Has Medical graded Honey a proven therapeutic value on wound care - Essay Example

Healing of wounds, expecially chronic wounds like long standing venous ulcers are a major challenge to sugeons. The of these wounds is burdened with the long healing times, small healing rates, increased sloughing, increased infection and increased cost to treatment. Many materials have been used to treat long standing wounds. However, recent surge in the search for newer wound care products which are more effective and cheap has led to the re-discovery of the traditional natural wound healing agent, honey. There are many studies which have been conducted to evaluate the benefits and side effects of honey therapy. In this review, these aspects of wound therapy with respect to medihoney have been explored through review of literature pertaining to this topic. The review was conducted after retrieving articles through PUBMED and subjecting them to critical analysis and content analysis. The study concludes that honey is a useful wound care product with good healing time and healing rate, with added property of antimicrobial activity. It is also a cheap product and has fewer side effects.. Role of Honey in Wound Therapy- A Literature Review Aim To ascertain if medical graded honey has a therapeutic value in would care and management. Objectives To evaluate the benefits, side effects and contraindications of use of medically graded honey for the purpose of wound care and healing. Rationale/Background Wounds are a costly source of suffering (Stillman, 2009). More so is the case with chronic wounds. This is because many factors play an important role in the healing of wounds and disturbace in the normal healing processes can cause delay in wound healing contributing to significant morbidity and mortality. The corner stone of wound care therapy is prevention of infection and facilitation of wound healing. Conventionally, there are many methods of wound healing and many substances have been used to enhance the process of wound healing and at the same time prevent infection. Some such wound dressing material are alginate, hydrofiber, debriding agents like hypergel and accuzyme, foam, hydrocolloid and hydrogel (Stillman, 2009). Recent search for novel methods of wound healing has led to the recognition of medically graded honey as a useful wound dressing material. Traditionally, honey has an important place in natural medicine as a remedy for many condtions like wound. Current research in the usefulness of honey in the management of wounds has made modern scientists research into the various applications of honey in modern medicine. Honey is a natural sweet material that is produced by honey bees from the secretions of various parts of living plants. It is defined as "the nectar and saccharine exudation of plants, gathered, modified and stored as honey in the honeycomb by honeybees, Apis melifera" (Olaitan, Adeleke, Oha, 2007). Many published studies have proved that honey application to wounds clears the infection of the wounds rapidly without any prolongation in wound healing. Infact, there are some reports that honey promotes active wound healing. Research in the antimicrobial action of honey has shown that the substance has many antimicrobial properties against various bacteria like pseudomonas aeruginosa which is resistant to antibiotics (Olaitan et al, 2007). Researchers are often perplexed by the beneficial effects of honey because it is the medium for many organisms like bacteria and yeast. The material is made up of mainly water and sugar. Other than these compounds, honey also has minerals, enzymes which have their origin from the saliva of the bees, and multivitamins. Honey has a characteristic taste and composition. It is highly viscous, acidic, hygroscopic and hyperosmolar (Olaitan et al, 2007). Thus the microorganisms which are present in honey are those which survive the physical and chemical properties of honey. They are mainly bacteria like Bacillus and Micrococcus and yeast like saccharomyces which come from bees, nectar and comb material (Olaitan et al, 2007). Research has shown that most of these microorganisms are in the dormant stage in the material and cannot grow or reproduce in that medium (Olaitan et al, 2007). Majority of these bacteria lose viability within 1-4 weeks (Olaitan et al, 2007). Those who continue to survive are spore forming organisms like clostridium species and bacillus cereus which can survive over 4 months to one year when stored in room temperature. Addition of water to honey supports the growth on various non-pathogenic organisms which inturn can kill pathogenic strains (Olaitan et al, 2007). Some of the bacterial strains which have been found to be affected by honey are those of shigella, salmonella, E.coli, V.cholera and many other gram positve and gram negative organisms. The cause for high microbicidal activity of honey has been attributed to certain phytochemical properties of honey along with acidity, high osmolarity and presence of hydrogen peroxide (Olaitan et al, 2007). The pH of honey is between 3.2 to 4.5 which is much below the survival and growth pH requirements of many organisma. The hydrogen