- Email: [email protected]
Honey based therapy for the management of a recalcitrant diabetic foot ulcer
Journal of Tissue Viability (2014) 23, 29e33
www.elsevier.com/locate/jtv
Case report
Honey based therapy for the management of a recalcitrant diabetic foot ulcer Hashim Mohamed a,b,*, Badriya El Lenjawi b, Mansour Abu Salma c, Seham Abdi c a
Family Medicine, Weill Cornell Medical College, Qatar Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar c Primary Care Corporation, Doha, Qatar b
KEYWORDS Diabetic foot ulcer; Honey based therapy; Primary care
Abstract Objective: Diabetic foot ulcers are usually treated at hospital podiatry clinics and not at primary care level. We report an alternative approach using honey based therapy in the successful management of diabetic foot ulcer at primary health care level. Methods: The case is discussed in relation to various modalities targeting diabetic foot ulceration in the literature. Result: A 65 years old female-Egyptian diabetic patient presented with a neuropathic plantar ulcer of 10 5 cm post-thermal burn following the use of a hot water bottle. The patient was treated with strict offloading using a pair of crutches, debridement of necrotic tissue using a sharp scalpel and commercial honey applied daily and covered with a glycerin based dressing. The honey dressing was changed daily along with strict offloading and by week 16 the ulcer completely healed. Conclusion: Treatment of diabetic foot ulcer is possible at primary care level. ª 2013 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.
Key points * Corresponding author. Family Medicine, Weill Cornell Medical College, Qatar. Tel.: þ974 55861008. E-mail addresses: [email protected] (H. Mohamed), [email protected] (B. El Lenjawi), Abusalma2000@yahoo. com (M.A. Salma), [email protected] (S. Abdi).
Natural honey is an effective wound dressing. Natural honey is cost effective and aesthetically acceptable. Natural honey is bactericidal, provides moisture and debrides wounds.
0965-206X/$36 ª 2013 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jtv.2013.06.001
30
H. Mohamed et al.
A case report Diabetes-related foot complications are a major burden for patients and society. Patients suffering from diabetic ulcers are at increased risk of hospitalization, lower limbs sepsis and amputation [1,2]. As a result patients suffer from decreased quality of life, decreased function and increased health care cost [3e6]. Worldwide, the majority of diabetic patients are being treated by family physicians thereby playing a pivotal role in the management of diabetes and its related complications. Managing diabetic foot ulcer requires an integrated health care delivery utilizing multiple investigative and therapeutic modalities. Although difficult to treat ulcers may require advanced biotechnologies including growth factors, the majority of ulcers may respond well to conventional therapies. Honey has been used to treat wounds for millennia [7] and this is further supported by its effectiveness in promoting healing in animal and human studies. Literature reviews, have been largely positive with regards to the antibacterial properties of honey especially against a wide variety of pathogens including Pseudomonas and methicillin-resistant Staphylococcus aureus (MRSA) [8e15]. Honey’s antibacterial properties are related to many properties including its hyperosmolarity, containing less than 20% water, its acidity (pH 3.5e5.0), its release of hydrogen peroxide, flavonoids and phenolic acids making bacteria unlikely to survive in a honey based ulcer bed [16,17]. Honey’s wound healing properties lie in its ability to provide moisture in the ulcer bed thereby aiding epidermal migration, providing trace nutrients and stimulating inflammatory cytokines (e.g., TN-a, IL-6, IL-1B) by macrophages [18e21]. Honey has been described in more than 500 reports in the literature and not a single complication with regards to clostridium spores wound infection has ever been reported [22].
