Efficacy of Honey Gel Tellechea

8/10/2019 Efficacy of Honey Gel Tellechea

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Oscar Tellechea

M.D., Ph.D.2

Ana Tellechea, D.Sc.1

Vera Teixeira, M.D.2

Fatima Ribeiro, RN2

1Neurosciences and Cell-

biology centre, University

of Coimbra, Coimbra,

Portugal

2Dermatology Service,

Hospitals of the University

of Coimbra, Coimbra,

Portugal

Correspondence:

[email protected]

Conflict of interest: none

Science, Practice and Education

ABSTRACTChronic leg ulcers are a common medical

problem among elderly patients and have a

dramatic impact on quality of life as a result

of pain, disability, and social isolation.

Regardless of their cause, chronic leg ulcers

remain difficult to treat. In recent years, there

has been increasing interest in the use ofhoney as a therapeutic agent.

Objective:To evaluate the efficacy of honey-

based dressings in the treatment of chronic

leg ulcers.

Methods:Ten patients with chronic (mean

duration 3.3 years) leg ulcers who had

received non-honey based treatments with

no improvement were included in this study.

A honey gel dressing was applied twice a

week as the only treatment.

Results: Seven patients experienced com-

plete healing of their leg ulcers. The remain-

ing three patients showed a significantreduction in wound size, which was achieved

in a mean time of 101 days (range 28-174

days).

Conclusion:Honey-based dressings appear

to be an efficient and easy to use treatment

for leg ulcers.

Key words: Chronic lower leg ulcer, venous

leg ulcer, dressings, honey gel

INTRODUCTION

Lower leg ulcers affect 15-18 out of 10,000 adults in de-veloped countries, with venous leg ulcers (VLUs) repre-senting up to 84% of all leg ulcer cases (Watson, 2011).These ulcers have an important impact on the quality oflife and health of patients (Cullum, 2000). Treatment ofVLU patients also has a significant economic impact; theannual cost of treatment of VLUs in the UK and Swedenis estimated to be between 1,300-2,500 Euros per patient.Costs increase for lesions with long healing times or forlarger ulcerations, as well as for ulcers that are defined asdifficult to treat (Ragnarson Tennvall, 2005). Difficultto treat cases can cause significant morbidity (Faria, 2011),seriously impact the patients quality of life (Gonzlez-Consuegra, 2011), and consequently increase treatmentcosts.

Evidence-based treatment options for VLUs include legelevation, compression therapy, topical (active) dressings,pentoxifylline, and aspirin therapy. Surgical managementcan be considered for ulcers that are large, of prolongedduration, or refractory to conservative measures (Collins,2010).

In clinical practice surgery is rarely an option due tothe nature of the pathology in the lower limb.

Instead, common treatment options include compres-sion therapy as standard care in combination with a varietyof dressings, although meta-analyses have not yet identi-fied the ideal dressing type (Palfreyman, 2006; OMeara,

2009). The recent resurgence of the use of honey in woundmanagement (Al-Waili, 2011) triggered our prospectivestudy of the efficacy of honey-based treatment in the man-agement of venous leg ulcers.

STUDY DESIGN

In this prospective study we evaluated the efficacy of ahoney gel dressing in a group of patients with difficult totreat VLUs. Patients with lower leg ulcers who presentedat the University Hospital between February and Octo-ber 2010 were recruited for this study. All patients with

chronic lower leg ulcers, regardless of ulcer depth, area,or presence of infection, were included. Patients were ran-domly selected for treatment as outpatients with consul-tation or for inpatient treatment. Exclusion criteria were

Efficacy of honey gelin the treatment of chronic lower

leg ulcers: A prospective study

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Table 1: Clinicopathological characteristics of patients and ulcers

