Archives of Medical Research 37 (2006) 425–435

REVIEW ARTICLE
Scientific and Medical Aspects of Ozone Therapy. State of the Art
Velio Alvaro Bocci
Department of Physiology, University of Siena, Siena, Italy
Received for publication May 26, 2005; accepted August 26, 2005 (ARCMED-D-05-00204).

The aim of this review is to dispel misconceptions and skepticism regarding ozone ther-
apy and to clarify the biochemical and pharmacological mechanisms of action of ozone
dissolved in biological fluids. The work performed in the last decade in our laboratory
allows drawing a comprehensive framework for understanding and recommending ozone
therapy in some diseases. It is hoped that this report will open a dialogue among clinical
scientists and will inform physicians about the beneficial effects of ozone therapy. Ó 2006
IMSS. Published by Elsevier Inc.
Key Words: Ozone, Antioxidants, Oxidative stress, Ozone tolerance, Ozone therapy.

Introduction generated a sort of crusade against ozone therapy in spite

of the fact that ozone is considered one of the best disinfec-
It is distressing to note that often ozone therapists are more
tants capable of preventing infection outbreaks. This is be-
interested in simply knowing the ozone dosage rather than
coming a crucial advantage because critically ill patients
to understand how ozone acts and why we can avoid toxic-
acquire infections while in hospitals and a number of them
ity. This behavior reveals a lack of knowledge of the funda-
die every year as a result.
mental bases regulating a judicious use of ozone and is the
Table 1 summarizes several good reasons for refusing
result of a superficial preparation acquired during an occa-
ozone therapy by orthodox medicine. However, problems
sional ozone therapy’s course of a few hours. This is not
1–5 have now been practically overcome, whereas the re-
surprising because during the last three decades, on the ba-
maining 6–9 are stumbling blocks hindering progress. Dur-
sis of Wolff’s suggestion (1), ozone therapy has been used
ing the last 14 years, we have made a great effort to
by practitioners in Europe in an empirical fashion. Unfortu-
examine ozone therapy in a scientific fashion both at a basic
nately, even today, most ozone therapists have either a mis-
and clinical level, and we now have some ideas how ozone
conception or know only a few technical tips for
acts, how and why its toxicity can be controlled and how
performing ozone therapy. This problem, associated with
therapeutic effects can be exerted (2–11). There is no need
the difficulties and cost of performing extensive clinical
to invoke philosophical speculations because the mecha-
studies, has hindered real progress, and ozone therapy re-
nisms of action are in the realm of classical biochemistry,
mains a scarcely known and objected complementary prac-
physiology and pharmacology.
tice. Worst of all, in some countries, often without any
This review aims to give the reader the essential infor-
medical qualification, quacks continue to inject either
mation and the frame of mind to operate as a real physician.
ozone intravenously, a procedure prohibited since 1984 in
An extensive description is available in three recent books
Germany because of the risk of pulmonary embolism and
(9–11).
death, or ozonated saline containing a certain toxic amount
of hypochloric acid. Moreover, a distinguished American
chemist has affirmed the dogma that ‘‘ozone is toxic any What Is Ozone and How Can We Use It?
way you deal with it,’’ reinforcing the concept that ozone
Ozone is normally present as a gas made of three atoms of
should never be used in medicine. This situation has
oxygen with a cyclic structure. The medical generator of
ozone produces it from pure oxygen passing through a high
voltage gradient (5–13 mV) according to the reaction:
Address reprint requests to: Prof. Velio Bocci, Dipartimento di Fisiolo-
gia, Via A. Moro 2, 53100, Siena, Italy; E-mail: [email protected] 3O2 168; 400 cal/2O3

0188-4409/06 $–see front matter. Copyright Ó 2006 IMSS. Published by Elsevier Inc.
doi: 10.1016/j.arcmed.2005.08.006
426 Bocci/ Archives of Medical Research 37 (2006) 425–435

