The use of medical grade honey

in clinical practice
Abstract
In the current healthcare environment, clinicians are increasingly
under pressure to use wound care products that are cost-effective. This
includes products that can be used in a variety of wounds to achieve
different outcomes, depending on the wound-bed requirements.
Medical grade honey has emerged as a product that can achieve a
variety of outcomes within the wound and is safe and easy to use.
This article reviews the use of a medical grade honey (Medihoney)
in various clinical applications, with a view to placement on the
wound care formulary in both primary and secondary care. It
provides an in-depth account of case studies featured in a poster
presentation at the 2008 European Wound Management Association
meeting in Lisbon, Portugal.
Key words: Formulary n Honey n Medical grade n Tissue viability
n Wound care
I
n recent years, honey has re-emerged as a wound
care product that can be used on a variety of wounds.
Honey is produced by bees as their food store for the
hive during winter. Honey consists of 20% water and
80% sugar (Molan, 2005) and contains enzymes added by
the bee. In more recent years, honey products have become
available as a sterile, regulated medical device and are often
referred to as medical grade honey. These products have
been shown to be effective in treating a variety of wound
types, including venous leg ulcers, pressure ulcers, burns,
surgical wounds, necrotizing fasciitis, diabetic foot wounds,
grafts and various oncological wounds (White and Molan,
2005; Molan, 2006; White and Acton, 2006; Emsen, 2007;
Gethin and Cowman, 2008).
Currently there is a need to source wound care products
that are safe, effective and easy to obtain in both primary and
secondary care, to enable continuity of care and reduce the
need for many different products throughout the wound-
healing process. Not all medical grade honeys work in the
same way, so they should not be referred to collectively
Claire Acton, Gillian Dunwoody
(Molan, 2002). Clinicians need to be aware of how individual
honey products work within the wound environment before
using them in practice.
This article provides an in-depth account of the case
histories featured in a poster presentation to the 2008
European Wound Management Association meeting in
Lisbon, Portugal. The poster used case studies to illustrate the
effects of a medical grade honey in clinical practice in both
primary and secondary care settings; the aim was to show
that medical grade honey is an effective product, and should
be included in a wound care formulary.
Medical grade honey
There are many medical grade honey products available
for use in wound management; Medihoney (Medihoney,
Slough) is one example. However, not all honey products
are the same: for example, they have differing antibacterial
potencies, which affects the efficacy of the mode of action
(Molan, 2002).
Medihoney consists of a blend of Leptospermum honeys.
The genus Leptospermum comprises more than 80 species of
plants, including two Australian species (L. semibaccatum and L.
polygalifolium), also known as jelly bush, and a New Zealand
species (L. scoparium), also known as manuka. Only honey from
these specific Leptospermum species have been shown to have
exceptional antibacterial activity (Cooper, 2005; 2008).
Medical grade honey has been identified as having five key
modes of action: antimicrobial; anti-inflammatory; promotes
debridement in sloughy and necrotic wounds; provides a
moist, wound environment; and reduces wound malodour.
Antimicrobial: The high-sugar, low-water content of medical
grade honey means that bacteria within a wound dressed
with a honey product have insufficient water to support their
growth (Molan, 2002), while the low pH of 3.9 inhibits their
growth (White, 1979; Dissemond et al, 2003). The low levels
of hydrogen peroxide produced by the dilution of honey
in wound exudate also have an antibacterial action (Molan,
2005), as do the naturally occurring phytochemicals found
only in Leptospermum honey (Simon et al, 2006).
Anti-inflammatory: The osmotic action of honey draws lymph
out of the cells, thereby reducing oedema (Molan, 2005).
Promotes debridement in sloughy and necrotic wounds: Honey
maintains a moist wound environment, aiding autolytic
debridement (Robson, 2002). Because of the speed of
debridement when using honey, there is likely to be an
associated enzymatic action; it has been suggested that honey
may activate plasmin, which then breaks down the blood clots
binding necrotic tissue to the wound bed (Molan, 2005).
Claire Acton is Tissue Viability and Vascular Nurse Specialist,
Surgical Directorate, Queen Elizabeth Hospital NHS Trust, London,
and Chairperson of the Tissue Viability Nurses Forum (South); and
Gillian Dunwoody is Tissue Viability Clinical Nurse Specialist,
Bromley Primary Care Trust, Kent
Accepted for publication: September 2008
S38 British Journal of Nursing, 2008 (TISSUE VIABILITY SUPPLEMENT), Vol 17, No 20
present for 6 months and were slow to heal, and there were
continuous infections requiring systemic antibiotic therapy.
Medihoney was selected as an appropriate dressing to
achieve the treatment goals, which were to:
Debride necrotic tissue from the wound bed
Reduce bacterial load
Promote the growth of granulation tissue, enabling the
wound to progress through the healing phase.
Medihoney wound gel was used with hydrofibre
secondary dressing under compression bandaging. Figure 1b
shows the ulcer after 101 days treatment. Previously the
patient had received no compression therapy, and dressing
pads had been applied to the ulcers to mop up the fluid,
but without success. There appeared to be a reduction in
the bacterial load at the wound bed; as a result, the patient
no longer required antibiotics, unlike previously, and the
wound showed granulation tissue formation. The nursing
staff found the product easy to use and the patient was
comfortable with the dressing in place.
Case study 2
An 85-year-old woman, who was immobile and bed bound,
presented with a grade 3 pressure ulcer (European Pressure

