75 Indian Journal of Surgery 2004 Volume 66 Issue 2 (March-April) © 2003 Indian Journal of Surgery www.indianjsurg.com Address for correspondence: Dr. M. Subrahmanyam, Old Civil Hospital Compound, Opposite Head Post Office, Rajwada Chowk, Sangli - 416416, India. E-mail: [email protected] Paper Received: July 2003. Paper Accepted: October 2003. Source of Support: Nil. Honey dressing beneficial in treatment of Fournier’s gangrene M. Subrahmanyam, S. P. Ugane Department of Surgery, Government Medical College, Miraj and General Hospital, Sangli, India. ABSTRACT Background: Fournier’s gangrene is a difficult infective condition to treat. We report our experience of the management of this disease with honey dressings. Material and Methods: Thirty patients admitted with the diagnosis of Fournier’s gangrene were randomly allocated to two groups, one group treated by honey dressing and the other by Eusol dressing. All patients were treated with broad-spectrum antibiotics and underwent debridement and delayed closure as required. Results: In 14 patients treated with honey dressing, healthy granulation appeared in 4 patients in one week and in all patients within 3 weeks. One patient died. In 16 patients treated with Eusol dressing, healthy granulation appeared in one week and by 4 weeks in remaining patients. Two patients died. Secondary suturing and skin grafting was required in 9 patients in each group. Mean hospital stay was 28 days (range 9-40 days) in the honey-treated group and 32 days (range12-52 days) in the Eusol-treated group. Conclusion: In this study, honey was found to be beneficial in the treatment of Fournier’s gangrene. KEY WORDS Gangrene, Fournier’s gangrene, Honey dressing. How to cite this article: Subrahmanyam U, Ugane SP. Honey dressing beneficial in treatment of fournier’s gangrene. Indian J Surg 2004;66:75-7. INTRODUCTION Fournier’ gangrene is a fulminating, rapidly spreading infection of the scrotum that also involves the perinium and the abdominal wall. 1,2 The infective process leads to the thrombosis of subcutaneous vessels resulting in gangrene of the overlying skin. It affects all ages and has been reported in both sexes and various aetiological factors have been noted. 3 The basic treatment involves prompt excision of all non-viable tissue, limitation and abolition of any infective process, antibiotics and occasional anatomical reconstruction. 4 Honey is a mixture of sugars prepared by the bees from natural sugar solutions called the nectar, obtained from flowers. By inverting the sucrose in the nectar, the bee increases the attainable density of the final product and thus raises the efficiency of the process in terms of caloric density. The higher osmotic pressure thus obtained precludes the bacterial growth. The medicinal properties of honey have been known for years. The Indian system of medicine ‘Ayurveda’ describes honey as the nectar of life and recommends its use in the treatment of various ailments. Honey produced by the Indian hive bee Apis cerana indica, extracted by modern extraction methods, is a transparent liquid and free from foreign materials. Granulation is the natural process of crystallization of the glucose content in honey and granulated honey can be made liquid by slight warming. Honey has been found to be useful in controlling the infection of wounds and burns 5,6 leading to rapid healing and it has also been tried in Fournier’s gangrene. 7,8 This study reports the use of honey in Fournier’s gangrene and its comparison with conventional dressing. Original Article
Honey dressing beneficial in treatment of Fournier’s gangrene
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IJS_Mar_04.pmdIndian Journal of Surgery 2004 Volume 66 Issue 2 (March-April)
© 2003 Indian Journal of Surgery www.indianjsurg.com
Address for correspondence: Dr. M. Subrahmanyam, Old Civil Hospital Compound, Opposite Head Post Office, Rajwada Chowk, Sangli - 416416, India. E-mail: [email protected] Paper Received: July 2003. Paper Accepted: October 2003. Source of Support: Nil.
Honey dressing beneficial in treatment of Fournier’s gangrene
M. Subrahmanyam, S. P. Ugane Department of Surgery, Government Medical College, Miraj and General Hospital, Sangli, India.