Table 1. Why oxygen ozone therapy has not yet been accepted by does ozone not react and, in a tightly closed glass bottle,
orthodox medicine the ozonated water (useful as a disinfectant) remains active
1. Excessive empiricism for a couple of days; b) on the other hand, at variance with
2. Lack of standardization oxygen, ozone reacts immediately as soon as it is dissolved
3. No precise ozone generator in biological water (physiological saline, plasma, lymph,
4. Lack of solid scientific biological and clinical data urine):
5. Ozone toxicity
6. The problem of charlatans O3 1biomolecules/O2 1O,
7. Lack of regulation and disinterest of health authorities
8. Lack of financial support
where atomic oxygen behaves as a very reactive atom. Con-
9. Skeptical and uninformed scientists
trary to the incorrect belief that ozone penetrates through
the skin and mucosae or enters into the cells, it is empha-
Consequently, we always collect a gas mixture compris- sized that, after the mentioned reaction, ozone does not
ing no less than 95% oxygen and no more than 5% ozone. exist any longer.
Air must be excluded because toxic nitrogen dioxide (N2O2) In order of preference, ozone reacts with polyunsaturat-
will be formed as well as ozone and it is imperative that ed fatty acids (PUFA), antioxidants such as ascorbic and
generators are made of high quality, ozone-resistant materi- uric acids, thiol compounds with -SH groups such as cyste-
als such as stainless steel, neutral glass and Teflon. ine, reduced glutathione (GSH) and albumin. Depending
Ozone is 1.6-fold denser and 10-fold more soluble in upon the ozone dose, carbohydrates, enzymes, DNA and
water (49.0 mL in 100 mL water at 0
C) than oxygen. Al- RNA can also be affected.
though ozone is not a radical molecule, it is the third most All of these compounds act as electron donor and
potent oxidant (E
5 12.076 V) after fluorine and persul- undergo oxidation. c) The main reaction:
fate. Ozone is an unstable gas that cannot be stored and
should be used at once because it has a half-life of R-CH5CH-R0 1O3 1H2 O/R-CH5O1R0 -CH5O1H2 O2
40 min at 20
C.
Ozone is a controversial gas because, although it is very shows the simultaneous formation of one mole of hydrogen
useful in the stratosphere by absorbing dangerous B and C peroxide (included among reactive oxygen species, ROS)
ultraviolet radiations, it is toxic for the pulmonary tract in and of two moles of lipid oxidation products (LOPs) (12).
the troposphere, particularly mixed with carbon monoxide The fundamental ROS molecule is hydrogen peroxide,
(CO), N2O2 and traces of acids as occurs in photochemical which is a non-radical oxidant able to act as an ozone mes-
smog. senger responsible for eliciting several biological and ther-
It must be clear that if we want to use ozone in medicine, apeutic effects (13,14). The concept that ROS are always
we must avoid its toxicity that can be controlled only if we harmful has been widely revised because, in physiological
operate cautiously by 1) using a precise ozone generator amounts, they act as regulators of signal transduction and
equipped with a well-standardized photometer, which allows represent important mediators of host defense and immune
us to determine the ozone concentration in real time, 2) by responses.
collecting a precise gas volume with a defined ozone concen- Presence of traces of Fe11 should be avoided because,
tration. The total dose is simply calculated by multiplying the in the presence of hydrogen peroxide, via the Fenton’s re-
ozone concentration with the gas volume. As an example, if action, they will catalyze the formation of the most reactive
we ozonate a blood volume of 225 mL with 225 mL of gas OH, (hydroxyl radical).
with an ozone concentration of 30 mg/mL, the total dose is
equivalent to 6.75 mg of ozone. 3) We must know the optimal Fe11 1H2 O2 /Fe111 1OH, 1OH2 :
dose for achieving a therapeutic effect without any toxicity. Interestingly, we (15) have also determined the forma-
At variance with blood, the eyes and the lungs are very tion of nitrogen monoxide (NO,) in human endothelial cells
sensitive to ozone because they have minimal antioxidant exposed to ozonated serum. Attention should be paid to the
and neutralizing capabilities and therefore ozone should fact that an excess of ROS can lead to the formation of
never contact these organs. other toxic compounds such as peroxynitrite (O5NOO2)
and hypochlorite anion (ClO2).
Although ROS have a lifetime of less than a second, they
What Is the Behavior and Fate of Ozone after
can damage crucial cell components and, therefore, their
Coming in Contact with Body Fluids?
generation must be precisely calibrated to achieve a biolog-
The essential concepts to bear in mind are the following: ical effect without any damage. This can be achieved by
a) as any other gas, ozone dissolves physically in pure water regulating the ozone dose (ozone concentration as mg/mL
according to Henry’s law in relation to the temperature, of gas per mL of blood in 1:1 ratio) against the antioxidant
pressure and ozone concentration. Only in this situation capacity of blood that can be measured and, if necessary,
 Ozone Therapy Today 427

strengthened by oral administration of antioxidants before effect), too high may elicit a negative effect (malaise, fa-
and throughout ozone therapy. d) LOPs production follows tigue) so that they must be just above the threshold level
peroxidation of PUFA present in the plasma: they are het- to yield an acute, absolutely transitory oxidative stress ca-
erogeneous and can be classified as lipoperoxides (LOO,), pable of triggering biological effects without toxicity.
alkoxyl radicals (LO,), lipohydroperoxides (LOOH), iso- In conclusion, it must be clear to the reader that the
prostanes and alkenals, among which are 4-hydroxy-2,3 ozonation process either happening in blood, or intradiscal
transnonenal (HNE) and malonyldialdehyde (MDA). Radi- or in an intramuscular site represents an acute oxidative
cals and aldehydes are intrinsically toxic and must be gen- stress. However, provided that it is precisely calculated ac-
erated in very low concentrations. They are in vitro far more cording to a judicious ozone dosage, it is not deleterious but
stable (6) than ROS but fortunately, upon blood reinfusion, is actually capable of eliciting a multitude of useful biolog-
they undergo a marked dilution in body fluids, excretion ical responses and, possibly, can reverse a chronic oxidative
(via urine and bile), and metabolism by GSH-transferase stress due to aging, chronic infections, diabetes, atheroscle-
(GSH-Tr) and aldehyde dehydrogenases. Thus, only submi- rosis, degenerative processes and cancer. Indeed, the ozono-
cromolar concentrations can reach all organs, particularly therapeutic act is interpreted as an atoxic but real
bone marrow, liver, central nervous system (CNS), endo- ‘‘therapeutic shock’’ able to restore homeostasis.
crine glands, etc., where they act as signaling molecules
of an ongoing acute oxidative stress (16).
If the stage of the disease is not too far advanced, these
Which Are the Biological Effects Elicited by
molecules can elicit the upregulation of antioxidant en-
ROS and LOPs?
zymes such as superoxide dismutase (SOD), GSH-peroxi-
dases (GSH-Px), GSH-reductase (GSH-Rd) and catalase The ozonation process is therefore characterized by the for-
(CAT). Interestingly, Iles and Liu (17) have just demon- mation of ROS and LOPs acting in two phases. This pro-
strated that HNE, by inducing the expression of glutamate cess happens either ex vivo (as a typical example in the
cysteine ligase, causes an intracellular increase of GSH, blood collected in a glass bottle) or in vivo (after an intra-
which plays a key role in antioxidant defense. Furthermore, muscular injection of ozone) but, while ROS are acting
LOPs induce oxidative stress proteins, one of which is immediately and disappear (early and short-acting messen-
heme-oxygenase I (HO-1 or HSP-32) which, after breaking gers), LOPs, via the circulation, distribute throughout the
down the heme molecule, delivers very useful compounds tissues and eventually only a few molecules bind to cell re-
such as CO and bilirubin (18). Bilirubin is a significant li- ceptors. Their pharmacodynamics allow minimizing their
pophilic antioxidant and a trace of CO cooperates with NO potential toxicity and allows them to become late and
in regulating vasodilation by activating cyclic GMP. Fe21 is long-lasting messengers.
promptly chelated by upregulated ferritin. The induction of Formation of ROS in the plasma is extremely rapid and
HO-1 after an oxidative stress has been described in hun- is accompanied by a transitory and small ozone dose-
dreds of papers as one of the most important antioxidant dependent decrease (ranging from 5 to 25%) of the antiox-
defense and protective enzyme. Moreover, LOPs exert idant capacity. Importantly, this return to normal within
a neuroimmunomodulatory effect highlighted by a feeling 15–20 min owes to the efficient recycling of oxidized com-
of well being reported by patients during ozone therapy. pounds such as dehydroascorbate to ascorbic acid (20).
Although it remains hypothetical, it is possible that H2O2 diffuses easily from the plasma into the cells and
LOP, throughout the treatments, acting as acute oxidative its sudden appearance in the cytoplasm represents the trig-
stressors in the bone marrow microenvironments activate gering stimulus: depending upon the cell type, different
the release of metalloproteinases, of which MP-9 particu- biochemical pathways can be concurrently activated in er-
larly may favor the detachment of staminal cells (11). ythrocytes, leukocytes and platelets resulting in numerous
These cells, once in the blood circulation, may be attracted biological effects. It must be noted that between the plasma
and home at sites where a previous injury (a trauma or an and the cytoplasm compartments there is a gradient and the
ischemic-degenerative event) has taken place. The potential intracellular H2O2 concentration is only about 1/10 of the
relevance of such an event would have a huge practical im- plasmatic one (21). The rapid reduction to water is operated
portance and will avoid the unnatural, costly and scarcely by the high concentration of GSH, CAT and GSH-Px; none-
effective practice of the bone marrow collection with the theless, H2O2 must be above the threshold concentration for
need of the successive and uncertain reinfusion (19). activating several biochemical pathways.
It is emphasized that submicromolar LOPs levels can be Let us now examine how hydrogen peroxide, now uni-
stimulatory and beneficial, whereas high levels can be tox- versally recognized as one of the main intracellular signal-
ic. This conclusion, based on many experimental data (16), ling molecules (13), acts on the different blood cells. The
reinforces the concept that optimal ozone concentrations mass of erythrocytes mops up the bulk of hydrogen perox-
are critical for achieving a therapeutic result: too low con- ide: GSH is promptly oxidized to GSSG and the cell, ex-
centrations are practically useless (at best elicit a placebo tremely sensitive to the reduction of the GSH/GSSG
428 Bocci/ Archives of Medical Research 37 (2006) 425–435

