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Item type Presentation

Title Use of Honey for Healing Pressure Ulcers: An Integrative

Review

Authors Ricossa, Katherine

Downloaded 15-Dec-2017 01:52:54

Link to item http://hdl.handle.net/10755/335628

Use of Honey for Healing
Pressure Ulcers: An
Integrative Review

Katherine Ricossa, RN, MS

University of Hawaii, Manoa

July 27, 2014

 Faculty Disclosure
• Katherine Ricossa, RN, MS
• No known or perceived conflicts of interest
• Employer: Kaiser Permanente
• No known sponsorship or commercial
support has been obtained
 Objectives
At the end of this presentation, the
participant will be able to:
1. Understand the action of medical grade
honey it’s significance to healing
pressure ulcers
 Purpose of the
Integrative Review
Using Complementary and
Alternative Methods (CAM)
– offers a holistic approach of caring
for those with pressure ulcers
– examines a Systematic Integrated
Review of 8 randomized clinical
trials on the use of honey and the
healing of pressure ulcers
Composition of Honey
 Significance
• The costs of wound • Honey is the ideal
healing continue to substance to provide
escalate effective wound
• It is important to explore healing properties:
alternative holistic – Antibacterial
modalities which are – Antimicrobial
cost effective and – Anti inflammatory
achieve the desired – Wound cleansing
outcome of wound – Debriding properties
healing
 Methods
Several databases were • Key Terms used
examined: – Honey
• Cumulative Index for – Pressure ulcers
Nursing & Allied Health – Clinical trials
• Natural Standard • Limits
• Google Scholar – Dates from 2002 to 2012
• PubMed – English
– Full Text
• Cochrane Library
• Web of Knowledge
• Ovid SP
• Clinical Evidence
• Web of Science
 Results
• Totally 8 randomized clinical trial
– Internationally 7 randomized clinical trials were
identified using honey for wound healing of mixed
etiology of wounds including pressure ulcers from
2002-2012
– Reviewing one study found
• 1 clinical trial found from 1991 in the US on pressure ulcers
• Pressure Ulcers were abstracted from each study for this
review
• Each sample size was different based on the geographical
area where the study was conducted
• Different types of honey were used to determine the
effectiveness on wound healing
• Honey was not always effective on all wounds, but the
evidence indicates that honey is effective in wound healing
• Little statistical data was available to compare each study
 The Studies Reviewed
1. Weheida, Nagubib, El-Banna,. & Marzouk, (1991)
2. Van der Weyden (2003)
3. Yapucu & Eser (2007)
4. Gethin, Cowman, & Conroy (2007)
5. Robson, Dodd, & Thomas (2009)
6. Shrivastava (2011)
7. Biglari, Vd Linden, , Simon , Aytac, Gerner, &
Moghaddam (2012)
8. Jull, Rodgers, & Walker (2008)
1. Weheida, S.M. Nagubib, H.H., El-Banna, N.M. & Marzouk, S. (1991). Comparing
the effects of 2 dressing techniques on healing low grade pressure ulcers.
Journal of Medical Research Institute, Alexandra University, 12(2), 259-278.

• Design • Method
– Quasi Experimental – 20 orthopedic patients were treated
• Study Location with honey dressings and 20 were
– Alexandria, Virginia, USA treated with saline dressings
• Purpose – Used honey and saline on pressure
– Evaluating the outcome of 2 ulcers with examination of lab values
healing practices: honey and • Hemoglobin, urea, creatinine, glucose,
saline for pressure ulcers along serum proteins, hydroxyproline &
with examination of lab values hemocrit
• Sample • Pressure Ulcer Types
– n = 40 orthopedic patients -Low Grade ulcers
– male (n =23); female (n = 17)
• Results
– Reduction in size (width, height,
depth) of pressure ulcer
– Serum hydroxyproline returned to
normal
 2. Van der Weyden, E.A. The use of honey for the treatment of two
patients with pressure ulcers. British Journal of Community
Nursing. 2005;8(12), 1-20.

• Design
• Methods
– Prospective Clinical Trial
• Applied Manuka Honey on pressure
• Study Location ulcers
– Haberfield, New South Wales, • Pressure Ulcer Types
Australia
– Sacrum - Unstageable
• Purpose – Ankle – Stage 4
– To evaluate the effectiveness
of using honey to treat • Results
pressure ulcers instead of – Rapid and complete wound
using current wound healing for both pressure ulcers
management techniques
• Sacrum (8 weeks)
• Sample • Ankle (10 weeks)
– n=2
– male (n = 2)
 3. Yapucu, G.U. & Eser. I. Effectiveness of a honey dressing for
wound healing. Journal of Wound Ostomy Continence
Nursing. 2007; 43(2), 1884-190.

