The Utility of Sugar for Complicated Wounds: An Old Solution Worth Revisiting

To the Editor:

Because the management of large post-traumatic soft tissue wounds can be particularly challenging in the setting of local infection, we write to share our experience with the topical application of sugar as a simple treatment for a traumatic extremity defect with resistant soft tissue sepsis.

A morbidly obese 43-year-old man was transferred to our center after a high-speed motorcycle crash. He was hypotensive and tachycardic. After establishing an airway and responding to fluid resuscitation, extended focused assessment with sonography for trauma (EFAST) confirmed normal peritoneal and thoracic cavities. He possessed obvious left femur and tibial fractures (Gustilo IIIC) [1] with a deep soft tissue defect (10 cm wide × 25 cm deep) inferior to his anterior-superior iliac spine. He also had a nearly circumferential degloving wound adjacent to his left knee with ongoing hemorrhage. Upon emergent exploration of his extremity wound, complete transections of his popliteal artery and vein were identified. Two 8-mm temporary intravascular argyle shunts (Covidien AG, Mansfield, MA) were placed. Orthopedists then applied a spanning external fixator to stabilize his floating knee. The popliteal vessels were repaired with 8-mm ringed polytetrafluoroethylene grafts secondary to an inappropriately small contralateral saphenous vein. Ipsilateral four-compartment, below-knee fasciotomies were then completed. The vascular grafts were covered with rotational flaps of adjacent muscle and skin. The knee and hip wounds were packed initially with wet-to-dry gauze dressings that were changed twice daily and exchanged for a vacuum-assisted device on hospital day three.

On postoperative day seven, the patient was febrile (39°C), with marked leukocytosis (18,000 cells/microliter). Gram stain of pus within the wound revealed Pseudomonas aeruginosa infections of the soft tissue defects in his left lower extremity. The local muscle and fascia appeared viable. Despite repeated dressing changes and various topical antimicrobial solutions (antibiotic, iodine, and Dakin solution), the infection remained resistant to eradication.

On hospital days 20 through 47, we packed over-the-counter granulated brown sugar into both wounds. They were irrigated with saline solution and repacked with sugar daily. With continued local treatment, the patient's infection resolved, as confirmed according to repeated negative wound cultures and resolution of his leukocytosis and fever. Split-thickness skin grafts were used to cover both fasciotomy sites. The limb was successfully salvaged, and the patient was transferred to a rehabilitation institution for continued physical therapy on postoperative day 59.

Although treatment options for resistant local wound infections are extensive, failure to achieve success with conventional techniques in this case prompted the use of sugar as a topical antimicrobial. The Egyptians, Greeks and Romans initially used sugar and honey as treatments for battlefield wounds [2]. Despite the use of sugar as an antimicrobial agent in well over 600 published patients [3], a systematic review of the literature has identified the need for additional investigations [4]. To this end, the Cochrane Collaboration is also planning further study to confirm claims of lower requirements for antibiotics, skin grafting, and hospital costs in infected patients [3,5]. Although sugar's mechanism of antimicrobial action is unclear, it appears to involve an inherent high osmolarity and a more-direct antiseptic effect. This ability to reduce bacterial counts and treat infection has been confirmed in vitro on repeated occasions [6–8]. Antimicrobial action remains intact despite dilution of sugar solutions beyond the point where osmolarity inhibits bacterial growth [6,9]. Sugar also has the reported ability to provide topical nutrition [10], stimulate tissue growth [11], reduce inflammation [12], improve epithelialization [12], and enhance debridement [13]. Furthermore, the antimicrobial action of sugar solutions appears to be broad in spectrum, with coverage of more than 70 bacterial species, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci [14]. In comparison with other therapies, this effect appears particularly impressive in the first seven days of treatment, with numbers needed to treat of only two to three in a recent systematic review [4].

Although the optimal format of sugar treatment is not clear, multiple solutions have been described in the literature. These include simple granulated sugar, sugar paste, sugar solutions mixed with iodine, and liquid honey. Regardless of format, sugar appears to be most helpful in deep, difficult-to-access infected wounds because of its ability to conform to any shape [2–5,14]. As a result, this patient's wounds were packed daily with the most readily available and cost-effective application: brown sugar.

In summary, the modern applicability of topical granulated sugar in complex, high-risk infected wounds should be considered. Sugar solutions remain a cost-effective, low-technology solution for difficult, deep post-traumatic soft tissue defects.