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IntroductionHoney has been used for wound treatment for more than 2000 years. Aristotle already knew of the effectiveness of honey for wound treatment (1). Many effects can be described: osmotic effects with drainage of secretion from the wound (2), antibacterial effects owing to enzymatic production of H2O2 (Glucose Oxidase) (3) or to Methylgluoxal (4), antioxidant effects (5), stimulation of angiogenesis (6), modulation of immune response (7) etc. Several studies, especially of Manuka honey, show positive effects on superficial burns (8), postoperative wound healing disorder (9), abrasions (10) and for Prevention of catheter-associated infections in dialysis patients (11). In addition, a radio-and chemotherapy-induced mucositis can be mitigated by honey (12,13). Honey acts on a variety of microorganisms bactericidal, antiviral and fungicidal, including the most relevant pathogens in clinical practice, amongst others multiresistant bacteria such as MRSA (14) and ESBL even when they are embedded in biofilm (15). So far, there are limited data on honey treatment of the diabetic foot syndrome (DFS) (16-18).

Case Report In this case report, the course of plantar ulcers on both sides stage Wagner 2D with Pseudomonas infection is described. Anamnestic data of the patient are shown in Table 1. The treatment includes a temporary systemic antibiotic therapy, repeating wound debridements and removal of hyperkeratosis at the wound edge , best possible pressure relief and topical treatment with Manukahoney wound dressings.

ResultsWith the help of the described therapy a reduction of the local inflammation, stimulation of granulation, size reduction and eventually healing of the wound on the left side consecutively set in. The tolerance and acceptance was excellent. The initial dense wound colonization of Staphylokokkensaprophyticus and Pseudomonas aeruginosa was no more provable during the course of observation.

DiscussionCurrently, about 250 different commercial wound-dressings are available in Germany. None of them could be proved superior to simple moist wound treatment (19). A Cochrane Review concludes that there is no sufficient evidence for Honey as a wound treatment, except for burns (20). However, this is also true for the common treatment with silver-based wound dressings for which no randomised or controlled clinical trials could be found (21). Systematic comparisons of different wound dressings are difficult because of heterogeneous wounds conditions (size, infections, perfusion, pressure load etc.). Interestingly enough, no development of resistance against honey has been described, which is advantageous in current times of increasing multi-drug resistant bacteria. Working in an acknowledged centre through the German Diabetes Association (DDG) for foot- and wound treatment, our experience with Manuka honey treatment of DFS appears promising. The therapy seems very cost-effective. Systematic comparative studies of efficacy and cost-effectiveness are required.

Treatment of Diabetic Foot Syndrom with Manuka Honey

Zerm, R1,2; Jecht, M2; Dé-Malter, P2; Friedrich, M2; Girke, M1,2; Kröz, M1,2

1Forschungsinsitut Havelhöhe Berlin, 2Gemeinschaftskrankenhaus Havelhöhe, Berlin

ECIM 2010 Berlin

References1. Aristotle. Historia Animalium; 350 BC. Smith JA, Ross WD, eds. The Works of Aristotle; Vol IV. Oxford University, UK;

1910.2. Molan P. Re-introducing honey in the management of wounds and ulcers - theory and practice. Ostomy Wound

Manage 2002;48(11):28-40.3. Molan P. The Antibacterial Activity of Honey. Bee World 1992;73(1):5-28.4. Mavric E, Wittmann S, Barth G, et al. Identification and quantification of methylglyoxal as the dominant antibacterial

constituent of Manuka (Leptospermum scoparium) honeys from New Zealand. Molecular Nutrition & Food Research 2008;52(4):483-9.

5. Henriques A, Jackson S, Cooper R, et al. Free radical production and quenching in honeys with wound healing potential. J Antimicrob Chemother 2006;58(4):773-7.

6. Molan PC. Potential of honey in the treatment of wounds and burns. American Journal of Clinical Dermatology 2001;2(1):13-9.

7. Abuharfeil N, Al-Oran R, Abo-Shehada M. The Effect of Bee Honey on the Proliferative Activity of Human Subrahmanyam M. A prospective randomised clinical and histological study of superficial burn wound healing with honey and silver sulfadiazine. Burns 1998;24(2):157-61.

