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Honey

I cram for TAM, and, combined with other commitments, not the least of which is that it is finally sunny and warm in Portland, after a year that has resembled All the Summer in a Day,  which leads to a relatively short post.  There are just so many hours in a day and if possible those days need to be spent in the sun.

In my first year in practice I was sitting on a nursing station writing a note when a patient started howling in pain.  Further investigation revealed that the patient had a chronic, open surgical wound and the (old) surgeon had ordered sugar poured into the wound as part of wound care.  The cafeteria mistakenly sent up salt, and a metaphor became reality.  It did pique my interest in both sugar and honey for wound care,  an area where you have to be careful not to fall prey to all the errors in CAM thinking: a reliance on anecdotes, using suboptimal studies as evidence, mistaking a gobbet of basic science as a meaningful clinical application, and not realizing the warping effect of confirmation bias.

That being said, I have suggested honey and sugar for years for patients, and many patients with prior refractory wounds had healing.  And what are the three most dangerous words in medicine?  In my experience.  I have recommended honey less in the era of the wound vac, but there are not an insignificant number of people with insufficient financial resources who cannot afford even simple wound care supplies. Many  of the ointments, creams and special bandages for wound care costs too much.  Patients also like honey as it is natural (people do love to fall for the naturalistic fallacy) and inexpensive, and I always tell patients that the data is iffy, but not stupid.

Wound  itself is mostly a combination of tradition and hype.  One doc learned from his attending who learned from their attending, in a line that stretches back to the first barber-surgeon.  I was told as a medical student, never put in a wound what you wouldn’t put in your eye, which seemed to be a good guiding principle, although it is expensive to pack a wound with soft contact lenses.  New products, often combinations of old treatments, come out monthly with flashy brochures and little good data.

“There is a lack of large, high-quality published RCTs evaluating debridement per se, or comparing different methods of debridement for surgical wounds, to guide clinical decision-making. ”

So I rely on basic principals. Keep the wound clean, keep the new tissue from drying out, remove the dead meat, and keep the bacteria at bay, and do not let your pet lick it are more or less guiding rules in wound care.  That, and no matter what you do, most people will heal.  My rule remains: take credit for success, blame nursing when things go wrong.  That’s ‘humor’ for the sarcasm impaired.

What is the rationale for sugar and honey for wounds and burns?

Basic Biologic Plausibility

The first is mechanism of action is primarily mechanical.  The high osmolality of sugar and honey prevents bacterial overgrowth.  Food can be preserved in sugar (jam is a good example) so the honey and sugar can prevent or decrease bacterial colonization of wounds.  Honey has a low pH and contains hydrogen peroxide, both of which are antibacterial, but I doubt clinical relevance of the latter.  And there may be bee and flower constituents that aid in antibacterial properties, although again I wonder about clinical relevance. Also, sugar and honey do not damage new tissues and when the honey is washed off, it painlessly removes the dead tissues with it, so it is good for debridement.

Honey, and to make sure you can charge a premium amount call it medical grade honey, can kill bacteria and decrease skin colonization.  Avoid raw honey, as it can contain C. botulinum and has been the source of botulism in children.  I don’t expect it would be of much use on facial wrinkles

At least from a basic science perspective, honey and sugar have mechanical, perhaps biochemical, and certainly financial, reasons it could be beneficial in wound care.

Clinical trials

So how are the clinical trials? There are lots of poor quality studies.  Almost 400 references if you are in the mood for cherry picking.  The preponderance of the poor quality studies points to benefit.

For burns?

“Available evidence indicates markedly greater efficacy of honey compared with alternative dressing treatments for superficial or partial thickness burns, although the limitations of the studies included in the meta-analysis restrict the clinical application of these findings.”

and

“Honey may improve healing times in mild to moderate superficial and partial thickness burns compared with some conventional dressings”

For Wounds?

From the ever helpful  and potentially flawed Cochrane reviews:

Honey dressings as an adjuvant to compression do not significantly increase leg ulcer healing at 12 weeks. There is insufficient evidence to guide clinical practice in other areas.

and as they note

The poor quality of most of the trial reports means the results should be interpreted with caution.”

So be it.  I have read many of the 400 references over the years, and the sense is that honey is of some value in wound care.

There is even less information of granulated sugar, where it looks encouraging and has been used to treat mediastinitis , diabetic foot ulcers and sloughing wounds.

