic wounds: Honey maintains a moist wound environment, aiding autolytic debridement (Robson, 2002). Because of the speed of debridement when using honey, there is likely to be an associated enzymatic action; it has been suggested that honey may activate plasmin, which then breaks down the blood clots binding necrotic tissue to the wound bed (Molan, 2005).

Claire Acton is Tissue Viability and Vascular Nurse Specialist,

Surgical Directorate, Queen Elizabeth Hospital NHS Trust, London,

and Chairperson of the Tissue Viability Nurses Forum (South); and

Gillian Dunwoody is Tissue Viability Clinical Nurse Specialist,

Bromley Primary Care Trust, Kent

Accepted for publication: September 2008

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present for 6 months and were slow to heal, and there were continuous infections requiring systemic antibiotic therapy.

Medihoney was selected as an appropriate dressing to achieve the treatment goals, which were to:

Debride necrotic tissue from the wound bedReduce bacterial loadPromote the growth of granulation tissue, enabling the wound to progress through the healing phase. Medihoney wound gel was used with hydrofibre

secondary dressing under compression bandaging. Figure 1b shows the ulcer after 101 days’ treatment. Previously the patient had received no compression therapy, and dressing pads had been applied to the ulcers to mop up the fluid, but without success. There appeared to be a reduction in the bacterial load at the wound bed; as a result, the patient no longer required antibiotics, unlike previously, and the wound showed granulation tissue formation. The nursing staff found the product easy to use and the patient was comfortable with the dressing in place.

Case study 2An 85-year-old woman, who was immobile and bed bound, presented with a grade 3 pressure ulcer (European Pressure

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Provides a moist, wound-environment: The osmotic action of honey draws the fluid from surrounding tissues, producing a moist wound interface (Chilvers and Maloney, 2006). Reduces wound malodour: Malodorous substances, such as ammonia, amines and sulphur compounds, are produced when bacteria in the wound bed metabolize amino acids. The amino acids result from the decomposition of serum and tissue proteins within necrotic tissue in the wound. Honey provides the bacteria with an alternative source of energy (glucose), so that malodorous compounds are no longer formed and malodour is reduced (Molan, 1999, 2005).

The antibacterial properties and debriding action of honey may also contribute to the reduction in malodour (Lay-flurrie, 2008).

Using medical grade honey in clinical practiceChilvers and Moloney (2006) reviewed the use of medical grade honey (Medihoney) in terms of the TIME principles, as defined by Schultz et al (2005). The TIME framework is a systematic approach to wound bed preparation and has four main components (Schultz et al, 2003):

Tissue type and managementInfection/inflammationMoisture balanceEdge of wound.Chilvers and Moloney concluded that medical grade honey

achieved effective results within this healing continuum. They also identified a large amount of research and case histories within the TIME framework to support their conclusion. Although this was a poster presentation, it included 32 references to support each aspect of the continuum, demonstrating the underlying pathophysiology and clinical indications for the use of medical grade honey on all types of wound.

The following case studies describe a range of patients, each with a different wound type. They were selected for study to determine whether the different modes of action of medical grade honey were clinically evident in the various wound types, with a view to including medical grade honey in the wound care formulary within the author’s areas of practice – an acute hospital setting and a primary care trust.

Selection of an appropriate dressing for a wound is an essential part of the patient’s holistic care, and should lead to positive patient outcomes (Baranoski, 2005). The choice of dressing should be based on sound wound care principles and a robust assessment process, to ensure that the right dressing is applied to achieve optimum patient outcomes.

Case study 1 A 44-year-old man with vasculitis (inflammation of the small blood vessels) presented with leucoclastic leg ulceration. Vasculitis causes damage to the lining of the vessels, leading to narrowing or blockage that restricts or stops blood flow. The resultant ischaemia damages or destroys the tissues supplied by the affected vessels – in this case, causing ulceration to the lower leg (Figure 1a).

