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com/1472-6882/1/2
BMC Complementary and Alternative Medi- cine (2001) 1:2
Research article
Systematic review of the use of honey as a wound dressing
Owen A Moore
1
, Lesley A Smith
1
, Fiona Campbell
2
, Kate Seers
2
,
Henry J McQuay
1
and R Andrew Moore*
1
Address:
1
Pain Research Unit and Nuffield Department of Anaesthetics, University of Oxford, Oxford, Radcliffe Hospital, The Churchill,
Headington, Oxford OX3 7LJ, UK and
2
RCN Institute, Radcliffe Infirmary, Woodstock Road, Oxford OX2 6HE, UK
E-mail: Owen A Moore - omoore@doctors.org.uk; Lesley A Smith - lesley.smith@pru.ox.ac.uk; Fiona Campbell - flona.campbell@rcn.org.uk;
Kate Seers - kate.seers@rcn.org.uk; Henry J McQuay - henry.mcquay@pru.ox.ac.uk; R Andrew Moore* - andrew.moore@pru.ox.ac.uk
*Corresponding author
Abstract
Objective: To investigate topical honey in superficial burns and wounds though a systematic
review of randomised controlled trials.
Data sources: Cochrane Library, MEDLINE, EMBASE, PubMed, reference lists and databases
were used to seek randomised controlled trials. Seven randomised trials involved superficial burns,
partial thickness burns, moderate to severe burns that included full thickness injury, and infected
postoperative wounds.
Review methods: Studies were randomised trials using honey, published papers, with a
comparator. Main outcomes were relative benefit and number-needed-to-treat to prevent an
outcome relating to wound healing time or infection rate.
Results: One study in infected postoperative wounds compared honey with antiseptics plus
systemic antibiotics. The number needed to treat with honey for good wound healing compared
with antiseptic was 2.9 (95% confidence interval 1.7 to 9.7). Five studies in patients with partial
thickness or superficial burns involved less than 40% of the body surface. Comparators were
polyurethane film, amniotic membrane, potato peel and silver sulphadiazine. The number needed
to treat for seven days with honey to produce one patient with a healed burn was 2.6 (2.1 to 3.4)
compared with any other treatment and 2.7 (2.0 to 4.1) compared with potato and amniotic
membrane. For some or all outcomes honey was superior to all these treatments. Time for healing
was significantly shorter for honey than all these treatments. The quality of studies was low.
Conclusion: Confidence in a conclusion that honey is a useful treatment for superficial wounds
or burns is low. There is biological plausibility.
Introduction
Superficial burns comprise a spectrum of injury severity
depending on the depth of the wound and the proportion
of the body affected. A burn may be superficial, involving
just the epidermal layer of the skin. Partial thickness
burns involve damage to more structures within the skin,
and full thickness burns involve all layers of the skin and
may involve structures beneath. The extent of the injury
is usually expressed in percent of total body surface area
(TBSA) which is burnt.
Published: 4 June 2001
BMC Complementary and Alternative Medicine 2001, 1:2
This article is available from: http://www.biomedcentral.com/1472-6882/1/2
(c) 2001 Moore et al, licensee BioMed Central Ltd.
Received: 8 March 2001
Accepted: 4 June 2001
BMC Complementary and Alternative Medicine (2001) 1:2 http://www.biomedcentral.com/1472-6882/1/2
Burn wounds are most commonly dressed using a com-
bination of paraffin-impregnated gauze (designed to
prevent adherence of the dressing to the wound) and an
absorbent cotton wool layer [1,2]. Silver sulphadiazine
(SSD) has also been commonly used in burn wound
management since 1968 to try to overcome the problem
of wound infection.
There is a dearth of good evidence about topical wound
agents from systematic reviews of randomised trials [3].
An exception is the subject of dressings and topical
agents for chronic wounds, which has been the subject of
systematic evidence collecting [4]. Perhaps because of a
perceived confusion about what is best in a difficult area,
complementary and alternative therapies are increasing-
ly seen as better than conventional. The lack of evidence
about either enhances this.
