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lipidocolloid tulle proven to be less pain, andnon sticky compared to parrafin-tulle thus thenewly formed epitel is not disrupted (EkoHarihadi , 2009).5

Honey has long been used as one of thetreatment for wounds. Peter Molan, aresearcher from Waikato University, NewZealand, honey will clear the wound frominfection and promote the healthy granulationtissue.6 Most studies used commercial honeyfor wound treatment compared to medicalhoney. Even though both have differencesrelating to the bacterial spores but theapplication itself has a relatively same effect.7

Pure honey has an antibacterial effect to severalpathogenic microorganism such as Salmonellaspp, Shigella spp, Escheria coli, Vibrio cholera,

Helicobacter pylori and other gram positive andnegative bacterias. Honey has even beenstudied to have a potential to inhibit the growthof Pseudomonas aeruginosa, Methicillin ResistantStaphylococcus aureus and Vancomysin resistantenterococci.8,9 H o n e y c a n p r o m o t eepithelialization, affordable and easy to get.10-12So the author decided to study the effect ofhoney in promoting wound healing in STSG

donor site.

METHODSThis study was designed according to,

and approved by the local medical ethicscommittee. An open, non-randomized clinicaltrial with a parallel design with intervention ofhoney application with transparent dressingwas done. The study was done by takingsamples from Cipto Mangunkusumo Hospital-

Jakarta, Gatot Soebroto Hospital-Jakarta,

Persahabatan Hospital-Jakarta, SardjitoHospitalYogyakarta, Kariadi HospitalSemarang.

From March to April 2010 , everypatient that was done a STSG in the previouslymentioned hospital was taken into the study.The inclusion criteria was a male or femalepatient from the age of 15 to 60 years old andwilling to be included in this study. The patientwas excluded from this study if the patient hada liver or renal disorder, receiving steroid orchemotherapy, diabetic patients withuncontrollable blood glucose, shock, septic or

unwilling to be included in this study. Eachpatient will have two intervention, half of thedonor site wound will be treated with honeyand transparent dressing (the subject of thisstudy), while the other half will be treated withtransparent dressing only as a control.

We collected the samples age andgender, after that the epithelialization rate anddepth of the donor site wound. For taking thegraft we used a Humby graft knife withdermatome scale 0.6. After that we used atransparent dressing and local honey(Nusantara) which has been registered at POMwith affordable price and easy to get. On top of

the transparent dressing we used elasticbandage.

From the samples we divided the donorsite wound into two parts, one was treated withhoney and transparent dressing and the otherwith transparent dressing only as a controlgroup. The honey was reapplied every twodays, and the epithelialization rate wasobserved everyday by clinical examination afterthe wound is cleaned. When there was doffcoloring, no blood, and pale color then itsconsidered full epithelialized. The observation

was done by two observer that has not beentold which part has been given honey treatment(single blind).

The data was analyzed with SPSSprogram version 17.0. The analysis included aunivariate analysis on each variable study tosee the distribution and percentage. The

bivar iate analys is was done to see th econnection between the epithelialization rateand the treatment used. A Wilcoxon test wasused to compare the epithelialization rate

between each group.

RESULTSThe samples were taken from April to

May 2010 from a few hospitals in jakarta sucha s C i p t o M a n g u n k u s u m o H o s p i t a l ,Persahabatan Hospital, Gatot Soebroto Hospitaland also involving other hospitals outside of

jakarta such as Kariadi Hospital andYogyakarta Hospital. We included 19 patientsin this study (Table 1). Seven of them werefemale and 12 were male. Each patient received

the same treatment which is the donor site for

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STSG was divided in two section given twokinds of treatment. One section was treated

with honey application with transparentdressing, and was done reapplication of honeytogether with dressing changes every two days.The second section was only treated withtransparent dressing as a control group.Photograph was taken for both sectioneveryday with the same camera to skin distanceusing the same camera with no flash.

The evaluation for epithelialization ratewas done everyday by observing the woundsurface after it has been cleaned and if therewas part that was already doff (no light

reflection), the color became whitish then it isconsidered epithelialized. The evaluationthrough photography was done by twoobserver who were blinded from which parthad been the treatment or control group (single

blind).From the 19 samples, we found that the

fastest full epithelialization on the Group 1 withhoney application and transparent dressing was

on day 8 and the longest was day 11. Therewere some samples were the epithelializationwas not as clearly differentiated as the others (4samples). After we did a statistical analysis wefound the mean epithelialization rate for the

Group 1 treated with with honey andtransparent dressing was 9,74 (0,24) days. Whilefor the Group 2 (control group) it was 10,79(1,23) days. The difference between theepithelialization rate between two groups werestatistically significant (p=0,00) as we can see inTable 1.