However, as vasculitis is a small vessel disease process, ankle-brachial pressure index (ABPI) readings of 0.89 on the right leg and 0.92 on the left were unexpected. The ulcers had been

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Figure 1a. Leucoclastic vasculitic leg ulcers of 6 months’ duration.

Figure 1b. Wound bed is clean and granulating, with a reduction in wound size, after 101 days’ treatment with Medihoney and hydrofibre under compression bandaging.

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Ulcer Advisory Panel [EPUAP], 1999) on her left upper arm, which had been present for 1 month (Figure 2a). Ninety per cent of the wound bed was covered with necrotic tissue, so the goal of treatment was to:

Debride the necrotic tissue (the patient had declined sharp debridement).The ulcer was treated with Medihoney wound gel, with

hydrofibre secondary dressing, and a film dressing to hold it in place. The dressings were changed every other day. At day 5, all the necrotic tissue had gone from the wound bed (Figure 2b), enabling granulation tissue formation. This is an example of how Medihoney promotes rapid debridement of a wound, achieving a positive outcome for both the patient and staff.

Case study 3An 83-year-old woman presented with a trauma-induced haematoma. This was removed manually on the ward, leaving a necrotic malodorous wound bed, which the patient found very distressing. The wound had been present with no progress for 1 month following removal of the haematoma. No bacterial growth was identified (Figure 3a); however, the wound bed was dark-looking and was not showing any signs of granulation tissue. The goals of treatment were to:

Reduce malodourReduce bacterial load.Medihoney wound gel was applied to promote further

debridement and reduce the malodour; a hydrofibre was used as a secondary dressing and was held in place with a crepe bandage. The wound was redressed every day.

After 7 days the wound bed was granulating and the malodour had gone (Figure 3b). Vacuum-assisted closure (VAC™) therapy was then applied to hasten the healing rate and ultimately facilitate a split-skin graft. The patient found the dressing comfortable and was very pleased with the reduction in malodour.

Case study 4A 46-year-old man with spina bifida, who was immobile, developed a chronic grade 4 (EPUAP) pressure ulcer on his left ischial tuberosity (Figure 4a). Healing had been compromised by infection, underlying osteomyelitis with bone destruction, low haemoglobin levels and external pressure.

The primary goals of treatment were to:Debride slough and necrosis from the wound bedReduce malodour. Medihoney wound gel was applied to the wound

bed to resolve the malodour and facilitate debridement of devitalized tissue. Sorbion® Sachet S (Sorbion AG, Germany) was used as a secondary dressing to absorb the high levels of exudate. Dressings were changed daily because of the high level of exudate and the additional problem of trying to keep the dressing in place. Various adhesive secondary dressings had been tried, but within 24–36 hours the adhesive would be lost and the dressings would peel off, exposing the wound bed.

Medihoney wound gel successfully reduced the malodour, and within 8 weeks had facilitated debridement of the necrosis (Figure 4b).

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Figure 2a. A grade 3 pressure ulcer of

1 month’s duration, with necrotic tissue

covering 90% of the wound bed.

Figure 2b. Wound bed is clear of necrotic

tissue after 5 days’ treatment with

Medihoney wound gel and hydrofibre

secondary dressing; granulation tissue is

beginning to form.

Figure 3a. Necrotic, malodorous wound following removal

of a trauma-induced haematoma 1 month

previously.

S42 British Journal of Nursing, 2008 (TISSUE VIABILITY SUPPLEMENT), Vol 17, No 20

Figure 3b. Wound bed is clean and

granulating following 7 days’ treatment with

Medihoney wound gel and hydrofibre

secondary dressing.

Case study 5A 61-year-old woman with type 2 diabetes, congestive heart failure and sleep apnoea presented with a long-standing ulcer of 3 years’ duration (Figure 5a). Previous attempts at compression bandaging had been unsuccessful. Repeated infections, persistent inflammation and associated pain meant that the patient could no longer tolerate the compression and it had been discontinued.

