Medical Honey Use in Patients with Ulcers

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Table of Contents

Abstract
Review of Literature: Identification of Levels of Evidence
Critical Thinking: Synthesis of Information
Critical Thinking: Conclusions
References

Abstract

Identification of Research Area of Interest

Wound healing is a mechanism that is preceded by tissue injury. A key goal of medical research is to treat a wound faster and with fewer side effects. Physicians have long sought ways to cure wounds in the least time possible with limited or no side effects, due to the advancement of successful procedures. Several experiments on tissue regeneration have been performed, utilizing various medications and introducing herbal products as catalysts, but none have been approved as an appropriate and conclusive cure (Takzaree et al., 2016). Antibiotics, in particular, are becoming highly inactive against wound infections because of unnecessary and improper use; as a result, there is increased interest in the reinvention and use of traditional remedies (Seckam & Mercer, 2018). Wound treatment is a dynamic and systemic mechanism that, according to histopathology, requires three phases: irritation, swelling, and remodeling. The steps include an appropriate treating agent, which in the current context is honey.

Healthy eating; vitamins, enzymes, oxygen, and weather factors have an impact on wound healing. Natural substances and organic medicines were the most popular treatment bases in history. They were deemed a therapy in certain circumstances and were often manufactured, advertised, and sold by pharmaceutical companies (Takzaree et al. 2016). Currently, a health movement including the WHO have emerged promoting the usage of certain ancient remedies and natural extracts because of their negligible side effects.

Honey has been used to heal untreated wounds for several years. It has antibacterial activity on several bacteria and microorganisms, and gram-positive and gram-negative microbes (Tukzaree et al., 2016). Honey contains high amounts of fructose and carbohydrates, which hinder the development of pathogenic microorganisms. Injury-induced vascular system disruption leads to hypoxia and lactate accumulation. These cells then send impulses, which cause angiogenesis through increased fibroblasts, and connective and granulation tissue. Honey contains 1 milmol/L hydrogen peroxide, which is steadily produced in the wound site and plays a crucial role in the removal of pathogenic microorganisms. For its insulin-like activity, hydrogen peroxide influences the cells involved in regeneration and causes cell growth. Wound curing is a complex response to injury that necessitates connections among various cell types, protein synthesis, and growth aspects.

Cells such as fibroblasts, neutrophils, and macrophages play essential roles in wound healing. Resurged fibroblasts are already secreting connective tissue components such as collagen fibers and glycoproteins, which contribute to the healing of wound edges. Fibroblast cells are an integral part of wound recovery when collagen develops when cells propagate in the wound, causing quicker tissue regeneration. Honey’s acidic pH, combined with its osmotic properties, promotes lymphocyte and phagocyte production in the infected area, as well as enhance the other antimicrobial products. Proline in honey, which has the antioxidant function, inhibits the development of free radicals and is essential for honey’s anti-inflammatory properties. The mixture of honey’s different products accelerates wound healing by enhancing cell proliferation, epithelialization, and granulation. Based on the general features of honey and the absence of an appropriate medication for the treatment of injuries, this research aims at evaluating the impact of local administration of honey and its effectiveness on ulcers wounds. A detailed literature review is used to show empirical evidences on the effectiveness of this natural treatment approach.

Review of Literature: Identification of Levels of Evidence

Conceptualization of Medical-grade Honey

Honey comprises water and sugars like fructose, glucose, amino acid, proteins, and vitamins and minerals. Through enzymatic action and evaporation, sugar and water molecules bind limiting microbes from accessing water. Moreover, enzymes change glucose to an acidic form, which makes honey too acidic for the growth and survival of microbes. The enzymatic process also forms hydrogen peroxide that contains antimicrobial functions. The hydrogen peroxide stimulates proteases by oxidation, which facilitates debridement, improved cutaneous blood movement in ischemic nerves, causes new tissue development, and creates free radicals providing honey with anti-inflammatory features (Evans and Mahoney, 2013).

