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Honey for Wound Healing, Ulcers, and Burns; Data Supporting Its Use in Clinical Practice

Wiley
The Scientific World Journal
Authors:
  • Waili Foundation for Science

Abstract

The widespread existence of unhealed wounds, ulcers, and burns has a great impact on public health and economy. Many interventions, including new medications and technologies, are being used to help achieve significant wound healing and to eliminate infections. Therefore, to find an intervention that has both therapeutic effect on the healing process and the ability to kill microbes is of great value. Honey is a natural product that has been recently introduced in modern medical practice. Honey's antibacterial properties and its effects on wound healing have been thoroughly investigated. Laboratory studies and clinical trials have shown that honey is an effective broad-spectrum antibacterial agent. This paper reviews data that support the effectiveness of natural honey in wound healing and its ability to sterilize infected wounds. Studies on the therapeutic effects of honey collected in different geographical areas on skin wounds, skin and gastric ulcers, and burns are reviewed and mechanisms of action are discussed. (Ulcers and burns are included as an example of challenging wounds.) The data show that the wound healing properties of honey include stimulation of tissue growth, enhanced epithelialization, and minimized scar formation. These effects are ascribed to honey's acidity, hydrogen peroxide content, osmotic effect, nutritional and antioxidant contents, stimulation of immunity, and to unidentified compounds. Prostaglandins and nitric oxide play a major role in inflammation, microbial killing, and the healing process. Honey was found to lower prostaglandin levels and elevate nitric oxide end products. These properties might help to explain some biological and therapeutic properties of honey, particularly as an antibacterial agent or wound healer. The data presented here demonstrate that honeys from different geographical areas have considerable therapeutic effects on chronic wounds, ulcers, and burns. The results encourage the use of honey in clinical practice as a natural and safe wound healer.
Review
TheScientificWorldJOURNAL (2011) 11, 766787
ISSN 1537-744X; DOI 10.1100/tsw.2011.78
*Corresponding author.
©2011 with author.
Published by TheScientificWorld; www.thescientificworld.com
766
Honey for Wound Healing, Ulcers, and
Burns; Data Supporting Its Use in Clinical
Practice
Noori S. Al-Waili1,2,*, Khelod Salom1, and Ahmad A. Al-Ghamdi2
1Al-Waili`s Foundation for Sciences, Chronic Wound Management and Hyperbaric
Medicine, Life Support Technology Group, New York, U.S.A.; 2Bee Research Chair,
King Saud University, Riyadh, K.S.A.
E-mail: noori1966@yahoo.com
Received November 20, 2010; Revised March 3, 2011; Accepted March 3, 2011; Published April 5, 2011
The widespread existence of unhealed wounds, ulcers, and burns has a great impact on
public health and economy. Many interventions, including new medications and
technologies, are being used to help achieve significant wound healing and to eliminate
infections. Therefore, to find an intervention that has both therapeutic effect on the
healing process and the ability to kill microbes is of great value. Honey is a natural
product that has been recently introduced in modern medical practice. Honey’s
antibacterial properties and its effects on wound healing have been thoroughly
investigated. Laboratory studies and clinical trials have shown that honey is an effective
broad-spectrum antibacterial agent. This paper reviews data that support the
effectiveness of natural honey in wound healing and its ability to sterilize infected
wounds. Studies on the therapeutic effects of honey collected in different geographical
areas on skin wounds, skin and gastric ulcers, and burns are reviewed and mechanisms
of action are discussed. (Ulcers and burns are included as an example of challenging
wounds.) The data show that the wound healing properties of honey include stimulation
of tissue growth, enhanced epithelialization, and minimized scar formation. These effects
are ascribed to honey’s acidity, hydrogen peroxide content, osmotic effect, nutritional
and antioxidant contents, stimulation of immunity, and to unidentified compounds.
Prostaglandins and nitric oxide play a major role in inflammation, microbial killing, and
the healing process. Honey was found to lower prostaglandin levels and elevate nitric
oxide end products. These properties might help to explain some biological and
therapeutic properties of honey, particularly as an antibacterial agent or wound healer.
The data presented here demonstrate that honeys from different geographical areas have
considerable therapeutic effects on chronic wounds, ulcers, and burns. The results
encourage the use of honey in clinical practice as a natural and safe wound healer.
KEYWORDS: honey, wound, ulcer, healing, infection, nitric oxide, prostaglandin
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PATHOPHYSIOLOGY OF WOUND HEALING
Every year in the U.S., more than 1.25 million people have burns and 6.5 million have chronic skin ulcers
caused by pressure, venous stasis, or diabetes mellitus[1]. Diabetes represents a major impact on wound
healing outcome. In 2004, according to the World Health Organization (WHO), more than 150 million
people worldwide suffered from diabetes. Its incidence is increasing rapidly and it is estimated that by the
year 2025, this number will double.
A wound is a disruption of the continuity of a tissue structure. Injury, by surgery or accident, causes
destruction of tissue, disruption of blood vessels, and extravasation of blood constituents and hypoxia.
Wound healing is a complex, continual process that has three phases: inflammation, a proliferative phase,
and tissue remodeling. Basically, wound healing is the result of interactions among cytokines, growth
factors, blood and cellular elements, and the extracellular matrix. The cytokines promote healing by
various pathways, such as stimulating the production of components of the basement membrane,
preventing dehydration, and increasing inflammation and formation of granulation tissue.
At the cellular level, monocytes infiltrate the wound site and become activated macrophages that
release growth factors, such as platelet-derived growth factor (PDGF) and vascular endothelial growth
factor (VEGF), which initiate the formation of granulation tissue. Macrophages have a key role in
inflammation and repair[2]. It has been found that macrophage-depleted animals have defective wound
repair[3]. We have found that macrophage transfusion accelerates wound healing in patients with
nonhealing wounds[4]. Platelets facilitate the formation of a hemostatic plug and secrete PDGF, which
attracts and activates macrophages and fibroblasts[2]. Re-epithelialization of wounds begins shortly after
injury. Epidermal cells at the wound margin begin to proliferate within 1 to 2 days after injury. On day 4
after injury, new granulation tissue begins to invade the wound gap and numerous new capillaries grow
through the new stroma with its granular appearance. After migrating into wounds, fibroblasts begin the
synthesis of the extracellular matrix[2,5].
The induction of angiogenesis was initially attributed to acidic or basic fibroblast growth factors,
which are released from macrophages after cell disruption. Angiogenesis is the process of new vessel
formation from an existing vasculature network. Once the wound is filled with new granulation tissue,
angiogenesis ceases and many of the new blood vessels disintegrate as a result of apoptosis[6]. Wound
contraction involves a complex interaction of cells, extracellular matrix, and cytokines.
