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There is insufficient reliable information available about the effectiveness of birch.

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INSUFFICIENT RELIABLE EVIDENCE to RATE

• Atopic dermatitis (eczema). It is unclear if topical fig fruit extract is beneficial in children with eczema. Details: Preliminary clinical research in children 4 months to 14 years of age with mild to moderate atopic dermatitis shows that topical application of a cream containing fig fruit extract 8% twice daily for 14 days reduces the severity of symptoms by 56% and itchiness by 64% when compared with baseline. Fig cream is as effective as a cream containing 1% hydrocortisone and more effective than placebo (99958).
• Constipation. It is unclear if oral fig fruit is beneficial for constipation. Details: A small clinical study in adults with constipation shows that taking fig fruit paste 300 grams daily for 8 weeks improves stool consistency by 58%, compared to a 27% improvement with placebo. Fig paste also modestly improves abdominal discomfort; however, it does not affect stool frequency, abdominal pain, effort, or relief (99956).
• Diabetes. It is unclear if oral fig leaf is beneficial for glycemic control in patients with type 1 diabetes. Details: A very small clinical crossover study in adults with type 1 diabetes shows that consuming a tea made from fig leaves modestly reduces postprandial, but not pre-prandial, glucose levels and also reduces insulin requirements when compared with consuming a non-fig tea (12578).
• Vitiligo. Although there has been interest in using oral fig for vitiligo, there is insufficient reliable information about the clinical effects of fig for this condition.
• Warts. It is unclear if topical fig latex is beneficial for warts in adults and children. Details: Preliminary clinical research in adults and children 5 years of age and older shows that applying fig latex directly to a common wart three times daily for at least 4 days is slightly less effective than cryotherapy for producing complete resolution of the wart after 2 weeks (99962).
• Wound healing. Although there has been interest in using topical fig for wound healing, there is insufficient reliable information about the clinical effects of fig for this purpose. More evidence is needed to rate fig for these uses.

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INSUFFICIENT RELIABLE EVIDENCE to RATE

• Iron deficiency anemia. Preliminary clinical research shows that consuming diluted lime juice 500 mL standardized to contain ascorbic acid 25 mg twice daily, 6 days weekly, for 8 months does not improve iron status in iron-deficient women who consume diets high in phytate and non-heme iron (59927).
• Malaria. Preliminary clinical research in children aged 5 months to 13 years with malaria shows that taking lime juice 10-15 mL three times daily in addition to artemisinin combination therapy reduces the time to achieve a reduction in parasite load of at least 75% by approximately 8 hours when compared with using artemisinin combination therapy alone. Also, by 72 hours, more than twice as many children taking lime had achieved complete clearance (100120).
• Sickle cell disease. Preliminary clinical research in infants, children, and adolescents with sickle cell disease shows that taking lime juice 5-15 mL twice daily depending on weight for 6 months, in addition to folic acid, vitamin B complex, and proguanil, reduces the rate of a painful bone crisis by approximately 55% compared with not taking lime. Rates of painful episodes, febrile illness, and hospital admission were reduced by 46%, 47%, and 10%, respectively. There was no benefit on rates of blood transfusion, hepatomegaly, splenomegaly, or jaundice (100121).
• Smoking cessation. Preliminary clinical research in people quitting smoking shows that taking fresh lime as needed for 12 weeks is as effective as nicotine gum for reducing cravings. It also seems to improve continuous abstinence over the last 3 weeks of treatment and after an additional 12 weeks. Abstinence was measured using exhaled carbon monoxide (100131). More evidence is needed to rate lime for these uses.

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POSSIBLY SAFE ...when used orally and appropriately (12). ...when applied topically and appropriately, short-term. Birch bark ointment has been used safely for up to 2 months (35655).

PREGNANCY AND LACTATION:
Insufficient reliable information available; avoid using.

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LIKELY SAFE ...when the fresh or dried fruit is used orally in amounts commonly found in foods.

POSSIBLY SAFE ...when fig fruit paste is consumed orally in amounts of up to 300 grams daily for up to 8 weeks (99956).

POSSIBLY UNSAFE ...when fig leaf decoctions are used topically. Fig leaf contains psoralens (12579,12581). There have been reports of photodermatitis with burn-like lesions and rashes after fig decoctions were applied prior to sun exposure (49962,49968,49973,49975,49981). There is insufficient reliable information available about the safety of fig leaf when used orally.

PREGNANCY AND LACTATION: LIKELY SAFE
when the fresh or dried fruit is used orally in amounts commonly found in foods. There is insufficient reliable information available about the safety of fig leaf or fruit used in medicinal amounts during pregnancy and lactation; avoid use.

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LIKELY SAFE ...when used orally in amounts commonly found in foods. Lime has Generally Recognized As Safe status (GRAS) for use in foods in the US (4912).

