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HoneyDressingVersusSilverSulfadiazeneDressingforWoundHealinginBurnPatients:ARetrospectiveStudy

JCutanAesthetSurg.2011SepDec4(3):183187.

PMCID:PMC3263128

doi:10.4103/09742077.91249

HoneyDressingVersusSilverSulfadiazeneDressingforWoundHealinginBurn
Patients:ARetrospectiveStudy
ShilpiSinghGupta,OnkarSingh,PraveenSinghBhagel,SoniaMoses,SumitShukla,andRajKumarMathur
DepartmentofSurgery,MGMMedicalCollegeandMYHospital,Indore,MadhyaPradesh,India
Addressforcorrespondence:Dr.ShilpiSinghGupta,Sangowal,Nakodar,Jalandhar144041,Punjab,India.Email:
[email protected]
Copyright:JournalofCutaneousandAestheticSurgery
ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNoncommercialShareAlike3.0Unported,which
permitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

Abstract
Objective:

Theaimwastoevaluatetheeffectofhoneydressingandsilversulfadiazene(SSD)dressingonwound
healinginburnpatients.
MaterialsandMethods:

Weretrospectivelyreviewedtherecordsof108patients(1468yearsofage),withfirstandseconddegree
burnsoflessthan50%ofthetotalbodysurfaceareaadmittedtoourinstitution,overaperiodof5years
(20042008).Fiftyonepatientsweretreatedwithhoneydressingsand57withSSD.Timeelapsedsince
burn,site,percentage,degreeanddepthofburns,resultsofculturesensitivityatvarioustimeintervals,
durationofhealing,formationofposttreatmenthypertrophicscar,and/orcontracturewererecordedand
analyzed.
Results:

Theaveragedurationofhealingwas18.16and32.68daysforthehoneyandSSDgroup,respectively.
Woundsofallpatientsreportingwithin1hofburnsbecamesterilewiththehoneydressinginlessthan7
dayswhiletherewasnonewithSSD.Allwoundstreatedwithhoneybecamesterilewithin21dayswhile
forSSDtreatedwounds,thisfigurewas36.5%.Acompleteoutcomewasseenin81%ofallpatientsinthe
honeygroupwhileinonly37%patientsintheSSDgroup.
Conclusion:

Honeydressingsmakethewoundssterileinlesstime,enhancehealing,andhaveabetteroutcomeinterms
ofhypertropicscarsandpostburncontractures,ascomparedtoSSDdressings.
KEYWORDS:Burns,honeydressing,silversulfadiazinedressing
INTRODUCTION
Theexactnumberofburncasesisdifficulttodeterminehowever,inacountrylikeIndia,withapopulation
ofover1billion,therearearound700,000800,000burnadmissionsperyear.[1]Burninjuriestotheskin
resultinlossofitsprotectivefunctionasabarriertomicroorganismsleadingtothehighriskofinfection.
Thus,burnpatientsfacehighmorbiditythanmortalitybecauseofthelargeuncoveredburnsurfacegetting
infected,healingofwhichtakeslongperiodsofdressings,leadingtodeformitiesandcontractures.[2]
Unfortunately,themanagementoftheburnwoundsstillremainsamatterofdebateandanidealdressingfor
burnwoundshasnotbeendiscovered.[2]Moreover,indevelopingcountries,burnmanagementisriddled
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HoneyDressingVersusSilverSulfadiazeneDressingforWoundHealinginBurnPatients:ARetrospectiveStudy

