Sweetening wound care: honey and sugar bandages

The medicinal use of honey and sugar dates back thousands of years. Both are antimicrobial, decrease edema, facilitate autolytic debridement, stimulate macrophage migration and promote the development of granulation tissue. When used appropriately, honey and sugar are excellent options in the early phases of wound healing and can hasten patient recovery.

Why honey and sugar?

The primary mechanism through which sugar exerts an antimicrobial effect is increased osmotic concentration, drawing fluid from bacteria and leading to desiccation and bacterial death.

Honey has the same benefit but exerts additional positive effects on wounds through production of extremely low levels of hydrogen peroxide generated by the enzyme inhibin, acidity and antioxidants.

Honeys from different areas around the world may vary in their potency or spectrum of activity. Manuka honey, from Leptospermum spp, has received particular attention for the presence of an antimicrobial compound known as methylglyoxal. Even among Manuka honeys, however, the concentration of methylglyoxal varies and is often expressed as the unique Manuka factor (UMF).

Although a higher UMF is thought to correlate with antibacterial activity, a recent study identified an inverse relationship between UMF and antibacterial effect.¹ In this study, a lower minimum inhibitory concentration was documented with lower-UMF honeys for multiple strains of staphylococci (including methicillin-resistant bacteria) and Pseudomonas aeruginosa, suggesting that the UMF alone may not accurately report the antibacterial effect.

Manuka honey is effective against both gram-positive and gram-negative bacteria but seems to have more significant activity against gram-positive organisms. Honey is efficacious against multidrug-resistant bacteria and may continue to increase its relevance as antibiotic resistance increases.

When to use honey and sugar

Both honey and sugar are indicated in patients with wounds in the inflammatory to early repair phases. Honey and sugar dressings should be discontinued once a wound has developed healthy granulation tissue.

In humans, systematic reviews have documented the best evidence for use of honey to treat partial-thickness burns.^2,3

Common indications for the use of honey are contaminated, exudative wounds in an early phase of healing, chronic nonhealing wounds and wounds with known or suspected multidrug-resistant bacterial infection (Figure 1).

Use of honey or sugar is not appropriate in patients with dry wounds, as both agents will further remove fluid from the wound bed. In patients with very large wounds, careful monitoring of fluid loss is warranted, as it can be substantial.

Figure 1. After removal of the eschar, honey was used to facilitate development of the healthy granulation tissue bed in this burn wound. Here, the wound is shown at presentation (left) and six days later (right), after three Manuka honey bandage changes.

How to apply honey and sugar bandages

Prior to use of both honey and sugar dressings, standard preparation of the wound via clipping of hair, generous lavage and, if indicated, debridement is necessary. Although honey and sugar can facilitate autolytic debridement, sharp (surgical) debridement is still required if tissue is obviously devitalized.

Sugar dressings

Sugar dressings should be comprised of a thick layer of sugar, described as having a minimum thickness of 1 cm for equine wounds,⁴ applied directly to the wound bed, followed by a nonadherent dressing and thick absorptive layers to contain wound exudate.

Sugar bandages must be changed daily at a minimum, but significant exudate may necessitate bandage changes two to three times per day.

Honey dressings

Honey bandages can be changed less frequently, depending on the overall health of the wound and the degree of exudate present, but they should be changed at least every five to seven days.

The ideal honey product is unpasteurized and not heated above 37°C (98.6°F).⁴ Medical-grade honeys are available, and most have been irradiated to avoid the possibility of contamination. Some honey products are formulated as sheets for easier application to wounds; alternatively, honey can be applied to a nonadherent dressing that is then applied to the wound.

Both sugar and honey have been associated with discomfort in human patients, so monitoring veterinary patients for appropriate analgesia is warranted.

References

1. Girma A, Seo W, She RC. Antibacterial activity of varying UMF-graded Manuka honeys. PLoS One 2019;14(10):e0224495.

2. Jull AB, Cullum N, Dumville JC, et al. Honey as a topical treatment for wounds. Cochrane Database Syst Rev 2015;6(3):CD005083.

3. Saikaly SK, Khachemoune A. Honey and wound healing: an update. Am J Clin Dermatol 2017;18(2):237-251.

4. Dart AJ, Dowling BA, Smith CL. Topical treatments in equine wound management. Vet Clin North Am Equine Pract 2005;21(1):77-89.

Dr. Shaver, a board-certified veterinary surgeon, is an assistant professor of small animal surgery at Midwestern University in Arizona. She enjoys hiking, travel, friends and family and teaching veterinary students.