Figure 1
Plantar ulcer on presentation.
several conventional modalities were used including a non-adhesive foam dressing containing biotin, wet-to-moist dressing, Iodine based dressing & paraffin impregnated tulle and finally the patient had a dressing utilizing a silver containing alginate dressing (Sivercel-Systagenix). All of which have failed to render desirable results. A holistic assessment of the patient by the attending consultant family physicians found her to have uncontrolled diabetes (HbA1C > 10%), anemia (Hb ¼ 10.0) and suffering from hypertension and chronic obstructive airway disease. She was commenced on insulin twice daily regimen, given iron supplement, anti-hypertensive medications were stepped up to control her blood pressure and tiotropium inhaler þ a long acting salbutamol/fluticasone accuhaler were prescribed to control her chronic obstructive airway disease. A wound assessment was carried out by the attending consultant family physicians with the following findings; the ulceration on initial presentation had the largest length of 10 cm 5 cm being the largest perpendicular width (see Fig. 2). The peripheral pulses were manually palpable including dorsalis pedis & posterior tibial artery.
Case history A 65 years old female patient, with diabetes of 25 years, BMI ¼ 23 kg/m2, ex-smoker, who sustained a thermal burn to her right foot plantar surface following the application of a hot water bottle to treat the cold sensation felt in her leg secondary to diabetic peripheral neuropathy see Fig. 1. She had her plantar ulcer treatment throughout her attendance at the main general hospital out patient clinic for six weeks and was not improving,
Figure 2 Plantar ulcer showing hard callus around the margin and necrotic areas in the center.
Honey based therapy for the management of a recalcitrant diabetic foot ulcer This was further assessed by Doppler examination which revealed strong, regular, triphasic foot pulse. Neurological examination on the other hand revealed loss of vibration perception threshold using a 128 MHz tuning fork and this was further supported by loss of protective sensation using the 10 g monofilament indicative of sensory neuropathy in both feet. Furthermore, the 10 g monofilament was not used on any patient that day thereby maintaining its reliability & validity as a screening tool for diabetic peripheral neuropathy. A deep tissue biopsy was taken to rule out infection and was negative, similarly probing of the ulcer was done at different areas since the ulcer was relatively large and did not probe to bone thereby practically ruling out osteomyelitis. This was done since infection is known to slow wound healing, and warmth, swelling and redness may be absent in diabetic ulcers due to an altered immune state, thereby making diagnosis difficult [23,24]. Furthermore, the negative predicative value of 56% for “probing to bone “indicates that a negative test dose not exclude osteomyelitis. As a result, a plain radiograph was done and was negative. However, plain radiography has sensitivity of 60% and specificity of 60% respectively [25]. As a result we opted to send the patient for an MRI since it has a sensitivity of 99% and a specificity of 83% [26], which was also negative. The ulcer was cleaned with normal saline, necrotic tissues were debrided using a sharp scalpel. This was followed by the application of natural honey which was bought from a local shop importing natural honey from Yemen. The natural honey used was a homogenous set white honey produced by Russian bees (Apis mellifera) which is native to the Primorsky Krai region in Russia. The natural honey was applied onto on the wound using a sterile spatula and covered by (ADAPTIC-SYSTAGENIX) which is a non-adhering dressing made of knitted cellulose acetate fabric and impregnated with specially formulated petroleum emulsion. This was covered with a cotton wool bandage and a light creb bandage cover. The honey dressing provided moisture & antibacterial activity while the non-adherent a dressing (ADAPTIC) minimized the risk of tissue damage upon change of dressing. In this case the dressing was changed on a daily basis with total offloading of the ulcer using a pair of crutches which the patient already utilized for a previous ankle sprain. An ordinary offloading material consisting of multiple layered incontinence pad was applied around the ulcer. This option was used since the patient was managed at a busy primary care clinic in Qatar where total contact casts (gold standard) are unavailable, difficult to apply [27,28].
31
This technique was used to redistribute and relieve pressure from the ulcer site thereby facilitating the healing process and preventing further tissue trauma. At each review (daily) appointment the ulcer was debrided frequently and honey was applied on a daily basis and the wound was assessed for signs of infections. At week 2 the ulcer looked healthy with areas of granulation tissue which meant that our treatment strategy did not need to be modified (see Fig. 3). At week 3 dramatic improvement had taken place with an evidence of an advancing healing edge with a marked reduction in the ulcer size (>40%) and the remaining of the ulcer appeared healthy with normal skin (see Fig. 4). Progressive healing continued as shown by the image at 5 weeks (see Fig. 5). The ulcer is almost healed at week 6 (see Fig. 4) and by week 7 complete healing had taken place (see Fig. 6).
