AIP Conference Proceedings 2344, 020022 (2021); https://doi.org/10.1063/5.0047363 2344, 020022
© 2021 Author(s).
Efficacy of honey dressing versus hydrogel dressing for wound healing
Cite as: AIP Conference Proceedings 2344, 020022 (2021); https://doi.org/10.1063/5.0047363 Published Online: 23 March 2021
Nandita Melati Putri, Prasetyanugraheni Kreshanti, Narottama Tunjung, Alita Indania, Adi Basuki, and Chaula L.
Sukasah
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Efficacy of Honey Dressing versus Hydrogel Dressing for Wound Healing
Nandita Melati Putri
1, Prasetyanugraheni Kreshanti
1,2,a), Narottama Tunjung
1, Alita Indania
3, Adi Basuki
3, Chaula L. Sukasah
11Plastic and Reconstructive Division, Department of Surgery, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
2Research Center for Biomedical Engineering, Faculty of Engineering, Universitas Indonesia, Kampus Baru UI, Depok, 16424, West-Java, Indonesia
3Plastic and Reconstructive Division, Department of Surgery, Faculty of Medicine, Universitas Indonesia, Jl. Salemba Raya No. 6, Central Jakarta, DKI Jakarta 10430 Indonesia
a)Corresponding author: [email protected]
Abstract. Background: The field of plastic surgery involves wounds, such as acute and chronic or non-healing wounds.
The mortality and morbidity inflicted by wounds may be substantial. To enhance wound healing and decrease morbidity and mortality, wound dressing selection is critical. Hydrogel dressing is a modern dressing that is versatile for various clinical situations. Nevertheless, a hydrogel may be expensive and not always readily available. Since the Egyptian period, honey has been used as a dressing, which was suggested to have an antimicrobial, anti-inflammatory, and immunomodulatory effect. Aim: To compare hydrogel and honey as dressing for all types of wounds in terms of wound healing time and slough production. Method: We conducted literature searching in multiple online databases using the keywords "wound", "honey" or "honey dressing", "hydrogel" or "hydrogel dressing", "healing time", and "slough" or
"necrotic tissue". Key terms were combined using Boolean operators and also searched using Medical Subheading (MeSH terms). Literature searches were conducted in the following databases; ProQuest, MEDLINE, Ebsco, EMBASE, Cochrane, Scopus, and Science Direct for randomized-controlled trial studies. Results: Literature searching yielded two randomized- controlled trials. Critical appraisal revealed that both studies were deemed valid. Honey dressing were similar to hydrogel dressing in terms of healing time 30.3 ± 6.7 (7-58) days vs. 33.2 ± 5.4 (14-61) days; 16.08 (12.3-19.9) days vs 17.12 (11.7- 22.5) days; 17.13 (13.1- 21.1) days vs 16.53 (12.3-20.8) days, respectively. However, Honey group has a slightly higher risk of slough production with an absolute risk increase of 4% for the non-HIV group and 3% for the combined group (HIV and non-HIV). Conclusion: The efficacy of honey as a wound dressing is equivalent to hydrogel for treating wounds in terms of wound healing duration. Nevertheless, the risk of slough production is slightly higher in the honey group.
Keywords: Acute wound, chronic wound, honey dressing, hydrogel dressing, healing time
INTRODUCTION
Many plastic surgery cases involve wounds, such as acute and chronic or non-healing wounds [1]. These wounds may inflict substantial mortality and morbidity [2,3]. From 958 consecutive acute and chronic wound patients, 90 deaths were recorded (9.4%) and are usually associated with chronic wounds, such as cancer wounds [2, 3]. Infection, causing significant morbidity and mortality, is also a common problem in wounds [2].To enhance wound healing, decrease morbidity and mortality, wound dressing selection is critical [4].
Hydrogel dressing is a modern dressing, which creates adhesion-free protection [5]. It has a wide range of shapes, such as tubes, spray bottles, and foil packets [6]. They are also very versatile for a variety of clinical situations since hydrogels could create a moist environment either by absorbing exudate or moisturizing dry and necrotic wounds [5].
