The Effectiveness of Honey Therapy for the Treatment of Diabetic Wounds

8/18/2019 The Effectiveness of Honey Therapy for the Treatment of Diabetic Wounds

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Case report

Honey based therapy for the

management of a recalcitrant diabeticfoot ulcer

Hashim Mohamed a,b,*, Badriya El Lenjawi b,Mansour Abu Salma c, Seham Abdi c

a Family Medicine, Weill Cornell Medical College, Qatar b Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar c Primary Care Corporation, Doha, Qatar

KEYWORDSDiabetic foot ulcer;Honey based therapy;Primary care

Abstract Objective: Diabetic foot ulcers are usually treated at hospital podiatryclinics and not at primary care level. We report an alternative approach using honeybased therapy in the successful management of diabetic foot ulcer at primaryhealth care level.Methods: The case is discussed in relation to various modalities targeting diabeticfoot ulceration in the literature.Result: A 65 years old female-Egyptian diabetic patient presented with a neuro-pathic plantar ulcer of 10 5 cm post-thermal burn following the use of a hot water bottle.

The patient was treated with strict offloading using a pair of crutches, debride-ment of necrotic tissue using a sharp scalpel and commercial honey applied dailyand covered with a glycerin based dressing. The honey dressing was changed dailyalong with strict offloading and by week 16 the ulcer completely healed.Conclusion: Treatment of diabetic foot ulcer is possible at primary care level.ª 2013 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.

Key points

Natural honey is an effective wound dressing.Natural honey is cost effective and aestheti-cally acceptable.Natural honey is bactericidal, provides mois-ture and debrides wounds.

* Corresponding author. Family Medicine, Weill Cornell Medi-cal College, Qatar. Tel.: þ974 55861008.

E-mail addresses: [email protected] (H. Mohamed),[email protected] (B. El Lenjawi), [email protected] (M.A. Salma), [email protected] (S. Abdi).

0965-206X/$36 ª 2013 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.http://dx.doi.org/10.1016/j.jtv.2013.06.001

Journal of Tissue Viability (2014) 23, 29e33

www.elsevier.com/locate/jtv

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A case report

Diabetes-related foot complications are a major burden for patients and society. Patients sufferingfrom diabetic ulcers are at increased risk of hospi-talization, lower limbs sepsis and amputation [1,2].As a result patients suffer from decreased quality of

life, decreased function and increased health carecost [3e6].Worldwide, the majority of diabetic patients

are being treated by family physicians therebyplaying a pivotal role in the management of dia-betes and its related complications.

Managing diabetic foot ulcer requires an inte-grated health care delivery utilizing multipleinvestigative and therapeutic modalities.

Although difficult to treat ulcers may require ad-vancedbiotechnologies including growthfactors, themajority of ulcers may respond well to conventionaltherapies.

Honey hasbeenused to treat wounds for millennia[7] and this is further supported by its effectivenessin promoting healing in animal and human studies.

Literature reviews, have been largely positivewith regards to the antibacterial properties ofhoney especially against a wide variety of patho-gens including Pseudomonas and methicillin-resis-tant Staphylococcus aureus (MRSA) [8e15].

Honey’s antibacterial properties are related tomany properties including its hyperosmolarity, con-taining less than 20% water, its acidity (pH 3.5e5.0),its release of hydrogen peroxide, flavonoids and

phenolic acids making bacteria unlikely to survive ina honey based ulcer bed [16,17].

Honey’s wound healing properties lie in itsability to provide moisture in the ulcer bed therebyaiding epidermal migration, providing trace nutri-ents and stimulating inflammatory cytokines (e.g.,TN-a, IL-6, IL-1B) by macrophages [18e21].

Honey has been described in more than 500 re-ports in the literature and not a single com-plication with regards to clostridium spores woundinfection has ever been reported [22].

Case history

A 65 years old female patient, with diabetes of 25years, BMI ¼ 23 kg/m2, ex-smoker, who sustained athermal burn to her right foot plantar surfacefollowing the application of a hot water bottle totreat the cold sensation felt in her leg secondary todiabetic peripheral neuropathy see Fig. 1.

She had her plantar ulcer treatment throughouther attendance at the main general hospital outpatient clinic for six weeks and was not improving,

several conventional modalities were usedincluding a non-adhesive foam dressing containingbiotin, wet-to-moist dressing, Iodine based dres-sing & paraffin impregnated tulle and finally thepatient had a dressing utilizing a silver containingalginate dressing (Sivercel-Systagenix).

All of which have failed to render desirable re-sults. A holistic assessment of the patient by theattending consultant family physicians found her to have uncontrolled diabetes (HbA1C > 10%),anemia (Hb ¼ 10.0) and suffering from hyperten-sion and chronic obstructive airway disease. Shewas commenced on insulin twice daily regimen,given iron supplement, anti-hypertensive medica-tions were stepped up to control her blood pres-sure and tiotropium inhaler þ a long actingsalbutamol/fluticasone accuhaler were prescribedto control her chronic obstructive airway disease.

A wound assessment was carried out by theattending consultant family physicians with thefollowing findings; the ulceration on initial pre-sentation had the largest length of 10 cm 5 cmbeing the largest perpendicular width (see Fig. 2).The peripheral pulses were manually palpableincluding dorsalis pedis & posterior tibial artery.

Figure 1 Plantar ulcer on presentation.

Figure 2 Plantar ulcer showing hard callus around themargin and necrotic areas in the center.