POSSIBLY UNSAFE ...when used topically. Lime oil and lime juice contain photosensitizing constituents (12,11019,40894,59925,59928,100125,100126,100129). ...when used intravaginally. Lime juice has caused mild to moderate adverse effects in women using lime juice-soaked tampons or as a douche, especially in concentrations of 20% or more (100127,100128). There is insufficient reliable information available about the safety of lime when used orally in medicinal amounts.

PREGNANCY AND LACTATION:
Insufficient reliable information available; avoid using in amounts greater than those typically found in foods.

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ANTIDIABETES DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Probable •  Level of Evidence = B Theoretically, fig leaf might enhance the blood glucose lowering effects of hypoglycemic drugs.  Details A small clinical study in patients with type 1 diabetes shows that consuming a tea made from fig leaves modestly reduces postprandial glucose levels and insulin requirements (12578).

INSULIN Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Probable •  Level of Evidence = B Fig leaf may enhance the blood glucose lowering effects of insulin.  Details A small clinical study in patients with type 1 diabetes shows that consuming a tea made from fig leaves modestly reduces postprandial glucose levels and insulin requirements (12578).

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General ...Birch and birch pollen can cause allergic reactions (12192,35630,35666,97762,97763,97764).
Topically, birch bark, leaves and sap may cause allergic contact dermatitis (35666,97763).

Dermatologic ...Topically, a case of allergic contact dermatitis has been reported for a 51-year-old man who had been applying a cream containing 5% birch bark extract for 4 months prior to the reaction. The constituent betulin was considered to be the most likely cause (97763). Crushed birch leaves and fresh birch sap may also cause allergic contact dermatitis (35666).

Immunologic ...Birch and birch pollen can cause allergic reactions (12192,35630,35666,97762,97763,97764). Treatment of birch pollen allergy can involve immunotherapy with birch pollen extract given sublingually and by the oral vestibular route (97762).

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General ...Orally, the fresh or dried fig fruit is well tolerated in amounts commonly found in foods. A thorough evaluation of safety outcomes has not been conducted when fig fruit is used orally as medicine.
Topically, fig leaf may cause photodermatitis. There is limited reliable information available about the safety of fig fruit or latex when applied topically.
Serious Adverse Effects (Rare):
Orally: Allergy and, in rare cases, anaphylaxis.
Topically: The fig leaf may cause photodermatitis.

Dermatologic ...Topically, fig leaf might cause photodermatitis. The leaf contains psoralens (12579,12581). Many cases of photodermatitis from fig leaf have been reported (49962,49968,49973,49975,49981). In at least two cases, the burns were serious enough to require hospitalization. Severe anemia and sepsis developed in one patient (49962). Avoid excessive sunlight or ultraviolet light exposure while using products containing fig leaf.

Orally, fig fruit is unlikely to cause photodermatitis (12581).

Immunologic ...Orally, fig fruit can cause allergy and, in rare cases, anaphylaxis (8815,12580). Topically, exposure to fig fruit and leaves can cause contact dermatitis. In some cases, sun exposure can make contact dermatitis worse (12689,99961).

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General ...Orally, lime juice may cause diarrhea or tooth sensitivity and wear, but these adverse effects are rare (59927,100123,100131).
Topically, lime oil and lime juice can cause allergic contact dermatitis (12,4058,100122,100132). Phytophotodermatitis is common when topical exposure to lime is followed by exposure to the sun (40894,59925,59928,100125,100126,100129).
Intravaginally, 20% to 100% lime juice can cause burning, dryness, pain, itching, erythema, edema, or abnormal bleeding (100127).

Dental ...Orally, tooth sensitivity and erosion of teeth have been reported for a woman who had consumed 150-300 mL of lime juice each night before bed for 3 years without brushing her teeth (100123). Tooth sensitivity has also been reported in a clinical trial (100131).

Dermatologic ...Topically, lime can cause phytophotodermatitis hours to days after exposure (40894,59925,59928,100125,100126,100129). Lime phytophotodermatites related to shaking of Mexican beer and the preparation of mojitos or sangria have been reported. Symptoms include redness, swelling, bullae, and later hyperpigmentation (100125,100126,100129).

Gastrointestinal ...Orally, diarrhea has been reported as an adverse effects in a clinical trial (59927).

Genitourinary ...Intravaginally, 20% lime juice has resulted in burning, dryness, erythema, and edema (100127). Higher doses of 25%, 50%, or 100% lime juice were dose-dependently related to vaginal, cervical, or vulval symptoms, especially pain, itching, and abnormal bleeding. The abnormal bleeding was most common in women that had applied 100% lime juice with a tampon. Peeling, erythema, discharge, and tenderness also occurred (100128).

Immunologic ...Topically, lime can rarely contribute to allergic contact dermatitis (4058,100122,100132).

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