ABSTRACT Background: Fournier’s gangrene is a difficult infective condition to treat. We report our experience of the management of this disease with honey dressings. Material and Methods: Thirty patients admitted with the diagnosis of Fournier’s gangrene were randomly allocated to two groups, one group treated by honey dressing and the other by Eusol dressing. All patients were treated with broad-spectrum antibiotics and underwent debridement and delayed closure as required. Results: In 14 patients treated with honey dressing, healthy granulation appeared in 4 patients in one week and in all patients within 3 weeks. One patient died. In 16 patients treated with Eusol dressing, healthy granulation appeared in one week and by 4 weeks in remaining patients. Two patients died. Secondary suturing and skin grafting was required in 9 patients in each group. Mean hospital stay was 28 days (range 9-40 days) in the honey-treated group and 32 days (range12-52 days) in the Eusol-treated group. Conclusion: In this study, honey was found to be beneficial in the treatment of Fournier’s gangrene.
KEY WORDS Gangrene, Fournier’s gangrene, Honey dressing.
How to cite this article: Subrahmanyam U, Ugane SP. Honey dressing beneficial in treatment of fournier’s gangrene. Indian J Surg 2004;66:75-7.
INTRODUCTION
infection of the scrotum that also involves the perinium
and the abdominal wall.1,2 The infective process leads
to the thrombosis of subcutaneous vessels resulting in
gangrene of the overlying skin. It affects all ages and
has been reported in both sexes and various aetiological
factors have been noted.3 The basic treatment involves
prompt excision of all non-viable tissue, limitation and
abolition of any infective process, antibiotics and
occasional anatomical reconstruction.4
Honey is a mixture of sugars prepared by the bees
from natural sugar solutions called the nectar,
obtained from flowers. By inverting the sucrose in
the nectar, the bee increases the attainable density
of the final product and thus raises the efficiency of
the process in terms of caloric density. The higher
osmotic pressure thus obtained precludes the
bacterial growth. The medicinal properties of honey
have been known for years. The Indian system of
medicine ‘Ayurveda’ describes honey as the nectar
of life and recommends its use in the treatment of
various ailments. Honey produced by the Indian hive
bee Apis cerana indica, extracted by modern
extraction methods, is a transparent liquid and free
from foreign materials. Granulation is the natural
process of crystallization of the glucose content in
honey and granulated honey can be made liquid by
slight warming.
Honey has been found to be useful in controlling the
infection of wounds and burns5,6 leading to rapid
healing and it has also been tried in Fournier’s
gangrene.7,8 This study reports the use of honey in
Fournier’s gangrene and its comparison with
conventional dressing.
Original Article
76 Indian Journal of Surgery 2004 Volume 66 Issue 2 (March-April)
MATERIAL AND METHODS
gangrene admitted during the period April 2001 to
May 2003 formed the material for this study. Diagnosis
was established from the patient’s history and clinical
examination. Age, predisposing conditions, site of
primary infection, bacteriological findings, therapeutic
response, hospital stay and outcome were evaluated.
For assessing the beneficial effects of local dressings,
the patients were divided into two groups by
randomization, the rest of the treatment being the
same. Both the groups had similar age distribution,
involvement and were comparable in all respects. The
assessor was not aware of the treatment given (single
blind). In Group 1, 14 patients were treated with honey
of uni-floral origin obtained from Syzygium Cumini
(locally known as Jamun) which was unprocessed and
undiluted. The sterility of the honey was confirmed by
bacteriological tests. Gauze pieces were dipped in the
honey and were applied to the wound. In Group 2, 16
patients were given daily dressings with gauze pieces
dipped in Eusol solution. Cotton pads were placed,
bandage was applied and the dressings were changed
daily in both the groups .The amount of discharge, the
time taken for clearing of slough, appearance of healthy
granulation tissue, hospital stay and the outcome were
recorded in both the groups. The statistical analysis
was done by chi-square test. Informed consent of the
patients was taken and the hospital ethical committee
had earlier approved the study.
RESULTS
The age of the patients ranged from 21-70 years (mean
45.2). Thirty per cent of the patients were between
51-70 years. Twenty-three (76.7%) were from the lower
socio-economic group, the majority of them were
agricultural labourers, 7 (23.3%)were from the middle
class. Twenty-three (76.6%) were chronic alcoholics.
The period of time spent before presentation to the
hospital in both the groups ranged from 1-7 days.