30 H. Mohamed et al.


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This was further assessed by Doppler examinationwhich revealed strong, regular, triphasic foot pulse.Neurological examination on the other hand re-vealed loss of vibration perception threshold using a128 MHz tuning fork and this was further supportedby loss of protective sensation using the 10 gmonofilament indicative of sensory neuropathy in

both feet. Furthermore, the 10 g monofilament wasnot used on any patient that day thereby main-taining its reliability & validity as a screening toolfor diabetic peripheral neuropathy.

A deep tissue biopsy was taken to rule out in-fection and was negative, similarly probing of theulcer was done at different areas since theulcer wasrelatively large and did not probe to bone therebypractically ruling out osteomyelitis. This was donesince infection is known to slow wound healing, andwarmth, swelling and redness may be absent indiabetic ulcers due to an altered immune state,thereby making diagnosis difficult [23,24].

Furthermore, the negative predicative value of56% for “probing to bone “indicates that a negativetest dose not exclude osteomyelitis. As a result, aplain radiograph was done and was negative. How-ever, plain radiography has sensitivity of 60% andspecificity of 60% respectively [25]. As a result weopted to send the patient for an MRI since it has asensitivity of 99%and a specificity of 83% [26], whichwas also negative.

The ulcer was cleaned with normal saline, ne-crotic tissues were debrided using a sharp scalpel.Thiswas followed by the applicationof natural honey

which was boughtfroma local shop importing naturalhoney from Yemen. The natural honey used was ahomogenous set white honey produced by Russianbees ( Apis mellifera) whichis nativeto the PrimorskyKrai region in Russia. The natural honey was appliedonto on the woundusing a sterile spatula andcoveredby (ADAPTIC-SYSTAGENIX) which is a non-adheringdressing made of knitted cellulose acetate fabricand impregnated with specially formulated petro-leum emulsion. This was covered with a cotton woolbandage and a light creb bandage cover.

The honey dressing provided moisture & anti-bacterial activity while the non-adherent a dressing(ADAPTIC) minimized the risk of tissue damage uponchange of dressing. In this case the dressing waschanged on a daily basis with total offloading of theulcer using a pair of crutches which the patientalready utilized for a previous ankle sprain. An or-dinary offloading material consisting of multiplelayered incontinence pad was applied around theulcer. This option was used since the patient wasmanaged at a busy primary care clinic in Qatar where total contact casts (gold standard) areunavailable, difficult to apply [27,28].

This technique was used to redistribute andrelieve pressure from the ulcer site thereby facil-itating the healing process and preventing further tissue trauma. At each review (daily) appointmentthe ulcer was debrided frequently and honey wasapplied on a daily basis and the wound wasassessed for signs of infections.

At week 2 the ulcer looked healthy with areas ofgranulation tissue which meant that our treatmentstrategy did not need to be modified (see Fig. 3).

At week 3 dramatic improvement had taken placewith an evidence of an advancing healing edge with amarked reduction in the ulcer size (>40%) and theremaining of the ulcer appeared healthy with normalskin (see Fig. 4). Progressive healing continued asshown by the image at 5 weeks (see Fig. 5). The ulcer is almost healed at week 6 (see Fig. 4) and by week 7complete healing had taken place (see Fig. 6).

Discussion

Honey used in this case has provided moisture andantibacterial activity thereby accelerating tissuerepair, causing less scarring and less pain [29,30]and although a burning or stinging sensation hasbeen described with honey’s topical use [17], inour case no symptoms were reported by the pa-tient which could be attributed to advanced dia-betic peripheral neuropathy.

Many types of honey appear to be effective for wound healing with varying antibacterial activ-

ities. The mechanism of action of honey seems tostem from its hyperosmolar property containingless than 20% water creating an osmotic gradientthereby initiating a dual action in the wound bed.Firstly, it depletes the bacteria of its water con-tent leading to its death and secondly it draws fluid

Figure 3 Healthy granulation tissue with the center ofthe ulcer showing new skin growth.

Honey based therapy for the management of a recalcitrant diabetic foot ulcer 31


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from the edematous wound thereby enhancingwound circulation [17].

Furthermore, honey possesses a potent enzyme(glucose oxidase) which releases small amounts ofhydrogen peroxide enough to kill bacteria withoutundermining the ulcer bed. Additionally, honeyprovides essential trace elements which aid the

healing process [18]. All these properties includedin honey makes it an attractive cost effective andviable option for treating diabetic foot ulcer.Furthermore, resistance development by bacteria isunlikely since studies have shown that honey, evenwhen diluted 10-fold or more prevents the growthof a variety of organisms including bacteria [31].Histologically, honey seems to enhance tissue repair and growth in animal and human controlled trialswith reduced inflammatory reactions, enhancedepithalization and earlier tissue repair [8,32e34].

Macroscopically studies have demonstrated thedebriding action of honey in a variety of wounds

including diabetic foot ulcers, burns, arterial ul-cers and infected surgical wounds [35e38].

Conclusion

In our study we observed the effectiveness ofnatural commercial honey in combination with ahydroalginate and offloading in managing diabeticfoot ulcer at primary care level.

Currently, there is a paradigm shift in the fightagainst the diabetes plague and its multiple co-morbidities including diabetic foot ulcers, there-fore primary care physicians must take a leadingrole in this battle in order to improve quality of lifeand safe individuals from amputations.

In summary, we present what to our knowledgeis the first case of honey based management of arecalcitrant diabetic foot ulcer secondary to athermal burn being managed at primary care levelin this region of the world where diabetes hasreached epidemic proportions.

Conflict of interest statement

The authors hereby declare no conflict of interest.

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Figure 4 Reduction of the ulcer by >40% in size byweek 3.

Figure 5 98% healing of the ulcer by week 5.

Figure 6 Complete healing by week 7.

32 H. Mohamed et al.

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