Honey Dressings in Wound Care: A Nurses Guide at the Bedside

Quick Reference for: Wound Assessment Product Selection Dressing Application

Introduction
Manuka honey, derived from leptospermum plants found in New Zealand, has been medically certified for use in professional wound care in hospitals across Australia and Europe. In the U.S., however, it has been licensed as a medical product by the Food and Drug Administration only since 2007. Because the use of honey by nurses at the bedside is neither common nor emphasized, education regarding its proper use is necessary to encourage the use of honey in wound care. This quick reference guide contains information regarding the indications, advantages, and application of honey dressings .

How does honey assist in wound healing?

ANTIBACTERIAL
Active leptospermum honey acts as an antibacterial by releasing low levels of hydrogen peroxide into the wound bed. Honey is also hygroscopic, meaning that it withdraws moisture from the wound environment. By doing so, bacteria present in the wound bed become dehydrated and subsequently die. Finally, the mean pH of honey is usually 4.4. Because bacteria require a more basic environment in which to thrive, honeys low pH acts as an antibacterial. Not only is honey effective against many common bacterial strains, but also against MRSA, MSSA, and VRE. This fact is significant for nurses at the bedside because the number of patients infected with these drug-resistant strains has been on the rise in recent years majorly due to the decreased effectiveness of antibiotics. However, it is important to note that honey is not a substitute for antibiotics. Rather, honey may be used as a complementary intervention in treatment of an infected wound.

HONEY WORKS TO:

DECREASE BACTERIAL LOAD DEBRIDE THE SITE DECREASE INFLAMMATION & EDEMA LESSEN HEALING TIME REDUCE ODORS

DEBRIDEMENT
The osmolarity of honey, combined with its high sugar content, debrides the wound bed by promoting lymph outflow. This mechanism also assists in regulation of the inflammatory process.

ANTI-INFLAMMATORY
The high sugar content of honey acts as an antibacterial, reducing the amount of exudate emitted from the wound. Consequently, this causes lessening of edema and inflammation at the site.

DECREASED HEALING TIME

Because honeys low pH creates an acidic environment, oxygen diffusion is improved. This speeds healing at the wound site. A wound treated with honey may heal twice as quickly as a wound treated with commonly used antiseptics, such as hydrogen peroxide. However, honey is not an antiseptic: honey does not eradicate bacteria within ten minutes of application, whereas as antiseptics do.

ODOR REDUCTION
Due to the combination of actions mentioned above, odors commonly associated with infected wounds are reduced or, in some instances, eliminated.

Where and When Should I Use Honey?

TYPES OF WOUNDS
Honey is effective in treating both acute and chronic wounds . Acute wounds include minor lacerations, pressure ulcers, infected wounds, and burns. Chronic wounds include both venous and arterial leg ulcers, as well as diabetic ulcers.

APPLY HONEY TO:

Infected wounds Burns Pressure Ulcers Minor lacerations Venous Leg Ulcers Arterial Leg Ulcers Diabetic Ulcers

IDENTIFYING WOUNDS
In order to provide the best wound care for your patient, it is necessary to identify the type of wound that your patient presents with. The following are characteristics of wounds commonly treated with honey: Arterial leg ulcers are typically found on distal areas of the leg, usually below the ankle or on the foot. They are small in size, and do not hold great depth. The ulcer usually presents as a circular wound with smooth margins. Both the base and surrounding skin are pale in color. Venous leg ulcers present above the ankle as an irregularly shaped wound. The ulcer may range in size, but are commonly shallow in depth. Its base may either be pale or pigmented, with irregular margins and pigmented surrounding skin. Exudate may be emitted. Diabetic ulcers, commonly found on the foot, present in areas where pressure is often exerted: specifically, bony prominences. This type of wound is usually small, but may grow in size if left untreated. It is round in shape, with smooth margins. Depth ranges from shallow to deep, with callused skin surrounding it. The base of the wound may either be pale or pigmented, with signs of necrosis if the site is infected. Trackingor tunnelingof the wound may be evident. Pressure ulcers may be found anywhere on the leg or foot, in areas where pressure is exertedoften, at sites containing bony prominences. Size ranges from small to large, with varying depth. This type of wound is usually round, but may be irregularly shaped if the wound is larger. Depth varies from shallow to deep. Margins may be smooth or irregular. Both the base and the surrounding skin may be pale or pigmented. Tracking of the wound may be evident. Burns may present with varying characteristics in location, size, shape, depth, base, margins, and surrounding skin. Location depends on the sight at which the patient came into contact with a heat or electrical source. The remaining characteristics depend on the extent of the injury, and whether injury is still occurring (often internally, as from an electrical burn). It is necessary to acquire extensive data regarding how the burn occurred. Infected wounds may also present with varying characteristics in location, size, shape, depth, base, margins, and surrounding skin. It is necessary to determine the cause of the infection and the length of time the wound has been present. Close monitoring must be done to prevent further complications.