Vitamins C, E, and A, glucose, amino acids, antioxidants, fatty acids, proteins, water, and zinc are
important for wound healing[7,8,9,10,11,12]. Administration of ascorbic acid protected mice against
radiation-induced sickness and mortality, and improved healing of wounds after exposure to whole-body
gamma radiation[13]. Low levels of antioxidants accompanied by raised levels of markers of free radical
damage play a significant role in the delay of wound healing. In diabetic rats, reduced glutathione levels
had a role in delaying the healing process[14]. Hydrogen peroxide is one of the mediators of healing
responses[15]. Electrolyzed, strong acid aqueous solution irrigation may promote tissue growth in burn
wounds[16]. Acidic media enhances wound contraction[7].
Nitric oxide (NO) has a wide range of physiological and pathophysiological activities, including the
regulation of vessel tone and angiogenesis in wound healing, inflammation, ischemic cardiovascular
diseases, and malignant diseases[17]. NO has been shown to increase microcirculatory blood flow, to kill
infective organisms, and to have a significant effect in promoting wound healing[18,19,20,21,22,23].
Prostaglandins are mediators of inflammation and smooth-muscle stimulants, but inhibition of the
prostaglandins and their precursors failed to alter the course of wound contraction[24].
Acute or chronic wounds can usually be covered by synthetic or natural dressings. Conservative
methods of wound care include the use of standard wound dressings, management of underlying problems
(such as hyperglycemia), debridement of dead tissue, restoration of adequate tissue perfusion, limitation
of pressure at the wound site, and control of infection. These methods are successful in the majority of
patients with acute or chronic skin wounds. However, large and life-threatening skin wounds may require
the use of cultured, autologous, epidermal-cell grafts or biologic skin substitutes.
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Recombinant PDGF has been approved by the U.S. Food and Drug Administration (FDA) for the
treatment of wounds. Furthermore, topical treatment of wounds is an important aspect of wound care.
Proper selection of antiseptic or antimicrobial treatment for contaminated wounds is a cornerstone of
wound care. Five commonly used topical agents are 5% mafenide acetate, 10% povidone with 1% free
iodine, 0.25% sodium hypochlorite, 3% hydrogen peroxide, and 0.25% acetic acid[25]. In addition,
hyaluronic acid was used for wound dressing[26]. Basically, modulation of nutrition, underlining medical
problems (such as vascular and neural diseases, diabetes, and infection), acidity of wounds, host
immunity, cytokines, NO, or prostaglandins have a great impact on wound healing process.
HEALING PROPERTIES OF HONEY
Honey has long been documented as having healing properties[27,28,29]. Honey and sugar paste were
associated with scarless healing in cavity wounds[30]. It has been reported that rabbit wounds treated
with a topical application of honey showed less edema, fewer polymorphonuclear and mononuclear cell
infiltrations, less necrosis, better wound contraction, improved epithelialization, and lower
glycosaminoglycan and proteoglycan concentrations[31]. Furthermore, honey causes significantly greater
wound contraction than controls, and it promotes the formation of granulation tissue and epithelialization
of wounds[32,33,34,35,36,37]. Honey stimulates tissue growth, synthesis of collagen, and development of
new blood vessels in the bed of wounds[38,39,40,41,42,43]. Intraperitoneal honey administration after an
adhesion model in the cecum and terminal ileum of rats reduced postoperative adhesion[44].
HONEY AND WOUNDS
Generally, wound healing can be affected by endogenous (pathophysiology) and exogenous (micro-
organisms) factors. The risk of wound infection increases as local conditions favor bacterial invasion and
growth. Therefore, microbial colonization of both acute and chronic wounds is inevitable. Many species
of bacteria have been recovered from wounds, but Staphylococcus aureus is the most frequently isolated
from wound pathogens[45]. In addition, Pseudomonas aeruginosa is an important pathogen in chronic
wounds and burns; its presence has been demonstrated in numerous studies and has been found in one-
third of chronic leg ulcers[46,47,48,49]. Infection with S. aureus and pseudomonads retards ulcer healing
rates and, with pseudomonads and B-hemolytic streptococcus, reduces the success of skin grafts used for
leg ulcers[50,51].
The widespread development of antibiotic-resistant bacteria is a challenging problem. Therefore,
current interest is focused on an alternative to antibiotics and conventional therapies, such as honey,
antimicrobial moisture-retentive dressings, essential oils and cationic peptides, topical enzymes,
biosurgical therapies, and vacuum therapies. In addition, unregulated inflammation caused by both micro-
organisms and underlying abnormal pathophysiological conditions is a major factor associated with the
process of healing in chronic wounds[52].
Many research works reported the use of honey for treatment of both wounds and
infections[53,54,55]. Table 1 summarizes many papers that reported successful use of honey in wound
healing. Honey with proven antibacterial activity has the potential to be an effective treatment option for
wounds infected or at risk of infection with various human pathogens. The medical literature on treating
wounds with honey has been reviewed[56,57,58,59,60,61]. As a dressing on wounds, honey provides a
moist healing environment, rapidly clears infection, deodorizes, and reduces inflammation, edema, and
exudation. It increases the rate of healing by stimulation of angiogenesis, granulation, and
epithelialization[62]. Table 2 demonstrates general effects of honey on the healing process.
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TABLE 1
Effects of Honey on Wounds Healing
Origin of
Honey
Type of Lesion
Iran[31]
Surgical incision on rabbits
India[39]
Wounds created on buffalo
calves
India[40]
Wounds created on buffalo
calves infected with S.