General information Underlying pathology Etiology

2 75 Y F X Polycythemia vera 1 0 0 0 0 X

3 65 Y M Smoker 0 0 1 0 0 X

4 65 Y M X CRI, dialysis,awaiting kidneytransplant

0 0 0 1 0 X

5 75 Y F - 1 0 0 0 0

6 81 Y F X - 1 0 0 0 0 X

7 78 Y F X TEP (pulmonarythromboembolism)

1 0 0 0 0 X

8 57 Y M - 0 0 0 0 posttrauma

9 83 Y M - 1 0 0 0 0 X

10 67 Y F X X - 1 0 0 0 0 X

Y: years old F: female M: male

unlikelihood of wound improvement due to cutaneousnecrotizing vasculitis, lower limb cellulitis, or severe lowerlimb arterial insufficiency.

PATIENTS

The study included ten patients: six females and fourmales with an average age of 73 years (age range 57-83).Underlying pathologies included diabetes mellitus (n=3),hypertension (n=4), and a range of other factors that influ-ence wound healing (Table 1). Seven patients had venousulcers, one had a mixed venous and arterial ulcer, one had apost-trauma ulcer, and one had an ulcer related to diabetesmellitus (Table 1). Standard criteria for the diagnosis ofleg ulceration were used.

Leg ulcers had been present in these patients for anaverage of 3.3 years (range: 2 months-5 years). During thatperiod, patients were treated with a range of products andtechniques in primary care centres without improvement(Tables 2 & 3). For our study, the patients themselvesbefore initiation of the honey gel treatment were used ascontrols. To ensure that application of honey gel was theonly variable, the same wound management regimen that

was followed in the pre-study treatment period was applied

during our study, except that honey gel was now used asa topical dressing (Moghazy, 2010). Patients consentedto the honey gel regimen prior to the start of the study.During the treatment period no compression therapy wasperformed in any patient.

MATERIALS

The honey gel (L-Mesitran Soft, Triticum, NL) used in thisstudy contains 40% medical-grade honey, ultra-purifiedhypoallergenic medical grade lanolin (Medilan), polyethyl-ene glycol, and Vitamins C and E. All of these ingredients

have individual beneficial effects on wound managementand healing (Cutting, 2005) and the honey product as awhole has proven antibacterial efficacy (Stephen-Haynes,2011).

Fig 1. Patient 3. Ulcer pathology before honey gel treatment.

METHODS

Patients were treated only with honey gel. The honey gelwas applied twice weekly d directly over the wound andcovered with a sterile cotton dressing. Compression wasnot used during the period of treatment with the honeygel.

During the observation period the patients were seen

for consultation at weeks 2, 4, and on a monthly basisthereafter. Ulcer size was measured using the Opsite Flexi-gridsystem.

Fig 2. Patient 3. Complete healing of the wound after7 months of honey gel treatment.

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Table 4: Honey gel treatment

Patient#

Initiationoftreatment

Woundsizeat

theend

ofthetreatme

nt(cm

2)

Endofthetreatment

Periodoftreatment

withhoneygel(days)

Reductioninw

oundsize

Foldaccelerat

ionof

healingtime

1 16-06-2010 0 29-09-2010 103 100% 18

2 04-10-2010 8.4 25-11-2010 51 63% 25

3 18-03-2010 0 28-10-2010 220 100% 8

4 25-05-2010 0 01-07-2010 36 100% 20

5 08-02-2010 0 30-05-2010 112 100% 7

6 15-04-2010 0 25-10-2010 190 100% 8

7 15-06-2010 59.7 20-07-2010 35 12% 52

8 18-05-2010 0 16-06-2010 28 100% 29 06-04-2010 0 30-09-2010 174 100% 6

10 26-05-2010 27 26-07-2010 60 50% 18

Table 2: Characteristics of ulcer at initiation of honey treatment

Patie

nt#

Presenceofulcerspriorto

hone

ygeltreatment(years)

Presenceofulcerspriorto

hone

ygeltreatment(days)

Location

Previoustreatments

Woundsizeatthestartof

hone

ygeltreatment(cm

2)

