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Related Terms
  • Abrasions, anal fissure, autolytic debridement, bed sore, Clostridium sp., collagen, collagen matrix, cuts, debridement, decubitus ulcer, diabetic ulcers, electrotherapy, epithelial, epithelialization phase, extravasation, gangrene, gas gangrene, human growth factors, hydrocolloid, hyperbaric oxygen, incision wounds, incontinence, infected surgical wounds, infectious arthritis, inflammatory phase, injuries, laceration, macrophages, mechanical debridement, microvascular, minor injuries, myonecrosis, necrotizing fasciitis, pressure ulcers/wound care, proliferative phase, puncture wound, remodeling phase, scrapes, scratches, sepsis, septic arthritis, skin damage caused by incontinence, skin graft healing (split thickness), skin ulcer, surgical skin flap ischemia, skin wounds, squamous, stitches, superficial, suture, vulnerary, wound care, wound healing.

Background
  • A wound is a break in the outer layer of the skin, called the epidermis. Wounds are usually caused by cuts or scrapes. Different kinds of wounds may be treated differently from one another, depending upon how they happened and how serious they are. Other wounds include puncture wounds, lacerations (cuts), pressure sores, anal fissures, extravasations (a drug accidentally going outside of a vein causing tissue damage), skin damage caused by incontinence (lack of bladder control), skin graft healing (split thickness), diabetic ulcers, and surgical skin flap ischemia (lack of blood flow to surgically attached skin).
  • Healing is a response to the injury that sets into motion a sequence of events. With the exception of bone, all tissues heal with some external scarring. The object of proper care is to minimize the possibility of infection and scarring.
  • There are basically four phases to the healing process: the inflammatory phase, proliferative phase, remodeling phase, and epithelialization phase.
  • The inflammatory phase begins with the injury itself. In the inflammatory phase, there is bleeding, immediate narrowing of the blood vessels, clot formation, and release of various chemical substances into the wound that will begin the healing process. Specialized cells (macrophages) clear the wound of debris over the course of several days.
  • Next is the proliferative phase in which a matrix or latticework of cells forms. On this matrix, new skin cells and blood vessels will form. It is the new small blood vessels (known as capillaries) that give a healing wound its pink or purple-red appearance. These new blood vessels will supply the rebuilding cells with oxygen and nutrients to sustain the growth of the new cells and support the production of proteins (primarily collagen). The collagen acts as the framework upon which the new tissues build. Collagen is the dominant substance in the final scar.
  • The remodeling phase begins after 2-3 weeks. The framework (collagen) becomes more organized making the tissue stronger. The blood vessel density becomes less, and the wound begins to lose its pinkish color. Over the course of six months, the area increases in strength, eventually reaching 70% of the strength of uninjured skin.
  • Epithelialization is the process of laying down new skin, or epithelial, cells. The skin forms a protective barrier between the outer environment and the body. Its primary purpose is to protect against excessive water loss and bacteria. Reconstruction of this layer begins within a few hours of the injury and is complete within 24-48 hours in a clean, sutured (stitched) wound. Open wounds may take 7-10 days because the inflammatory process is prolonged, which contributes to scarring. Scarring occurs when the injury extends beyond the deep layer of the skin (into the dermis, which is the second layer of skin).

Signs and symptoms
  • Skin wounds: All bites and any cut or laceration greater than 1/2-inch long in which fat or deeper tissues (muscle or bone) can be seen will require medical attention.
  • Any redness extending from the wound after two days or yellow drainage from the area should warrant medical attention. Infection may cause redness, swelling, heat, pus, or watery discharge from a puncture wound that is not noticed or not treated properly.
  • Puncture wounds usually cause pain and mild bleeding at the site of the puncture. It is usually fairly obvious if cut. However, small pieces of glass may cause puncture wounds that the individual may not notice at first.
  • Most doctors will not stitch a cut or laceration that is more than eight to 12 hours old. This is because there is a greater chance of infection after that time. In fact, after three hours, the incidence of infection begins to increase. Therefore, do not wait to have the injury repaired. If in doubt, call a doctor or go to the nearest hospital's emergency department. An open wound takes longer to heal and leaves a bigger scar.
  • Healthcare providers recommend that 911 be called if: the wound is obviously life-threatening; any laceration is greater than 1/2-inch long and is through all layers of the skin exposing the underlying fat; the bleeding cannot be stopped; if the blood continues to spurt from the wound. Apply pressure and go to the hospital's emergency department: if there may be something in the wound such as glass, wood, or rust; if the individual cannot move their fingers or toes in the area of the laceration or if they have lost sensation in the area beyond the laceration; and for any bite wound (human or animal).
  • Pressure sores: Bedsores fall into one of four stages based on their severity. Pressure sores are categorized by severity, from Stage I (earliest signs) to Stage IV (worst). The National Pressure Ulcer Advisory Panel, a professional organization dedicated to the prevention and treatment of pressure sores, has defined each stage as follows:
  • Stage I: Initially, a pressure sore appears as a persistent area of red skin that may itch or hurt and feel warm and spongy or firm to the touch. In African Americans, Hispanics, and people with darker skin, the mark may appear to have a blue or purple cast, or look flaky or ashen. Stage I wounds are superficial and go away shortly after the pressure is relieved.
  • Stage II: In stage II, some skin loss has already occurred, either in the epidermis, the outermost layer of skin, in the dermis, the skin's deeper layer, or in both. The wound is now an open sore that looks like a blister or an abrasion, and the surrounding tissues may show red or purple discoloration. If treated promptly, stage II sores usually heal fairly quickly.
  • Stage III: When a pressure ulcer reaches stage III, the damage has extended to the tissue below the skin, creating a deep, crater-like wound.
  • Stage IV: Stage IV is the most serious and advanced stage. The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints. Stage IV wounds are extremely difficult to heal and can lead to lethal infections.
  • If an individual uses a wheelchair, they are most likely to develop a pressure sore on: the tailbone or buttocks; the shoulder blades and spine; or the backs of the arms and legs where they rest against the chair. When an individual is bed-bound, pressure sores can occur on: the back or sides of the head; the rims of the ears; the shoulders or shoulder blades; the hipbones, lower back, or tailbone; or the backs or sides of the knees, heels, ankles, and toes.
  • Anal fissure: The main signs and symptoms of an anal fissure include: pain or burning during bowel movements that eases until the next bowel movement; bright red blood on the outside of the stool or on toilet paper or wipes after a bowel movement; and itching or irritation around the anus.
  • Extravasation: During extravasation, the individual will feel burning, stinging, or pain at the injection site. Redness or swelling may be observed at the site of injection. Also, there may be no blood return in the syringe when the healthcare worker tries to get blood.

Diagnosis
  • If a skin injury required medical attention, a doctor will want to know how the injury occurred, what home care was performed, if there is any pain, and when the last tetanus shot may have been.
  • If a hand or finger is involved, the doctor will want to make sure the individual is able to move the extremity or finger through its full range of motion. Sensation and circulation to the area will be tested carefully as well. If there is some suspicion of a foreign body in the wound or an underlying bone break, an x-ray may be ordered.
  • Pressure sores (bedsores) are usually unmistakable, even in the initial stages, but a doctor is likely to order blood tests to check the individual's nutritional status and overall health. Other tests may include: urine analysis and culture, stool culture, and a wound biopsy. A wound biopsy is a sample of tissue taken from wounds that do not heal or from chronic (long-term) pressure sores. The tissue may also be checked for cancer, which is a risk in individuals with chronic wounds.

Complications
  • Complications from a lack of wound care can lead to other health problems.
