DMSO (dimethyl sulfoxide)

Dimethyl Sulfoxide (DMSO)

1. Identity: Chemical Names, Natural Sources, and Common Forms

1.1 Chemical Identity and Nomenclature

Dimethyl sulfoxide (DMSO) is an organosulfur compound with the formula (CH₃)₂S=O. It goes by several names, including methyl sulfoxide, sulfinylbismethane, and dozens of trade names. Additional synonyms include Dimethylis Sulfoxidum, Dimethyl Sulphoxide, Dimethylsulfoxide, Diméthylsulfoxyde, Dimetilsulfóxido, Methyl Sulphoxide, NSC-763, SQ-9453, and Sulfoxyde de Diméthyl.

This colorless liquid is the sulfoxide most widely used commercially. It is an important polar aprotic solvent that dissolves both polar and nonpolar compounds and is miscible in a wide range of organic solvents as well as water. It has a trigonal pyramidal molecular geometry consistent with other three-coordinate S(IV) compounds, with a nonbonded electron pair on the approximately tetrahedral sulfur atom. DMSO comprises a highly polar group and two non-polar domains, which render it soluble in both aqueous solutions and organic solutions.

1.2 Natural Sources and Industrial Production

Dimethyl sulfoxide is a colorless liquid derived as a by-product from wood pulp in the production of paper. DMSO also occurs in the environment as a result of a number of biogenic and anthropogenic production and emission processes. It is an environmentally significant compound because of its use as a substrate by bacteria and its potential role in the biogeochemical cycle of dimethyl sulfide (DMS), a climatically active trace gas.

Dimethyl sulfoxide is produced industrially from dimethyl sulfide, a by-product of the kraft process, by oxidation with oxygen or nitrogen dioxide. Russian chemist Alexander Zaytsev synthesized it by oxidizing dimethyl sulfide, another kraft process byproduct. Zaytsev's synthesis is the basis for the manufacturing process still used today.

1.3 Common Forms and Preparations

DMSO is available as both a prescription medicine and a dietary supplement. It can be taken by mouth, applied to the skin (used topically), or injected into the veins (used intravenously or by IV). DMSO is available without a prescription most often in gel or cream form.

DMSO may be available in industrial-grade and medical-grade forms. Industrial-grade DMSO may contain harmful contaminants that can cause serious side effects. Medical-grade or pharmaceutical (USP)-grade DMSO, on the other hand, has been purified to remove contaminants. The FDA-approved intravesical preparation is known as Rimso-50, a 50% aqueous solution of DMSO.

2. Historical Discovery and Early Medical Use

2.1 Discovery and First Synthesis

Dimethyl sulfoxide was first synthesized in 1866 by the Russian scientist Alexander Zaytsev, who reported his findings in 1867. DMSO was first discovered in the late 19th century as a byproduct of the kraft process for making paper from wood pulp. Its modern use as an industrial solvent began through popularization by Thor Smedslund at the Stepan Chemical Company.

The discovery of dimethyl sulfoxide (DMSO) can be traced back to the nascent German chemical industry in the 19th century, where DMSO was identified during the search for cheaper and more efficient methods for the production of paper from wood pulp. After its initial description, the compound attracted little scientific attention for approximately eight decades.

2.2 Entry Into Medicine: The Stanley Jacob Era

The history of DMSO as a pharmaceutical began in 1961, when Dr. Stanley Jacob was head of the organ transplant program at Oregon Health Sciences University. While investigating the potential for DMSO as a preservative for organs, he discovered that it penetrated the skin quickly and deeply without damaging it, and became intrigued. The first medical report concerning the usage of DMSO as a pharmacological agent was published in 1964.

In a medical setting, Dr. Stanley W. Jacob reported in 1963 that DMSO possesses high cutaneous permeability, acts as a substance carrier during biological membrane penetration, and promotes anti-inflammatory activity and wound healing. Since then, it has received interest as a drug with potential for treating various diseases.