1 5.0 1,825 Lateral, posterior (right side) 1,2,3,4,5 z1

2 3.5 1,278 Left internal malleolus 1,2,3,4,5,9 23

3 5.0 1,825 Left external malleolus 1,2,3,4,5 29,6

4 2.0 730 Injury next to the lap of the 1st metatarsal 4,5,8 1,5

5 2.0 730 Left supramaleolar 1,4,7,10 2,5

6 4.0 1,460 Right external malleolus 1,3,4,6 3,6

7 5.0 1,825 One-third distal right leg, circumferential 3,4,5 67,6

8 0.2 61 One-third distal right leg, anterior 1,2,3,4 1

9 3.0 1,095 Right internal malleolus 3,4 6,9

10 3.0 1,095 Right internal malleolus 1,4,5,9 54,3

Table 3

Previous Treatment

Hydrogel 1

Hydrocolloid 2

Calcium Alginate 3

Allevyn 4

Aquacel AG 5Activated charcoal 6

Fat gauze 7

Vaseline salicylated 10% 8

Silver sulfadiazine 9

HZN Reducol Gel 10

Dermocorticoids (betametasone valerate cream) andemollients were applied to the peri-wound area when nec-essary. No topical or systemic antibiotics were used.

Adverse reactions, including subjective unfavourablesymptoms, were registered when present.

RESULTS

A reduction in wound size was observed in all patients ina mean time of 101 days (range: 28-174 days) (Table 4).Seven patients showed complete healing of the woundand the mean degree of reduction of ulcer extension was90%, ranging from less than 10% to 100% (Table 4).Patient 7, who showed the smallest reduction in woundsize, complained of pain after application of the honey geland abandoned the study.

DISCUSSION

A primary factor contributing to the chronic nature ofVLUs is poly-microbial biofilm infection, where several

bacterial species colonize the wound. The most commonorganisms found in VLU biofilms include various anaer-obes, Staphylococcus (Wolcott, 2009), and Pseudomonasaeruginosa (Jacobsen, 2011). The honey-based productused in our study has a known broad-spectrum antibacte-rial effect, which could have contributed to the acceleratedhealing.In vitro research using antibiotic-resistant clini-cal isolates and extended spectrum b-lactamase (ESBL)-producing strains of bacteria showed that this honey gelis highly effective and has stronger antibacterial activitythan other honey products (Manuka) (Stobberingh, 2010;

Stephen-Haynes, 2011). The efficacy of honey in woundhealing is further attributed to its low pH, its ability to pro-duce hydrogen peroxide, and its osmotic action (Molan,

2006; Stephen-Haynes, 2011). It is particularly importantthat the honey used for wound care is free from residuesand sterilized, because honey can contain clostridial sporesin addition to non-pathogenic Bacillus spp. Only gammairradiation effectively sterilizes honey without reducingits efficacy (Postmes, 1993; Molan, 1996) and the use ofnon-sterilized honey samples cannot be justified (Cooper,2009).

The honey gel used in this study may also have a directpositive effect on wound healing. Du Toit (2009) exam-ined the cell morphological effects of honey- and silver-impregnated dressings on two key cellular componentsof wound healing, keratinocytes and fibroblasts, using an




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in vitrotissue explant culture model and found that thehoney-impregnated dressings promoted new tissue regen-eration. A second study comparing silver-sulphadiazine

with the honey gel used in our study reported similarfindings; the honey gel significantly stimulated re-epitheli-alisation, whereas silver sulphadiazine significantly reducedit (Boekema, 2013). In support of these findings, Rossiteret al.(2010) showed that honey products stimulated an-giogenesis in vitroin an investigation of the influence ofhoney on growth of the tubular length of rat aorta.

Several previous studies (Table 5, 601 patients) have re-ported that honey-based wound management has positiveeffects on wound healing, ulcer size, and patient comfort.

