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Honey in the Wilderness

Imagine this; you are on a fantastic multi-day hike in a remote area and you have prepared yourself for an entirely self-sufficient trip. A compass, a water filter, a few bags of dry food: let the adventure begin!

After a few hundred beautiful pictures and three days of hiking, fatigue creeps in. You trip over a rock, which causes a nasty abrasion. You manage to rinse it clean with some water and the abrasion is fortunately not so serious that the trip must be cut short. Nevertheless, you do not want the wound to get infected and ruin your trip. Since you are interested in wilderness medicine you have heard once that honey is a good disinfectant for wounds. Fortunately you have just bought a nice jar of honey from a local beekeeper. So is now the time to put that theory into practice…?

The Theory
Honey was already used for wound treatment by the Romans, Greeks and Egyptians. In 2007 the first wound product impregnated with honey was approved by the FDA (US Food and Drug Administration) (Stewart et al.). Honey possesses antibacterial properties, including low acidity, high osmolarity and it contains the substance hydrogen peroxide. Also, Manuka® honey from New Zealand contains the substance methylglyoxal, which also has an antibacterial effect (Tashkandi). In addition, honey appears to have properties, which are known to have a regenerative character in the wound healing process. The low acidity allows for increased release of oxygen by haemoglobin, which benefits wound healing. The high osmolarity attracts moisture from the wound bed; this is the same principle on which negative pressure therapy (V.A.C.® Therapy) is based. Honey also functions as a debridement agent by increasing the concentration of plasmin, which inhibits the formation of fibrin on the wound (Molan et al.).

Honey for wound treatment: evidence based?
The scientific literature is rich in studies on honey and wound healing. However, most studies focus on chronic-, surgical-, infected- or burn wounds; only few studies have investigated the use of honey in the treatment of acute wounds. In a large Cochrane review by Jull et al. with 26 trials on the effect of honey on wound healing, only three studies looked at the effect of honey on the healing of an acute wound. Just one of these included patients with traumatic wounds (Ingle et al.), finding no significant difference in time to wound healing between honey and a hydrogel. The other two studies included patients with surgical wounds. Not surprisingly Jull et al. conclude that the effect of honey on acute wounds is unclear. This conclusion is based on very low quality evidence.

In addition, the studies on the effect of honey on wound healing often use special medical honey or medical products with honey; not the honey of the local beekeeper. In case ‘normal’ honey is used, the researchers assure themselves that the honey does not contain any pathogens. The honey is sterilized by gamma radiation or it is cultured in advance to make sure it does not contain pathogens. After all, the ethics committee has to approve the study. Next to that, commercial honey from the store seems less suitable for wound treatment. Although these honeys are sterilized, this is usually done by heating. Unfortunately, this can cause beneficial properties to be lost (Stewart et al.).

What to do next
Assuming the beneficial properties, the AWLS manual is very clear: ‘Another ideal topical antimicrobial is honey. The osmolarity and bacteriostatic compounds in unprocessed honey make it an extremely effective, inexpensive and readily available alternative for topical application.

Auerbach’s Wilderness Medicine, however, draws a different conclusion: ‘… while there is allure to this centuries-old practice, simply pouring table honey onto a wound, especially in the austere environment, is not advised.’ Apart from the practical objections (sticky, difficult to change the wound, attracts insects), there are other disadvantages to using honey. Because of its viscosity, honey can have a sealing effect, preventing any pus or exudate from draining.

However, after a literature review, our colleagues Stewart et al. of Wilderness & Environmental Medicine draw a positive conclusion: while honey is not superior to other dressings, it is a drug that can be used for multiple purposes and different types of wounds. The risk of complications is low and the product is readily available. As always, a conclusion based on more research would be better. In the absence of more research, honey is worth considering adding to your medical kit!

For your information, the Dutch guidelines on wound care and the role of honey:

Dutch Society of General Practitioners: Standard Traumatic Wounds and Bite Wounds, 2017 (Dutch only): ‘Cover the wound with an ointment gauze if the wound does not close; discourage the use of iodine or honey gauze.’

Federation of Medical Specialists: Guideline: wound care (2013) (Dutch only): Honey is not mentioned in primary wound care, but is mentioned in infected wounds: ‘The working group believes that a locally infected wound can be treated with iodine or honey, after adequate cleansing.’ … ‘The working group believes that future research on acute wound disinfectants should include honey or iodine in one of the study arms.

Literature

  1. James Austin Stewart, et al., ‘Wound Care in the Wilderness : Is There Evidence for Honey?’ 2014, Wilderness & Environmental Medicine
  2. Hanaa Tashkandi, ‘Honey in wound healing: An updated review’, 2021, Open Life Sciences
  3. Advanced Wilderness Life Support, Textbook Edition 9.0 Copyright 2016 by AdventureMed, LLC
  4. Jull et al., ‘Honey as a topical treatment for wounds’, 2015, Cochrane review
  5. Molan et al., Honey: A Biologic Wound Dressing, 2015, Wounds
  6. Auerbach’s Wilderness Medicine, 7th edition, 2017