Twenty-six (86.6%) had aetiological factors and in 4
patients no apparent cause was found. Table 1 shows
the aetiological factors in the 30 patients. The gangrene
was confined to the scrotum in 28, it had extended to
the penile shaft in 8, to the perineal area in 6, anterior
abdominal wall in 4 and to the medial side of the thigh
in 4. Diabetes mellitus was associated in 8 patients.
The organisms isolated were Staphylococcus areus (13),
E.coli (7), Proteus mirabilis (2), candida albicans (3),
Klebsiella (1), pseudomonas aeruginosa (1), citrobactor
Table 1: Aetiology of Fournier’s gangrene
Aetiology No. of patients No aetiological causes (Idiopathic) 4 Scrotal causes - Scratch 0 - Insect bite 0 - Boil-infected 3 - Urinary tract infection 0 - Urethral stricture 2 - Anal abscess 1 - Ischiorectal abscess 3 - Fistula in Ano 3 - Chronic skin infection, eczema 5 - Dermatitis fungal infection 4 Post-Surgical Procedure 0 Varicocoele, Vasectomy 0 Urethral dilatation (instrumentation) 3 Traumatic Catheterization 0 Haemorrhoid banding Self-inflicted banding of penis 2
Subrahmanyam M, et al
(1), and no organism in 1. Three patients were found
to be HIV +ve and 27 were negative. Twenty-six of
them had undergone one surgical debridement and 4
had two debridements.
clearance of slough took place within one week in 8
patients (57.1%), within 10 days in 1 patient and within
14 days in 5 patients. In all the patients, the foul smell
reduced within two days of dressing and the oedema
was also reduced with less inflammatory changes in
the honey-treated group. One death occurred. In the
Eusol-treated group (n=16), the clearance of slough
took place within 7 days in 8 patients (50%), within 10
days in 2 (18.7%), and by 14 days in 3 patients. Two
deaths occurred in this group. In Group1, healthy
granulation was seen within one week in 4 (28.5%)
patients; in the Eusol-treated group, healthy granulation
appeared in 3 (18.7%) patients in one week. Secondary
suturing and skin grafting was required in 9 patients in
each group. The mean hospital stay was 28 days (range
9-40 days) in the honey-treated group and 32 days
(range 12-52 days) in the Eusol-treated group (P<0.01,
significant).
DISCUSSION
region of the perinium and genitalia, irrespective of
presence of absence of proven infection.2 Although
Fournier’s original description emphasized idiopathy,
it is now believed that there are predisposing causes
in many cases. In this study, 26 patients (86.6%) had
predisposing causes. There were no female patients in
77
Indian Journal of Surgery 2004 Volume 66 Issue 2 (March-April)
this study. The age incidence and clinical presentation
were similar to other studies.1,2 This study was specially
designed to study the role of honey in the treatment
of Fournier’s gangrene.
accelerating wound healing since ancient times and
honey’s antibacterial and anti-fungal properties have
been well documented. Honey is produced from may
floral sources and its antibacterial activity varies, which
explains why there is so much of variation in in-vitro
of the sensitivity of wound- infecting bacteria to honey.
In studies conducted in superficial, partial–thickness
burns and other wounds, honey was helpful. Moore et
al9 concluded that in some or all of the outcomes honey
was superior to the other treatments and suggested
that there is a biological plausibility. This review
included 6 studies conducted by senior authors. Honey
was found to inhibit bacterial growth which is found to
be due to its low pH, high viscosity, the hygroscopic
effect and presence of inhibine and anti-oxidants.
Though there was some debate whether honey should
be sterilized by gamma irradiation before use, many
authors have used unprocessed honey and in several
clinical trials conducted there was no clostridial infection
or any other complication. Honey was found to be
sterile and can be safely used.10 In this study the honey-
treated group showed faster clearing of slough as well
as appearance of healthy granulation tissue. This
resulted in a reduced hospital stay. The difference in
mortality in the honey-treated group and the Eusol-
treated group was not significant. The studies by Hejase
et al8 and Effem7 have noted similar findings. There
was no allergy or irritation in the honey-treated group.