8. Al-Waili N, Saloom K. Effects of topical honey on post-operative wound infections due to gram positive and gram negative bacteria following caesarean sections and hysterectomies. EurJ Med Res 1999;4(3):126-30.

9. Ingle R, Levin J, Polinder K. Wound healing with honey--a randomised controlled trial. S Afr Med J 2006;96(9):831-5.10. Johnson DW, van Eps C, Mudge DW, et al. Randomized, Controlled Trial of Topical Exit-Site Application of Honey

(Medihoney) versus Mupirocin for the Prevention of Catheter-Associated Infections in Hemodialysis Patients. J Am Soc Nephrol 2005;16(5):1456-62.

58-year-old male. Occupation: innkeeper1. Diabetes mellitus type 2, initial diagnosis in 2000

- Diabetic foot ulcers both sides - Diabetic macroangiopathy- Diabetic autonomic neuropathy - Diabetic nephropathy stage 2 - Diabetic proliferative retinopathy

2. Coronary heart disease - CABG (LIMA to LAD, ACVB to RIVP) 2001 - PCI 11/2006 D1 - posterior wall aneurysm - Left heart failure NYHA III - Ischemic cardiomyopathy

3. Peripheral arterial occlusive disease both sides- Percutaneous transluminal angioplasty and stenting superficial femoral

artery 06/2002 - Percutaneous transluminal angioplasty posterior tibial artery 11/2006

4. Obesity 5. Sleep apnea syndrome 6. Hypertension7. Nicotine abuse

Fig. 1: 14/06/2010Deep ulcers as deep as tendon on both sides with necrotic surface.

Fig. 2: 25/06/2010Initiation of granulation. Especially on the left foot remaining necrotic layers.

Fig. 3: 15/10/2010Significant reduction of the wound size with a clean wound base and granulation tissue. Note: No maceration at the wound edge.

Fig. 4: 28/10/2010 Further reduction of the wound surface areas. Hyperkeratosis at the wound edge of the right foot to be removed.

12. Motallebnejad M, Akram S, Moghadamnia A, et al. The effect of topical application of pure honey on radiation-induced mucositis: a randomized clinical trial. J Contemp Dent Pract 2008;9(3):40-7.

13. Biswal B, Zakaria A, Ahmad N. Topical application of honey in the management of radiation mucositis: a preliminary study. Support Care Cancer 2003;11(4):242-8.

14. Maeda Y, Loughrey A, Earle JAP, et al. Antibacterial activity of honey against community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). Complementary Therapies in Clinical Practice 2008;14(2):77-82.

15. Merckoll P, Jonassen TØ, Vad ME, et al. Bacteria, biofilm and honey: a study of the effects of honey on 'planktonic' and biofilm-embedded chronic wound bacteria. Scandinavian Journal of Infectious Diseases 2009;41(5):341-7.

16. Makhdoom A, Khan MS, Lagahari MA, et al. Management of diabetic foot by natural honey. Journal of AyubMedical College, Abbottabad: JAMC 2009;21(1):103-5.

17. Moghazy AM, Shams ME, Adly OA, et al. The clinical and cost effectiveness of bee honey dressing in the treatment of diabetic foot ulcers. Diabetes Research and Clinical Practice 2010;89(3):276-81.

18. Shukrimi A, Sulaiman AR, Halim AY, et al. A comparative study between honey and povidone iodine as dressing solution for Wagner type II diabetic foot ulcers. The Medical Journal of Malaysia 2008;63(1):44-6.

19. Palfreyman SJ, Nelson EA, Lochiel R, et al. Dressings for healing venous leg ulcers. Cochrane Database of Systematic Reviews (Online) 2006;3:CD001103.

20. Jull AB, Rodgers A, Walker N. Honey as a topical treatment for wounds. Cochrane Database of Systematic Reviews (Online) 2008(4):CD005083.

21. Bergin SM, Wraight P. Silver based wound dressings and topical agents for treating diabetic foot ulcers. Cochrane Database of Systematic Reviews (Online) 2006(1):CD005082.

Fig. 5: 24/11/2010 Further reduction of the wounds. On the left foot wound closure.

Table 1: Patient characteristics and diagnoses.