Discussion Honey used in this case has provided moisture and antibacterial activity thereby accelerating tissue repair, causing less scarring and less pain [29,30] and although a burning or stinging sensation has been described with honey’s topical use [17], in our case no symptoms were reported by the patient which could be attributed to advanced diabetic peripheral neuropathy. Many types of honey appear to be effective for wound healing with varying antibacterial activities. The mechanism of action of honey seems to stem from its hyperosmolar property containing less than 20% water creating an osmotic gradient thereby initiating a dual action in the wound bed. Firstly, it depletes the bacteria of its water content leading to its death and secondly it draws fluid
Figure 3 Healthy granulation tissue with the center of the ulcer showing new skin growth.
32
H. Mohamed et al.
Figure 4 week 3.
Reduction of the ulcer by >40% in size by
from the edematous wound thereby enhancing wound circulation [17]. Furthermore, honey possesses a potent enzyme (glucose oxidase) which releases small amounts of hydrogen peroxide enough to kill bacteria without undermining the ulcer bed. Additionally, honey provides essential trace elements which aid the healing process [18]. All these properties included in honey makes it an attractive cost effective and viable option for treating diabetic foot ulcer. Furthermore, resistance development by bacteria is unlikely since studies have shown that honey, even when diluted 10-fold or more prevents the growth of a variety of organisms including bacteria [31]. Histologically, honey seems to enhance tissue repair and growth in animal and human controlled trials with reduced inflammatory reactions, enhanced epithalization and earlier tissue repair [8,32e34]. Macroscopically studies have demonstrated the debriding action of honey in a variety of wounds including diabetic foot ulcers, burns, arterial ulcers and infected surgical wounds [35e38].
Conclusion
Figure 5
98% healing of the ulcer by week 5.
In our study we observed the effectiveness of natural commercial honey in combination with a hydroalginate and offloading in managing diabetic foot ulcer at primary care level. Currently, there is a paradigm shift in the fight against the diabetes plague and its multiple comorbidities including diabetic foot ulcers, therefore primary care physicians must take a leading role in this battle in order to improve quality of life and safe individuals from amputations. In summary, we present what to our knowledge is the first case of honey based management of a recalcitrant diabetic foot ulcer secondary to a thermal burn being managed at primary care level in this region of the world where diabetes has reached epidemic proportions.
Conflict of interest statement The authors hereby declare no conflict of interest.
References
Figure 6
Complete healing by week 7.
[1] Reiber GE, Boyko EJ, Smith DG. Lower extremity foot ulcers and amputations in diabetes. In: National Diabetes Data Group, editor. Diabetes in America. 2nd ed. Washington, DC: U.S. Govt. Printing Office; 1995. p. 409e28. [2] Boyko EJ, Lipsky BA. Infection and diabetes. In: National Diabetes Data Group, editor. Diabetes in America. 2nd ed. Washington, DC: U.S. Govt. Printing Office; 1995. p. 485e500.