withdifficulties.
Variousdressingmaterialshavebeenusedfordressingtheburnwoundssuchasamnioticmembrane,boiled
potatopeel,bananaleaf,soframycincream,silversulfadiazene,skingrafting,epidermalgrowthfactor,honey
dressing,etc.Honeybeingcheapandeasilyavailableisareasonablygooddressingmaterialindeveloping
countries.Thepresentstudyisaimedtocomparetheeffectofthehoneydressingandsilversulfadiazene
(SSD)dressingonwoundhealing.
MATERIALSANDMETHODS
Therecordsofpatientswithburnswhohadbeentreatedwitheitherhoneydressingsorsilversulfadiazine
dressingsatourcenteroveraperiodof5years(January2004toDecember2008)werereviewed.Records
ofatotalof108patients(completerecords)ofbothsexesaged1468years,withfirstandseconddegree
burns,havingaburnedarealessthan50%ofthetotalbodysurfacearea(TBSA)wereincluded.Patients
whowereinanimmunocompromisedstate,anyorganfailure,andonchemotherapywerenotincluded.For
convenienceandcomparison,thepatientsweredividedintotwogroups:honeygroupandsilver
sulfadiazine(SSD)group.
Apartfromage/sexandusualpatientdata,timeelapsedsinceburntoreachthehospital,andresultsofroutine
bloodinvestigationsandwoundswabsamplesallwerecollected.Also,theresultsoftheclinicalassessment
ofthewoundsdonetimetotimeintermsofsite,affectedsurfacearea,degree,depth,presenceorabsenceof
slough,culturesensitivityeveryseventhday,anyadditionaltreatment,andtheoutcomewerealsonoted.
Alongwithstabilization,inallthepatients,intravenousororalantibioticswerestartedasperhospital
protocols.Woundswabsamplesweretakenonadmissionandeveryseventhdayfromthetimeofadmission.
Antibioticswerechangedappropriatelyaccordingtotheresultsofculturesensitivity.Antibioticsweregiven
forminimum5daysorafter48hoursofsubsidenceoffever.Woundswereexaminedcarefullyandwashed
withnormalsaline.Patientsmentionedunderthehoneygroupweredressedwithpureundilutedhoney
andthoseintheSSDgroupwithSSDcream,everyday.Aftertheapplicationofthedressingmaterial,we
preferredtoleavetheburnareaopen.Patientswerefollowedupeveryfortnightforinitial2months,monthly
fornext4months,andoncein6monthsthereafter.
Wemeasuredthefinaloutcome,intermsofcompleteandincompleterecovery.Criteriaforacomplete
recoveryincludedcompletehealingwithoutanyscarorcontracture.Formationofasoftscar,hypertrophic
scarand/orcontracturewaslabeledasanincompleterecovery.
RESULTS
PatientscharacteristicsandtimeelapsedafterburnstoreachthehospitalareshowninTable1.Outofatotal
of108patients,amajority(n=36)reportedwithin18hofburns.Sixtyfivepatientspresentedwithinfirst
24hofburns[Table1].Therewerenosignificantdifferencesamongpatientsinbothgroupsasfaras
patientscharacteristicswereconcernedexceptthatmorepatientsinthe"honeygroup"presentedwithinfirst
8h.
Onlyonepatientinthehoneygroup,amongthosewhopresentedinlessthan1hoftheburn,hadhis
woundswabculturespositiveatthetimeofadmission,whilethecorrespondingfigurefortheSSDgroup
was35%.Patientswhocamewithin18hfollowingburns(83%and75%intwogroups,respectively)had
woundswabculturespositiveatthetimeofadmission.Allpatientsinbothgroupsreportingafter24h
(100%)hadwoundswabculturespositiveonadmission[Table2].
Theaveragedurationofwoundhealingamongpatientsinthehoneygroupcomingwithin1,28,and9
24h,andmorethan48hwas18.8,17.8,21.25,and14.25days,respectively.AmongpatientsintheSSD
groupaveragedurationsofhealingwere27.6,32.4,32.5,32.5,and38.6daysforsimilartimesofreporting
[Table3].Thusaveragedurationsofhealingofpatientsinthehoneygroup(18.1days,SD=2.3)was
significantlylowerthanthatofpatientsintheSSDgroup(32.6days,SD=3.6,P<0.05).
Amongpatientstreatedwithhoneydressings,woundswabculturesbecamenegativeinlessthan7days,in
62%,50%,and40%ofthetotalnumberofpatientsreportingin28,924,andafter48h,respectively[
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Table4].AmongpatientstreatedwithSSDdressings,noneofthepatient'swoundbecamesterileinlessthan
7days.Woundsofhalf(50%)ofthepatientswhopresentedwithinlessthan1hofburnsbecamesterilein
lessthan21days,thoseof14%inlessthan14days,andof16%inmorethan28days.Amongpatientswho
presentedwithin28h,28.5%hadtheirwoundssterileinlessthan28days,42.8%inlessthan21days,and
14.2%inmorethan28days.Amongpatientswhopresentedafter48h,62.5%hadtheirwoundssterilein
morethan28days,and25%and14.2%inlessthan28and21days,respectively[Table4].Allthese
differencesweresignificantlyinfavorofthehoneydressing.
Among41patientstreatedwithhoneydressingswhoreportedwithin24h,32patients(80%)hadacomplete
recoverywhile9hadincomplete.Twoamongthesenineprogressedtothethirddegree.Outoftotal51
patienttreatedwithhoneydressings,41(81%)hadacompleterecovery.IntheSSDgroupoutof42patients
presentingwithin24h,only17patients(45%)hadacompleteoutcome,andoutoftotal57patients,only27
(47%)achievedacompleteoutcome.ThreepatientsintheSSDgroupevolvedtothethirddegree.These
differenceswerestatisticallysignificant(P=0.002for24h,andP=0.003for48hresults[Table5]).
DISCUSSION
Foratleast2700years,honeyhasbeenusedtotreatavarietyofailmentsthroughtopicalapplication,but
onlyrecentlyitsantisepticandantibacterialpropertieshavebeenchemicallyexplained.Theantibacterial
activityofhoneyismainlyduetothepresenceofinhibines,whichconsistofhydrogenperoxide,flavonoids,
phenolicacids,andmanyotherunidentifiedsubstances.[35]Otherfeaturesthatimpartantibacterial
propertiestohoneyareitslowwateractivitycausingosmosis[5]andhighacidity.[6]
Although,Mooreetal.,[7]throughareviewofpreviousrandomizedcontrolledtrialscomparinghoneywith
othermaterials,concludedthattheconfidenceinaconclusionthathoneyisausefultreatmentforsuperficial
woundsorburnsislow,however,recentlyin2004,ProfessorPeterMolanfromNewZealand,basedonhis
workatHoneyResearchUnitattheUniversityofWaikatosaidthathoneymightbeusefulintreating
methicillinresistantStaphylococcusaureus(MRSA)infections.[8]Thetopicaluseofhoneypreventsthe
dressingfromstickingtothehealingwound,andmayreduceodors,swelling,andscarringwhenusedto
treatwounds.[6]
Infectionisoneofthemostfrequentcomplicationsofwoundhealingdespitetheuseofantibioticsand
modernsteriletechniquesitaccountsforconsiderablepatientmorbidity,discomfort,andprolonged
hospitalizationanditmustbeavoidedtopermitproperhealing.[9]Burnpatientshavegreatchancesof
infectionduetothepresenceofnecrotictissueintheburnwounds.Delayedreportinghasbeenfoundtobe
animportantfactorthatcausesanincreaseinwoundinfectionandthusmorbidity.[10]Thisisamajor
probleminthethirdworldcountieslikeIndia,owingtopoortransportconditions,illiteracy,anddistant
tertiaryhealthcarecenters.Delayandinadequatefluidresuscitationandoverwhelminginfectionwerethe
majorfactorsinthemorbidityandmortality.[11]Honeybecauseofitsantisepticandantibacterialproperties
canthusbeausefuldressingmaterialinsuchregions.
Inthepresenceofinfection,healingbecomesveryslowordoesnottakeplaceatall.Thesituationbecomes
worseastheantibioticsareineffectiveinthissetting,andantisepticscausetissuedamage,furtherslowingthe
woundhealing.Honeyontheotherhanddoesnotcausetissuedamage,andappearstoactuallypromotethe
healingprocess,decreasingtheaveragedurationofwoundhealing.[12]Patientstreatedwithhoneyhada
significantlyloweraveragedurationofwoundhealingthanthosewhoweretreatedwithSSD[Table3].A
similartypeofresultwasfoundinthepreviousstudydonebySubrahmanyam.[13]
Inthepresentstudy,amongpatientsinthehoneygroup,100%ofpatientswoundswhoreportedwithin1h
ofburnsbecamesterileinlessthan7days.Thosewhoreportedwithin28and924handmorethan48h
ofburn(62.5%,50%,and50%,respectively)hadgottheirwoundssterilewithin7days[Table4].This
observationisalsocomparablewithanotherstudydonebySubrahmanyam.[14]
Honeyalsohasapositiveeffectinreducingtheoxidativestressfulstateinburntraumathatresultsinrapid
woundhealing.[15]Ontheotherhand,althoughthereisevidenceoftheantibacterialeffect,thereisnodirect
evidenceofimprovedwoundhealingorreducedinfectionbySSDdressingsinburnpatients.[16]
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Subrahmanyam[13]notedsustainedinflammatoryreactionevenonepithelializationinSSDtreatedburn
wounds,buttheearlysubsidenceofacuteinflammatorychanges,bettercontrolofinfection,andquicker
woundhealingwereseeninthosetreatedwithhoney.[13]
Fromthepresentstudy,itisclearthattheincreaseinthetimeelapsedafterburntraumaandadmissiontothe
hospitalhasadverseeffectsonwoundhealingandcomplicationsatfollowup.SSDdressingshavebeen
foundtobelessereffectiveincounteractingthiswhencomparedtohoney.[14]Subrahmanyam[14]found
betterreliefofpainandlowerincidenceofhypertrophicscarsandpostburncontractureswiththehoney
dressingthat,alongwithitslowcostandeasyavailability,makeitanidealdressinginthetreatmentofburns.
CONCLUSION
Thedelayinhospitaladmissionincreasesthewoundinfection,woundcontamination,andtimeinwound
sterilizationandhealing,andhasadetrimentaleffectonthefinaloutcome.Honeydressingsimprovewound
healing,makewoundsterileinlesserduration,andhavebetteroutcomesintermsofincidenceof
hypertrophicscarsandpostburncontractureswhencomparedtoSSDdressings.
Footnotes
SourceofSupport:Nil.
ConflictofInterest:Nonedeclared.

