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CONTINUING PROFESSIONAL DEVELOPMENT
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The benefits of honey in Tissue viability multiple Read Paul Endean’s Guidelines on how to
wound management choice questionnaire practice profile on write a practice profile
wound healing

The benefits of honey This article has been supported by

an educational grant from:

in wound management
NS318 White R (2005) The benefits of honey in wound management. Nursing Standard. 20, 10, 57-64.
Date of acceptance: October 10 2005.

Describe how honey should be used clinically

Summary
In recent years there has been a renewed interest in honey in wound
management. There is a range of regulated wound care products
that contain honey available on the Drug Tariff. This article
addresses key issues associated with the use of honey, outlining how
it may be best used, in which wounds, and which clinical outcomes
may be anticipated.
Author
Richard White is senior research fellow in tissue viability, Grampian
NHS Trust, Aberdeen. Email: Richard@medicalwriter.co.uk
Keywords
Dressings; Infection control; Malodour; Wounds
These keywords are based on the subject headings from the British
Nursing Index. This article has been subject to double-blind review.
For related articles and author guidelines visit our online archive at
www.nursing-standard.co.uk and search using the keywords.
Aim and intended learning outcomes
In recent years there has been a growing interest
in the use of honey in wound management. This
has led to the development of regulated medical
products in the form of sterile dressings designed
for use on wounds. The aim of this article is to
raise nurses’ awareness of the role of honey-based
dressings in wound management. After reading
this article you should be able to:

Know how honey dressings work in relation to
wound management.

Identify the types of wounds for which honey
dressings are indicated.

Discuss the evidence to support the use of these
dressings.
to provide cost-effective care.
Background
According to Molan (2002): ‘Dressing wounds
with honey, a standard practice in past times,
went out of fashion when antibiotics came into
use. As antibiotic-resistant bacteria have become
a widespread clinical problem, a renaissance in
honey use has occurred.’ This alone is sufficient
justification to consider the use of honey in
dressings and, in conjunction with increasing
scientific and clinical data, it may make honey
even more appealing. Clinically, topical honey
treatment has been shown to (White and Molan
2005):

Possess antimicrobial properties.

Promote autolytic debridement.

Deodorise malodorous wounds.

Stimulate growth of wound tissues to hasten
healing and to start the healing process in
dormant wounds.

Stimulate anti-inflammatory activity that
rapidly reduces pain, oedema and exudate, and
minimises hypertrophic scarring.

Promote moist wound healing.
These actions are encapsulated in the modern
systematic approaches to wound management
known as ‘applied wound management’ (Gray
et al 2005), ‘wound bed preparation’ and TIME
(Tissue, Infection or inflammation, Moisture
balance, Edge of wound) – a clinical framework
based on the assessment and treatment of the
barriers to wound healing (Schultz et al 2003).