Honey based therapy for the management of a recalcitrant diabetic foot ulcer [3] Harrington C, Zagari MJ, Corea J, Klitenic J. A cost analysis of diabetic lower-extremity ulcers. Diabetes Care 2000;23: 1333e8. [4] Brod M. Quality of life issues in patients with diabetes and lower extremity ulcers: patients and care givers. Qual Life Res 1998;7:365e72. [5] Price P, Harding K. The impact of foot complications on health-related quality of life in patients with diabetes. J Cutan Med Surg 2000;4:45e50. [6] Klonoff DC, Schwartz DM. An economic analysis of interventions for diabetes. Diabetes Care 2000;23:390e404. [7] Majno G. The healing hand: man and wound in the ancient world. Cambridge, Mass: Harvard University Press; 1975. [8] Bergman A, Yanai J, Weiss J, Bell D, David MP. Acceleration of wound healing by topical application of honey, an animal model. Am J Surg 1983;145:374e6. [9] Gupta SK, Singh H, Varshney AC, Prakash P. Therapeutic efficacy of honey in infected wounds in buffaloes. Indian J Anim Sci 1992;62:521e3. [10] Kumar A, Sharma VK, Singh HP, Prakash P, Singh SP. Efficacy of some indigenous drugs in tissue repair in buffaloes. Indian Vet J 1993;70:42e4. [11] Rozini MZ, Zuki ABZ, Noordin Y, Nazrul Hakin A. Macroscopic evaluation of burn wound healing progress treated with different types of honey. Pak J Biol Sci 2005;8:672e8. [12] Cooper R, Halas E, Molan P. The efficacy of honey in inhibiting strains of Pseudomonas aeruginosa from infected burns. J Burn Care Rehabil 2002;23:366e70. [13] Cooper RA, Molan PC, Harding KG. Antibacterial activity of honey against strains of S. aureus from infected wounds. J R Soc Med 1999;92:283e5. [14] Molan PC, Brett M. Honey has potential as a dressing for wounds infected with MRSA. In: Paper presented at: 2nd Australian wound management association conference; 1998, Brisbane, Australia. [15] Nzeako BC, MoHamdi J. Antimicrobial potential of honey on some microbial isolates. J Med Sci 2000;2:75e9. [16] Cushine TP, Lamb AJ. Antimicrobial activities of flavonoids. Int J Antimicrob Agents 2005;26:343e56. [17] Eddy JJ, Gideonsen MD, Gregory P, Mack DPM. Practical considerations of using topical honey for neuropathic diabetic foot ulcers: a review. Wis Med J 2008;107(4):187e9. [18] Molan PC. Potential of honey in the treatment of wounds and burns. Am J Clin Dermatol 2001;2:13e9. [19] Tonks AJ, Dudley E, Porter NG, Parton J, Brazier J, Smith EL, et al. A 5.8-kD component of manuka honey stimulates immune cells via TLR4. J Leukoc Biol 2007;82: 1147e54. [20] Majtan J, Kovacova E, Bilikova K, Simuth J. The immunestimulatory effect of the recombinant apalbumin 1-major
[21]
[22] [23] [24] [25] [26] [27]
[28] [29]
[30]
[31] [32] [33]
[34] [35]
[36]
[37]
[38]
33
honeybee royal jelly protein on TNF-a release. Int Immunopharmacol 2006;6:269e78. Tonks A, Cooper RA, Price AJ, Molan PC, Jones KP. Stimulation of TNF-a in monocytes by honey. Cytokine 2001;14: 240e2. Molan PC. Potential of honey in the treatment of wounds and burns. J Wound Care 2004;13(9):353e6. Edmonds M, Foster A. The use of antibiotics in the diabetic foot. Am J Surg 2004;187:S25e8. Falanga V. Wound healing and its impairment in the diabetic foot. Lancet 2005;366:1736e43. Schinabeck MK, Johnson JL. Osteomyelitis in diabetic foot ulcers. Post Grad Med 2005 Jul;118(1):1e7. Lipsky BA. Osteomyelitis of the foot in diabetic patients. Clin Infect Dis 1997;25(6):1318e26. Armstrong DG. Pressure offloading and “advanced “wound healing: isn’t it finally time for an arranged marriage? Int J Lower Extrem