  • Cellulitis: Cellulitis is a potentially serious bacterial infection of the skin. Cellulitis appears as a swollen, red area of skin that feels hot and tender, and it may spread rapidly. Skin on the face or lower legs is most commonly affected by this infection, though cellulitis can occur on any part of the body. Cellulitis may only affect the surface of the skin. However, cellulitis may also affect the tissues underlying skin and can spread to lymph nodes and the bloodstream. Left untreated, the spreading bacterial infection may rapidly turn into a life-threatening condition.
  • Bone and joint infections: Bone and joint infections develop when the infection from a bedsore burrows deep into the joints and bones. Joint infections (called septic or infectious arthritis) can damage cartilage and tissue within days, whereas bone infections (osteomyelitis) may develop over years if not treated. Eventually, bone infections can lead to bone death, reduced function of the joints and limbs, and amputation.
  • Necrotizing fasciitis: Necrotizing fasciitis is a rapidly spreading infection that destroys the layers of tissue that surround the muscles. Initial signs and symptoms include fever, pain, and massive swelling. Without treatment, death can occur in as little as 12-24 hours.
  • Gas gangrene (myonecrosis): Gas gangrene is a rare and severe form of gangrene. Gas gangrene develops suddenly and dramatically and spreads so rapidly that changes in tissue are noticeable within minutes. The bacteria responsible for gas gangrene (Clostridium sp.) produce toxins that completely destroy affected muscle tissue and cause potentially fatal systemic problems.
  • Sepsis: Sepsis (a whole body response to an infection) can occur from a wound such as advanced pressure sores. Sepsis occurs when bacteria from a massive infection enter the bloodstream and spread throughout the body. Sepsis is a rapidly progressing, life-threatening condition that can cause shock and organ failure.
  • Skin cancer: Cancer resulting from poor wound healing may occur. This type of cancer is usually an aggressive carcinoma affecting the skin's squamous cells.
  • Fistulas: A fistula is an abnormal connection between an organ, vessel, or intestine and another structure. Fistulas are usually the result of a wound from an injury or surgery. They may also result from infection or inflammation.

Treatment
  • General Self-treatment:
  • Minor cuts and scrapes usually do not require a trip to the emergency room, yet proper care is essential to avoid infection or other complications. Puncture wounds do not usually cause excessive bleeding. Puncture wounds resulting from human or animal bites, including those of domestic dogs and cats, may be especially prone to infection. Puncture wounds on the foot are also more vulnerable to infection.
  • Guidelines developed by healthcare professionals can help individuals care for simple wounds at home. These guidelines include:
  • Stopping the bleeding: Minor cuts and scrapes usually stop bleeding on their own. If they do not, apply gentle pressure with a clean cloth or bandage. Hold the pressure continuously for 20-30 minutes. Lifting the pressure to check on bleeding may damage or dislodge the fresh clot that has forming and cause bleeding to resume. If the blood spurts or continues to flow after continuous pressure, seek medical assistance.
  • Cleaning the wound: Rinse out the wound with clear water in order to clean the wound. It is best to avoid getting soap into the wound itself, as soap can irritate the wound. If debris remains embedded in the wound after cleaning, see a doctor. Thorough wound cleaning reduces the risk of tetanus. Tetanus (also called lockjaw) is a preventable disease that affects the muscles and nerves, usually due to a contaminated puncture wound.
  • To clean the area around the wound, use soap and a washcloth. Hydrogen peroxide, iodine, or an iodine-containing cleanser may irritate living cells. If they are used, do not apply them directly on the wound.
  • Medicines: After cleaning the wound, apply a thin layer of an antibiotic cream or ointment such as Neosporin® or Polysporin® to help keep the surface moist. The products do not make the wound heal faster, but they can discourage infection and allow the body's healing process to close the wound more efficiently. Certain ingredients in some ointments can cause a mild rash in some individuals. If a rash appears, stop using the ointment.
  • Over-the-counter (OTC) pain relievers such as acetaminophen (Tylenol®) or ibuprofen (Motrin®) are usually sufficient for any pain.
  • Doctors recommend getting a tetanus shot every 10 years. If the wound is deep or dirty and the individual's last shot was more than five years ago, a doctor may recommend a tetanus shot booster within 48 hours of the injury.
  • Bandaging the wound: Bandages can help keep the wound clean and keep harmful bacteria out. After the wound has healed (three to four days) enough to make infection unlikely, exposure to the air will speed wound healing.
  • Dressing change: Change the dressing at least daily or whenever it becomes wet or dirty. If the individual is allergic to the adhesive used in most bandages, switch to adhesive-free dressings or sterile gauze held in place with paper tape, gauze roll, or a loosely applied elastic bandage. A local pharmacy will carry these supplies.
  • Stitches: A wound that cuts deeply through the skin or is gaping or jagged-edged and has fat or muscle protruding usually requires stitches. A strip or two of surgical tape may hold a minor cut together, but if the individual cannot easily close the opening of the wound, see a doctor as soon as possible. Proper closure within a few hours minimizes the risk of infection.
  • Signs of infection: It is recommended by healthcare professionals to see a doctor if the wound does not heal in a five to seven days or if there is redness, drainage, warmth, or swelling.
  • Treatments for specific wounds:
  • Animal bites:
  • If an animal (especially a stray dog or a wild animal) inflicted the wound, the individual may have been exposed to rabies. A doctor may give antibiotics and suggest initiation of a rabies vaccination series. Report such incidents to county public health officials. If possible, the animal should be confined for ten days of observation by a veterinarian.
  • Pressure sores:
  • Once a pressure ulcer is identified, steps must be taken immediately to: relieve the pressure on that area. Use pillows, special foam cushions, and sheepskin to reduce the pressure; treat the sore based on the stage of the ulcer. A healthcare provider will give specific treatment and care instructions; avoid further trauma or friction. Powder the sheets lightly to decrease friction in bed; improve nutrition and other underlying problems that may affect the healing process; if the pressure ulcer is at Stage II or worse, a healthcare provider will give specific instructions on how to clean and care for open ulcers. It is very important to do this properly to prevent infection; keep the area clean and free of dead tissue. Generally, pressure ulcers are rinsed with a salt-water rinse to remove loose, dead tissue. The sore should be covered with special gauze dressing made for pressure ulcers. Do not massage the area of the ulcer, as massage can damage tissue under the skin. Donut-shaped or ring-shaped cushions are not recommended. They interfere with blood-flow to that area and cause complications, such as pressure sores.
  • Non-surgical treatment: Treating pressure sores is challenging. Open wounds are slow to close, and because skin and other tissues have already been damaged or destroyed, healing is never perfect. Although it may take some time, most stage I and stage II sores will heal with conservative measures. But stage III and stage IV wounds, which are less likely to resolve on their own, may require surgery.
  • The first step in treating a sore at any stage is relieving the pressure that caused it. Pressure can be reduced by changing positions often. Carefully follow a schedule for turning and repositioning - approximately every 15 minutes if in a wheelchair and at least once every two hours when in bed. If the individual is unable to change position on their own, a family member or other caregiver must be able to help. Using sheepskin or other padding over the wound can help prevent friction when moving.
  • Using support surfaces is important. These are special cushions, pads, mattresses, and beds that relieve pressure on an existing sore and help protect vulnerable areas from further breakdown. The most effective support depends on many factors, including the individual's level of mobility, their body build, and the severity of their wound. Healthcare professionals recommend avoiding using pillows and rubber rings, which actually cause compression.
  • Mattresses should be low-air-loss beds or air-fluidized beds. Low-air-loss beds use inflatable pillows for support, whereas air-fluidized beds suspend the individual on an air-permeable mattress that contains millions of silicon-coated beads.
  • Other non-surgical treatments of pressure sores include cleaning the wound to prevent infection. A stage I wound can be gently washed with water and mild soap, but open sores should be cleaned with a saltwater (saline) solution each time the dressing is changed. Saline solution is available at a pharmacy, or can be made at home by boiling 1 teaspoon of salt in 1 quart of water for five minutes. Store the solution in a sterile container and cool before using. It is best to avoid antiseptics such as hydrogen peroxide and iodine, which can damage sensitive tissue and delay healing.