New research shows that medical-grade honey is useful in wound care. These characteristics entail control of local contamination, rapid purification of wounds, enhancement of autolytic debridement, regeneration of new tissue formation, and enhancement of granulation. Medical honey is approved and licensed for treating wounds by keeping them moist and facilitating autolytic care of necrotic membranes. This operation is dependent on honey’s high soluble content and, as a result, its low water levels (Gibson et al, 2014). To handle wound bioburden, honey is often mixed with other additional dressings that comprise silver compounds. Given the in vitro results that silver interferes with the action of enzymatic debriding substances, other combinations, like honey, must be evaluated for some observable effect. Although honey is a nuanced natural substance, its physical properties by mass are a combination of sugars, with fructose and glucose accounting for an estimate of 70% of overall honey volume, which is about 80% of total sugars, based on the location (Gibson et al, 2014, p.310). Honey’s strong osmotic capacity is attributed to its higher sugar content and lower water content than body tissues; any conditions that change one of these two leading elements to osmotic potential is likely to change this mode of operation, for a positive outcome or worse. Osmotic intensity is determined by the amount of readily diffusing solubilized compounds in relation to the volume of liquid, such as water, a component that changes this quantity or the volume of water is intended to degrade or improve the osmotic activity of a solution.

The monovalent silver ion, ionic silver, obtains its main antimicrobial properties from chemically interacting with and creating conjugates with polypeptide chains in microbial enzymes. This process necessitates that the silver stays ionized, tolerant of dissipating to its microbial receptors inside the dressing, which does not shape adducts with other substances en route to the bacterial cells. Silver’s antibacterial activities rea reduced by agents or factors that inhibit silver absorption or have a surrogate adduction goal. Given silver’s process for binding protein adducts, even though silver reacts with the carbohydrates in honey, it does not reduce the number of transformed sugar molecules and hence would interfere with honey’s osmotic potential. However, there is also a chance that the silver can intervene by an unintended process. Honey, on the other side, has a challenging atmosphere for silver absorption and several alternative substitute sites for the silver to conjugate, possibly attenuating the antibacterial function of silver-containing dressings.

The Efficiency of Honey on Ulcers Wounds

Various empirical research has been conducted on the efficacy of honey on various wounds to prove its efficiency. In recent research, Bashir et al. (2018) compared negative pressure wound healing using honey in diabetic foot ulcers. The authors hypothesized that honey treatment was more effective in treating diabetic foot ulcers. To test the proposition the authors conducted randomized controlled research in a military hospital for seven months. They used a sample of 95 patients presenting with diabetic ulcer wounds. They divided the patients into two random groups. The researchers applied the two pressure wound treatment options and findings revealed healthy tissues in vacuum treatment accompanied by honey dressing. The findings clearly support the current study proposal on the function of honey in facilitating the healing of diabetic foot ulcers.

Honey as a treatment ingredient shows positive outcomes in burns. In a research, El-Kased et al. (2017) used honey-based hydrogel to treat burn wounds. The authors prepared a topical honey hydrogel content using honey concentrations containing carbopol 934, chitosan, and gelling agents. The incorporated formulae were assessed for PH, swelling index, spreadability, antimicrobial function, and in-vitro release process. The spreadability and PH ranged from 5.7-8.6 cm and 4.3 to 6.8 cm consecutively (El-Kased et al., 2017). The findings illustrated a higher in-vitro in Chitosan-based hydrogel for honey component with a diffusion rate ‘n ≤ 0.5 illustrating the Fickian dispersion strategy. Hydrogel matrices were tested for in-vitro antimicrobial properties against Streptococcus pyogenes, P. aeruginosa, Klebsiella pneumonia, and Staphylococcus aureus utilizing the Disc Diffusion antibiotic susceptibility examination. The honey-chitosan polymer with 75% honey had the best antimicrobial efficacy (El-Kased et al., 2017, p.2). This method was studied for in-vivo burn treatment in mice with burn-induced injuries. As opposed to a consumer product, the solution was tested for burn treatment and antibacterial activity. Honey-chitosan hydrogel with a concentration of 75% was discovered to have the fastest degree of burn curing. According to the findings of this report, a 75 percent honey-chitosan hydrogel has greater therapeutic potential than a commercial formulation and should be used effectively as an effective natural topical tissue repair remedy. Overall, honey was shown to have effective healing potential for burns as compared to other treatment options. The findings match those of Bashir et al, (2018) that honey is an effective wound treatment option.

Honey is effective in treating long-term lower leg ulcers because of its antibacterial properties. Recent research by Tellechea et al. (2013) evaluates the function of honey dressing in treating chronic ulcers. The researcher used ten patients with long-term ulcer wounds who had undergone ineffective non-honey-based treatment approaches. The findings confirmed complete healing among seven patients, and a significant decrease in wound size among the remaining three patients. The authors concluded that honey-based wound dressing was efficient and easy to use in treating leg ulcers. The findings agree with those of Bashir et al. (2018) that honey is effective in treating leg ulcers.