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Volume 1 - Number 3 - The Effect of Honey Application with Transparent Dressing

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Variable n (%)

MaleFemale

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Age 41,42 ( 13,06 )*

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DISCUSSION

The STSG was taken by the same personand with the same level of thickness for bothtreatment. After the STSG was taken, the donorsite was closed temporarily with adrenalinemoist gauze until the fixation of the graft to therecipient site was done. This was done to get aclear operating field and will make theobservation easier. During the first grouptreatment using honey and transparentdressing, we needed to change the dressingevery 2 days. This was done to clear the visualfield from any blood clots and to do honeyreapplication. Actually it was found that thehoney itself did not dry off but will de-concentrate due to exudation from the wounditself. The exudate will promote oxidationprocess and create a hydrogen peroxide thatwill stimulate angiogenesis and fibroblastgrowth. The low pH of honey and moistcharacteristic will also hasten the tissueregeneration for wound healing. But because ofthe mixing with exudate, the concentration ofhoney become less and thus needing the

reapplication every two days. On day 2 postoperatively, the patient did not complainedgreat pain during dressing change. For day 4and so on none of the patient complained anypain. It was observed that there was a thin layeron the donor site that was thought to havemade the dressing changes less painful.Compared to the control donor site, until day 7post operatively the patients still complained ofpain. The transparent dressing changes did notdisrupt the newly formed epithel. Epithelialization process was observed

through actual visual observation and photodocumentation. To reduce bias, the observationwas done by two observer (single blind) whoare both capable to differentiate which part hasfull epithelialization. There was no difference inthe observation result from both observer. The difference between epithelializationrate of the donor site treated with honey andtransparent dressing compared to the onestreated with transparent dressing only wass t a t i s t i c a l l y s i g n ifi c a n t . T h e m e a nepithelialization rate of the wound using honeyand transparent dressing was 9,74 days while

in the control group it was 10,79 days. Thisresult shows difference for the time needed in

wound healing process. There was no wound infection orallergic reaction in all samples. Two of thesamples had been through another STSG donorsite treatment previously with a conventionaltulle grass and moist gauze. According to thistwo patients the new treatment was moreconvenient due to lack of odor.

This method of treatment with honeyand transparent dressing was thought to have agood effect due to several factors. The first oneis that a moist condition was preserved.

Because the honey has a high osmolaritycombined with the transparent dressing thuscreating a moist environment. The second one is

because honey has been proven to induceangiogenesis, fibroblast growth, granulationformation and re epithelialization. The thirdfactor is there were no infection on the woundwhich obviously promote wound healingprocess. The low infection rate is thought to becaused by the low pH of honey, hydrogenperoxide formation, high osmolarity andcontains inhibin thus creating an antibacterialeffect. the fourth factor is less odor, this is

because honey can lessen the production of freefatty acid, ammonia, sulfur, and amino created

by bacteria from dead tissue. The last point isthat this treatment create less pain because ofthe formation of a thin layer on the surface ofdonor site.

CONCLUSIONThe mean time of epithelialization rate

for the STSG donor site treated with honey andtransparent dressing was 9.74 days.

The epithelialization rate is consideredfaster in this method compared to the onestreated with transparent dressing only or withconventional method by using tulle grass andmoist gauze. The reapplication of honey had to

be done every 2 days. So we concluded that thismethod is safe and applicable for the patient

because the honey used in this study is acommercial honey that can be easily found andaffordable for many patients. We still need

another study using other kind of honey tofurther conclude this study on honey and

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wound healing. Comparing the bactericidaleffect of commercial honey and the medical

honey also need further study.

AcknowledgementThe authors would like to thank Erythrina P.S., M.D. forher tremendous assistances and work in this research atKariadi Hospital, Semarang. Also Rosadi S.,M.D. andDanu M., M.D. for helping this research at Sardjito

Hospital, Yogyakarta, Yantoko,M.D. for sample collectionin Persahabatan Hospital, and Rahmi SKM forbiostatistical analysis assistantances.

REFERENCES1. Singer AJ, Clark RAF; Cutaneous Wound Healing; In:

Epstein F.H, editor. Mechanism of Disease; NEJM, vol341 nomor 10, 1999; 738-746.

2. Sudjatmiko G, Syarif N A, Handayani S; 2009Menjahit Luka Supaya Bekasnya Susah Dicari, 2009 ;3-5

3. Gemberling RM, Miller TA, Caffee H. Dressingcomparison in the healing of donor site. J Trauma1976; 16: 812814

4. Bellinger CG, Conway H. Effects of silver nitrate andSulfamylon on epithelial regeneration. Plast ReconstrSurg 1970; 45: 582587

5. Harihadi E. Tesis : Perbandingan Hasil PemakaianTulle Dengan Lipidocolloid dan Tulle Dengan ParafinPada Perawatan Luka Donor Split Thickness SkinGraft. RSCM; 2009.

6. Gomes S, Dias LG, Moreira LL, Rodrigues P,Estevinho L. Physicochemical, microbiological andantimicrobial properties of commercial honeys fromPortugal. Food and Chemical Toxicology. 2009:1 - 5.

7. Broughton II G, Janis JE, Attinger CE. A Brief Historyof Wound Care. Plast Reconstr Surg. 2006;117(Suppl):6S - 11S.

8. Cooper R. Honey in wound care: antibacterialp r o p e r t i e s . G M S K r a n k e n h a u s h y g i e n eInterdisziplinr. 2007;2(2).

9. National Honey Board. Honey Health andTherapeutic Qualities. In press 2004.

10. Davies P, Murphy J. Mechanisms of Action of Honeyin Relation to Wound Healing A Review. Journal[serial on the Internet]. 2007 Date [cited 2008 12th

Ju ly ]: Av ai labl e fr om : ww w. rama me di ca l. se /catalog.object.aspx?id=519.

11. Molan PC. Using Honey in Wound Care. Int J ClinAromatherapy 2006;3(2):21 - 4.

12. White R. The benefits of honey in woundmanagement. Nursing Standard. 2005;20(10):57 64.

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Gentur Sudjatmiko, M.D.Cleft Craniofacial Center. Plastic Surgery Division

Cipto Mangunkusumo General National HospitalJalan Diponegoro.No.71, Gedung A, Lantai 4.dr_gentur@yahoo.co.id