However, when compared to standard methods or othercomparative methods, honey has not been shown to su-perior to these methods significant difference in woundhealing. This might reflect the type of honey used in thesestudies (Jull, 2008), the study design (Firth, 2010), andthe complexity of VLU management.

However,we did see a significant improvement inwound healing in our study. The patients previous treat-ments were less effective (Table 2) than honey treatment(Table 4), with an observed shortening of healing timefrom an average of 3.3 years to 101 days. The honey gel

was used in monotherapy. Only emollients and, whenindicated, topical corticosteroids were allowed as comple-mentary treatment on the peri-ulcerous skin, and in nocircumstance were antibiotics or antiseptics used.

Table 5: Previous studies on the efficacy of honey in VLU tretament

Author Type of studyNumber

of patientsStudyperiod

Outcome

Olabanji (2000) Comparative study 50 4 weeks Reduction in wound size was significantly different.

Natarajan(2001)

Case report 1 untilhealing

MRSA was eradicated from the ulcer and rapidhealing was successfully achieved.

Alcaraz(2002)


The patients wounds improved with thehoney-based dressing.

Dunford (2004) Four-centre feasibility 40 12 weeks Overall, ulcer pain and size decreased significantly,and odorous wounds were deodorised promptly.

Schumacher(2004)


No significant difference from conventional methodsrecorded.

van der Weyden(2005)


Honey was found to be an effective antibacterial,anti-inflammatory, and deodorizing dressing,with total healing of the ulcer achieved.

Timmons(2008)


Honey promoted the removal of slough, encouragingthe formation of granulation tissue and epithelialtissue growth

Jull (2008) Community-based, open-labelrandomised trial

368 12 weeks Honey-impregnated dressings promoted healing,however, not significantly more than usual care.

Sare (2008) Case report 3 untilhealing

Promotion of healing occurred in all instances witha reduction in the incidence of infection, reductionin pain, and the provision of comfort.

Gethin (2009) Prospective, multicentre, openlabel randomised controlled trial

108 12 weeks Increased incidence of healing, effectivedesloughing, and a lower incidence of infectionthan the control.

Kegels (2011) Retrospective study 22 untilhealing

Infected wounds were controlled within a few days.All the wounds progressed to healing without anyadverse effects.

Similar results were obtained in a recent retrospectivestudy in which 22 patients with lower extremity ulcera-tions had delayed healing, in part attributed to applicationof povidone iodine or fusidic acid, and 50% of the wounds

were infected. After treatment with honey-based products,all cases progressed to healing (Kegels, 2011).The use ofhoney may therefore have a place in VLU treatment (Jull,2013). Antibiotics are not recommended because there isno evidence that the routine use of systemic antibioticspromotes VLU healing. In addition, in light of the in-creasing problem of bacterial resistance to antibiotics, cur-rent prescribing guidelines recommend that antibacterialpreparations should only be used in cases of clinical infec-tion and not for bacterial colonisation (OMeara, 2010).

Honey gel treatment may also be superior to traditionaltreatments because it is easier for patients to administer.The patients in our study showed low compliance withcompression bandage treatment during the pre-studytreatment period because a lack of local health facilities,advanced patient age, and the low economic status of thepatients often precluded maintenance of correct compres-sion treatment. In contrast, application of honey gel to the

wound surface was easy and could be accomplished by thepatients themselves or by a relative without specialisedskills, as previously reported (Smaropoulos, 2011). Pa-

tients were therefore able to follow the treatment protocolprovided no adverse effects occurred.Another advantage of honey-based treatment is that

it requires fewer materials and the procedure is less time

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consuming than traditional methods, which has the po-tential to reduce treatment costs. The reduction in healthcare costs might be expected when the faster healing timesare taken into consideration. In addition, although thepresent study did not analyse quality of life data, the pa-tients welcomed the faster wound healing with honey-based treatment. We therefore believe that honey-basedtreatments of VLUs should be more seriously consideredfor the treatment of leg ulcer patients.

