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Since ancient times, speculations have been made about the curative properties of honey. The ancient Greeks, Chinese and Romans used honey to heal wounds and cure diseases of the gastrointestinal tract. Today, the use of honey in wound management has greatly resurged mainly due to increasing clinical problems of antibiotic-resistant bacteria and the combined difficulties for the practitioner in managing chronic wound types, such as burns, leg ulcers or surgical wounds, which may become infected. The application of honey to severely infected wounds clears infection and also improves tissue healing. The development and licensing of modern honey wound dressings has relieved many patients from the escalating costs associated with treating such wounds. honey also possess anti-inflammatory activity and stimulates immune response within a wound. It is also known that honeys derived from particular floral sources in Australia and New Zealand (Leptospermum spp) have enhanced antibacterial activity, and these honeys have been approved for marketing as therapeutic honeys. Namely, active Manuka honey. This review outlines what is known about the medical properties of honey and indicates the potential for honey to be incorporated into the management of a large number of wound types. This article also focuses on the potential importance of honey in modern day medicine due to its antibacterial properties.
For centuries, honey has been used as an effective remedy for wounds and burns, yet, there was no recognition of its antimicrobial properties. Lately, there have been renewed interest in the medicinal properties of honey. the effectiveness of honey in many of its medical uses is probably due to its antibacterial activity. It is well established that honey restrains a wide-range of bacterial species. There are many reports of honey having bactericidal as well as antifungal activity. That is, honey is active against a wide range of bacterial and fungal species, many of which cause infections. These numerous reports of the antimicrobial activity of honey will been comprehensively outlined in this review.
There are many features in the composition of honey that together combine to give it its antimicrobial properties. From the numerous studies conducted on the antimicrobial properties of honey, a few have been highlighted below:
How does honey work to treat infections?
There are many features in the composition of honey that together combine to give it its antimicrobial properties.
Honey is a saturated or supersaturated solution of sugars. For instance, almost eighty four percent comprises of glucose and fructose while, the water content is usually less than twenty one percent by weight. The lack of ââ‚¬Ëœfreeââ‚¬â„¢ water inhibits the growth of microorganisms. Thus, many species of bacteria have their growth completely inhibited.
When honey is diluted by wound exudates, hydrogen peroxide is produced through a glucose oxidase enzyme reaction. Upon dilution of honey, the activity increases by a factor of 2,500 - 50,000. This is gradual release of hydrogen peroxide provides antibacterial activity and does not damage the tissue.
2.1.4. Phytochemical Factors
Some honeys still have antimicrobial activity even when hydrogen peroxide activity has been removed. The honey from Manuka trees (Leptospermum scoparium) has been found to have high levels of this antibacterial phytochemical. It has also been discovered that by subjecting honey to alot of heat inactivates the glucoe oxidase which causes the loss of activity against some species while retaining it against the rest.
Variation in Antibacterial Activity
For decades it has been known that different types of honey exhibit differences in the degree of antibacterial activity. In recent years, honey from different sources has been studied and a few have been identified as having particularly high antibacterial activity. Namely, the Manuka honey gathered from the manuka tree Leptospermum scoparium, native to New Zealand, has exceptionally high antibacterial activity, with about half of this type of honey having high levels of non-peroxide activity (that is: high levels of antibacterial phytochemical activity present). It is imperative for honey to have this supplementary non-peroxide antibacterial component as factors such as acidity, catalase and protein-digesting enzymes in wound fluids all work towards lowering the hydrogen peroxide antibacterial effectiveness. However, it is recommended that honey collected in specific regions and seasons (and therefore presumably from different floral sources) be used for the treatment of particular ailments. A few decades ago, it was recognised that there are differences in the antibacterial activity of different types of honey and a method was devised to determine the "inhibine number" of honeys. The inhibine number is a measure of the antibacterial activity. Such that, the degree of dilution to which a honey will retain its antibacterial activity. The major variations seen in overall antibacterial activity are due to variation in the level of hydrogen peroxide that arises in honey, and in some cases to the level of non-peroxide factors.