In 1964, DMSO was alleged to have therapeutic value for treating arthritis and diseases or conditions affecting muscles and bones and even mental disorders. Jacob discovered that DMSO effectively penetrates the skin, an observation he first made in a series of nine patients treated for dermatitis using topical DMSO. This prompted a flurry of activity assessing effectiveness for different dermatological conditions with mixed results arising from incompletely understood mechanisms.

From about the mid-20th century, researchers have explored its use as an anti-inflammatory agent. During the late 1960s, initial regulatory attention paused broad investigation; DMSO was again approved for use in humans since its toxic side effect—initially observed in animal studies—was not proven in humans.

2.3 Traditional and Folk Use

DMSO does not have a documented history of traditional or ethnobotanical use in the sense of ancient herbal medicine—it is an industrial by-product identified in the mid-19th century. DMSO has been used as an industrial solvent since the mid-1800s. Its application as a therapeutic agent is entirely a product of 20th-century biomedical research rather than traditional healing systems.

DMSO has since been used for a variety of purposes, such as treatment of musculoskeletal and dermatological diseases, cryopreservation of stem cells, treatment of interstitial cystitis, treatment of increased intracranial pressure, and many more. Over the latter half of the 20th century, particularly in the United States, DMSO acquired a broad reputation as a folk remedy for musculoskeletal pain and was widely self-administered by athletes, a practice that was not based on formally approved indications.

3. Chemistry, Key Constituents, and Mechanisms of Action

3.1 Structural and Physical Chemical Properties

This colorless liquid found immediate application as a polar, aprotic solvent miscible with water and able to dissolve an enormous catalog of polar and nonpolar small molecules. Given its chemical property, DMSO can be a highly efficient solvent for water-insoluble compounds by disruption of the hydrogen bonds. Because it is aprotic, relatively inert, nontoxic, and stable at high temperatures, it is a frequently used solvent for chemical reactions.

3.2 Skin and Membrane Penetration

DMSO readily penetrates and diffuses through biological membranes. When instilled into the bladder, DMSO easily penetrates the mucosa and infiltrates the submucosal and muscular layers, and is absorbed into the bloodstream, where it is rapidly metabolized. DMSO does not cause irreversible damage to membranes during penetration and absorption; rather, it has a protective effect on cells and organs.

DMSO comprises a highly polar group and two non-polar domains, which render it soluble in both aqueous solutions and organic solutions. Furthermore, DMSO can penetrate the cell membrane of both mammalian cells and non-mammalian cells and prevent freeze-thaw injuries to the cells.

3.3 Anti-inflammatory and Analgesic Activity

At low concentrations, DMSO exhibits anti-inflammatory, analgesic, diuretic, vasodilator, anti-platelet aggregation, radio-protective, and muscle-relaxing properties. DMSO is also a vigorous scavenger of hydroxyl free radicals, which may explain its observed beneficial effects on skin rejuvenation and recovery from thermal injury.

DMSO has ex-vivo anti-inflammatory activity using E. coli- and herpes simplex virus-1 (HSV-1)-stimulated whole human blood. Specifically, researchers found that between 0.5%–2%, DMSO significantly suppressed the expression of many pro-inflammatory cytokines/chemokines and prostaglandin E2 (PGE2). However, a significant reduction in monocyte viability was also observed at 2% DMSO, suggesting a narrow window of efficacy. Anti-inflammatory concentrations of DMSO suppressed E. coli-induced ERK1/2, p38, JNK and Akt phosphorylation, suggesting DMSO acts on these signaling pathways to suppress inflammatory cytokine/chemokine production.

3.4 Immunomodulatory Effects

DMSO has been shown to possess immunomodulatory effects, such as immune enhancement, and anti-inflammatory effects in the innate immunity. In addition, DMSO also affects the adaptive immunity by regulating the expression of transcription factors in immune cells.

3.5 Cryoprotective Mechanism

DMSO is used as a cryoprotectant because it decreases osmotic stress and cellular dehydration, and thereby enables stem cells to be stored for several years.