Of course, honey is not the end all and bee all of treating soft tissue infections. Depending on the process, surgery and antibiotics will do far more to resolve the infection and promote healing, espcially for acute and/or acutely infected wounds. Relying on only natural products has lead to one death in a complimentary practitioner who treated himself with honey:

“a minor injury became infected with gangrene, the judge was told. He died, aged 52, in April 2007. Instead (of standard care)  he used honey and magnesium sulphate.”’

The doctor who treats themself has a fool for a patient and an idiot for a doctor.

So in the end, do I recommend honey and sugar?  Yes.  The literature is interesting and I give patients a long  list of caveats.  It is maybe sort of probably useful in patients with chronic wounds who cannot afford other interventions.  In my experience it always works.  Back to TAM.

Posted in: Herbs & Supplements, Science and Medicine, Surgical Procedures

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34 thoughts on “Honey

  1. Mojo says:

    Of course, honey is not the end all and bee all of treating soft tissue infections.

    Ouch.

  2. xwolp says:

    I personally would advice against using _regular honey_ in wound care, given that it is known to harbor botulism spores, among other things. That’s just a hunch but I guess that’s the reason why there is specially treated medicinal honey
    (Also my experience as both a beekeeper and feeding thousands of ant colonies for the sake of evolutionary biology has taught me that this stuff can go south pretty fast, turning from a hygroscopic, safe high energy food into a bacteria infested cesspool)

  3. swoop ” this stuff can go south pretty fast, turning from a hygroscopic, safe high energy food into a bacteria infested cesspool.”

    Oh, I hope you are talking about raw honey, cause I’m contemplating the honey that I store in my cupboard and thinking “yum, how about a little bacteria infested cesspool on my toast this morning?”

  4. Mark, our buddy Grant Jacobs down in New Zealand blogged a bit about this subject at Code for Life:

    http://sciblogs.co.nz/code-for-life/2010/07/14/honey%E2%80%99s-antibiotic-properties-found/

    He did a really nice job examining the composition of honey and biological activities of each component.

  5. lilady says:

    A very interesting article about honey used for wound treatment…which I learned about in nursing school.

    Of course CAM practitioners without any knowledge of wound care or the osmotic properties of honey dressings have grabbed hold of honey as the “natural” treatment thus diverting patients who should be evaluated by a medical doctor and treated by wound care specialists. One only needs to “google” “diabetic wound care honey” to find advertisements and referrals to alternative medicine “practitioners”.

    I did locate a site at the University of Wisconsin “Topical Honey for Diabetic Foot Ulcers” which describes a double blinded randomized study that is being conducted by Dr. Jennifer Eddy. Recruitment for the study is ongoing and participants will receive care free-of-charge through the University”s Family Practice Clinic from Dr. Eddy, a podiatrist and through trained home care nurses. The abstract about the study is available at:

    Pubmed 18702435

  6. tmac57 says:

    although it is expensive to pack a wound with soft contact lenses.

    It might cause you to have a sees-yer too. That’s payback for the “bee all” comment ;)

  7. @xwolp – sorry about calling you swoop. Mrs. iPad renamed you and I missed it.

  8. Costner says:

    Of course, honey is not the end all and bee all of treating soft tissue infections.

    I see what you did there. Well played.

    I hear maggots are useful for treating soft tissue infections as well, but maybe you really do catch more flies with honey.

  9. Calli Arcale says:

    Zing! Love the puns. Beehave, everybody. :-P

    Would you think there is any reason to be concerned about allergies? I’ve used honey (including raw honey, which regrettably is frequently what you find in the stores, pasteurization not being a routine practice for honey in the US) for cooking, for sweetening my tea, and for spreading on toast for as long as I can remember. I’ve never had any allergic responses, even though I am allergic to many kinds of pollen, including several plants which rely on insect pollination such as lilacs and true lilies. (Daylilies, which are unrelated, do not bother me at all.) But I have heard of people who did have allergy issues with honey due to residual pollen. I would think it would be unwise to slather honey on their wounds, but then, how common is a honey allergy anyway? I really don’t know, but it’s a concern that comes to mind. Honey is a widely variable product, after all, depending on what the bees have been eating.

