WOUND CARE

Use of manuka honey for autolytic debridement in necrotic and sloughy wounds Theresa Mitchell wounds are managed in two stages The scientific and clinical focus on honey which has come about (Sibbald et al, 2011; Barrett, 2017). in the past 30 years has led to the classification of medical grade honey and the commercial availability of highly regulated products. Stage 1 Medical grade honey has proven antibacterial activity, traceability Full holistic assessment is undertaken of source, and lack of contaminants. It is gamma-irradiated to kill by a healthcare professional to bacterial spores that may be present in raw honey (Amaya, 2015; identify and establish any underlying Cooper, 2016). It is available in a wide range of products, including diseases or causes which might delay sterile tubes of honey ointment, honey impregnated tulles, alginates, an individual’s ability to heal in a gels and meshes. normal way. This includes common chronic conditions such as diabetes, heart, vascular or lung diseases, a KEYWORDS: poor immune system, or lifestyle  Medical grade honey  Antimicrobial agent choice, such as smoking or obesity.  Autolytic debridement  Activon® Manuka Honey Range Stage 2 The second stage examines local ebridement of slough barriers to healing within the wound and/or necrotic tissue ‘Honey is well-recognised itself. This involves removing non- Dis a key element of care as a safe and effective viable tissue, such as necrosis or associated with best practice and debriding agent, which slough, reducing oedema, exudate wound bed preparation (Atkin and the bacterial burden, and and Rippon, 2016; Barrett, 2017), possesses multifactorial choosing the most appropriate care as their presence is associated antimicrobial properties.’ pathway that will promote healing with an increased risk of infection and improve patient outcomes. and biofilms, especially if patients (MRSA) and Pseudomonas aeruginosa are frail, elderly or have a weak (P. aeruginosa); both of which have As said, debridement is a immune system (Grothier, 2015; been implicated in wound infection key component of wound bed Cooper, 2016; Halstead et al, 2016). and an increased risk of mortality preparation, as it helps to improve Honey is well-recognised as a (Jenkins, 2012; Leaper et al, 2015). conditions at the wound bed to safe and effective debriding agent, However, evidence, both in vivo and encourage healing (Dowsett, 2008; which possesses multifactorial in vitro, suggests that Manuka honey Strohal et al, 2013). The most antimicrobial properties (Carter et is effective at reducing bioburden and appropriate method of debridement al, 2016; Cooper, 2016; Ahmed et biofilms within a wound (Maddocks should be identified by the al, 2018). 2013; Bolognese et al, 2016; Cooper, healthcare professional during initial 2016; Malone and Swanson, 2017). assessment, as implementing best Recently, there has been practice in a timely manner is key. increasing concern about the rising WOUND BED PREPARATION number of antibiotic-resistant pathogens, particularly meticillin- Wound bed preparation was Practice point resistant Staphylococcus aureus developed and continually reviewed ▼ to deliver effective management Debridement is an important of chronic wounds and has been element of wound bed preparation accepted as best practice both and is defined as, ‘the removal nationally and internationally of foreign matter or devitalized, (European Wound Management injured, infected tissue from a Association [EWMA], 2004; Atkin wound until the surrounding healthy and Rippon, 2016; Barrett, 2017). tissue is exposed’ (Sibbald et al, 2011; Leaper et al, 2012; Madhok et Theresa Mitchell, specialist service lead, Mount In principal, wound bed al, 2013; Strohal et al, 2013). Gould Hospital, Plymouth; Queen’s Nurse preparation recommends that