3.6 Metabolism and Excretion

DMSO is mostly excreted through the kidneys, but a small part is excreted through the lungs and liver. Part of the DMSO is transformed to the volatile metabolite dimethyl sulfide, which gives a characteristic garlic- or oyster-like smell when excreted through the lungs. DMSO is a colourless liquid, which is rapidly absorbed when administered dermally or orally.

3.7 Antiviral Properties

In a study examining the effect of DMSO on several parameters of herpes simplex virus (HSV) replication, some surprising results were found. DMSO reduces virion infectivity, inhibits viral DNA replication, and reduces the transcript levels of many HSV-1 genes. These findings suggest that DMSO itself may have a role in antiherpetic activity, diverging from previous thought that it only functioned as a penetrant for antiviral drugs.

4. Scientific Evidence by Area of Use

4.1 Interstitial Cystitis / Bladder Pain Syndrome (IC/BPS)

Regulatory status: In 1978, the Food and Drug Administration (FDA) approved DMSO's use for interstitial cystitis in humans, and recent AUA guidelines also list Rimso-50® (50% DMSO solution) as a treatment for IC/BPS, although the evidence strength is grade C. The American Urological Association Guideline for IC/BPS recommends the intravesical instillation of DMSO as a second-line treatment. However, the European Association of Urology guidelines on chronic pelvic pain do not recommend its use because of insufficient evidence.

Clinical trial data: To evaluate the effectiveness of dimethyl sulfoxide in the treatment of patients with biopsies suggestive of interstitial cystitis, 33 patients underwent a controlled crossover trial. Patients were allocated randomly to receive 50% dimethyl sulfoxide or placebo (saline). The medication was administered intravesically every 2 weeks for 2 sessions of 4 treatments each. Response was assessed urodynamically and symptomatically. When assessed subjectively, 53% of dimethyl sulfoxide-treated patients were markedly improved compared to 18% of the placebo-treated patients. Of the dimethyl sulfoxide group, 93% had objective improvement versus 35% of the placebo group.

A single-institution retrospective observational study was conducted between 2021 and 2022 to evaluate the outcomes of 30 patients with refractory Hunner-type interstitial cystitis (HIC) who received intravesical DMSO therapy according to the approved standardized regimen: administration of DMSO every 2 weeks for a total of 12 weeks. The response rates at 2, 4, 6, 8, 10, and 12 weeks were 36.7%, 43.3%, 53.3%, 60.0%, 70.0%, and 70.0%, respectively.

Evidence appraisal: A systematic review was conducted using the PRISMA checklist to identify published articles involving intravesical DMSO for the treatment of IC. Thirteen cohort studies and three randomized-controlled trials were identified. Response rates relying on subjective measurement scores range from 61 to 95%. No increased efficacy was found with "cocktail" DMSO therapy. Great variation existed in diagnostic criteria, DMSO instillation protocols, and response measurements. The current evidence backing DMSO is a constellation of cohort studies and a single randomized-controlled trial versus placebo. The optimal dose, dwell time, type of IC most likely to respond to DMSO, definitions of success/failure, and the number of treatments are not universally agreed upon.

It has been reported that anti-inflammatory action is one of the major mechanisms inducing therapeutic efficacy of DMSO in IC/BPS patients. Overall, the evidence base for intravesical DMSO in IC/BPS is moderate in quantity but limited in methodological quality—the AUA's grade C designation reflects this.

4.2 Musculoskeletal Pain, Arthritis, and Osteoarthritis

Dermal application of DMSO in medicine is used for relief of pain in the case of arthritis and connective tissue injuries. A clinical study examined the effects of dimethyl sulfoxide in 103 patients with acute and chronic musculoskeletal injuries and inflammations.