    And ironically, it may not always be as “natural” as people think. There have been cases of honey spiked with corn syrup not because of adulteration but because the bees had discovered a puddle of the stuff and gone to town. (One can only imagine the frenetic excitement as the first worker returned and started dancing for her sisters the bee equivalent of “go here now, it’s awesome!”) The most hilarious case involved a maraschino cherry factory; a woman’s bees had been traveling miles to what must’ve been bee nirvana — a puddle of leaking corn syrup from a pallet behind the factory. She noticed because this corn syrup had been dyed red, and the red dye of course got into the honey. :-D

  10. lilady says:

    Dr. Crislip only touched on the problem of infant botulism caused by ingestion of honey. An excellent site to check this out is the:

    Mayo Clinic: Infant botulism

    Also there are a number of sites about botulism contaminated food products that have caused botulism in the consumer of sun-dried tomatoes and chopped garlic mixed in oil. The CDC has reported a number of cases.

    (That’s why I nixed one of hubby’s concoctions of chopped fresh garlic in olive oil as a salad base)

  11. Ken Hamer says:

    Is a tube of Polysporin really that much more expensive than “medical grade” (yes, I know it’s humour) honey? I’m guessing that many people who opt for this type of “treatment” would also opt to purchase organic honey at “health” supplement type store, and significantly inflated prices.

    I suppose there might be some who purchase inexepensive honey at Safeway for economic reasons. But in the long run, as almost always, it seems the “more expensive” proper treatment would be much cheaper in the long run.

  12. tmac57 says:

    I’m on a diet,so, can I use Sweet-N-Low instead?
    On second thought,maybe I should use Stevia,cause it’s…you know…non-toxic.

  13. JPZ says:

    @Mark Crislip

    What about studies on the use of honey in immediate treatment of an injury (e.g. large scrape, deep cut, etc.)? In an RV camping or cabin camping situation, I might have honey on hand but not enough bandages to cover or pack the wound for the 50 mile drive down a dirt road to civilization.

    The following example not only illustrates my question but gives another true story to tell about “salt in the wound.” When I was about six, my extended family went out into the deep woods on a fall day to cook chicken over a wood fire, hang out and let us kids run wild (give us a few miles of forest, no matches, and we were pretty safe, comparatively). One of my uncles was chopping deadwood for the fire and succeeded in dividing his 3rd and 4th toes by an additional 3/4″ inch of steel axe. We had a jar of honey on hand because it was part of the sauce for the chicken, but we were not aware of this particular bit of lore. Instead, as many of us sped off in the back of a pickup truck (tearing off shirts for bandages), my great-grandmother tossed a carton of Morton’s salt in the truck saying “Pour some salt in it, that’ll help!” Fortunately, my mother had been a Candy Striper and tossed the salt out of the moving truck before anyone listened to the family matriarch.

    Ah, the good ‘ol days.

  14. JPZ says:

    @tmac57

    Check your science before you make fun of something:

    http://www.accessdata.fda.gov/scripts/fcn/gras_notices/grn000282.pdf

  15. JPZ says:

    @Ken Hamer

    The cheap honey at Safeway may very well have originated in China where they are thought to trans-ship to other countries (Vietnam, India, etc. that have minimal honey production capacity but huge exports) in order to avoid US tariffs imposed for Chinese dumping of underpriced honey.

    And when it is from China, you know it has to be good! ;)

  16. tmac57 says:

    JPZ-

    Check your science before you make fun of something:

    Sooooo….I’m good to go putting Stevia on my wounds then?

  17. JPZ – three posts in a row? You must have a bee in your bonnet…

    (groan)

  18. daedalus2u says:

    Honey also contains nitrate and a little nitrite.

    http://www.ncbi.nlm.nih.gov/pubmed/20451343

    That would be reduced to NO in a wound, especially at low pH. The Clostridia are exquisitely sensitive to nitric oxide.

    It is my understanding that the hydrogen peroxide comes from glucose oxidase that the bees put in the honey.

    The very high glucose levels of topical honey might also produce Advanced glycation end products observed in diabetes and those could increase oxidative stress locally.

  19. Paddy says:

    A couple of anecdotes about other uses:

    In my experience (heh), the old wive’s cough linctus made by dissolving honey in hot water works a treat. Some also add lemon as a decongestant (don’t overdo this, however) and/or rum/whisky, and one mexican friend of mine also adds garlic. I personally doubt such infusions work as anything more than symptomatic treatment, but on the plus side, it’s certainly tasty (YMMV as regards garlic) and comforting.

    I also heard a claim from a friend who worked for the CDC that honey may present small amounts of pollen allergens in such a way as to actually promote tolerance to them in hayfever sufferers. No solid evidence for this, however.