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WHAT IS AUTOLYTIC flavonoids, phenolic acids, and patients with chronic wounds DEBRIDEMENT? lysozyme (Ahmed et al, 2018). leading to embarrassment, isolation and depression (Grothier, 2015; Autolytic debridement describes The unique property of Manuka Dickinson, 2016; Jones, 2018). a normal healing process, which honey is attributed to the content Malodour is due to ammonia, amines makes use of the body’s own selective of methylglyoxal (MGO) — termed and sulphur compounds, which are ability to dissolve necrotic or sloughy the Unique Manuka Factor (UMF). produced when infecting bacteria tissue through phagocytosis. This is Manuka honey is assigned a rating metabolise amino acids from proteins done by the action of macrophages based on quantification of the in the serum and necrotic tissue and lymphocytes and provides a presence of MGO (Amaya, 2015; (Molan, 1999; Cooper, 2016). Some supportive environment without Cooper, 2016; Rabie et al, 2016). common wound pathogens have damaging healthy tissue. It is The activity of Manuka honey is distinctive odours, for example, P. important to remember that adequate aeruginosa produces a fishy smell, moisture is required at the wound and MRSA a cheesy smell (Cooper, interface to allow this process. ‘Manuka honey promotes 2016). However, sugars, such as those autolytic debridement by found in Activon® Manuka Honey, Manuka honey promotes autolytic drawing water from skin cells change the way in which bacteria debridement by drawing water metabolises, resulting in less odorous from skin cells via osmosis, which via osmosis, which rehydrates, wounds (Akhmetova et al, 2016). rehydrates, softens and liquefies hard softens and liquefies hard eschar and slough (Wounds UK, eschar and slough.’ MANUKA HONEY AS A 2013; Atkin and Rippon, 2016). This is DEBRIDING AGENT attributed to stimulation of plasmin activity in the wound, thus denaturing not inhibited by catalase, whereas Honey has been shown to be an fibrin which attaches slough to the peroxide activity is (Molan, 2009). effective antimicrobial debriding wound bed. This theory is based upon The level of MGO correlates to the agent on a variety of different wound the known effects of plasminogen level of antimicrobial activity and is types, including burns, leg ulcers, activator inhibitor (Cooper, 2016; measured as non-peroxide activity pressure ulcers, diabetic foot ulcers White, 2016). This mechanism is (NPA). An NPA rating of 10 or more and fungating wounds. consistent with autolysis, where is considered suitable for medical use, the creation of a moist wound for example, Activon® Manuka Honey THE EVIDENCE environment at the appropriate pH (Advancis Medical) is guaranteed leads to the removal of slough (Molan to have a minimum NPA of 10 and A recent 15-day evaluation by Barcic and Rhodes, 2015). Some patients may is usually higher. There is extensive et al (2014) compared a chemical experience discomfort or a drawing and well-established evidence for debriding agent against three sensation as the osmotic pressure Manuka honey’s antimicrobial different commercially available rises. The patient should be informed activity in vitro, including antibiotic- honey products in 20 patients of this and the most appropriate resistant species (Bolognese et al, presenting with diabetic foot ulcers, analgesia offered. 2016; Malone and Swanson, 2017). which had 100% fibrous sloughy tissue. Patients were divided into MANUKA HONEY’S Indeed, Manuka honey has been four groups. The chemical group ANTIMICROBIAL ACTIVITY shown to be clinically effective in had daily dressing changes, as per reducing bioburden and inhibiting manufacturer’s directions, and the As bees have different nutritional bacteria, including resistant strains other three groups were changed behaviour and collect nourishment such as antibiotic-resistant MRSA every three days. The rate of from various plants, honeys have and vancomycin-resistant enterococci debridement varied between each different compositions (Oryan et al, (VRE) (Gottrup et al, 2013). It has group. The chemical agent was the 2016). Manuka honey is derived from also been found to prevent biofilm slowest, with 90% of devitalised honey bees that forage on the nectar formation in a wide variety of tissue still present at the end of the of Manuka bushes (Leptospermum wound types in both adults and study. While the honey products did scoparium), which are indigenous neonates (White, 2016). Additionally, debride the foot ulcers, only one to New Zealand and Australasia. Manuka honey has been found to Honey has a complex chemistry be effective against organisms such which is dependent on its source and as P. aeruginosa and Escherichia coli ▼ Practice point processing techniques. As with all (E. coli), which are known to be honeys, Manuka honey can restrict involved in malodour (Cooper, 2016; Manuka honey can directly affect microbial growth due its acidic White 2016). bacterial cells embedded in a pH, osmotic effect of sugars, and biofilm and exhibits antiadhesive production of hydrogen peroxide REDUCING MALODOUR properties against common wound

(H2O2) by peroxidase. Some non- pathogens (Bolognese et al 2016, peroxidase substances also support Wound odour can have a significant Maddocks 2013). antibacterial activity, including impact on the quality of life for

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achieved 100% debridement. This was the honey which contained 100% pure medical grade Manuka honey with no additives or preservatives.

