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Forsch Komplementmed 2015;22:00–00 Published online: February 9, 2016
DOI: 10.1159/000441994

Topical Application of Honey on Surgical Wounds:

A Randomized Clinical Trial
Peiman Goharshenasan a  Shahideh Amini b  Ali Atria a  Hamidreza Abtahi c  
       

Ghasemali Khorasani d   

a Plasticand Reconstructive Surgery Division, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran;
b
 Clinical Pharmacy Department, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran;
c
 Department of Pulmonary Care, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran;
d Department of Surgery, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
 

Keywords Schlüsselwörter
Honey · Surgical wound · Aesthetic result · VAS Honig · Operationswunde · Ästhetisches Ergebnis · VAS

Summary
Background: The antimicrobial and anti-inflammatory
activity of honey and its ability to accelerate wound heal­
ing make it an attractive option in surgical wound care.
We performed a randomized clinical trial to compare the
efficacy of honey dressing with conventional dressing
regarding the aesthetic outcome. Patients and Methods:
Bilateral symmetric incisions in randomly selected plas­
tic surgical patients were randomly covered postopera­
tively with conventional dressing and honey dressing for
five days. The aesthetic outcome of the two sides was
rated on a Visual Analog Scale by the surgeon and the
patient and compared at month three and six after sur­
gery. Results: Seventy two symmetrical incisions in 52
patients were evaluated during the study. The mean
width of the scar after the third and the sixth month was
3.64 +/– 0.83 mm and 3.49 +/– 0.87 mm on the side that
received honey dressing and 5.43 +/– 0.05 mm and
5.30+/– 1.35 mm in the control group. Wilcoxon signed-
rank test showed significant difference between honey
and conventional dressing outcomes at third and sixth
month (p < 0.001). Conclusion: The healing process of
the surgical wound and its final aesthetic result could be
improved by using honey dressing.
© 2016 S. Karger GmbH, Freiburg
Zusammenfassung
Hintergrund: Honig besitzt antimikrobielle und entzün­
dungshemmende Eigenschaften, die die Wundheilung
beschleunigen. Somit könnte der Einsatz von Honig auch
zur Beschleunigung des Heilungsprozesses nach chirur­
gischen Eingriffen nützlich sein. Wir führten eine rando­
misierte, kontrollierte Studie durch, in der die Auswir­
kung eines Honigverbands und einer herkömmlichen
Binde auf das ästhetische Ergebnis verglichen wurde.
Patienten und Methoden: Beidseitig symmetrische chi­
rurgische Schnittwunden bei zufällig ausgewählten Pati­
enten wurden postoperativ fünf Tage lang je mit einem
herkömmlichen und einem Honigverband behandelt.
Das ästhetische Ergebnis wurde von den Patienten und
den Chirurgen auf einer visuellen Analogskala (VAS) 3
und 6 Monate nach dem Eingriff beurteilt. Ergebnisse:
Zweiundsiebzig symmetrische Schnittwunden bei 52 Pa­
tienten wurden in die Studie einbezogen. Drei und sechs
Monate nach Eingriff betrug die mittlere Breite der
­Wunden 3,64 +/– 0,83 mm und 3,49 +/– 0,87 auf der Seite,
die mit einem Honigverband behandelt wurde und 5,43
+/– mm sowie 5,30 +/– 1,35 mm in der Kontrollgruppe.
Auch der Wilcoxon-Vorzeichen-Rang-Test ergab signifi­
kante Unterschiede zwischen den Ergebnissen unter An­
wendung eines Honigverbands und der herkömmlichen
­Behandlung (p < 0,001). Schlussfolgerung: Der Wund­
heilungsprozess nach chirurgischen Eingriffen sowie das
ästhetische Ergebnis könnten durch die Anwendung von
Honigverbänden verbessert werden.
198.143.33.33 - 3/14/2016 10:33:51 PM
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© 2016 S. Karger GmbH, Freiburg Ghasemali Khorasani, M.D.