  • Controlling incontinence as far as possible is crucial to helping sores heal. If the individual is experiencing bladder or bowel problems, they may be helped by lifestyle changes, behavioral programs, incontinence pads, or medications.
  • To heal properly, wounds need to be free of damaged, dead, or infected tissue. One approach to removing dead tissue is surgical debridement, a procedure that involves using a scalpel or other instrument to remove dead tissue. Surgical debridement is quick and effective, but it can be painful. A doctor may use one or more non-surgical approaches. These include removing devitalized tissue with a high-pressure irrigation device (mechanical debridement), allowing the body's own enzymes to break down dead tissue (autolytic debridement), or applying topical debriding enzymes, such as Granulex®.
  • Dressings: A variety of dressings are used to help protect wounds and speed healing. The type of dressing used usually depends on the stage and severity of the wound. The basic approach, however, is to keep the wound moist and the skin surrounding it dry. Stage I sores may not need any covering, but stage II lesions are usually treated with hydrocolloids, or transparent semi-permeable dressings that retain moisture and encourage skin cell growth. Examples of hydrocolloid dressings include Tegasorb® and Relicare®. Other types of dressings may be more beneficial for weeping wounds or those with surface debris. Contaminated sores may also be treated with a topical antibiotic cream.
  • Hydrotherapy: Whirlpool baths can aid healing by keeping skin clean and naturally removing dead or contaminated tissue. Whirlpool baths used for burn treatment are specialized, stainless steel baths used by trained healthcare professionals.
  • Healthy diet: Eating a nutritionally rich diet with adequate calories and protein and a full range of vitamins and minerals, especially vitamins A, C, E, and zinc, has been reported to improve wound healing. A well nourished body can produce healthy skin, which guards against breakdown.
  • Surgical repair: The goals of surgery include improving the hygiene and appearance of the sore, preventing or treating infection, reducing fluid loss through the wound, and lowering the risk of future cancer. The type of reconstruction that's best in any particular case depends mainly on the location of the wound and whether there's scar tissue from a previous operation. In general, though, most pressure wounds are repaired using a pad of muscle, skin, or other tissue that covers the wound and cushions the affected bone (flap reconstruction). The tissue is usually harvested from the individual's own body. In spite of every precaution, flap reconstruction has one of the highest complication rates of any surgery, and the recovery period is long and arduous. Individuals must have a strong social support system, optimal nutritional status, state-of-the-art resources such as a pressure-release bed, and the ability and motivation to participate in their own recovery to be a candidate for this operation.
  • Other treatment options: Hyperbaric oxygen, electrotherapy, and the topical use of human growth factors are methods of wound healing that are being researched. Growth factors, proteins that stimulate cell growth, have been approved for the treatment of diabetic ulcers but not, as yet, for pressure sores.
  • Anal fissures:
  • Anal fissures are fairly common and usually heal without treatment or with non-surgical treatments. Signs and symptoms may go away within two weeks, but it may take up to eight weeks for the tear to heal. If the tear doesn't heal within six to eight weeks, however, the individual may need surgery.
  • For infants, the only intervention necessary may be changing the diaper regularly and keeping the anal area clean. A pediatrician can help provide ways to avoid constipation and ensure regular bowel movements to prevent the baby from straining.
  • Non-surgical treatments: Lifestyle and dietary changes include adding more fiber to the diet, drinking more water, getting regular exercise, and taking a stool softener, such as docusate sodium (Colace®). A doctor may recommend non-surgical treatments including medicated creams or suppositories. A doctor may prescribe a rectal corticosteroid (Anusol® or Anusol HC®) or recommend an over-the-counter (OTC) cream or ointment containing hydrocortisone (Preparation H®) to help reduce inflammation and ease discomfort.
  • Some doctors recommend applying nitroglycerine ointment (Nitrol® ointment) to the anus, which widens blood vessels and increases blood flow to the tear, promoting healing. This fairly new therapy also helps reduce pressure in the anal sphincter, which eases the spasm and decreases pain, thereby promoting healing. The dose of nitroglycerine is small to avoid dangerous side effects. However, it may cause side effects such as headaches, low blood pressure, and dizziness. Men shouldn't use nitroglycerine within 24 hours of taking erectile dysfunction medications such as sildenafil (Viagra®), tadalafil (Cialis®), and vardenafil (Levitra®) because of the possibility of significantly lowered blood pressure.
  • Another fairly new treatment involves injecting a small dose of botulinum toxin type A (Botox®) into the internal anal sphincter. Botox paralyzes the muscle for up to three months, causing the spasm to relax. A possible side effect is temporary, mild leakage of gas or stool (anal incontinence).
  • Both topical nitroglycerine and Botox® have shown promise in relieving anal fissures in most studies. Researchers are testing these treatments alone and in combination with other drugs. Blood pressure medications nifedipine (Adalat®) and diltiazem (Cardizem®), taken orally or ground into a gel and applied to the tear, also have shown some promise.
  • Surgery: If an individual has a chronic anal fissure that will not heal on its own, a doctor may recommend surgery. Surgery usually involves cutting a portion of the anal sphincter muscle to reduce spasm and pain and promote healing. Surgery may also include removal of the fissure and any scar tissue resulting from it.
  • Adults usually have outpatient surgery. Children who have surgery may need to stay overnight in the hospital. Rarely, cutting the anal sphincter results in loss of ability to control bowel movements.

Integrative therapies
  • Unclear or conflicting scientific evidence:
  • Aloe: Transparent gel from the pulp of the meaty leaves of Aloe vera has been used topically for thousands of years to treat wounds, skin infections, burns, and numerous other dermatologic conditions. Study results of aloe on wound healing are mixed with some studies reporting positive results and others showing no benefit or potential worsening of the condition. Early studies suggest that aloe may help heal skin ulcers. High-quality studies comparing aloe alone with placebo are needed.
  • Avoid if allergic to aloe or other plants of the Liliaceae family (garlic, onions, tulips). Avoid injecting aloe. Do not apply to open skin, surgical wounds or pressure ulcers. Avoid taking by mouth with diarrhea, bowel blockage, intestinal diseases, bloody stools or hepatitis. Avoid with a history of irregular heartbeat (arrhythmia), electrolyte imbalances, diabetes, heart disease or kidney disease. Avoid taking by mouth if pregnant or breastfeeding.
  • Alpha-lipoic acid: Alpha-lipoic acid (ALA) may reduce tissue damage that is often caused by long-term exposure to high levels of oxygen. While early studies are promising, more research is needed to fully understand how ALA might work for wound healing in patients undergoing hyperbaric oxygen therapy.
  • Avoid if allergic to alpha-lipoic acid (ALA). Use cautiously with diabetes and thyroid diseases. Avoid with thiamine deficiency or alcoholism. Avoid if pregnant or breastfeeding.
  • Arginine: Arginine, or L-arginine, is considered a semi-essential amino acid, because although it is normally synthesized in sufficient amounts by the body, supplementation is sometimes required (for example, due to inborn errors of urea synthesis, protein malnutrition, excess ammonia production, excessive lysine intake, burns, infection, peritoneal dialysis, rapid growth, or sepsis). Arginine has been suggested to improve the rate of wound healing in elderly individuals. A randomized, controlled clinical trial reported improved wound healing after surgery in head and neck cancer patients, following the use of an enteral diet supplemented with arginine and fiber. Arginine has also been used topically (on the skin) to attempt to improve wound healing. Early studies suggest that arginine may also help treat chronic anal fissures. Additional studies are needed.
  • Avoid if allergic to arginine, or with a history of stroke, liver, or kidney disease. Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (like warfarin or Coumadin®) and blood pressure drugs or herbs or supplements with similar effects. Blood potassium levels should be monitored. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control sugar levels.
