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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.

  • 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).

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.

  • In order to prevent wounds from occurring, healthcare providers recommend that individuals: take care when using sharp objects such as knives, scissors, saws, and trimmers; wear shoes or boots on the feet; use helmets when riding a bicycle; use helmets, kneepads, wrist protectors, and elbow pads when using in-line skates or skateboards; and avoid picking up broken pieces of glass and handling razor blades.
  • If bedridden or immobile with diabetes, circulation problems, incontinence, or mental disabilities, healthcare providers recommend that the individual be checked for pressure sores every day. Also, look for reddened areas that, when pressed, do not turn white. Also look for blisters, sores, or craters. In addition, take the following steps: change position at least every two hours to relieve pressure; use items that can help reduce pressure such as pillows, sheepskin, foam padding, and powders from medical supply stores; eat healthy, well-balanced meals; exercise daily, including range-of-motion exercises for immobile patients; and keep skin clean and dry. Incontinent people need to take extra steps to limit moisture.
  • Individuals with diabetes should check their feet daily for blisters, sores, or other wounds in order to prevent serious infection and possibly amputation.

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

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  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.

Delayed sleep phase syndrome (dsps)
  • Overview: Delayed sleep phase syndrome (DSPS), also called circadian rhythm sleep disorder- delayed sleep phase type, occurs when a person's internal clock is not in sync with the normal sleep patterns of most adults. The patient's sleep pattern is delayed by two or more hours, causing later bedtimes and wake times.
  • When patients follow their internal clocks and go to bed when they are tired, they get enough sleep. However, patients with DSPS have abnormal internal clocks, and they typically do not feel tired until 2:00 a.m. or later. Since this does not match normal school and work schedules, patients feel tired when they try to follow conventional sleeping schedules.
  • DSPS patients typically find that sleeping aids do not help them fall asleep any earlier.
  • DSPS is a long-term condition that is most common among adolescents. DSPS can develop suddenly or gradually. Symptoms generally go away spontaneously without treatment.
  • Causes: DSPS is not caused by jet lag, working late shifts, working irregular shifts, or other external factors. Instead, DSPS is caused by an abnormality in the patient's internal clock (called the circadian rhythm).
  • Symptoms: Patients with DSPS generally have difficulty falling asleep before 2:00 a.m. Individuals often feel tired upon waking. Individuals may continue to feel fatigued or drowsy throughout the day.
  • Diagnosis: If it is suspected that a patient has DSPS, the individual may be asked to keep a sleep log. In the log, the patient writes what time they fell asleep and woke up each day. In order for DSPS to be diagnosed, symptoms must last at least three months. However, DSPS is often misdiagnosed because symptoms of this disorder are very general and similar to insomnia or some types of mental illness (such as depression).
  • Treatment: There is currently no cure for DSPS, but symptoms generally go away on their own. Treatment is available to help manage symptoms by reprogramming the patient's internal clock. The goal is to synchronize the patient's sleep patterns with their work and/or school schedules. Treatment often includes light therapy and chronotherapy. Patients may also benefit from melatonin supplements taken 30 minutes to one hour before bed. Melatonin should be used cautiously because high doses may disturb sleep and cause nightmares and uncontrollable yawning the next day. If treatment does not help, patients may need to change their work and social lives to accommodate their internal clocks.

