Topical Application of Honey on Surgical Wounds: A Randomized Clinical Trial

Natural agents as wound-healing promoters

The management of acute and chronic wounds resulting from diverse injuries poses a significant challenge to clinical practices and healthcare providers. Wound healing is a complex biological process driven by a natural physiological response. This process involves four distinct phases, namely hemostasis, inflammation, proliferation, and remodeling. Despite numerous investigations on wound healing and wound dressing materials, complications still persist, necessitating more efficacious therapies. Wound-healing materials can be categorized into natural and synthetic groups. The current study aims to provide a comprehensive review of highly active natural animal and herbal agents as wound-healing promoters. To this end, we present an overview of in vitro, in vivo, and clinical studies that led to the discovery of potential therapeutic agents for wound healing. We further elucidated the effects of natural materials on various pharmacological pathways of wound healing. The results of previous investigations suggest that natural agents hold great promise as viable and accessible products for the treatment of diverse wound types.

The effect of medical grade honey on tensile strength, strain, and Young's modulus of synthetic absorbable suture material used in equine surgery

BACKGROUND

Medical grade honey (MGH) has been introduced as a protective measure against surgical site infections in equine surgery, but the effect on suture material has not been investigated.

OBJECTIVE

To evaluate the effect of MGH on the tensile properties of three synthetic absorbable suture materials.

STUDY DESIGN

In vitro experiments.

METHODS

Ten strands of Polydioxanone USP 2 (PD2), Polyglactin 910 USP 2 (PG2) and Polyglecaprone USP 2-0 (PC2-0) were incubated 1, 7, 14, 21 and 28 days in MGH, phosphate-buffered saline (PBS), equine plasma (EP) and MGH mixed with equine plasma (HP). Mechanical testing was performed recording maximum load at failure (N), strain at failure and Young's modulus (N/mm2 ). The results were reported from a Welch or regular ANOVA.

RESULTS

PD2 in MGH had a significantly higher tensile strength compared to PD2 in EP (p < 0.05, mean difference (md) = 16.95 N, CI95% (9.19-24.70 N)) and PBS (p < 0.05, md = 14.48 N CI95% (6.73-22.23 N)) on day 7 and the remaining time points. PG2 incubated in MGH had a significantly higher tensile strength compared to EP (p < 0.05, md = 69.28 N CI95% (64.16-74.40 N)) and PBS (p < 0.05, md = 56.90 N CI95% (51.78-62.02 N)) until day 28. PC2-0 incubated in MGH had a significantly higher tensile strength compared to EP (p < 0.05 md = 12.40 N CI95% (4.59 N-20.20 N)) and PBS (p < 0.05 md = 11.23 CI95% (3.42-19.03 N)) on day 7 and the remaining time points.

MAIN LIMITATIONS

The sutures were unloaded during incubation and a single cycle to failure test was only performed, which does not reflect the in vivo environment where shear forces are present.

CONCLUSIONS

MGH did not negatively affect the tensile strength of the suture material and can safely be applied in contact with suture materials commonly used in equine surgery.

The impact of wound pH on the antibacterial properties of Medical Grade Honey when applied to bacterial isolates present in common foot and ankle wounds. An in vitro study

BACKGROUND

Diabetic foot ulcers (DFUs) and post-surgical wound infections are amongst the most troublesome complications of diabetes and following foot and ankle surgery (FAS) respectively. Both have significant psychosocial and financial burden for both patients and the healthcare system. FAS has been reported to have higher than average post-surgical infections when compared to other orthopaedic subspecialties. Evidence also indicates that patients with diabetes and other co morbidities undergoing FAS are at a much greater risk of developing surgical site infections (SSIs). With the growing challenges of antibiotic resistance and the increasingly high numbers of resilient bacteria to said antibiotics, the need for alternative antimicrobial therapies has become critical.

AIM

The aim of this study was to investigate the use of medical grade honey (MGH) when altered to environments typically present in foot and ankle wounds including DFUs and post-surgical wounds (pH6-8).