High osmolarity has been considered a valuable tool in
the treatment of infections, because it prevents the
growth of bacteria and encourages healing [5]. Use of
sugar to enhance wound healing has been reported for
several hundred patients [6]. High osmolarity can safely
be achieved topically by the use of sugar paste or honey,
though honey has additionally been regarded as having
specific antibacterial properties. For example, honey di-
luted seven to fourteen-fold beyond the point where os-
molality ceased to be completely inhibitory still
prevented growth of Staphylococcus aureus [7,8,9].
We sought to investigate the clinical effects of topical
honey in superficial burns and wounds though a system-
atic review of published randomised controlled trials
(RCTs). Our view was that key outcomes would be meas-
ures of wound healing time and of infection rates.
Methods
Full published reports of randomised controlled trials of
honey in the treatment of burns or wounds were sought.
Different search strategies identified reports in
MEDLINE (1966 to January 2000), EMBASE (1980 to
January 2000), CINAHL (1982 to 2000), PSYCHLIT
(1982 to 2000), PubMed (July 2000), and the Cochrane
Library (online July 2000). A broad free text search with
no restriction to language was undertaken. Reference
lists of retrieved reports and reviews [3,4] were searched
for additional trials. The Internet was searched, particu-
larly an electronic wound journal (World Wide Wounds;
[http://www.smtl.co.uk/World-Wide-Wounds/] ). The
date of the last search was 1 August 2000. Unpublished
reports and abstracts were not considered. Authors were
not contacted for original data.
Inclusion criteria were RCTs comparing honey with a
control group in adults or children with burns or
wounds, infected or sterile. For inclusion a study had to
have at least 10 individuals per treatment group, and
clinical or microbiological outcomes. Studies on animals,
or laboratory experiments involving assessment of anti-
microbial properties of honey were excluded.
Each report that could possibly be described as an RCT
was read independently by three of the authors (LAS,
OAM, RAM). Trials meeting inclusion criteria were
screened independently (authors were not blinded be-
cause they already knew the literature) and scored using
a three item, 1-5 score, quality scale [10]. The scale takes
into account proper randomisation (two possible
points), double-blinding (two possible points), and re-
porting of withdrawals and dropouts (one possible
point). Trials were also scored using a five item, 0-16
score, validity scale [11]. This scale takes into account not
only the quality of blinding (trials have to be ran-
domised), but also trial size, the validity or appropriate-
ness of outcomes, baseline characteristics of patient
groups to ensure sensitivity of the trial, and the quality of
data analysis.
From each trial data were extracted on trial design, de-
tails of honey and control interventions, outcome meas-
ures, statistical analysis, and geographic location of the
trial. The main outcomes sought were wounds healed at
seven and 21 days, and the number of wounds initially
with bacterial growth rendered sterile by treatment at
seven and 21 days. The number of patients randomised,
or who had initially infected wounds was used as the ba-
sis for analysis of healing and infection resolution re-
spectively.
Studies were regarded as having a positive result accord-
ing to original authors if honey was statistically better
than control on any outcome. Authors of the review had
to agree that the result was statistically different and that
the outcome was useful. Relative benefit and relative risk
estimates were calculated with 95% confidence intervals
(CI) using a fixed effects model [12]. Number-needed-to-
treat (NNT) or number-needed-to-harm (NNH) with
95% confidence intervals were calculated by the method
of Cook and Sackett [13]. A statistically significant differ-
ence from control was assumed when the 95% confi-
dence interval of the relative benefit did not include 1.
Calculations were performed using Excel v 5.0 on a Pow-
er Macintosh G3. Heterogeneity tests were not used as
they have previously been shown to be unhelpful [14].
Publication bias was not assessed using funnel plots as
these tests have been shown to be unhelpful [15,16].