  • Aromatherapy: Aromatherapy is a technique in which essential oils from plants are used with the intention of preventing or treating illness, reducing stress, or enhancing well-being. Preliminary data from one small study suggests aromatherapy may contribute to reduced pain intensity during dressing changes in wound care. Data are insufficient for forming any opinion for or against this application.
  • Essential oils should only be used on the skin in areas without irritation. Essential oils should be administered in a carrier oil to avoid toxicity. Avoid with a history of allergic dermatitis. Use cautiously if driving or operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.
  • Ayurveda: There is some evidence that a traditional Ayurvedic treatment using specially prepared alkaline threads (ksharasutra or Ayurvedic setons) to achieve gradual cauterization may provide an effective alternative to surgery in patients being treated for anal fissures. Further research is needed to confirm these results.
  • Ayurvedic herbs should be used cautiously. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs can interact with other herbs, foods and drugs. A qualified healthcare professional should be consulted before taking. Use guggul cautiously with peptic ulcer disease. User should avoid sour food, alcohol and heavy exercise. Mahayograj guggul should not be taken for long periods of time. Pippali (Piper longum) should be taken with milk and avoided with asthma. Avoid sweet flag, and avoid amlaki (Emblica officinalis) at bedtime. Avoid Terminalia hebula (harda) if pregnant. Avoid Ayurveda with traumatic injuries, acute pain, advanced disease stages and medical conditions that require surgery.
  • Bovine cartilage: Reduction in inflammation and edema (swelling) and enhancement of the healing of wounds were effects that appeared in the medical literature of bovine cartilage during the 1950s and 1960s. In a preliminary comparison of potential wound healing effects with a commercially available ointment of 10% powdered bovine cartilage (Catrix® 10 Ointment) or Aquaphor® original formula in post-operative facial skin care with a laser resurfacing agent, Catrix® 10 Ointment was better. However, this study was a pilot study so its results need confirmation by follow-up clinical studies that clearly have the appropriate randomization and are double-blinded, given that such were in absence in this study. Also lacking in this study was a definition of primary outcome that therapeutically differentiated Catrix® 10 Ointment.
  • Avoid if allergic or hypersensitive to bovine cartilage or any of its constituents. Use cautiously with cancer, renal (kidney) failure, or hepatic (liver) failure. Avoid if pregnant or breastfeeding.
  • Calendula: Calendula (Calendula officinalis), also known as pot marigold, has been widely used on the skin to treat minor wounds, skin infections, burns, bee stings, sunburn, warts, and cancer. Calendula is commonly used topically (on the skin) to treat minor skin wounds. Reliable human research is necessary before a firm conclusion can be drawn regarding the use of calendula for wound healing.
  • Avoid if allergic to plants in the Aster/Compositae family, such as ragweed, chrysanthemums, marigolds, and daisies. Use cautiously in patients taking sedatives, blood pressure medications, cholesterol medications, blood sugar-altering agents, and immunomodulators. Use cautiously with diabetes and in children. Avoid if pregnant or breastfeeding.
  • Chamomile: Chamomile (Matricaria recutita, Chamaemelum nobile) has been used medicinally for thousands of years, and is widely used in Europe. There is promising preliminary evidence supporting the topical use of chamomile for wound healing. However, the available literature is not adequate to support the use of chamomile for this indication.
  • Avoid if allergic to chamomile. Anaphylaxis, throat swelling, skin allergic reactions and shortness of breath have been reported. Chamomile eyewash can cause allergic conjunctivitis (pinkeye). Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Use cautiously if driving or operating machinery. Avoid if pregnant or breastfeeding.
  • Chitosan: There is limited evidence on the effects of chitosan in wound healing. Better studies are needed.
  • Avoid if allergic or sensitive to chitosan or shellfish. Use cautiously with diabetes or bleeding disorders. Use cautiously if taking drugs, herbs, or supplements that lower blood sugar or increase the risk of bleeding. Chitosan may decrease absorption of fat and fat-soluble vitamins from foods. Chitosan is not recommended during pregnancy or breastfeeding.
  • Dimethylsulfoxide (DMSO): Dimethylsulfoxide (DMSO) is a sulfur-containing organic compound. DMSO occurs naturally in vegetables, fruits, grains, and animal products. DMSO applied to the skin may prevent tissue death after extravasation of anticancer agents. It can be applied alone or with steroids. Limited available study also suggests that DSMO improves lack of blood flow in surgical skin flap ischemia. Currently, there is not enough scientific evidence available for the use of topical DMSO for diabetic ulcers.
  • Avoid if allergic or hypersensitive to DMSO. Use caution with urinary tract cancer or liver and kidney dysfunction. Avoid if pregnant or breastfeeding.
  • Eucalyptus oil: Eucalyptus (Eucalyptus globulus) oil contains 70-85% 1,8-cineole (eucalyptol), which is also present in other plant oils. Limited evidence suggests that eucalyptus essential oil may be beneficial for patients with skin ulcers when combined with antibiotics. More studies are needed to confirm these early findings.
  • Case reports describe allergic rash after exposure to eucalyptus oil, either alone or as an ingredient in creams. Avoid if allergic to eucalyptus oil or with a history of seizure, diabetes, asthma, heart disease, abnormal heart rhythms, intestinal disorders, liver disease, kidney disease, or lung disease. Use caution if driving or operating machinery. Avoid with a history of acute intermittent porphyria. Avoid if pregnant or breastfeeding. A strain of bacteria found on eucalyptus may cause infection. Toxicity has been reported with oral and inhaled use.
  • Gotu kola: Gotu kola, Centella asiatica (formerly known as Hydrocotyle asiatica), has a long history of use, dating back to ancient Chinese and Ayurvedic medicine. Preliminary study has demonstrated the ability of Centella asiatica extracts to promote wound healing, possibly through the stimulation of collagen synthesis. However, additional human study is needed in this area.
  • Avoid if allergic to gotu kola, asiaticoside, asiatic acid, or madecassic acid. Avoid with a history of high cholesterol, cancer, or diabetes. Avoid if pregnant or breastfeeding.
  • Honey: Honey is a sweet, viscid fluid produced by honeybees (Apis melliflera) from the nectar of flowers. The primary studied use of honey is for wound management, particularly in promoting rapid wound healing, deodorizing, and debriding necrotic tissue. The types of wounds studied are varied; most are non-healing wounds such as chronic ulcers, postoperative wounds, and burns. Currently, there is insufficient human evidence to support the use of honey for skin graft healing. Although honey has apparent antibacterial effects, more human study is needed in this area.
  • Avoid if allergic or hypersensitive to honey, pollen, celery, or bees. Honey is generally considered safe in recommended doses. Avoid honey from the genus Rhododendron because it may cause a toxic reaction. Avoid in infants younger than 12 months of age. Use cautiously with antibiotics. Potentially harmful contaminants (like C. botulinum or grayanotoxins) can be found in some types of honey and should be used cautiously in pregnant or breastfeeding women.
  • Hydrotherapy: Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. These approaches have been used for the relief of various diseases and injuries, or for general well being. Hydrotherapy has been used in patients with pressure ulcers, and preliminary research suggests that daily whirlpool baths may reduce the time for wound healing. Better research is necessary in this area before a firm conclusion can be drawn.
  • There is a risk of infection from contaminated water if sanitary conditions are not maintained. Avoid sudden or prolonged exposure to extreme temperatures in baths, wraps, saunas, or other forms of hydrotherapy, particularly with heart disease, lung disease, or if pregnant. Avoid with implanted medical devices like pacemakers, defibrillators, or hepatic (liver) infusion pumps. Vigorous use of water jets should be avoided with fractures, known blood clots, bleeding disorders, severe osteoporosis, open wounds, or during pregnancy. Use cautiously with Raynaud's disease, chilblains, acrocyanosis, erythrocyanosis, and impaired temperature sensitivity, such as neuropathy. Use cautiously if pregnant or breastfeeding. Hydrotherapy should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses. Patients with known illnesses should consult their physician(s) before starting hydrotherapy.