Provides a moist, wound-environment: The osmotic action of

honey draws the fluid from surrounding tissues, producing a
moist wound interface (Chilvers and Maloney, 2006).
Reduces wound malodour: Malodorous substances, such as
ammonia, amines and sulphur compounds, are produced
when bacteria in the wound bed metabolize amino acids.
The amino acids result from the decomposition of serum and
tissue proteins within necrotic tissue in the wound. Honey
provides the bacteria with an alternative source of energy
(glucose), so that malodorous compounds are no longer
formed and malodour is reduced (Molan, 1999, 2005).
The antibacterial properties and debriding action of
honey may also contribute to the reduction in malodour
(Lay-flurrie, 2008).
Using medical grade honey in clinical practice
Chilvers and Moloney (2006) reviewed the use of medical
grade honey (Medihoney) in terms of the TIME principles,
as defined by Schultz et al (2005). The TIME framework is
a systematic approach to wound bed preparation and has four
main components (Schultz et al, 2003):
Tissue type and management
Infection/inflammation
Moisture balance
Edge of wound.
Chilvers and Moloney concluded that medical grade honey
achieved effective results within this healing continuum.
They also identified a large amount of research and case
histories within the TIME framework to support their
conclusion. Although this was a poster presentation, it
included 32 references to support each aspect of the
continuum, demonstrating the underlying pathophysiology
and clinical indications for the use of medical grade honey
on all types of wound.
The following case studies describe a range of patients,
each with a different wound type. They were selected for
study to determine whether the different modes of action of
medical grade honey were clinically evident in the various
wound types, with a view to including medical grade honey
in the wound care formulary within the authors areas of
practice an acute hospital setting and a primary care trust.
Selection of an appropriate dressing for a wound is an
essential part of the patients holistic care, and should lead
to positive patient outcomes (Baranoski, 2005). The choice
of dressing should be based on sound wound care principles
and a robust assessment process, to ensure that the right
dressing is applied to achieve optimum patient outcomes.
Case study 1
A 44-year-old man with vasculitis (inflammation of the small
blood vessels) presented with leucoclastic leg ulceration.
Vasculitis causes damage to the lining of the vessels, leading to
narrowing or blockage that restricts or stops blood flow. The
resultant ischaemia damages or destroys the tissues supplied
by the affected vessels in this case, causing ulceration to the
lower leg (Figure 1a).
However, as vasculitis is a small vessel disease process, ankle-
brachial pressure index (ABPI) readings of 0.89 on the right
leg and 0.92 on the left were unexpected. The ulcers had been

Figure 1a. Leucoclastic vasculitic leg ulcers of 6 months duration.