Wounds December 2004;3(4):184e7. Sato Y, Miyata G. The natraceutical benefit, part III: honey. Nutr Pharm 2000;16:468e9. Nemeth AJ, Eaglstein WH, Taylor JR, Peerson LJ, Falanga V. Faster healing and less pain in skin biopsy sites treated with an occlusive dressing. Arch Dermatol 1991; 127(11):1679e83. Foertsch CE, O’Hara MW, Stoddard FJ, Kealey GP. Treatment resistant pain and distress during pediatric burndressing changes. J Burn Care Rehabil 1998;19:219e24. Molan O. The evidence supporting the use of honey as a wound dressing. Int J Lower Extrem Wounds 2006;5:40e54. Subrahmanyam M. Topical application of honey in treatment of burns. Br J Surg 1991;78(7):497e8. Subrahmanyam M. A prospective randomised clinical and histological study of superficial burn wound healing with honey and silver sulfadiazine. Burns 1998;24(2):157e61. Efem SEE. Clinical observations on the wound healing properties of honey. Br J Surg 1988;75:679e81. Oryan A, Zaker SR. Effects of topical application of honey on cutaneous wound healing in rabbits. J Vet Med Ser A 1998;45(3):181e8. Postmes TJ, Bosch MMC, Dutrieux R, van Baare J, Hoekstra MJ. Speeding up the healing of burns with honey. An experimental study with histological assessment of wound biopsies. Bee products. In: Mizrahi A, Lensky Y, editors. Properties, applications and apitherapy. New York: Plenum Press; 1997. Ndayisaba G, Bazira L, Habonimana E, Muteganya D. Clinical and bacteriological results in wounds treated with honey. J Orthop Surg 1993;7(2):202e4. Bloomfield R. Honey for decubitus ulcers. J Am Med Assoc 1973;224(6):905.
www.elsevier.com/locate/jtv
Case report
Honey based therapy for the management of a recalcitrant diabetic foot ulcer Hashim Mohamed a,b,*, Badriya El Lenjawi b, Mansour Abu Salma c, Seham Abdi c a
Family Medicine, Weill Cornell Medical College, Qatar Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar c Primary Care Corporation, Doha, Qatar b
KEYWORDS Diabetic foot ulcer; Honey based therapy; Primary care
Abstract Objective: Diabetic foot ulcers are usually treated at hospital podiatry clinics and not at primary care level. We report an alternative approach using honey based therapy in the successful management of diabetic foot ulcer at primary health care level. Methods: The case is discussed in relation to various modalities targeting diabetic foot ulceration in the literature. Result: A 65 years old female-Egyptian diabetic patient presented with a neuropathic plantar ulcer of 10 5 cm post-thermal burn following the use of a hot water bottle. The patient was treated with strict offloading using a pair of crutches, debridement of necrotic tissue using a sharp scalpel and commercial honey applied daily and covered with a glycerin based dressing. The honey dressing was changed daily along with strict offloading and by week 16 the ulcer completely healed. Conclusion: Treatment of diabetic foot ulcer is possible at primary care level. ª 2013 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.
Key points * Corresponding author. Family Medicine, Weill Cornell Medical College, Qatar. Tel.: þ974 55861008. E-mail addresses: [email protected] (H. Mohamed), [email protected] (B. El Lenjawi), Abusalma2000@yahoo. com (M.A. Salma), [email protected] (S. Abdi).
Natural honey is an effective wound dressing. Natural honey is cost effective and aesthetically acceptable. Natural honey is bactericidal, provides moisture and debrides wounds.
0965-206X/$36 ª 2013 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jtv.2013.06.001