  • Iodine: It is not clear if healing of wounds or skin ulcers is improved with the application of topical iodine solutions. Iodine solutions may assist with sterilization as a part of a larger approach to the wound healing process.
  • Reactions can be severe, and deaths have occurred with exposure to iodine. Avoid iodine-based products if allergic or hypersensitive to iodine. Do no use for more than 14 days. Avoid Lugol solution and saturated solution of potassium iodide (SSKI, PIMA) with hyperkalemia (high amounts of potassium in the blood), pulmonary edema (fluid in the lungs), bronchitis, or tuberculosis. Use cautiously when applying to the skin because it may irritate/burn tissues. Use sodium iodide cautiously with kidney failure. Avoid sodium iodide with gastrointestinal obstruction. Iodine is safe in recommended doses for pregnant or breastfeeding women. Avoid povidone-iodine for perianal preparation during delivery or postpartum antisepsis.
  • Magnet therapy: The use of magnets to treat illness has been described historically in many civilizations. In modern times, magnetic fields play an important role in Western medicine, including use for magnetic resonance imaging (MRI), pulsed electromagnetic fields, and experimental magnetic stimulatory techniques. Early scientific evidence suggests that the time to heal wounds, including ulcers, may decrease with the use of static magnets. Better quality studies are needed before a firm recommendation can be made for wound healing.
  • Avoid with implantable medical devices, such as heart pacemakers, defibrillators, insulin pumps, or hepatic artery infusion pumps. Avoid with myasthenia gravis or bleeding disorders. Avoid if pregnant or breastfeeding. Magnet therapy is not advised as the sole treatment for potentially serious medical conditions, and it should not delay the time to diagnosis or treatment with more proven methods. Patients are advised to discuss magnet therapy with a qualified healthcare provider before starting treatment.
  • Pantothenic acid (vitamin B5): Pantothenic acid (vitamin B5) is essential to all life and is a component of Coenzyme A (CoA), a molecule that is necessary for numerous vital chemical reactions to occur in cells. Pantothenic acid is essential to the metabolism of carbohydrates, proteins, and fats, as well as for the synthesis of hormones and cholesterol. In animal research, oral and topical pantothenic acid has been associated with accelerated skin wound healing. However early human study results conflict. Additional evidence is necessary before a clear conclusion can be reached regarding this use of pantothenic acid or dexpanthenol.
  • Avoid if allergic or hypersensitive to pantothenic acid or dexpanthenol. Avoid with gastrointestinal blockage. Pantothenic acid is generally considered safe in pregnant and breastfeeding women when taken at recommended doses.
  • Papain: Papain is an enzyme that breaks protein bonds and has been used in Africa for treating burns. In standard western medical care, papain-containing debridement agents are commonly used to remove necrotic tissue and slough in burns, postoperative wounds, pilonidal cyst wounds, carbuncles, trauma wounds, infected wounds, and chronic lesions, such as pressure ulcers, and varicose and diabetic ulcers. According to reviews and clinical trials, papain may be very useful for wound debridement and for stimulating wound healing. More high-quality research is needed in this area.
  • Use cautiously in patients sensitive to papain. Use cautiously in patients being treated for prostatitis. Use Wobenzym®, which contains papain, cautiously, especially in those with bleeding disorders or taking anticoagulants or antiplatelets. Use cautiously as an adjuvant to radiation therapy. Avoid in patients with gastroesophageal reflux disease. Avoid in patients using immunosuppressive therapy.
  • Physical therapy: Physical therapy techniques, such as laser treatment, have been used to clean and heal wounds. Early evidence also suggests that high voltage stimulation or pulsed electrical stimulation may speed the healing of some types of skin ulcers. More research with similar outcome measures is needed to better understand the role of physical therapy for wound care.
  • Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the literature although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking in the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.
  • Psyllium: Psyllium, also referred to as ispaghula, is derived from the husks of the seeds of Plantago ovata. Psyllium contains a high level of soluble dietary fiber, and is the chief ingredient in many commonly used bulk laxatives. Results from human study suggest that psyllium may reduce the number of surgeries necessary to heal anal fissures. Further evidence is necessary.
  • Avoid if allergic or hypersensitive to psyllium, ispaghula, or English plantains (Plantago lanceolata). Avoid in patients with esophageal disorders, gastrointestinal atony, fecal impaction, gastrointestinal tract narrowing, swallowing difficulties, and previous bowel surgery. Avoid ingestion of psyllium-containing products in individuals with repeated or prolonged psyllium exposure who have not manifested allergic or hypersensitive symptoms. Prescription drugs should be taken one hour before or two hours after psyllium. Adequate fluid intake is required when taking psyllium-containing products. Use cautiously with blood thinners, antidiabetic agents, carbamazepine, lithium, potassium-sparing diuretics, salicylates, tetracyclines, nitrofurantoin, calcium, iron, vitamin B12, other laxatives, tricyclic antidepressants (amitriptyline, doxepin, and imipramine), antigout agents, anti-inflammatory agents, hydrophilic agents, and chitosan. Use cautiously with diabetes and kidney dysfunction. Use cautiously if pregnant or breastfeeding.
  • Rose hip: Rose hips are the fruits that develop from the blossoms of the wild rose (Rosa spp.). They are typically orange to red in color, but some species may be purple or black. When applied topically, the volatile oils of aromatic plants may have physiological effects that will facilitate wound healing. Rose hips contain several vitamins and minerals, including vitamin C, vitamin B1, vitamin E, calcium, zinc, and carotenoids, which could potentially promote wound healing when applied to the skin. Much larger and high quality clinical trials are needed to establish the therapeutic efficacy of rose hip and rose oil preparations in the topical treatment of surgical wounds and ulcers.
  • Use cautiously in patients who are avoiding immune system stimulants. Use cautiously in patients who are taking anticoagulant or anti-platelet aggregating agents, antibiotics, antineoplastics, antiretrovirals, anti-inflammatory agents, "Long-Life CiLi", antilipemics, aluminum-containing antacids, salicylates, or laxatives. Avoid in patients who are allergic to rose hips, rose pollen, its constituents, or members of the Rosaceae family.
  • TENS: Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. Electrodes are temporarily attached with paste in various patterns, depending on the specific condition and treatment goals. TENS is often used to treat pain, as an alternative or addition to pain medications. Therapy sessions may last from minutes to hours. TENS is often used in conjunction with acupuncture therapy. TENS has been tested for its effects on blood flow to skin flaps used in plastic surgery procedures such as breast reconstruction. TENS has also been evaluated in patients with skin ulcers, diabetic foot ulcers, and chronic ulcers of various causes. More research is needed in this area.
  • Avoid with implantable devices, like defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation, like neuropathy, and with seizure disorders. Avoid if pregnant or breastfeeding.
  • Therapeutic touch: Although some studies report an improvement in wound healing with therapeutic touch, others show no benefits.
  • Therapeutic touch is believed to be safe for most people. Therapeutic touch should not be used for potentially serious conditions in place of more proven therapies. Avoid with fever or inflammation, and on body areas with cancer.
  • Vitamin A: In preliminary study, retinol palmitate significantly reduced rectal symptoms of radiation proctopathy, perhaps because of wound healing effects. Further research is needed to confirm these results.
  • Avoid if allergic or hypersensitive to vitamin A. Vitamin A toxicity can occur if taken at high dosages. Use cautiously with liver disease or alcoholism. Smokers who consume alcohol and beta-carotene may be at an increased risk for lung cancer or heart disease. Vitamin A appears to be safe in pregnant women if taken at recommended doses; however, vitamin A excess, as well as deficiency, has been associated with birth defects. Excessive doses of vitamin A have been associated with central nervous system malformations. Use cautiously if breastfeeding because the benefits or dangers to nursing infants are not clearly established.