With such a complex medical history, compression therapy can be contraindicated. However, in this case the problem that was having the greatest impact on the patient’s quality of life was her long-standing leg ulcer. ABPI can be falsely elevated in diabetes; however, there was no clinical evidence of arterial disease and Duplex scanning revealed triphasic signals. Cardiac failure was well managed by her GP.

On referral to the tissue viability service the patient was under the care of a pain clinic, and analgesia consisted of Sevredol, tramadol and gabapentin. Despite this, she was still experiencing considerable pain and this was having a dramatic impact on her daily activities and work life.

Infection was initially treated with systemic antibiotic therapy, according to sensitivities for a heavy growth of Staphylococcus, and Medihoney wound gel was applied to the wound bed with N-A Ultra® (Johnson & Johnson) as a secondary dressing.

The goals of treatment were to: Reduce bacterial load and inflammationReduce pain and promote healing.Reducing bacterial load and inflammation would in turn

reduce pain and allow adequate compression to be applied, promoting the formation of granulation tissue and healing. Following a full leg ulcer assessment and under the close supervision of the tissue viability specialist, a 4-layer bandage system was applied based on ankle circumference. Dressings were changed twice weekly.

Opiate analgesia was discontinued within 17 days of treatment, and after 6 weeks’ treatment analgesia was no longer required. Figure 5b shows the wound after 8 weeks’ treatment.

Case study 6An 86-year-old man with type 2 diabetes presented with a venous leg ulcer to his left medial malleolus, extending laterally (Figure 6a). Unmanaged high levels of exudate had resulted in extensive maceration and skin breakdown. Malodour and green staining on the removed dressings were indicative of colonization with Pseudomonas.

He also had localized wound pain, which was poorly controlled despite analgesia. Within the period of this evaluation, his pain was not resolved. Compression therapy had been discontinued because of pain. Although ABPI was normal, his GP had referred him for vascular review because of his diabetes.

The goals of treatment were to:Reduce bacterial loadDebride slough.Following tissue viability review, Medihoney wound gel

was applied to the wound bed to reduce local bacterial load and enhance autolytic debridement. Sorbion Sachet S was

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HONEY

British Journal of Nursing, 2008 (TISSUE VIABILITY SUPPLEMENT), Vol 17, No 20 S43

Figure 4a. Chronic grade 4 (EPUAP) ischial pressure ulcer.

Figure 4b. Wound bed showing successful debridement of slough and necrosis after 61 days’ treatment with Medihoney wound gel and Sorbion Sachet S secondary dressing.

Figure 5a. Venous leg ulcer of 3 years’ duration.

Figure 5b. Wound bed is clean, granulation tissue is forming and healing has begun, following 59 days treatment with Medihoney wound gel and N-A Ultra dressing under compression bandaging.

chosen as the secondary dressing for its ability to absorb exudate and reduce maceration. Within 16 days of treatment, malodour was no longer evident and debridement of devitalized tissue was complete (Figure 6b).

ConclusionThe clinical case study outcomes demonstrate the effectiveness of Medihoney in all the documented modes of action, as outlined previously and in the research (Molan, 2005), and on a wide variety of wounds (Molan, 2006). In clinical practice the product was safe and easy to use.

The inappropriate use of wound care products can be costly, both for the healthcare trust and for the patient, and there is a drive for healthcare practitioners to use products that are cost-effective and ensure optimum clinical outcomes. The versatility of medical grade honey and its ability to achieve different clinical outcomes in a variety of wounds reduces the need for multiple product use during the wound healing process, thereby helping less experienced clinicians when selecting an appropriate product for a particular wound.

In each of the clinical cases described, medical grade honey demonstrated effectiveness in more than one mode of action. Results were obtained rapidly, were clearly defined, and achieved the outcomes selected for each individual.

