Honey for Pilonidal Wounds

One of the interesting ways of dressing open wounds is with honey. It is available in “medical grade” form, and often Manuka honey is specifically used. (This is honey from the manuka tree which has a antibacterial compound not present in other types of honey.)

The characteristics of honey that make it something that can be used on open wounds are:

  • It has some antibacterial properties
  • Because it is such a concentrated substance it pulls water out of tissues, which may decrease swelling
  • It has a slightly acidic ph, which may help wound healing

But, the real question is whether or not the physical characteristics of honey promote better or faster wound healing than other topical wound treatments. One important concept in treating patients is that:

Just because something logically sounds like it would be beneficial, doesn’t mean it actually will be.

This is why clinical trials, research studies, and literature searches are so important in determining what we should actually do to solve clinical problems. A simple example of this is that Betadine, is a great antiseptic that we use all the time to sterilize skin. But, we’ve found that when used for any length of time on open, infected, wounds it not only impairs healing, but is toxic to the patient!

As far as honey goes, it doesn’t seem to be much better or worse than other topical treatments when used on open wounds. It may be beneficial for some types of burns.

As far as pilonidal wounds goes, there are studies that show that pilonidal wounds can heal when honey is used. But, when compared to other topical treatments, such as silver, zinc, hydrogel, foam, wound VAC, etc., there does not seem to be a particular advantage to any of them. The benefit of using something that has antibacterial properties at all is open to debate.

My analysis of all this is:

  • It is reasonable to use honey on an open wound, but it is not preferred over other modalities for any specific reason.
  • Honey is not an appropriate treatment for an acute abscess or for application on closed incisions.
  • The most important maneuvers to get pilonidal wounds to heal are to keep things clean and dry and get air circulation to the wound. Unfortunately, this may not be possible without further surgery.
  • If sinus tracts have formed, even the smallest wound will never stay healed with honey or any kind of wound care.
  • Proper nutrition, including high protein and vitamin intake is probably more important than the specific local wound care.

If pilonidal surgery is done properly, such that the cleft is flattened and the incision is off the midline, complex and prolonged wound care will not be needed. In our clinic we do not have to deal these issues, except in complicated situations where we are trying to fix poorly done surgery elsewhere.

What is the place of silver nitrate for pilonidal wounds?

The “art” of surgery.

As surgeons, we each have have years of training and experience plus an enormous body of scientific and clinical information at our fingertips. There is so much information, that the correct way to apply it is open to interpretation. This is where the “art” comes in. Here, I would like to discuss my opinion regarding the use of silver nitrate, as applied to pilonidal wounds after surgery, or in place of surgery to get pits and openings to close.

Silver nitrate is a chemical that chemically burns tissues. It usually comes on a wooden applicator stick, and when applied to exposed tissues, causes a chemical cauterization (burning) of the wound.

Surgeons do this when they have no idea why something is not healing. This is the surgical equivalent of “turning-it -off and back-on-again”. (We do this with our electronics when we don’t know how to fix something, but hope that a reboot will do the trick.)

In this instance, surgeons are blaming the lack of wound closure on “hyper-granulation tissue”. This occurs when there is visible, good, healing tissue inside the wound, but the skin isn’t closing over it. There are times in surgery when this makes sense and is a reasonable strategy – but NEVER with pilonidal wounds. The hope is that burning away the tissue, will give the wound a fresh start at healing – but without understanding why it wasn’t healing in the first place!

The reasons that this is not a good strategy are:

  • It is painful.
  • It takes time away from doing the correct thing to fix the problem (surgeons can keep applying silver nitrate for MONTHS before they give up on it as a therapy).
  • The reason for lack of healing of pilonidal wounds is NEVER because of hyper-granulation tissue. (More here on the reasons why pilonidal wounds won’t heal.)

The correct solution is to:

  • Perform corrective surgery to adjust the location of the incision, (which in my preference is a cleft-lift).
  • Make sure the area is being kept clean and dry.
  • Keep gauze tucked in any folds with open wounds, to allow air circulation.
  • Consider GENTLE, topical medications that promote healing and/or control specific bacteria.
  • Maximize protein intake, and consider the vitamins and supplements I’ve recommended.

I believe that many patients have proper care delayed, are traumatized, and may even have small wounds enlarged buy the use of silver nitrate.

Are Wound VAC’s Really That Great?

The pros and cons of wound V.A.C.’s

A suction device used to help heal a wound has several names: Wound V.A.C, VAC, “vacuum assisted wound closure” or “negative pressure wound therapy (NPWT)”. Sometimes they are referred to based on the specific brand of the machine, like a “Pico” or “VERAFLO”. VAC stands for” Vacuum Assisted Closure”. It consists of foam placed over an open wound, that is sealed with adhesive plastic, and connected to a machine that applies suction and removes fluid.

Note: this is not the same as a “closed suction drain”, also called a JP Drain, Jackson Pratt Drain, or Blake Drain. These are tubes that go INSIDE closed wounds to remove fluid.

Negative Pressure Wound Therapy is very helpful in getting wounds to heal faster and minimize daily dressing changes. The VAC has to be changed periodically, but less frequently than usual open wound care.

But, is it a good solution for pilonidal wounds?

I suppose it depends on how you look at the situation. There are quite a few negatives (no pun intended) attributed to the use of the wound VAC for pilonidal wounds:

  • It is an extremely awkward location to have a wound VAC, and it is hard to keep it well secured in place, especially with wounds next to the anus.
  • It has to be changed frequently, the materials are expensive, and it has to be changed by a wound care professional, either in their clinic, or by a home-care visit.
  • It is noisy, smelly, and embarrassing; and the VAC changes can be painful.
  • It may have to be in place for months at at time.
  • Even if it helps a wound to heal, it provided no guarantee that it will stay healed once the VAC is removed. The placement of a VAC is an extremely abnormal situation which does not replicate the environment and anatomy that will exist when it is removed. Frequently, when it is removed, the wounds open up again. Note: This is true for gluteal crease wounds, not wounds elsewhere on the body.

Although philosophically one could look at the use of a VAC in this situation as a difficult therapy that is trying to make the best of a bad situation, I don’t agree with that analysis. I think the smarter choice is to see a pilonidal expert and have surgery to close the wound. This short-cuts the whole situation, and usually turns this into a full recovery in about six weeks with a very low chance of recurrence. (I have not used a VAC on any of my patients in 27 years of pilonidal surgery.)

FURTHER SURGERY may seem like an illogical way of dealing with an open wound, that occurred BECAUSE of surgery, but if done properly it works. It is also appropriate with failed flap procedures, including previous failed cleft-lifts. If your current surgeon says that the wound can’t be closed – get another opinion. It may just mean that he or she does not know how to close it. There is almost always a faster and easier solution.

Contact us if you need help!