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Journal of Tissue Viability (2014) 23, 29e33

www.elsevier.com/locate/jtv

Case report

Honey based therapy for the


management of a recalcitrant diabetic
foot ulcer
Hashim Mohamed a,b,*, Badriya El Lenjawi b,
Mansour Abu Salma c, Seham Abdi c
a

Family Medicine, Weill Cornell Medical College, Qatar


Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
c
Primary Care Corporation, Doha, Qatar
b

KEYWORDS
Diabetic foot ulcer;
Honey based therapy;
Primary care

Abstract Objective: Diabetic foot ulcers are usually treated at hospital podiatry
clinics and not at primary care level. We report an alternative approach using honey
based therapy in the successful management of diabetic foot ulcer at primary
health care level.
Methods: The case is discussed in relation to various modalities targeting diabetic
foot ulceration in the literature.
Result: A 65 years old female-Egyptian diabetic patient presented with a neuropathic plantar ulcer of 10  5 cm post-thermal burn following the use of a hot water
bottle.
The patient was treated with strict offloading using a pair of crutches, debridement of necrotic tissue using a sharp scalpel and commercial honey applied daily
and covered with a glycerin based dressing. The honey dressing was changed daily
along with strict offloading and by week 16 the ulcer completely healed.
Conclusion: Treatment of diabetic foot ulcer is possible at primary care level.
2013 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.

Key points
* Corresponding author. Family Medicine, Weill Cornell Medical College, Qatar. Tel.: 974 55861008.
E-mail addresses: fmcc2000@gmail.com (H. Mohamed),
Blenjawi@hmc.org.qa (B. El Lenjawi), Abusalma2000@yahoo.
com (M.A. Salma), Sabdi@hmc.org.qa (S. Abdi).

Natural honey is an effective wound dressing.


Natural honey is cost effective and aesthetically acceptable.
Natural honey is bactericidal, provides moisture and debrides wounds.

0965-206X/$36 2013 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jtv.2013.06.001

30

H. Mohamed et al.

A case report
Diabetes-related foot complications are a major
burden for patients and society. Patients suffering
from diabetic ulcers are at increased risk of hospitalization, lower limbs sepsis and amputation [1,2].
As a result patients suffer from decreased quality of
life, decreased function and increased health care
cost [3e6].
Worldwide, the majority of diabetic patients
are being treated by family physicians thereby
playing a pivotal role in the management of diabetes and its related complications.
Managing diabetic foot ulcer requires an integrated health care delivery utilizing multiple
investigative and therapeutic modalities.
Although difficult to treat ulcers may require advanced biotechnologies including growth factors, the
majority of ulcers may respond well to conventional
therapies.
Honey has been used to treat wounds for millennia
[7] and this is further supported by its effectiveness
in promoting healing in animal and human studies.
Literature reviews, have been largely positive
with regards to the antibacterial properties of
honey especially against a wide variety of pathogens including Pseudomonas and methicillin-resistant Staphylococcus aureus (MRSA) [8e15].
Honeys antibacterial properties are related to
many properties including its hyperosmolarity, containing less than 20% water, its acidity (pH 3.5e5.0),
its release of hydrogen peroxide, flavonoids and
phenolic acids making bacteria unlikely to survive in
a honey based ulcer bed [16,17].
Honeys wound healing properties lie in its
ability to provide moisture in the ulcer bed thereby
aiding epidermal migration, providing trace nutrients and stimulating inflammatory cytokines (e.g.,
TN-a, IL-6, IL-1B) by macrophages [18e21].
Honey has been described in more than 500 reports in the literature and not a single complication with regards to clostridium spores wound
infection has ever been reported [22].

Figure 1

Plantar ulcer on presentation.

several conventional modalities were used


including a non-adhesive foam dressing containing
biotin, wet-to-moist dressing, Iodine based dressing & paraffin impregnated tulle and finally the
patient had a dressing utilizing a silver containing
alginate dressing (Sivercel-Systagenix).
All of which have failed to render desirable results. A holistic assessment of the patient by the
attending consultant family physicians found her
to have uncontrolled diabetes (HbA1C > 10%),
anemia (Hb 10.0) and suffering from hypertension and chronic obstructive airway disease. She
was commenced on insulin twice daily regimen,
given iron supplement, anti-hypertensive medications were stepped up to control her blood pressure and tiotropium inhaler a long acting
salbutamol/fluticasone accuhaler were prescribed
to control her chronic obstructive airway disease.
A wound assessment was carried out by the
attending consultant family physicians with the
following findings; the ulceration on initial presentation had the largest length of 10 cm  5 cm
being the largest perpendicular width (see Fig. 2).
The peripheral pulses were manually palpable
including dorsalis pedis & posterior tibial artery.

Case history
A 65 years old female patient, with diabetes of 25
years, BMI 23 kg/m2, ex-smoker, who sustained a
thermal burn to her right foot plantar surface
following the application of a hot water bottle to
treat the cold sensation felt in her leg secondary to
diabetic peripheral neuropathy see Fig. 1.
She had her plantar ulcer treatment throughout
her attendance at the main general hospital out
patient clinic for six weeks and was not improving,

Figure 2 Plantar ulcer showing hard callus around the


margin and necrotic areas in the center.

