Date Last Updated: 12/04/06
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Does honey help heal burns and
scalds?
Abstract
A variety of dressings and
topical agents (such as creams) are used for burn wounds. The most common
dressings and agents used are paraffin-impregnated gauze, polyurethane film
or foam, gel-forming agents known as hydrocolloids and creams containing
silver. Honey has traditionally been used for wound healing, and there are
biologically plausible reasons why it should be an effective treatment, such
as its ability to absorb liquids (osmolarity), its acidity and its
antibacterial properties (Molan 2004).
We reviewed six fair-quality randomised
controlled trials of honey for dressing burns and scalds, all carried out by
the same research group in India. None were blinded.
Superficial and partial thickness burns
dressed with honey healed significantly faster and were less likely to be
colonised with bacteria than those dressed in more conventional ways. No
adverse events were reported with the use of either honey or conventional
dressings.
More serious burns healed significantly better
with early surgical excision and skin grafting.
1.
Type of
treatment:
Honey
Indication:
Treatment of burns and scalds
2.
Background
Burns are very common. Each year
about one person per hundred is burnt in New Zealand, of whom about 10 per
hundred need hospital admission (National Burn Centre 2005). In New Zealand most
burns occur in the home, with young children being the most vulnerable group.
The commonest type of injury is scalding from hot liquids (Skinner 2002).
The severity of a burn
or scald depends on the depth of the wound and the proportion of the body
affected. The injury may be very superficial, involving just the top (epidermal)
layer of the skin, partial thickness involving more structures within the skin
such as blood vessels, nerves and hair follicles, or full thickness, involving
all layers of the skin and possibly also the structures beneath, such as muscle
and bone. The extent of the injury is usually described in terms of the depth of
the burn, as well as the area of the total body surface area (TBSA) that is
burnt, and expressed as a percentage (Campbell 2000).
Burn wounds are very prone to infection, as the
warm moist site of the wound presents an ideal environment for bacteria to
multiply (Edwards-Jones 2003).
A variety of dressings and topical agents (such as
creams) are used for burn wounds. The most common dressings used are
paraffin-impregnated gauze, polyurethane film, polyurethane foam and gel-forming
agents known as hydrocolloids. Creams containing silver are also commonly used
in the first few days after a burn, to reduce the risk of infection.
Honey has traditionally been used for wound
healing, and there are biologically plausible reasons why it should be an
effective treatment. Its high sugar content gives it the ability to absorb water
from a wound (osmolarity) and this deprives bacteria of the moisture they need
to thrive. The honey provides a non-adherent interface between the dressing and
the wound bed, which creates a moist healing environment and prevents the
dressing from tearing away newly formed tissue when removed. There is also
evidence from laboratory studies to suggest that honey has antibacterial
properties that are due partly to its acidity and partly to phytochemicals from
the nectar of particular plants. The antibacterial properties of honey vary
according to its source and are often particularly high in New Zealand's manuka
(Leptospermum scoparium) honey (Molan 2004).
3. Objectives
The aim of this review is to assess the potential
benefits and harms of honey for the treatment of burns and scalds
4.
Criteria for including studies
Types of study:
published systematic reviews or
randomised controlled trials
(RCTs) of honey versus
placebo, no treatment or any other treatment.
Types of participants:
adults or children with burns or scalds
Types of intervention:
honey dressing versus any other type of dressing commonly used in New Zealand
Types of outcome measure:
healing rate, measured by an objective measure such as time to complete
healing, infection rate, adverse events.
Exclusions:
studies that compare honey dressings with dressings not available or in common
use in New Zealand
5.
Search strategy
We searched the following databases in November
2005: AMED, The Cochrane Library, MEDLINE, EMBASE, and CINAHL. We also checked
the reference lists of publications retrieved by the search for further relevant
studies.
6.
Methods
We used the above search strategy to obtain titles
and abstracts of studies that were potentially relevant to this review. Where
studies met the criteria for inclusion, they were assessed in full text. The
quality of each study was evaluated using the SIGN criteria (http://www.sign.ac.uk/methodology/checklists.html)
for the evaluation of RCTs and
systematic reviews. Where primary studies were
included in a good quality systematic review, the systematic review was included
rather than the individual primary studies.