  • Overview: Insomnia occurs when individuals have difficulty falling or staying asleep, and they wake up too early in the morning. It is a common health problem that can cause excessive daytime sleepiness and a lack of energy. Long-term insomnia may cause an individual to feel tired, depressed, or irritable. Individuals may also have trouble paying attention, learning, and remembering, which may prevent them from performing fully on the job or at school. Severe insomnia can result in neurochemical (brain chemical) changes that may lead to problems, such as depression and anxiety, further complicating the insomnia.
  • Causes: There are many potential causes of insomnia. Psychological disorders, such as stress, anxiety, depression, and bipolar disorder, may lead to insomnia. Certain health conditions, including arthritis, overactive thyroid glands, gastrointestinal disorders (such as diarrhea or ulcers), Alzheimer's disease, Parkinson's disease, sleep apnea (discussed in detail below), and restless legs syndrome (RLS), may cause insomnia. Other factors, such as taking certain medications (such as stimulants, nasal decongestants, and some antidepressants), consuming caffeine, jet lag, wake-sleep pattern disturbances, excessive sleep during the day, and excessive physical or intellectual stimulation before bed, may cause insomnia.
  • Symptoms: The main signs and symptoms of insomnia are trouble falling or staying asleep or waking early, followed by a distinct feeling of fatigue (tiredness) the following day. Most often, daytime symptoms will bring people to seek medical attention. Daytime problems caused by insomnia include anxiousness, irritability, fatigue, poor concentration and difficulty focusing, impaired memory, decreased motor coordination, irritability, impaired social interaction, and motor vehicle accidents because of fatigued, sleep-deprived drivers.
  • Diagnosis: A doctor will ask the individual experiencing insomnia questions to evaluate his/her medical history. Questions investigate mental health problems, medications (prescription and non-prescription drugs, herbs, and supplements), history of pain, leisure habits, work and home situation, and others. The doctor will also inquire about the individual's sleep history. Questions about length and severity of the sleeping problem, routines before sleeping, snoring, and noise levels may also be asked. The doctor will also give the individual a full physical exam, including blood tests for conditions (such as thyroid problems) that may interfere with sleep. A polysomnogram is a recording of the breathing, movements, heart function, and brain activity during sleep. For this study, the individual sleeps overnight at a sleep center or hospital. A sleep study will be recommended if there are signs of sleep apnea or restless legs syndrome (RLS).
  • Treatment: Treatment for insomnia depends on the underlying cause. For instance, if a psychological problem is causing symptoms, a healthcare provider may recommend psychotherapy or cognitive behavioral therapy. If a medication is the suspected cause, a healthcare provider may be able to recommend a different drug or dosage.
  • There are many sedative-hypnotic medications available to help patients fall asleep and stay asleep throughout the night. Commonly prescribed medications for insomnia include temazepam (Restoril®), flurazepam (Dalmane®), estazolam (ProSom®), triazolam (Halcion®), zolpidem (Ambien®), zaleplon (Sonata®), and eszopiclone (Lunesta®).
  • However, the U.S. Food and Drug Administration (FDA) has issued warnings for all sedative-hypnotic drugs used for sleep because they may cause serious side effects. Anaphylaxis and severe facial angioedema (swelling) can occur the first time a sleep product is taken. Complex sleep-related behaviors may include sleep-driving (driving while not fully awake, and with no memory of driving), making phone calls, and preparing and eating food while asleep.
  • Over-the-counter (OTC) sleep aids may be used short-term to treat insomnia. For instance, diphenhydramine (Benadryl®) is the most commonly used OTC antihistamine sleep aid. It can be purchased alone (Benadryl®, Nytol®, or Sominex®) or in combination with other OTC items such as acetaminophen (Tylenol PM®). OTC sleep aids are not intended for long term use, because dependency can develop.
  • Melatonin agonists, such as ramelteon (Rozerem®), have also been used to treat insomnia. Ramelteon promotes the onset of sleep by increasing levels of the natural hormone melatonin, which helps normalize normal circadian rhythm and sleep/wake cycles. These drugs are less likely to cause morning drowsiness than sedative-hypnotics. Side effects are generally mild and may include daytime sleepiness, dizziness, and fatigue.
  • Sedating antidepressants, including trazodone (Desyrel®), amitriptyline (Elavil®), and doxepin (Sinequan®), have been used to treat insomnia. When used to promote sleep, these medicines are used in lower doses than when used to treat depression. Side effects may include dry mouth, blurred vision, a "hangover" in the morning, constipation, urinary retention, and nausea.

