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Honey dressings

VIEW PRODUCTS: Honey dressings

Honey is a topical antibacterial agent that has been used for centuries in wound care. Medical grade wound care products can be used to treat various wound types including acute, chronic and infected wounds. Laboratory studies have shown that honey has a broad spectrum of activity against several bacteria and fungi (Molan, 1992; Blair and Carter, 2005). Staphylococcus aureus, which is the most common cause of wound infection, has been shown to be inhibited by relatively low concentrations of honey (Cooper et al, 2002; Blair et al, 2009; Henriques et al, 2010), as well as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-sensitive and vancomycin-resistant enterococci (VSE and VRE, respectively) (Cooper et al, 2002; George and Cutting, 2007; Sherlock et al, 2010; Jenkins, et al, 2011), coagulase negative staphylococci (French et al, 2005) and Pseudomonas aeruginosa (Cooper et al, 2002; Blair et al, 2009; Sherlock et al, 2010).  

How do honey dressings work?

The therapeutic properties of honey are largely attributed to antimicrobial activity and the enhancement of wound healing (Molan, 1999; 2011).

It is important to note that not all honeys are equivalent (Allen et al, 1999; Cooper and Jenkins, 2009; Kwakman et al, 2011), and research into the bioactive components in honey is still being discovered. In Manuka honey, methylglyoxal and leptosin (Kato et al, 2012) have been shown to contribute to its antibacterial activity (Adams et al, 2008; Mavric et al, 2008). Bee defensin (an antimicrobial peptide synthesised as part of the insect innate immune system), was found in the honey used in Revamil® (Kwakman et al, 2010). Several honeys generate hydrogen peroxide on dilution (Allen et al, 1991); however, Manuka honey does not produce detectable levels and is known as a non-peroxide honey (Kwakman et al, 2011).

Buckwheat honey has been shown to inhibit E. coli, VRE, MRSA and Bacillus subtilis by the degradation of DNA attributed to the generation of hydrogen peroxide on dilution (Brudzynski, et al, 2012).

What are the therapeutic properties of honey?

There has been a substantial amount of work published about the therapeutic properties of honey (Molan, 1999; 2011), which can best be summarised as:

  • Broad spectrum of antimicrobial activity
  • Debriding action
  • Reduces oedema
  • Moist wound environment
  • Deodorising action
  • Antioxidant activity
  • Anti-inflammatory activity
  • Enhanced rate of healing (Molan, 1999; 2011).

What are the modalities of honey dressings?

Wound care products containing honey come in four modalities:

  • Honey gel or ointments: effective at managing low volumes of exudate
  • Honey-impregnated tulle: suitable for superficial wounds with low to moderate volumes of exudate
  • Honey gel sheet: effective at managing low volumes of exudate
  • Honey-impregnated calcium alginate dressing: effective at managing moderate to high volumes of exudate (Hewish, 2012).

There are many honey products available, how do I select the right one?

Each patient has different needs that need to be considered when choosing the correct product. The following questions can help with dressing selection.

How much exudate is the wound producing?

If the wound is producing medium to high volumes of exudate, a plus or superabsorbent product may be required. However, if exudate production is low, a light or thin dressing may be more suitable. Correct exudate assessment (based on colour and amount) and management are essential both to maintain a moist wound healing environment and to prevent the peri-wound skin from maceration.

Methods for assessing exudate have been suggested by Falanga (2000), Bates-Jensen (wound assessment tool) (Bates-Jensen, 2007) and a proposed national wound assessment form (Fletcher, 2010). The latter uses the term 'wound moisture level' rather than exudate, and is based on the World Union of Wound Healing Societies (WUWHS) document on exudate (WUWHS, 2007). Clinicians should also refer to their local policy on exudate assessment.

How fragile is the patient’s skin: adherent or non-adherent?

Non-adherent honey dressings need to be secured in place by tape or light retention bandages. These dressings are suitable for use on fragile or damaged skin, where adhesive dressings may result in skin damage. Most honey wound care products require appropriate secondary dressings because of their fluid nature.

Adherent honey dressings have an adhesive backing so that they stick directly to the skin without needing to be held in place by other products. 

Is honey difficult to apply?

Honey is sticky and difficult to apply to the wound especially when there are high levels of exudate; however, honey-impregnated products are available. A secondary dressing must be used with most honey wound care products. Manufacturers' instructions must always be followed. Certain honey products can also be used with 4-layer bandages. 

Is the dressing going to be used under compression?

Honey is viscous in nature. This means that if pressure is applied, such as by compression bandaging, or by body weight if the dressing is placed on the sacrum or heel, the fluid in the dressing may leak out. In such circumstances, dressings which have the ability to wick and lock fluid away should be used.

Do honey dressings have film backings?

The majority of honey dressings require a secondary dressing. Some honey dressings have a film-backing which prevents fluid leaking out of the back, which can prevent bandages or other dressings used to fix them in place from becoming wet.

Is antimicrobial action needed?

Honey has antimicrobial components, which help the dressings to kill microorganisms that may be responsible for local wound infection or delayed healing. Antimicrobial dressings should only be used if infection is present, or if the patient is considered to be at an increased risk of wound infection.