peroxide is produced enzymically in the honey due to the action of glucose oxidase from the hypopharyngeal gland of bee. Research has thrown light on another impotant property of honey that destroys the bacteria (Olaitan et al, 2007). It has been found that low concentrations of honey stimulate the proliferation of immune cells like the B-lymphocytes, T-lymphocytes, monocytes and phagocytes and triggers the release of various mediators inflammatory mediators like cytokines, interleukins and tumor necrosis factor which not only fight infection but also enhance would healing (Olaitan et al, 2007). Though honey is easily available in the market in any store, the kind of honey that had been established for medical uses is the one which is is a mixture of different Leptospermum spp. honey, commonly known as Manuka, Tea tree, Jelly Bush and Goo Bus (Simon, Traynor, Santos, Blaser, Bode, and Mola, (2007). Prior to distribution for medical purposes, the standard antibacterial activity will be predetermined by invitro testing and then gamma irradiated to kill any clostridium spores than may be present. It is important to use only irradiated honey for wounds because clostridium can multiply in the anerobic environment of wounds can cause botulinism (Simon et al, 2007). With this background, the following literature review was conducted. Inspiration from reflection The observation made by the reviwer during clinical practice placements in surgical wards inspired him to this literature review. Also, the fact that many studies have demonstrated the wonderful benefits of honey therapy on wounds has intrigued him to take up this topic for literature review. As Burns and Grove (1997) stated, clinical experience frequently gives rise to the identification of a research topic and expands scope for reflection. Reflective practice is essential to clinical practice and provides a retrospective look at current practice and questions the reason for doing so. Thus, it is because of reflection that the reviewer was able to raise questions which prompted to this literature review. In this topic, the main questions that shall be addressed are whether honey therapy heals wounds faster than conventional wound therapy? If so, does it prevent infection in the wounds too? Also, is it cost effective? Does honey therapy cause increased patient satisfaction when compared to conventional wound therpies? Methods The commencement of search in electronic databases was based on the inclusion/exclusion criteria and knowledge of the hierarchies of evidence. As Benton & Cormack (2000) mentioned, electronic databases are resourceful in presenting large amounts of recently published literature. For the purpose of this review, articles were retrieved from electronic database PUBMED by using the search terms "honey" "medihoney" "wound care". A total of 69 articles appeared with a combination of these MESH words. From these, based on the inclusion and exclusion criteria, articles were selected after scanning through the abstracts of all the articles manually. Totally 6 articles were selected. The inclusion criteria are: 1. Articles published in English Language or those translated into English only were included because of the lack of knowledge of other languages by the reviewer. 2. Articles which are trials (randomised control trial), because they provide level-1 eveidence. 3. Articles published beyond 2004 only were considered to include latest information regarding the subject. 4. Research conducted on humans only 5. Mainly full text articles were considered for the study. In cases where full text articles are not available abstracts were used as proxy to full text articles. The exclusion criteria are: 1. Articles not related to honey therapy for wound care or those related to these but are mainly descriptive or essay type were excluded in the study. 2. Articles published before 2004 3. Articles not presented in English 4. Articles posted anonymously in the internet were also excluded because these articles not necessarily impart genuine and authentic knowledge. 5. Articles on general wound therapy were also excluded because of lack of topic oriented discussions. Hierarchy of evidence To consider what articles must be included in the review to make the review more authentic and reliable, knowledge on the different levels of accorded studies is essential. The different levels of studies are called hierarchy. Hierarchy provides a confidence measure to the end-user (Evans, 2003). According to Evans (2003), random control trials can be considered of good standard and they are infact labeled as the gold standard of research for providing optimal research designs to answer pertinent questions. However, systemic reviews and meta-analysis have topped the hierarchy list. In this literature review, randomised control trials were chosen for review. The following articles were selected for the purpose of review of literature and critical analysis. 1. Ingle, R., Levin, J., Polinder, K. (2006). Wound healing with honey – a randomised controlled trial. SAMJ, 96(9), 9-14. 2. Robson, V., Dodd, S., and Thomas, S. (2009). Standardized antibacterial honey (Medihoney) with standard therapy in wound care: randomized clinical trial. J Adv Nurs., 65(3), 565-75. 