Systematic review evidence for OA: A systematic review evaluated existing evidence from randomised controlled trials of dimethyl sulfoxide (DMSO) and methylsulfonylmethane (MSM) in the treatment of OA, including six studies evaluating a total of 681 patients with OA of the knee for DMSO (N = 297 on active treatment). Two of the four DMSO trials reported significant improvement in pain outcomes in the treatment group compared to comparator treatments; however, methodological issues and concerns over optimal dosage and treatment period were highlighted. No definitive conclusion can currently be drawn for either supplement. The findings from all the DMSO studies need to be viewed with caution because of poor methodology including possible unblinding, and questionable treatment duration and dose.

4.3 DMSO as a Transdermal Drug Delivery Vehicle (Penetration Enhancer)

Dimethyl sulfoxide is a molecule with a long history in pharmaceutics and is now well established as a penetration enhancer in topical pharmaceutical formulations. It is currently used for this purpose in diclofenac sodium topical solution (approved in the United States to treat signs and symptoms of osteoarthritis) and idoxuridine topical solution (approved in Europe for the treatment of herpes zoster).

The clinical use of pharmaceutical-grade DMSO as a penetration enhancer is supported by robust data that have accumulated over the past 3 decades demonstrating a favorable safety and tolerability profile. Since DMSO has been shown to have anti-inflammatory and analgesic activity, when used as a topical pharmaceutical excipient, DMSO cannot be viewed as a clinically inert, inactive ingredient for certain localized skin conditions.

4.4 Cryopreservation of Stem Cells and Biological Tissues

Dimethyl sulfoxide has been approved as a pharmaceutical active ingredient, is used as the industry standard biological tissue cryoprotectant, and is a pharmaceutical excipient that enhances the transdermal permeation of various drugs. DMSO can penetrate the cell membrane of both mammalian and non-mammalian cells and prevent freeze-thaw injuries to the cells. Thus, it is frequently used for the cryopreservation of cells and tissues for laboratory and clinical applications.

Clinical and safety research on DMSO concentration in cryopreservation: DMSO is used most commonly for cryopreserving hematopoietic stem cell (HSC) products but can cause infusional toxicities and affect cell viability and engraftment after transplant. A meta-analysis found that reducing the concentration of DMSO from 10% to 5% during cryopreservation of autologous peripheral blood stem cells (PBSCs) may improve cell viability and reduce DMSO-associated adverse effects in patients undergoing autologous hematopoietic cell transplantation (AHCT).

4.5 Amyloidosis

DMSO is taken by mouth, used topically, or given intravenously for the management of amyloidosis and related symptoms. Amyloidosis is a condition in which certain proteins are deposited abnormally in organs and tissues.

Clinical evidence: In one study, investigators examined the role of oral dimethylsulfoxide (DMSO) therapy in 2 patients with primary amyloidosis (AL) and in 2 patients with secondary amyloidosis (AA) to long-standing rheumatoid arthritis. DMSO treatment produced no beneficial effects in the patients with idiopathic amyloidosis. Instead, the patients with secondary amyloidosis experienced a subjective improvement, a decrease of inflammatory activity of the rheumatoid arthritis, and an unequivocal improvement of renal function following 3–6 months of DMSO therapy.

A more substantial retrospective chart review examined oral DMSO in secondary amyloid A amyloidosis. Fifteen secondary amyloid A amyloidosis patients (4 men, 11 women; age 23–70 years) were treated with DMSO between 1995 and 2003. DMSO was administered orally in all patients at a dose of 3–20 g/day. DMSO treatment was successful in 10 (66.7%) of the 15 patients. Eight weeks of DMSO administration improved the renal function and proteinuria in five out of ten renal amyloidosis patients, but had no effect on those patients with severe and/or advanced renal dysfunction. The authors concluded that oral administration of DMSO is an effective treatment for amyloid A amyloidosis, especially for gastrointestinal involvement and the early stage of renal dysfunction. This evidence is limited by retrospective design and small sample size.