  20. JPZ says:

    @Paddy

    The evidence is mixed, but my read has been that honey is better than no treatment at all for pediatric cough (http://www.ncbi.nlm.nih.gov/pubmed/18056558). Also, oral tolerance to antigens (taking a large dose of an antigen orally to suppress systemic immune responses to the antigen) is a well-studied immune phenomenon, but I am not aware of a lot of evidence for its use in humans. So, the idea of consuming allergenic pollen in honey to suppress allergies is plausible.

    @tmac57

    Groan! I meant the non-toxic comment, but I did leave myself wide open for that.

    @micheleinmichigan

    GROAN! Actually, I have been chatting with the US Honey Board folks, so all this info is fresh on my mind.

  21. CC says:

    I’ll vouch for honey on a sore throat. After a cold, I tend to have a dry cough that lingers for sometimes two weeks or more, even if otherwise I don’t feel sick, and it’s hell on my throat. When it’s raw from coughing, hot honeyed water is incredibly soothing. Since the rawness triggers the coughing for me in a nasty positive feedback loop, it’s an effective cough suppressant on that basis – and with the coughing stopped, the throat can heal. It may not heal the sore throat itself but it certainly helps the symptoms! (I put the lemon in for extra flavour, I had never heard of it used as a decongestant.)

    I had heard that honey is good on a wound to keep it from getting infected, but also that that it had to be washed off and fresh honey reapplied regularly because once it gets enough moisture in it, it becomes a source of food for bacteria?

    I’ve also heard (and always wondered at) the claim that honey kills bacteria by being so aggressively hygroscopic that it bursts the bacteria’s cell walls. If that were true, then why wouldn’t it do that to our healthy cells as well as the bacteria?

  22. tmac57 says:

    @JPZ- Actually ,I wasn’t even having a go at Stevia in my original comment,as much as tweaking those who view Sweet-N-Low as some sort of dangerous toxin,and Stevia as ‘all good and pure’.
    I think either of them is okay in small amounts,but I prefer plain old sugar myself (also in small amounts) if I want something sweetened.

  23. rmgw says:

    “….do not let your pet lick it….” – here’s a bit of old catalan folklore – if you cut yourself or whatever when out and about, call over the dog to lick your wound: that’ll cure it. Just saying…

    Didn’t a doctor friend tell me that the problem with wounds in diabetics is that the high sugar level in the blood promotes infections? Am I hopelessly confused here?

  24. lilady says:

    @rmgw: I don’t think you would want any pet to lick a wound after you read this:

    CDC Emerging Infectious Diseases Journal-Zoonosis in the Bedroom (February 2011)

    I know if I had a wound that had failed to heal, I would head over to my medical doctor and expect that my physician would be ordering at a minimum a CBC with differential along with a blood glucose level to determine if I had higher than normal blood glucose level and also take a specimen of the wound for culturing.

  25. opisthokont says:

    @rmgw – Diabetics are susceptible to infections because of the various effects that high blood sugar has on the body, but it’s not necessarily the sugar itself that causes impairs immune function. Applying topical honey eliminates or at least reduces the number of bacteria in and on the wound, thus preventing them from causing an infection in the first place. Chronically elevated blood glucose can cause a decreased in leukocytes (white blood cells) which makes it harder for the body to fight infections, while externally applied sugar or honey prevents bacteria from colonizing wounds in the first place.

  26. xwolp says:

    @micheleinmichigan the problem with honey (or rather certain types of honey) is two fold:
    If it is not properly sealed it will draw moisture from the air until it eventually begins to spoil.
    Or, with certain types of honey, it the sugar will slowly crystallize, leaving a low sugar solution behind that spoils easily as well.

    If you avoid this it will keep forever, though

  27. tommyhj says:

    @rmgw

    DON’T ever let your pet lick your wound. The specific bacteria in a dog or cats saliva makes for a very nasty infection. I’ve seen a few amputations because of small wounds with dog saliva involved, that didn’t get treated quickly enough with high enough doses of potent antibiotics intravenously.

  28. lilady says:

    Actually people who have diabetes are considered somewhat immune suppressed, according to those who practice in infectious diseases, due to the poor circulation they experience in their extremities and the developmental of metabolic syndrome (obesity, elevated blood glucose levels, hypertension and peripheral artery disease)…which in turn may cause retinopathy and end stage diabetic renal disease.

    Diabetics must take extra care to protect their feet, by washing and drying meticulously, careful inspection of their extremities, keeping the skin supple, always wearing socks and comfortable shoes as diabetics also suffer from peripheral neuropathy…and unawareness of the slightness injury that can precipitate dangerous lesions and sores that are slow to heal. The neuropathy is also quite painful.