3. Gethin G, and Cowman, S. (2009). Manuka honey vs. hydrogel--a prospective, open label, multicentre, randomised controlled trial to compare desloughing efficacy and healing outcomes in venous ulcers. Evid Based Med., 14(5), 148. 4. Gethin, G., and Cowman, S. (2008). Bacteriological changes in sloughy venous leg ulcers treated with manuka honey or hydrogel: an RCT. J Wound Care, 17(6), 241-4. 5. Jull, A., Walker, N., Parag, V., Molan, P., Rodgers, A. (2008). Honey as Adjuvant Leg Ulcer Therapy trial collaborators. Randomized clinical trial of honey-impregnated dressings for venous leg ulcers. Evid Based Nurs., 11(3), 87. 6. Mcintosh, C.D. and Thomson, C.E. (2006). Honey dressing versus paraffin tulle gras following toenail surgery. J Wound Care., 15(6), 257. Review and Critical appraisal of the selected studies Evaluation and critical review of the 8 selected papers was done. Duffys research appraisal checklist approach and Critiquing nursing research (Cutcliffe 2003) were used for this purpose. Duffys research appraisal checklist approach was used because it mainly gauges the methodological rigour, exposition, validity and credibility of the studies. Study-1: Ingle, R., Levin, J., Polinder, K. (2006). Wound healing with honey – a randomised controlled trial. SAMJ, 96(9), 9-14. The study by Ingle, Levin and Polinder (2006)compared 2 wound healing agents, honey and hydrogel (IntraSite Gel) with respect to side-effects, patient satisfaction and cost-effectiveness. The study was a prospective randomised control double-blind trial carried out among goldmine workers with shallow, uncomplicated, small size wounds and abrasions. The results of the study showed that healing time following application of honey to wound was similar to that of hydrogel. The hydrogel used in this trial was Intrasite gel. Infact, after adjusting to wound size, there was a 2.8 day advantage with honey therapy which is statistically not significant. This difference was not noticed in abrasive wounds. As far as side effects were concerned, 27 percent of patients treated with honey complained of itching and 10 percent of them complained of pain. Similar reports were seen with hydrogel. 31 percent of the patients treated with hydrogel reported itching. Patient satisfaction-wise, both patient groups were satisfied to the same extent. The most important difference was noted in the cost for treatment. The treatment with honey was atleat 25 times lower than the treatment with hydrogel. Based on these results, the authors concluded that for shallow wounds and abrasive wounds, both honey and hydrogel are equally effective healing agents and considering the enormous cost effectiveness of honey, this substance serves as a useful wound thrapeutic agent in shallow wounds and abrasive wounds.The study was conducted on uninfected, uncomplicated, small wounds and in these wounds the main purpose of wound therapy is to initiate and fasten healing. Study 2: Robson V., Dodd, S., and Thomas, S. (2009). Standardized antibacterial honey (Medihoney) with standard therapy in wound care: randomized clinical trial. J Adv Nurs., 65(3), 565-75 Robson, Dodd and Thomas (2009) conducted a randomised control trial to compare the benefits of medical honey wound therapy with conventional therapy in cchronic wounds which heal by secondary intention. In their study, they found that healing time for those treated with honey therapy was 100 days as against the healing time of 140 days in the control group. At the same time, the rate of healing also was higher in the honey care group in which 46.2 percent of the cases showed healing rate at 12 weeks as against healing rate of 34 percent in the conventional group. Following adjustment of the treatment effect for confounding factors like wound type, sex, age and the clinical features of wound area at the begining of the treatment, the hazrd ratio was determined to be 1.52 which was not statistically significant. The study concluded that honey has some clinical benefits in wound care, but recommendation of its use is warranted by further research. Study 3: Gethin G, and Cowman, S. (2009). Manuka honey vs. hydrogel--a prospective, open label, multicentre, randomised controlled trial to compare desloughing efficacy and healing outcomes in venous ulcers. Evid Based Med., 14(5), 148. The benefits of honey when compared to hydrogel wound therapy is further enhanced by the study by Gethina and Cowman (2009) who conducted a prospective multicenter open label randomised controlled trial to study the benefits of honey therapy in comparison with hydrogel therapy. The outcomes mainly measured in this study were desloughing efficacy after four weks of initiating treatment and healing outcomes after 12 weeks. The study was conducted in patients with long standing venous ulcers having atleast 50 percent wound area covered with slough and not on any antibiotic therapy or immunosuppresant therapy. In both the groups, treatment was applied once a week for four weeks and final comparison and evaluation was done at 12 weeks. As early as 4 weeks of therapy there was significant improvement noticed