Limitations

The small number of patients and the use of the patientsthemselves as the treatment controls are limitations of thisstudy.

CONCLUSION

We believe that honey gel treatment may provide a practi-cal and well-tolerated treatment for the management oflower leg venous ulcers, particularly when patient compli-ance with compression therapy is poor.

Acknowledgement

The authors wish to thank the patients who volunteeredin this study.

Postmes T, Van den Boogaard T, Hazen M (1993) Honeyfor wounds, ulcers and skin graft preservation. The LancetVol 341; March 20:756-757

Ragnarson Tennvall G, Hjelmgren J (2005) Annual costsof treatment for venous leg ulcers in Sweden and the

United Kingdom. Wound Repair Regen.13(1):13-8

Rossiter K, Cooper AJ, Voegeli D, Lwaleed B (2010)Honey promotes angiogeneic activity in the rat aortic ringassay.Journal of Wound Care 19(10):440-446

Sare JL (2008) Leg ulcer management with topicalmedical honey. Br J Community Nurs.13(9):S22, S24,S26 passim.

Schumacher HH (2004) Use of medical honey in patientswith chronic venous leg ulcers after split-skin grafting.JWound Care13(10):451-2

Smaropoulos E, Romeos S, Dimitriadou C (2011) Honey-based therapy for paediatric burns and dermal traumacompared to standard hospital protocol. Wounds UK7(1):33-40

Stephen-Haynes J, Callaghan R (2011) Properties ofhoney: its mode of action and clinical outcomes. WoundsUK 7(1):54-57

Stobberingh EE (2010) Antibacterial activity of honeyagainst ESBL -producing strains. Report by the depart-ment of Medical Microbiology University of Maastricht,The Netherlands.

Timmons J (2008) Treatment of a bilateral necrotic legulcer with Mesitran. Wounds UK4(4):129

van der Weyden EA (2005) Treatment of a venous legulcer with a honey alginate dressing. Br J CommunityNurs.Suppl:S21, S24, S26-7

Watson JM, Kangombe AR, Soares MO, Chuang LH,Worthy G, Bland JM, Iglesias C, Cullum N, Torgerson D,Nelson EA; VenUS III team (2011) VenUS III: a ran-domised controlled trial of therapeutic ultrasound in themanagement of venous leg ulcers. Health Technol Assess.15(13):1-192

Wolcott RD, Gontcharova V, Sun Y, Dowd SE (2009)Evaluation of the bacterial diversity among and withinindividual venous leg ulcers using bacterial tag-encodedFLX and Titanium amplicon pyrosequencing andmetagenomic approaches. BMC Microbiology 9:226doi:10.1186/1471-2180-9-226

References

Alcaraz A, Kelly J. (2002) Treatment of an infectedvenous leg ulcer with honey dressings. Br J Nurs.11(13):859-60, 862, 864-6

Al-Waili N, Salom K, Al-Ghamdi AA (2011)Honey forwound healing, ulcers, and burns; data supporting its use

in clinical practice. Scientific World Journal11:766-87

Boekema B, Pool L, Ulrich M (2013) The effect of ahoney based gel and silver sulphadiazine on bacterialinfections of in vitro burn wounds. Burns 39(4):754-759

Collins L, Seraj S (2010) Diagnosis and treatment ofvenous ulcers.Am Fam Physician.81(8):989-96

Cooper RA, Jenkins L (2009) A comparison betweenmedical grade honey and table honeys in relation toantimicrobial efficacy. Wounds21(2):29-36

Cullum N, Nelson EA, Fletcher AW, Sheldon TA (2000)Compression bandages and stockings for venous leg ul-cers. Cochrane Database Syst Rev. 2000;(2):CD000265.