A multi-centred retrospective study examined the safety and efficacy of Manuka honey in 115 neonates and paediatric wounds all Figure 1. requiring debridement (Amaya, 2015). Activon Tube. Neonatal and paediatric skin tends to be very fragile, and premature babies have immature immune systems and impaired thermoregulation, putting them at higher risk of infection when necrotic or sloughy tissue is present. In addition, there is a risk of percutaneous absorption of topical agents used in some dressings (King Figure 2. et al, 2014). Successful debridement Activon Tulle. was achieved in 86.0% (104 wounds), and 77.7% wounds (94 wounds) were successfully closed using non-surgical intervention. Silicone foam was used as a secondary dressing. A transient stinging sensation on application was reported in two patients (1.7%). There was no evidence of wound infection during this study. The author concluded that Manuka honey was a safe and effective treatment option in this group of patients (Amaya, 2015) Figure 3. Algivon plus Manuka honey. Biglari et al (2011) undertook an observational study of 20 patients ulcers for the 12-week study period. 16cm long x 8cm wide, with with spinal cord injuries who had Overall, malodour, pain and wound evidence of skin flap, necrosis and category III and IV chronic pressure size decreased. The average rate of sloughy tissue. Activon Tulle (mesh ulcers. All patients were treated with reduction in wound area was 5.46%. impregnated with medical grade Manuka honey to support autolysis At first assessment (after two weeks honey) was applied as a primary of necrotic and sloughy tissue, and of treatment), the average score for dressing to reduce the haemoserous reduce wound bacterial load. After odour had decreased from 1.58 ± exudate and malodour and support just one week of treatment, all swabs 0.90 to 0.69 ± 0.79 (on a scale where autolytic debridement. Within two were void of bacterial growth, and 3 indicated severe odour), with 11/26 weeks, the wound and infection after a period of four weeks, 18 (42%) having no odour, thereby had improved significantly, and patients (90%) showed complete improving the patients’ quality of life. honey dressings were changed to wound healing after a period of four hydrofiber. However, the following weeks (Biglari et al, 2011). A case study of a 90-year-old week, the wound had deteriorated patient who had been admitted to with friable granulation and an Dunford et al (2004) examined a local community hospital with a increase in exudate volume. Honey 40 patients with leg ulcers that wound on the plantar aspect of her dressings were reapplied, thus had not responded to 12 weeks right foot associated with erythema supporting the effectiveness of of compression therapy. Manuka and cellulitis also found that using honey as a first-line antimicrobial honey dressings were applied to the honey as a first-line antimicrobial agent (Lloyd-Jones, 2012) dressing had positive outcomes (Lloyd-Jones, 2012). Investigations A recent pilot study on seven Practice point confirmed that the patient had an patients with facial burns treated with ▼ infection of unknown aetiology and Manuka honey measured healing Using honey to treat wounds is an intravenous (IV) antibiotics and time, bacterial growth, patient ancient global remedy that has analgesia were prescribed and non- satisfaction and costs (Duncan et al, been handed down through the weight bearing was recommended. 2016). Healing time was consistent ages (Irish, 2011; Cooper, 2016). Following referral to the tissue with, or better than standard viability team, the wound measured treatment, with a mean healing time