  • Zinc: Although zinc is frequently cited as having beneficial effects on healing of incision wounds, few studies have investigated this use. Further research is needed. There are conflicting findings regarding the potential benefit of zinc for healing leg ulcers. Available studies reported no or few adverse effects.
  • Preliminary evidence suggests that topical zinc oxide oil may help manage perianal and buttock skin damage in incontinent patients. Further research is needed to better understand the role of zinc for treatment of skin damage caused by incontinence.
  • Zinc is generally considered to be safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. Avoid with kidney disease. Use cautiously if pregnant or breastfeeding.
  • Fair negative scientific evidence:
  • Aloe: A well-designed human trial found no benefit of topical acemannan hydrogel (a component of aloe gel) in the treatment of pressure ulcers.
  • Avoid if allergic to aloe or other plants of the Liliaceae family (garlic, onions, tulips). Avoid injecting aloe. Do not apply to open skin, surgical wounds or pressure ulcers. Avoid taking by mouth with diarrhea, bowel blockage, intestinal diseases, bloody stools or hepatitis. Avoid with a history of irregular heartbeat (arrhythmia), electrolyte imbalances, diabetes, heart disease or kidney disease. Avoid taking by mouth if pregnant or breastfeeding.

Author information
  • This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography
  1. American Academy of Family Physicians. .
  2. American Academy of Pediatrics. .
  3. Arnold M, Barbul A. Nutrition and wound healing. Plast Reconstr Surg. 2006;117(7 Suppl):42S-58S.
  4. Centers for Disease Control and Prevention. .
  5. Dini V, Bertone M, Romanelli M. Prevention and management of pressure ulcers. Dermatol Ther. 2006;19(6):356-64.
  6. Langemo D, Anderson J, Hanson D, et al. Nutritional considerations in wound care. Adv Skin Wound Care. 2006;19(6):297-8, 300, 303.
  7. de Laat EH, Schoonhoven L, Pickkers P, et al. Epidemiology, risk and prevention of pressure ulcers in critically ill patients: a literature review. J Wound Care. 2006;15(6):269-75.
  8. Natural Standard: The Authority on Integrative Medicine. .
  9. National Institute of Allergy and Infectious Diseases. .
  10. Pieper B, Sieggreen M, Nordstrom CK, et al. Discharge knowledge and concerns of patients going home with a wound. J Wound Ostomy Continence Nurs. 2007;34(3):245-53; quiz 254-5.
  11. Wu SC, Driver VR, Wrobel JS, et al. Foot ulcers in the diabetic patient, prevention and treatment. Vasc Health Risk Manag. 2007;3(1):65-76.

Prevention and self-management
  • Self-management of physical symptoms:
  • Many health problems that occur during pregnancy can be managed at home using methods recommended by healthcare professionals.
  • Constipation and hemorrhoids: One of the reasons for constipation may be changes produced in the digestive tract due to hormones slowing down the movement of food. Additionally, during the last trimester of pregnancy there is more pressure on the rectum from the uterus. To avoid these problems, healthcare professionals recommend drinking plenty of water and eating fruit and vegetables with a high fiber content, such as green, leafy vegetables. Some pregnant women experience relief drinking a glass of room temperature water before breakfast. Over-the-counter (OTC) stool softeners may be used, such as docusate sodium (Colace®). It is recommended to tell the doctor of any OCT medication or dietary supplement taken during pregnancy.
  • Nausea: Nausea occurs due to metabolic changes. In the morning before getting up, eating crackers and standing up very slowly is recommended to decrease feelings of nausea. It is best to try to eat in small quantities every three hours (fractionated diet). During pregnancy, it is good to eat proteins (meat, eggs, beans) before going to bed at night.
  • Heartburn: Heartburn can occur when stomach acid from digesting food is pushed into the esophagus. During pregnancy, all digestive processes are slowed down and the engrossed uterus presses up on the stomach. To avoid heartburn, eat in small quantities, several times a day. Avoiding spicy and greasy foods and not eating at least one hour before going bed is important. Some pregnant women experience relief resting at night by elevating their heads with two or three pillows.
  • Fatigue: Pregnancy may stress a woman's body. It is important to try to sleep eight hours daily and if possible, take a nap during the day. Avoiding hard work and eating a balanced diet throughout pregnancy is recommended by healthcare professionals.
  • Headaches: Headaches may develop during pregnancy. This may be in part due to stress or in some cases it is cased by the higher level of blood in the body during pregnancy. Relaxing in a dark room may help decrease the pain and length of a headache. It is recommended by healthcare professionals to not take medications for headaches while pregnant unless directed by a doctor.
  • Frequent urination: During pregnancy, the uterus is pressing down on the bladder. Even if the bladder is almost empty, this pressure produces the same sensation as if it were full. Do not avoid the urge to urinate.
  • Cramps: Cramps are due to circulatory problems associated with the weight gain as the individual progresses in pregnancy. Exercises can be recommended by a healthcare professional to alleviate these discomforts.
  • Chloasma: Chloasmas are obscure marks in the skin caused by the hormones secreted during pregnancy. They tend to disappear after delivery. Common areas of chloasmas include the forehead, temples, cheeks, or upper lip. Avoiding sunlight on sensitive areas can help prevent chloasma.
  • Stretch marks: Skin tissue that has to support extra weight causes these marks. They appear on the abdomen and breasts and in most cases slowly disappear after delivery. Creams that contain cocoa butter may be useful in preventing stretch marks.
  • Varicose veins: Varicose veins are produced by the pressure of the uterus on the lower part of the abdomen that causes difficulty in circulation during the nine months of pregnancy. Varicose veins usually appear in the legs especially if the mother must stand or sit for long periods of time. Moving frequently helps improve circulation. Elevate the legs when possible or lie in bed with a pillow under the feet. While sitting, try to keep the feet up. Do not wear tight clothing. A doctor may recommend support stockings.
  • Breathing difficulties: Breathing difficulties may happen during the third trimester of pregnancy because the fetus is occupying more space in the abdomen; breathe deeply several times a day but avoid hyperventilation. Sleep propped up and avoid crowded places and smoggy environments.
  • Backaches: Backaches are a consequence of the growing of the abdomen and weight increase associated with pregnancy. If an individual is suffering from backaches, healthcare professionals recommend: to avoid wearing high-heeled shoes; try to keep the back straight; and avoid lifting heavy weights. It is good to practice some relaxation exercises that will help to lower the tension in the muscles.
  • Swelling: Swelling can occur due to the retention of water in the tissues. Swelling has a high occurrence in the feet. Try to elevate the legs whenever possible and avoid tight clothes that bind the legs. It is important to notify a doctor if swelling is taking place in uncommon areas, such as the face, or if weight increases suddenly.
  • Pregnancy prevention, family planning:
  • Abstinence: Abstinence is a lack of sexual relations. There are many ways to prevent pregnancy, but only abstinence is 100% effective.
  • Natural family planning (NFP): Researchers have found that a method of natural family planning that uses two indicators to identify the fertile phase in a woman's menstrual cycle is as effective as the contraceptive pill for avoiding unplanned pregnancies if used correctly. The study specifically investigated the efficacy and the acceptability of the symptothermal method (STM), a method that uses two indicators of fertility, temperature and cervical secretions observation. In the largest study of STM, the researchers found that if the couples either abstained from sex = during the fertile period, the rate of unplanned pregnancies per year was 0.4%. The study authors suggested that the effectiveness of STM is comparable to the effectiveness of modern contraceptive methods such as oral contraceptives, and is an effective and acceptable method of family planning.