Honey for the Treatment of Gastroenteritis
Honey has been found to be a useful component in the treatment of bacterial gastroenteritis in infants. It is used in place of glucose in an oral re-hydration fluid. The antibacterial activity of honey cleared the infection in bacterial diarrhoea. Moreover, honey was tested for its antibacterial potency against all the bacterial species that commonly cause gastroenteritis, comparing Manuka honey and a honey with the usual hydrogen peroxide activity and also an artificial honey to assess how much of the antibacterial activity was due simply to the acidity and the osmotic effect of the sugar in honey. it was discovered that honey with an average level of hydrogen peroxide activity is bacteriostatic at 4-8% (v/v) and bactericidal at 5-10% (v/v). The non-peroxide activity of an average manuka honey is bacteriostatic at 5-11% (v/v) and bactericidal at 8-15% (v/v). Bacteriostatic activity was not seen with artificial honey unless it was at 20-30% (v/v), clearly showing the importance of factors other than sugar and acidity.
Potential Uses of Honey as an Antimicrobial Agent
Limitations to Usage
The antimicrobial activity would be insignificant when an oral dose of honey becomes diluted after absorption from the gut into the many litres of fluid in the circulation and tissues of the body. In addition, the potential for honey as an antimicrobial agent in medicine is in topical application rather than as a systemic agent. However, there are some situations, for instance, gastrointestinal infections or mastitis where the honey could remain localised to be effectively antibacterial.
3.2. Honey as an Antiseptic Dressing
3.2.1. Established Usage of Honey as a Dressing
Honey has a well established usage as a wound dressing in ancient and traditional medicine 10. In recent times this has been re-discovered, and honey is in fairly widespread use as a topical antibacterial agent for the treatment of wounds, burns and skin ulcers, there being many reports of its effectiveness 11-23. The observations recorded are that inflammation, swelling and pain are quickly reduced, unpleasant odours cease, sloughing of necrotic tissue occurs without the need for debridement, dressings can be removed painlessly and without causing damage to re-growing tissue, and healing occurs rapidly with minimal scarring, grafting being unnecessary. In many of the cases honey was used on infected lesions not responding to standard antibiotic and antiseptic therapy. It was found in almost all of the cases to be very effective in rapidly clearing up infection and promoting healing.
Importance of Antibacterial Activity
Much of the effectiveness of honey as a dressing appears to be due to its antimicrobial properties. The healing process will not occur unless infection is cleared from a lesion: swabbing of wounds dressed with honey has shown that the infecting bacteria are rapidly cleared 13, 16, 18, 20, 24. In this respect honey is superior to the expensive modern hydrocolloid wound dressings as a moist dressing. Although tissue re-growth in the healing process is enhanced by a moist environment, and deformity is prevented if the re-growth is not forced down by a dry scab forming on the surface, moist conditions favour the growth of infecting bacteria. Antibiotics are ineffective in this situation, and antiseptics cause tissue damage, so slow the healing process 25. Honey is reported to cause no tissue damage, and appears to actually promote the healing process. There are also numerous reports of sugar being used as a wound dressing, this also being found to be effective 26-31. Antibacterial activity is attributed by several authors to the high osmolarity of the sugar or honey 11, 17, 22, 27, it not being generally recognised that some honeys can have additional antibacterial activity considerably greater than that due to the osmolarity. This additional activity would be of particular significance in situations where the dressing becomes diluted by body fluids, and in regions of a lesion that are not in direct contact with the dressing. Staphylococcus aureus is exceptionally osmotolerant: for complete inhibition of its growth the aw has to be lowered below 0.86, which would be a typical honey at 29% (v/v). In the reports of sucrose syrup or paste being used as a wound dressing it is noted that infection with Staphylococcus aureus is hard to clear. Measurements that have been reported 27 of the dilution occurring from the uptake of water from surrounding tissues when an abdominal wound was packed with sugar reveal that a saturated sucrose syrup containing undissolved granules becomes diluted in 7.5 hours to a concentration that is 30% of that of a saturated solution. Although the aw of this solution is low enough to prevent the growth of most human pathogens, it is not low enough to seriously restrict the growth of Staphylococcus aureus, a species which has developed resistance to many antibiotics and has become the predominant agent of wound sepsis in hospitals 32. But Staphylococcus aureus is one of the species most sensitive to the antibacterial activity of honey. There have been many reports of complete inhibition of Staphylococcus aureus by honeys diluted to much lower concentrations 4, showing the importance of the other antibacterial factors in selected honeys.