in the honey group (67 percent) when compared to the hydrogel group (52.9 percent). Also, in the honey therapy group, the reduction of slough was significant and was at 29 percent when compared to 43 percent for the group treated with hydrogel. Another benefit of honey therapy noted in this study was the reduced number of patients who contracted infection when compared to the hydrogel group. The incidence of infection in the hydogel was 100 percent more than the infection in honey group. The authors opined that Manuka honey was useful in the treatment of chronic would infection and cause desloughing which enhanced healing. Stydy 4: Gethin, G., and Cowman, S. (2008). Bacteriological changes in sloughy venous leg ulcers treated with manuka honey or hydrogel: an RCT. J Wound Care, 17(6), 241-4. Gethin and Cowman (2008) conducted a prospective open label multicentric randomised control trial to evaluate the bacteriological changes following application of honey for wound therapy in comparison with the standard hydrogel therapy. The study included chronic venous wounds with atleast 50 percent sloughs. Swabs from the wound were taken prior to institution of therapy and after 4 weeks of therapy to evaluate quantitative microbiological changes following wound care. A total of 108 patients were enrolled in the study. Of these, 18 patients were excluded due to wound infection. the base line infection state was eveluated by microbiological testing and culture. The most common isolate was staphylococcus aureus which was found in 38 percent of the wounds. Methicillin resistant staphylococcus were found in 16 wounds, 10 of which belonged to the honey group, prior to initiation of therapy. Another significant pathogen which was found was psuedomonas aeruginosa which was found in 14 percent of all wounds. After the microbiological evaluation, the wounds were subjected to wound care therpay. Medicated honey was applied to the study group while hydogel was applied to the control group. Four weeks after initiation of therapy, the swabs from the wounds were gain subjected to microbiological evaluation. This evaluation revealed that methicillin resistant staphylococcus aureus was eradicated better in the honey group (70%) as against control group (16%). However, pseudomonas aeruginosa was better eradicated in the hydrogel treated (50% as against honey-33%) group. One interesting finding of this study was that though the above microorganisms got eradicated, the number of bacteria species in the wounds remained the same over four weeks. The study concluded that manuka honey was effective in controlling the growth and spread of various pathogenic bacteria including pseudomonas aeruginosa and methicillin resistant staphylococcus aureus similar to the microbiological effects of hydrogel. Study 5: Jull, A., Walker, N., Parag, V., Molan, P., Rodgers, A. (2008). Honey as Adjuvant Leg Ulcer Therapy trial collaborators. Randomized clinical trial of honey-impregnated dressings for venous leg ulcers. Evid Based Nurs., 11(3), 87. This study evaluated the usefulness of honey wound care over standard wound care in terms of wound healing rates, wound healing time, change in ulcer area, incidence of infection, cost to treatment, quality of life and adverse effects to treatment. The study was a community based open label randomised trial counducted in patients with long standing venous ulcers. The study group had 187 participants and were administered calcium alginate dressings impregnated with manuka honey. The control group received usual care. The therapies were insituted for 12 weeks. Analysis was done on intention-to-treat basis using statistical software. The results revealed that healing was observed in 55.6 percent in the usual care group and 49.7 percent in the honey therapy group. Also, treatment with honey was more expensive (95% CI: 1.1 to 1.6) and had higher risk of adverse events. No significant differences was noted as far as wound healing time, change in ulcer area and quality of life were concerned. Study 6: Mcintosh, C.D. and Thomson, C.E. (2006). Honey dressing versus paraffin tulle gras following toenail surgery. J Wound Care., 15(6), 257 This study was aimed to study the benefits of honey wound care therapy in comparison with paraffin dressing. The study was a double-blind randomised controlled trial conducted in patients who underwent matrix phenolisation for toenail surgery. The primary outcome of the study was the time taken for complete re-epithelialisation of the nail bed. For the study group, active manuka honey dressing was applied for the wound and for the control group, paraffin-impregnated tulle gras was applied. The mean healing times for both the groups were similar; 40.3 days for the study group and 39.98 days for the control group as far as complete avaulsion wounds were concerned while partial avulsion wounds healed faster with paraffin therapy than honey therapy. The study concluded than honey therapy was inferior to paraffin therapy in partial toenail avaulsion, but was similar in case of total avulsion therapy. Study/Yr Type Case vrs. Control Wound type Outcome Result Ingle et al, 2006 RCT Honey/hydrogel Shallow, small, uncomplicated