The Veterinary Journal 199 (2014) 56

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The Veterinary Journal

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Guest Editorial

Honey in wound management: Myth, mystery, magic or marvel?

The value of honey in wound management has been appreciated world-wide for millennia in almost all civilisations; the Edwin Smith papyrus (1500 BC) mentioned the treatment of burns with honey and grease, and written reports of its value in wound management date back to mediaeval times. Despite the general recognition of the benets of the use of honey in wound management, medical and veterinary texts published through the 19th and 20th centuries singularly failed to recognise it as an aid to wound management; almost no reference is made in any veterinary surgical texts honey seemed to have become a forgotten topic. In contrast, in the 21st century the breadth of honeys properties in wound management (both veterinary and human) and in other medical areas has resulted in several hundred publications and even text books dedicated to it. The problem was always that whilst the benets of honey as a wound dressing were well appreciated, the science behind the treatment was uncertain and led to myths and folk-lore. There was an impression that all you needed to do was cover a wound in honey and it would heal! Honey took on an almost magical reputation for having tissue reparative powers that were probably not really justied and were certainly unproven from a scientic standpoint. Furthermore, there was no suggestion that some honey types were better than others. There was certainly no strong suggestion that honey could be contraindicated for its adverse direct effects and could also be responsible for importing signicant bacteria to the wound site. Of late however, some of its medical benets and limitations have been explored in modern medical and veterinary practice. There is now a burgeoning publication list relating to the positive medicinal and biological effects of honey in a wide variety of medical and surgical conditions although most of this relates to its value as a wound dressing (Cooper and Molan, 1999; Molan, 1999). The number of publications reporting the use of honey has increased, yet systematic reviews have been critical of the design of some of those studies (Jull et al., 2013). Certainly much of the clinical evidence to support the use of honey in the treatment of supercial wounds and burns is of low quality (Dunford et al., 2000). Although the overall impact of honey as a wound healing aid topical treatment for wounds remains unclear (Cooper, 2013). A paper published in The Veterinary Journal by Reagan Carnwath and her colleagues at the University of Glasgow opens the debate about honey in general and particularly about its antimicrobial properties through the application of a properly conducted, clinically informative and balanced study into one of the major suggested properties of honey in wound management, i.e. its antibacterial effects (Carnwath et al., 2014). It is now accepted that at least some honey types have signicant antibacterial effects. Majtan et al. (2013) identied that Man1090-0233/$ - see front matter 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.tvjl.2013.10.026

uka honey also has a signicant role in breaking down and preventing the formation of biolms, which are now recognised as having a major role in inhibiting would healing and in particular the control of wound infection. The paper by Carnwath et al. (2014) is testament to its in vitro efcacy against signicant wound pathogens of horses. Additionally, honey has some deodorising, debriding and osmotic properties along with important proinammatory and antioxidant activity. In combination it would seem an almost ideal, universally benecial wound management tool in natural and experimental conditions. Essentially, honey has become regarded as a natural antimicrobial agent with an almost magical ability to promote wound healing. There are signicant risks in attributing magical properties to naturally occurring substances with inevitable commercially driven inuences on the value of one type of honey over another. The overall perception has been that Manuka honey, which is produced exclusively by bees in New Zealand from the Manuka tree, has the best medicinal properties. Of course, it depends what properties are being measured and how these are compared with other materials used for the same purposes. Unsurprisingly the hype associated with Manuka honey has created commercial pressures to maximise the return from the limited production capability of the particular honey type leading to the blending of honeys so that the trade description of a product can make value out of the name of the gold standard. There is probably no possibility that New Zealand can produce enough pure Manuka honey to satisfy the market and so other honeys are added whilst still retaining the Manuka name with the intention of maximising the commercial return without regard for its actual clinical value. Little research has been done to establish how this blending or dilution affects the individual properties of the honey. Furthermore, the Manuka honey marketing machine has created a detailed description of its medicinal properties called the Manuka Grade, that relate primarily to its antimicrobial benets. The question arises as to whether the Manuka grade is a real index of its overall value and indeed whether it is actually or always the best available honey dressing. Based upon the paper by Carnwath et al. (2014), it is a valid suggestion that honeys produced locally may have at least as effective medicinal properties as Manuka honey and this will certainly bring material benets in animal welfare and in economics in many parts of the world. Honey is generally available and relatively cheap. It is the responsibility of medical and veterinary scientists to test local honeys in a standard and scientic manner to establish whether there are bets to be gained from them; a standard testing protocol that can be applied universally would be a signicant step forward. The combined evidence for the efcacy of honey as a wound management aid has been systematically reviewed and it is clear