4.6 Scleroderma and Connective Tissue Conditions

Cutaneous scleroderma showed potential promise with DMSO treatment, both subjectively and objectively. DMSO has shown promise in the off-label treatment of basal cell carcinoma, pressure ulcers, scleroderma, herpes simplex, cutaneous fungal infections, and amyloidosis. However, the evidence for scleroderma is derived from older, small, non-randomized studies, and no robust modern randomized controlled trials have been conducted to formally establish efficacy.

4.7 Autoimmune Arthritis

A large number of publications have reported a wide range of other biological activities that suggest the potential use of DMSO as a versatile pharmacotherapy agent in a variety of medical conditions ranging from acute musculoskeletal disorders, arthritis, and scleroderma. Despite its widespread use, there is a paucity of data regarding its safety and efficacy as well as its mechanism of action in human cells. Much of the evidence for rheumatoid arthritis and related autoimmune conditions remains at the preclinical or uncontrolled clinical-series level.

4.8 Dermatological Applications

DMSO is presently scarcely used in dermatology, but given its useful properties as a penetration-enhancing solvent excipient and active anti-inflammatory pharmaceutical agent, dimethyl sulfoxide has the potential to be used in a much broader capacity. Its use in dermatology is now limited. It is most commonly used as a keratolytic agent in conjunction with potassium hydroxide (KOH) to enhance visualization of fungal hyphae when ascertaining the presence of dermatophyte infection.

4.9 Intracranial Pressure

DMSO has been used for treatment of musculoskeletal and dermatological diseases, cryopreservation of stem cells, treatment of interstitial cystitis, treatment of increased intracranial pressure, and many more conditions. An early preliminary trial (Marshall et al., 1984) evaluated DMSO for the treatment of intracranial hypertension; however, this work has not been followed by large randomized trials, and this use is not approved or widely practiced.

5. Body Systems and Health Areas Associated With DMSO

• Urinary system: FDA-approved for intravesical treatment of interstitial cystitis/bladder pain syndrome.
• Musculoskeletal system: DMSO is used topically to decrease pain and speed the healing of wounds, burns, and muscle and skeletal injuries. It is also used topically to treat painful conditions such as headache, inflammation, osteoarthritis, rheumatoid arthritis, and severe facial pain called tic douloureux.
• Immune/connective tissue system: DMSO has recently been shown to possess immunomodulatory effects, such as immune enhancement, and anti-inflammatory effects in the innate immunity.
• Hematological/oncology support: DMSO is used mostly for cryopreservation of stem cells, treatment of interstitial cystitis, and as a penetrating vehicle for various drugs.
• Dermatological system: DMSO's unique chemical properties allow for its broad applications in a wide variety of cutaneous challenges.
• Hepatic/metabolic: Animal and preliminary cell-culture research has suggested DMSO may reduce hepatocellular lipid accumulation through autophagy induction; this has not been confirmed in clinical human trials.

6. Dosage Forms and Doses Reported in Clinical Studies

6.1 Intravesical (Bladder Instillation)

The intravesical regimen is to instill 50 mL intravesicularly into the bladder and allow it to remain for 15 minutes; it is repeated every 2 weeks until symptom relief. Intravesical administration involves directly instilling the drug into the bladder using a catheter or syringe using the dimethyl sulfoxide 50% aqueous irrigation solution (RIMSO-50). The solution is allowed 15 minutes to pass before voiding the bladder.

In the Japanese multicenter RCT evaluating IC/BPS, administration was given every 2 weeks for a total of 12 weeks, consistent with the product label and AUA guidance.

6.2 Oral Administration

In the retrospective review of amyloid A amyloidosis, DMSO was administered orally in all patients at a dose of 3–20 g/day. This is a research dose range and is not part of any FDA-approved indication.

6.3 Topical Administration

Topical use, as referenced in some sources, involves 99% DMSO applied on an area twice the size of the affected area with a local cooling pack. In the context of the FDA-approved diclofenac sodium topical solution (e.g., Pennsaid), DMSO is used as the penetration-enhancing vehicle in the approved US formulation for signs and symptoms of osteoarthritis.

