Published in Family Practice Medicine
Topical honey for diabetic foot ulcers
A 79-year-old man with type 2 diabetes mellitus developed heel and forefoot ulcers, for which he received currently recommended therapy,1–5 including an off-loading orthotic, systemic antibiotics selected by infectious disease consultants, and topical therapies directed by a wound care expert.
After 14 months of care costing more than $390,000””which was the cost of 5 hospitalizations and 4 surgeries””the ulcers measured 8 x 5 cm and 3 x 3 cm. Deep tissue cultures grew methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and Pseudomonas.
During this time the patient lost 2 toes but refused below-the-knee amputation. He was informed by 2 different surgical teams that without this surgery he would likely die. This opinion was based on the patient’s recurrent episodes of heel osteomyelitis and multiple medical complications, including acute renal failure from culture-specific antibiotics.
The patient was eventually discharged to his home at his request, after consulting with his family and the hospital’s ethics committee. He lost a third toe before consenting to a trial of topical honey.
Course of treatment with honey
Once-daily, thick applications of ordinary honey purchased at a supermarket were smeared on gauze 4x4s and placed on the wounds, which were then wrapped. Oral antibiotics and saline dressings were discontinued, but otherwise treatment was unchanged. Since the patient’s family purchased and applied the honey, the cost of this therapy was merely that of the dressings. Dressing changes were painless and the serum glucose remained in excellent control.
Granulation tissue appeared within 2 weeks; in 6 to 12 months the ulcers resolved (see FIGURES 1–6). Two years later, the ulcers have not recurred; the patient ambulates with a walker and reports improved quality-of-life.
After 3 weeks
Forefoot ulcer after 3 weeks of honey therapy.
After 3 months
Forefoot ulcer after 3 months of honey therapy.
After 12 months
Forefoot ulcer after 12 months of honey therapy.
After 3 weeks
Heel ulcer after 3 weeks of honey therapy.
After 3 months
Heel ulcer after 3 months of honey therapy.
After 6 months
Heel ulcer after 6 months of honey therapy.
Honey as wound treatment in the medical literature
Honey has been used to treat wounds for millennia,6 but the medical evidence supporting its use is limited. While there are many case reports of honey’s effectiveness, 7 controlled trials demonstrating effectiveness for treating burns and wounds are limited by poor quality and the use of nonstandard controls,7 while another trial found minimal benefit when “a very thin smear” was used.8 Concerns about wound infection from Clostridium spores9 appear unfounded, as no such complication has been described in more than 500 reports in the literature,10 and honey has repeatedly been shown to suppress bacterial growth.11
Gamma-irradiated “medical” honey is available, which has also been selected for its potent antibacterial properties, although most of the cases in the medical literature have used raw honey. A burning or stinging sensation has been described with honey’s topical use.
As rates of diabetes increase, it is important to identify effective strategies to reduce amputation rates, both to improve quality of life12 and to decrease cost.13 Given honey’s potential for improved outcomes, cost savings, and decreasing antibiotic use and resistance, we advocate publicly funded randomized controlled trials to determine its efficacy. Meanwhile, we encourage others to consider topical honey therapy for patients with refractory diabetic foot ulcers.
· Acknowledgments ·
The authors gratefully acknowledge Guido Majno, MD, for his scholarship and generous assistance.
1. Consensus Development Conference on Diabetic Foot Wound Care: 7-8 April 1999,
2. Boulton AJM, Kisner RS, Vileikyte L. Clinical practice. Neuropathic diabetic foot ulcers. N Engl J Med 2004;351:48-55.
3. Jeffcoate WJ, Harding KG. Diabetic foot ulcers. Lancet 2003;361:1545-1551.
4. Watkins PJ. ABC of diabetes: the diabetic foot. BMJ 2003;326:977-980.
5. Frykberg RG. Diabetic foot ulcers: Pathogenesis and management. Am Fam Phys 2002;66:1655-1662.
6. Majno G. The Healing Hand: Man and Wound in the Ancient World.
8. Wood B, Rademaker M, Molan PC. Manuka honey, a low cost ulcer dressing. NZ Med J 1997;110:107.
9. Postmes T. Honey for wounds, ulcers, and skin graft preservation (letter). Lancet 1993;34:756-757.
10. Molan PC. Clinical usage of honey as a wound dressing: an update. J Wound Care 2004;13(9):353-356.
11. Molan PC. Potential of honey in the treatment of wounds and burns. Am J Clin Dermatology 2001;2(1):13-19.
12. Lindholm C. Quality of life in chronic leg ulcer patients. Acta Derm Venereol 1993;73:440-443.
13. Ollendorf AD, Kotsanos JG, Wishner WJ, et al. Potential economic benefits of lower-extremity amputation prevention strategies in diabetes. Diabetes Care 1998;21:1240-1245.