aureus
India[42]
Full-thickness skin wounds
made on back of rats
Egypt[64]
Infected diabetic foot wounds
Turkey[65]
Split-thickness skin graft
donor site
Turkey[44]
An adhesion model
constituted in the cecum
and terminal ileum of rats
Turkey[66]
Intraurethral injury in rats
United Arab
Emirates[67]
Injured skin or conjunctiva in
mice or rat
Yemen[68]
Postoperative wound
Thailand[69]
Postoperative wound
disruption
Nepal[71]
Radiation-induced oral
mucositis
Nigeria[72]
Wounds and ulcers
Nigeria[73]
Fournier's gangrene
Mexico[33]
Fournier's gangrene
Malawi[76]
Patients with open or
infected wounds
Norway[80]
Chronic wound infection
Ireland[81]
Nonhealing ulcers
France[82]
Wounds
Germany[84]
Resistant wound infection in
seven patients
U.K.[85]
Toenail surgery
U.K.[88]
Chronic wounds
U.K.[89]
Meningococcal skin lesions
Netherlands[91]
Sixty patients with chronic
wounds
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TABLE 2
General Effects of Honey on Wound Healing
1. Causes greater wound contraction[31,32,33,34,35,36,37,211])
2. Promotes the formation of granulation tissue[32,33,34,35,36,37,39,92]
3. Promotes epithelialization of wounds[32,33,34,35,36,37,66,73,92]
4. Stimulates tissue growth, synthesis of collagen[38,39,40,41,42,43,92]
5. Stimulates development of new blood vessels in the bed of wounds[38,39,40,41,42,43,62,93]
6. Reduces postoperative adhesion[44]
7. Reduces edema[62,73,92,93]
8. Reduces inflammation[61,62,68,92,93,119]
9. Deodorizes wounds[62,92,93]
10. Promotes moist wound healing[61,92]
11. Facilitates debridement[61,72,93]
12. Reduces pain[66,84,92]
Molan[63] published a review article that covered the various reports that have been published on the
clinical usage of honey. Positive findings on honey in wound care have been reported from 17
randomized controlled trials (1965 patients) and five clinical trials of other forms (97 patients) treated
with honey. On experimental animals, the effectiveness of honey in assisting wound healing has also been
demonstrated in 16 trials. There is also a large amount of evidence in the form of case studies[63]. In a
recent review aimed to determine whether honey increases the rate of healing in acute wounds (burns,
lacerations, other traumatic wounds) and chronic wounds (venous ulcers, arterial ulcers, diabetic ulcers,
pressure ulcers, infected surgical wounds), 19 trials (n = 2554) were identified. Conclusively, honey may
improve healing times in mild to moderate superficial and partial-thickness burns compared with some
conventional dressings. However, honey dressings as an adjuvant to compression do not significantly
increase leg ulcer healing at 12 weeks[58]. Another article provides an overview of the use of honey in
wound management and reviews the evidence to support its effectiveness in the management of wound
healing[59]. Honey has anti-inflammatory and antibacterial effects without antibiotic resistance; it
promotes moist wound healing and facilitates debridement. A summary of the current evidence base for
the use of honey, a review of its therapeutic effects, and a discussion of the implications for WOC nursing
practice was published recently[61]. In the U.S., a honey product received FDA approval in 2007.
In Iran, topical application of honey on wounds created on rabbits showed less edema and necrosis,
fewer polymorphonuclear and mononuclear cell infiltrations, better wound contraction, improved
epithelialization, and lower glycosaminoglycan and proteoglycan concentrations[31].
In India, a study showed that granulation, scar formation, and complete healing of full-thickness
wounds created on buffalo calves occurred faster with honey than with nitrofurazone or sterilized
petrolatum[39]. In another study, full-thickness skin wounds were made on buffalo calves after infecting
the wound by subcutaneous injections of S. aureus 2 days prior to wounding. Topical application of
honey, ampicillin ointment, and saline were compared. Honey gave a faster rate of healing compared with
ampicillin ointment and saline treatments, the least inflammation, the most rapid fibroblastic and
angioblastic activity, and epithelialization[40]. Full-thickness skin wounds made on the backs of rats were
treated with topical application of honey to the wound, oral administration of honey, or intraperitoneal
administration of honey. Honey increased significantly the quantity of collagen synthesized and degree of
cross-linking of the collagen in the granulation tissue. Systemic treatment gave greater increase than
topical treatment, while the intraperitoneal route produced better results than the oral route[42]. The
thickness of granulation tissue and the distance of epithelialization from the edge of the wound were
significantly greater and the area of the wound significantly smaller in wounds treated with honey
compared with control when honey was applied on excising skin on the mice down to muscles[43].
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In Egypt, 30 infected diabetic foot wounds were randomly selected for treatment with clover honey.
The honey dressing was applied to wounds for 3 months until healing, grafting, or failure of treatment.
Results showed that complete healing was significantly achieved in 43.3% of ulcers, and decrease in size
and healthy granulation was significantly observed in another 43.3% of patients. After 1 week, bacterial
load of all ulcers was significantly reduced. The authors reported that commercial clover honey is a
clinical and cost-effective dressing for diabetic wounds in developing countries[64].
From Turkey, for the treatment of a split-thickness skin graft donor site, honey-impregnated gauze
showed faster epithelialization time and a lower sense of pain than paraffin gauzes and saline-soaked
gauzes[65]. Another study was performed to evaluate the effect of honey applied intraurethrally after
urethral injury on histopathological healing in male rats. Results showed that intraurethral honey, applied
after urethral injury, prevents inflammation and accelerates urethral healing[66]. A study has shown that
intraperitoneal honey administration reduces postoperative peritoneal adhesion; the wound healing
accelerative effect and the mechanical barrier formed by the honey was explained to be the reasons for its
inhibitory effect on the adhesion[44].
From the United Arab Emirates, Al-Waili found that topical application of multifloral honey on
wounds infected with various human pathogens inoculated onto injured skin or conjuctiva in mice and
rats accelerates wound healing and eradicates bacterial infections[67]. Al-Waili and Salom have reported
that multifloral honey collected from Yemen applied to postoperative wound infections could eradicate
bacterial infections, accelerate wound healing, and minimize scar formation[68].
In Thailand, the usefulness of honey application as an alternative method of managing abdominal
wound disruption was assessed. Fifteen patients whose wounds disrupted after caesarean section were
treated with honey application and wound approximation by Micropore tape instead of the traditional
method of wound dressing with subsequent resuturing. Within 2 weeks, an excellent result was achieved
in all the cases with complete healing[69].
In Israel, nine infants with large, open, infected wounds that failed to heal with conventional
treatment were treated with honey. All infants showed marked clinical improvement after 5 days of
treatment with topical application of 510 ml of honey twice daily[70].
Another study from Nepal investigated whether honey’s anti-inflammatory properties might limit the
severity of radiation-induced oral mucositis. A single-blinded, randomized, controlled clinical trial was
carried out to compare the mucositis-limiting qualities of honey with lignocaine. It was found that honey
is strongly protective against the development of mucositis. The authors concluded that honey applied
topically to the oral mucosa of patients undergoing radiation therapy appears to provide a considerable
benefit by limiting the severity of mucositis[71].