  • Overview: Narcolepsy is a sleep disorder that occurs when individuals are overwhelmingly tired and spontaneously fall asleep throughout the day. Patients have a hard time staying away for extended periods of time, regardless of the circumstances or how much sleep they get.
  • The severity of narcolepsy varies among patients. Most patients are diagnosed between the ages of 10 and 25. It is uncommon for patients to be diagnosed with the disorder when they are older than 40 years of age.
  • Causes: Researchers are still performing studies to fully understand the causes of narcolepsy. Scientists believe that genetics may play a role in the disorder. However, since only about two percent of narcoleptic patients have family histories of the disorder, other factors besides genetics are probably involved.
  • Narcoleptic patients may have imbalances in the brain chemicals that help control sleep. For instance, one chemical called hypocretin has been shown to help individuals wake from sleep and stay awake. Patients with narcolepsy typically have low levels of this chemical. However, researchers do not know what causes individuals to have low levels of hypocretin. It has been suggested that the body's immune system might attack hypocretin-producing cells by mistake.
  • Symptoms: Patients with narcolepsy are excessively tired throughout the day. Individuals can fall asleep at any time or any place throughout the day. For instance, they may fall asleep in the middle of conversations with friends. These sleep attacks may last anywhere from a few minutes to a half hour. Individuals also experience decreased alertness and concentration.
  • About 70% of narcoleptic patients also experience periodic episodes of cataplexy, which is a sudden and temporary loss of muscle tone. This condition, which may last anywhere from a few seconds to a few minutes, may cause symptoms that range from slurred speech and drooling to complete muscle weakness. Laughter or strong emotions, especially excitement and sometimes fear or anger, typically trigger cataplexy. Some patients may only experience cataplexy a few times a year, while others may experience symptoms several times a day.
  • Sleep paralysis may also occur while the individual is falling asleep or awakening. This temporary inability to move typically lasts anywhere from a few seconds to several minutes. When sleep paralysis occurs, patients may feel scared because they are often aware of what is happening even though they cannot move.
  • Some patients may experience hallucinations. This occurs if the patient is semi-awake when he/she starts dreaming.
  • Additional symptoms may include restless nighttime sleep or sleepwalking. Some patients may also act out their dreams and talk or move their arms or legs.
  • Diagnosis: If narcolepsy is suspected, the patient may be required to spend the night at a sleep center. During the night, a team of specialists will observe the patient's sleep patterns and behavior. Electrodes may also be placed on the patient's scalp before he/she falls asleep. This test, called a polysomnogram, measures the electrical activity of the brain and heart, as well as the movements of the muscles and eyes.
  • Patients may also be asked to fill out a sleep questionnaire, called the Epworth Sleepiness Scale. This survey asks the patient to rank how tired they are during certain activities.
  • A multiple sleep latency test may also be performed at a sleep center. The patient will be asked to take several naps that are about two hours apart. Narcoleptic patients will fall asleep quickly and enter rapid eye movement (REM) sleep almost immediately.
  • Treatment: Because narcolepsy is a neurological disorder, the condition does not improve if the patient gets more sleep. Although there is no cure for narcolepsy, medications can help manage symptoms. Patients typically receive medications called central nervous system (CNS) stimulants. These drugs help narcoleptic patients stay awake during the day. Modafinil (Provigil®), a newer stimulant, is less addictive and better tolerated than other older types of stimulants. However, some patients need treatment with methylphenidate (Ritalin®) or other types of amphetamines.
  • In addition, patients often take antidepressants, such as protriptyline (Vivactil®), imipramine (Tofranil®), and amitriptyline (Elavil®). These medications suppress REM sleep. As a result, they help control symptoms of cataplexy, hallucinations, and sleep paralysis.
  • Another prescription medication, called sodium oxybate (Xyrem®), may also be prescribed to some patients. This medication, which is taken at night, helps reduce symptoms of sleep paralysis, hallucinations, and cataplexy. Even though this medication is taken at night, high doses may also help control daytime sleepiness. Serious side effects, including difficulty breathing during sleep, sleepwalking, and bedwetting, have been reported. Therefore, this medication is only taken when other medications are unsuccessful. Xyrem® is not sold in local pharmacies. Instead, a healthcare provider must enroll a patient in a restricted distribution risk-management program that offers the drug from a single centralized pharmacy, the Xyrem® Success ProgramT.