Where is the wound? Is it in a place that is difficult to dress?

Some wound sites such as the sacrum or heel can be difficult to dress. Honey products can be used in most anatomical areas with a secondary dressing for support and protection. Honey gel sheets, for example, are flexible and not sticky.

Selecting a honey dressing

Selection of a honey dressing should be guided by:

  • Volume of exudate
  • Condition of skin
  • Location of wound
  • Use under compression
  • Presence of infection.

Patient choice

Patient choice and preference should always be considered. This helps to build up a good nurse-patient relationship and is in line with national policy.

Precautions

Wound care specialists should ensure that the patient is not sensitive to any additives or agents in the honey and should ask about known bee stings, bee and honey sensitivities and allergies before application.

Performance indicators

  • Antimicrobial
  • Debriding action and osmotic effect
  • Deodorising action
  • Antioxidant activity
  • Anti-inflammatory activity
  • Self-adherent/non-adherent
  • Secondary dressing required
  • Can be used under compression

References

Adams C, Boult CH, Deadman BJ, Farr JM, Grainger MN, Manley-Harris M, Snow MJ (2008) Isolation by HPLC and characterisation of the bioactive fraction of New Zealand manuka (Leptospermum scoparium) honey. Carbohydrate Res 343: 651–9

Allen KL, Molan PC, Reid GM (1991) A survey of the antibacterial activity of some New Zealand honeys. J Pharm Pharmacol 43: 817–22

Bates-Jensen B (1997) The pressure sore status tool a few thousand assessments later. Adv Wound Care 10(5): 65–73

Blair SE, Carter DA (2005) The potential for honey in the management of wound and infection. J Aust Infect Control 10: 24–31

Blair SE, Cokcetin NN, Harry EJ (2009) The unusual antibacterial activity of medical-grade Leptospermum honey: antibacterial spectrum, resistance and transcriptome analysis. Eur J Clin Microbiol Infect Dis 28(10): 1199–208

Brudzynski K, Abubaker K, Wang T (2012) Powerful killing by buckwheat honeys is concentration-dependent, involves complete DNA degradation and requires hydrogen peroxide. Frontiers Microbiol 3: 242

Cooper RA, Jenkins L (2009) A comparison between medical grade honey and table honeys in relation to antimicrobial efficacy. Wounds 21(2): 29–36

Cooper RA, Halas E, Molan PC (2002) The efficacy of honey in inhibiting strains of Pseudomonas aeruginosa from infected burns. J Burns Care Rehabil 23: 366–70

Falanga V (2000) Classifications for wound bed preparation and stimulation of chronic wounds. Wound Rep Regen 8(5): 347–52

Fletcher J (2010) Development of a new wound assessment form. Wounds UK 6(1): 92–9

French VM, Cooper RA, Molan PC (2005) The antibacterial activity of honey against coagulase-negative staphylococci. J Antimicrob Chemother 56: 228–31

George NM, Cutting KF (2007) Antibacterial honey (MedihoneyTM): in-vitro activity against clinical isolates of MRSA, VRE, and other multiresistant Gram-negative organisms including Pseudomonas aeruginosa. Wounds 19(9): 231–6

Henriques AF, Jenkins RE, Burton NF, Cooper RA (2010) The intracellular effects of manuka honey on Staphylococcus aureus. Eur J Clin Microbiol Infect Dis 29(1): 45–50

Hewish J (2012) Understanding the role of antimicrobial dressings. Wounds UK 7(1): 84-9

Jenkins R, Burton N, Cooper RA (2011) Manuka honey inhibits cell division in methicillin-resistant Staphylococcus aureus. J Antimicrob Chemother 66: 2536–42

Kato Y, Umeda N, Maeda A, Matsumoto D, Kitamoto N, Kikuzaki H (2012) Identification of a novel glycoside, leptosin, as a chemical marker of manuka honey. J Agric Food Chem 60: 3418–23

Kwakman PH, te Velde AA, de Boer L, Speijer D, Vandenbroucke-Grauls CM, Zaat SA (2010) How honey kills bacteria. FASEB 24: 2576–82

Mavric E, Wittmann S, Barth G, Henle T (2008) Identification and quantification of methylglyoxal as the dominant antibacterial constituent of manuka (Leptospermum scoparium) honeys from New Zealand. Mol Nutr Food Res 52: 483–9

Molan PC (1992) The antibacterial activity of honey 1. The nature of the antibacterial activity. Bee World 73: 5–28

Molan PC (2011) The evidence and the rationale for the use of honey as a wound dressing. Wound Practice Res 19(4 ): 204–20

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

Sherlock O, Dolan A, Athman R, Power A, Gethin G, Cowman S, Humphreys H (2010) Comparison of the antibacterial activity of IUlmo honery from Chile and manuka honey against methicillin-resistant Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa. BMC Complement Altern Med 10: 47

World Union of Wound Healing Societies (2007) Principles of Best Practice: Wound Exudate and the Role of Dressings. A Consensus Document. MEP, London