  • A number of fertility awareness based methods of family planning have been advocated over the years, but comparisons between different methods and studies of their effectiveness have been limited and hampered by problems such as differences in cultural backgrounds, different ways to measure the effectiveness of a FAB method, different ways of classifying unintended pregnancies and other study design problems. Researchers recommend that women or couples who want to learn the method should buy a book, attend an NFP course, or get some teaching by a qualified NFP teacher.
  • Early studies have also suggested that couples who practice NFP: have a dramatically low (0.2%) divorce rate; experience happier marriages; are happier and more satisfied in their everyday lives; have considerably more marital relations; share a deeper intimacy with their spouse; and realize a deeper level of communication with their spouse. Further, more well-designed studies are needed.
  • Sterilization: Sterilization in the male is termed vasectomy and in the female tubal ligation, or tubal sterilization.
  • Tubal sterilization, or tubal ligation, is surgery to block a woman's fallopian tubes. Tubal sterilization is a permanent form of birth control. After this procedure, eggs cannot move from the ovary through the tubes (a woman has two fallopian tubes), and eventually to the uterus. Also, sperm cannot reach the egg in the fallopian tube after it is released by the ovary. Thus, pregnancy is prevented.
  • Vasectomy is a procedure in which the two tubes that carry sperm from the testicles to the urinary tract are surgically altered so sperm cannot pass through and be released to fertilize a woman's egg during sexual intercourse. For couples who have made the decision not to have any further children, vasectomy is the safest and easiest form of surgical sterilization. While reversible in many cases, vasectomy should be considered a permanent form of birth control.
  • Hormonal contraception: Hormonal contraception to prevent pregnancy includes birth control pills, birth control patches, and birth control vaginal rings.
  • Birth control pills, also known as oral contraceptives, have been marketed in the United States since 1962. Over the past 40 years, the type of estrogen and progestin (hormones) used in the pills has changed and the amounts of those hormones has been lowered. Birth control pills today are designed to improve safety and reduce side effects. Lower doses of estrogen are associated with a decrease in side effects, such as weight gain, breast tenderness, and nausea.
  • Over 30 different combinations of birth control pills are available in the United States. Most of the combinations of these pills have 21 hormonally active pills followed by seven pills containing no hormones. A woman begins taking a pill on the first day of her period or the first Sunday after her period has begun.
  • If a dose of oral contraceptive is missed, the individual may not be protected from pregnancy. A backup method of birth control, such as condoms, may be used for seven days or until the end of the cycle. Every brand of oral contraceptives comes with specific directions to follow if one or more doses have been missed. It is recommended to call a doctor or pharmacist with questions regarding missed oral contraceptive dosages. It is recommended by healthcare professionals to continue to take the tablets as scheduled and use a backup method of birth control until the questions are answered. Advantages of using birth control pills include their use to treat irregular menstrual periods. Women can manipulate the cycle to avoid a period during certain events, such as vacations or weekends by extending the number of intake days of hormonally active pills or by skipping the non-active pill week. Birth control pills may help prevent certain conditions, such as benign breast disease, pelvic inflammatory disease (PID), and functional cysts. Functional cysts are reduced by the suppression of stimulation of the ovaries. Ectopic pregnancies are prevented by the cessation of ovulation. The relationship between birth control pills and certain types of cancer is still being studied.
  • Disadvantages of birth control pills include nausea, breast tenderness, breakthrough bleeding, no periods, headaches, depression, anxiety, and lower sexual desire. Birth control pills do not provide protection from sexually transmitted diseases (STDs). Taking the pills daily and consistently (same time every day) is important. If a woman stops taking birth control pills, she may need a few months to get her normal ovulatory cycle back. After six months, her healthcare provider may need to examine her.
  • Additional risks include blood clots (venous thrombosis). At particular risk are heavy smokers (especially those older than 35 years), women with high or abnormal blood lipids (cholesterol levels), and women with severe diabetes, high blood pressure, and obesity. The association of birth control pill use and breast cancer in women remains controversial.
  • The relationship between birth control pill use and cervical cancer is also quite controversial. Important risk factors include early sexual intercourse and exposure to the human papillomavirus (HPV). Women who use birth control pills should have a periodic Pap test.
  • Intra-uterine device (IUD): An intrauterine device (IUD) is a small T-shaped plastic device that is placed in the uterus to prevent pregnancy. A plastic string is attached to the end to ensure correct placement and for removal. IUDs are an easily reversible form of birth control, and they can be easily removed. However, an IUD should only be removed by a medical professional.
  • Birth control barriers: Birth control barriers such as diaphragms, cervical caps, and condoms may also be used.
  • Spermicides: Spermicides are chemical barriers to conception. They are a reversible method of birth control, meaning that when a woman stops using them, full fertility returns. Vaginal spermicides are available in forms such as foam, cream, jelly, film, suppository, or tablet. Spermicides are not as effective as many other forms of birth control when used alone. They are often used with barrier methods of birth control and are much more effective when used in this context.
  • Emergency contraception: Plan B is the only emergency contraceptive pill ("morning after pill" or "day after pill") being sold in the United States today, although women can also use many kinds of daily birth control pills to prevent pregnancy after sex.
  • Plan B contains the hormone progestin. Other options for emergency contraception include taking a different dose of daily birth control pills (most of which contain both progestin and estrogen, so they are called "combined" pills) or having a healthcare provider insert an IUD within five days after the birth control failed and having had sex without using contraception, or if the individual was forced to have sex. Preven®, the brand name of a combined emergency contraceptive pill that was approved for use in the United States, is no longer being sold here. Plan B is more effective and has fewer side effects than other emergency contraceptive pills.
  • Emergency contraceptive pills are available without prescription to women and men 18 and older in the United States, though women 17 and under will still need a prescription from a healthcare provider to buy them. In some states, women of all ages can get emergency contraceptive pills directly from a pharmacist, without having to see a doctor first.

Common dental problems, causes, and risk factors
  • Dental caries: Dental caries is an infectious disease that damages the structures of teeth. Tooth decay or cavities are consequences of caries. All individuals are at risk for getting cavities throughout their lifetime. By the time most people are adults, 85% of people will have had a cavity. Cavities are caused by the bacteria Streptococcus mutans, which can attach themselves to hard surfaces like the enamel that covers the teeth. If the bacteria are not removed, they multiply and grow in number until a colony forms. More bacteria of different types attach to the colony already growing on the tooth enamel. Proteins that are present in the saliva (spit) also mix in and the bacteria colony becomes a whitish film on the tooth. This film, called dental plaque, damages and decays the teeth and causes cavities.
  • Plaque begins to accumulate on teeth within 20 minutes after eating (the time when most bacterial activity occurs). If this plaque is not removed thoroughly and routinely, tooth decay will not only begin, but flourish. The acids in plaque dissolve the enamel surface of the tooth and create holes in the tooth (cavities). Cavities are usually painless until they grow very large inside the tooth and destroy the nerve and blood vessels in the tooth. If left untreated, a tooth abscess (pus enclosed in the tissues of the jaw bone at the tip of an infected tooth) can develop. Untreated tooth decay also destroys the internal structures of the tooth (pulp) and ultimately causes the loss of the tooth. Pulp refers to the softest part of the tooth that lies in its root and extends all of the way to the top part of the tooth (the crown). The pulp contains the blood vessels, the nerves, and connective tissue inside a tooth and provides the tooth's blood and nutrients.
  • Gum disease: Gum diseases include gingivitis and periodontitis. Gingivitis is inflammation of the gums that causes the gums to bleed and swell. Gum diseases are more often seen as people age, with most people showing signs of them by their mid-30s. Gingivitis is caused by infection or plaque around the teeth and is a common cause of tooth loss after age 35. The most common type of gum disease is gingivitis.