In Nigeria, 59 patients with wounds and ulcers, most of which had failed to heal with conventional
treatment, were treated with unprocessed honey. Fifty-eight cases showed remarkable improvement
following topical application of honey. Honey debrided wounds rapidly, replacing sloughs with
granulation tissue. It also promoted rapid epithelialization and absorption of edema from around the ulcer
margins[72]. In another study from Nigeria, 20 consecutive cases of Fourniers gangrene managed
conservatively with systemic antibiotics and topical application of honey were compared retrospectively
with 21 similar cases managed by wound debridement and excision[73]. Honey has been compared with
phenytoin in a prospective randomized controlled trial on chronic leg ulcers[74]. Two groups of 25
patients with ulcers were involved, with a mean duration of 56.5 months. There was no significant
difference found in the rate of healing between the honey and phenytoin treatments.
In Burundi, 40 patients with wounds of various origins were treated with topical honey, which
provided healing in 88% of the cases[75]. In Mexico, 38 patients with Fourniers gangrene were treated
with antimicrobial therapy, broad debridement, and application of unprocessed honey dressings. Patients
then underwent split-thickness skin grafts or delayed closure as needed. It was found that topical
application of honey is beneficial to the healing process[33]. Results showed that topical application of
honey was better than conventional methods. Three deaths occurred in the orthodox method, whereas no
deaths occurred in those treated with honey.
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In Malawi, to investigate whether there is a difference between the efficacy of honey and sugar as
wound dressings, patients with open or infected wounds were randomized to receive either honey or sugar
dressings. Forty patients were enrolled. In the honey group, 55% of patients had positive wound cultures
at the start of treatment and 23% at 1 week, compared with 52 and 39%, respectively, in the sugar group.
Honey was more effective than sugar in reducing bacterial contamination and promoting wound healing,
and was slightly less painful than sugar during dressing changes[76].
From South Africa, the effects of silver- and honey-based dressings on cell viability (keratinocyte
cultures) were compared. Results showed that there was no significant difference between the best
performing silver- and honey-based wound preparations with regard to cell viability[77]. Another study
from the same area was planned to establish whether honey (L-Mesitran®) and silver-impregnated
dressings are cytotoxic in vitro to human skin keratinocytes and dermal fibroblasts. In cultures with
honey-impregnated implants, cell viability remained intact and cell toxicity was not evident at 4 months
after continuous tissue culture. In cultures with nanocrystalline silver, marked toxicity was observed with
high nonviability staining and cell-scoring counts. The honey-based product showed excellent
cytocompatibility with tissue cell cultures compared with the silver dressing[78]. Furthermore, it was
found that there was no evidence of a real difference between honey and IntraSite Gel as healing
agents. It was concluded that honey is a safe, satisfying, and effective healing agent and is cost
effective[79].
In Norway, the effects of different concentrations of Medihoney therapeutic honey and Norwegian
Forest Honey (1) on the real-time growth of typical chronic wound bacteria, (2) on biofilm formation, and
(3) on the same bacteria already embedded in biofilm were studied. Reference strains of MRSE, MRSA,
ESBL Klebsiella pneumonia, and P. aeruginosa were incubated with dilution series of the honeys in
microtiter plates for 20 h. It was found that both honeys were bactericidal against all the strains of
bacteria. Biofilm was penetrated by biocidal substances in the honey[80]. In Ireland, a study was
conducted to analyze the changes in surface pH and size of nonhealing ulcers following application of
manuka honey dressing. Reduction in wound pH after 2 weeks was statistically significant. Wounds with
pH 8.0 did not decrease in size and wounds with pH 7.6 had a 30% decrease in size. The use of
manuka honey dressings was associated with a statistically significant decrease in wound pH and a
reduction in wound size[81].
In France, 40 patients with wounds of various etiology surgical, accidental, infective, trophic, and
burns were treated with topical application of honey. Of the 33 patients treated only with honey
dressing, 29 patients healed successfully. Honey delimited the boundaries of the wounds and cleansed
them rapidly[82].
In Sweden, when commercial unboiled honey was applied topically to open wounds in mice, the
wounds of the honey-treated animals healed much faster than the wounds of the control animals[43].
In Poland, the case of a 55-year-old woman with extensive phlegmonous and necrotic lesions of the
abdominal integuments and the lumbar area following traumatic colonic rupture, treated with manuka
honey wound dressings and the GENADYNE A4 negative pressure wound healing system, was
discussed. The results showed that this intervention brought good effects, ultimately enabling skin
autografting on the wound site and complete wound healing[83].
In Germany, full healing was achieved in seven patients whose wounds were either infected or
colonized with MRSA. Antiseptics and antibiotics had previously failed to eradicate the clinical signs of
infection[84].
In the U.K., honey-impregnated dressings successfully were used in the wound care clinic and on the
maxillofacial ward[85]. A double-blind, randomized controlled trial investigated the effect of a honey
dressing on wound healing following toenail surgery with matrix phenolization. One hundred patients
were randomly assigned to receive either an active manuka honey dressing or paraffin-impregnated tulle
gras. Mean healing times were 40.30 days for the honey group and 39.98 days for the paraffin tulle gras
group. Partial avulsion wounds healed statistically significantly faster with paraffin tulle gras than with
the honey dressing[86]. In another report, a case study explored the healing of a chronic wound (20 years
duration) in a patient with dystrophic epidermolysis bullosa with use of a honey-impregnated dressing;
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the wounds were not responding to different dressings and creams[87]. Another study from the U.K. that
was conducted to compare a medical-grade honey with conventional treatments on the healing rates of
wounds healing by secondary intention included 105 patients who were involved in a single-center, open-
label, randomized controlled trial in which patients received either a conventional wound dressing or
honey. The median time to healing in the honey group was 100 days compared with 140 days in the
control group. The authors concluded that there are clinical benefits from using honey in wound care[88].
Chronic infected meningogococcal skin lesions were successfully treated with honey[89]. In another
study from the same country, manuka honey was found to eradicate MRSA in a hydroxyurea-induced leg
ulcer developed in an immunosuppressed patient; rapid healing was successfully achieved[90].
In the Netherlands, authors evaluated the use and safety of a honey-medicated dressing in a feasibility
(phase II) study featuring 60 patients with chronic, complicated, surgical, or acute traumatic wounds. In
all but one patient, honey was found easy to apply, helpful in cleaning the wounds, and without side
effects[91].
Generally, it has been shown that topical honey possesses antimicrobial properties, promotes autolytic
debridement, stimulates growth of wound tissues to hasten healing and to start the healing process in
dormant wounds, stimulating anti-inflammatory activity that rapidly reduces pain, edema, and exudate
production[92]. Patients with recalcitrant wounds and ulcers, including Fourniers gangrene, burns,
cancrum oris and diabetic ulcers, decubitus, sickle-cell and tropical ulcers, were successfully treated with
topical honey application; all had been treated for a long time with conventional treatment with no signs
of healing or with the wounds increasing in size[93]. Basically, there have been many reports of case
studies, animal experiments, and randomized controlled trials that provide considerable evidence for the
effectiveness of honey in wound healing. As a dressing on wounds, honey provides a moist healing
environment, rapidly clears infection, deodorizes, and reduces inflammation, edema, and exudation.
