I cram for TAM, and, combined with other commitments, not the least of which is that it is finally sunny and warm in Portland, after a year that has resembled All the Summer in a Day,  which leads to a relatively short post.  There are just so many hours in a day and if possible those days need to be spent in the sun.

In my first year in practice I was sitting on a nursing station writing a note when a patient started howling in pain.  Further investigation revealed that the patient had a chronic, open surgical wound and the (old) surgeon had ordered sugar poured into the wound as part of wound care.  The cafeteria mistakenly sent up salt, and a metaphor became reality.  It did pique my interest in both sugar and honey for wound care,  an area where you have to be careful not to fall prey to all the errors in CAM thinking: a reliance on anecdotes, using suboptimal studies as evidence, mistaking a gobbet of basic science as a meaningful clinical application, and not realizing the warping effect of confirmation bias.

That being said, I have suggested honey and sugar for years for patients, and many patients with prior refractory wounds had healing.  And what are the three most dangerous words in medicine?  In my experience.  I have recommended honey less in the era of the wound vac, but there are not an insignificant number of people with insufficient financial resources who cannot afford even simple wound care supplies. Many  of the ointments, creams and special bandages for wound care costs too much.  Patients also like honey as it is natural (people do love to fall for the naturalistic fallacy) and inexpensive, and I always tell patients that the data is iffy, but not stupid.

Wound  itself is mostly a combination of tradition and hype.  One doc learned from his attending who learned from their attending, in a line that stretches back to the first barber-surgeon.  I was told as a medical student, never put in a wound what you wouldn’t put in your eye, which seemed to be a good guiding principle, although it is expensive to pack a wound with soft contact lenses.  New products, often combinations of old treatments, come out monthly with flashy brochures and little good data.

“There is a lack of large, high-quality published RCTs evaluating debridement per se, or comparing different methods of debridement for surgical wounds, to guide clinical decision-making. ”

So I rely on basic principals. Keep the wound clean, keep the new tissue from drying out, remove the dead meat, and keep the bacteria at bay, and do not let your pet lick it are more or less guiding rules in wound care.  That, and no matter what you do, most people will heal.  My rule remains: take credit for success, blame nursing when things go wrong.  That’s ‘humor’ for the sarcasm impaired.

What is the rationale for sugar and honey for wounds and burns?

Basic Biologic Plausibility

The first is mechanism of action is primarily mechanical.  The high osmolality of sugar and honey prevents bacterial overgrowth.  Food can be preserved in sugar (jam is a good example) so the honey and sugar can prevent or decrease bacterial colonization of wounds.  Honey has a low pH and contains hydrogen peroxide, both of which are antibacterial, but I doubt clinical relevance of the latter.  And there may be bee and flower constituents that aid in antibacterial properties, although again I wonder about clinical relevance. Also, sugar and honey do not damage new tissues and when the honey is washed off, it painlessly removes the dead tissues with it, so it is good for debridement.

Honey, and to make sure you can charge a premium amount call it medical grade honey, can kill bacteria and decrease skin colonization.  Avoid raw honey, as it can contain C. botulinum and has been the source of botulism in children.  I don’t expect it would be of much use on facial wrinkles

At least from a basic science perspective, honey and sugar have mechanical, perhaps biochemical, and certainly financial, reasons it could be beneficial in wound care.

Clinical trials

So how are the clinical trials? There are lots of poor quality studies.  Almost 400 references if you are in the mood for cherry picking.  The preponderance of the poor quality studies points to benefit.

For burns?

“Available evidence indicates markedly greater efficacy of honey compared with alternative dressing treatments for superficial or partial thickness burns, although the limitations of the studies included in the meta-analysis restrict the clinical application of these findings.”

and

“Honey may improve healing times in mild to moderate superficial and partial thickness burns compared with some conventional dressings”

For Wounds?

From the ever helpful  and potentially flawed Cochrane reviews:

Honey dressings as an adjuvant to compression do not significantly increase leg ulcer healing at 12 weeks. There is insufficient evidence to guide clinical practice in other areas.

and as they note

The poor quality of most of the trial reports means the results should be interpreted with caution.”

So be it.  I have read many of the 400 references over the years, and the sense is that honey is of some value in wound care.

There is even less information of granulated sugar, where it looks encouraging and has been used to treat mediastinitis , diabetic foot ulcers and sloughing wounds.

Of course, honey is not the end all and bee all of treating soft tissue infections. Depending on the process, surgery and antibiotics will do far more to resolve the infection and promote healing, espcially for acute and/or acutely infected wounds. Relying on only natural products has lead to one death in a complimentary practitioner who treated himself with honey:

“a minor injury became infected with gangrene, the judge was told. He died, aged 52, in April 2007. Instead (of standard care)  he used honey and magnesium sulphate.”’

The doctor who treats themself has a fool for a patient and an idiot for a doctor.

So in the end, do I recommend honey and sugar?  Yes.  The literature is interesting and I give patients a long  list of caveats.  It is maybe sort of probably useful in patients with chronic wounds who cannot afford other interventions.  In my experience it always works.  Back to TAM.

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