ratio, immediately corrects the unbalance by either extrud- During ozonation of blood, particularly if it is anticoagu-
ing GSSG or reducing it with GSH-Rd at the expense of lated with heparin, we have noted an ozone dose-dependent
ascorbate or of the reduced nicotinamide adenine dinucleo- increase of activation of platelets (8,26) with a consequent
tide phosphate (NADPH), which serves as a crucial electron release of typical growth factors, which will enhance the
donor. Next, the oxidized NADP is reduced after the activa- healing of chronic ulcers in ischemic patients. Whenever
tion of the pentose phosphate pathway, of which glucose-6- possible, the use of heparin as an anticoagulant is preferable
phosphate dehydrogenase (G-6PD) is the key enzyme. We to sodium citrate because, by not chelating plasmatic Ca11,
have determined a small but significant increase of ATP for- it reinforces biochemical and electric events.
mation (10,11), but whether this is due to the activation of During reinfusion of the ozonated blood into the donor,
the pentose cycle or to phosphofructokinase or to both re- the vast expanse of the endothelial cells will be activated by
mains to be clarified. Moreover, for a brief period the rein- LOPs, resulting in an increased production of NO, plasma
fused erythrocytes enhance the delivery of oxygen into S-nitrosothiols and S-nitrosohemoglobin (15,27). Whereas
ischemic tissues because of a shift to the right of the oxy- NO has a half-life of less than 1 sec, protein-bound-NO
gen–hemoglobin dissociation curve, due either to a slight can exert vasodilation also at distant ischemic vascular sites
decrease of intracellular pH (Bohr effect) or/and an increase with relevant therapeutic effect.
of 2,3-diphosphoglycerate (2,3-DPG) levels. Obviously, Moreover, on the basis of the phenomenon of ozone tol-
one AHT treatment has a minimal effect and we need erance that says the exposure of an organism to a low level
to ozonate at least 2.5–4 L of blood within a period of of an agent, harmful at high levels, induces an adaptive and
30–60 days. During this period, LOPs act as repeated stres- beneficial response (28,29), we have postulated that LOPs,
sors on the bone marrow and these frequent stimuli cause by acting as long-distance messengers, can transmit to all
the adaptation to the ozone stress during erythrogenesis organs the information of an acute oxidative stress
with upregulation of antioxidant enzymes. As a conse- (10,11). The bone marrow is particularly relevant because
quence, a patient with chronic limb ischemia undergoing it can upregulate antioxidant enzymes during erythrogene-
ozone therapy can have a clinical improvement due to the sis and allows the release of staminal cells for possibly re-
formation of successive cohorts of erythrocytes progres- generating infarcted organs. Moreover, the stimulation of
sively more capable of delivering oxygen to his/her ische- the endocrine and central nervous systems may help to un-
mic tissues. However, the final improvement is also due derstand why most patients during prolonged ozone therapy
to the localized release of NO, CO and growth factors re- report a feeling of euphoria and wellness, probably due to
leased from platelets and endothelial cells. an improved metabolism as well as to an enhanced hormon-
Although ozone is one of the most potent disinfectants, al or neurotransmitter release.
it cannot inactivate bacteria, viruses and fungi in vivo The paradoxical concept that ozone eventually induces
because, paradoxically, the pathogens are well protected, an antioxidant response capable of reversing a chronic ox-
particularly inside the cells, by the powerful antioxidant idative stress is common in the animal and vegetal kingdom
system. Thus, as I proposed a long time ago (22,23), ozone and there is good experimental evidence (30–34) that this
acts as a mild enhancer of the immune system by activating phenomenon is present in the animal and vegetal kingdom.
neutrophils and stimulating the synthesis of some cytokines Moreover, it is already supported by our findings of an in-
(2,5–7). Once again, the crucial messenger is hydrogen per- creased level of antioxidant enzymes and HO-1 during
oxide, which after entering into the cytoplasm of blood ozone therapy (10,11). It also suggests that a judicious
mononuclear cells (BMC) by oxidizing selected cysteines, use of ozone, in spite of acting as an oxidant, enhances
activates a tyrosine kinase, which then phosphorylates the the antioxidant capacity, which represents the critical factor
transcription factor nuclear factor kB (24), allowing the re- for overcoming chronic viral infections, ischemia and cell
lease of a heterodimer (p501p65). This complex moves on degeneration.
to the nucleus and switches on some hundred genes eventu-
ally responsible for causing the synthesis of several pro-
teins, among which are the acute-phase reactants and
Which Are the Routes of Ozone Administration?
numerous interleukins. In the past, we have measured the
release of several cytokines from ozonated blood upon Table 2 shows that ozone can be administered with great
in vitro incubation (2–7). Once the ozonated leukocytes re- flexibility but it should not be injected intravenously as
turn to the circulation, they home in lymphoid microenvir- a gas because of the risk of provoking oxygen embolism,
onments and successively release cytokines acting in given the fact that the gas mixture contains always no less
a paracrine fashion on neighboring cells with a possible re- than 95% oxygen.
activation of a depressed immune system (25). This pro- So far the most advanced and reliable approach has been
cess, described as the physiological cytokine response, is the major ozonated AHT because, on the basis of the pa-
part of the innate immune system and helps us to survive tient’s body weight, a predetermined volume of blood
in a hostile environment. (200–270 mL) can be exposed to an equal volume of gas
 Ozone Therapy Today 429