• Design • Pressure Ulcer Types

– Randomized Clinical Trials – Pressure Ulcers with multiple pressure
• Study Location ulcers totally 68 with Stage II & Stage III
– Izmar, Turkey • Results
• Purpose – Wound differed: venous ulcers, mixed
etiology, arterial and pressure ulcers.
– To compare the effect of honey to
– After 2 weeks of applying Manuka honey
ethoxydiaminoacridine plus
dressings, the pH was significantly
nitrofuazone (EDN) dressings on
significant (p<0.0001)
pressure ulcers
– Those wounds with a pH lower than 7.6
• Sample had a 30% decrease in size.
– n = 26 – Surface pH may contribute to improved
– male (n = 17); female (n = 9) wound healing.
• Methods – Wound healing with honey was 4 times
– 2 Groups randomly selected; either greater than those who were treated with
had unprocessed honey or EDN EDN dressings
applied on wounds
– PUSH Method for Measurements
 4. Gethin, G.T., Cowman, S, & Conroy, R.M. The impact of Manuka honey
dressing on the surface pH of chronic wounds. International Wound
Journal. 2008; 5(2), 185-194.
• Methods
• Design – Manuka Honey with calcium alginate fiber
dressing (Apinate Dressing) applied to
• Open Label Non Randomized
Chronic Wounds of different etiologies
Prospective
• Pressure Ulcer Types
• Study Setting
– Chronic Wounds: Venous Ulcers (10
– Dublin, Ireland
wounds; Mixed Etiology; 7 wounds; not
• Study Location identified; Arterial Ulcers (2); Pressure
• Purpose ulcers (1)
– The goal of this study is to • Results
evaluate the changes in pH on – 2 Weeks study: Improvements noted in
wounds after the application of wound healing:
honey over a 2 week period. – Wound size reduction;
• Sample – Decrease with wound pH; wound size
– Sample Size: n = 17 1. Venous Ulcers (77.8%)
– males (n = 8); Females (n = 9) 2. Mixed Etiology (43.8%)
3. Arterial Ulcers (100%)
4. Pressure Ulcers (100%)
 5. Robson, V., Dodd, S. & Thomas, S. Standardized antibacterial honey
(Medihoney) with standard therapy in wound care: Randomized
Clinical Trial. Journal for Advances in Nursing, 2009; 65(3), 565-575

• Design • Methods
– Open Label Randomized – District General Hospital) single location
Clinical Trial (inpatient or outpatient) either receiving
medical grade honey or traditional
• Study Location therapies for wound healing.
– Liverpool, United Kingdom
• Wound Types
• Purpose – Leg Ulcer (39); Breast Wound (7);
– To compare honey used in Eczema (1); Ears Nose Throat Wound
medical treatment with (6); Foot Ulcer (1); Stump (2); Varicose
standard treatments for wound Eczema (1); Abdominal Wound (1); Heal
healing. Pressure Sore (1); Hernia Incision
• Sample n = 105 Wound (1); Neck Wound (1)
– Male (n = 69) Female (n = 36) • Results
– Only 1 Pressure Ulcer – Healing Time within 12 weeks:
– Honey (46.2%)
– Conventional Wound Healing (34.0%)
 6. Shrivastava, R. (2011).Clinical evidence to demonstrate that simultaneous
growth of epithelial and fibroblast cells is essential for deep wound
healing. Diabetes Research Clinical Practice. 92(1), 92-99.

• Design • Methods
– Randomized Clinical Research – Applied glycerol & honey to wounds
Trial
• Pressure Ulcer Types
• Study Location – Diabetic Wounds (65%); Pressure Ulcers
– Issoire, France (17%); Venous Insufficiency (18%)
• Purpose Results
– To evaluate chronic wound – Wound surface improved by 33.37%
healing using tannin rich plant – Wound volume decreased by 29.45%.
extracts: glycerol and honey – Treatment product reduced the wound
• Sample n = 93 surface area 97.87
– Male (n=77) Female (n= 16) – Wound volume decreased by 94.17%.
– The treatment product promoted a reduction
in wound surface by 64.5%
– Reduction in wound volume by 64.72%
 8. Biglari, B., Vd Linden, P.H., Simon A., Aytac, S, Gerner, H.J., and
Moghaddam, A. Use of Medihoney as a non-surgical therapy for
chronic pressure ulcers in patients with spinal cord injury. Spinal
Cord. 2012;50(2): 165-169. doi: 10.1038/sc.2011.87