Honey is cheap, cost-effective, and easily available. In
this study, honey was found to be beneficial in the
treatment of Fournier’s gangrene; this needs to be
confirmed by multi-centric trials before routine use of
honey is recommended in this condition.
REFERENCES
1. Yaghan RJ, Al-Jaber TM, Bani-Hani I. Fournier’s gangrene. Chang-
ing face of the disease. Dis Colon Rectum 2000;43:1300-8.
2. Eke N, Echem RC, Elenwo SN. Fournier’s gangrene in Nigeria; a
review of 21 consecutive patients. Int surg 2000;85:77-81.
3. Fahal AH, Hassan MA. Fournier’s gangrene in Khartoum. Br J
Urol1988;61:451-4.
4. Diettrich NA, Mason JH. Fournier’s gangrene. A general surgery
problem. World J Surg 1983;7:288-94.
5. Subrahmanyam M. Honey as a surgical dressing for burns and
ulcers. Indian J Surg 1993;55:468-73.
6. Subrahmanyam M. Topical application of honey in treatment of
burns. Br J Surg 1991;78:497-8.
7. Effem SEE. Recent advances in the management of Fournier’
gangrene:preliminary observations. Surgery 1993;13:2000-4.
8. Hejase MJ, Simonin JE, Bhirle R, Coogan CL. Genital Fournier’s
gangrene: Experience with 38 patients. Urology 1996;47:
734-9.
9. Moore OA, Smith LA, Campbell F, Seers K, McQuay HJ, Moore
RA. Systematic review of the use of honey as a wound dressing.
BMC Complementary and Alternative Medcine 2001;1:2-8.
10. Subrahmanyam M. The sensitivity to honey of multi-drug resist-
ant Pseudomonas aeruginosa from infected buns. Ann Burns Fire
Disasters 2003;16:84-6.
© 2003 Indian Journal of Surgery www.indianjsurg.com
Address for correspondence: Dr. M. Subrahmanyam, Old Civil Hospital Compound, Opposite Head Post Office, Rajwada Chowk, Sangli - 416416, India. E-mail: [email protected] Paper Received: July 2003. Paper Accepted: October 2003. Source of Support: Nil.
Honey dressing beneficial in treatment of Fournier’s gangrene
M. Subrahmanyam, S. P. Ugane Department of Surgery, Government Medical College, Miraj and General Hospital, Sangli, India.
ABSTRACT Background: Fournier’s gangrene is a difficult infective condition to treat. We report our experience of the management of this disease with honey dressings. Material and Methods: Thirty patients admitted with the diagnosis of Fournier’s gangrene were randomly allocated to two groups, one group treated by honey dressing and the other by Eusol dressing. All patients were treated with broad-spectrum antibiotics and underwent debridement and delayed closure as required. Results: In 14 patients treated with honey dressing, healthy granulation appeared in 4 patients in one week and in all patients within 3 weeks. One patient died. In 16 patients treated with Eusol dressing, healthy granulation appeared in one week and by 4 weeks in remaining patients. Two patients died. Secondary suturing and skin grafting was required in 9 patients in each group. Mean hospital stay was 28 days (range 9-40 days) in the honey-treated group and 32 days (range12-52 days) in the Eusol-treated group. Conclusion: In this study, honey was found to be beneficial in the treatment of Fournier’s gangrene.
KEY WORDS Gangrene, Fournier’s gangrene, Honey dressing.
How to cite this article: Subrahmanyam U, Ugane SP. Honey dressing beneficial in treatment of fournier’s gangrene. Indian J Surg 2004;66:75-7.
INTRODUCTION
infection of the scrotum that also involves the perinium
and the abdominal wall.1,2 The infective process leads
to the thrombosis of subcutaneous vessels resulting in
gangrene of the overlying skin. It affects all ages and
has been reported in both sexes and various aetiological
factors have been noted.3 The basic treatment involves
prompt excision of all non-viable tissue, limitation and
abolition of any infective process, antibiotics and
occasional anatomical reconstruction.4
Honey is a mixture of sugars prepared by the bees
from natural sugar solutions called the nectar,
obtained from flowers. By inverting the sucrose in
the nectar, the bee increases the attainable density
of the final product and thus raises the efficiency of
the process in terms of caloric density. The higher
osmotic pressure thus obtained precludes the
bacterial growth. The medicinal properties of honey
have been known for years. The Indian system of
medicine ‘Ayurveda’ describes honey as the nectar
of life and recommends its use in the treatment of
various ailments. Honey produced by the Indian hive
bee Apis cerana indica, extracted by modern
extraction methods, is a transparent liquid and free
from foreign materials. Granulation is the natural
process of crystallization of the glucose content in
honey and granulated honey can be made liquid by
slight warming.