Table 2. Routes of ozone administration diseases superior to those achieved by conventional medi-
cine. Moreover, the therapeutic modalities, until now re-
Parenteral
stricted to major AHT and to the empirical and imprecise
Intravenous, intra-arterial,a intramuscular, subcutaneous, intraperitoneal, rectal insufflation of gas (11), have been extended: they in-
intrapleural, intra-articular, periarticular, myofascial, intradiscal, clude the quasi-total body exposure to O2–O3 (35) and the
intraforaminal, intralesionalb
extracorporeal blood circulation against O2–O3 (36). The
Topical or locoregional
Nasal,c tubal,c auricular, oral,c vaginal, urethral and intrabladder, rectal, latter procedure is rather invasive because blood collected
cutaneous, dental from a vein circulates through an ozone-resistant gas ex-
changer and, with the help of a peristaltic pump, returns
a
No longer used for limb ischemia. Hepatic metastasis could be embolized to the circulation via a contralateral vein. On the other
via the hepatic artery.
b hand, the partial cutaneous exposure to oxygen-ozone does
Intratumoral or via a fistula.
c
To be performed during 30–40 sec apnea. not need any venous puncture and, owing to the vast ex-
panse of the skin, allows a generalized and beneficial effect.
Clearly, today we can select the most suitable method for
(O2–O3) in a stoichiometric fashion, with the ozone concen- different pathologies, their stage and the patient’s condition.
tration precisely determined. Figure 1 shows a schematic A discussion on its own is needed for the minor AHT,
drawing of the components necessary to perform AHT with which basically consists of withdrawing 5 mL of blood to
an ozone-resistant glass bottle (plastic bags must be be immediately and vigorously mixed for 1 min with an
avoided because they are not ozone resistant and contami- equal volume of O2–O3 at an ozone concentration ranging
nate blood with pthalates and plastic microparticles). between 80 and 100 mg/mL of gas per mL of blood. It
Blood, drawn from a cubital vein via a G19 Butterfly nee- has been extensively described in Bocci (11). The strongly
dle, is rapidly sucked inside the bottle under vacuum via oxidized blood, including the foam, is promptly injected in-
Segment A. Then a precise volume of gas is delivered via to the gluteus muscle without the need of any anesthetic. As
segment B. With gentle mixing to avoid foaming, ozonation an unspecific immunomodulatory approach, I have used
of blood is completed in 5–10 min and the ozonated blood this treatment since 1953 and, during the last two decades,
is reinfused, via suitable tubing with blood filter, into the several ozone therapists have successfully treated herpetic
donor in about 15 min. This simple, inexpensive (all the infections (for review, see Reference 11). I have speculated
necessary disposable material costs about 12 US$) proce- that blood infiltrated into the muscular tissue will undergo
dure has already yielded therapeutic results in vascular coagulation due to platelet and prothrombin activation.