CORRESPONDING AUTHOR: Jennifer J. Eddy, MD, Assistant Professor of Family Medicine,
The use of honey-derived dressings to promote effective wound management.
Lecturer in Tissue Viability,
Clinical observations suggest that honey holds significant promise as an effective treatment for a number of medical conditions and particularly in the management of non-healing wounds. This article explores the healing properties of honey and illustrates the effectiveness of using honey in the management of chronic leg ulcers.
3: J Wound Care. 2004 Nov;13(10):451-2.
Use of medical honey in patients with chronic venous leg ulcers after split-skin grafting.
OBJECTIVE: To assess the use of medical honey on healing times and complications in patients with venous leg ulcers after split-skin grafting. METHOD: Healing time and morbidity were evaluated in six patients with chronic venous leg ulcers who underwent split-skin grafting followed by the application of medical honey at the vascular unit of University Hospital Aintree in
7: Br J Community Nurs. 2003 Dec;8(12):S14-20.
The use of honey for the treatment of two patients with pressure ulcers.
Chronic wounds such as pressure ulcers, leg ulcers and diabetic wounds are a common problem among older people and alternative methods to the current time-consuming and costly practices of wound management in the nursing home need to be identified. To this end, we trialled the use of a honey alginate on two elderly males in our nursing home who were suffering from pressure ulcers (one on the ankle and one on the sacral region), to evaluate its effectiveness as a viable alternative to the current wound management practices in nursing homes. The use of honey resulted in a rapid and complete healing of both wounds. In addition, the antibacterial activity of honey had a deodorizing effect on the wounds and its anti-inflammatory actions helped reduce the level of pain. Similar healing results are also being observed in other patients with pressure-induced ulcers and as a result honey alginates are now being used as the ‘standard’ treatment for chronic wounds in our nursing home.
9: Lancet Infect Dis. 2003 Oct;3(10):608.
Sweet solution to superbug infections?
10: Ann Plast Surg. 2003 Feb;50(2):143-7; discussion 147-8.
Honey-medicated dressing: transformation of an ancient remedy into modern therapy.
Department of Plastic and Reconstructive Surgery, Onze Lieve Vrouwe Gasthuis, 1090 HM
Honey has been applied for medicinal purposes since ancient times. Its antibacterial effects have been established during the past few decades. Still, modern medical practitioners hesitate to apply honey for local treatment of wounds. This may be explained by the expected messiness of such local application. Moreover, secondary infectious disease may be caused by contamination of honey with microorganisms. Hence, if honey is to be applied for medicinal purposes, it has to meet certain criteria. The authors evaluated the use and safety of a honey-medicated dressing that was developed to meet these criteria in a feasibility (phase II) study featuring 60 patients with chronic (n = 21), complicated surgical (n = 23), or acute traumatic (n = 16) wounds. In all but 1 patient, it was found easy to apply, helpful in cleaning the wounds, and without side effects. Based on these results, the authors advise to subject this dressing to a randomized, double blind, phase III study.
11: Exp Toxicol Pathol. 2002 Nov;54(3):217-21.
Gastroprotective effects of honey and glucose-fructose-sucrose-maltose mixture against ethanol-, indomethacin-, and acidified aspirin-induced lesions in the rat.
The gastric cytoprotective properties of natural honey (monofloral and polyfloral specimens) and of a glucose-fructose-sucrose-maltose mixture (GFSM) was evaluated in the rat using absolute ethanol, indomethacin and acidified acetylsalicylic acid (ASA-HCl) as necrotising agents. Prior gastric administration of honey (2.5 g/kg) to animals induced a net reduction of hemorrhagic lesions length of the mucosa. Protection of the stomach elicited by both types of honey and GFSM was almost total against ethanol-induced lesions. Similar results were also observed when using ASA-HCl except that the percent protection was 87%. The percent reduction of indomethacin-induced gastric lesions was variable according to the nature of the test solution: GFSM mixture (41.1%) < polyfloral honey (55.2%) < monofloral honey (64.0%). Perfusion of the stomach with isotonic honey resulted in (1) a 70% reduction of the area of the lesions caused by ethanol, (2) the failure to prevent the transmural potential difference fall induced by ethanol, (3) an increase of basal and histamine-stimulated acid secretion. These results suggest that sugar rich solutions (GFSM and honey) may prevent gastric damage by a mechanism involving the release of some protective agents.
