Trent Gall, DVM, MS, DACVS (Small Animal Surgeon)
Contaminated wounds, especially large wounds can be very difficult and expensive to treat. Especially those that are infected with resistant bacteria. There is a plethora of wound care products available nowadays. Many of these have little scientific evidence to back them up or they are quite pricey. Two simple, yet very effective, ways to treat these challenging wounds are honey and sugar dressings. These two treatments have been around since 2000 BC (honey) and 1679 (sugar). These two treatments have been underutilized in recent years but the adage “oldie but a goodie” holds very true for these two elegantly simple treatments.
Up until fairly recently the mechanisms for these two treatments were poorly understood. The mechanisms associated with the wound cleansing and healing properties of honey include decreased inflammatory edema, attraction of macrophages to further cleanse the wound, accelerated sloughing of devitalized tissue, provision of a local cellular energy source, and formation of a protective layer of protein over the wound and healthy granulation bed. Another added benefit is that honey has a deodorizing affect, which is probably due to its rich supply of glucose which would be used by the infecting bacteria in preference to amino acids, resulting in the production of lactic acid instead of malodorous compounds.
The antibacterial properties of honey are attributed to its high osmolarity, acidity, and hydrogen peroxide content. The high osmolarity of honey draws lymph from a wound which results in dissolved nutrients within the lymph that then provides nutrition for regenerating tissue.
Another antibacterial property of honey is the factor “inhibine” which has been isolated from multiple plant sources. Inhibine, which has been determined to be hydrogen peroxide, is produced by the natural glucose oxidase in honey. Now I know what you might be thinking. “Doesn’t hydrogen peroxide actually inhibit wound healing?” The short answer is yes…. But in high concentrations such as that found in hydrogen peroxide solutions that are found in antiseptic solutions. The short answer is yes, but only in high concentrations such as those found in hydrogen peroxide solutions that are found in antiseptic solutions.This solution concentration being 3%. That is approximately 1000 times the hydrogen peroxide concentration found in honey. The other benefit to the low levels of hydrogen peroxide from honey is that it is continuously produced by the activity of the glucose oxidase enzyme. This continuous low level of hydrogen peroxide has been shown to stimulate angiogenesis and the growth of fibroblasts.
All honey used for wound treatments must be UNPASTEURIZED! Yes that is what I said. Heating honey over 39 degrees C (102.2 degrees F) will degrade the properties that are so vital in honey for wound healing and the antibacterial properties. Unpasteurized honey can contain cloistral spores which is a concern when given orally to very young children and immunocompromised people, but have not been associated with any infections clinically when used as a topical treatment. There is a commercially available medical version of honey that comes from a consistent plant source: Maduka. It has been shown that depending on the plant source, the antibacterial properties of honey can differ. This commercially available medical grade honey is called “MEDIHONEY” from Derma Sciences.
To use the honey clinically, the wound needs to be lavaged as you would normally. Then apply a generous amount of honey to fully cover the wound. Next, a dressing needs to be placed over the wound. The dressing will need to be changed 1-2 times a day depending on how exudative the wound is initially. Then the wound dressing can be changed every other day until a good granulation tissue bed is present. Each time the dressing is changed, the wound should be lavaged and then padded dry with a sterile towel. Typically, the honey dressings are used until a good granulation bed is present (typically 5-10 days but dependent on the wound and healing capabilities of the patient). Then switching to a non-adherent bandage is needed at that time with no honey. Then either surgical closure of the wound is performed or continued bandaging with a non-adherent bandage to promote epithelialization.
The other sweet product is sugar. Yup, good ‘ol granulated (table) sugar. Sugar has many of the same properties of honey, such as providing a local nutrient source, decreases inflammatory edema, and enhances sterilization of the wound, draws macrophages to the wound and accelerates the sloughing of devitalized tissue. The main antibacterial affect is due to the high osmolarity of sugar as compared to the wound bed. The key to using sugar is to use a lot of it. The general rule is having 1 cm of a sugar “bed” on top of the wound. There must be some dry sugar present when you change the bandage or you lose the osmotic pull that is needed. So daily to twice daily bandage changes may be needed initially on highly exudative wounds. Then daily to every other day changes are needed. Like using a honey dressing, the sugar is used until a good granulation bed is present. Then surgical closure or second intention closure (with a non-adherent bandage) is continued.
So, if you are tackling a large contaminated wound, consider honey or sugar as your debridement bandage. These are easily available, low cost, and have many proven benefits to our patients.