30
H. Mohamed et al.
A case report Diabetes-related foot complications are a major burden for patients and society. Patients suffering from diabetic ulcers are at increased risk of hospitalization, lower limbs sepsis and amputation [1,2]. As a result patients suffer from decreased quality of life, decreased function and increased health care cost [3e6]. Worldwide, the majority of diabetic patients are being treated by family physicians thereby playing a pivotal role in the management of diabetes and its related complications. Managing diabetic foot ulcer requires an integrated health care delivery utilizing multiple investigative and therapeutic modalities. Although difficult to treat ulcers may require advanced biotechnologies including growth factors, the majority of ulcers may respond well to conventional therapies. Honey has been used to treat wounds for millennia [7] and this is further supported by its effectiveness in promoting healing in animal and human studies. Literature reviews, have been largely positive with regards to the antibacterial properties of honey especially against a wide variety of pathogens including Pseudomonas and methicillin-resistant Staphylococcus aureus (MRSA) [8e15]. Honey’s antibacterial properties are related to many properties including its hyperosmolarity, containing less than 20% water, its acidity (pH 3.5e5.0), its release of hydrogen peroxide, flavonoids and phenolic acids making bacteria unlikely to survive in a honey based ulcer bed [16,17]. Honey’s wound healing properties lie in its ability to provide moisture in the ulcer bed thereby aiding epidermal migration, providing trace nutrients and stimulating inflammatory cytokines (e.g., TN-a, IL-6, IL-1B) by macrophages [18e21]. Honey has been described in more than 500 reports in the literature and not a single complication with regards to clostridium spores wound infection has ever been reported [22].
Figure 1
Plantar ulcer on presentation.
several conventional modalities were used including a non-adhesive foam dressing containing biotin, wet-to-moist dressing, Iodine based dressing & paraffin impregnated tulle and finally the patient had a dressing utilizing a silver containing alginate dressing (Sivercel-Systagenix). All of which have failed to render desirable results. A holistic assessment of the patient by the attending consultant family physicians found her to have uncontrolled diabetes (HbA1C > 10%), anemia (Hb ¼ 10.0) and suffering from hypertension and chronic obstructive airway disease. She was commenced on insulin twice daily regimen, given iron supplement, anti-hypertensive medications were stepped up to control her blood pressure and tiotropium inhaler þ a long acting salbutamol/fluticasone accuhaler were prescribed to control her chronic obstructive airway disease. A wound assessment was carried out by the attending consultant family physicians with the following findings; the ulceration on initial presentation had the largest length of 10 cm 5 cm being the largest perpendicular width (see Fig. 2). The peripheral pulses were manually palpable including dorsalis pedis & posterior tibial artery.
Case history A 65 years old female patient, with diabetes of 25 years, BMI ¼ 23 kg/m2, ex-smoker, who sustained a thermal burn to her right foot plantar surface following the application of a hot water bottle to treat the cold sensation felt in her leg secondary to diabetic peripheral neuropathy see Fig. 1. She had her plantar ulcer treatment throughout her attendance at the main general hospital out patient clinic for six weeks and was not improving,
Figure 2 Plantar ulcer showing hard callus around the margin and necrotic areas in the center.
Honey based therapy for the management of a recalcitrant diabetic foot ulcer This was further assessed by Doppler examination which revealed strong, regular, triphasic foot pulse. Neurological examination on the other hand revealed loss of vibration perception threshold using a 128 MHz tuning fork and this was further supported by loss of protective sensation using the 10 g monofilament indicative of sensory neuropathy in both feet. Furthermore, the 10 g monofilament was not used on any patient that day thereby maintaining its reliability & validity as a screening tool for diabetic peripheral neuropathy. A deep tissue biopsy was taken to rule out infection and was negative, similarly probing of the ulcer was done at different areas since the ulcer was relatively large and did not probe to bone thereby practically ruling out osteomyelitis. This was done since infection is known to slow wound healing, and warmth, swelling and redness may be absent in diabetic ulcers due to an altered immune state, thereby making diagnosis difficult [23,24]. Furthermore, the negative predicative value of 56% for “probing to bone “indicates that a negative test dose not exclude osteomyelitis. As a result, a plain radiograph was done and was negative. However, plain radiography has sensitivity of 60% and specificity of 60% respectively [25]. As a result we opted to send the patient for an MRI since it has a sensitivity of 99% and a specificity of 83% [26], which was also negative. The ulcer was cleaned with normal saline, necrotic tissues were debrided using a sharp scalpel. This was followed by the application of natural honey which was bought from a local shop importing natural honey from Yemen. The natural honey used was a homogenous set white honey produced by Russian bees (Apis mellifera) which is native to the Primorsky Krai region in Russia. The natural honey was applied onto on the wound using a sterile spatula and covered by (ADAPTIC-SYSTAGENIX) which is a non-adhering dressing made of knitted cellulose acetate fabric and impregnated with specially formulated petroleum emulsion. This was covered with a cotton wool bandage and a light creb bandage cover. The honey dressing provided moisture & antibacterial activity while the non-adherent a dressing (ADAPTIC) minimized the risk of tissue damage upon change of dressing. In this case the dressing was changed on a daily basis with total offloading of the ulcer using a pair of crutches which the patient already utilized for a previous ankle sprain. An ordinary offloading material consisting of multiple layered incontinence pad was applied around the ulcer. This option was used since the patient was managed at a busy primary care clinic in Qatar where total contact casts (gold standard) are unavailable, difficult to apply [27,28].