More research shows the importance of manuka honey; a refined medical-grade hone, in chronic wound dressing. In a research Rafter et al. (2017) investigated the efficiency of Algivon Plus manuka honey in healing long-term wounds. The authors engaged an extensive literature review involving Algivon Plus, which contains 100% medically approved honey with a foam dressing. Data on the rate of wound dressing adjustments and the materials used were gathered. The clinical practice nurse specialist changed the dressings on an interval of 7, 7, 14, 7, 7, and 7 days, bi-weekly (Rafter et al., 2017). Every Monday, patients who had been released to go home were evaluated and a TIME was used to evaluate periwound tissue, maceration, psoriasis, and swelling, and all wounds were photographed to keep records of their progress. The size, color, and odor of the abscess were determined, and the injuries’ pH levels were also registered using Likert-type scales. Pressure, sleep, abscess odor, and effect on wellbeing were all evaluated in patients. The findings showed the pH rates of the wound lesions to be related to the form of existing tissues (Rafter et al., 2017). As the research continued, participants slept better and became less affected by effusion and the accompanying odor. The bandages used were recommended by best practice and resulted in favorable health effects of recovery or improvement of healing.

The findings confirmed the efficacy of honey-based wound dressing in chronic wounds as illustrated by Tellechea et al. (2013) and Bashir et al. (2018). Indeed, Manuka honey is safe for body tissue and has no cytotoxic effects. Currently, health experts are reintroducing honey as a useful agent for wound treatment. Honey speeds up the recovery of tissue loss burns when opposed to regular dressings. Honey is more successful than antiseptics in healing contaminated body parts. Manuka honey achieves all of the requirements for an effective wound dressing element because of its antimicrobial properties that enhance autolytic debridement, activate wound tissue development, thus speeding tissue repair in latent wounds, and activates anti-inflammatory action that quickly reduces discomfort, exudate development, and oedema.

Moreover, has anti-inflammatory and oxidative properties that help to strengthen the immune system facilitating tissue regeneration. Honey’s pH ranges from 3.2 to 4.5, making it an inappropriate habitat for bacterial development, as most bacteria require a balanced to moderately alkaline pH of 7 to develop (Rafter et al., 2017). The fructose in honey facilitates the formation of hydrogen peroxide and gluconic acid during distillation, resulting in an acidic state. Sugars easily attach to water molecules in honey since it is a super-saturated mixture of carbohydrates with low moisture content, rendering them inaccessible to microorganisms. Algivon® honey comprises 100% medically approved honey, offering it consistent amounts of antibacterial activity. The osmotic action of Algivon® honey aids in the debridement and desloughing of wounds, and the reduction of odor caused by infection while ensuring an optimal moist wound healing atmosphere (Rafter et al., 2017). Manuka honey is particularly efficient than other types of honey because of its 100% content of honey and accompanying essential products. The findings advocate for honey treatments with 100% honey content to be medically approved.

The efficiency of Manuka honey is confirmed by more empirical findings on its purposed in speeding wound healing. For instance, Thomas et al. (2011) investigated the purpose of topical manuka honey in treating long-term and recurring pilonidal sinus illness. The authors evaluated the time taken in attaining complete healing and the reappearance. The study involved 17 subjects who received manuka honey therapy after surgery for chroming of reoccurring pilonidal sinus disease. The findings revealed that manuka honey provided an efficient treatment for the condition and quick healing. The findings match those of a later study, Rafter et al. (2017) that manuka honey is efficient in wound healing.

Manuka honey illustrates wide usage in wound healing confirming its effectiveness as a type of pure honey. Frydman et al. (2020) aimed to improve the production of MH microneedles (MHMs) while retaining the MH therapeutic benefits MHMs are produced using various methods and tested in vitro. MHMs showed outstanding bactericidal behavior against MRSA at quantities of 10% honey, with suction prepared honey proving to be the most bactericidal, destroying bacterial quantities as large as 8 107 CFU/mL. The wound recovery test revealed that, at 0.1 percent levels, while cooked honey had the insufficient healing process, suction-treated honey had stronger wound closure. The findings demonstrated that the process of MHM synthesis is critical to preserving MH properties. They improved the production of MHMs and showed their possible usefulness in treating MRSA infections and tissue regeneration. The findings also mirror those of Rafter et al (2017) and Thomas et al. (2017) who illustrate the efficiency of manuka honey in tissue regeneration.

