Hippocrates, often hailed as the father of Western medicine, once said, "let food be thy medicine and medicine be thy food". Credited as the first person to believe diseases were naturally occurring rather than caused by mystic forces, the ancient Greek’s ethical oath is still sworn to by doctors today.
Although Hippocrates certainly wasn’t right about everything, healthcare providers are now starting to reconsider the healing properties of a substance that might more commonly be placed on a piece of toast.
Honey, I’m home
Having been used in medicine throughout human history, honey appears to again be enjoying something of a renaissance. Its antimicrobial properties are well known, but the carbohydrate-rich syrup, for which Hippocrates himself had a penchant, largely fell out of favour during the golden age of antibiotics, when the developed world mistakenly believed it had won the battle against infectious disease.
These days, antibiotic resistance is regarded as a persistent and significant threat. Last year, Professor Dame Sally Davies, the UK’s chief medical officer described the situation as being like "a ticking time bomb".
Bacteria are gaining coping mechanisms for the drugs we use against them faster than we can develop new ones, and that’s an alarming scenario. A post-antibiotic era, where routine operations routinely kill, potentially beckons. Could looking back, by revisiting ancient remedies, be a prospective answer?
One area of healthcare hinging on the ability to treat infections effectively is wound healing. It’s an extremely complex discipline – a molecular choreography in a number of acts – and such conditions represent a significant burden for the industry, accounting for a large proportion of hospital stays across Europe. With an aging population, increasing cases of diabetes and thinning armour against bacteria, the problem can only get worse.
"We have a population that’s getting older because people are living longer," explains Nicola Ivins, a clinical trials manager at Cardiff University. "Chronic wounds like leg ulcers and diabetic foot ulcers are increasing. These take up a huge amount of resources, but they’re not just expensive, they impact on a patient’s quality of life and social well-being."
A surgical nurse by background, Ivins has been in the field of wound care for more than 20 years. She now directs clinical trials in the university’s Wound Healing Research Unit, testing commercial and academic therapies for patients suffering from chronic and acute lesions.
She says honey has been catapulted into the public’s awareness of late. The much-hyped but costly Manuka, produced by New Zealand bees feeding on the Leptospermum scoparium tree, has been hailed as something of a ‘superfood’ in recent years by the mainstream media.
Work that appears to back this suggestion up, pioneered by Professor Peter Molan in the early ’80s at the University of Waikato, has turned anecdotal claims into empirical evidence. Numerous studies are now conducted each year attempting to clarify honey’s potential as a wound-healing agent.
"I first used honey-based dressings over ten years ago," reveals Judy Belcher, a tissue viability nurse at Worcester Royal Hospital, who has undertaken and presented research on the efficacy of the treatment. "I was impressed by the positive results and have continued, where appropriate, to use such dressings ever since."
Belcher and Ivins acknowledge that dressings containing a familiar product tend to go down well with the patients, and they believe approaching treatment for unpleasant conditions with a positive attitude can only be a good thing.
"They like the thought of using a natural product," says Ivins. "There are many who actually come in and ask for it. It’s something with a long history of healing qualities, and, for some patients, it’s really effective."
"While patient mental positivity is a whole separate issue," adds Belcher, "I do think confidence and knowledge in the treatment they are receiving contributes to the healing process."
Sweet smell of success
Patient popularity has led to a surge of dressings containing sterilised and regulated honey. In fact, a medical-grade version of the sticky amber substance first appeared in 1999. Honey is now used to treat many types of lesion, including traumatic wounds, surgical incisions sites, burns, sloughy wounds and pressure ulcers.
Its antibacterial properties arise from its high sugar content, acidic nature and ability to produce hydrogen peroxide. In vitro studies have shown the honey to be effective against the hard-to-beat bacteria often involved in hospital-acquired wound infection, such as Staphyloccocus auereus and Pseudomonas aeruginosa. Its mechanisms of action are varied but appear to include gene and protein expression modulation, and the disruption of bacterial cell division or cell wall formation.