Nevertheless, the hydrogel may be expensive and not always readily available [5].
The use of honey can be an alternative for wound dressing. Honey plays many roles as dressing for acute and
and immunomodulatory effect [8]. The widely used honey that has been used as a wound dressing is the Manuka honey and its medical-grade production, called Medihoney [9,10]. The presence of methylglyoxal (MGO) gives the direct antimicrobial effect of Manuka honey [11]. However, in Indonesia, Manuka honey and MediHoney are costly and not widely available. Alternatively, local honey called Madu Nusantara has been used more for wound treatment [12,13,14]. Sundoro A. et al. reported similar physical and chemical characteristics between Madu Nusantara and Manuka honey [15]. Laboratory tests also suggested comparable MGO levels between Madu Nusantara and Manuka honey [16]. A number of studies reported the positive effect of Madu Nusantara on wound healing in animal models and clinical cases [17,18,19]. In this study, we aim to compare hydrogel and honey as dressing for all types of wounds.
The outcomes measured are healing time and slough production.
METHODS Clinical Scenario
A 60-year-old female with a chief complaint of a small wound on her sacrum. This complaint has been present for the past two weeks. The patient has been diagnosed with ischemic stroke, thus unable to reposition herself. No signs of infection, such as purulent discharge, malodor, fever, and necrotic tissue, were present from clinical examination.
The hydrogel is often used to treat the pressure sores to maintain moist wound healing. However, this modern dressing is not always available in Indonesia. The patient's family asked whether honey, which is easily obtained and inexpensive, could be used as an alternative dressing for this patient.
Clinical Question
P : Patient with all types of wounds I : Honey dressing
C : Hydrogel dressing
O : Healing time and slough production Clinical question:
In patients with all types of wounds, does honey dressing yield shorter healing time and less slough production compared to hydrogel dressing?
To answer the clinical question, we conducted literature searching in multiple online databases using the keywords
"wound", "honey" or "honey dressing", "hydrogel" or "hydrogel dressing", "healing time", and "slough" or "necrotic tissue". Key terms were combined using Boolean operators and also searched using Medical Subheading (MeSH terms). Literature searches were conducted in the following databases; ProQuest, MEDLINE, Ebsco, EMBASE, Cochrane, Scopus, and Science Direct for randomized controlled trial studies. The inclusion criteria are randomized- controlled trial studies, meta-analysis and studies investigating honey and hydrogel as wound dressing. The exclusion criteria are studies done in animal subject, unavailable in English language, case report and case series. Articles were screened for duplicates and availability of full text. Screened articles were then assessed using the University of Oxford Appraisal for Therapy Study for their validity, importance, and applicability.
RESULTS
Literature searching was done using PRISMA METHOD standard, as presented in Fig. 1. After applying the eligibility criteria, 699 articles were excluded for being unsuitable to the PICO and inclusion criteria; hence only three articles were obtained. However, one article was excluded due to article retraction by the journal. Thus, only two articles were deemed suitable.
Two studies were included in this review; Al Saeed et al. and Ingle et al. Both studies compared between honey and hydrogel despite using different kinds of honey (Manuka Honey-impregnated dressing for Al Saeed et al. study and monofloral aloe honey for the Ingle et al. study). The two studies also included different kinds of wounds; diabetic foot ulcer in Al Saeed et al. and shallow wounds and abrasions in Ingle et al. Characteristics of the included studies are summarized in Table 1.
FIGURE 1. Literature searching algorithm.
TABLE 1. Characteristics of included studies
Author Title Intervention
and control Location Participants Outcome Duration Level of evidence
Al Saeed, et al.