Figure 1b. Wound bed is clean and granulating, with a reduction in wound
size, after 101 days treatment with Medihoney and hydrofibre under
compression bandaging.
S40 British Journal of Nursing, 2008 (TISSUE VIABILITY SUPPLEMENT), Vol 17, No 20
Ulcer Advisory Panel [EPUAP], 1999) on her left upper
arm, which had been present for 1 month (Figure 2a). Ninety
per cent of the wound bed was covered with necrotic tissue,
so the goal of treatment was to:
Debride the necrotic tissue (the patient had declined sharp
debridement).
The ulcer was treated with Medihoney wound gel, with
hydrofibre secondary dressing, and a film dressing to hold it in
place. The dressings were changed every other day. At day 5, all
the necrotic tissue had gone from the wound bed (Figure 2b),
enabling granulation tissue formation. This is an example of
how Medihoney promotes rapid debridement of a wound,
achieving a positive outcome for both the patient and staff.
Case study 3
An 83-year-old woman presented with a trauma-induced
haematoma. This was removed manually on the ward, leaving
a necrotic malodorous wound bed, which the patient found
very distressing. The wound had been present with no
progress for 1 month following removal of the haematoma.
No bacterial growth was identified (Figure 3a); however, the
wound bed was dark-looking and was not showing any signs
of granulation tissue. The goals of treatment were to:
Reduce malodour
Reduce bacterial load.
Medihoney wound gel was applied to promote further
debridement and reduce the malodour; a hydrofibre was
used as a secondary dressing and was held in place with a
crepe bandage. The wound was redressed every day.
After 7 days the wound bed was granulating and the
malodour had gone (Figure 3b). Vacuum-assisted closure
(VAC) therapy was then applied to hasten the healing
rate and ultimately facilitate a split-skin graft. The patient
found the dressing comfortable and was very pleased with
the reduction in malodour.
Case study 4
A 46-year-old man with spina bifida, who was immobile,
developed a chronic grade 4 (EPUAP) pressure ulcer on
his left ischial tuberosity (Figure 4a). Healing had been
compromised by infection, underlying osteomyelitis with
bone destruction, low haemoglobin levels and external
pressure.
The primary goals of treatment were to:
Debride slough and necrosis from the wound bed
Reduce malodour.
Medihoney wound gel was applied to the wound
bed to resolve the malodour and facilitate debridement
of devitalized tissue. Sorbion

Sachet S (Sorbion AG,

Germany) was used as a secondary dressing to absorb
the high levels of exudate. Dressings were changed daily
because of the high level of exudate and the additional
problem of trying to keep the dressing in place. Various
adhesive secondary dressings had been tried, but within
2436 hours the adhesive would be lost and the dressings
would peel off, exposing the wound bed.
Medihoney wound gel successfully reduced the malodour,
and within 8 weeks had facilitated debridement of the
necrosis (Figure 4b).

Figure 2a. A grade 3

pressure ulcer of
1 months duration,
with necrotic tissue
covering 90% of
the wound bed.
Figure 2b. Wound bed
is clear of necrotic
tissue after 5 days
treatment with
Medihoney wound
gel and hydrofibre
secondary dressing;
granulation tissue is
beginning to form.
Figure 3a. Necrotic,
malodorous wound
following removal
of a trauma-induced
haematoma 1 month
previously.
S42 British Journal of Nursing, 2008 (TISSUE VIABILITY SUPPLEMENT), Vol 17, No 20
Figure 3b. Wound
bed is clean and
granulating following
7 days treatment with
Medihoney wound
gel and hydrofibre
secondary dressing.
Case study 5
A 61-year-old woman with type 2 diabetes, congestive heart
failure and sleep apnoea presented with a long-standing
ulcer of 3 years duration (Figure 5a). Previous attempts at
compression bandaging had been unsuccessful. Repeated
infections, persistent inflammation and associated pain meant
that the patient could no longer tolerate the compression and
it had been discontinued.
With such a complex medical history, compression therapy
can be contraindicated. However, in this case the problem
that was having the greatest impact on the patients quality
of life was her long-standing leg ulcer. ABPI can be falsely
elevated in diabetes; however, there was no clinical evidence
of arterial disease and Duplex scanning revealed triphasic
signals. Cardiac failure was well managed by her GP.
On referral to the tissue viability service the patient was
under the care of a pain clinic, and analgesia consisted of
Sevredol, tramadol and gabapentin. Despite this, she was
still experiencing considerable pain and this was having a
dramatic impact on her daily activities and work life.
Infection was initially treated with systemic antibiotic
therapy, according to sensitivities for a heavy growth of
Staphylococcus, and Medihoney wound gel was applied to
the wound bed with N-A Ultra