Recent research even suggests honey could be effective against biofilms, one of the hardest to treat occurrences of antibiotic resistance prevalent in hospitals. Some wound-infecting species of bacteria are able to prolong their survival in the wound bed and resist the effects of contemporary antibiotics by sticking together, forming what’s known as a biofilm. But honey has been shown to counteract this protective mechanism.
"You need to break those biofilms, because the bugs have got really good at protecting themselves," explains Ivins. "You get a film you can’t always see with the eye around these bacteria that sit in the wound bed and prevent the lesion from healing."
She says that patients with infected or highly exuding wounds may experience a significant dent in their well-being due to the prevalence of malodour. But, among its many other attributes, honey has also been shown to have a deodorising quality.
"Honey has also got an osmotic effect that will encourage lymphatic flow and get rid of devitalised tissue, so it’s got a debridement action as well," Ivins adds.
To bee or not to bee
While studies on the therapeutic properties of honey have increased in recent years, robust evidence of its efficacy in randomised controlled trials, in which the paper’s authors do not have conflicts of interest, has yet to be found. It’s also worth bearing in mind that not all kinds of honey are created equal.
"There’s limited research because there are different types of honey that haven’t been compared. And I don’t know of any major studies where they’ve looked at honey vs other antimicrobials," states Ivins.
It might not be the solution for every type of wound either, particularly those producing large amounts of exudate – the generic term used to describe the fluid released by wounds at some stage of their healing cycle. Because honey is considered a "wet dressing" itself, it’s use is inappropriate if the wound is already very moist.
If exudate levels become unmanageable, this can lead to problems such as periwound skin maceration, increased odour and delayed healing. In these cases, a dressing that doesn’t contain honey might be more suitable.
"There aren’t many honey dressings that are known to hold exudate," says Ivins. "But, if you’re using your honey as an antimicrobial, you’re really hoping it will be effective on the bacteria in the wound, and it will also reduce exudate because you’re controlling the number of bacteria in the wound bed."
But she says there are hundreds of super-absorbent wound dressings out there that might be better placed to deal with these excess levels of fluid, most commonly seen in chronic lesions. Such products, however, might not always have adequate antibacterial properties.
"You almost need something to combine the two, which they’ve tried to do in some of the alginate dressings," reveals Ivins.
Here, honey is impregnated into a more absorbent dressing, so it isn’t washed away with the exudate and is able to remain on the wound site for longer.
"Patients get really distressed if the dressing is leaking and there’s a smell. Sometimes the combination of the fluid and the dressing really can be quite odorous," says Ivins. "You need a dressing that prevents damage to periwound skin and the wound bed, diminishes odour and reduces pain."
She says that, until such a multipurpose dressing arrives on the market, the situation can be managed by increasing the frequency of dressing changes or combining an antimicrobial like honey with an absorbent secondary dressing. The technology will no doubt come eventually, but, for now, there’s still much we don’t know.
Clearly, more research and clinical trials are required before the medical industry can be sure honey will be the best bet for the treatment of some types of wounds.
"Wound healing is in its infancy, because there’s still so much we don’t quite understand about why a wound fails to heal," says Ivins. "There’s more funding going into research now, but we don’t always understand the science behind it."
Belcher, however, believes there will be a move towards traditional remedies in the future.
"I do think there will be a significant shift towards more natural therapies, partly due to the resistance of bacteria against the established products and partly due to the excessive cost of bringing a new product to the market," she says. "Specifically, there will be continuing development in absorbent dressings that will perhaps combine natural products such as honey."
But, regardless of what the future might hold, Ivins and Belcher are focusing on present treatment guidelines, and emphasise the need to first conduct a holistic patient assessment.
"Why do some wounds heal but others don’t? There are so many different factors, because the wound is actually a manifestation of an underlying disease," says Ivins. "So, when you do your initial assessment, the main thing is to get a comprehensive history, to look at the medications patients are on, to give the wound a description and only then to plan your care."