Honey has been found to be useful in controlling the
infection of wounds and burns5,6 leading to rapid
healing and it has also been tried in Fournier’s
gangrene.7,8 This study reports the use of honey in
Fournier’s gangrene and its comparison with
conventional dressing.
Original Article
76 Indian Journal of Surgery 2004 Volume 66 Issue 2 (March-April)
MATERIAL AND METHODS
gangrene admitted during the period April 2001 to
May 2003 formed the material for this study. Diagnosis
was established from the patient’s history and clinical
examination. Age, predisposing conditions, site of
primary infection, bacteriological findings, therapeutic
response, hospital stay and outcome were evaluated.
For assessing the beneficial effects of local dressings,
the patients were divided into two groups by
randomization, the rest of the treatment being the
same. Both the groups had similar age distribution,
involvement and were comparable in all respects. The
assessor was not aware of the treatment given (single
blind). In Group 1, 14 patients were treated with honey
of uni-floral origin obtained from Syzygium Cumini
(locally known as Jamun) which was unprocessed and
undiluted. The sterility of the honey was confirmed by
bacteriological tests. Gauze pieces were dipped in the
honey and were applied to the wound. In Group 2, 16
patients were given daily dressings with gauze pieces
dipped in Eusol solution. Cotton pads were placed,
bandage was applied and the dressings were changed
daily in both the groups .The amount of discharge, the
time taken for clearing of slough, appearance of healthy
granulation tissue, hospital stay and the outcome were
recorded in both the groups. The statistical analysis
was done by chi-square test. Informed consent of the
patients was taken and the hospital ethical committee
had earlier approved the study.
RESULTS
The age of the patients ranged from 21-70 years (mean
45.2). Thirty per cent of the patients were between
51-70 years. Twenty-three (76.7%) were from the lower
socio-economic group, the majority of them were
agricultural labourers, 7 (23.3%)were from the middle
class. Twenty-three (76.6%) were chronic alcoholics.
The period of time spent before presentation to the
hospital in both the groups ranged from 1-7 days.
Twenty-six (86.6%) had aetiological factors and in 4
patients no apparent cause was found. Table 1 shows
the aetiological factors in the 30 patients. The gangrene
was confined to the scrotum in 28, it had extended to
the penile shaft in 8, to the perineal area in 6, anterior
abdominal wall in 4 and to the medial side of the thigh
in 4. Diabetes mellitus was associated in 8 patients.
The organisms isolated were Staphylococcus areus (13),
E.coli (7), Proteus mirabilis (2), candida albicans (3),
Klebsiella (1), pseudomonas aeruginosa (1), citrobactor
Table 1: Aetiology of Fournier’s gangrene
Aetiology No. of patients No aetiological causes (Idiopathic) 4 Scrotal causes - Scratch 0 - Insect bite 0 - Boil-infected 3 - Urinary tract infection 0 - Urethral stricture 2 - Anal abscess 1 - Ischiorectal abscess 3 - Fistula in Ano 3 - Chronic skin infection, eczema 5 - Dermatitis fungal infection 4 Post-Surgical Procedure 0 Varicocoele, Vasectomy 0 Urethral dilatation (instrumentation) 3 Traumatic Catheterization 0 Haemorrhoid banding Self-inflicted banding of penis 2
Subrahmanyam M, et al
(1), and no organism in 1. Three patients were found
to be HIV +ve and 27 were negative. Twenty-six of
them had undergone one surgical debridement and 4
had two debridements.
clearance of slough took place within one week in 8
patients (57.1%), within 10 days in 1 patient and within
14 days in 5 patients. In all the patients, the foul smell
reduced within two days of dressing and the oedema
was also reduced with less inflammatory changes in
the honey-treated group. One death occurred. In the
Eusol-treated group (n=16), the clearance of slough
took place within 7 days in 8 patients (50%), within 10
days in 2 (18.7%), and by 14 days in 3 patients. Two
deaths occurred in this group. In Group1, healthy
granulation was seen within one week in 4 (28.5%)
patients; in the Eusol-treated group, healthy granulation
appeared in 3 (18.7%) patients in one week. Secondary
suturing and skin grafting was required in 9 patients in
each group. The mean hospital stay was 28 days (range
9-40 days) in the honey-treated group and 32 days
(range 12-52 days) in the Eusol-treated group (P<0.01,
significant).