13: Ostomy Wound Manage. 2002 Nov;48(11):28-40.
Re-introducing honey in the management of wounds and ulcers – theory and practice.
Department of Biological Sciences, University of Waikato, Private Bag 3105, Hamilton, New Zealand. firstname.lastname@example.org.
Dressing wounds with honey, a standard practice in past times, went out of fashion when antibiotics came into use. Because antibiotic-resistant bacteria have become a widespread clinical problem, a renaissance in honey use has occurred. Laboratory studies and clinical trials have shown that honey is an effective broad-spectrum antibacterial agent that has no adverse effects on wound tissues. As well as having an antibacterial action, honey also provides rapid autolytic debridement, deodorizes wounds, and stimulates the growth of wound tissues to hasten healing and start the healing process in dormant wounds. Its anti-inflammatory activity rapidly reduces pain, edema, and exudate and minimizes hypertrophic scarring. It also provides a moist healing environment for wound tissues with no risk of maceration of surrounding skin and completely prevents adherence of dressings to the wound bed so no pain or tissue damage is associated with dressing changes. Using appropriate dressing practice overcomes potential messiness and handling problems.
14: J Dermatolog Treat. 2001 Mar;12(1):33-6.
Healing of an MRSA-colonized, hydroxyurea-induced leg ulcer with honey.
Wound Healing Research Unit,
BACKGROUND: With the everincreasing emergence of antibiotic-resistant pathogens, in particular methicillin-resistant Staphylococcus aureus (MRSA) in leg ulcers, a means of reducing the bacterial bioburden of such ulcers, other than by the use of either topical or systemic antibiotics, is urgently required. METHODS: We report the case of an immunosuppressed patient who developed a hydroxyurea-induced leg ulcer with subclinical MRSA infection which was subsequently treated with topical application of manuka honey, without cessation of hydroxyurea or cyclosporin. RESULTS: MRSA was eradicated from the ulcer and rapid healing was successfully achieved. CONCLUSION: Honey is recognized to have antibacterial properties, and can also promote effective wound healing. A traditional therapy, therefore, appears to have enormous potential in solving new problems.
15: J Dermatolog Treat. 2001 Mar;12(1):29-31.
Bi-lateral eosinophilic ulcers in an infant treated with propolis.
Division of Family Medicine, The
BACKGROUND: Propolis is a natural substance, produced by the honey bee, containing amino acids, flavanoids, terpenes and cinnamic acid. It has long been used in folk-medicine for topical inflammatory conditions including ulcerative lesions of different aetiologies. METHODS: A 13-month-old female infant developed bilateral eosinophilic ulcers of the mouth, becoming the youngest patient in the literature so far reported to have done so. Following a protracted 4-month course, during which time the lesions remained unchanged despite various treatments, the ulcers were treated locally with a lanolin-based propolis ointment. RESULTS: Application of the propolis ointment was associated with the rapid resolution of the ulcers within 3 weeks and they did not subsequently recur. CONCLUSIONS: Although inevitably circumstantial, the abrupt healing of this child’s chronic eosinophilic ulcers suggests that, in the light of its previously known therapeutic associations, propolis deserves further evaluation in the treatment of this condition, and perhaps in other forms of oral ulceration as well.
16: Br J Nurs. 2002 Jul 11-24;11(13):859-60, 862, 864-6.
Treatment of an infected venous leg ulcer with honey dressings.
An infectious diseases unit is potentially an ideal environment in which to carry out research into honey-based dressings. This article looks at the barriers to carrying out case study-based research, and describes the treatment of an elderly gentleman with venous leg ulcers. The patient’s wounds improved with the honey-based dressing, but it failed to free the wound of microbes. One possible explanation is that the honey, instead of killing the microbes, actually provided them with a food source.
18: Nurs Stand. 2000 Nov 29-Dec 5;15(11):63-8.
The use of honey in wound management.
Honey has been used as a wound treatment for more than 2,000 years. Greater scientific understanding of how it works, particularly as an antibacterial agent, has led practitioners to reconsider the therapeutic value of honey. Once honey is commercially available as a regulated product in the