To know for certain the clinical significance of the additional antibacterial activity in honey, a clinical trial will need to be conducted to compare dressings of sugar and selected honeys. The little comparative work reported to date indicates that more rapid healing is achieved with honey than with sugar 12, 15. Since infection is one of the most common impediments to wound healing 33, then such results would be expected if the sugar dressing were not able to fully suppress the growth of bacteria as the sugar became diluted. The additional antibacterial activity of honey could be the reason for the remarkable rates of healing reported when honey has been used as a dressing 11, 13, 14.
Honey for the Treatment of Tineas
Honey has been reported to have antifungal activity, but not many species of fungi have been tested. An important group of fungi which regularly infect humans are the dermatophytes (Deuteromycotina). Cutaneous or superficial mycoses, caused through host infection by these fungi, are one of the most common diseases of humans. Only a small number of species of these, from the genera Epidermophyton , Microsporum and Trichophyton, regularly infect humans 45. Superficial fungal infections are amongst the most difficult diseases to successfully treat, antibiotics which successfully combat bacterial diseases being largely ineffective against fungi. A common predisposition to some fungal infections is poor host immunity, thus bacterial infections may also be present quite often. So a treatment which has both antifungal and antibacterial activities would be most beneficial. Therefore the effectiveness of honey against the dermatophyte species which most frequently cause superficial mycoses (tineas such as ringworm and athletes foot) was investigated 46.
For this investigation two sorts of natural honey were used: a mixed pasture honey with an average level of antibacterial activity due to hydrogen peroxide production, and a manuka honey with an average level of non-peroxide antibacterial activity. An artificial honey was also used, to assess how much of the antibacterial activity was due simply to the acidity and the osmotic effect. The honeys were tested against clinical isolates of seven species of dermatophytes. An agar well diffusion assay was used, the contents of the wells being replaced with freshly prepared honey solutions at 24 hour intervals over the 3 - 4 days of incubation. The honeys were diluted with either sterile distilled water or a sterile solution of 0.2% catalase, a 5% (v/v) step dilution series being used for testing.
The results are summarised in Table 5. No inhibitory activity was detected with any of the seven species with the pasture honey at any concentration up to the highest tested, 50% (v/v), when catalase was present, nor with the artificial honey even at 100%. This showed that it was the the hydrogen peroxide in the pasture honey, and the non-peroxide activity in the manuka honey, that were inhibiting the growth of the fungi. Although the concentrations of honey needed to inhibit some of the dermatophytes are higher than needed to inhibit bacteria, less dilution of the honey is likely with a tinea than with infected wounds, burns and ulcers where there would be serum exudation. It could be that manuka honey may be more effective
Treatment of Burn Wounds and Skin Ulcers with Honey
Subrahmanyam (1991) conducted a study comparing a conventional method of burn treatment (silver sulfadiazine) with topical applications of honey. Burn patients of a variety of ages were divided into two treatment groups. The burns of patients in Group 1 were cleaned with saline solution and pure, undiluted, unprocessed honey was applied daily. Burns of Group 2 (control) were cleaned and covered with gauze that was soaked in 5% silver sulfadiazine which was changed daily. Results showed that within 7 days 91% of the infected wounds treated with honey were free of infection, compared to less than 7% of the silver sulfadiazine treated burns. Within 15 days, 87% of the honey treated wounds were healed whereas only 10% of the control group wounds were healed. Patients treated with honey experienced less irritation, more relief of pain, and no allergic reactions or side effects.
Subrahmanyam (1991) suggests that honey is effective for treatment of burn wounds because: 1) It prevents infection because of its antibacterial or bacteriostatic properties (i.e., inhibits the growth of both Gram- negative and Gram-positive bacteria). 2) It provides a viscous barrier to fluid loss and wound invasion by bacteria thus preventing infection. 3) It contains enzymes which may aid the healing process by promoting tissue formation. 4) It absorbs edema fluid (pus) thereby cleaning the wound. 5) It reduces pain and irritation and eliminates offensive smell.