• Methods
• Design – MediHoney applied on the pressure ulcers with
– Randomized Clinical the octenidin-hydrochloride 0.1%,
Research Trial phenoxyethanole 3%, Schülke, norferstedt,
Germany (Octenispect)
• Study Location
– octenidinehydrochloride 0.1 Vol%, 1-propanol 30
– Ludwigshafen, Germany Vol%, 2-propanol 45 Vol%, Schülke
• Purpose (Octeniderm) to disinfect outside the P\pressure
– To determine the effects ulcer
of Medi- honey on • Pressure Ulcers Locations
bacterial growth on Sacrum (9); Ischium (3); Heel (2); Leg (2); Ankle
pressure ulcers for (1); Abdomen (1); Thigh (1); Groin (1)Staging or
patients with spinal cord Grading based on the National Pressure Ulcer
injury. Advisory Panel: Grade IV (5) & Grade III (15)
• Sample n = 20 • Results
– Male (n=13) Female – Absence of bacterial growth (1 week)
(n=7)
– 90% Wounds were completely healing
(4 weeks)
 8. Jull, A.B., Rodgers, A., & Walker, N. Honey as a topical treatment for
wounds (Review). The Cochrane Collaboration. 2008; 8(4)1-47.

• Design • Methods
– Randomized and Quasi – Literature review of 3/19 Clinical
Randomized Trials Trials using honey for wound
• Study Location healing
– Auckland, New Zealand – Study 1: Honey versus Sugar
Dressing
• Purpose
– Study 2: Healing mixed wounds
– To determine if honey including pressure ulcers with
has healing properties Honey or saline soaked gauze
for both chronic and dressing
acute wounds.
– Study 3: Mixed wounds both
• Sample acute and chronic using honey for
– Total of 19 trials wound healing
– (n = 2,554)
 8. Jull, A.B., Rodgers, A., & Walker, N. Honey as a topical treatment for
wounds (Review). The Cochrane Collaboration. 2008; 8(4)1-47.

• Wound Types • Results

-Acute Wounds – Study I: Honey versus Sugar
• Burns Dressing. Healing with honey was
• Lacerations
• Traumatic Wounds 31.5 days; with Sugar dressing 56
- Chronic Wounds days.
• Venous Ulcers – Study 2: Honey was more effective
• Arterial Ulcers than saline soaked gauze.
• Diabetic Ulcers
• Pressure Ulcers – Study 3: Inconclusive results since
• Infected Surgical Wounds the wound types were so different.
This study was not generalizable
since only one trial on one pressure
ulcer was tested.
– In general; lacked healing based on
the mixed etiology of wounds
Beitz, J. & Bolton, L. (2013). A Scientific Review of the Cochrane Review: Honey as a
Topical Treatment. Jull et al. Cochrane Database of Systematic Reviews 2013
Article No CDC005083.

• Studies performed with • Identified Errors

– Focused on specific data with
Honey
omission of others
– Statistical Significance
– Lack of clarity of effects on
– No statistical significance treatments
• Critique of Systematic – Adverse effect are unclear
Review – Studies with burn, venous
– Many red flags in abstracting ulcers
data • Concluded
– Lacks clarity when describing – Lack of evidence in the effect
studies of honey on wound healing
– Several studies omitted which – Recommendation to avoid the
identified other conventional use of honey
treatments not considered
– US FDA took 100% pure
(grafting or excision)
honey off the market and is to
– Mixed etiology of wounds be used for ingestion as a food
made it difficult to understand product not for wound healing
the studies
 Conclusion
• Few studies have been conducted on the
effectiveness of wound healing with honey
internationally
• It is suggested that honey is nature’s perfect
substance for wound healing for pressure ulcers
• It is difficult to generalize on the effectiveness of
honey based on these randomized clinical trials
with heterogeneous samples and wound types
• Based on these studies, honey is effective on
healing pressure ulcers
• Additional research must be conducted using
homogenous samples and pressure ulcer types to
establish a basis for practice
• Contact Information
– Kathy Ricossa, RN, MS
– Kathy_ricossa@hotmail.com
– 408.893.0467