Honey dressing on a leg ulcer with tendon exposure in a patient with type 2 diabetes

Honey has been used as a wound dressing for hundreds of years by ancient civilizations, but only recently it has acquired scientific interest because of its relevant biological properties. In the last decade, indeed, several trials and observational studies have reported that, compared to conventional treatment (e.g. antiseptics, polyurethane film, paraffin gauze, soframycin-impregnated gauze), honey dressings seem to be better in healing time of different types of wounds, including diabetic foot ulcers. However, to date, information about a potential favorable biological effect of honey dressings on diabetic ulcers with exposed tendon are still scarce. Notably, foot or leg ulcers with exposed tendon are serious complications in patients with type 2 diabetes, as they are associated with an increased risk of adverse outcome. Therefore, the use of effective and safe treatments to bring these lesions to timely healing is very important in clinical practice. We herein report the case of a Caucasian adult patient with type 2 diabetes presenting a chronic right posterior lower limb ulcer (Texas University Classification (TUC) 2D) with tendon exposure that was successfully treated with honey dressings (glucose oxidase (GOX) positive with peroxide activity) in addition to systemic antibiotic therapy, surgical toilette and skin graft. In our case, the use of honey dressing for treating exposed tendon tissue probably allowed the timely wound healing. Although further studies are required, such treatment may constitute part of the comprehensive management of diabetic wounds, including those with tendon exposure, and should be considered by clinicians in clinical practice. Learning points: Honey has been used as a wound dressing for hundreds of years, but only recently it has acquired scientific interest for its biological properties. Several studies have documented that, compared to conventional dressings, honey seems to be better in healing time of different types of wounds, including diabetic foot ulcers. Our case report is the first to highlight the importance to use honey dressings also for the treatment of ulcers with tendon exposure in patients with type 2 diabetes, suggesting that this kind of dressing should be considered by clinicians in clinical practice. Introduction Honey is a viscous, supersaturated sugar solution derived from nectar assembled and worked by honeybees (i.e., Apis mellifera), which contains approximately 40% of fructose, 30% of glucose, 20% of water and 5% of sucrose, as well as many bioactive substances, including amino acids, vitamins, minerals and enzymes (1, 2). Honey has been used as a wound dressing for hundreds of years by numerous ancient civilizations, but only recently it has acquired scientific interest because of its biological properties (for a detailed review on this topic please see 2). Indeed, it is established that honey is able to promote healing processes of wounds through multiple mechanisms (1, 2). For instance, several experimental studies have documented that the relative acidity of honey may help the deliverance of oxygen from hemoglobin, thus making the wound environment less advantageous to the bacterial growth (2). The high osmolarity of honey may even draw fluid out of the wound bed in order to promote an outflow of lymph as happens during negative pressure wound therapy (2). In addition, honey has an important broad-spectrum antibacterial activity, although there is difference in efficacy among specific honeys (2). In the last decade, given the aforementioned biological properties of honey, several trials and observational studies have reported that, compared to other conventional treatment (e.g., antiseptics and gauze), honey dressings appear to be better in healing time of different wounds (2, 3, 4, 5, 6, 7). In addition, although apparently in a counter-intuitive manner, almost identical results were observed for foot ulcers in patients with type 2 diabetes (3, 4). However, to date, information regarding the potential favorable biological effects of honey dressings on ulcers with exposed tendon are still scarce, especially in those with type 2 diabetes mellitus. Importantly, foot or leg ulcers with exposed tendon are serious complications in such patients, as they are strongly associated with an increased risk of adverse outcome and even limb amputation (8). In this context, a retrospective observational study of nearly 400 patients with type 2 diabetes underwent surgical treatment for diabetic foot syndrome (8% of whom underwent immediate surgical debridement resulting in exposed tendon) shows the importance to cover an exposed and (still) healthy tendon as soon as possible, in order to avoid a rapid spread of infection and also preserving maximal residual foot length for future potential rehabilitation and mobility (9). Given the multiple bioactivities of honey, although more information is at present required, it is reasonable to suppose that honey dressings may be effectively considered for the treatment of leg ulcers with exposed tendon in individuals with type 2 diabetes. Thus, we herein report the case of a Caucasian adult patient with type 2 diabetes, presenting a chronic right posterior lower limb ulcer (Texas University Classification (TUC) 2D) with tendon exposure that was treated with honey dressings in addition to systemic antibiotic therapy, surgical toilette and skin graft.