DISCUSSION
region of the perinium and genitalia, irrespective of
presence of absence of proven infection.2 Although
Fournier’s original description emphasized idiopathy,
it is now believed that there are predisposing causes
in many cases. In this study, 26 patients (86.6%) had
predisposing causes. There were no female patients in
77
Indian Journal of Surgery 2004 Volume 66 Issue 2 (March-April)
this study. The age incidence and clinical presentation
were similar to other studies.1,2 This study was specially
designed to study the role of honey in the treatment
of Fournier’s gangrene.
accelerating wound healing since ancient times and
honey’s antibacterial and anti-fungal properties have
been well documented. Honey is produced from may
floral sources and its antibacterial activity varies, which
explains why there is so much of variation in in-vitro
of the sensitivity of wound- infecting bacteria to honey.
In studies conducted in superficial, partial–thickness
burns and other wounds, honey was helpful. Moore et
al9 concluded that in some or all of the outcomes honey
was superior to the other treatments and suggested
that there is a biological plausibility. This review
included 6 studies conducted by senior authors. Honey
was found to inhibit bacterial growth which is found to
be due to its low pH, high viscosity, the hygroscopic
effect and presence of inhibine and anti-oxidants.
Though there was some debate whether honey should
be sterilized by gamma irradiation before use, many
authors have used unprocessed honey and in several
clinical trials conducted there was no clostridial infection
or any other complication. Honey was found to be
sterile and can be safely used.10 In this study the honey-
treated group showed faster clearing of slough as well
as appearance of healthy granulation tissue. This
resulted in a reduced hospital stay. The difference in
mortality in the honey-treated group and the Eusol-
treated group was not significant. The studies by Hejase
et al8 and Effem7 have noted similar findings. There
was no allergy or irritation in the honey-treated group.
Honey is cheap, cost-effective, and easily available. In
this study, honey was found to be beneficial in the
treatment of Fournier’s gangrene; this needs to be
confirmed by multi-centric trials before routine use of
honey is recommended in this condition.
REFERENCES
1. Yaghan RJ, Al-Jaber TM, Bani-Hani I. Fournier’s gangrene. Chang-
ing face of the disease. Dis Colon Rectum 2000;43:1300-8.
2. Eke N, Echem RC, Elenwo SN. Fournier’s gangrene in Nigeria; a
review of 21 consecutive patients. Int surg 2000;85:77-81.
3. Fahal AH, Hassan MA. Fournier’s gangrene in Khartoum. Br J
Urol1988;61:451-4.
4. Diettrich NA, Mason JH. Fournier’s gangrene. A general surgery
problem. World J Surg 1983;7:288-94.
5. Subrahmanyam M. Honey as a surgical dressing for burns and
ulcers. Indian J Surg 1993;55:468-73.
6. Subrahmanyam M. Topical application of honey in treatment of
burns. Br J Surg 1991;78:497-8.
7. Effem SEE. Recent advances in the management of Fournier’
gangrene:preliminary observations. Surgery 1993;13:2000-4.
8. Hejase MJ, Simonin JE, Bhirle R, Coogan CL. Genital Fournier’s
gangrene: Experience with 38 patients. Urology 1996;47:
734-9.
9. Moore OA, Smith LA, Campbell F, Seers K, McQuay HJ, Moore
RA. Systematic review of the use of honey as a wound dressing.
BMC Complementary and Alternative Medcine 2001;1:2-8.
10. Subrahmanyam M. The sensitivity to honey of multi-drug resist-
ant Pseudomonas aeruginosa from infected buns. Ann Burns Fire
Disasters 2003;16:84-6.
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