Figure 1. Schematic drawing of the components necessary to perform the ozonated autohemotherapy with an ozone-resistant glass bottle under vacuum.
430 Bocci/ Archives of Medical Research 37 (2006) 425–435

Although patients rarely report a slight swelling and pain at stress (33) and of activating regulatory T cells for downre-
the injection site, a mild sterile inflammatory reaction may gulating a chronic inflammation. In conclusion, while I am
take place with infiltration of monocytes and neutrophils not using this variant, I systematically couple the major and
scavenging denatured proteins, lysed erythrocytes and apop- minor AHT as above described in all patients because I
totic cells. If plama contains some free virions (HCV, HBV, have noticed a potentiation of the biological and therapeutic
HHV, HIV and so on), these will be inactivated by the high effects. My opinion is that only by using a double-focused
ozone concentration and may act as an autovaccine. At the approach (it is less expensive than the variant minor AHT),
same time a moderate release of cytokines will modulate able to simultaneously expand the interaction of ozonated
the physiological response (25), and the abundance of heme messengers with both blood and muscular tissue, one can
will upregulate the synthesis of both antioxidant enzymes achieve a more rapid and intense therapeutic efficacy.
and oxidative stress proteins, particularly of heme oxygen- On the basis of experimental data obtained during the
ase I. It is wonderful that such a simple and autologous last decade (3–11) and on the average antioxidant capacity
treatment can act as a powerful enhancer of several biolog- of human blood, we have determined the so-called ‘thera-
ical responses. peutic window,’ that is the range of ozone concentrations
A variant and unnecessarily complicated procedure (expressed as mg/mL of gas per mL of blood) within which
proposed in the 1990s consists of treating a similarly small ozone can exert therapeutic effects without toxicity with re-
volume of citrated blood with ozone, ultraviolet light (obvi- gard to major AHT. The range is surprisingly wide: 10–15
ously generating more ozone and ROS) and heat (42.5
C) mg/mL as a minimum and 80 mg/mL as a maximum. Above
for 3 min. To my knowledge, without clarifying the ratio- 90 mg/mL, an incipient hemolysis (4–5%) warns about tox-
nale of using three physicochemical stresses, this method icity. The threshold level varies between 15 and 20 mg/mL,
appears superfluous because ozone, as an oxidizer, is more depending upon the individual antioxidant capacity. The
than enough and the addition of other stresses makes the in- scheme presented in Figure 2 is meant to illustrate the
terpretation of the response very difficult. A first pilot study breadth of action expressed by the ozonated blood through-
by Garber et al. (37) testing this technique in HIV patients out the whole organism.
was badly conceived and showed neither toxicity nor effica- It is clear that the ozone oxidative activity is efficiently
cy, but it has amply discredited the use of ozone. This ap- counteracted by the wealth of plasmatic and intracellular
proach has been subsequently used in patients with either antioxidants so that an ozone concentration of 5–10 mg/mL
vasculitis (38) or advanced chronic heart failure (39). As per mL of blood is practically neutralized: only a trace
might be expected, two biological studies (40,41) have of ROS and LOPs become detectable and therefore, at this
shown the possibility of controlling a chronic oxidative very low level of ozonation, AHT may only have a placebo

Figure 2. Ozonated blood, after reinfusion into the donor patient, is distributed throughout the whole organism. Erythrocytes continue to circulate in the
vascular system delivering more oxygen into ischemic areas while leukocytes, migrated through post-capillary venules into various organs, slowly induce
an immune response. Platelets will release their hormonal contents into the blood and will disappear. The reinfused LOPs undergo dilution into about 3
L plasma and 9–11 L interstitial fluid but will deliver the message of an acute oxidative stress to the whole body.
 Ozone Therapy Today 431

effect. As we are particularly conscious of ozone toxicity, Osteomyelitis, pleural empyema, peritonitis, abscesses with
we always apply the strategy ‘‘start low go slow’’ and, de- fistulae, bed sores, chronic ulcers, diabetic foot, burns,
pending on the stage of the disease and the patient’s con- insect and jellyfish stings, infected wounds, onychomycosis
dition, we usually scale up the concentrations from 15, and candidiasis. These infections, often supported by
then 20, 30 and 40 mg/mL, and more when necessary, dur- antibiotic-resistant bacteria, like methicillin-resistant
ing the 1st, 2nd, 3rd and 4th weeks, respectively. By using Staphyloccocus aureus and poor penetration of antibiotics
this strategy, after many thousands of autotransfusions, we into infected areas, are responsible for too many cases of
have never recorded any acute or chronic toxicity. The ve- death occurring in hospitals of even the most advanced
nous puncture is usually well tolerated because it is per- countries. In such cases, ozonated AHT associated with
formed with a G19 Butterfly needle (quite suitable for the topical application of ozonated olive or sunflower oils
withdrawing blood into the glass bottle under vacuum) allows a rapid disinfection and enhances healing tremen-
that remains inserted throughout the 35–40 min treatment. dously. Unfortunately, the use of ozonated oils is hardly
However, a small percentage of women have a very poor known and a detailed description of their preparation, appli-
venous access: in this case we can select one of the fol- cation and results is reported in my most recent book (11).
lowing three options: rectal insufflation of gas, body expo- It is most interesting that ozone, an unstable gas, can be sta-
sure to gas, or the slow infusion into a visible vein on the bly trapped as an ozonide between a double bond of a
hand dorsum, via a G25–27 needle, of an isotonic glucose PUFA: dðCH2 Þ7 dO3 dðCH2 Þ7 CH3 . When the ozonated
solution containing a final concentration of 0.03–0.06% oil is layered over the ulcer’s exudate at the oil2water
(8.8–17.6 mM) hydrogen peroxide (11,14). This last ap- interface, the ozone moves slowly into the water and, by
proach cannot be as effective as the classical ozonated reacting with biomolecules, generates a steady flow of
AHT, but it is useful. We absolutely discourage the use H2O2. The effects of sterilization and improved oxygena-
of ozonated saline because it contains sodium hypochlo- tion are responsible for the accelerated cicatrization. In
rite and can cause phlebitis (14). comparison to pharmaceutical creams often containing
Normally we perform the treatment bi-weekly but, if useless antibiotics and growth factors, once ozonated oil
necessary, we can do it every day or even three times daily. is known and used, it will be extremely beneficial to mil-
lions of patients. 3) Herpetic infections (HHVI and II),
herpes zoster and papillomavirus infection. The modality
of the intramuscular injection of minor ozonated AHT,
When Ozone Therapy Should Be Used?
used as an autovaccine and associated with the topical
Whenever orthodox medicine fails to solve the medical therapy with ozonated oil, is very effective in preventing
problem, the physician has the duty to fully inform the pa- relapse of herpetic infections. This approach, particularly
tient of all valid options available before beginning ozone when used in combination with the acyclovirs, can cure
therapy. I dislike antagonizing ozone therapy to orthodox herpetic infections in the majority of patients (11). It must
medicine because I believe that there is only good medi- be mentioned that a new vaccine can significantly reduce
cine, which is the one that is able to cure the patient. the incidence of herpes zoster infection and post-herpetic
So far our experience is ample only for chronic limb neuralgia (49). Chronic hepatitis-C and HIV infections,
ischemia (11,42–45), cutaneous chronic ulcers due to is- whenever possible, must be basically treated with either
chemia and diabetes (10,11), and in the atrophic form of PEG-interferon alpha 1 ribavirin or highly active anti-ret-
age-related macular degeneration (ARMD) (11). In chronic roviral therapy, respectively, because these drug combina-
limb ischemia, the orthodox treatment is performed by tions usually lower the viral load rapidly. However, ozone
prostanoid infusions, but the benefit is inferior and far more therapy could be simultaneously performed as a useful ad-
expensive than ozone therapy. Ozone therapy really helps juvant treatment (11). 4) Autoimmune diseases (multiple
about 70% of the ARMD (dry form) patients (11) because sclerosis, rheumatoid arthritis, Crohn’s disease): results
there is no other conventional option. The neovascular, ex- with AHT seem encouraging but are anecdotal. 5) Other
udative (or wet form) must be first treated with photody- chronic ischemic diseases (cerebral and heart ischemia).
namic therapy (46) or radiation (47) or with other Ozone therapy exerts beneficial effects because it can a)
experimental approaches based on blocking the activity of increase oxygen, glucose and ATP delivery within ische-
extracellular vascular endothelial growth factor (48). mic tissues, b) enhance neoangiogenesis and possibly
I will then enumerate other pathologies where ozone facilitate the implantation of bone marrow stem cells,
therapy can be proficiently combined with orthodox thera- which can provide neovascularization and tissue regenera-
pies: 1) Acute and chronic infectious diseases, particularly tion, c) induce the preconditioning phenomena by upregu-
due to antibiotic or chemoresistant bacteria, virus and fungi lating the expression of antioxidant enzymes and heme
(11). Even parasitic infections such as giardiasis and cryp- oxygenase I and d) trigger a neurohumoral response for im-
tosporidiosis have been treated in children by Cuban proving quality of life. Our preliminary study (11) in end-
physicians after administration of ozonated oil (11). 2) stage cardiopathic patients, when either transplantation or
432 Bocci/ Archives of Medical Research 37 (2006) 425–435