(Johnson & Johnson) as a

secondary dressing.
The goals of treatment were to:
Reduce bacterial load and inflammation
Reduce pain and promote healing.
Reducing bacterial load and inflammation would in turn
reduce pain and allow adequate compression to be applied,
promoting the formation of granulation tissue and healing.
Following a full leg ulcer assessment and under the close
supervision of the tissue viability specialist, a 4-layer bandage
system was applied based on ankle circumference. Dressings
were changed twice weekly.
Opiate analgesia was discontinued within 17 days of
treatment, and after 6 weeks treatment analgesia was no
longer required. Figure 5b shows the wound after 8 weeks
treatment.
Case study 6
An 86-year-old man with type 2 diabetes presented with
a venous leg ulcer to his left medial malleolus, extending
laterally (Figure 6a). Unmanaged high levels of exudate
had resulted in extensive maceration and skin breakdown.
Malodour and green staining on the removed dressings were
indicative of colonization with Pseudomonas.
He also had localized wound pain, which was poorly
controlled despite analgesia. Within the period of this
evaluation, his pain was not resolved. Compression therapy
had been discontinued because of pain. Although ABPI was
normal, his GP had referred him for vascular review because
of his diabetes.
The goals of treatment were to:
Reduce bacterial load
Debride slough.
Following tissue viability review, Medihoney wound gel
was applied to the wound bed to reduce local bacterial load
and enhance autolytic debridement. Sorbion Sachet S was

HONEY
British Journal of Nursing, 2008 (TISSUE VIABILITY SUPPLEMENT), Vol 17, No 20 S43
Figure 4a. Chronic
grade 4 (EPUAP)
ischial pressure ulcer.
Figure 4b. Wound bed
showing successful
debridement of slough
and necrosis after
61 days treatment
with Medihoney
wound gel and
Sorbion Sachet S
secondary dressing.
Figure 5a. Venous
leg ulcer of 3 years
duration.
Figure 5b. Wound bed
is clean, granulation
tissue is forming and
healing has begun,
following 59 days
treatment with
Medihoney wound
gel and N-A Ultra
dressing under
compression bandaging.
chosen as the secondary dressing for its ability to absorb
exudate and reduce maceration. Within 16 days of treatment,
malodour was no longer evident and debridement of
devitalized tissue was complete (Figure 6b).
Conclusion
The clinical case study outcomes demonstrate the
effectiveness of Medihoney in all the documented modes
of action, as outlined previously and in the research (Molan,
2005), and on a wide variety of wounds (Molan, 2006). In
clinical practice the product was safe and easy to use.
The inappropriate use of wound care products can be
costly, both for the healthcare trust and for the patient,
and there is a drive for healthcare practitioners to use
products that are cost-effective and ensure optimum
clinical outcomes. The versatility of medical grade honey
and its ability to achieve different clinical outcomes in a
variety of wounds reduces the need for multiple product
use during the wound healing process, thereby helping
less experienced clinicians when selecting an appropriate
product for a particular wound.
In each of the clinical cases described, medical grade
honey demonstrated effectiveness in more than one mode
of action. Results were obtained rapidly, were clearly
defined, and achieved the outcomes selected for each
individual.
Within a wound care formulary, medical grade honey
does not have to be restricted to a single category but could
be placed in a number of categories. Clinicians should
consider adding medical honey to their formularies.
BJN
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Chilvers C, Moloney A (2006) Antibacterial medical honey: meeting the
criteria for total wound bed preparation using the TIME principles.
Proceedings of the Wounds UK Conference. Harrogate, UK. Nov 2006.
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KEY POINTS
n The properties of honey from different sources vary, and
only certain types of honey are beneficial in wound care.
n Only medical grade honey should be used in wound care.
n Medical grade honey has five modes of action, which
means that it can be used in a variety of wounds to
achieve varied clinical outcomes simultaneously.
n Medical grade honey is safe and easy to use for the
inexperienced practitioner.
n Medical grade honey is a valued addition to the nurses
toolkit and fits into various categories within a wound
care formulary in both primary and secondary care.
Figure 6b.
Debridement of
devitalized tissue is
complete after 16 days
treatment with
Medihoney wound gel
and Sorbion Sachet S
secondary dressing.
Figure 6a. Venous
leg ulcer on the left
medial malleolus,
extending laterally
and showing extensive
maceration and skin
breakdown.
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