6.4 Cryopreservation

The doses of DMSO delivered via intravenous administration of mesenchymal stromal cell (MSC) products were 2.5–30 times lower than the dose of 1 g DMSO/kg typically accepted for hematopoietic stem cell transplantation. The standard cryopreservation concentration for hematopoietic stem cell products has traditionally been 10%, with research now suggesting that reducing the concentration of DMSO from 10% to 5% during cryopreservation may improve cell viability and reduce DMSO-associated adverse effects.

7. Safety Considerations and Drug Interactions

7.1 General Safety Profile

DMSO has a relatively low level of toxicity. A systematic review of 109 studies showed that the most common adverse effects of DMSO were mild, transient gastrointestinal and skin reactions, and that small doses appear to be safe.

Adverse reactions due to DMSO are often mild and transient and do not qualify as serious adverse events. Cardiovascular and respiratory adverse reactions occur mostly when DMSO is administered intravenously, whereas dermatological reactions have a higher incidence when DMSO is administered transdermally.

7.2 Garlic Odor and Taste

DMSO is metabolized to compounds that leave a garlic-like taste in the mouth after DMSO is absorbed by skin. Part of the DMSO is transformed to the volatile metabolite dimethyl sulfide, which gives a characteristic garlic- or oyster-like smell when excreted through the lungs. This is considered a consistent and well-documented adverse effect across all routes of administration.

7.3 Cardiovascular and Respiratory Adverse Events

One study reported 11 cases of transient extrasystoles in 22 patients receiving cryopreserved autologous blood stem cells, monitored with Holter during infusion. Dyspnea was reported in seven studies. A single study reported eight patients with transient shock after stem cell transfusion. Some of these patients developed loss of consciousness and cyanosis but recovered promptly and had no need for additional therapy, whereas the rest of the patients developed severe hypotension or transient dyspnea. Several studies found a correlation between the dose of DMSO used and the incidence of cardiovascular adverse reactions.

7.4 Histamine-Mediated Reactions

DMSO may induce histamine release, which can be the reason for adverse reactions such as flushing, dyspnoea, abdominal cramps, and cardiovascular reactions.

7.5 Ocular Toxicity (Animal Data)

DMSO was shown to cause neural damage in mice. Clinical relevance is not known. In early studies, concern about lens changes in experimental animals led the FDA to temporarily halt broader investigations, though this effect has not been replicated in humans.

7.6 Pregnancy and Lactation

The safety of DMSO if used in pregnancy is not established and it has been shown to cause teratogenic effects in preclinical studies. It is not known whether this drug can cause fetal harm or adversely affect reproductive capacity in humans. Excretion into human milk is unknown and effects in the nursing infant are unknown.

7.7 Risk From Industrial-Grade DMSO

DMSO's potent ability to permeate the skin means it can transport anything dissolved in it directly into the body, including dangerous impurities found in industrial-grade products. Industrial-grade DMSO may contain harmful contaminants that can cause serious side effects. Medical-grade or pharmaceutical (USP)-grade DMSO has been purified to remove contaminants.

7.8 Regulatory Limitations on Non-Approved Use

DMSO is approved for the treatment of interstitial cystitis, when administered intravesically. But it is not approved for over-the-counter use in any form due to insufficient evidence of efficacy and potential toxicities. Widely available in the USA as a solvent, DMSO is FDA-approved only for the treatment of interstitial cystitis and for use as a preservative for organ transplant.

7.9 Known Drug Interactions

Sulindac: concurrent use reduces plasma concentration of dimethyl sulfoxide and has reportedly caused peripheral neuropathy. Verteporfin: concomitant use reduces verteporfin efficacy. DMSO's capacity to enhance transdermal absorption means it has the potential to increase the systemic delivery of any co-applied substance, which is a broadly relevant safety concern even when not captured in formal drug interaction databases.

7.10 Special Populations

The safety profile of DMSO is not established in the pediatric age group. DMSO should be used with caution in urinary tract malignancy, especially bladder cancer, because this drug causes vasodilation.

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