REFERENCES
1.JaiswalAK,AggarwalH,SolankiP,LubanaPS,MathurRK,OdiyaS.Epidemiologicalandsocio
culturalstudyofburnpatientsinM.Y.Hospital,Indore,India.IndianJPlastSurg.200740:15863.
2.SubrahmanyamM.Honeydressingversusboiledpotatopeelinthetreatmentofburns:Aprospective
randomizedstudy.Burns.199622:4913.[PubMed:8884013]
3.WahdanH.Causesoftheantimicrobialactivityofhoney.Infection.199826:2631.[PubMed:9505176]
4.SchepartzAI,SubersMH.CatalaseinHoney.JApicRes.19665:3743.
5.SubrahmanyamM.Additionofantioxidantandpolyethyleneglycole4000enhancesthehealingproperty
ofhoneyinburns.AnnBurnsFireDisasters.19969:935.
6.WaikatoHoneyResearchUnit,UniversityofWaikato,Hamilton,NewZealand.Honeyasan
AntimicrobialAgent.Availablefrom:http://bio.waikato.ac.nz/honey/honey_intro.shtml.
7.MooreOA,SmithLA,CampbellF,SeersK,McQuayHJ,MooreRA.Systematicreviewoftheuseof
honeyasawounddressing.BMCComplementAlternMed.20011:2.[PMCID:PMC32305]
[PubMed:11405898]
8.AngieKnox.Harnessinghoney'shealingpower.BBCExcerptfrom:
http://news.bbc.co.uk/2/hi/3787867.stm.
9.GoldenheimPD.Anappraisalofpovidoneiodineandwoundhealing.PostgradMedJ.199369:97105.
10.OzbekS,OzgenelY,EtozA,AkinS,KahveciR,HeperY,etal.Theeffectofdelayedadmissionin
burncentersonwoundcontaminationandinfectionrates.UlusTravmaAcilCerrahiDerg.200511:2307.
[PubMed:16100669]
11.OnubaO,UdoidiokE.Hospitalmanagementofmassiveburnsinthedevelopingcountries.BurnsIncl
ThermInj.198713:38690.[PubMed:3427495]
12.BrnemarkPI,EkholmR,AlbrektssonB,LindstromJ,LundborgG.LundskogJ.TissueInjurycaused
bywounddisinfectants.JBoneJointSurgAm.196749:4862.[PubMed:6015758]
13.SubrahmanyamM.Aprospectiverandomisedclinicalandhistologicalstudyofsuperficialburnwound
healingwithhoneyandsilversulfadiazine.Burns.199824:15761.[PubMed:9625243]
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3263128/?report=printable