CHOOSING THE IDEAL DRESSING: The goal of wound care is to first remove the offending insult, then to provide the best possible environment to facilitate wound healing.
The following should be considered when choosing a dressing: Exudate management Secure application Easy removal Increased wear time (to minimize the number of dressing changes) Cost-effectiveness Comfort STEP-BY-STEP DRESSING APPLICATION: 1. Wash hands thoroughly. 2. Apply non-sterile gloves. 3. Assess wound for sign of infection: pain, redness, heat, inflammation. 4. Apply sterile gloves and maintain sterile field. 5. Cleanse wound and surrounding skin with sterile saline or wound cleanser. 6. Dry skin around wound by patting gently with sterile gauze. 7. Apply a skin protectant barrier around the wound. 8. Choose a honey dressing appropriate for amount of drainage. Light-Moderate: hydrocolloid dressing Moderate-Heavy: honey with calcium alginate 9. Apply dressing to fit wound. Ensure dressing is in contact with wound base, but not in contact with peri-wound skin. 10. Apply absorbent cover dressing to hold honey dressing in place.

HONEY VERSUS OTHER APPLICATIONS

In order to determine whether or not to use honey, it is important to familiarize yourself with other topicals that may also be used on wounds so that the benefits and risks may be weighed in order to provide the most effective treatment. The three most commonly used are silver sulfadiazine, hydrogen peroxide, and povidone-iodine. Silver sulfadiazine is a topical cream commonly used on minor lacerations and burns as an antifungal and/or an antibacterial. Compared to honey, studies have shown that it is actually less effective in treating minor burns, and may actually delay wound healing. Although uncommon, adverse effects may include the following: rash (as a result of an allergic reaction), erythema multiforme, hyperosmolality, crystalluria, methemoglobinemia, neutropenia, hemolysis, and staining of the treated wound site. Hydrogen peroxide is commonly used as an antiseptic for debridement. In some cases it may be used as an antibacterial, but few studies have shown that it is actually effective in this type of treatment. Although it does not manifest adverse effects in wound healing, it is ineffective in reducing bacterial load. Povidone-iodine is an antiseptic often used prior to surgical procedures on wound sites. Iodine may also be used to treat diabetic foot ulcers. A major concern in using this topical treatment is the fact that it interacts with protease activity in the wound. Iodine absorption by the body is thus increased, possibly leading to adverse effects on the thyroid gland.

Adverse Effects
MANUKA HONEY
In patients treated for wounds with a honey dressing, 5% have experienced pain. If this occurs, the dressing should be removed immediately, and this intervention should be discontinued. An alternative topical treatment must be sought.

STORE-BOUGHT HONEY
It is important to remember, and to inform patients, that active leptospermum honey is different from store-bought honey. Honey sold in supermarkets contains high fructose corn syrup, an ingredient absent in medically-certified honey. It has not been sterilized, and therefore may contain spores of clostridium botulinum that may adversely affect the wound site.

Applying a Honey Dressing

Use your hospital-designated practice guidelines for applying a dressing. A step-by-step explanation for applying a honey dressing is provided in this guide. The dressing must be changed every 24-48 hours, or up to twice a day for acute wounds. Honey may be used with calcium alginate to compound healing effects. Continuous assessment of the wound site must be conducted to monitor progress and signs of any complication.

Research Studies
Gethin G, Cowman S. Manuka honey vs. hydrogel a prospective, open label, multicentre, randomised controlled trial to compare desloughing efficacy and healing outcomes in venous [2008]. J Clin Nurs. doi:10.1111/j.1365-2702.2008.02558.x. Click to view this abstract Gethin G, Cowman S. Bacteriological changes in sloughy venous leg ulcers treated with manuka honey or hydrogel: an RCT. J Wound Care. 2008;17(6):241-244,246-247. Click to view this abstract Robson V, Dodd S, Thomas S. Standardized antibacterial honey (Medihoney) with standard therapy in wound care: randomized clinical trial. J Adv Nurs. 2009 Mar;65(3):565-75. Click to view this abstract

Resources
Medihoney: www.dermasciences.com 3M: http://solutions.3m.com/wps/portal/3M/en_US/3MSWC/SkinWound-Care/ Applying Wound Care Dressings: http://www.cwiprogram.org/patient-care/application-ofwound-care-dressings Advances in Skin and Wound Care: http://journals.lww.com/aswcjournal/pages/default.aspx International Wound Journal: http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1742481X Advanced Wound Applications: http://www.theprescriptionshops.net/adv_products.html

Johnson DW, van Eps C, Mudge DW, et al. Randomized, controlled trial of topical exit-site application of honey (Medihoney) versus mupirocin for the prevention of catheter-associated infections in hemodialysis patients. J Am Soc Nephrol. 2005;16(5):1456-1462. doi:10.1681/ASN.2004110997. Click to view this abstract

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