Few comparative studies have been performed on the efficacy of sugar to treat diabetic ulcers, both in countries where resources are scarce and in countries where drugs and technology are more readily available. A brief review of the existing reports is discussed here.
In 1958, Rostenberg and coworkers18
reported the use of sugar paste composed of powdered cane sugar, wool fat, and compound benzoin tincture to treat 19 patients with a variety of ulcers, including stasis ulcers, trophic and/or decubitus ulcers, sclerodermatous ulcers, radiation ulcers, and mixed peripheral vascular disease ulcers. The sugar paste was applied twice daily. Nine patients had their ulcers healed at the end of one year. Of these 9 patients, 4 had trophic and/or decubitus ulcers and 5 had stasis ulcers. While the authors do not mention whether the patients had diabetes or discuss the mechanism of action of the sugar paste, the study reports successful healing of certain ulcer pathology.
The mechanism of action of sugar's effect on wounds was first reported by Herszage and associates.39
As mentioned previously, Herszage and associates39
described the treatment of infected wounds and superficial lesions with simple granulated sugar in 120 patients, with a cure rate of 99.2%. Commercial granulated sugar was applied to the wounds every 24 h in ordinary cases and every 8 h in serious cases during the first 48 to 72 h, after which the interval resumed to every 24 h. Of the 120 patients, 6 cases had diabetes and had a healing rate that varied from 9 days to 17 weeks, with a mean of 5 weeks. The authors reported the decrease in the odor of infected wounds and the decrease of purulent secretions. Moreover, the use of sugar as a wound-healing agent was justified by satisfying the necessary specifications of antiseptic: broad-spectrum antibiosis, rapid effect, low toxicity, persistence of activity, and efficacy.49
One of the largest series of wounds treated with sugar was performed by Knutson and colleagues.27
Granulated sugar directly instilled into the wound and covered with gauze soaked in povidone-iodine was used to treat 605 patients (out of 759 total patients) with traumatic wounds, burns, and ulcers over a 5-year period. The authors noted that, regardless of the type of wound, burn, or ulcer and despite contamination of many of the wounds at the time of initial survey, all wounds, burns, and ulcers rapidly became clean with sugar and povidone-iodine treatment. The contaminated tissue rapidly became free of purulent material and surrounding erythema. The wounds quickly became free of odor as well. The wounds also healed with minimal or no scarring. The overall healing rate progressed more rapidly than with other modalities of wound care as reflected by the reduction of required visits to the physical therapist at the authors' respective institutions. The authors reported that 79.7% were treated with the sugar and povidone-iodine combination, with healing times reduced by 25% represented by required physical therapy visits compared to physical therapy visits for wounds in 1976. Of the 605 cases, 13 were diabetic ulcers. The authors noted that the healing time for diabetic wounds, and those wounds complicated by vascular insufficiency tended to be somewhat longer, although successful, compared to patients with normal vasculature.
described a method to treat chronic wounds and ulcers using a sequence involving irrigation with a balanced salt solution followed by irrigation with an amino acid solution and finally covering the wound with powdered sugar. A total of 58 patients were treated with this method. The wounds involved were large open traumatic wounds, burns, decubitus ulcers, stasis ulcers, and diabetic ulcers. There were no adverse reactions to the treatment sequence. Three cases showed no improvement due to terminal condition, malnourishment due to alcoholism, and noncompliance to treatment regimen. The number of diabetes cases was not specified; however, similar observations were seen as previous studies regarding rapid control of infection and purulence, easily removed necrotic tissue, and rapid growth of granulation tissue.
Viau and associates19,20,50
reported several cases of ulcer treatment with granulated sugar. In their first case study, 21 patients with ulcers varying from sacroiliac, heel, back, scalp, and trochanter were evaluated over a 9-month period.19,20
Eighteen ulcers had satisfactory results, with 9 ulcers completely healed and 9 ulcers with decrease of wound dimension and decrease of bacterial contamination. In their next case study, Viau and associates50
treated 38 wounds, pressure sores, and leg ulcers with granulated sugar over a 9-month period. The authors reported an 89.5% satisfactory healing result. Five of the 38 cases were ulcers (2 stasis ulcers and 3 mixed arterial ulcers), and 4 of those 5 cases healed with satisfactory result. The only case that did not heal was a mixed arterial ulcer. The mixed ulcer cases were not specified to include diabetic ulcers. The authors report consistent observations with previous studies regarding the sugar's antibacterial effects within these wounds, although further studies are needed to clarify the reasons why sugar therapy failed within a mixed-pathology ulcer.
The first study to specifically address the use of sugar for the healing of DFU was a report of two cases by Anania and coworkers.51
The authors used a mixture of 70–80% granulated sugar by weight with appropriate amounts of povidone-iodine ointment and povidone-iodine solution to make a sugar paste with a consistency similar to peanut butter. This method was similar to the one described by Knutson et al
The sugar paste was administered four times per day and was covered by gauze. The first case was a diabetes patient who had a draining ulceration between the fourth and fifth metatarsals on the plantar surface and an abscess between the fourth and fifth metatarsal heads on the dorsal surface extending into the digits. The culture results yielded Corynebacterium
species and Bacteroides melaninogenicus
. The previously described treatment regimen developed granulation tissue and covered the exposed tendons and bone within 4 weeks. The second case was a diabetes patient with multiple right foot infected ulcers, two in the longitudinal arch and one at the hallux. The culture results yielded polyflora consisting of Proteus mirabilis, Corynebacterium, Streptococcus
group D, Morganella morganii, Escherichia coli, Klebsiella
, α-hemolytic Streptococcus, Citrobacter
, and Pseudomonas aeruginosa
. Within 4 weeks of treatment with sugar paste, the wound appeared clean with granulation tissue and no signs of infection. The observations were similar to previous reports regarding antimicrobial activity, edema reduction, debridement of necrotic tissue, promotion of granulation tissue, and promotion of epithelial tissue.
The second study to specifically address the use of sugar for the healing of DFU was performed by Kilic33
who published a case report of one patient with a diabetic ulcer on the left foot that was treated with granulated sugar. The author performed twice daily dressings with bandages to hold the granulated sugar in place and found similar observations as previous authors, such as decreased odor, inhibition of bacterial growth, and debridement of necrotic tissue. One notable observation was that, once granulation tissue was well established, the granulated sugar caused bleeding of the wound bed. In this instance, the author reconstructed the tissue with a skin graft once adequate granulation tissue formed, but he concluded that granulated sugar treatment leads to faster healing of diabetic ulcers, shorter hospital stays, and less cost for dressing supplies. Kilic's conclusions require a larger trial to determine sugar's efficacy for decreasing inpatient hospital stays and cost of dressing supplies. Currently, no studies exist to support Kilic's claim.
Another case report that specifically evaluated the use of sugar in the treatment of leg ulcers was performed by Lisle.52
In this case report, however, the patient had developed multiple resistances to topical applications, was allergic to systemic antibiotics, and had four multipathogen-infected venous stasis ulcers that had been recurrent for 17 years. Sugar paste made from caster sugar, icing sugar, hydrogen peroxide, and polyethylene glycol was used to treat the four ulcers on her lower extremities. The observations made were reduction in odor, reduction of exudate, reduction of pain, increased granulation tissue, and suppression of Methicillin-resistant S. aureus
, β-hemolytic streptococci, and mixed enteric flora in the wound. All four of the patient's wounds were completely healed at the end of treatment.