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Time out 1
Consider the clinical environment in
which you work. Compile a list of the
types of wounds you encounter on a regular
basis and the range of dressing types that
you use.
Clinical evidence on honey
When evaluating clinical evidence it is important
to rank the available information according to
current standards. Thus, a randomised
controlled trial (RCT) is recognised as the
highest level of clinical evidence. Such trials are
time-consuming to plan, conduct, analyse and
report, and have financial costs. However, RCTs
should not, and do not, discount all other
evidence (Rolfe 1999). There is a hierarchy of
evidence ranging from meta-analyses of RCTs to
case studies and expert opinion. In the absence of
RCT evidence practitioners should consider
‘lower’ grades of evidence. However, it should be
acknowledged that lower grades of evidence
have limitations. In the opinion of the author,
there is now sufficient evidence to justify the
clinical use of honey according to manufacturer’s
instructions. The evidence supporting the use of
honey is already more substantial than for many
other wound treatments.
A systematic review has been conducted on the
published evidence for RCTs on honey in wound
care (Moore et al 2001). This concluded that the
evidence available (at that time) from seven
comparative studies on 264 patients was limited
by lack of blinding, poor reporting and poor
validity. Much has changed since the Moore
review – many comparative studies have been set
up and more data are available on the new
generation of ‘medical device grade’ honey
products, that is, the standards of quality and
purity as set out in the medical device directives
(Johnson et al 2005, Marshall et al 2005, Simon
et al 2005, Val Robson, Tissue Viability Nurse,
University Hospital Aintree, Liverpool, 2005,
personal communication).
Until recently, the honey used in wound
management has generally been non-sterile
material from non-specified floral sources,
obtained from supplies intended for nutritional
rather than medical use. However, a number of
honey-based wound treatments have been
introduced to the UK market. They have the
European conformity (CE) mark and regulatory
approval as sterile medical devices for use on
58 november 16 :: vol 20 no 10 :: 2005
full-thickness wounds. Many honey-based
dressings bearing the CE mark are now available in
the UK and are listed on Drug Tariff (Prescription
Pricing Authority, Department of Health 2005).
Clinical reports
The topical application of generic honey has been
reported to clear existing wound infection rapidly
(Lusby et al 2002, Sofka et al 2004, White and
Molan 2005), to facilitate healing of deeply
infected surgical wounds (McInerney 1990, Vardi
et al 1998, Al-Waili and Saloom 1999, Cooper
et al 2001, Ahmed et al 2003) and halt spreading
necrotising fasciitis (Hejase et al 1996). In some
cases, the application of honey has promoted
healing in infected wounds that were not
responding to conventional therapy, such as
antibiotics and antiseptics (Harris 1994, Wood
et al 1997, Dunford et al 2000a, 2000b, Ahmed
et al 2003), including wounds infected with
antibiotic-resistant bacteria such as methicillin-
resistant Staphylococcus aureus (Dunford et al
2000a, Natarajan et al 2001).
Honey deodorises wounds (Subrahmanyam
1991, Kingsley 2001, Molan 2002, Van der
Weyden 2003, Stephen-Haynes 2004, Cooper
2005) and promotes autolytic debridement to
facilitate the rapid development of a clean,
granulating wound bed (Subrahmanyam 1998,
Stephen-Haynes 2004). A rapid rate of healing has
been reported in wounds treated with honey
(Bloomfield 1976, Hejase et al 1996, Ahmed et al
2003). Honey also serves to kick-start the healing
process in otherwise ‘dormant’ wounds
(Bloomfield 1976, Efem 1988, Somerfield 1991,
Wood et al 1997, Stephen-Haynes 2004). Such
wounds might be ‘critically colonised’ and the
response occurs because of the antibacterial action
of honey (Gray and White 2005). These claims are
valid because they have been reproduced by other
investigators; the level of the evidence is grade IIb
according to the Scottish Intercollegiate
Guidelines Network (www.sign.ac.uk).
In addition, honey has been used successfully
on skin grafts (Schumacher 2004), infected skin
graft donor sites (Misirlioglu et al 2003), infected
traumatic wounds (Green 1988), paediatric
oncological lesions (Sofka et al 2004, Simon et al
2005), radiation mucositis (Biswal et al 2003),
necrotising fasciitis (or Fournier’s gangrene)
(Hejase et al 1996), abscesses (Okeniyi et al
2005), catheter-associated infections (Johnson
et al 2005), diabetic foot ulcers (Eddy and
Gideonsen 2005), and malignant ulcers (Simon
et al 2005). Honey is also claimed to be a reliable
alternative to conventional dressings for
managing skin excoriation around stomas
(ileostomy and colostomy) by facilitating
epithelialisation of the damaged surface
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(Aminu et al 2000). This aspect of skin care is
supported by reports of the beneficial effects of
honey on paediatric (napkin/diaper) dermatitis
(Al-Waili 2005), and on atopic eczema and
psoriasis (Al-Waili 2003). Validity was
established by reproducibility, evidence level IIa.
An outline of the wound types suitable for
honey treatment is given in Box 1. The key areas
with regard to wound assessment are highlighted
in Box 2.
Time out 2
Consider the different wound types
that may benefit from a honey dressing.
What is the nature of the evidence to
support the use of honey on these wounds? A
useful exercise would be to access some of the
references that advocate the benefits of honey
as cited in this article and consider whether
they are sufficiently valid to influence your
practice or whether you need to seek further
information.
In the selection of the most appropriate honey
dressing to use for particular wounds it is essential
to undertake a full assessment of the wound type
(Box 2) as the choice of dressing will be dictated by
this assessment. Box 3 provides useful indicators
in the correct choice of dressing. Figures 1-3 show
the wound healing process in a patient with a left
below knee amputation that was treated using
honey ointment and dressings.
Time out 3
Make a list of the signs that indicate
a wound’s suitability for a honey-based
dressing or treatment. Write down three
different wound types and decide the best
application of honey for each.
Comparative effectiveness
In prospective, clinical RCTs, honey was found to
help heal superficial burns quicker than
polyurethane film (OpSite®), to be superior to
silver sulfadiazine 1% cream (Flamazine®) in
preventing infection in burn wounds, and to be no
different to mupirocin (Bactroban®) in
preventing catheter-associated infections in
haemodialysis patients (Johnson et al 2005).
In a study comparing honey-impregnated
gauze with polyurethane film, the mean times to
healing in each group (n=46) were 10.8 days and
15.3 days respectively (P<0.001). In addition,
significantly fewer honey-dressed wounds became
infected (P<0.001) (Subrahmanyam 1993).
In the first of the two studies that compared
honey-impregnated gauze with silver sulfadiazine
NURSING STANDARD
(SSD)-impregnated gauze (n=52 patients in each
group), 87 per cent of the wounds treated with
honey healed within 15 days, compared with 10
per cent of those treated with SSD (P<0.001)
(Subrahmanyam 1991). In this study a
statistically significant difference (P<0.001) was
found in the clearance of bacteria from the burns.
In the 43 out of 52 cases that presented positive
swab cultures on admission in the group treated
with honey, 39 (91 per cent) became sterile within
seven days. In the comparison (SSD) group, only
three (7 per cent) of 41 wounds with positive
BOX 1
Indications for the use of honey in wound
management