METHODS

MGH (Activon) was altered to pH 6, 7 and 8 and experimental inoculums of Pseudomonas aeruginosa (NCTC10782), Escherichia coli, (NCTC10418), Staphylococcus aureus (NCTC10655) and Staphylococcus epidermidis (NCTC 5955) were transferred into each pH adjusted MGH and TSB solution and the positive and negative controls.

RESULTS

MGH adjusted to various pH values had the ability to reduce bacteria cell survival in all pH variations for all bacteria tested, with the most bacterial reduction/elimination noted for Staphylococcus epidermidis. No correlations were noted among the pH environments investigated and the colony counts, for which there were small amounts of bacteria survived.

CONCLUSION

This research would indicate that the antibacterial properties of honey remains the same regardless of the pH environment. MGH could therefore potentially be considered for use on non-infected foot and ankle wounds to reduce the bacterial bioburden, the risk of infections and ultimately to improve healing outcomes.

Does application of honey improve surgical outcome in pilonidal cyst excision with secondary intention healing? A prospective randomized placebo-controlled clinical trial

Background

Pilonidal sinus disease (PSD) is a common chronic inflammatory debilitating illness caused by ingrowth of hair into the skin. Excision and healing by secondary intention is one of the acceptable managements. The post-operative wound care needs frequent and time-consuming follow-ups. Honey is considered to be a traditional remedy for wound healing. The current study aimed at finding if application of honey could improve surgical outcome in pilonidal cyst excision with secondary intention healing.

Methods

This study was designed as a randomized placebo-controlled parallel assignment interventional (clinical trial) study conducted at the surgical ward of Shahid Beheshti Hospital affiliated to the Yasuj University of Medical sciences, Yasuj, Iran, and was consisted of the 48 patients who underwent surgical resection for PSD with secondary intention healing (24 patients in intervention and placebo-controlled groups). The main element of honey medicinal gel was the unheated natural honey of Dena Biosphere Reserve within the Zagros Mountains. Patients' wounds were visited by a surgeon and a nurse on the days 7, 15, 30, 45, 60, and 90 post-operation. The surgical outcomes including the time to complete wound healing, pain intensity, odor, discharge at the site of surgery, use of analgesics, the time of to return to the daily activities, and occurring of any side effects including infection, erythema, and bleeding were all recorded.

Results

In intervention group, there was significantly lower wound healing time, the lower time to return to the daily activities, lower mean wound volume at the days of 30, 45, 60, and 90 of the follow-up, higher mean post-operative pain level at the days of 15, 30, 45, 60, and 90 of the follow-up, and more usage of analgesics at the days of 15, 30, 45, and 60 of the follow-up. There was no significant difference between intervention and placebo-controlled groups according to the foul smell and fluid discharge at the site of the operation. There were no side effects and complications in both groups of the study.

Conclusions

Application of honey after resection surgery with secondary wound healing is associated with a better surgical outcome and could eventually decrease healing time and reduce duration of return to normal activities, but could increase post-operation pain and analgesic consumption, and no effect on foul smell and discharge.

Trial registration

The project was found to be in accordance to the ethical principles and the national norms and standards for conducting research in Iran with the approval ID and date of IR.YUMS.REC.1399.088 and 2020.05.30 respectively, and is the result of a residency dissertation to get the specialty in general surgery, which has been registered with the research project number 960508 in the Vice Chancellor for Research and Technology Development of Yasuj University of Medical Sciences, Yasuj, Iran, URL: https://ethics.research.ac.ir/EthicsProposalViewEn.php?id=144742

Wound Healing Activities and Potential of Selected African Medicinal Plants and Their Synthesized Biogenic Nanoparticles

In Africa, medicinal plants have been traditionally used as a source of medicine for centuries. To date, African medicinal plants continue to play a significant role in the treatment of wounds. Chronic wounds are associated with severe healthcare and socio-economic burdens despite the use of conventional therapies. Emergence of novel wound healing strategies using medicinal plants in conjunction with nanotechnology has the potential to develop efficacious wound healing therapeutics with enhanced wound repair mechanisms. This review identified African medicinal plants and biogenic nanoparticles used to promote wound healing through various mechanisms including improved wound contraction and epithelialization as well as antibacterial, antioxidant and anti-inflammatory activities. To achieve this, electronic databases such as PubMed, Scifinder^® and Google Scholar were used to search for medicinal plants used by the African populace that were scientifically evaluated for their wound healing activities in both in vitro and in vivo models from 2004 to 2021. Additionally, data on the wound healing mechanisms of biogenic nanoparticles synthesized using African medicinal plants is included herein. The continued scientific evaluation of wound healing African medicinal plants and the development of novel nanomaterials using these plants is imperative in a bid to alleviate the detrimental effects of chronic wounds.