The overall quality of the body of evidence
(considering all the included studies) was graded according to the CEBM levels
of evidence system (http://www.cebm.net/levels_of_evidence.asp).
Relevant data were extracted from the studies
selected for inclusion.
7.
Description of studies
Six studies met the criteria for inclusion. These
were randomised controlled trials, all conducted by the same research group.
Five compared honey dressings against various conventional dressings for
superficial or partial thickness wounds. The sixth compared the use of honey
dressings, with skin grafts used as necessary, versus prompt wound excision and
skin grafting for partial and full thickness wounds. In all cases unprocessed
honey was used. No trials mentioned the use of manuka honey.
Summary details of the included trials are as
follows:
|
Studies of honey
compared with silver sulphadiazine cream (SSD)ß |
|
Study
|
Participants |
Intervention &
Comparison |
Outcomes measured |
Comment |
|
Subrahmanyam 2001
India |
100 people
with partial thickness burns involving <40% TBSA.
52 males,
48 females
Age range
3-65 yrs |
1. 15-30
mls unprocessed honey
2. SSD
impregnated gauze applied
Dressings
replaced every 2 days until wounds healed |
1.
Wound healing time
2.
Bacteria count
3.
Adverse effects
|
Not
blinded
|
|
Subrahmanyam 1998
India |
50 people
with partial thickness thermal burns (45 flame burns, 5 scalds)
involving <40% TBSA (range 10-40%)
27 male,
23 female
Age range
3-60 yrs
|
1.
Unprocessed honey 16-30 mls covered with dry sterile gauze & bandaged.
Redressed
on alternate days
2. SSD
impregnated gauze applied.
Replaced
daily
|
1.
Wound healing time
2.
Bacteria count
|
Not
blinded
|
|
Subrahmanyam 1991
India |
n = 104
patients with superficial burns over <40% TBSA (range 5-40%)
82 male,
22 female
Age range
1-65 yrs |
1.
Unprocessed honey 15-30 mls covered with dry sterile gauze & bandaged.
Redressed
daily
2. SSD
impregnated gauze applied.
Replaced
daily
|
1.
Wound healing time
2.
Bacteria count
3.
Allergy, adverse events
|
Not
blinded
|
|
Study of
honey compared with polyurethane film
ß |
|
Study
|
Participants |
Intervention & Comparison |
Outcomes
measured |
Comment |
|
Subrahmanyam 1993
India |
92 people
with partial thickness burns <40% TBSA (mean 22.7%, range 15-35%).
Extremities and abdomen involved in 90% cases.
44 males,
48 females
Age range
3-65
|
1.
Unprocessed honey 15-30 mls covered with dry sterile gauze & bandaged.
Redressed
on alternate days (sooner if signs of infection)
2. Bio
occlusive permeable polyurethane membrane applied (Opsite). removed Day
8 (sooner if signs of infection) |
1.
Wound healing time
2.
Bacteria count
3.
Adverse effects
|
Not
blinded
|
|
Study of
honey compared with range of conventional dressings
ß |
|
Subrahmanyam 1996a
India |
900 people
with partial thickness burns <40% of TBSA
Groups
"well matched at baseline"
Age range
2-65 yrs, mean 30 yrs
Burn TBSA
mean 24-26% (range 5-40%) |
Unprocessed honey 15-30 mls covered with dry sterile gauze & bandaged (n
= 450).
Redressed
on alternate days
2.
Soframycin (n = 90)
3.
Paraffin gauze (n = 90)
4.
Opsite (n = 90)
5. Sterile
gauze (n = 90)
6.
Exposed, with sterile linen changed often (n = 90) |
1.
Wound healing time
2.
Bacteria count
|
Not
blinded
|
|
Study of
honey versus excision and grafting
ß |
|
Subrahmanyam 1999 |
50
haemodynamically stable
people with moderate burns <30% TBSA, no systemic illness or smoke
inhalation injury, aged 10-40 yrs.
22 males,
28 females.
