With the rise in cases of diabetes, more and more people will suffer from foot ulcers that do not heal and may end up needing amputation because treatment of chronic wounds is so difficult.
Today, an alternative treatment based on a remedy used since antiquity is getting increased attention -- smearing wounds with honey.
Manuka Honey, a medicinal honey harvested from beekeepers in New Zealand, is now being marketed for application on wounds. In June, Health Canada approved it under the brand name Medihoney for use as a wound dressing and antimicrobial. In July, the Food and Drug Administration cleared it for use in wounds and burns in the U.S.
The effects of treating wounds with honey have been noted mostly in anecdotal reports and case histories, making it hard for scientists to know whether the remedy compares favorably with standard wound dressings such as hydrogels, silver-impregnated gauzes or topical antibiotics.
But in recent years, larger studies have shown promising results, and more are underway.
“In the last few years, a lot of good science has been done in the area,” says Shona Blair, a microbiologist at the University of Sydney, Australia, who studies the antibacterial properties of honey.
Chronic wounds -- most commonly diabetic foot ulcers but also burn wounds, venous pressure ulcers, arterial leg ulcers and bedsores -- are a growing medical problem. An estimated 3 million people in the U.S. suffer from pressure ulcers, or bedsores. Each year, an estimated 100,000 diabetics will lose a limb through amputation, mostly as a result of nonhealing wounds. With diabetes on the rise, doctors expect to see a lot more diabetic foot ulcers.
Acute wounds are usually treated by keeping them moist and sterile, which promotes the innate wound-healing ability of the body. But in patients with underlying conditions such as diabetes, a small crack in the skin often fails to heal and can develop into a chronic wound.
Such a wound runs a great risk of becoming infected, which in turn reduces the chance of healing -- a vicious cycle that can lead to severe infection, even down to the bone. Chronic wounds are sometimes treated surgically, by removing dead skin to promote healing. Patients are also treated with off-loading orthotic shoes to prevent applying pressure on the wound, but these are cumbersome and rarely efficiently used.
The honey treatment involves putting it on bandages and applying it to wounds. Because there is a concern among some physicians that untreated honey may carry a risk of botulism -- a rare but fatal disease caused by contamination -- companies such as Comvita, which markets Medihoney, irradiate the product to sterilize it.
There are several possible ways that honey helps wounds heal, researchers say.
Honey, rich in sugars, provides a hyperosmotic environment -- meaning it will suck the water out of bacteria, killing them. (Such a hyperosmotic environment is the principle behind making preserves from fruit and regular sugar.)
Honey is antibacterial in other ways, too. During its creation, worker bees add an enzyme -- glucose oxidase -- to the nectar they’ve collected. When the honey is applied to a wound, it is exposed to oxygen in the air, and the glucose oxidase produces hydrogen peroxide -- bleach -- killing the bacteria.
Honey, Blair adds, seems to be active against troublesome antibiotic-resistant strains such as methicillin-resistant Staphylococcus aureus -- an important thing, because chronic wounds are often colonized by such bacteria. She’s tested various Australian and New Zealand honeys against bacterial strains obtained from hospitals and found that even the strains most resistant to antibiotics failed to grow and were killed in the presence of honey.
Peter Molan, a New Zealand biochemist at the University of Waikato, has reported that Manuka honey, named after a New Zealand tree, can stop bacterial growth even when diluted up to 56 times. And in studies in piglets and rats he’s found that honey has anti-inflammatory properties, stimulating skin to grow into a wound, advancing its closure.
Patient case histories also provide evidence that honey can help wounds heal. In 2001, Dr. Jennifer Eddy, associate professor at the department of family medicine at the University of Wisconsin, was treating a patient with an extreme case of diabetic foot ulcer. It had refused to heal despite treatment with conventional remedies: surgical debridement (or removal of dead tissue) antibiotics, hydrogel dressings and use of an off-loading orthotic.
The foot was infected down to the bone. With the threat of amputation looming, Eddy treated the patient’s wound with honey, smearing it on the bandage and applying it to the wound.
The wound healed, the leg was salvaged, and in 2005 Eddy published the case report in the Journal of Family Practice. There are more than 200 similar case reports in the medical literature, according to a 2006 review, for a wide variety of chronic wounds -- diabetic foot ulcers, ulcers due to insufficient venous or arterial blood flow, bed sores, burns, wounds containing antibiotic-resistant bacteria and ones caused by weakened immunity.
Anecdotes are one thing, but the medical gold standard is a clinical trial. And that is a problem for honey, Eddy says. Last year, while at a conference, she discussed with a colleague the possibility of conducting a trial on honey. “He told me, ‘There’s no money in honey’ ,” she says.
Eddy did manage to obtain funds for a randomized, clinical trial comparing store-bought honey against standard treatments for intractable foot ulcers. Since March, seven patients have been recruited; the goal is to recruit 40. Results are expected in about two years, Eddy says.
A three-year-long study at the University of Bonn, Germany, reported good healing rates in the use of honey as a dressing for wounds in 15 children with cancer, a population prone to nonhealing ulcers because of weakened immunity after radiation and chemotherapy.
Preliminary results of another clinical trial comparing honey with hydrogel dressings in 100 patients with chronic leg ulcers were presented in May at a wound meeting in Scotland. The honey-dressing group healed faster and had less infection than the standard treatment group. Complete findings are expected later this year.
Other studies are underway: One, at the Red Cross War Memorial Children’s Hospital in Cape Town, South Africa, will compare a honey-based antibacterial wound gel product to standard treatment in about 80 children with burns. A smaller pilot study will look at honey treatment in head and neck cancer patients undergoing radiation.
Some specialists are not too optimistic about the benefits of honey in wound management. “It’s good with butter and bread -- I don’t think honey on Band-Aid is the answer,” says Dr. Adrian Barbul, chair of surgery at Sinai Hospital in Baltimore and professor of surgery at Johns Hopkins University.
But Dr. Arne Simon, director of pediatric oncology at the Children’s Hospital of Bonn University and first author of the study on children with cancer, says that although more clinical studies are needed, the data for the children, at least, looked good. Specialists, he says, should consider standardized honey when faced with other wounds that just don’t want to heal.
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A cheap fix in a war zone
Honey is cheap, making it potentially useful for treating wounds in earthquake-stricken and war-torn areas where running water is scarce and often contaminated. It is being used in Iraq to treat burn wounds in children.
When Col. Dr. Craig Lambrecht, an emergency physician working at the MedCenter One Health Clinic in Bismarck, N.D., served in Iraq for his second mission late last year as part of the National Guard, he was involved in overseeing a makeshift civilian outpatient care center to treat Iraqi children suffering from burns. The Smith Gate Burn Clinic, an hour south of Baghdad, is the only service in the country offering such burn care to children.
The center was supplied with Medihoney, now produced by the company Comvita in New Zealand, to fill the need for a cost-effective wound-dressing solution. The sterile, medical-grade honey was paid for by donations.
Patients’ wounds were dressed with honey instead of the silver sulfadiazine gauze dressings usually used to treat burn wounds. The children were sent home with the honey, and their parents told to reapply it.
“We were seeing great results,” Lambrecht says. “Patients were following our instructions and reapplying honey to dress their wounds. There were no problems with allergies. The [edges of the wounds] were healing, there were less infections.” In fact, he says, “observations were that it worked better than the silver dressings.”
The clinic, which continues to treat children with honey and see good results, drew patients based on word of mouth and was treating 600 to 700 children a month at the end of 2006, when Lambrecht was last stationed there, he says. “We saw families with their children coming in from across the borders from Iran and Syria. . . . They knew that our outcomes were so good.”