HONEY AND SKIN ULCERS
Honey has been used in the treatment of ulcers due to various etiologies[42,94,95,96,97,98,99,100,101].
In a review of the literature, more than 470 cases were treated with honey; there were only five cases
where successful healing was not achieved[102]. In another review study, the authors summarized
evidence of honeys effectiveness, its hypothesized mechanism of action, potential risks and benefits, the
types of honey available, and the nature of its application. Critical aspects of ulcer care are also reviewed.
It was concluded that honey is a low-cost topical therapy with important potential for healing[103]. The
use of honey in two patients with pressure ulcers resulted in a rapid and complete healing of both wounds.
The antibacterial activity of honey had a deodorizing effect on the wounds and its anti-inflammatory
actions reduced the level of pain[95]. Further, honey was used successfully for necrotizing breast ulcer
management[101]. Out of 59 treated patients with wounds and ulcers, 58 patients showed remarkable
improvement following topical application of honey; sloughs, necrotic, and gangrenous tissue separated
and could thus be lifted off painlessly[73].
In the U.K., three patients with chronic leg ulceration were assessed as potentially benefiting from the
action of medical honey to achieve wound healing. The etiology of ulceration in patient 1 was mixed
arterial and venous, and in patients 2 and 3, venous. All had several years history of recurrence.
Promotion of healing occurred in all the cases, with a reduction in the incidence of infection, reduction in
pain, and the provision of comfort[104]. In Malaysia, authors carried out a prospective study to compare
the effect of honey dressing for 30 Wagners grade-II diabetic foot ulcers with a controlled dressing group
(povidone iodine followed by normal saline). Surgical debridement and appropriate antibiotics were
prescribed for all patients. The mean healing time in the standard dressing group was 15.4 days compared
to 14.4 days in the honey group; ulcer healing was not significantly different in both study groups. It was
concluded that honey dressing is a safe, alternative dressing for Wagner’s grade-II diabetic foot
ulcers[105]. In another study, 40 patients whose leg ulcers had not responded to 12 weeks of compression
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therapy were recruited. Medihoney dressings were applied on their ulcers for the 12-week study period;
ulcer pain and size decreased significantly and odorous wounds were deodorized promptly[106].
In Ireland, a study was done to determine the qualitative bacteriological changes that occurred during
a 4-week treatment period with either manuka honey or a hydrogel dressing; 108 patients enrolled in the
study. At baseline, MRSA was identified in 16 wounds (10 in the honey group vs. six in the hydrogel
group). Results showed that manuka honey was effective in eradicating MRSA from 70% of chronic
venous ulcers. The potential to prevent infection is increased when wounds are desloughed and MRSA is
eliminated[107]. In another report, three males and five females with leg ulceration of different etiologies
were treated with honey. The wounds were dressed weekly with manuka honey. The size of the ulcers
was significantly reduced, the odor was eliminated, and the pain was relieved. The authors concluded that
the use of manuka honey was associated with a positive wound healing outcome[108].
In Turkey, a 5-week, randomized clinical trial evaluated the effect of a honey dressing on pressure
ulcer healing, and comparison with an ethoxy-diaminoacridine plus nitrofurazone dressing was
conducted. Thirty-six patients with a total of 68 stage II or III pressure were enrolled in the study. After 5
weeks of treatment, patients who were treated by honey dressing had significantly better PUSH tool
scores than subjects treated with the ethoxy-diaminoacridine plus nitrofurazone dressing[109].
In Pakistan, a study was carried out to export the results of topical wound dressings in diabetic
wounds with natural honey. Initially, all wounds were washed thoroughly, necrotic tissues were removed,
and dressings with honey were applied. The study demonstrated excellent results in treating diabetic
wounds with dressings soaked with natural honey. The disability of diabetic foot patients was minimized
by decreasing the rate of leg or foot amputations and, thus, enhancing the quality and productivity of
individual life[110].
Contrary to previous works, a community-based, open-label, randomized trial allocated people with
venous ulcers to calcium alginate dressings impregnated with manuka honey or usual care. Of 368
participants, 187 were randomized to honey and 181 to usual care. At 12 weeks, 104 ulcers in the honey-
treated group and 90 in the usual care group had healed. The authors stated that the treatment with honey
was probably more expensive and associated with more adverse events. It was concluded that honey-
impregnated dressings did not significantly improve venous ulcer healing at 12 weeks compared with
usual care[111]. In Nigeria, the efficacy of locally applied natural honey was compared to that of Eusol
solution in an open trial involving 20 patients with sickle cell anemia who were in steady clinical states
and had chronic leg ulceration. Eleven ulcers were dressed with honey, while eight were dressed with
Eusol. No significant differences were found in the rates of healing of the ulcers in either treatment
groups[112].
HONEY AND BURNS
Burn injuries are associated with a high incidence of death and disability. Advances in cellular biology,
and knowledge in wound healing and growth factors, have helped to move steps toward burn
management. Split-thickness skin grafting with autografts is the standard of care. Honey was used for
management of burns and the use of honey for burns has been reviewed[113,114,115,116,117,118].
Various modalities have been reviewed, including honey, human amnion, xenograft, allograft, cultured
epithelial autograft, and various engineered commercial products, for use in the biologic treatment of burn
wounds[116]. A systematic review and meta-analysis of randomized controlled trials that compared the
efficacy of honey with a comparator dressing treatment in the management of burns was conducted. Eight
studies with 624 subjects were included. It was found that in most studies, honey covered by sterile gauze
was compared with silver sulfadiazineimpregnated gauze. The fixed effects odds ratio for healing at 15
days was 6.1 (95% CI 3.79.9) in favor of honey having a superior effect. The secondary outcome
variables all showed significantly greater efficacy for honey treatment. It was concluded that available
evidence indicates markedly greater efficacy of honey compared with alternative dressing treatments for
superficial or partial-thickness burns[118].
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In the U.K., a review study aimed to investigate topical honey for superficial burns through a
systematic review of randomized controlled trials. Five studies in patients with partial-thickness or
superficial burns involving <40% of the body surface were reviewed. Comparators were polyurethane
film, amniotic membrane, potato peel, and silver sulfadiazine. The number needed to treat for 7 days with
honey to produce one patient with a healed burn was 2.6 (2.13.4) compared with any other treatment,
and 2.7 (2.04.1) compared with potato peel and amniotic membrane. For most of the outcomes, honey
was superior to all other treatments. In addition, time for healing was significantly shorter for honey than
other treatments[117]. In France, it was found that healing was rapid for first- and second-degree
burns[119]. Honey produced attenuation of inflammation and exudation, plus rapid regeneration of outer
epithelial tissue and cicatrization. In the Netherlands, honey-treated burns showed less inflammation than
those treated with sugar and silver sulfadiazine[120].