On chronic wounds, for example, leg ulcers
and pressure ulcers.

When there is delayed healing and local
infection.

On acute wounds, for example, burns, locally
infected wounds (not cellulitis).

When preparing the wound bed for grafting.
Note: diabetic foot ulcers can be treated with
honey by experienced practitioners. Honey is a
potential source of glucose absorption and
experienced clinicians will be aware of this;
honey can be a valuable aid to wound bed
preparation because it can control bioburden,
debride, and promote healing.
BOX 2
Wound assessment
Assess the patient’s wound and note the
following signs: presence of slough and/or
necrosis, signs and symptoms of infection,
wound malodour.
With reference to the previous progress of the
wound towards healing: is the wound showing
evidence of healing, that is, granulation and
epithelialisation? Is the wound failing to heal,
despite ‘appropriate’ treatment?
If the wound is sloughy or necrotic, malodorous,
or locally infected, consider using honey. This
should debride the wound, reduce the malodour,
and control the local infection rapidly. Honey is
also appropriate for non-healing wounds,
provided that the reasons for a lack of healing
have been eliminated. It is important to exclude
misdiagnosis, treatment with systemic steroids
or cytotoxics and local radiotherapy. One can
expect to see positive outcomes in days.
(Van der Weyden 2003, Stephen-Haynes 2005)
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When compared with other products in these