[20]
Prospective randomized comparison of controlled release ionic silver hydrophilic dressings and medicated honey- impregnated dressings in treating neuropathic diabetic foot ulcer
Manuka honey- impregnated dressing TheraHoney
And silver hydrophilic dressing (Silvasorb
perforated sheet dressings)
Saudi Arabia
71 patients with diabetic foot ulcer
Time of infection eradication, length of hospital stays, mean time for ulcer healing
Follow up was done during treatment in the diabetic care unit until the infection was eradicated and granulation formed
Level IB (Randomized- controlled trial)
Ingle R, et al.
[21]
Wound healing with honey – a randomized controlled trial
Monofloral aloe honey and (IntraSite) hydrogel
South Africa
82 patients with shallow wounds and abrasions
Time of complete epithelization, slough/necrotic tissue
production
Follow up was done until complete epithelization
Level IB (Randomized- controlled trial)
Critical appraisal of the studies was conducted using The Oxford University Critical Appraisal Tool for Therapy Studies, as shown in Table 2. Overall, both studies adhere to the appraisal criteria except on certain aspects. The study by Al Saeed et al. did not treat both groups equally and failed to mention blinding methods. Meanwhile, Ingle et al.
did not segregate patients based upon their HIV status in the baseline characteristics and conducted the per-protocol analysis. Based on the criteria, we deemed both studies of moderate validity.
Overall, the difference in the mean duration of wound healing between honey and the silver hydrogel group was insignificant (30.3 r 6.7 vs. 33.2 r 5.4 days). The absolute risk increase for slough production was 4% for honey dressing in the non-HIV group and 3% for the combined group (HIV and non-HIV).
We consider both studies to be applicable in our patients, both in chronic and acute wound cases. However, there is no similar preparation of honey dressing in Indonesia, as described in both studies. Yet there is local-made commercial honey, which could serve as an alternative. In addition, honey has the potential to reduce the overall cost of treating wound cases.
TABLE 2. Importance of critical appraisal of included studies using Oxford University critical appraisal for therapy studies.
(CER: control event rate, EER: experimental event rate, RRI: relative risk increase, ARI: absolute risk increase, NNH: number needed to harm, RR: risk ratio)
DISCUSSION
From the thorough literature searching, there were only two eligible studies to assess. This demonstrates a lack of proper randomized-controlled trial studies comparing honey and hydrogel as wound dressings. Ingle et al. conducted a randomized clinical trial among 82 participants in South Africa. Methods of randomization and blinding were explicitly stated. However, the study revealed that a portion of subjects was discovered to be HIV positive. Therefore, the patients' baseline condition may not be comparable. According to Davis et al., HIV positive status was also correlated with a higher incidence of wound breakdown than those of the control group [22, 23]. Albaran et al. also revealed that patients with HIV and CD4 count lower than 0.20 x 109/L were correlated with major postoperative complications following major abdominal surgery [24]. However, animal studies discovered that despite being
Questions Al Saeed et al. Ingle et al.
What were the results?
x How large was the treatment effect?
x How precise was the estimate of the treatment effect?
Mean duration of healing time x Honey group: 30.3 r 6.7 (7-58)
days
x Silver hydrogel group: 33.2 r 5.4 (14-61) days (p> 0.05)
Slough in shallow and abrasion wound: (p>0.05)
Non-HIV and HIV group:
x CER = 0.42 x EER = 0.45 x RRI = 0.05 x ARI = 0.03 x NNH = 33.3 x RR = 1.05
x 95% CI = 45%r9.8%
Non-HIV group:
x CER = 0.46 x EER = 0.48 x RRI = 0.04 x ARI = 0.04 x NNH = 50 x RR = 1.04
x 95% CI = 48%r11.7%
Healing time: (p>0.05) x Shallow Wound
- Honey : 16.08 (12.3-19.9) days
- Hydrogel : 17.12 (11.7- 22.5) days
x Abrasion
- Honey : 17.13 (13.1- 21.1) days
- Hydrogel : 16.53 (12.3- 20.8) days
impact on inflammatory cell infiltrate, rate of wound closure, wound breaking strength, collagen content, and angiogenesis [23]. The pathophysiologic association between HIV status and wound healing remains inexplicable.