In Malaysia, full-thickness burn wounds created on the dorsum of 36 rats were inoculated with P.
aeruginosa, K. pneumoniae, or Acinetobacter baumannii. The wounds were dressed with tualang honey,
hydrofiber, and hydrofiber silver. Results showed that there was a rapid reduction in wound size by day 6
in the tualang honeytreated wounds. Tualang honeytreated rats demonstrated a reduction in bacterial
growth in P. aeruginosainoculated wounds. However, hydrofiber silver and hydrofiber-treated wounds
are superior to honey-treated wounds with A. baumannii[121]. Antibacterial activity of Aquacel-tualang
honey, Aquacel-manuka honey, Aquacel-Ag, and Aquacel-plain dressings against bacteria isolated from
burn patients were tested in vitro. Seven organisms were isolated: Enterobacter cloacae, K. pneumoniae,
Pseudomonas spp., Acinetobacter spp., S. aureus, coagulase-negative S. aureus, and Streptococcus spp.
Aquacel-Ag and Aquacel-manuka honey dressings gave a better zone of inhibition for Gram-positive
bacteria compared to the Aquacel-tualang honey dressing. However, comparable results were obtained
against Gram-negative bacteria tested with Aquacel-manuka honey and Aquacel-tualang honey dressings.
Tualang honey has a bactericidal as well as bacteriostatic effect[122].
In Pakistan, in a randomized, comparative clinical trial, the efficacy of honey for the treatment of
superficial and partial-thickness burns covering <40% of body surface area was evaluated in 150 patients
and compared its results with those of silver sulfadiazine. The rate of re-epithelialization and healing of
superficial and partial-thickness burns was significantly faster in the sites treated with honey than in the
sites treated with silver sulfadiazine. Six patients had positive culture for P. aeruginosa in the honey-
treated site, whereas 27 patients had positive culture in the silver sulfadiazinetreated site[123].
Another study was carried out in Iran to compare the effect of honey and mafenide acetate on
auricular burn in rabbits. Results showed that although the pathologic score of the honey group was better
than that of the mafenide group, both on 14 and 21 days after burning, it was not statistically significant.
In the mafenide acetate group, deep complication of burn (chondritis) was significantly lower than that of
the honey group[124].
In Turkey, a study evaluated honey use for the split-thickness skin graft fixation because of its
adhesive and other beneficial effects in 11 patients. No complications, such as graft loss, infection, or
graft rejection, were reported[125].
In India, a prospective, randomized clinical study to compare honey-impregnated gauze with amniotic
membrane dressing in partial-thickness burns was performed. Sixty-four patients were studied; 40 were
treated with honey-impregnated gauze and 24 were treated with amniotic membrane. The burns treated
with honey healed earlier as compared to those treated with the amniotic membrane (mean 9.4 vs. 17.5
days). Residual scars were noted in 8% of patients treated with honey-impregnated gauze and in 16.6% of
cases treated with amniotic membrane[126]. In another study, 104 cases of superficial burn injury were
treated with honey as a dressing or with silver sulfadiazine gauze dressing. In the 52 patients treated with
honey, 91% of wounds were rendered sterile within 7 days. In the 52 patients treated with silver
sulfadiazine, 7% showed control of infection within 7 days. In addition, healthy granulation tissue was
observed earlier in patients treated with honey, and of the wounds treated with honey, 87% healed within
15 days as compared to 10% in the control group[113]. In India, the effect of honey dressing and silver
sulfadiazine dressing on wound healing in burn patients was studied in 78 patients with first- and second-
degree burns of <50% of total body surface area. Honey dressings improved wound healing, made the
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wound sterile in less time, had a better outcome in terms of prevention of hypertrophic scarring and
postburn contractures, and decreased the need of debridement irrespective of time of admission, when
compared to silver sulfadiazine dressings[127].
Twenty-five patients with burns were randomly allocated for treatment with honey or silver
sulfadiazine. Of the wounds treated with honey, 84% showed satisfactory epithelialization by the 7th day
and 100% of the patients by the 21st day. In addition, in honey-dressed wounds, early subsidence of acute
inflammatory changes, better control of infection, and quicker wound healing was observed[38]. Honey-
impregnated gauze was compared with OpSite as a cover for fresh, partial-thickness burns in two
groups of 46 randomly allocated patients. Results showed that wounds dressed with honey-impregnated
gauze showed earlier healing as compared those dressed with OpSite[127].
HONEY AND WOUND DRESSING
Honey has been used for its healing properties for centuries and has been used to dress wounds with
promising results. Honey dressings increase healing, minimize debridement, prompt successful graft,
remove dry crust, prevent dry scab formation on burns, cleanse wounds, ease separation of sloughs,
deodorize wounds, cause soothing of wounds, and minimize scar formation[33,38,41,73,75,
126,127,128,129,130,131]. Honey dressings are easy to apply and remove[73,128,129,130,131,132]. The
use of honey as a wound dressing was reviewed recently[133].
Honey has antibacterial activity and, consequently, it is effective in treating infected
wounds[43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,76,
77,132,134,135,136,137,138,139,140,141,142,143,144,145,146,147,148,149,150]. Clinical studies on the
use of honey as a dressing for infected wounds report that the wounds become sterilized in 310
days[100,101,102]. Al-Waili and Salom have used honey dressings for treatment of postoperative
caesarean section wound infections[68]. Honey applied to the wounds after washing with normal saline
and covered with dry gauze reduced healing time and hospital stay, promoted fast eradication of bacterial
infection, prevented wound dehiscence, and caused minimal scar formation. Honey could act as a barrier,
which would prevent wound infection[38,72,132]. In clinical practice, honey is spread on the wound, then
covered with dry gauze[38,69,75]. In case of abscess or necrotic tissue, honey is applied after drainage of
abscess or removal of necrotic tissues[33,151].