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the most appropriate for volume of exudate, such as sloughy Practice point their patients or infected, wet wounds. Algivon ▼ Plus Ribbon is suitable for cavities ® Key benefits of medical grade Activon Tube or sinuses, such as pilonidal sinuses, honey are: As with all products in the Activon pressure ulcers or dehisced surgical Manuka Honey range, this contains wounds (Molan and Rhodes, 2015;  Broad spectrum 100% Manuka honey. Activon® Halstead et al, 2016). antimicrobial activity Tube can be applied to any type  Provides a moist of wound, especially if there is Actilite® wound environment necrotic or sloughy tissue present, Actilite® is a viscose net dressing  Supports autolytic debridement and is particularly useful for cavity coated with 100% Manuka honey  Reduces malodour produced by wounds, such as pressure ulcers or and Manuka oil. It can be used on some bacteria contaminated postsurgical wounds shallow wounds with a low volume of exudate to clear infection or  Anti-inflammatory where multiresistant strains of bacteria are present (Biglari et al, reduce bacterial burden. It has been  Reduces interstitial oedema. 2011; Cooper, 2016; Jull et al, 2015). found to be particularly useful for (Cooper and Gray, 2012; Bolognese A secondary dressing will need to be immunocompromised patients et al 2016; Carter et al, 2016) applied depending on the volume (Molan and Rhodes, 2015; of exudate present. Activon Tube can Cooper, 2016). also be used to top up other dressings of 8.1 days. None of the patients in the Activon Manuka Honey range, CONCLUSION were given antibiotic treatment, where the honey has been washed with wound culture results yielding away by wound fluid. When following the principals of no abnormal bacterial growth and, wound bed preparation, medical overall, patient satisfaction was Activon® Tulle grade Manuka honey is a valuable high. Average hospital-based cost Activon® Tulle is a knitted viscose treatment choice. Debridement is of treatment was $26.15 per patient. mesh impregnated with 100% seen as a key component of wound This study suggests that Manuka Manuka honey. It is ideal for bed preparation, in that it quickly medical grade honey is a clinically shallow wounds that need debriding removes devitalised tissue and and economically valuable treatment to reduce the risk of bacterial thereby reduces the risk of infection, for partial-thickness facial burns. colonisation in vulnerable adults or as well as improving visibility of the (Duncan et al 2016) children, as well as wounds, such wound bed to aid assessment. as skin tears and partial-thickness Furthermore, a Cochrane review burns (Amaya, 2015; Cooper, 2016; Medical grade Manuka honey concluded that honey appeared to White, 2016 ). is seen as an effective agent for promote healing in partial-thickness burn wounds and infected post- Algivon® operative wounds more quickly Algivon® is a soft alginate dressing Revalidation than antiseptics, such as silver impregnated with 100% Manuka Alert sulphadizaine or gauze honey. The alginate fibres allow a (Jull et al, 2015). slower release of honey into the Having read this article, wound than viscose mesh and reflect on: ACITVON® HONEY RANGE net-impregnated dressings. Algivon should be used on wounds with a  Why debridement is a key The Activon Manuka Honey moderate-to-high volume of exudate, component of wound product range provides healthcare such as sloughy wounds, or infected, bed preparation professionals with a choice of wet wounds, such as chronic venous  The role that medical dressings so that they can select leg, pressure or diabetic foot ulcers grade Manuka honey (Halstead et al, 2016; White, 2016). can play in autolytic debridement ▼ Practice point Algivon® Plus This is a reinforced, soft alginate  The key benefits of using When considering the use of honey dressing impregnated with 100% medical grade Manuka to support autolytic debridement, Manuka honey. The reinforced honey products as part of always apply an appropriate alginate allows for one-piece dressing care pathways for patients secondary dressing to manage the removal and a slower release of with wounds. volume of exudate being produced, honey into the wound than honey-  Then, upload the article as this will increase following initial impregnated viscose mesh and net to the free JCN revalidation application. This is both to be dressings. It is available as a pad or e-portfolio as evidence of your expected and a natural part of the ribbon with a probe. Algivon® Plus continued learning: healing process. should be used on wounds which www.jcn.co.uk/revalidation are producing a moderate-to-high

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autolytic debridement (Blaser et al, et al (2001) Manuka honey used to heal King A, Stellar JL, Blevins A, Shah KN 2007; Molan, 2005), as a result of its a recalcitrant surgical wound. Eur J Clin (2014) Dressings and products in pediatric high osmotic properties (Cooper et al, Microbiol Infect Dis 20(10): 758–9 wound care. Adv Wound Care 3(4): 324–34 2001), and thus should be considered Cooper R, Gray D (2012) Is Manuka honey Leaper DJ, Schultz G, Carville K, Fletcher as part of the community nurses’ a credible alternative to silver in wound J, Swanson T, Drake R (2012) Extending wound care armamentarium. JCN care? Wounds UK 8(4): 54–63 the TIME concept: what have we learned in the past 10 years? Int Wound J 9(Suppl Cooper R (2016) Honey for wound care 2): 1–19 REFERENCES in the 21st century. J Wound Care 25(9): 544–52 Lloyd-Jones M (2012) Case study: treating an infected wound of unknown aetiology. 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