4/6

10/21/2015

HoneyDressingVersusSilverSulfadiazeneDressingforWoundHealinginBurnPatients:ARetrospectiveStudy

14.SubrahmanyamM.Topicalapplicationofhoneyintreatmentofburns.BrJSurg.199178:4978.
[PubMed:2032114]
15.NaganeNS,GanuJV,BhagwatVR,SubramaniumM.Efficacyoftopicalhoneytherapyagainstsilver
sulphadiazinetreatmentinburns:Abiochemicalstudy.IndianJClinBiochem.200419:1736.
[PMCID:PMC3454216]
16.HussainS,FergusonC.Bestevidencetopicreport.Silversulphadiazinecreaminburns.EmergMedJ.
200623:92932.[PMCID:PMC2564257][PubMed:17130603]
FiguresandTables
Table1

Patientscharacteristicsandtimeofreportingafterburns
Table2

Timeelapsedafterburnsandtillreporting,andthewoundswabcultureatadmissioninbothgroups
Table3

Timeelapsedafterburnstillreporting,andhealingwithtreatment
Table4

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SterilizationofwoundsofdifferentreportingtimesachievedbyhoneyandSSD
Table5

FinaloutcomeinthehoneygroupandSSDgroupinrelationtodifferenttimesofreportingafterburns
ArticlesfromJournalofCutaneousandAestheticSurgeryareprovidedherecourtesyofMedknow
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