Efem (1988) showed that various types of wounds and skin ulcers which had not responded to conventional methods of treatment such as antibiotics and medicated dressings responded favorably to a topical honey treatment. Wounds and ulcer types treated with honey included: Fournier's gangrene, burn wounds topical ulcers, bed sores, and diabetic ulcers. After the wounds were cleaned with saline, honey and clean bandages were applied daily. Infected wounds that had not responded to conventional treatments were free of infection within 7 days of the first honey application. Following treatment with honey, dead tissue was quickly replaced with healthy granulation tissue. In some cases, diabetic ulcers were successfully treated with honey and skin grafts, thus preventing amputation. Apparently, the antibacterial properties of honey allow it to work on wounds and skin ulcers in the same manner it works on burns.
The antibacterial activity of honey is partially due to its osmotic effects (Molan, 1992a). Honey is a saturated or super saturated solution of sugars and is said to have osmotic properties (i.e., water-with drawing). Water molecules strongly react with the sugars in honey leaving little water available for micro-organisms. The bacteria that cause infection are unable to survive in honey because they become dehydrated. Molan (1992a) compared the antibacterial activity of natural honey to artificial honey solutions (i.e., super saturated solutions of sugars of the same proportion as those in honey). Results showed that these artificial honey solutions did not have the same degree of antibacterial activity as natural honey, indicating that while the removal of water from bacteria is important, other factors are operating to provide the observed antibacterial effects.
The presence of hydrogen peroxide generated by the enzymatic activity of glucose oxidase in dilute honey also contributes to its antibacterial activity (Molan, 1992a). As hydrogen peroxide decomposes, it generated highly reactive free radicals which react with and kill bacteria (Note: Prior to chemical identification of hydrogen peroxide, it was often referred to as inhibine in the literature).
In addition to its antimicrobial properties, honey also appears to stimulate lymphocytic and phagocytic activity. These are key body immune responses in the battle against infection.
What is honey used to treat?
Honey is most commonly used as a topical antibacterial agent to treat infections in a wide range of wound types. These include:
Diabetic foot ulcers
Infected wound resulting from injury or surgery
In most cases, honey is used when conventional antibacterial treatment with antibiotics and antiseptics are ineffective. Numerous studies have shown that these difficult-to-heal wounds respond well to honey dressings. Inflammation, swelling and pain rapidly subside, unpleasant odours stop, debridement is enhanced as the honey dressings remove dead tissue painlessly and without causing damage to the regrowing cells. Honey promotes rapid healing with minimal scarring.
Honey can also be used as first aid treatment for burns as it has potent anti-inflammatory activity.
How to use honey on wounds
All difficult to heal wounds should be seen by your doctor. The following are general tips on how honey may be used for wound care.
The amount of honey used depends on the amount of fluid exuding from the wound. Large amounts of exudate require substantial amounts of honey to be applied.
The frequency of dressing changes depends on how rapidly the honey is being diluted by the exudate. This should become less frequent as the honey starts to work on healing the wound.
Occlusive dressings help to prevent honey oozing out from the wound.
It is best to spread the honey on a dressing and apply this to the wound than apply the honey directly onto the wound. Dressing pads pre-impregnated with honey are commercially available and provide an effective and less messy alternative.
Abscesses, cavity or deep wounds need more honey to adequately penetrate deep into the wound tissues. The wound bed should be filled with honey before applying the honey dressing pad.
Honeys from different floral sources in the thermal stability of their glucose oxidase content, and in the sensitivity of this hydrogen peroxide-producing enzyme to denaturation by light because of a photosensitizing component that comes from some floral sources. Thus it is important that when honey is to be used as an antimicrobial agent it is selected from honeys that have been assayed in the laboratory for antimicrobial activity. It is also important that honey for use as an antimicrobial agent be stored at low temperature and not exposed to light, so that none of the glucose oxidase activity is lost. Although all honey will stop the growth of bacteria because of its high sugar content, when the sugars are diluted by body fluids this antibacterial action is lost. The additional antibacterial components then become important.