Various pure honey types have been assessed for their importance in wound healing. Tan et al. (2011). Evaluated the use of Gelam Honey in wound dressing and speed of healing. Gelam honey is 100% pure hone produced by Apis mellifera. In this article, the potency of Gelam honey in tissue regeneration was assessed. Sprague-Dawley rats were spontaneously classified into four categories of 24 rats each with a 2 cm by 2 cm full lenghth surgical wound on the neck region formed. Wounds were covered therapeutically based on the group. Rats were cut on the first, fifth, tenth, and fifteenth days of therapy. Following that, wounds were treated for macroscopic and record examination. Gelam-honey-dressed scars healed faster (day 13) than controlled ones and saline-treated classes, as did Intrasite Gel-treated wounds. Honey-treated wounds developed fewer scabs with just small scars. Gelam honey had a beneficial impact on the wounds based on histological findings. This study found that applying Gelam honey coating to an excisional wound improved the recovery process. The findings matched those of other reviews including Thomas et al. (2017) and Rafter et al confirming the function of 100% honey extracts in healing wounds.

Gelam is a pure type of honey whose function is extended to burn wounds. In a study, Zohdi et al. (2012) investigated the purpose of Gelam, a honey-based hydrogel in tissue regeneration after injury. In the research, a new cross-linked honey hydrogel coating was created by adding Malaysian honey to a hydrogel would covering mixture, which was then cross-linked and disinfected using electrical current irradiation (25 kGy). The structural features of the synthesized honey hydrogel, as well as its wound-healing effects on deep debridement severe burns in rats, were evaluated in this research. Skin specimens were taken on separate days after the injuries for histological and molecular analysis. When contrasted to the placebo hydrogel and OpSite film clothing, the use of honey coatings greatly improved healing at (P 0.05) and facilitated the frequency of re-epithelialization (Zohdi et al., 2012, p.1). As soon as seven days following the burns, honey hydrogel-treated wounds showed a substantial decline in inflammatory reaction (P 0.05). Semi-quantitative RT-PCR study showed that therapy with honey hydrogel substantially (P 0.05) reduced the release of proinflammatory cytokines (Zohdi et al., 2012, p.1). The current research supports the possible effectiveness of honey hydrogel condiments in speeding up burn wound healing. The findings reiterate previous reviews on the importance of honey on wound healing, particularly Gelam honey as also noted by Thomas et al. (2017). The honey type is identified based on its composition of 100 percent honey, which makes it as effective as manuka honey.

The efficiency of honey improves when combined with other natural ingredients such as milk for wound healing after tonsillectomy, which causes pain and bleeding. To confirm this function, Gilbetekin & Tufeci (2017) assess the role of milk and honey in treating wounds of children after tonsillectomy. The authors employed an experimental with a control group in a public hospital. Standardized bee honey was smeared on the wounded areas of the children after the surgery on a daily basis. A control group was also used for comparison. The findings revealed less bleeding, pain, and decreased size of wounds among children in the experimental group. The authors concluded that a combination of milk and honey is efficient in preventing bleeding, easing pain, and speeding wound healing in patients who have undergone tonsillectomy. The findings match the previous findings such as those of Rafter et al. (2017) illustrating that a combination of honey with other natural ingredients and careful wound care facilitates healing.

The function of honey on chronic wounds is well recorded in literature. For instance, recent research by Zeleníkováa and Vyhlídalováb (2019) investigate the function of applying honey to long-term non-healing wounds among older people in-home care settings. The researchers use an interventional future research involving 40 Czech home care patients aged 65 years and above with non-healing bruises. The subjects were randomly allocated to one of two categories; experimental and control groups. Scars were dressed with honey (experimental group) or traditional dressings (controlled group) and wounds were studied for changes over three months. A detailed illustration of a wound was documented (site, scale, wound bed, sides, volume of effusion, smell, neighboring skin). The Wound Healing Continuum was used to measure the tissue repair process, and the Visual Analog Scale was used to evaluate pain severity. Within a three-month stretch, 16 (80 percent) of those in the experimental category had their scars fully healed, as opposed to just six (30 percent) of those in the control group (Zeleníkováa and Vyhlídalováb, 2019). On Day 1, there was no clinically significant variation in scar size but the disparity in wound diameter became evident between the groups after ninety days. There was a significantly positive discrepancy in pain severity between the two groups. The introduction of honey bandages on non-healing lesions resulted in quicker healing, reduced wound size, and decreased pain severity.