Despite the systemic disease, generally, there was no significant difference in baseline characteristics between the honey and hydrogel groups in terms of age, body mass index, blood pressure, and smoking status.
Al Saeed et al. conducted a study on 71 patients with diabetic foot ulcers treated with Manuka honey (MH) dressing compared to silver hydrogel dressing. In the Patients and Methods section of the study, the occlusive secondary absorbent dressing protocol on top of the studied dressing was stated daily for MH group. It can be left for 7 days for the silver hydrogel group. Based on the aforementioned protocol, ascertainment of blinding to either patient, clinician, and evaluator was not explicitly described, thus may affect the validity of this study.
From the Al Saeed et al. study, the honey group tends to present a shorter healing duration than silver hydrogel (p>0.05). Another study from Ingle et al. also presented similar honey and hydrogel results for the shallow wounds.
However, the result on abrasion wounds showed that hydrogel is superior to honey in terms of wound healing duration.
These results indicate that honey's healing time is slightly superior to hydrogel without any statistical significance in both studies.
In contrast to the healing duration, Ingle et al. study made a subgroup analysis for slough and necrotic tissue production. Slough production was more frequent in the honey group than in hydrogel group with no statistical significance in either combination of Non-HIV patients and HIV patients or HIV patients alone. Slough itself is a form of non-viable tissue and has a potential for acting as a reservoir for microorganisms [25]. The honey group, even with the presence of slough, showed faster healing than control. We postulate that this may occur since honey also has an antimicrobial effect from its enzymatic production of hydrogen peroxide. Nevertheless, the antimicrobial effect of each type of honey is different due to the variation of its nectar source [26].
In Indonesia, Manuka Honey is not always available, yet other natural local-made honey may serve as an inexpensive alternative and easily obtained. One of the research using Indonesian natural honey showed a faster healing rate than conventional dressing for the chronic traumatic wound [27]. Haryanto et al. also stated that Indonesian natural honey has a similar result in partial-thickness burn wound compare to Manuka Honey [28].
The antibacterial effect of Manuka honey is directly correlated with the presence of MGO. The MGO level of multi-floral honey is low, ranging from 0.4-5.4 mg/kg, while for Manuka honey, the MGO level ranges between 48- 835 mg/kg, and its content increases during storage at 37°C [29]. Laboratory tests were performed on Madu Nusantara and revealed MGO level of 25 mg/kg, which will increase to 33 mg/kg during storage [16]. This result showed that MGO level of Manuka honey and Madu Nusantara is still comparable.
Aside from its comparable efficacy, cost-efficiency may be an aspect to consider in dressing selection for the intended patient in the scenario. Various manufacturers provide hydrogel in Indonesia (IntraSite, Cutimed Gel) with prices starting from 6.4 USD for 15 grams tube (0.4 USD/grams). Meanwhile, in Indonesia, Manuka Honey impregnated dressing as the ones used in the included studies are scarce. Manuka honey is commercially available in grocery stores, with prices starting from 12.8 USD per 250-gram jars. From an economic perspective, Manuka honey costs less per gram compared to hydrogel. With the need for daily dressing change for honey dressing, the overall cost may be similar or even higher than hydrogel, which may be changed within 3-4 days. An alternative would be Madu Nusantara, which costs 4.48 USD per 250-gram jars. Madu Nusantara is also proven to have similar efficacy in decreasing wound size, necrotic tissue, and slough and promoting granulation tissue compared to Manuka honey [17].
However, the quantity of honey that should be applied according to the wound area is yet to be established.
CONCLUSION
From the included studies, the efficacy of honey as a wound dressing is equivalent to hydrogel for treating wounds in terms of duration of wound healing, yet the risk of slough production is slightly higher in the honey group. In addition, there is no statistically significant difference in the outcomes between the groups. Nevertheless, honey is a more economical and accessible option than hydrogel. Therefore, the use of honey is overall more advantageous than hydrogel. Further studies involving a larger sample size to evaluate more outcomes regarding the overall costs and patient conveniences should be conducted in the future.
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