Night terrors
  • Overview: Night terrors are similar to nightmares. However, night terrors are scarier and more intense. Night terrors typically cause individuals to scream and thrash about during sleep. Individuals usually do not remember their night terrors when they wake in the morning.
  • Night terrors primarily affect young children, usually between the ages of four and 12. Night terrors during childhood are not usually a cause for concern, and most children outgrow night terrors by adolescence.
  • In rare cases, adults may experience night terrors, usually in response to extreme stress or anxiety. Adults may benefit from medications if they experience frequent night terrors.
  • Causes: Many factors, including fatigue, stress, illnesses (especially those that cause fevers) and medications that affect the brain or spinal cord (such as stimulants), may cause night terrors.
  • Symptoms: Night terrors typically occur two to three hours after an individual has fallen asleep. During sleep, the patient may scream or yell, sit up in bed, thrash around, sweat, or breathe rapidly. If a parent or bedmate tries to hold or comfort the patient during a night terror, the patient may unknowingly put up a fight. Adults, who are larger and stronger than children, may even injure their bedmate as they thrash around during night terrors. Most night terrors only last a few minutes. Once the individual wakes up, he/she probably will not remember the episode.
  • Diagnosis: Night terrors usually do not require a diagnosis. A healthcare provider may perform a physical and/or psychological exam to determine what might be triggering the terrors.
  • Treatment: Children who experience night terrors generally do not require any treatment. Parents may gently restrain their children to try and calm them down. Speaking softly and calmly is recommended because shouting or shaking the child awake typically worsens the episode.
  • Although rarely used, medications called benzodiazepines, such as clonazepam (Klonopin®) may be used short-term to reduce symptoms in children. Antidepressants, such as imipramine (Tofranil®), may also help if night terrors affect the child's performance at school. Adults may also benefit from these medications if they experience frequent night terrors or if they are harming their bedmates during episodes. If stress or anxiety seems to be causing night terrors, a healthcare provider may recommend psychotherapy.
  • It is also important to ensure that the patient's bedroom is safe. For instance, children who experience night terrors should not sleep on the top of a bunk bed. Consider blocking stairways with a gate. Any sharp or unsafe objects should be out of the patient's reach.

Rem sleep behavior disorder
  • Overview: REM sleep behavior disorder (RBD) occurs when patients do not experience temporary paralysis during REM sleep. As a result, patients act out their dreams, which are often intense, vivid, and violent. The patient may yell, punch, kick, jump up from bed, and punch the air.
  • RBD typically occurs in middle-aged to elderly patients. It is more common in men than women.
  • Causes: The exact cause of RBD remains unknown. However, the disorder has been linked to many degenerative neurological (brain) disorders, including Parkinson's disease. It is important to note that not all patients with RBD develop neurological disorders.
  • Symptoms of RBD may also occur during withdrawal from alcohol or sedative-hypnotic drugs. However, this form is only temporary and goes away once the person has gone through withdrawal.
  • Symptoms: Patients with RBD act out their dreams. This may include yelling, screaming, thrashing around, kicking, punching, sitting up in bed, or getting out of bed during sleep. In some cases, RBD may cause self injury or injury to the bed partner. If the person wakes up in the middle of an attack, he/she is often able to remember the dream in detail.
  • Diagnosis: A polysomnographic video recording is typically performed to diagnose RBD. During the test, the patient will spend the night at a sleep center. When the patient is asleep, researchers will monitor the electrical activity of the brain and heart, the movement of the muscles, the movements of the eyes, and breathing patterns. A video recording is also made to monitor the physical behavior of the patient during sleep. Patients with RBD will have an increase in muscle movements in association with increased brain activity.