Healing time P=0.75, 95% CI: -5.41; 7.49 days Side effects Itching Pain Honey-27%, gel- 31% Honey-10% Robson et al, 2009 RCT Honey/conventional wound dressing Chronic wounds Healing time Healing rate 12wk Honey-100d Control-140d Honey-46.2% Control-34% 95%CI-12.2%(-13.6%, 37.9%). Gethin and Cowman, 2009 RCT Honey/hydrogel Sloughy venous leg ulcers Reduction in slough size at 4 wk Mean area covered with slough at 12 wk Healing rate at 12wk Infection Honey-67% Hydrogel -52.9% (p = 0.054) Honey- 29% Hydrogel- 43% (p= 0.001) Honey- 44% Hydrogel- 33% (p=0.037) Incidence double in hydrogel as against honey Gethin and Cowman, 2008 RCT Honey/hydrogel Long standing venous ulcers with min.50 % slough MRSA colonisation Pseudomonas colonisation Honey- Eradicated at 4 wk in 70% Hydrogel- Eradicated at 4 wk in 16% Honey- Eradicated at 4 wk in 33% Hydrogel- Eradicated at 4 wk in 50% Jull et al, 2008 RCT Honey/usual care Venous ulcer Healing at 12 wks Honey- 55.6% Usual care- 49.7% (95% CI: -4.3 to 15.7) (p= 0.258) McIntosh and Thomson, 2006 RCT Honey/paraffin Surgical toenail avulsion Healing time Healing time in partial avulsion wounds Healing time in total avulsion wounds Honey- 40.3 days (SD 18.21) Paraffin- 39.98 days (SD 25.42) Honey- 31.76d Paraffin- 19.63d (p=0.001) Honey- 45.28d Paraffin- 52.03 (p=0.21) Table-1: Review of selected studies. Literature analysis and emerging themes The aggregation of the findings from the literature was done by content analysis. The reviewer of this study carried out a content analysis of the findings from the nominal papers by looking at relationships among ideas or concepts, reality and language (Burns and Grove 1997). Categorisation of common themes was done in this review by the reviewer. The literature review presented in this paper is mainly interpretative. Medihoney and effects on wound healing In the study by Ingle et al (2006) on shallow and abrasive wounds, the healing time of honey therapy was 2.8 days ahead of the healing time for hydrogel. In Robson et als study (2009), secondary healing time for chronic wounds treated with honey therapy was 100 days as against the healing time of 140 days in the control group. The desloughing efficacy of honey was also proved to be high when compared to conventional dressings. Gethina and Cowman (2009) reported that in long standing venous ulcers, the reduction of slough was significant and was at 29 percent when compared to 43 percent for the group treated with hydrogel. Improvemnt in the wound after 12 weks of therapy was noticed in 67 percent of patients treated with honey as against 52.9 percent patients treated with hydrogel group. In the study by Jull et al (2008) on long standing venous ulcers, healing after 12 weeks of therapy was observed only in 49.7 percent of those treated with honey as against those treated with usual care. McIntosh and Thomson (2008) reported that healing time with honey therapy was as effective as that with paraffin dressing as far as completion avulsion wounds were concerned. In partial toenail avulsion, honey therapy was not as effective as hydrotherapy. Medihoney and effects on wound infection In the study by Gethina and Cowman (2009), the number of patients who contracted infection of long standing venous ulcers was significantly less when compared to the hydrogel group. The incidence of infection in the hydogel was 100 percent more than the infection in honey group. In the study by the same authors in 2008 during which time microbiological aspects of wound therapy were studied, honey therapy eradicated colonisation with methicillin resistant staphylococcus aureus. It was not effective in eradicating peudomonas aeruginosa. However, complete decolonisation was not possible with other species of bacteria. Medihoney and adverse effects In the study by Ingle et al (2006), 27 percent of patients treated with honey complained of itching and 10 percent of them complained of pain. However, similar reports were produced from the control group treated with hydrogel. Jull et al (2008) gave a different opinion. In their study on long satnding venous ulcers, they found that side effects were more with honey than with usual care. Medihoney and cost effectiveness In the study by Ingle et al (2006), the treatment with honey was atleast 25 times lower than the treatment with hydrogel. However, study by Jull et al (2008) revealed that treatment of long standing wounds with honey was much more costlier than usual care. Medihoney and patient satisfaction In the study by Ingle et al (2006), patients treated with homey therapy were as satisfied as those with hydrogel. Potential Sources of bias Bias may be defined as delivery of opinions, values and views as if they were universal without looking at other points of view. In this review, bias could either be introduced by the researchers’ strong allegiance to their sponsors or could be introduced by the reviewer’s own perspectives. There is not much scope for bias from the reviewer because he is not affected by the "cause" or "effect" involved in the study. However, his profound preoccupation with the subject could be a potential source of bias. The personal evaluations and values