  • Periodontitis is a more serious type of gum disease. Periodontitis is a dental disorder that results from progression of gingivitis, involving inflammation and infection of the ligaments and bones that support the teeth. Plaque, formed from bacteria, hardens into calculus (tartar) when left on the teeth. As plaque and calculus continue to build up, the gums begin to pull away, or recede, from the teeth, and pockets form between the teeth and gums. As the gums recede, more bone and the periodontal ligament are damaged. Teeth - even healthy teeth - may become loose and need to be extracted.
  • Gum diseases such as gingivitis and periodontitis can be caused by numerous factors, including: smoking/tobacco use; genetics - up to 30% of the population may be genetically susceptible to gum disease; pregnancy, puberty, and menopause (hormonal changes can make individuals more susceptible to gum diseases); stress; medications, such as oral contraceptives, the anti-seizure drug phenytoin (Dilantin®), the immune system drug cyclosporin (Sandimmune®), and some heart medicines including nifedipine (Procardia®); clenching or grinding the teeth - clenching or grinding the teeth can put excess force on the supporting tissues of the teeth and could speed up the rate at which these periodontal tissues are destroyed; diabetes - diabetes makes the individual more susceptible to developing infections, including gum diseases; poor nutrition - vitamin deficiencies can impair the immune system, leading to periodontitis; and disease such as human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), and cancer can impair immunity and lead to gum diseases.
  • It has been estimated that 50%-75% of women experience gingivitis during pregnancy. Pregnancy-related gingivitis is caused by increased hormone levels and is most common between the second and eighth month of pregnancy. The increased hormones result in more overall fluid retention throughout the body, which can cause swollen, red, and tender gums. Hormonal changes in pregnancy have also been found to reduce resistance to infection in gum tissue and to promote growth of certain bacteria and plaque (particularly increased levels of progesterone), which causes inflammation. Swelling and tenderness in the gums may be severe and cause bleeding. Untreated gingivitis may lead to periodontitis. Research has found an association between chronic gum disease and premature delivery. One well-known study reported that compared to mothers with healthy gums, pregnant women with chronic gum disease were four to seven times more likely to deliver prematurely. Experts suggest that pregnancy gingivitis can be prevented by proper oral hygiene both prior to and during pregnancy, including brushing at least twice a day (with a fluoride-containing toothpaste), flossing once a day, using an antimicrobial mouth rinse, and regularly scheduled professional dental cleanings. Following delivery, gums usually return to normal. If symptoms such as bleeding, sensitivity, swelling, and irritation persist after delivery or get worse, it is advised to contact a dentist.
  • Phenytoin-induced gingival hyperplasia is an enlargement of the gums. The gums can grow along the sides of, or over the teeth. Phenytoin (Dilantin®) causes gingival hyperplasia in approximately 50% of those who take it within two weeks to three months after initiation of therapy. This may progress to the point that the teeth are virtually submerged. Phenytoin is commonly used for seizure control.
  • Canker sores: Canker sores, also known as aphthous stomatitis or mouth ulcers, are common, but mostly harmless, sores. Stomatitis means inflammation of the mouth. Canker sores appear as ulcers (an eroded area of the oral cavity, marked by tissue disintegration) that are white or gray with a red border inside the mouth. They occur in women more often than men, often during menstrual periods. The reason why they appear is unknown but some experts believe that problems with the immune system, the body system that fights disease, bacteria, or viruses, may be involved. Fatigue, stress, or allergies can increase the chances of getting a canker sore. Canker sores tend to heal by themselves in one to three weeks. If an individual gets a large sore (larger than 1 centimeter), it may need to be treated. Canker sores are vulnerable to infection by bacteria in the mouth.
  • Canker sores are usually seen in children and adolescents from the ages of 10 - 19 years. For about one-third of the children affected, lesions continue to reappear for years after the initial outbreak. These ulcers are not contagious and cannot be spread from one child to another.
  • Oral thrush: Oral thrush is a fungal or yeast infection (candidiasis) in the mouth caused by an overgrowth of Candida albicans. Oral thrush appears as red or white lesions, flat or slightly raised, in the mouth. When severe, this fungus can spread down the esophagus, making chewing and swallowing very painful. They are common among denture wearers and occur most often in those who are very young, in the elderly, or in those who have a problem with their immune system, such as in cancer and HIV/AIDS patients. Individuals who have dry mouth syndrome (xerostomia) and those taking antibiotics may also get oral yeast infections. These yeast infections can be prevented with good oral hygiene, such as cleaning dentures appropriately and brushing the teeth.
  • Oral leukoplakia: Oral leukoplakia is a condition in which thickened, white patches form on the gums, on the inside of the cheeks, and sometimes on the tongue. The cause of leukoplakia is unknown, but it is considered to result from chronic irritation. Tobacco, either smoked or chewed, is the main cause, but irritation can also come from other sources, such as long-term alcohol use.
  • Leukoplakia is the most common of all chronic mouth lesions. Although anyone can develop leukoplakia, it's most common in older men. People with compromised immune systems sometimes develop an unusual form of the disorder called hairy leukoplakia. Hairy leukoplakia of the mouth is an unusual form of leukoplakia that is seen only in people who are infected with human immunodeficiency virus (HIV), have acquired immunodeficiency syndrome (AIDS), or AIDS-related complex. Hairy leukoplakia consists of corrugated, fuzzy, hence the name "hairy," white patches on the lateral borders of the tongue and less frequently elsewhere in the mouth. It may resemble thrush, an infection caused by the fungus
  • In general, leukoplakia is not painful, but the patches may be sensitive when the individual touches them or eats spicy foods. Although the disorder usually is not dangerous, a small percentage of leukoplakic patches show early signs of cancer. Many cancers of the mouth occur next to areas of leukoplakia. For that reason, it is best to see a dentist if there are unusual changes in the mouth lasting longer than a week.
  • The cause of leukoplakia is unknown. Many possible causes have been linked to leukoplakia, including tobacco, long-term alcohol use, and other chronic irritants. Tobacco use appears to be responsible for most cases of leukoplakia. The majority of individuals who develop leukoplakia are smokers, and most leukoplakic patches either improve or disappear within a year after stopping smoking. Chewing tobacco and snuff also play a key role. As many as three out of four regular users of "smokeless tobacco" products eventually develop leukoplakia where they hold the tobacco against their cheeks. Other factors contributing to leukoplakia include the fungus Candida albicans, which causes oral thrush, and human papillomavirus (HPV), the virus that causes genital warts.
  • Oral cancer is the most advanced stage of leukoplakia. Oral cancer most often occurs in people over the age of 40. It is often found at late stages when it is harder to treat. This is because oral cancer is not usually painful so individuals may not recognize the problem early. Also, many people do not visit their dentists often enough to find the cancer early. The most common sites of oral cancer are on the tongue, lips, and floor of the mouth. Use of tobacco, especially with alcohol, is the main cause for these cancers.
  • Chemotherapy or radiation treatments to the head and neck can cause dry mouth, tooth decay, painful mouth sores, leukoplakia, and cracked, peeling lips.
  • Mucositis: Mucositis, or stomatitis, is inflammation of the mucous membranes lining the digestive tract from the mouth on down to the anus. Mucositis is a common side effect of chemotherapy and of radiotherapy that involves any part of the digestive tract. Mucositis affects the rapidly dividing mucosal cells lining the mouth, throat, stomach, and intestines. These cells normally have a short life span. Chemotherapy or radiation therapy can destroy the cells quickly and they are not replaced right away. Destruction of mucosal cells in the oral cavity leads to ulcers or sores. Mucositis is painful, can interfere with eating, and may require pain medication for a week or two until the tissues recover.
  • Mucositis is also the primary cause of pain for patients undergoing bone marrow transplants due to chemotherapy and/or radiation therapies. Good mouth care is essential. Infection calls for prompt antibiotic treatment.

Copyright © 2011 Natural Standard (www.naturalstandard.com)


The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.