Honey based therapy for the management of a recalcitrant diabetic foot ulcer
This was further assessed by Doppler examination
which revealed strong, regular, triphasic foot pulse.
Neurological examination on the other hand revealed loss of vibration perception threshold using a
128 MHz tuning fork and this was further supported
by loss of protective sensation using the 10 g
monofilament indicative of sensory neuropathy in
both feet. Furthermore, the 10 g monofilament was
not used on any patient that day thereby maintaining its reliability & validity as a screening tool
for diabetic peripheral neuropathy.
A deep tissue biopsy was taken to rule out infection and was negative, similarly probing of the
ulcer was done at different areas since the ulcer was
relatively large and did not probe to bone thereby
practically ruling out osteomyelitis. This was done
since infection is known to slow wound healing, and
warmth, swelling and redness may be absent in
diabetic ulcers due to an altered immune state,
thereby making diagnosis difficult [23,24].
Furthermore, the negative predicative value of
56% for probing to bone indicates that a negative
test dose not exclude osteomyelitis. As a result, a
plain radiograph was done and was negative. However, plain radiography has sensitivity of 60% and
specificity of 60% respectively [25]. As a result we
opted to send the patient for an MRI since it has a
sensitivity of 99% and a specificity of 83% [26], which
was also negative.
The ulcer was cleaned with normal saline, necrotic tissues were debrided using a sharp scalpel.
This was followed by the application of natural honey
which was bought from a local shop importing natural
honey from Yemen. The natural honey used was a
homogenous set white honey produced by Russian
bees (Apis mellifera) which is native to the Primorsky
Krai region in Russia. The natural honey was applied
onto on the wound using a sterile spatula and covered
by (ADAPTIC-SYSTAGENIX) which is a non-adhering
dressing made of knitted cellulose acetate fabric
and impregnated with specially formulated petroleum emulsion. This was covered with a cotton wool
bandage and a light creb bandage cover.
The honey dressing provided moisture & antibacterial activity while the non-adherent a dressing
(ADAPTIC) minimized the risk of tissue damage upon
change of dressing. In this case the dressing was
changed on a daily basis with total offloading of the
ulcer using a pair of crutches which the patient
already utilized for a previous ankle sprain. An ordinary offloading material consisting of multiple
layered incontinence pad was applied around the
ulcer. This option was used since the patient was
managed at a busy primary care clinic in Qatar
where total contact casts (gold standard) are
unavailable, difficult to apply [27,28].

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This technique was used to redistribute and


relieve pressure from the ulcer site thereby facilitating the healing process and preventing further
tissue trauma. At each review (daily) appointment
the ulcer was debrided frequently and honey was
applied on a daily basis and the wound was
assessed for signs of infections.
At week 2 the ulcer looked healthy with areas of
granulation tissue which meant that our treatment
strategy did not need to be modified (see Fig. 3).
At week 3 dramatic improvement had taken place
with an evidence of an advancing healing edge with a
marked reduction in the ulcer size (>40%) and the
remaining of the ulcer appeared healthy with normal
skin (see Fig. 4). Progressive healing continued as
shown by the image at 5 weeks (see Fig. 5). The ulcer
is almost healed at week 6 (see Fig. 4) and by week 7
complete healing had taken place (see Fig. 6).

Discussion
Honey used in this case has provided moisture and
antibacterial activity thereby accelerating tissue
repair, causing less scarring and less pain [29,30]
and although a burning or stinging sensation has
been described with honeys topical use [17], in
our case no symptoms were reported by the patient which could be attributed to advanced diabetic peripheral neuropathy.
Many types of honey appear to be effective for
wound healing with varying antibacterial activities. The mechanism of action of honey seems to
stem from its hyperosmolar property containing
less than 20% water creating an osmotic gradient
thereby initiating a dual action in the wound bed.
Firstly, it depletes the bacteria of its water content leading to its death and secondly it draws fluid

Figure 3 Healthy granulation tissue with the center of


the ulcer showing new skin growth.

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H. Mohamed et al.

Figure 4
week 3.

Reduction of the ulcer by >40% in size by

from the edematous wound thereby enhancing


wound circulation [17].
Furthermore, honey possesses a potent enzyme
(glucose oxidase) which releases small amounts of
hydrogen peroxide enough to kill bacteria without
undermining the ulcer bed. Additionally, honey
provides essential trace elements which aid the
healing process [18]. All these properties included
in honey makes it an attractive cost effective and
viable option for treating diabetic foot ulcer.
Furthermore, resistance development by bacteria is
unlikely since studies have shown that honey, even
when diluted 10-fold or more prevents the growth
of a variety of organisms including bacteria [31].
Histologically, honey seems to enhance tissue repair
and growth in animal and human controlled trials
with reduced inflammatory reactions, enhanced
epithalization and earlier tissue repair [8,32e34].
Macroscopically studies have demonstrated the
debriding action of honey in a variety of wounds
including diabetic foot ulcers, burns, arterial ulcers and infected surgical wounds [35e38].

Conclusion

Figure 5

98% healing of the ulcer by week 5.

In our study we observed the effectiveness of


natural commercial honey in combination with a
hydroalginate and offloading in managing diabetic
foot ulcer at primary care level.
Currently, there is a paradigm shift in the fight
against the diabetes plague and its multiple comorbidities including diabetic foot ulcers, therefore primary care physicians must take a leading
role in this battle in order to improve quality of life
and safe individuals from amputations.
In summary, we present what to our knowledge
is the first case of honey based management of a
recalcitrant diabetic foot ulcer secondary to a
thermal burn being managed at primary care level
in this region of the world where diabetes has
reached epidemic proportions.

Conflict of interest statement


The authors hereby declare no conflict of interest.

References

Figure 6

Complete healing by week 7.

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