Cutting K, Davies P (2005) Natural therapeutic agents forthe topical management of wounds. Wounds UK Supple-ment1(3):4-13

Dunford CE, Hanano R (2004) Acceptability to patients

of a honey dressing for non-healing venous leg ulcers.JWound Care13(5):193-7

DuToit DF, Page B (2009) An in vitroevaluation of thecell toxicity of honey and silver dressings.Journal ofWound Care18(9):383-389

Faria E, Blanes L, Hochman B,Mesquita Filho M, FerreiraL (2011) Health-related Quality of Life, Self esteem, andFunctional Status of Patients With Leg Ulcers. Wounds23(1):4-10

Firth J, Nelson EA, Hale C, Hill J, Helliwell P (2010) Areview of design and reporting issues in self-reportedprevalence studies of leg ulceration.J Clin Epidemiol.63(8):907-13

Gethin G, Cowman S (2009) Manuka honey vs. hydrogel--a prospective, open label, multicentre, randomisedcontrolled trial to compare desloughing efficacy and heal-ing outcomes in venous ulcers.J Clin Nurs. 18(3):466-74.Epub 2008 Aug 23.

Gonzlez-Consuegra RV, Verd J (2011). Quality oflife in people with venous leg ulcers: an integrativereview.J Adv Nurs. 67(5):926-44. doi: 10.1111/j.1365-2648.2010.05568.x

Jacobsen JN, Andersen AS, Sonnested MK, Laursen I, Jor-gensen B, Krogfelt KA (2011)Investigating the humoralimmune response in chronic venous leg ulcer patientscolonised with Pseudomonas aeruginosa. Int Wound J.8(1):33-43 doi: 10.1111/j.1742-481X.2010.00741.x.

Epub 2010 Nov 19Jull A, Walker N, Parag V, Molan P, Rodgers A (2008)Randomized clinical trial of honey-impregnated dress-ings for venous leg ulcers British Journal of Surgery95:175-182

Jull AB, Walker N, Deshpande S (2013) Honey as atopical treatment for wounds. Cochrane Database SystRev. 2013 Feb 28;2:CD005083. doi: 10.1002/14651858.CD005083.pub3.

Kegels F (2011) Clinical evaluation of honey-based prod-ucts for lower extremity wounds in a home care setting.Wounds UK7(2):46-53

Moghazy AM, Shams ME, Adly OA, Abbas AH, El-BadawyME, Elsakka DM, Hassan SA, Abdelmohsen WS, Ali OS,Mohamed BA (2010) The clinical and cost effectivenessof bee honey dressing in the treatment of diabetic foot ul-cers. Diabetes Research and Clinical Practice89:276-281

Molan PC, Allen KL (1996) The effect of gamma-

irradiation on the antibacterial activity of honey.J PharmPharmacol.48(11):1206-9

Molan PC (2006) The evidence supporting the use ofhoney as a wound dressing. Int J Low Extrem Wounds5(1); 40-54

Natarajan S, Williamson D, Grey J, Harding KG, CooperRA (2001) Healing of an MRSA-colonized, hydroxyurea-induced leg ulcer with honey.J Dermatolog Treat.12(1):33-6

Olabanji JK, Tijani LA, Oluwatosin OM, Onyechi HU,Oluwatosin OA (2000) A comparison of topical honey andphenytoin in the treatment of chronic leg ulcers.AfricanJournal of Medicine and Medical Sciences29(1):31-34

OMeara S, Cullum NA, Nelson EA.(2009) Compres-sion for venous leg ulcers. Cochrane Database Syst Rev.21;(1):CD000265

OMeara S, Al-Kurdi D, Ologun Y, Ovington LG(2010)Antibiotics and antiseptics for venous leg ulcers. Cochrane

Database Syst Rev. 20;(1):CD003557

Palfreyman SJ, Nelson EA, Lochiel R, Michaels JA. (2006)Dressings for healing venous leg ulcers. Cochrane Data-base Syst Rev. Jul 19;3:CD001103


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Efficacy of Honey Gel Tellechea

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