1661–4119/16/0000–0000$39.50/0 Department of Surgery, Faculty of Medicine
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 Introduction
For thousands of years honey has been used to accelerate healing
of wounds, burns, and skin ulcers [1]. Its medical property has been
mentioned in different traditional writings [2–5]. However, it was in
the late 1980’s, when it was considered as a potential alternative to
antibiotics to treat wound infection [6–7]. Honey is a viscous, super-
saturated sugar-containing solution derived from nectar gathered
and modified by the honey bee. It is composed of a mixture of car-
bohydrates with small quantities of enzymes, vitamins, minerals as
well as amino and organic acids [7]. The exact composition depends
on the geographic area and the plants on which the bees have been
feeding [7]. The antimicrobial activity of honey, its ability to speed
up the process of wound healing, and the low-cost production make
honey an attractive alternative option in wound management.
We performed a randomized clinical trial to evaluate the effi-
cacy of applying honey dressing on surgical wounds and evaluated
the aesthetic outcome by ratings of both the surgeon and the pa-
tient on a VAS (Visual Analog Scale).
Patients and Methods
September 2011 and September 2013. The right- and left-sided incisions in each
patient were randomly covered postoperatively with conventional dressing and
honey dressing using a block randomization. Patients with a history of psy-
chotic disorders or allergy to honey/bee products and those suffering from dis-
eases that could interfere with wound healing such as diabetes, renal failure,
malnourishment, and cancer were excluded from the study.
The honey was obtained from Uraman area (Kordestan Province, Western
Iran) and sterilized by gamma irradiation (25kGY) to eliminate bacterial spores.
After the closure of the operation, when the patient was under anesthesia, the
surgical wound was covered randomly with a three-millimeter honey dressing
on one side of the incision and a sterile piece of petrolatum-impregnated gauze
on the opposite side, both followed by a low-adherent dressing. The patient and
the observer surgeon were both blind to the type of dressing. On the 5th day
after surgery, the dressings were removed by the surgeon in charge. Three and
six months after surgery, the aesthetic outcome was rated semi-quantitatively
on a VAS by the patient and the observer surgeon (1 = poor, 2 = fair, 3 = good,
4 = excellent). Also, the width of the scar was measured and the results were re-
corded. If the incisions were complicated by infection or dehiscence, they were
managed by conventional treatments.
The study protocol was approved by the Ethics Committee of Tehran Uni-
versity of Medical Science and informed written consent was obtained from all
the participants after study registration (IRCT201102085781N1).
Paired t-test was used to compare the scar width and Wilcoxon signed-rank
test to compare VAS score three and six months after surgery. The data were ana-
lyzed using SPSS software version 18 and p < 0.05 was considered significant.

The patients who underwent an elective plastic surgery at Vali-Asr Hospital, Results
a tertiary university hospital in Tehran, with incisions that could be divided in
two symmetric right- and left-sided parts, were included in this study between
Seventy-two symmetrical incisions in 52 patients were evaluated
during the study (table 1). Mean ± SD (standard deviation) of the
patients’ age was 34 ± 3 and all of them were female. Three (two
Table 1. Frequency of different surgical procedures
mammoplasty and one abdominoplasty) patients with five bilateral
Surgical procedures Patients, n Pair incisions, n incisions and seven patients (four mammoplasty, two abdomino-
Mammoplasty 20 35* plasty, and one breast prothesis) with eleven bilateral incisions
Abdominoplasty 21 21 dropped out of the study because they did not return for follow-up
Mammoplasty and abdominoplasty  4  8 visits three and six months after surgery.
Breast prosthesis  4  4 Table 2 shows the patients’ and surgeons’ ratings of the aesthetic
Mastopexy  1  2*
result at month three and six after surgery (VAS). Most results
Face incision  2  2
have been scored by the surgeons and patients as excellent or good
Total 52 72
in the honey dressing group and fair or poor in conventional dress-
*
In 15 patients with mammoplasty and one patient with mastopexy, right and ing group (table 2, fig. 1). Wilcoxon signed-rank test showed sig-
left incisions were divided into two equal parts, one part covered with honey
nificant difference between honey and conventional dressing
dressing and the other part with conventional dressing.
groups at third and sixth month (table 2).

Table 2. Comparison of surgeons’ and patients’ ratings of honey vs. conventional dressing at follow-up visits on a VAS

VAS score By surgeon By patient By surgeon By patient

after 3 months, n (%) after 3 months, n (%) after 6 months, n (%) after months, n (%)

Honey Conventional Honey Conventional Honey Conventional Honey Conventional

dressing dressing dressing dressing dressing dressing dressing dressing

Excellent 11 (16.67)   1 (1.51) 10 (14.93)   3 (4.48)   7 (11.07)   0 (0)   6 (9.84)   0 (0)

Good 52 (78.79) 18 (27.27) 54 (80.60) 17 (25.37) 51 (85)   0 (0) 51 (83.61) 19 (31.15)
Fair   3 (4.45) 45 (68.18)   3 (4.48) 43 (64.18)   2 (3.33) 21 (35)   4 (3.56) 40 (65.57)
Poor   0 (0)   2 (3.13)   0 (0)   4 (5.97)   0 (0) 39 (65)   0 (0)   2 (3.28)
Total 66*(100) 67 (100) 60*(100) 61 (100)

*One patient was not scored by the observer surgeon.