surgical revascularization was no longer feasible, has could it potentiate the effect of the cytotoxic drugs but
already shown that ozone therapy combined with the con- by inducing the antioxidant response, it could reduce che-
ventional best medical therapy can improve a gloomy prog- motoxicity (55). It is deplorable that oncologists do not
nosis. 6) Degenerative disorders: AHT helps patients in want to cooperate and want to apply only their protocols.
the early phase of senile dementia. On the other hand, it is Meantime, even if survival is moderately prolonged at the
rarely and minimally useful in diabetic retinopathy, retinitis cost of a poor quality of life, the mortality remains very
pigmentosa, sudden hearing loss and chronic tinnitus. 7) high. Peter Boyle, Director of the International Agency
Pulmonary diseases: emphysema, asthma, chronic obstruc- for Cancer Research in Lyon, France has communicated
tive pulmonary disease (COPD) and acute respiratory dis- that in Europe, in 2004, new cancer cases amounted to
tress syndrome. COPD is becoming the fourth cause of 2.9 million with over 1.7 million deaths. These impressive
death in spite of orthodox therapy based on the inhaled com- numbers indicate that the war on cancer remains wide
bination of corticosteroids plus long-acting b2-agonists and open and that a skeptical attitude against the use of ozone
antibiotics, when necessary (50). Unfortunately these drugs, therapy is unjustified. 11) Orthopedic diseases (the prob-
if prolonging the patient’s life, do not arrest the progression lem of backache): the direct intradiscal injection of oxy-
of the disease. The rationale for using ozone therapy is gen-ozone is a great success in about 75% of patients
briefly based upon a) blood reinfusion, LOPs, present in (11,56) and is one of the few modern techniques able to
low concentrations act on the vast endothelial surface solve the problem of a hernial disc with a mini-invasive
and enhance the release of prostacyclin and NO while re- approach. The indirect procedure that I defined as a
lease of endothelin-1 is depressed (8,15). It is known that ‘‘chemical acupuncture’’ consists of injecting 10-20 mL
the release of NO and S-nitrosothiols represents the phys- of gas into the paravertebral muscle corresponding to
iological mechanism for vasodilation (51,52) and contrasts the metameres of the disc; it is also effective in about
the release of the anion superoxide, which causes vaso- two thirds of patients but, in this case, the mechanism
constriction and deploys negative influences on platelets of action is linked to the activation of the antinociceptor
and endothelial cells. Secondly, the delivery of oxygen system. The gas injection appears also effective in allevi-
in ischemic tissues is enhanced and the progressive in- ating osteoarthrosis and several other joint–tendinitis
crease of antioxidant enzymes and heme oxygenase-1 affections. 12) Chronic fatigue syndrome and fibromyal-
counteracts the chronic oxidative stress, typical of pulmo- gia: AHT has been found beneficial in the majority of pa-
nary diseases. Moreover, the mild stimulation of the im- tients (11). 13) Dentistry and stomatology: ozone has been
mune system helps to contain recurrent and chronic found very useful for treating primary root carious lesions
pulmonary infections. Recently, I have been able to treat (57). Moreover, local application of ozonated oil in aph-
advanced COPD patients with very encouraging results thous ulcers (cold sores) occurring on the tongue, lips
demonstrated by a marked improvement of the respiratory and cheeks of many people allows an extremely rapid
parameters and the walking test (11). 8) Terminal ne- healing and disappearance of pain (11). 14) Emergency
phropathies are progressively worsened by a chronic oxi- situations such as those occurring after extensive trauma,
dative stress not yet controllable by orthodox medicine burns, acute peritonitis and toxic sepsis often lead to mul-
and therefore ozone therapy could stabilize this serious tiple organ failure and death. The combination of the best
dysfunction and improve the quality of life of these pa- orthodox therapy with three to four daily mild ozonated
tients (11). 9) In a similar manner, ozonated AHT com- major AHT can prevent or reduce the worsening of the
bined with topical application of ozonated oil is proving metabolic impairments and reduce mortality. Moreover,
to be very useful in the metabolic syndrome well exempli- patients waiting for organ (particularly heart) transplanta-
fied in patients with type 2 diabetes suffering from chron- tion may improve resistance to infections and immunesup-
ic ulcers with no tendency to heal (11). There is no doubt pression (due to anesthesia and surgery) if they could
that patients prefer ozone therapy to hyperbaric oxygen undergo six to eight major and minor AHTs presumably
and local larval (maggot) therapy (53). Needless to say, during 6–15 days before surgery. During heart transplanta-
we must continue to strictly control the glycemic level. tion, organs such as the brain and kidneys may be dam-
9) Skin diseases (psoriasis, atopic dermatitis): available aged by the ischemia reperfusion syndrome that can be
data seem positive but there are no randomized studies. attenuated by previous adaptation to oxidative stress. A
10) Chemoresistant metastatic cancer; therapy of cancer- similar concept could be adopted for scheduled complex
related fatigue: we have reported (11,54) that a 6-month, operation or application of joint implants. This sort of
biweekly, ozone therapy session in preterminal patients prophylactic ozone therapy, with little effort and expense,
previously heavily treated with chemo- or/and radiothera- may reduce the risk of infections, shorten the hospitaliza-
py does improve their quality of life but is unable to block tion and save money. However, the implementation of the
cancer progression. On the other hand, ozone therapy may prophylactic ozone therapy remains a dream in so far as
be far more useful immediately after surgery, possibly World Health Authorities remain aloof and entangled in
combined with chemo- or/and radiotherapy. Not only economic and political problems.
 Ozone Therapy Today 433