31
This technique was used to redistribute and relieve pressure from the ulcer site thereby facilitating the healing process and preventing further tissue trauma. At each review (daily) appointment the ulcer was debrided frequently and honey was applied on a daily basis and the wound was assessed for signs of infections. At week 2 the ulcer looked healthy with areas of granulation tissue which meant that our treatment strategy did not need to be modified (see Fig. 3). At week 3 dramatic improvement had taken place with an evidence of an advancing healing edge with a marked reduction in the ulcer size (>40%) and the remaining of the ulcer appeared healthy with normal skin (see Fig. 4). Progressive healing continued as shown by the image at 5 weeks (see Fig. 5). The ulcer is almost healed at week 6 (see Fig. 4) and by week 7 complete healing had taken place (see Fig. 6).
Discussion Honey used in this case has provided moisture and antibacterial activity thereby accelerating tissue repair, causing less scarring and less pain [29,30] and although a burning or stinging sensation has been described with honey’s topical use [17], in our case no symptoms were reported by the patient which could be attributed to advanced diabetic peripheral neuropathy. Many types of honey appear to be effective for wound healing with varying antibacterial activities. The mechanism of action of honey seems to stem from its hyperosmolar property containing less than 20% water creating an osmotic gradient thereby initiating a dual action in the wound bed. Firstly, it depletes the bacteria of its water content leading to its death and secondly it draws fluid
Figure 3 Healthy granulation tissue with the center of the ulcer showing new skin growth.
32
H. Mohamed et al.
Figure 4 week 3.
Reduction of the ulcer by >40% in size by
from the edematous wound thereby enhancing wound circulation [17]. Furthermore, honey possesses a potent enzyme (glucose oxidase) which releases small amounts of hydrogen peroxide enough to kill bacteria without undermining the ulcer bed. Additionally, honey provides essential trace elements which aid the healing process [18]. All these properties included in honey makes it an attractive cost effective and viable option for treating diabetic foot ulcer. Furthermore, resistance development by bacteria is unlikely since studies have shown that honey, even when diluted 10-fold or more prevents the growth of a variety of organisms including bacteria [31]. Histologically, honey seems to enhance tissue repair and growth in animal and human controlled trials with reduced inflammatory reactions, enhanced epithalization and earlier tissue repair [8,32e34]. Macroscopically studies have demonstrated the debriding action of honey in a variety of wounds including diabetic foot ulcers, burns, arterial ulcers and infected surgical wounds [35e38].
Conclusion
Figure 5
98% healing of the ulcer by week 5.
In our study we observed the effectiveness of natural commercial honey in combination with a hydroalginate and offloading in managing diabetic foot ulcer at primary care level. Currently, there is a paradigm shift in the fight against the diabetes plague and its multiple comorbidities including diabetic foot ulcers, therefore primary care physicians must take a leading role in this battle in order to improve quality of life and safe individuals from amputations. In summary, we present what to our knowledge is the first case of honey based management of a recalcitrant diabetic foot ulcer secondary to a thermal burn being managed at primary care level in this region of the world where diabetes has reached epidemic proportions.