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Fig. 1. Comparison of surgeons’ and patients’
ratings of honey vs. conventional dressing at fol-
low-up visits on a VAS.

Table 3. Frequency of surgical complications in honey dressing and conven- flammatory state, i.e. 24 h after the injury, leukocytes, chemotactic
tional dressing group factors, cytokines, growth factors, and free radicals enter the
Complication Honey dressing Conventional dressing wound and persist up to 2 weeks [8–9]. Regarding the high con-
group, n (%) group, n (%) centration of sugar, honey is a hygroscopic substance that draws
fluid from the underlying wound. Thus it creates a moist wound
Marked erythema   10 (7.75)   52 (40.31)
Dehiscence   0 (0)   16 (12.40) while protecting the skin from maceration and kills bacteria by de-
Infection   3 (2.33)   6 (6.20) hydration [10–11]. Moreover, honey produces a consistently low
No complication 116 (89.92)   53 (41.09) level of hydrogen peroxide that has antimicrobial effects, but is
Total 129 (100) 127 (100) non-toxic as compared to 3% hydrogen peroxide solution which is
considered harmful due to its inflammatory and toxic impact on
cells [12, 13]. Honey has also anti-inflammatory properties which
have been comprehensively observed in clinical contexts and in
The mean width of the scars at month three and six was 3.64 animal models [13–18]. The wound healing properties of honey
+/–0.83 mm and 3.49+/– 0.87 mm on the side that received honey are based on a stimulation of angiogenesis, granulation, and epi-
dressing and 5.43 +/–0.05 mm and 5.30+/–1.35 mm in the control thelialization found in animal models [18–21]. Bacterial coloniza-
group (p < 0.001). Marked erythema was considered as surgical tion is often accompanied by PH level >7.3 in wound exudates [18,
complication, while mild erythema was ignored. In this regard, the 22, 23]. Also, protease activity which hampers the wound healing
application of honey dressing led to significant lower frequency of process via destroying growth factors, protein fibers, and fibronec-
complications (P<0.001). The most frequent complication in both tin in wound matrix optimally acts at a neutral PH level [16, 20].
groups was erythema followed by infection in the honey dressing Low pH level of honey (about 3.4–5.5) decreases bacterial coloniza-
group and dehiscence in the control group (table 3). tion and speeds up wound healing by increasing the amount of ox-
ygen offloaded from hemoglobin in the capillaries and suppression
of protease activity [11, 18, 24].
Discussion In a systematic review [10] on honey as a topical treatment for
wounds, only two randomized trials were identified, in which
In this randomized clinical trial, we evaluated the impact of honey was applied on toenail surgical wounds with no significant
honey dressing on aesthetic appearance of plastic surgery incisions difference to conventional dressing. In two clinical trials [7, 26],
in comparison with conventional dressing. Enhanced aesthetic re- wound size decreased significantly during the study period by
sults were observed at the third and sixth month from both pa- using MedihoneyTM. However, the treatment effect was influenced
tients and surgeons. by factors such as sex, wound type, age, and wound area at the start
This shows that the later appearance of surgical incisions exten- of the treatment [7]. Both author teams concluded that future com-
sively depends on the healing process in the first few days. Wound parative trials are still needed to evaluate the exact role of honey in
healing is a complex process. The inflammatory phase has the wound care. By now, there is little progress in aesthetic appearance
greatest impact on the desirable healing process. In the early in- of plastic surgical incisions.
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Topical Application of Honey after Surgery Forsch Komplementmed 2016;23:00–00

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 Conclusion
In this study, we applied honey and conventional dressings on
bilateral symmetric incisions. In terms of the aesthetic result,
honey was shown to be more effective than the control. A high sta-
tistical power is an important prerequisite to adequately evaluate
the effects of honey in wound healing.
Honey from different sources and geographic areas vary in
chemical properties. MedihoneyTM (approved by the Food and
Drug Administration and one of the first medically certified hon-
eys licensed as a medical product for professional wound care in
Europe and Australia) was shown to be an effective treatment in
speeding up wound healing of different natures [7, 18, 26, 27]. Al-
though still not standardized, we used irradiated honey from the
Uraman area showing good would healing properties in plastic
surgical incisions. Furthermore, surgical complications including
marked erythema and dehiscence reduced significantly after the
application of honey dressing. According to the results of this
study, we recommend five days of application of honey dressing to
speed up the wound healing process and to enhance the desired
aesthetic result in plastic surgery incisions.
Disclosure Statement
The authors declare that there is no conflict of interests regarding this
paper.

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