learning zone tissue viability trials, honey offered better or equivalent control
of infection.
In recent reports where selected honey was used
swab cultures became sterile. This provides on infected wounds following surgical treatment
evidence of the antibacterial effect of honey in of hidradenitis suppurativa (a chronic disease of
vivo (in a living organism). the apocrine gland) (Cooper et al 2001) and
In the second burns trial (25 patients in each infected skin lesions from meningococcal
group), all of the wounds treated with honey septicaemia (Dunford et al 2000a), the
healed within 21 days, compared to 21 (84 per antibacterial activity gave rise to rapid clearance
cent) of those treated with SSD (P<0.001) of infection and healing of the wounds. In both
(Subrahmanyam 1998). In a RCT of honey versus these studies, it had not been possible to achieve
mupirocin (Bactroban®) in 101 haemodialysis
patients, no exit site infections occurred in either FIGURE 1
group (Johnson et al 2005). Wound dehiscence following removal of
A prospective RCT on severe post-operative sutures
wound infections following Caesarean section or
abdominal hysterectomy was conducted to
compare dressing with honey (n=26) to washing
wounds with 70 per cent ethanol and applying
povidone iodine (n=24). Both groups received
systemic antibiotics according to culture and
sensitivity. In the group treated with honey,
infection was rapidly eradicated (6±1.9 days v
14.8±4.2 days), wounds healed faster (10.7±2.5
days v 22±7.3 days), post-operative scars were
less than half the size, and the period of
hospitalisation was less than half that for the
patients in the control group (9.4±1.8 days v
FIGURE 2
19.9±7.4 days: P<0.05 for each parameter
(Al-Waili and Saloom 1999)). This study was of Granulation and epithelialisation after
particular interest because all patients were 35 days of treatment
treated with appropriate antibiotics, yet the
topical application of honey still proved to be
effective in reducing wound bioburden. This
might be because of low local tissue levels of
antibiotic from poor perfusion of the wound.

BOX 3
Selection of the most appropriate
honey-based dressing

Use honey gel or honey-based ointment from a

tube on wounds with dry (black) eschar and
cover with an adhesive foam or film for up to FIGURE 3
seven days. In the presence of exudate, consider Wound is functionally healed after three
using a honey-impregnated alginate dressing; months
this can be covered with an absorbent pad in
wounds with high/very high exudate, or with an
adhesive foam or hydrocolloid when exudate is
light/moderate.
Do not use adhesive dressings on fragile or
macerated skin, or where wear times are likely
to be short as this will cause skin trauma
(Cutting and White 2002). Do not adjust wear
time for your convenience – it should suit the
needs of the wound and the patient (White
2001a, 2001b).