MECHANISMS OF ACTION
Wound infection is an important factor that delays or inhibits wound healing. Wound healing needs a
good healthy environment so that the normal physiological process will result in a normal healing process
with minimal scar formation. One of the most important strategies to keep the process of healing ongoing
is to sterilize damaged tissue from any microbial infection. Honey has many effects, such as antibacterial,
antioxidant, antitumor, anti-inflammatory, and various metabolic effects. Regarding antibacterial activity,
inhibition of bacterial growth has been shown using impregnated honey disks or incorporating honey into
agar plates[152]. How much of this inhibition is due to honey’s antimicrobial properties or to its acidity
and hyperosmolar nature is not well established[152]. In this regard, the hyperosmolar sugar paste also
has antibacterial activity and is superior to antiseptics[153]. Various studies explore that honey has
beneficial effects on wound healing apart from its antibacterial properties. The accelerative effect of
honey in the wound healing process is related to its physical properties of hygroscopicity, hypertonicity,
lower pH, and complex chemical composition. However, the stimulatory effects obtained when honey
was administered orally or parenterally suggest that a tissue growth factor may be involved, rather than
stimulation of growth being a consequence of wound acidification or improved nutrition of the tissue.
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Hydrogen Peroxide
Hydrogen peroxide (H2O2) is important as an antiseptic and stimulates the wound healing process. Recent
work using zebrafish reveals a novel mechanism of early leukocyte recruitment to wounds through a
concentration gradient of H2O2[154]. Neutrophils release bactericidal reactive oxygen species and H2O2 to
kill bacteria and prevent infection. Macrophages arrive at the wound in response to environmental stimuli
and release VEGF, an angiogenic factor crucial for wound healing. H2O2 increases macrophage VEGF
through an oxidant induction of the VEGF promoter. This oxidant stimulation can be mediated by
activated neutrophils[155].
It has been assumed that the antibacterial activity of honey is due to H2O2[156]. H2O2 is an oxidizing
agent released by the action of the enzyme oxidase that is added by bees to nectar[156]. Much of the
literature indicates that rates of H2O2 production by glucose oxidase in honey vary greatly and increase
disproportionately with different degrees of honey dilution[157,158,159,160]. H2O2 is generated on
dilution of honey[161]. The concentration of H2O2 produced in honey is about 1000 times less than in the
3% solution commonly used as an antiseptic[56]. The rate of H2O2 production per milliliter of honey
solution decreased at higher honey concentrations[162]. When honey and sugar are used as dressings,
they become diluted[163]. H2O2 has been reported to stimulate fibroblast proliferation in vitro and
angiogenesis in vivo[164]. Interestingly, honey has high levels of antioxidants that would protect wound
tissues from oxygen radicals that may be produced by H2O2[165].
In Canada, it was suggested that the antimicrobial activity in some honeys depends on the
endogenous H2O2 content. The study was aimed to determine whether honeys H2O2 level could serve as
a honey-specific, activity-associated biomarker that would allow the prediction and assessment of the
therapeutic effects of honey. Using a broth microdilution assay, antibacterial activities of 42 Canadian
honeys against two bacterial strains, Escherichia coli (ATCC 14948) and Bacillus subtilis (ATCC 6633),
were analyzed. The results show that all Canadian honeys exhibited antibacterial activity, with higher
selectivity against E. coli than B. subtilis, and that these antibacterial activities were correlated with H2O2
production in honey[166]. Obviously, H2O2 generated from honey application could help to control
wound infection as well as to help wound healing.
Osmolarity
It was found that solutions of high osmolarity, such as honey, glucose, and sugar pastes, inhibit microbial
growth because the sugar molecules tie up water molecules so that bacteria have insufficient water to
grow[163]. Therefore, high osmolarity is valuable in the treatment of infections because it prevents the
growth of bacteria and encourages healing[153]. Sugar was used to enhance wound healing for several
hundred patients[167]. It has been claimed that the sugar content of honey is responsible for its
antibacterial activity, which is due entirely to the osmotic effect of its high sugar
content[98,132,168,169]. High osmolarity can safely be achieved topically by the use of sugar paste or
honey.
Nonperoxide Activity and Antioxidants
It was found that antibacterial activity persist in honeys treated with catalase to remove the H2O2
activity[170,171,172,173]. Manuka honey was found to have an exceptionally high level of nonperoxide
antibacterial activity[173]. Some floral sources provide additional antibacterial components by way of
plant-derived chemicals in the nectar, such as flavonoids and aromatic acids[150]. Oxygen radicals are
involved in various aspects of inflammation. Free radicals cause inflammation and damage to
tissue[174,175,176,177,178]. The application of antioxidants to burns has been shown to reduce
inflammation[1]. Honey inactivates the free iron, which catalyzes the formation of oxygen free radicals
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produced by H2O2, and its antioxidant components help to mop up oxygen free radicals[165,179]. Darker
honeys were more inhibitory than light-colored honeys. Since antimicrobial activity of the darker honeys
was not eliminated by catalase, nonperoxide components, such as antioxidants, may contribute to
controlling the growth of some food-borne pathogens[150].
Physical Properties
The physical properties of honey provide a protective barrier and, by osmosis, create a moist wound
healing environment that does not stick to the underlying wound tissues.
Increased Lymphocytic and Phagocytic Activity
In the U.K., a study was carried out to investigate the effect of each of three honeys (manuka, pasture, and
jelly bush) on the release of inflammatory cytokines from MM6 cells. These honeys, together with a
sugar syrup control (artificial honey), were incubated with MM6 cells. All honeys significantly increased
the TNF-α, IL-1β, and IL-6 release from MM6 cells (and human monocytes) when compared with
untreated and artificial honeytreated cells. Jelly bush honey significantly induced the maximal release of
each cytokine compared with manuka, pasture, or artificial honeys. These results suggest that the effect of
honey on wound healing may in part be related to the stimulation of inflammatory cytokines from
monocytic cells. Such cell types are known to play an important role in healing and tissue repair[180].
Honey stimulates proliferation and activation of peripheral blood B and T lymphocytes in cell culture.
Jungle honey was found to enhance the immune system and possess chemotactic activity for neutrophils
having antitumor activity; the effective immune component of jungle honey is substrate of molecular
weight 261[181].
Acidity
Chronic nonhealing wounds have an elevated alkaline environment. Lowering the wound pH can
potentially reduce protease activity, increase fibroblast activity, and increase oxygen release,
consequently aiding wound healing. The glucose content of honey and the acid pH may assist in the
bacterial-killing action of macrophages[182]. We have found that honey activity increased in acidic
media[68]. However, the antibacterial activity was not significantly suppressed upon neutralization of its
acidity[68]. In addition, many bacteria and fungi can survive or resist acidic media and can tolerate
extremely acidic conditions[183,184,185,186,187]. Therefore, as we previously demonstrated, the acidity
of honey could not be a sole factor for its antibacterial activity[68].