Results
We found seven randomised trials
[17,18,19,20,21,22,23], six performed in India by the
BMC Complementary and Alternative Medicine (2001) 1:2 http://www.biomedcentral.com/1472-6882/1/2
same researcher [18,19,20,21,22,23], and one [17] per-
formed in the United Arab Emirates (1supplementary
material). Two of the studies involved superficial burns
[19,23], three partial thickness burns [20,21,22], one
moderate to severe burns that included full thickness in-
jury [18], and one infected postoperative wounds [17]. All
the controls were active comparisons, though these in-
cluded potato peelings [20] and amniotic membrane [21]
as well as conventional treatments. The main outcomes
were the effects of honey and controls on healing time
and infection rate, though antibiotic use and hospital
stay were also noted in some studies.
None of the studies was blinded and only one designated
a primary outcome [23]. The quality score for each trial
was 1 out of a possible range of 1-5, and validity scores
ranged between 5 and 10 out of range of 0 to 16. Of the
seven studies, six were deemed positive by the original
authors and by authors of this review. One [18] was neg-
ative, where tangential excision was statistically better
than honey. Because the quality score was 1 in all trials,
sensitivity analysis was not possible. Five studies had a
mean OPVS score of 8 or less, and four were positive.
Both studies with validity scores above 8 were positive.
The single study in infected postoperative wounds com-
pared honey with antiseptics in addition to systemic an-
tibiotics after culture and sensitivity [17]. For all
outcomes honey was significantly better, with much
shorter times for healing, eradication of infection, use of
antibiotics and hospital stay (supplementary material).
The proportion of wounds healed without dehiscence or
resuturing was 22/26 (85%) for honey compared with
12/24 (50%) with antiseptic. The number needed to treat
with honey for good wound healing compared with anti-
septic was 2.9 (1.7 to 9.7).
The single study of moderate or severe burns [18] com-
pared honey with tangential excision. For all outcomes
tangential excision followed by grafting by six days post
burn was significantly better than initial honey treat-
ment followed by grafting where necessary. Half of all
the patients had full thickness burns, and half of those
treated with honey eventually needed skin grafts.
The other five studies [19,20,21,22,23] were conducted
in patients with partial thickness or superficial burns in-
volving less than 40% of the body surface. Comparators
were polyurethane film [22], amniotic membrane [21],
potato peel [20] and silver sulphadiazine [19,23]. For
some or all outcomes honey was superior to all these
treatments. Time for healing was significantly shorter for
honey than all these treatments.
Table 1: Major outcomes for wound healing and infection for superficial and partial thickness burns
Outcome Number of trials Outcome achieved
with honey (%)
Outcome achieved
with control (%)

Relative benefit (95%
CI)
NNT (95% CI)
7-day 4 97/167 29/151 3.0 (2.2 to 2.6 (2.1
wound (58%) (19%) 4.3) to 3.4)
healing
2 43/90 8/74 4.1 (2.1 to 2.7 (2.0
(48%) (11%) 8.2) to 4.1)
21-day 4 165/167 113/151 1.3 (1.2 to 4.2 (3.3
wound (99%) (75%) 1.4) to 6.0)
healing
2 90/90 70/74 1.05 (0.99 to 21 (10 to
(100%) (95%) 1.1) no
benefit)
7-day 4 114/134 37/124 2.7 (2.0 to 1.8 (1.5
infections (85%) (30%) 3.5) to 2.2)
2 60/68 18/61 2.6 (1.8 to 1.7 (1.4
(88%) (30%) 3.7) to 2.3)
Trials included were 16-18, 20 for all four comparisons with honey, and 17 and 18 for comparisons with treatments without biological plausibility
BMC Complementary and Alternative Medicine (2001) 1:2 http://www.biomedcentral.com/1472-6882/1/2
Four studies had dichotomous information about the
number of patients healed or with wounds initially in-
fected but which became sterile on treatment
[19,20,21,23]. Information from these studies has been
combined for all four comparisons and for those compar-
isons (potato, amniotic membrane) where there was no
biological plausibility for efficacy (Table 1). The study
without dichotomous information [22] reported a statis-
tically significant reduced mean healing time of 10.8
days with honey compared with 15.3 days with poly-
urethane film.