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healing with the many systemic antibiotics and
modern dressing materials previously used over a
long period.
Good infection control was reported in a
crossover study of nine infants with large infected
surgical wounds (Vardi et al 1998). Honey was
used on the wounds after they failed to heal
following at least 14 days of treatment with
intravenous antibiotics – a combination of
vancomycin and cefotaxime, subsequently
changed according to bacterial sensitivity – fusidic
acid ointment, and wound cleaning with aqueous
0.05% chlorhexidine solution. Marked clinical
improvement was seen in all cases after five days
of treatment. All wounds were closed, clean and
sterile after 21 days of honey application. It is of
interest that in-vitro (in the experimental
laboratory situation of the test tube or culture
dish) studies have shown a synergy between honey
and common antibiotics in multidrug-resistant
Pseudomonas spp. (Karayil et al 1998). This
would, therefore, appear to justify the
combination of systemic antibiotics with use of
topical antibacterials, such as honey, in wounds
where poor perfusion and drug resistance might
compromise healing.
Wound malodour and deodorising
Malodour is a common feature of chronic
wounds and is attributed to the presence of
anaerobic bacterial species such as Bacteroides
spp., Peptostreptococcus spp. and Prevotella
spp. (Bowler et al 1999, Cooper and Gray 2005).
It is reasonable to interpret the reduction in
malodour when treating wounds with honey as
an antibacterial action in vivo; honey has also
been demonstrated to be active against
anaerobes in vitro (Elbagoury and Rasmy 1993).
However, the rapid deodorising of wounds
observed when honey dressings are used is
probably the result of more than just the
antibacterial action of honey against these
anaerobes. The malodorous substances
produced by bacteria are short-chain fatty acids,
ammonia, amines, and sulphur compounds.
These are formed by the metabolism of amino
acids from decomposed serum and tissue
proteins. Honey provides a copious quantity of
glucose, a substrate metabolised by bacteria in
preference to amino acids (Molan 2005).
Wound debridement
Like any other moist wound dressings, honey
facilitates the debridement of wounds by
autolysis. Honey promotes conversion of inactive
plasminogen in the wound matrix to the active
form, plasmin (Molan 2005), which is the major
proteolytic enzyme involved in blood clot
NURSING STANDARD
retraction or the lysis of fibrin. It is an enzyme
that is able to break down fibrin clots which
attach slough and eschar to the wound bed
(Esmon 2004).
Honey, through its strong osmotic action, may
create a moist environment by drawing out lymph
fluid from the wound tissues. This osmotic action
provides a constantly replenished supply of
proteases at the interface of the wound bed and
the overlying necrotic tissue, which may in part
explain the rapid debridement brought about by
honey (Stephen-Haynes 2005). It also ‘washes’
the surface of the wound bed from beneath,
which explains the frequent observation of honey
dressings removing debris, for example, foreign
bodies such as dirt and grit (Molan 2002). The
action also helps to explain the painless lifting off
of slough and necrotic tissue that is observed
(Efem 1988, 1993, Hejase et al 1996,
Subrahmanyam 1993, 1998). In black necrotic
heels, the steady softening/debriding action of
honey allows granulation to begin before the
eschar is removed (Gray and White 2005).
Anti-inflammatory action
Clinical observations of reduced inflammation
following application of honey to a wound are
substantiated by the results of in-vivo studies that
have shown that honey, when compared to
various controls, reduces inflammation.
Histological evidence of reduced numbers of
inflammatory cells present in wounds dressed
with honey exists from studies of deep and
superficial burns as well as full-thickness wounds
(Postmes et al 1997). These effects were the result
of components other than the sugar in honey
(Postmes et al 1997). Evidence also has come
from findings in biopsy samples from burn
wound tissue of hospital patients
(Subrahmanyam 1998).
Although it is a vital part of the normal
response to infection or injury, excessive or
prolonged inflammation can prevent healing or
cause further damage to tissues (Agren et al
2000). Suppressing inflammation, as well as
reducing pain for the patient, also reduces the
opening of blood vessels, thus lessening oedema
and exudate (Molan 2005). Pressure in tissues
secondary to oedema restricts the flow of blood
through the capillaries, starving the tissues of the
oxygen and the nutrients that are vital for
leucocytes to fight infection and for fibroblasts to
multiply for wound healing.
Stimulation of tissue growth
With regard to the stimulation of tissue growth,
the evidence provided supports the following
statements:
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factor (TNF)-1, interleukin (IL)-1, and IL-6,

learning zone tissue viability

Honey is a bioactive wound dressing that
promotes rapid wound healing (White and
Molan 2005).

Honey promotes the formation of clean,
healthy granulation tissue and
re-epithelialisation (Stephen-Haynes 2005).

Honey stimulates the healing process in
chronic wounds that have demonstrated
delayed healing (Dunford 2005).
Immune system activity
The clearance of infection may not just be the
result of the antibacterial action of honey. Recent
research indicates that honey may work by
stimulating the activity of the immune system
(Cooper 2005). Honey at concentrations as low
as 0.1% has been found to stimulate
proliferation of peripheral blood B and T
lymphocytes and activate phagocytes from
blood. Also, honey at a concentration of 1% has
been reported to stimulate monocytes in cell
culture to release the cytokines tumour necrosis
BOX 4
Honey dressings available on the Drug Tariff

Honey (liquid), gel, ointment, soft ointment,
all in tube presentations.

Honey-impregnated tulle.

Honey-based sheet hydrogel.

Honey-based mesh.