Hyperbaric Oxygen Therapy (HOT) during a lifetime or during a chronic disease, and the calcu-
and Ozone Therapy lated, extremely brief and exogenous oxidative stress that
we induce on blood by using a precise and small ozone
It appears relevant to briefly clarify the validity and scopes
dose. We know that any drug, depending upon its dosage,
of these two different approaches. In the hyperbaric cham-
can be either therapeutic or toxic. The following elementary
ber, the breathing of pure oxygen at 2.6 atmospheres greatly
observation is even more compelling: the normal glucose
increases the solubilization of oxygen in the plasma (about
concentration in the plasma ranges between 0.7 and
5 mL/dL) so that the dissolved oxygen is sufficient to sat-
1 mg/mL and is essential for survival. However, when this
isfy the cellular requirements even in ischemic tissues. That
concentration falls below 0.4 mg/mL, the consequent hypo-
is the reason why patients with chronic limb ischemia, or
glycemic coma can be deadly. On the other hand, if the glu-
with diabetic foot, or ARMD often undergo HOT. Unfortu-
cose concentration remains constantly above 1.3 mg/mL, it
nately, this is only a palliative treatment because, after 2 h,
induces the metabolic syndrome, as is well exemplified by
as soon as the patient comes out of the chamber, hypoxia
the current diabetic epidemic. Thus, the dogma about ozone
resumes in the ischemic areas and the therapeutic effect
toxicity is futile because, after millions of treatments, we
is minimal and temporary. On the other hand, during ozone
have never observed any acute or chronic toxicity. More-
therapy, while the hyperoxygenation of the reinfused blood
over, most of the patients report a feeling of wellness.
has a negligible relevance, the ozone triggers a series of bi-
Needless to say, ozone therapy does not ‘‘cure’’ ARMD
ological mechanisms that lead to normalizing the delivery
or other chronic pathologies but, by performing the mainte-
of oxygen for several days with consequent therapeutic ef-
nance therapy, it does improve the condition and maintain
fects. Two excellent reviews (58–59) clarify the exclusive
a good quality of life. On the other hand, even orthodox
role of HOT in air embolism, decompression sickness,
medicine, with the exception of several infectious diseases
CO-poisoning and clostridial myonecrosis but, regrettably,
thanks to antibiotics, antivirals, antibodies and vaccines
do not examine the relevance of ozone therapy. Indeed, they
and far less frequently of cancer thanks to surgery/chemo-
objectively report that HOT may be useful in chronic limb,
therapy, is unable to "cure" most human diseases such as
heart and cerebral ischemia, autoimmune colitis, sickle cell
atherosclerosis, advanced cancer, diabetes, degenerative,
anemia, chronic osteomyelitis, ARMD, diabetic foot, ther-
metabolic and autoimmune diseases.
mal burns, extensive chronic ulcers and bed sores, but the
We are certainly not blinded by ozone therapy but the
actual evidence is flawed and anecdotal. All of these latter
great strides of molecular biology and gene therapy during
conditions can instead greatly benefit by the use of paren-
the last decade have not yet been paralleled by comparable
teral (and when necessary topical) ozone therapy because
advances in therapeutic innovations and many unforeseen
the multiple mechanisms of action of ozone can correct pa-
difficulties still have to be overcome (61). I do not want
thologies linked to ischemia, infections, delayed healing
to diminish scientific achievements but simply to point
and chronic oxidative stress (reviewed in Reference 11).
out that we are often unable to predict the pitfalls when
In conclusion, both HOT and ozone therapy are important,
new treatments are applied from mice to patients. This is
but it is necessary to understand that their respective field of
probably one reason for the worldwide boom of comple-
application is different and each approach must be used
mentary medicine, not only in underdeveloped countries
profitably only in selected pathologies.
but also in the U.S. Patients, as human beings, are often dis-
appointed by the high-tech therapist. Moreover, conven-
Conclusions and Perspectives
tional therapy often has side effects, and about 55,000
I often ask myself if ozone therapy is obsolete or worth- Americans may have died as a result of taking the now
while being pursued. Our many treated patients answer infamous Vioxx (62,63).
for me and they loudly say that it is very beneficial. The Ozone therapy is capturing increasing attention all over
compliance is excellent and the patients, as soon as the ther- the world, since our studies reported in two books (10,11)
apeutic effect declines, ask for a new cycle. This is an ex- have clarified the main biochemical mechanisms of action
cellent proof that provided we are using judicious ozone and the real possibility of taming ozone toxicity. We now
concentrations, there is neither acute nor chronic toxicity. have the first comprehensive framework for understanding
It has been unfortunate that, in the past, the direct intrave- and recommending ozone therapy in a few diseases as a first
nous injection of the gas, now prohibited, and misuse of choice and in combination with orthodox therapy in many
ozone by incompetent quacks has generated the dogma that others. Indeed, one important characteristic of ozone thera-
ozone is toxic and should not be used in medicine. This py is that it can be experimentally verified both at the bio-
concept is wrong and has also been based first on non-phys- chemical and clinical levels.
iological studies (60) performed in washed erythrocytes, So far, the most advanced and reliable approach has
hence unprotected by the plasma antioxidants and second, been the major ozonated AHT but today we also have other
in not recognizing the profound difference between the technical possibilities and we can select the optimal method
endogenous chronic oxidative stress, occurring every day for different pathologies. As far as chronic diseases are
434 Bocci/ Archives of Medical Research 37 (2006) 425–435