    Poor circulation itself can lead to dry gangrene…due to loss of circulation/very poor circulation to to the extremities. It is marked by a blackening of the toes and other parts of the foot.

    Wet gangrene is an oozing sore that is usually colonized with clostridrium bacteria. Intensive medical attention is required to debride necrotic tissue and for frequent dressing changes.

    Even in the hospital, with a post-op patient who has well controlled Type II Diabetes with oral anti-diabetic medication, patients are monitored and are often switched to insulin to maintain strict blood glucose control. Diabetics are taught that any stress to the body such as illnesses or surgery may cause wide swings in the blood glucose levels. Higher than normal range blood glucose levels delay healing from surgery and delay recovery from various infectious diseases.

    The honey treatment study for diabetic ulcerations as I mentioned in a posting above which is being conducted at the University of Wisconsin, may turn out to be another viable treatment for healing of lesions. But, note that the treatment is being strictly monitored in a family practice clinic with the participation of specialists including a podiatrist and with frequent at-home visits by wound care specialist nurses. Simply not appropriate to try at home own your own and certainly inappropriate for a CAM practitioner to attempt as alternative treatment.

  29. Simmerja says:

    To add a little anecdote to the mix:

    Shortly after my 11th birthday I incurred second and third degree burns across my arm and torso after a tactical misjudgment involving gasoline and the uses thereof. After a few weeks of debridement and standard treatment my mother opted for a natural approach, and for the next several months the large raw areas of my anatomy (about 15% TBSA) were kept slathered in honey (plain ‘ol unpasturized local stuff), various powdered herbs (comfrey and goldenseal, as I recall), and covered with a layer of plastic wrap and Ace bandages.

    Looking back on it from my current perspective as a medical student, I’m not sure if I should be retroactively scared to death or just take it as some sort of lesson in the efficacy of simple treatments and the bodies innate ability to heal….

  30. Calli Arcale says:

    Ken Hamer:

    Is a tube of Polysporin really that much more expensive than “medical grade” (yes, I know it’s humour) honey?

    If it is now, that’s probably a temporary condition — what with Colony Collapse Disorder, honey prices are liable to rise even faster than other foodstuffs. (All foodstuffs are getting more expensive.)

    I found Polysporin at Amazon for 4.16 per 1/2 oz. Finding the cheapest price for honey was more of a challenge, but $5 for 12 oz seems pretty common. So food grade honey is clearly considerably cheaper than Polysporin at present. No idea about “medical grade”.

    JPZ:

    The cheap honey at Safeway may very well have originated in China where they are thought to trans-ship to other countries (Vietnam, India, etc. that have minimal honey production capacity but huge exports) in order to avoid US tariffs imposed for Chinese dumping of underpriced honey.

    Watch the labels also; not all “honey” products are actually 100% honey, even if made in the US. The US doesn’t have many standards for honey, and products can call themselves honey even if they include other things, such as corn syrup. (Mind you, it would be difficult to detect corn syrup adulteration, as sometimes that’s added by the bees themselves upon finding a source. Bees aren’t very picky, or more accurately, have different priorities than we do.) They do have to disclose it on the ingredient list if there is anything besides honey in there.

  31. Calli Arcale “Bees aren’t very picky, or more accurately, have different priorities than we do.) They do have to disclose it on the ingredient list if there is anything besides honey in there.”

    …of course bee’s have pretty bad handwriting and a poor grasp of english language concepts, so it may be difficult to figure out their label disclosure.

    :) Sorry, the heat has broiled what little brain I had.

  32. Calli Arcale says:

    BWAHAHAHA! (The heat has broiled my brain as well, evidently, because that cracked me up, Michele.)

    Of course I meant that the humans packaging and selling the stuff have to disclose it. But now I have a hilarious mental image of bees working together to lift a pen and try to write out the ingredient list…..

  33. Chris says:

    Also beware of bees getting nectar from certain plants:

    His symptoms led to the conclusion that his troubles were likely caused by grayanotoxin poisoning, also known as rhododendron poisoning and “mad honey intoxication.” The problem is typically caused by bees that snacked on rhodies, picking up the natural neurotoxin.

    Yay! Another reason for me to dislike rhododendrons, not just because they are ungainly for most of the year. (the news article is actually an interesting one on all natural toxins found in food)

  34. woo-fu says:

    @lilady

    Here’s the link to that CDC article:
    http://www.cdc.gov/eid/content/17/2/167.htm

    Thanks for the info!

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