Within a wound care formulary, medical grade honey does not have to be restricted to a single category but could be placed in a number of categories. Clinicians should

consider adding medical honey to their formularies. BJN

Acton C, Dunwoody G (2008) Honey: where should it be placed on the wound care formulary? Proceedings of the European Wound Management Association Conference, Lisbon, Portugal. May 2008. Poster presentation

Baranoski S (2005) Wound dressings: a myriad of challenging decisions. Home Healthc Nurse 23(5): 307–17

Chilvers C, Moloney A (2006) Antibacterial medical honey: meeting the criteria for total wound bed preparation using the TIME principles. Proceedings of the Wounds UK Conference. Harrogate, UK. Nov 2006. Poster presentation

Cooper R (2005) The antimicrobial activity of honey. In: White R, Cooper R, Molan P (eds). Honey – A Modern Wound Management Product. Wounds-UK Publishing, Aberdeen: 24–32

Cooper R (2008) Using honey to inhibit wound pathogens. Nurs Times 104(3): 46–9

Dissemond J, Witthoff M, Brauns T, Haberer D, Goos M (2003) pH values in chronic wounds. Evaluation during modern wound therapy (article in German). Hautarzt 54(10): 959–65

Emsen I (2007) A different and safe method of split thickness skin graft fixation: medical honey application. Burns 33(6): 782–7

European Pressure Ulcer Advisory Panel (1998) Pressure Ulcer Treatment Guidelines. EPUAP, Oxford

Gethin G, Cowman S (2008) Bacteriological changes in sloughy venous leg ulcers treated with manuka honey or hydrogel: an RCT. J Wound Care 17(6): 214–17

Lay-flurrie K (2008) Honey in wound care: effects, clinical application and patient benefit. Br J Nurs 17(11): S30–6

Molan P (1999) The role of honey in the management of wounds. J Wound Care 8(8): 415–18

Molan P (2002) Re-introducing honey in the management of wounds and ulcers – theory and practice. Ostomy Wound Manage 48(1): 28–40

Molan P (2005) Mode of action. In: White R, Cooper R, Molan P (eds). Honey: A Modern Wound Management Product. Wounds-UK, Aberdeen: 1–16

Molan P (2006) The evidence supporting the use of honey as a wound dressing. Int J Low Extrem Wounds 5(1): 40–54

Robson V (2002) Leptospermum honey used as a debriding agent. Nurse2Nurse 2(11): 66–8

Schultz G, Sibbald R, Falanga V et al (2003) Wound bed preparation: a systematic approach to wound management. Wound Repair Regen 13(Suppl 4): S21–28

Schultz G, Mozingo D, Romanelli M, Claxton K (2005) Wound healing and TIME; new concepts and scientific applications. Wound Repair Regen 13(4 Suppl): S1–11

Simon A, Sofka K, Wiszniewsky G, Blaser G, Bode U, Fleischhack G (2006) Wound care with antibacterial honey (Medihoney) in pediatric hematology-oncology. Support Care Cancer 14(1): 91–7

White J (1979) Composition of honey. In: Crane E (ed). Honey: A Comprehensive Survey. Heinemann, London

White R, Acton C (2006) Honey in modern wound management. MIMS Dermatology 2(1): 40–2

White R, Molan P (2005) A summary of published clinical research on honey in wound management. In: White R, Cooper R, Molan P (eds). Honey:

KEY POINTS

n The properties of honey from different sources vary, and only certain types of honey are beneficial in wound care.

n Only medical grade honey should be used in wound care.

n Medical grade honey has five modes of action, which means that it can be used in a variety of wounds to achieve varied clinical outcomes simultaneously.

n Medical grade honey is safe and easy to use for the inexperienced practitioner.

n Medical grade honey is a valued addition to the nurse’s toolkit and fits into various categories within a wound care formulary in both primary and secondary care.

Figure 6b. Debridement of

devitalized tissue is complete after 16 days’

treatment with Medihoney wound gel and Sorbion Sachet S

secondary dressing.

Figure 6a. Venous leg ulcer on the left

medial malleolus, extending laterally

and showing extensive maceration and skin

breakdown.

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