TBSA and depth of burns: Honey group 24% (SD 4), of which 13% full
thickness
Excision
group 23% (SD 4), of which 12% full thickness |
1. Wash
with NaCl then apply unprocessed honey 15-30 mls & cover with dry
sterile gauze & bandage.
Place
autologous skin grafts as necessary.
2.
Tangential excision (TE) and grafting on day 3-6 post burn. Dressing
assessed at 5 days post op.
Swabs
taken for culture if infection suspected |
1.
Success of grafting
2.
Mortality
|
Not
blinded
|
Three potentially relevant studies were excluded –
a systematic review and two RCTs. These studies were excluded because they
included comparisons of honey with dressings not commonly used in New Zealand,
such as potato peelings and amniotic membrane (Subrahmanyam 1994,
Subrahmanyam
1996b, Moore 2001). The systematic review did not contain any additional RCTs
that were eligible for inclusion.
8.
Methodological quality
The included studies were evaluated using the
SIGN criteria. They were of fair quality
only, the main weakness being that they were unblinded. Outcomes were reported
in differing ways, in some cases with a p value only.
9.
Results
Effectiveness for healing burns and scalds
In five of the studies, superficial and partial
thickness burns dressed with honey healed significantly faster than those
dressed in more conventional ways. In these studies honey was compared with
silver sulphadiazine (SSD) impregnated gauze (3 studies), polyurethane film (1
study) and a range of dressing techniques including soframycin ointment,
paraffin gauze, polyurethane film, sterile gauze and wound exposure (in 1
study). Wound healing time was measured by the proportion healed by 21 days
and/or the average number of days that wounds took to heal.
The sixth study, which compared honey dressings
with prompt surgical excision and grafting for partial and full thickness burns,
reported that healing was significantly better in the surgical group. Healing
rates were measured by the length of hospital stay, the success of skin grafting
in those from each group who underwent this procedure and wound appearance at
three months.
Summary of results for the outcome
Time to healing
|
Subrahmanyam 1998 |
50 |
Honey vs
SSD |
% healed
by 21 days:
Honey:
100%
SSD: 84% |
<0.001 |
|
Subrahmanyam 1991 |
104 |
Honey vs
SSD |
Mean
healing time in days: figures not reported |
0.001 |
|
Subrahmanyam 1996a |
900 |
Honey vs
others |
Mean
healing time: figures not clearly reported |
<0.001 |
|
Subrahmanyam 1993 |
92 |
Honey vs
polyurethane film (Opsite) |
Mean
healing time:
Honey:
10.8 days
Opsite:
15.3 days |
<0.001 |
In five of the studies, superficial and partial
thickness burns dressed with honey had significantly lower rates of infection
than wounds dressed in other ways. Infection rates were measured by the number
of bacteria that grew on wound swabs (bacterial colonisation).
In the sixth study, which compared honey dressings
with prompt surgical excision and grafting for partial and full thickness burns,
bacterial colonisation rates were not reported but there were 3 deaths in the
honey group from septicaemia (infection of the bloodstream).
·
Adverse events
Only one of the studies of superficial and partial
thickness burns reported on adverse events. When honey with gauze was compared
with SSD cream with gauze there were no adverse events such as allergic
reactions or inflammation in either group.
In the study, which compared honey dressings with
prompt surgical excision and grafting for partial and full thickness burns, the
only adverse events reported were deaths. As mentioned above, there were 3
deaths in the honey group from septicaemia (infection of the bloodstream). There
was also a death in the surgical group, from asthma.
10.
Discussion of Findings
These studies found that honey healed superficial
and partial thickness burns and scalds significantly faster than the other
dressings tested, with a lower rate of infection. For more serious burns and
scalds, early surgical excision and skin grafting was significantly more
successful and safer.
The results need to be regarded with caution
because the researchers were not blinded (ie, they knew which type of dressing
each person had received) and there was thus considerable room for bias in their
assessment of whether wounds were healed. Moreover, all the studies were carried
out by the same research group, which could increase the effect of any bias
worse. Infection rates were measured by rates of bacterial colonisation, a
measure which is less relevant than rates of clinical infection (ie, with signs
and symptoms of disease)
Honey is a natural product and the characteristics
associated with wound healing may be affected by species of bee, geographical
location and botanical origin, as well as processing and storage conditions
(Moore 2001). Raw honey is not sterile and commercially available honey
dressings with standardised anti-bacterial properties may prove more suitable
for wound dressing.