concerned, the problem is that official medicine tends to 4. Bocci V, Luzzi E, Corradeschi F, Paulesu L, Rossi R, Cardaioli E,
treat symptoms rather than the cause(s) of the disease. Be- et al. Studies on the biological effects of ozone: 4. Cytokine produc-
tion and glutathione levels in human erythrocytes. J Biol Regulat
sides the fact that the etiology is too complex or remains Homeost Agent 1993;7:133–138.
obscure, the treatment is often limited and remains unsatis- 5. Bocci V, Luzzi E, Corradeschi F. Studies on the biological effects of
factory. On the other hand, a simple gaseous molecule like ozone: 5. Evaluation of immunological parameters and tolerability
ozone, that probably is even produced in vivo (64), by act- in normal volunteers receiving ambulatory autohaemotherapy. Bio-
ing on many targets, at least in part can recover functional therapy 1994;7:83–90.
6. Bocci V, Valacchi G, Corradeschi F, Aldinucci C, Silvestri S,
activities that have gone astray. We have good reasons to Paccagnini E, et al. Studies on the biological effects of ozone: 7. Gen-
believe that the therapeutic power of ozone therapy consists eration of reactive oxygen species (ROS) after exposure of human
of simultaneously improving circulation and oxygen deliv- blood to ozone. J Biol Regulat Homeost Agent 1998;12:67–75.
ery, in enhancing the release of autacoids, growth factors 7. Bocci V, Valacchi G, Corradeschi F, Fanetti G. Studies on the biolog-
and cytokines and in reducing the endogenous, chronic ox- ical effects of ozone: 8. Effects on the total antioxidant status and on
interleukin-8 production. Mediat Inflamm 1998;7:313–317.
idative stress. In other words, ozone therapy seems to act as 8. Bocci V, Valacchi G, Rossi R, Giustarini D, Paccagnini E, Pucci AM,
a biological response modifier. et al. Studies on the biological effects of ozone: 9. Effects of ozone on
Finally, I cannot omit mentioning some drawbacks. Al- human platelets. Platelets 1999;10:110–116.
though the cost of ozone is very low, it represents an im- 9. Bocci V. Ossigeno-ozono terapia, Comprensione dei meccanismi di
practical drug because it is unstable and cannot be stored azione. Milano: Casa Editrice Ambrosiana;2000.
10. Bocci V. Oxygen-Ozone Therapy. A critical evaluation. Dordrecht,
in any form. However, by using a portable ozone generator The Netherlands: Kluwer Academic Publishers;2002.
we can perform domiciliary AHT treatments, useful for the 11. Bocci V. OZONE. A New Medical Drug. Dordrecht, The Netherlands:
elderly and for those patients with chronic diseases. More- Springer;2005.
over, rectal insufflation of gas can be easily done by the 12. Pryor WA, Squadrito GL, Friedman M. The cascade mechanism to
patient at home, under the ozone therapist’s supervision. explain ozone toxicity: the role of lipid ozonation products. Free Radic
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Topical therapy of chronic ulcers and infectious wounds 13. Halliwell B, Clement MV, Long LH. Hydrogen peroxide in the human
with ozonated oil is very practical and easy because we body. FEBS Lett 2000;486:10–13.
have standard and stable preparations. The last, but certain- 14. Bocci V, Aldinucci C, Bianchi L. The use of hydrogen peroxide as
ly not the least, problem is the lack of financial support for a medical drug. Riv Ital Ossigeno Ozonoterapia 2005;4:30–39.
performing controlled and randomized clinical trials, whose 15. Valacchi G, Bocci V. Studies on the biological effects of ozone: 11.
Release of factors from human endothelial cells. Mediat Inflamm
results are critical and urgently needed to prove the validity 2000;9:271–276.
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bility of convincing the biased opponents of this approach. 17. Iles KE, Liu R-M. Mechanisms of glutamate cysteine ligase (GCL)
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cytokines may have a therapeutic role. Mediat Inflamm 1994;
The English revision and editorial assistance of Mrs. H. Carter is 3:315–321.
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