Demanding New Honey Qualitative Standard Based on Antibacterial Activity

Honey is a functional food with health-beneficial properties and it is already used as a medical device in wound care management. Whether ingested orally or applied topically, honey must fulfill the requirements of international standards based on physicochemical characteristics. However, there is an urgent need for some additional standards reflecting biological properties. The aim of the study was to evaluate the antibacterial activity of 36 commercial honey samples purchased from supermarkets and local food shops and compare their efficacy to that of three honey samples from local beekeepers and three types of medical-grade honey. Furthermore, the hydrogen peroxide (H₂O₂) content and protein profile were assessed in all honey samples. Analysis of the antibacterial activity of commercial honeys revealed that 44% of tested samples exhibited low antibacterial activity, identical to the activity of artificial honey (sugars only). There was a significant correlation between the overall antibacterial activity and H₂O₂ content of honey samples. However, in some cases, honey samples exhibited high antibacterial activity while generating low levels of H₂O₂ and vice versa. Honey samples from local beekeepers showed superior antibacterial activity compared to medical-grade honeys. The antibacterial activity of honey can be easily altered by adulteration, thermal treatment or prolonged storage, and therefore it fulfils strict criteria to be suitable new additional quality standard.

Bee Products in Dermatology and Skin Care

Honey, propolis, bee pollen, bee bread, royal jelly, beeswax and bee venom are natural products which have been used in medicine since ancient times. Nowadays, studies indicate that natural bee products can be used for skin treatment and care. Biological properties of these products are related to flavonoids they contain like: chrysin, apigenin, kaempferol, quercetin, galangin, pinocembrin or naringenin. Several pharmacological activities of phenolic acids and flavonoids, and also 10-hydroxy-trans-2-decenoic acid, which is present in royal jelly, have been reported. Royal jelly has multitude of pharmacological activities: antibiotic, antiinflammatory, antiallergenic, tonic and antiaging. Honey, propolis and pollen are used to heal burn wounds, and they possess numerous functional properties such as: antibacterial, anti-inflammatory, antioxidant, disinfectant, antifungal and antiviral. Beeswax is used for production of cosmetics and ointments in pharmacy. Due to a large number of biological activities, bee products could be considered as important ingredients in medicines and cosmetics applied to skin.

Wound Healing Properties of Selected Natural Products

Wound healing is a complex process of recovering the forms and functions of injured tissues. The process is tightly regulated by multiple growth factors and cytokines released at the wound site. Any alterations that disrupt the healing processes would worsen the tissue damage and prolong repair process. Various conditions may contribute to impaired wound healing, including infections, underlying diseases and medications. Numerous studies on the potential of natural products with anti-inflammatory, antioxidant, antibacterial and pro-collagen synthesis properties as wound healing agents have been performed. Their medicinal properties can be contributed by the content of bioactive phytochemical constituents such as alkaloids, essential oils, flavonoids, tannins, saponins, and phenolic compounds in the natural products. This review highlights the in vitro, in vivo and clinical studies on wound healing promotions by the selected natural products and the mechanisms involved.

Role of honey in modern medicine

Use of honey has a very long history. Honey has been used since ancient time due to its nutritional and therapeutic values. There had been varied ways of consumption honey including its use as a sweetener and flavoring agent. Honey is produced all over the world. The most important nutriment of honey is carbohydrates present in the form of monosaccharides, fructose and glucose. Honey plays an important role as an antioxidant, anti-inflammatory, anti-bacterial agent and augments the adherence of skin grafts and wound healing process. The role of honey has been acknowledged in the scientific literature and there is convincing evidence in support of its antioxidant and antibacterial nature, cough prevention, fertility and wound healing properties. However, its use has been controversially discussed and has not been well accepted in the modern medicine. The aim of this review was explore and highlight the role of honey in modern medicine.