However, these positive findings for honey are
supported by laboratory studies showing that honey inhibits bacterial growth (Karayil
1998, Cooper 1999a and b).
Larger well-designed studies with blinded
assessment methods are needed to provide stronger evidence of the role of honey
in healing burns (Moore 2001). Studies of manuka honey would be especially
useful, since this type of honey proved most promising in laboratory studies (Molan
2004).
However, whatever type of dressing is used for
burns and scalds, there is very good evidence that the first aid treatment of
the burn or scald is crucial. The best form of first aid is the immediate
immersion of the injured body part under cold running tap water for at least 20
minutes (unless the victim is attached to a live electrical device). Milk or
soft drink is effective if cold water is unavailable. Care must be taken to
avoid over-cooling, especially in children: Ice should never be used. No
creams, lotions or home remedies such as butter should be applied (Skinner 2002)
11. Conclusions
There is level two evidence from the five RCTs
included in this evidence review that honey heals minor burns and scalds
effectively and reduces bacterial colonisation of the wounds. No adverse effects
were reported in these trials.
It is unclear what type of honey product is best
for burns. All the RCTs were conducted in India using raw honey and gauze
dressings.
There is level 2 evidence that honey is not safe
or effective as a dressing for more serious burns.
12.
References
Campbell F, Seers K. Dressing and topical agents
for burns. (Protocol) The
Cochrane Database of Systematic Reviews 2000,
Issue 2).
Cooper R, Molan P. The use of honey as an
antiseptic in managing Pseudomonas infection. J Wound Care 1999a, 8:161-4;
Cooper R, Molan P, Harding KG. Antibacterial
activity of honey against strains of Staphylococcus aureus from infected wounds.
J Roy Soc Med 1999, 92:283-5
Edwards-Jones V, Greenwood JE. What's new in burn
microbiology? James Laing Memorial Prize Essay 2000. Burns 2003; 29: 15-24)
Karayil S, Deshpande SD, Koppikar GV. Effect of
honey on multidrug resistant organisms and its synergistic action with three
common antibiotics. J Postgrad Med 1998, 44:93-6)
Molan PC, Betts JA. Clinical usage of honey as a
wound dressing: an update. Journal of Wound Care 2004; 13(9): 353-6)
Moore OA, Smith LA et al. Systematic review of the
use of honey as a wound dressing. BMC Complementary & Alternative Medicine
2001;1(2).
National Burn Centre 2005 available at:
www.burn.org.nz
Skinner A, Peat B. Burns treatment for children
and adults: a study of initial burns first aid and hospital care. The New
Zealand Medical Journal 2002; 115(1163): 199-207.
Subrahmanyam M. Topical application of honey in
treatment of burns. British Journal of Surgery 1991; 78(4): 497-8.
Subrahmanyam M. Honey impregnated gauze versus
polyurethane film (OpSite) in the treatment of burns--a prospective randomised
study. British Journal of Plastic Surgery 1993; 46(4): 322-3.
Subrahmanyam M. Honey-impregnated gauze versus
amniotic membrane in the treatment of burns. Burns 1994; 20(4): 331-3.
Subrahmanyam M. Honey dressing for burns – an
appraisal. Annals of Burns and fire disasters 1996a IX 33-5.
Subrahmanyam M. Honey dressing versus boiled
potato peel in the treatment of burns: a prospective randomized study. Burns
1996b; 22(6): 491-3.
Subrahmanyam M. A prospective randomised clinical
and histological study of superficial burn wound healing with honey and silver
sulfadiazine. Burns 1998; 24(2): 157-61.
Subrahmanyam M. Early tangential excision and skin
grafting of moderate burns is superior to honey dressing: a prospective
randomised trial. Burns 1999; 25(8): 729-31.
Subrahmanyam M. Effect of topical application of
honey on burn wound healing. Annals of Burns and Fire Disaster 2001; XIV: 143-5.
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