Various healthcare experts have branded pure honey for wound healing purposes but the central component of these types of scar treatments is 100 % pure honey. In a research, Gilligan et al (2016) compared the usefulness of clostridial collagenase balm to honey in treating pressure ulcers. The authors employed literature reviews dating from 2007 to 2013. The findings confirmed faster healing rates for granulation for patients treated using medicinal honey. Charambous et al. (2018) used thyme honey in reducing radiation. The researchers used a randomized controlled trial whose findings revealed lower rates of oral mucositis among patients in an experimental group. The patients’ quality of life also improved significantly attesting to the healing function of honey. Biglari et al. (2012) used Medihoney for non-surgical therapy purposes among patients with pressure ulcers. A total of 20 patients were included in the study. The results showed that eliminated bacteria in the wounds of the study subjects after a week of honey-based wound dressing treatments. Equally Sare et al. (2008) also found reduced pain, size of the wound, and increased comfort among patients treated with Medihoney for ulceration. Overall, the studies clearly support the proposition that honey is vital in speeding healing as compared to other treatment options.

Critical Thinking: Synthesis of Information

Honey has a long history of usage as an important wound healing product. With the introduction of antibiotics in the twentieth century, the use of honey declined. With recent spikes in multi-resistant microbes and a decrease in successful antibiotics, honey’s activities have rekindled curiosity about wound healing. According to the research evaluated, honey is helpful in wound healing in a number of ways, including odor removal, debriding, moisture wound healing, and promoting tissue development. While different experts have created different honey labels, the major ingredient is 100 percent, pure honey. Biofilms, swelling, antibiotic action, pH regulation, protease reduction, growth factor activation, granulation, vascularization, hydration, and diet are all factors that affect wound healing.

All of the factors mentioned above are critical in promoting tissue repair. The antimicrobial function of honey, for example, can differ greatly based on the floral ingredient of the honey and the manufacturing conditions. Honey from the Leptospermum genus (Manuka) plant may have extraordinary bacterial activity, although the efficacy of the honey can differ significantly due to the climate and the degree of conversion of plant enzymes inside the flower to the honey. As a result, honey cannot be regarded as a generic food.

Proof and antimicrobial strength can instruct clinicians. The directions for usage found inside the package include accurate advice and this material has been evaluated by the Health and Consumer Healthcare Regulatory Agency. They need marketers to keep documentation to back up arguments made on food packaging and it does not apply to advertisement literature. MedihoneyTM is actually the best antibacterial medicinal honey accessible at antimicrobial phenol pressure, and it is recommended for use on contaminated wounds inside the product details wrapping. MedihoneyTM wound gel is a combination of various honey extracts, mostly from the Leptospermum genus (Manuka). Organic oils and extracts are combined to create a high viscosity solution that is easy to apply and retain at the wound bed. MedihoneyTM also includes honey that produces hydrogen peroxide, which increases the antimicrobial and antioxidant effects on tissue repair. The evidence for MedihoneyTM is substantial, including in vivo studies data as well as randomized control research; nevertheless, as with all wound care condiments, blinded randomized tests are required. MedihoneyTM antibacterial medicinal honey has the ability to aid regeneration across the wound healing spectrum and falls across many of the TIME system groups, and has the additional benefit of odor reduction.

Critical Thinking: Conclusions

Chronic and slow wound recovery of leg ulcers is a specific source of worry for both the patient and the clinician, as well as the financial pressure levied on the NHS. In the case studies presented, the enhancement of patient ease, wellbeing, and quality of life was prioritized during the recovery phase. Accurate wound evaluation within the context of a full comprehensive evaluation provided the foundation for successful wound treatment, which facilitated the recognition of variables influencing results. As a consequence, recovery was promoted in the studies. Elevation, cleaning of the wound and underlying tissue during dressing adjustments, and application of topical surgical honey anti-bacterial gel are also part of the wound care strategy. While there is no evidence to prevent or limit the application of medical honey to wounds, further research is required to provide universal diagnostic practice honey recommendations about the scale, form, and age of wounds best handled with medical honey to ensure long-term protection and effectiveness, as well as to discover potential side effects.