Dressings for the prevention of surgical site infection

BACKGROUND

Surgical wounds (incisions) heal by primary intention when the wound edges are brought together and secured, often with sutures, staples, or clips. Wound dressings applied after wound closure may provide physical support, protection and absorb exudate. There are many different types of wound dressings available and wounds can also be left uncovered (exposed). Surgical site infection (SSI) is a common complication of wounds and this may be associated with using (or not using) dressings, or different types of dressing.

OBJECTIVES

To assess the effects of wound dressings compared with no wound dressings, and the effects of alternative wound dressings, in preventing SSIs in surgical wounds healing by primary intention.

SEARCH METHODS

We searched the following databases: the Cochrane Wounds Specialised Register (searched 19 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library 2016, Issue 8); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations, MEDLINE Daily and Epub Ahead of Print; 1946 to 19 September 2016); Ovid Embase (1974 to 19 September 2016); EBSCO CINAHL Plus (1937 to 19 September 2016).There were no restrictions based on language, date of publication or study setting.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing wound dressings with wound exposure (no dressing) or alternative wound dressings for the postoperative management of surgical wounds healing by primary intention.

DATA COLLECTION AND ANALYSIS

Two review authors performed study selection, 'Risk of bias' assessment and data extraction independently.

MAIN RESULTS

We included 29 trials (5718 participants). All studies except one were at an unclear or high risk of bias. Studies were small, reported low numbers of SSI events and were often not clearly reported. There were 16 trials that included people with wounds resulting from surgical procedures with a 'clean' classification, five trials that included people undergoing what was considered 'clean/contaminated' surgery, with the remaining studies including people undergoing a variety of surgical procedures with different contamination classifications. Four trials compared wound dressings with no wound dressing (wound exposure); the remaining 25 studies compared alternative dressing types, with the majority comparing a basic wound contact dressing with film dressings, silver dressings or hydrocolloid dressings. The review contains 11 comparisons in total.

PRIMARY OUTCOME

SSIIt is uncertain whether wound exposure or any dressing reduces or increases the risk of SSI compared with alternative options investigated: we assessed the certainty of evidence as very low for most comparisons (and low for others), with downgrading (according to GRADE criteria) largely due to risk of bias and imprecision. We summarise the results of comparisons with meta-analysed data below:- film dressings compared with basic wound contact dressings following clean surgery (RR 1.34, 95% CI 0.70 to 2.55), very low certainty evidence downgraded once for risk of bias and twice for imprecision.- hydrocolloid dressings compared with basic wound contact dressings following clean surgery (RR 0.91, 95% CI 0.30 to 2.78), very low certainty evidence downgraded once for risk of bias and twice for imprecision.- hydrocolloid dressings compared with basic wound contact dressings following potentially contaminated surgery (RR 0.57, 95% CI 0.22 to 1.51), very low certainty evidence downgraded twice for risk of bias and twice for imprecision.- silver-containing dressings compared with basic wound contact dressings following clean surgery (RR 1.11, 95% CI 0.47 to 2.62), very low certainty evidence downgraded once for risk of bias and twice for imprecision.- silver-containing dressings compared with basic wound contact dressings following potentially contaminated surgery (RR 0.83, 95% CI 0.51 to 1.37), very low certainty evidence downgraded twice for risk of bias and twice for imprecision. Secondary outcomesThere was limited and low or very low certainty evidence on secondary outcomes such as scarring, acceptability of dressing and ease of removal, and uncertainty whether wound dressings influenced these outcomes.

AUTHORS' CONCLUSIONS

It is uncertain whether covering surgical wounds healing by primary intention with wound dressings reduces the risk of SSI, or whether any particular wound dressing is more effective than others in reducing the risk of SSI, improving scarring, reducing pain, improving acceptability to patients, or is easier to remove. Most studies in this review were small and at a high or unclear risk of bias. Based on the current evidence, decision makers may wish to base decisions about how to dress a wound following surgery on dressing costs as well as patient preference.