Treatment with honey produced significantly more heal-
ing at seven days. At seven days 58% (97/167) of patients
were healed with honey, and 19% (29/151) with other
treatments (Figure 1). The number needed to treat for
seven days with honey to produce one patient with a
healed burn was 2.6 (2.1 to 3.4) compared with any other
treatment and 2.7 (2.0 to 4.1) for potato and amniotic
membrane. By 21 days 99% (165/167) of patients were
healed with honey, and 75% (113/151) with other treat-
ments. The number needed to treat for 21 days with hon-
ey to produce one patient with a healed burn was 4.2 (3.3
to 6.0) compared with any other treatment.
At seven days 85% (114/134) of patients with initially in-
fected wounds had them rendered sterile with honey
compared with 30% (37/124) for other treatments (Fig-
ure 2). The number needed to treat for seven days with
honey to produce one patient with a sterile wound was
1.8 (1.5 to 2.2) compared with any other treatment and
1.7 (1.4 to 2.3) for potato and amniotic membrane. Only
one study gave the sterile wound rate at 21 days, 96% for
honey and 76% for silver sulphadiazine based on limited
numbers of patients.
The absence of any adverse effects with honey was posi-
tively reported in three studies [17,20,23].
Discussion
These seven studies give information on 264 patients
treated with honey. The studies were of limited quality,
and could be influenced by known sources of bias, espe-
cially lack of blinding [24], poor reporting quality
[25,26], poor validity [11], or size [27]. In addition, six of
the studies were conducted by the same researcher. This
must mean that the conclusions of the review should be
treated with caution. Despite this, six of seven studies
comparing honey to other treatments, both conventional
and unconventional, showed it to be superior for wound
healing, maintenance of sterility or eradication of infec-
Figure 1
Percent of patients healed with honey and other treatments
after seven days. The size of the symbol is proportional to
the size of the study.
Figure 2
Percent of patients with infected wounds rendered sterile
with honey and other treatments after seven days. The size
of the symbol is proportional to the size of the study.
BMC Complementary and Alternative Medicine (2001) 1:2 http://www.biomedcentral.com/1472-6882/1/2
tion. The degree of agreement is considerable (Figures 1
and 2), and the magnitude of the effect impressive (Table
1). The natural resolution of wounds was such that at 21
days the healing rates were high both for honey and com-
parator treatments. It was the seven day results that were
consistently better with honey, using two or four studies,
and for wound healing and resolution of infection. The
numbers needed to treat were of the order of 2 to 3, and
the effect was comparable with that found for wound
healing without dehiscence or resuturing in infected
postoperative wounds [17].
There is a biological plausibility, because inhibition of
bacterial growth has been shown using impregnated
honey discs [9] or incorporating honey into agar plates
[7]. How much of this inhibition is due to inherent anti-
microbial properties [7,8,9] or to its hyperosmolar na-
ture is unknown. We do know that hyperosmolar sugar
paste is effective in experimental animals, and superior
to antiseptics [5].
Sugar paste was reported as being used successfully in
605 patients with wounds, burns and ulcers, with lower
requirements for skin grafting, antibiotics, and lower
hospital costs [6]. What is lacking a way of defining
whether the use of honey or sugar paste has any rele-
vance to modern wound management. The problem is a
lack of high quality comparative evidence for both con-
ventional and unconventional treatments.
It is difficult to see how the 21
st
century can be upon us
without such evidence being available. The nature of the
evidence we have now is such that caution needs still to
be exercised. But this review should be of help in design-
ing new, large, randomised studies, with blinded assess-
ment of useful clinical outcomes and compared with
standard wound treatments for burns, postoperative
wounds and for venous ulcers.
Those studies will not be easy. With honey, we also need
to be aware that it is a natural product, and that those
characteristics associated with wound healing may be af-
fected by species of bee, geographical location and botan-
ical origin, as well as processing and storage conditions.
Some basic knowledge of the importance of these issues
is necessary before trials could begin. While these trials
would be relevant to industrialised countries to compare
honey with conventional treatments, it would be impor-
tant to conduct them in the less developed world where
cost and availability are the key issues.
Acknowledgements
The study was supported with Pain Research funds.
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Additional material
File 1
[http://www.biomedcentral.com/content/supplementary/1472-
6882-1-2-s1.xls]
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