Use of Honey in Healing Deep, Infected Wounds in Patients with Diabetes Mellitus
Diabetes mellitus is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin production,...
Diabetes mellitus is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. Diabetes can be associated with serious complications including diabetic foot disease. Diabetic foot disease is estimated to affect 15% of people with diabetes.
Wound healing is a process that involves inflammation, proliferation/regeneration and finally remodeling. The normal orderly pattern is disrupted in chronic non-healing wounds, which are characterized by decreased levels of growth factors and increased protease activity. Wound healing is affected by serum albumin, tissue oxygenation, infection, hyperglycaemia, cytokines and proteases.
A marker of non-healing wounds may be the prolonged presence of extra-cellular matrix molecules in the dermis. Other markers and potential mediators include increased levels of transforming growth factor (TGF)-b proteolytic factors such as matrix metalloproteinases, and the absence of IGF-I.
Wound care includes a variety of approaches to enhance healing, with treatment of infection, vascular reconstruction, achieving adequate glycaemic control, removal of pressure, and ongoing wound debridement being important aspects of this care.
A deep wound with tissue loss in the right foot of a 65-year-old male patient with diabetes mellitus was treated by a standard protocol that included strict control of blood sugar level. In addition, an antibiotic regimen was included to combat anaerobic and aerobic infection. Also, a paste consisting of myrrh, bee propolis and honey (MPH) was applied to the wound. Following treatment, the wound settled and healed well.
The patient presented to the out-patient clinic of Minufiya University Hospital (MUH) with possible osteomyelitis. A foot wound showed severe oedema and the patient was unable to bear weight on the foot. On examination, the patient had a large abscess beneath the skin of the foot. An incision (3 cm) was made, pus was drained and the wound was cleaned. The patient returned home with antibiotic (gatifloxacin; 400 mg twice a day for five days) and an anti-inflammatory agent.
X-ray examination showed no bony abnormality and inflammation was prominent around the smallest toe. Two days later, the patient’s foot was re-examined and debridement of the wound was performed to remove dead skin and necrotic tissue inside the opened cavity.
At all times during treatment, blood sugar level was controlled (in the range 150–170 mg/dL) using insulin. The patient was kept on metronidazole (1500 mg/day) and combined amoxicillin with clavulanic acid (1500 mg/day) for 10 days. Thereafter, ciprofloxacin (1500 mg/day) was used instead of the combined amoxicillin with clavulanic acid. Pentoxifylline, vitacid calcium (vitamin C and calcium carbonate) and vitazinc (vitamins A and E plus zinc) were added to the treatment regimen to aid vascularity and healing. From the beginning of treatment until the deep wound healed, the patient was maintained on an oral dose of bee propolis (400 mg/day). Erythrocyte sedimentation rate (a good indicator of treatment efficacy) was 125 mm prior to treatment and dropped to 65 mm after two weeks and 25 mm after four weeks, where it stabilized.
The most significant results were obtained during the use of the MPH paste (800 mg bee propolis, 50 g myrrh, mixed together in honey). The paste was prepared every three days and stored in a refrigerator. Wound cleaning was performed daily using standard methods in addition to the MPH paste to fill the wound cavity. The effectiveness of the paste in keeping the wound clean was indicated by a complete absence of pus and cellular exudate. After four weeks the wound had healed well and the patient returned to work.
Poor wound healing in people with diabetes is well recognized. However, there is little information about many aspects of foot care in people with diabetes, including wound healing. The American Diabetes Association suggests a range of predisposing factors to explain poor healing of wounds in people with diabetes, including abnormal cellular and/or inflammatory pathways, peripheral neuropathy and vascular disease and/or tissue hypoxia. Abnormal cellular function, particularly in fibroblasts and neutrophils, has been found in people with diabetes. In vitro, hyperglycaemia may be toxic to these cellular elements, while in vivo it may result in a greater susceptibility to infection.
Modest differences in the function of neutrophils, macrophages and fibroblasts associated with hyperglycaemia have been postulated, but these have not been demonstrated conclusively in vivo. Advanced glycosylation end products accumulate in diabetes as a result of hyperglycaemia, leading to the non-enzymatic glycosylation of collagen. This process results in the production of abnormal collagen, which is highly inflexible and prone to breakdown, particularly over pressure areas.
In this report, a paste is described that keeps a wound clean, which is especially important in cases that involve tissue loss. The MPH paste contains safe and effective components that have prominent antimicrobial activity.
Myrrh is an oleogum resin obtained from the stem of the plant Commiphora molmol. It is a safe, natural flavoring substance approved by the US Food and Drug Administration. In experimental studies on Swiss albino mice, myrrh from C. molmol exhibited no mutagenicity and proved to be a potent cytotoxic drug against Ehrlich solid tumor cells. The anti-tumor potential of C. molmol was comparable with that of the standard cytotoxic drug cyclophosphamide.14 Studies with animal and human models demonstrate anti-schistosomal and other anti-parasitic activity for myrrh and have found it to be safe and effective.
Myrrh has considerable antimicrobial activity and is used in a variety of diseases.17 It has antibacterial and anti-fungal activity against standard pathogenic strains of Escherichia coli, Staphylococcus aureus, Pseudomonas aeruginosa and Candida albicans.18 In addition, it has an anti-diabetic effect, especially in non-insulin-dependent diabetes mellitus (NIDDM).19 Moreover, Myrrh has found pharmacological application in the reduction of cholesterol and triglycerides.
Antimicrobial activity has been observed against S. aureus,22,23 Streptococcus pyogenes,24 Gram-positive and Gram-negative bacterial species and Candida species, S. mutans, anaerobic bacteria in the human oral cavity, salmonellas and other microorganisms including mycobacteria. Antibacterial activity of propolis against Staphylococcus aureus is higher when extracts are prepared in 60–80% ethanol. In vitro synergy between propolis and antimicrobial drugs has been investigated,31,32 and preparations combining propolis with antibiotic and anti-fungal agents are of potential medical interest.
Honey is an ancient remedy that has regained popularity as an alternative treatment for antibiotic-resistant bacteria. Both honey and sugar pastes are considered useful as topical antimicrobial agents, mainly because of their high osmolarity and the ability to minimize water availability to bacteria. Although the dilution of honey by wound fluid is likely to reduce the efficacy of its osmotic effect, the slow and sustained production of hydrogen peroxide by some types of honey (e.g., Manuka honey) is capable of maintaining an antimicrobial effect at a concentration approximately 1000-fold higher than that used commonly in antiseptic solutions (i.e., 3%). Also, certain components of Manuka honey (e.g., flavonoids and aromatic acids) demonstrate antimicrobial properties.
Honey is also an effective wound deodorant, an effect attributed to the presence of glucose, which is metabolized by bacteria in preference to proteinaceous necrotic tissue, resulting in the production of lactic acid and not the malodorous compounds generated by protein degradation. In addition, the observed benefits of honey in infected wounds may be attributed to the high glucose content and low pH, both of which stimulate macrophages.
In the present case study, application of MPH resulted in a clean and odor-free wound, which healed well. However, the results of this single case need to be confirmed in a study of a larger number of patients. In the meantime, use of the MPH paste would appear to reduce the cost of deep wound treatment and improve the outcome in the patients affected.