Guest Editorial / The Veterinary Journal 199 (2014) 56

that honey should not be regarded a cure all and the only option (Jull et al., 2013; Vandamme et al., 2013). Honey is not a universally benecial substance and there are clear contraindications for its use. It can be responsible for wound healing delays if it is used inappropriately; it has a strong osmotic effect and so for a dry wound or a wound where granulation tissue is slow to develop, honey may be contraindicated. Like all wound management procedures there is right time and a wrong time for it and the clinician needs to be able to identify the right circumstances when its positive value can be fully exploited. Honey may be superior in some circumstances to some conventional dressing materials, but there is considerable doubt about the certainty of this evidence. Currently, there is insufcient evidence to guide its full use in clinical practice and clinicians should be careful about perpetuating the myth that honey is a panacea for wound management. Its actions are not incredible or magical but they are almost certainly real and its natural origin makes it something of a marvel of natural evolution. Honey does not heal wounds nature heals wounds. Honey is certainly a useful addition to the ever increasing resources available to clinicians but more research effort is required to investigate the wider properties of honeys derived from different sources and a standard needs to be set that helps clinical decision making about what honeys have what functions and what clinical indications are best answered by its use. There are circumstances when honey might be contraindicated in wound management but the myths persist and other explanations are used to account for the failures of its perceived magical properties. It is clearly a wonderful product in many ways but it cannot be viewed as the great panacea for all ills. It should only be regarded as one of the available aids to wound management careful selection and appropriate use should be based on clear evidence derived data from proper clinical and laboratory investigations. There are some alarming features of the ndings in the paper by Carnwath et al. (2014), including the potential for pathogen import into a wound when some honeys

are used. Clearly from a microbiological aspect at least supermarket honey should be avoided and much more information is needed about the other properties of honey in wound management. Derek C. Knottenbelt Weipers Centre for Equine Welfare, School of Veterinary Medicine, University of Glasgow, 464 Bearsden Road, Glasgow, Lanarkshire G611QH, UK E-mail address: knotty@liverpool.ac.uk

References
Carnwath, R., Graham, E.M., Reynolds, K., Pollock, P.J., 2014. The antimicrobial activity of honey against common equine wound bacterial isolates. The Veterinary Journal 199, 110114. Cooper, R., 2013. Impact of honey as a topical treatment for wounds remains unclear. Evidence Based Medicine (Epub ahead of print). Cooper, R., Molan, P.C., 1999. Honey in wound care. Journal of Wound Care 8, 340. Dunford, C., Cooper, R., Molan, P., White, R., 2000. The use of honey in wound management. Nursing Standards 15, 6368. Majtan, J., Bohova, J., Horniackova, M., Klaudiny, J., Majtan, V., 2013. Anti-biolm effects of honey against wound pathogens Proteus mirabilis and Enterobacter cloacae. Phytotherapy Research. http://dx.doi.org/10.1002/ptr.4957 (Epub ahead of print). Molan, P.C., 1999. The role of honey in the management of wounds. Journal of Wound Care 8, 415418. Jull, A.B., Walker, N., Deshpande, S., 2013. Honey as a topical treatment for wounds. Cochrane Database Systematic Review (2). http://dx.doi.org/10.1002/ 14651858.CD005083.pub3 (article no. CD005083). Vandamme, L., Heyneman, A., Hoeksema, H., Verbelen, J., Monstrey, S., 2013. Honey in modern wound care: A systematic review. Burns. http://dx.doi.org/10.1016/ j.burns.2013.06.014, pii:S0305-4179(13)00197-6 (Epub ahead of print).