Q: Should I use collagenase or manuka honey for pressure ulcers?

A: What is the best treatment option for necrotic wounds — collagenase or manuka honey?  Though collagenase is often suggested for pressure ulcers, it is both costly and not easily accessible.

Let’s review a few details regarding these treatment options. Collagenase is the only agent that functions as an enzymatic debridement. Collagenase formulation is an enzyme derived from the fermentation by clostridium histolyticum. It has the ability to digest collagen in necrotic tissue.

Santyl is the only FDA-approved enzymatic debrider. It is indicated for debriding chronic dermal ulcers (diabetic foot ulcers and pressure ulcers) and severely burnt areas. Ointment is applied once a day or as needed. Antibiotics are applied prior to the application of collagenase if a local infection is present. Treatment can last for a few weeks until debridement is complete or granulation tissue is established. 

Manuka honey is a monofloral honey derived from manuka tree (leptospermum scoparium). Its chemical composition is suggested to have antioxidant and antibacterial activity and can help maintain a moist wound environment. It has pro- and anti-inflammatory effects leading to absorption of the devitalized and necrotic tissue as autolytic debridement agent, which promotes healing by better re-epithelializing and decreasing the bioburden on the wound bed. 

Most of the research is expert opinion or meta-analyses that may involve bias.  This makes it difficult to find conclusive evidence. Whatever treatment is chosen, review wound progress daily and weekly, or with every dressing change. There may be many local or systemic factors leading to the maceration of the skin around the wound, worsening infection, or compromised circulation that can stall the wound healing.