Conflict of interest statement The authors hereby declare no conflict of interest.
References
Figure 6
Complete healing by week 7.
[1] Reiber GE, Boyko EJ, Smith DG. Lower extremity foot ulcers and amputations in diabetes. In: National Diabetes Data Group, editor. Diabetes in America. 2nd ed. Washington, DC: U.S. Govt. Printing Office; 1995. p. 409e28. [2] Boyko EJ, Lipsky BA. Infection and diabetes. In: National Diabetes Data Group, editor. Diabetes in America. 2nd ed. Washington, DC: U.S. Govt. Printing Office; 1995. p. 485e500.
Honey based therapy for the management of a recalcitrant diabetic foot ulcer [3] Harrington C, Zagari MJ, Corea J, Klitenic J. A cost analysis of diabetic lower-extremity ulcers. Diabetes Care 2000;23: 1333e8. [4] Brod M. Quality of life issues in patients with diabetes and lower extremity ulcers: patients and care givers. Qual Life Res 1998;7:365e72. [5] Price P, Harding K. The impact of foot complications on health-related quality of life in patients with diabetes. J Cutan Med Surg 2000;4:45e50. [6] Klonoff DC, Schwartz DM. An economic analysis of interventions for diabetes. Diabetes Care 2000;23:390e404. [7] Majno G. The healing hand: man and wound in the ancient world. Cambridge, Mass: Harvard University Press; 1975. [8] Bergman A, Yanai J, Weiss J, Bell D, David MP. Acceleration of wound healing by topical application of honey, an animal model. Am J Surg 1983;145:374e6. [9] Gupta SK, Singh H, Varshney AC, Prakash P. Therapeutic efficacy of honey in infected wounds in buffaloes. Indian J Anim Sci 1992;62:521e3. [10] Kumar A, Sharma VK, Singh HP, Prakash P, Singh SP. Efficacy of some indigenous drugs in tissue repair in buffaloes. Indian Vet J 1993;70:42e4. [11] Rozini MZ, Zuki ABZ, Noordin Y, Nazrul Hakin A. Macroscopic evaluation of burn wound healing progress treated with different types of honey. Pak J Biol Sci 2005;8:672e8. [12] Cooper R, Halas E, Molan P. The efficacy of honey in inhibiting strains of Pseudomonas aeruginosa from infected burns. J Burn Care Rehabil 2002;23:366e70. [13] Cooper RA, Molan PC, Harding KG. Antibacterial activity of honey against strains of S. aureus from infected wounds. J R Soc Med 1999;92:283e5. [14] Molan PC, Brett M. Honey has potential as a dressing for wounds infected with MRSA. In: Paper presented at: 2nd Australian wound management association conference; 1998, Brisbane, Australia. [15] Nzeako BC, MoHamdi J. Antimicrobial potential of honey on some microbial isolates. J Med Sci 2000;2:75e9. [16] Cushine TP, Lamb AJ. Antimicrobial activities of flavonoids. Int J Antimicrob Agents 2005;26:343e56. [17] Eddy JJ, Gideonsen MD, Gregory P, Mack DPM. Practical considerations of using topical honey for neuropathic diabetic foot ulcers: a review. Wis Med J 2008;107(4):187e9. [18] Molan PC. Potential of honey in the treatment of wounds and burns. Am J Clin Dermatol 2001;2:13e9. [19] Tonks AJ, Dudley E, Porter NG, Parton J, Brazier J, Smith EL, et al. A 5.8-kD component of manuka honey stimulates immune cells via TLR4. J Leukoc Biol 2007;82: 1147e54. [20] Majtan J, Kovacova E, Bilikova K, Simuth J. The immunestimulatory effect of the recombinant apalbumin 1-major
[21]
[22] [23] [24] [25] [26] [27]
[28] [29]
[30]
[31] [32] [33]
[34] [35]
[36]
[37]
[38]
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