of the reviewer can be reflected in the choice of methodology, interpretation of findings and the choice of a research topic and the reviewer may select fragments of data which only support his argument. The reviewers own perspective and historical context are horizons that may influence interpretation (Kahn 2000). Critiquing the findings The Validity and Generalisability of Findings Validity is a measure of the integrity of the drawn conclusions and is the actual truth-value of a study (Bryman, 2004). Making decisions on the findings by looking at their relevance and applicability is an important aspect of critical review (Cutcliffe 2003). Construct validity may be defined as the extent to which a scale measures a certain construct (Parahoo, 2006) in which the link between conceptual definitions and operational definitions is examined. In all the nominal studies, the essence of construct validity was not intact. This is because, the definition of honey was different in different studies. Robson et al (2009) used the term medihoney, Gethin and Cowman (2008 and 2009) used the term Manuka honey, Jull et al (2008) used honey impregnated dressings, McIntosh and Thomson (2006) used honey dressings and Ingle et al (2006) "honey" Internal validity Internal validity was evaluated in this review. Internal validity is the extent to which the findings in the study reflect reality. It provides an effective measure in studies investigating causality (Burns & Grove, 1997). The factors attributed to internal validity are biases and confounders (Parahoo, 2006). Many factors other than application of wound dressing affect the process of wound healing and control of infection. Some of the factors include sex, age of the person, associated conditions like diabetes and hypertension, position of the wound, personal hygiene, nutritious diet, alcoholism, smoking, medicines, HIV, etc. External Validity and Generalizability Generalizability is a measure of the applicability of study findings and conclusions to other similar settings and populations (Burns and Grove, 1997). This aspect is important to know in the study because it gives an idea as to what extent the suggested causality is likely to hold true in other settings. Most of the studies have been performed on a diverse population and thus the findings can be generalised. The Rigour, Trustworthiness and Statistical and Clinical Significance of the Results of the Studies Significance of the findings is considered to be directly dependent upon the rigour and trustworthiness of the process because flawed data can render findings meaningless (Polit and Hunger, 1997). Rigour is the means to demonstrate integrity and competence and is determined by its truth value, applicability, consistency and neutrality. It involves rigid adherence to research designs as mentioned in the methodology of studies and precise statistical analyses and can be influenced by poor observations and failure to utilise the available data (Burns & Grove 1997). In this review, it was noticed that rigour was maintained by all the studies. All the studies selected were randomised control trials with strict adherence to research design and statistical analysis. Trustworthiness Data from all the studies were from original participants of the study and hence it can be said that the studies are trustworthy Statistical and Clinical Significance All the studies were randomised control trials. They were analysed through a statistical software with intention treat. Comparison of results between the two groups was analysed using analysis of covariance. The analysis was done after adjustment of confounding factors. This type of analysis seems significant for the study. Implications for practice Honey is a useful wound care agent that can be used from simple abrasions to chronic long standing venous ulcers. The physical properties of the material make it difficult for pathogenic organisms to survive in it and thus honey acts as an antimicrobial medium. Also various other non-pathogenic organisms in honey dominate the growth of pathogenic organisms in the wound, further suppressing the growth of pathogens. Honey acts as an excellent wound healer on par with other conventional wound care products. It is also a good sloughing agent. It is cost effective, has less number of adverse events and has similar patient satisfaction rates as other conventional wound care materials. However, further research is warranted in specific wound therapy and also to outline recommendations and policies pertaining honey therapy in wound care. Conclusions This literature review has demonstrated the beneficial effects of honey on wound therapy. However, the small number of studies reviewed, the different types of wounds on which the studies have been performed, the different types of honey used and the different wound care products that have been compared with honey limit the results of this study. To arrive at a more defined benefit of honey therapy, large scale studies using a specific type of honey on a specific type of wound against all the commonly used conventional wound care products must be performed. 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