Sleep apnea
  • Overview: Sleep apnea is a serious condition that occurs when the individual stops breathing for short periods of time during sleep. Because sleep apnea causes individuals to wake up frequently throughout the night, patients are often drowsy during the day.
  • Causes: There are two main types of sleep apnea: obstructive sleep apnea and central sleep apnea. Obstructive sleep apnea is the most common form that occurs when the muscles in the throat relax. These muscles support the soft palate, the small piece of tissue that hangs from the soft palate (called the ulva), the tonsils, and the tongue. When these muscles relax, the patient is unable to breathe.
  • The brain senses this inability to breathe and causes the individual to wake up and start breathing again. This process may occur 20 to 30 times or more each hour during sleep. Most patients do not even realize this happens.
  • Obstructive sleep apnea occurs most often in older adults. It is also twice as likely to occur in men as women. Obese individuals have an increased risk of experiencing obstructive sleep apnea because they have excess fat in their upper airways.
  • Central sleep apnea occurs when the brain does not send proper signals to the muscles that control breathing during sleep. This is usually caused by heart disease. They are more likely to remember waking up in the middle of sleep than patients with obstructive sleep apnea.
  • It is possible to have a combination of both types of sleep apnea, which is called complex sleep apnea. Central sleep apnea may develop at any age, and it affects males and females equally. Some evidence suggests that 15% of patients with sleep apnea have complex sleep apnea.
  • Symptoms: Many of the symptoms of obstructive sleep apnea and central sleep apnea are the same. Common symptoms of both of these disorders include loud snoring, waking from sleep abruptly, difficulty staying asleep, waking up with a dry mouth or sore throat, and drowsiness during the day
  • In addition, individuals with central sleep apnea often wake up with shortness of breath and headaches.
  • Patients with central sleep apnea may also experience shortness of breath and headaches when they wake up from sleep.
  • Diagnosis: If sleep apnea is suspected, the patient may be asked to spend a night at a sleep center. At a sleep center, the patient's sleep patterns will be observed and analyzed. Several tests, including a nocturnal polysomnography, oximetry, and portable cardiorespiratory test, may be performed to monitor the patient's conditions.
  • During a nocturnal polysomnography test, a specialist will monitor the electrical activity of the brain and heart, the movement of the muscles, the movements of the eyes, and breathing patterns of the patient during sleep.
  • During an oximetry test, a small machine monitors and records the oxygen level of the patient during sleep. A small sleeve is placed over one of the fingers. This test may be performed at a sleep center or at home. Patients with sleep apnea will have low levels of oxygen before each awakening.
  • A healthcare provider may give the patient a portable cardiorespiratory test to perform at home. These tests involve oximetry, measurement of breathing patterns, and the measurement of airflow.
  • Treatment: Milder cases of sleep apnea may be treated with lifestyle changes, including weight loss and smoking cessation. More severe cases may be treated with devices to open the airway and/or surgery.
  • A machine called a continuous positive airway pressure (CPAP) is the most common and effective treatment for patients with moderate to severe sleep apnea. This machine delivers air through a mask that is placed over the nose during sleep. The mask does not breathe for the patient. Instead, it pushes air into the patient's mouth when he/she inhales. This air movement keeps the airways open, preventing sleep apnea and snoring. Patients who use a CPAP should tell their doctors if their weight changes. If the patient loses or gains weight, the pressure settings may need to be changed.
  • Patients may also wear devices over their mouths to control sleep apnea. Some devices bring the jaw forward in order to open the throat and control symptoms of mild obstructive sleep apnea. Patients should talk to their dentists to determine the best oral appliance for them. Patients should visit their dentists every six months for the first year once they find an oral appliance that works for them. After the first year, patients should visit their dentists and healthcare provider annually to make sure that the device is effectively relieving symptoms of sleep apnea.
  • In addition to CPAP, patients with central sleep apnea may benefit from bilevel positive airway pressure (BiPAP). This device provides a higher air pressure when the patient inhales and a lower pressure when the patient exhales. The goal of this treatment is to strengthen the weak breathing pattern of central sleep apnea. Some machines can be set to automatically provide oxygen if the device detects a breath has not been taken in a certain amount of seconds.
  • Another airflow device, called an adaptive servo-ventilation (ASV) may be used to treat central sleep apnea and complex sleep apnea. This device detects the patient's normal breathing pattern and stores it in a built-in computer. When the patient falls asleep, the machine uses the stored information to regulate the patient's breathing pattern and prevent sleep apnea.
  • Moderate to severe sleep apnea may need to be treated with surgery. During surgery, the extra tissue from the throat or nose that is blocking the airway passage is removed.

Copyright © 2011 Natural Standard (

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.

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