To the Editor:

I wish to thank Barbara Pieper for her wonderful article, "Honey-Based Dressings and Wound Care" published in the January issue.1 Dr Pieper's article provided an unbiased, educational approach for the use of honey-based dressings in wound care. The author did a great job, focusing on the facets of honey-based dressings that facilitate healing in chronic wounds and burns.

In Dr Pieper's article, there was no discrimination between studies using Leptospermum species (manuka) honey versus other honeys. Leptospermum honey contains unique, plant-derived characteristics that maintain their activity even in the presence of catalase. Only this type of honey has been shown to possess the immunomodulatory component cited in the article, and this honey tests above almost all other honeys for its free radical-quenching capabilities.2 When wound fluid degrades the active components in typical honey, the dressings must be changed very frequently but this is not the case with Leptospermum honey-based dressings. The dressings have been left under compression bandaging for up to a week.

At the time Dr Pieper's article was in press, another large-scale, randomized controlled trial (RCT) and 2 smaller case series were in press and have since been published.3-5 In these cases, active Leptospermum honey was used beneath compression bandages. The studies are summarized below.

Randomized Clinical Trial

Gethin and Cowman3 completed an RCT, comparing manuka (Leptospermum sp) honey (Woundcare 18+; Comvita, TePuke, New Zealand) and hydrogel (IntraSite Gel, Smith & Nephew, Hull, United Kingdom) therapy in 104 subjects. Inclusion criteria were as follows: adult patients with an ankle/brachial systolic blood pressure ratio of (ABI) 0.8 or more from vascular centers in the United Kingdom, venous leg ulcers with an area of less than 100 cm2 in size present for greater than 6 months, and slough present in more than 50% of the wound bed. The study protocol was designed so that subjects were randomly assigned to weekly treatment with either manuka honey (MH) (n = 54) or amorphous hydrogel (n = 50). The primary wound dressing was covered with hydrocellular foam and all subjects received sustained multilayer compression bandages.

Primary endpoints for the study included the percentage of the ulcer covered with slough at week 4 and the percentage of ulcers healed at week 12. Secondary outcomes included decreases in wound size and epithelization.

The median wound area was smaller at 4 weeks (P = .001), and the percentage of patients healed during 12 weeks was higher (P = .03) for MH patients (44%) than for hydrogel patients (33%). In addition, slough reduction was greater in the MH group at 4 weeks (P = .001), although the percentage of the venous leg ulcer covered in slough significantly declined in both groups from the baseline to week 4 (from 85% to 29% in the honey group and from 78% to 43% for the hydrogel group).

Subject withdrawals from the study were consistent with other venous leg ulcer studies. The main reasons for patient withdrawal included venous ulcer infections (hydrogel, 22%; MH, 11%) and patient request (5.5% of hydrogel patients; no MH patients). The authors concluded that MH aided in debridement of slough and increased healing of venous ulcers compared to hydrogel therapy.

Eleven-Patient Confirmatory Case Series

Smith and coworkers5 investigated the use of active Leptospermum honey-impregnated calcium alginate dressings (HICAD) (MEDIHONEY Absorbent Calcium Alginate Dressing with Active Leptospermum Honey, Derma Sciences, Inc, Princeton, New Jersey) in 11 patients with confirmed venous incompetence and nonhealing venous leg ulcers that failed to respond to an assortment of therapeutic modalities including 4 layer compression, topical silver, nonadherent dressings, and antibiotic therapy. Subjects were assigned to weekly treatment with active Leptospermum HICAD and a multilayer compression bandage. The study endpoints were complete wound closure with a secondary endpoint of a normal healing rate. Complete wound closure was achieved within 3 to 4 weeks for all patients. No participants withdrew during the study. The authors concluded that the effects of HICAD increased the velocity of healing when used in combination with multilayer compression bandages.

Eight-Patient Confirmatory Case Series

Regulski4 completed a case series by using active Leptospermum HICADs for a group of 8 patients with recalcitrant venous leg ulcers. Participants had nonhealing venous leg ulcers that failed to heal (recalcitrant) despite compression therapy with either alginate or collagen dressings. Each of the participants had delayed wound closure, pain, inflammation, and periwound edema. They received weekly sharp debridement followed by application of HICAD and a multilayer compression bandage. The primary outcome was wound closure and secondary outcomes included reduction of pain, inflammation, periwound edema, and serum glucose levels.

Five of 8 patients healed within 6 weeks, and 3 patients achieved at least 75% closure at the end of a 12-week period. No changes in serum glucose levels during routine monitoring occurred in the 5 patients with diabetes mellitus. The author noted that accelerated wound closure and healing were achieved in all 8 patients with stalled (recalcitrant) venous ulcers who had previously failed to heal with compression therapy and alginate or collagen dressings. Patients reported elimination of pain, and treatment was judged effective in managing slough, exudates, and inflammation.

Summary

Since the US Food and Drug Administration has approved Leptospermum honey for use in wound and burn care in November 2007, we have heard many anecdotal success stories on a variety of wound etiologies. Healthcare professionals all across the United States are working diligently to compile their results to add to the growing evidence base. Special thanks to Dr Pieper for her evidence-based review.

Sincerely, Diane Maydick Youngberg, MSN, RN, ACNS-BC, CWOCN

Director of Clinical Affairs, Derma Sciences, Princeton, New Jersey.

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