References

Biglari, B., Vd Linden, P. H., Simon, A., Aytac, S., Gerner, H. J., & Moghaddam, A. (2012). Use of Medihoney as a non-surgical therapy for chronic pressure ulcers in patients with spinal cord injury. Spinal cord, 50(2), 165-169.

Charalambous, M., Raftopoulos, V., Paikousis, L., Katodritis, N., Lambrinou, E., Vomvas, D.,… & Charalambous, A. (2018). The effect of the use of thyme honey in minimizing radiation-induced oral mucositis in head and neck cancer patients: A randomized controlled trial. European Journal of Oncology Nursing, 34, 89-97.

El-Kased, R. F., Amer, R. I., Attia, D., & Elmazar, M. M. (2017). Honey-based hydrogel: in vitro and comparative in vivo evaluation for burn wound healing. Scientific reports, 7(1), 1-11.

EVANS, J., & MAHONEY, K. (2013). Efficacy of medical-grade honey as an autolytic debridement agent. Wounds UK, 9(1).

Frydman, G. H., Olaleye, D., Annamalai, D., Layne, K., Yang, I., Kaafarani, H. M., & Fox, J. G. (2020). Manuka honey microneedles for enhanced wound healing and the prevention and/or treatment of Methicillin-resistant Staphylococcus aureus (MRSA) surgical site infection. Scientific Reports, 10(1), 1-11.

Gibson, D. J., Yang, Q., Kerekes, D. T., & Schultz, G. S. (2014). Medical honey and silver dressings do not interfere with each other’s key functional attributes. Wounds, 26(11), 309-16.

Gilligan, A. M., Waycaster, C. R., Bizier, R., Chu, B. C., Carter, M. J., & Fife, C. E. (2017). Comparative effectiveness of clostridial collagenase ointment to medicinal honey for treatment of pressure ulcers. Advances in wound care, 6(4), 125-134.

Gulbetekin, E., & Tufekci, F. G. (2017). Milk with Honey Heals after Tonsillectomy; Bleeding, Pain and Wound Healing are in a Better Condition: An Experimental Study with Control Group. International Journal of Caring Sciences, 10(1), 433.

Leigh Sare, J. (2008). Leg ulcer management with topical medical honey. British journal of community nursing, 13(Sup4), S22-S32.

Maqsood, R., Bashir, U., & Shabbir, H. (2018). Comparing negative pressure wound treatment with honey dressing in healing of foot ulcers in diabetics. Pakistan Armed Forces Medical Journal, 68(1), 34-38.

Mohd Zohdi, R., Abu Bakar Zakaria, Z., Yusof, N., Mohamed Mustapha, N., & Abdullah, M. N. H. (2012). Gelam (Melaleuca spp.) honey-based hydrogel as burn wound dressing. Evidence-Based Complementary and Alternative Medicine, 2012.

Rafter, L., Reynolds, T. I. M., Collier, M., Rafter, M., & WEST, M. (2017). A clinical evaluation of Algivon® Plus manuka honey dressings for chronic wounds. Wounds UK, 13(4).

Seckam, A. M., & Mercer, J. (2018). Older patients’ experiences and perceptions of having their wounds treated with medical-grade honey. British Journal of Nursing, 27(15), S22-S29.

Takzaree, N., Hassanzadeh, G., Rouini, M. R., Manayi, A., Hadjiakhondi, A., & Zolbin, M. M. (2017). Evaluation of the effects of local application of thyme honey in open cutaneous wound healing. Iranian journal of public health, 46(4), 545.

Tan, M. K., Hasan Adli, D. S., Tumiran, M. A., Abdulla, M. A., & Yusoff, K. M. (2012). The efficacy of Gelam honey dressing towards excisional wound healing. Evidence-Based Complementary and Alternative Medicine, 2012.

Tellechea, O., Tellechea, A., Teixeira, V., & Ribeiro, F. (2013). Efficacy of honey gel in the treatment of chronic lower leg ulcers: A prospective study. EWMA Journal, 13(2).

Thomas, M., Hamdan, M., Hailes, S., & Walker, M. (2011). Manuka honey as an effective treatment for chronic pilonidal sinus wounds. journal of wound care, 20(11), 528-533.

Zeleníková, R., & Vyhlídalová, D. (2019). Applying honey dressings to non-healing wounds in elderly persons receiving home care. Journal of tissue viability, 28(3), 139-143.

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