Honey-impregnated alginate.
which are intermediates in the immune response
(Tonks et al 2003).
In addition to the reported stimulation of
leucocytes, honey has the potential to augment
further the immune response by supplying
glucose. This is essential for the ‘respiratory
burst’ in macrophages that generates endogenous
hydrogen peroxide, the dominant component of
the natural bacteria-destroying activity of these
cells (Molan 2002).
Time out 4
What are the different stages of
wound healing? It is important to revise
these stages otherwise you may have
difficulty deciding on which is the most
appropriate dressing for different wounds.
List the key actions of medical grade honey
and consider why honey is a useful addition to
the range of wound management products.
Honey:in-use characteristics and safety
Given the wide range of honey-based dressings
available in the UK (Box 4), it is appropriate to
provide some guidance for their clinical use. As
with all medical products, it is important to read
and follow the manufacturer’s instructions as
provided on the package insert. The tube
presentations of honey, honey gel and ointment
may be applied directly to the wound or to a
suitable dressing. It is important not to let these
preparations dry out. Occlusive dressings, selected
according to wound exudate levels, will help to
maintain a moist environment (Bolton et al 2000).
Foams, hydrocolloids and films are useful
secondary dressings. The honey-impregnated
tulle dressing will require a suitable secondary,
retaining dressing. The bordered sheet hydrogel

TABLE 1
Reported pain sensation on the application of a honey-based wound ointment in a study of
89 patients
Wound type No pain Mild pain Severe pain
Venous ulcers 31 4 1
Burns 5 2 0
Diabetic foot ulcers 5 1 0
Mixed wounds 9 2 3
Pressure ulcers 15 3 0
Skin tears 8 0 0
Note: not all medical honey dressings are advocated for the treatment of full-thickness burns; always
read the manufacturer’s instructions before use
(Vandeputte and Van Waeyenberge 2003)

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serves as an effective secondary dressing, without

fixation, on wounds with low to high exudate.
The honey mesh dressing acts as a non-adherent
wound contact layer. It can be used in
conjunction with honey ointment and will, when
used on heavily exuding wounds, require an
absorbent pad as a secondary dressing.
In general, honey is a safe treatment; however,
some patients report a stinging sensation on
application which they find painful (Vandeputte
and Van Waeyenberge 2003) (Table 1). This may
be transient, reducing within one hour, or longer
lasting. It may be overcome by the use of
analgesia or a more dilute honey preparation.
Conversely, honey can have a ‘soothing’ effect
when applied to wounds, including burns
(Subrahmanyam 1993), breast wounds
(Keast-Butler 1980), and donor sites
(Misirlioglu et al 2003).
Time out 5
What honey dressings can now be
prescribed in the UK? List the different
types and indicate on which type of wound
you would use them.
Conclusion
The clinical evidence for the use of honey in
wound management is steadily accumulating
and, with the introduction of various forms of
manufactured honey dressings available
commercially, will continue. While the evidence
before 2000 was focused on unspecified honeys,
more recent research has focused on the sterile
medical grade honey products intended
specifically for wound management. These
products have been designed to overcome many

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individually in a range of products. Honey

learning zone tissue viability provides an ideal wound bed preparation for
many wounds NS

of the problems of messiness and difficulty in Acknowledgement

handling, making honey-based products as
convenient to use as the more familiar modern
wound dressings. Some involve the combination
of honey with a modern dressing such as alginate
or sheet hydrogel. Others present honey as an
ointment formulation with additional agents
known to support wound healing, or as a wound
gel comprising honey, oils and waxes.
This brings the most ancient form of wound
dressing known into the realms of the most
modern, easy-to-use, bioactive dressing that
provides a moist healing environment. There is
the added advantage of having within a single
product a range of actions usually available only
The author is indebted to Professor Peter Molan
and Dr Rose Cooper for their contributions to
research on honey, without which we would not
have the evidence base to develop these dressings.
Thanks to Gill Weaver and Kath Crawford at
Manchester Royal Infirmary for the use of the
photographs in this article.
Time out 6
Now that you have completed this
article, you may like to write a practice
profile. Guidelines to help you are on page 68.

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