In Ireland, a study was conducted to analyze the changes in surface pH and size of nonhealing ulcers
following application of a manuka honey dressing after 2 weeks. Wounds with pH 8.0 did not decrease
in size and wounds with pH 7.6 had a 30% decrease in size. The use of manuka honey dressings was
associated with a statistically significant decrease in wound pH and a reduction in wound size[82]. It was
found that topical acidification of experimental deep partial-thickness burns promoted
healing[188].Therefore, honey acidity might help wound healing.
Nitric Oxide
NO is important for healing, bacterial killing, viral inhibition, immunological response, and respiratory,
renal, cardiovascular, and nervous systems functions. Investigators have implicated NO in the
inflammatory and proliferative phases of wound healing[189]. Wound healing involves platelet,
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inflammatory cell, fibroblast, and epithelial cells; all of them are capable of producing NO[190]. NO can
reverse impaired healing in diabetic patients[191]. Moreover, NO can enhance bone healing, and it
inhibits tumor growth and metastasis[192,193].
It has been shown that NO plays a role in the host defense against various infections[191]. Killing of
intracellular pathogens is mediated by NO[192]. Replication of many viruses can be inhibited by
NO[194]. It was found that NO is a very important mediator of immune responses and could prevent skin
damage induced by UVB[194,195]. We have found that honey contains NO end products[196]. In
addition, honey increases NO end products in various biological fluids, such as urine, saliva, and
plasma[197,198]. Intravenous honey increased NO end products in plasma and urine[196]. We have
found that antimicrobial activity of honey was decreased by exposure to heating and prolong storage[68].
Heating and prolonged storage decreased NO metabolites identified in various kinds of honey. In
addition, the concentration of NO metabolites varies in various types of honey. This might help to explain
the fact that the antimicrobial activity of honey varies markedly with its origin[199]. Furthermore, it was
suggested that many effects of honey on immunity, bacterial infections, and wound healing could be
explained by the ability of honey to increase NO production[196,197,198].
Prostaglandins
Prostaglandins are mediators of inflammation and pain. They are widely regarded as immunosuppressive,
which can decrease many aspects of B- and T-lymphocyte functions[200]. They are effective in inhibiting
antibody production by B lymphocytes and they increased the induction of a specific T
suppressor[201,202]. Prostaglandins reduce immunity and play a critical role in cancer
development[203].
Dr. Al-Waili was the first who reported the immunosuppressive effects of prostaglandins on antibody
production and, consequently, prostaglandin synthesis inhibitors used to combat tumors and increase
immunity[204,205,206,207]. In addition, prostaglandins change serum protein components during antigen
stimulation[208]. We have found that honey can lower plasma prostaglandin concentrations in normal
individuals[209]. Its inhibitory effect was increased with time. The site of actions could be either at COX-
1 or COX-2, or both. Recently, it was found that artificial honey made of glucose and fructose increased
prostaglandin concentrations[209]. Therefore, natural honey might contain raw materials that are capable
of inhibiting prostaglandin synthesis[209]. The ability of honey to lower prostaglandin concentrations
could explain many of its biological and therapeutic effects, particularly those related to inflammation,
pain, immunity, and wound healing.
Antibody Production
It has been demonstrated that honey increased antibody production during primary and secondary
immune responses against thymus-dependent and thymus-independent antigens. The actual mechanism to
stimulate antibody production was not identified. NO is an important mediator of immune
responses[193]. A single dose of L-arginine, a known precursor of NO, caused a significant increase in
humoral response[210]. Therefore, honey might increase humoral immunity by means of its ability to
enhance NO production. Prostaglandins are immunosuppressive; they are found to inhibit antibody
production by B lymphocytes and to increase the induction of T suppressor cells[201,202]. As honey
lowers prostaglandin concentrations, the enhancing effect of honey on antibody production was suggested
to be attributed to its ability to inhibit prostaglandins[208].
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Nutritional Composition
Honey contains defined substances, such as glucose, fructose, sucrose, minerals, vitamins, antioxidants,
amino acids, and other products. Its wide range of activity raised the possibility of the presence of other
unidentified substances. The composition with the natural proportion of each substance in the honey
might play a significant role in the mechanism of its action and potency. More investigations are needed
in order to disclose the possible presence of other natural materials in honey that might play a role in
exhibition of its wide biological and therapeutic effects.
Wound Contracture
In Nigeria, dressing wounds of rats with honey significantly enhanced percentage wound contraction on
day 10 with a value of 79.20 ± 2.94 compared to the control value of 53.50 ± 4.32. There was no
significant difference in fibroblast count per high power field in the honey group compared to the control
group. In addition, honey dressing increased mean blood vessel count per high power field. Also, honey
dressing caused increased granulation tissue formation in wounds compared to those of the control
group[211].
CONCLUSION
There are tremendous data supporting the effectiveness of honey in the management of wounds. The data
clearly demonstrate that with the use of honey, no allergic reaction is elicited and no significant side
effects were reported, and there is rapid elimination of wound odor, improvement of granulation and
epithelialization, reduction of amount of exudates, and sterilization of wounds from microbes. In addition
to its valuable nutritional constituents, honey has anti-inflammatory and antioxidant activities that make it
a suitable natural subject for wound healing. Honey increases NO, which is important for wound healing,
and decreases prostaglandins, which are mediators of inflammation. Honey’s acidity and osmolarity play
an important role in the healing process. Its antioxidant contents are important as wound healers and help
in the eradication of microbial infections. In addition, honey has considerable effects on the cellular
elements of immunity and antibody production. Although most studies on honey did not mention its plant
source, honeys collected from various geographical areas share a similar ability to help both wound
healing and microbial control.
The antibacterial, anti-inflammatory, antioxidant, as well as nutritional and physical properties of
honey, make it a logical and accepted natural agent for wound dressing.
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This article should be cited as follows:
Al-Waili, N.S., Salom, K., and Al-Ghamdi, A.A. (2011) Honey for wound healing, ulcers, and burns; data supporting its use in
clinical practice. TheScientificWorldJOURNAL 11, 766787. DOI 10.1100/tsw.2011.78.
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... This antimicrobial and antioxidant-rich nature positions honey a managing chronic inflammation and provides analgesic effects, fostering tissue tion [107][108][109]. Honey's multifaceted analgesic effects showcase its versatilit tional and complementary medicine, impacting pain perception [101,110] a healing [111]. Honey's hypoglycemic and hypolipidemic effects further contribu aging diabetes and hyperlipidemia, offering potential benefits for cardiovascu [112][113][114]. ...
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The inhibine values of 25 honeys were diminished or destroyed by the action of catalase. All the honeys had a ‘peroxide value’ as determined iodometrically; this was destroyed by the action of catalase.