Tips for Managing Graft-Versus-Host Disease (GVHD)

This information will help you care for your body while you have GVHD. It will also help you manage GVHD side effects.

Visit www.mskcc.org/gvhd for information about GVHD, including its types, symptoms, and treatment.

Caring for Your Body While You Have GVHD

The tips in this section can help you care for your body while you have GVHD. Taking good care of your body can help manage GVHD symptoms.

Mouth and teeth

It’s important to have good oral hygiene (take good care of your mouth and teeth). The guidelines below can help. For more tips, read Mouth Care During Your Cancer Treatment.

• Brush your teeth and tongue twice daily. Use a soft or extra-soft toothbrush.
• Floss your teeth gently every day. If you don’t already floss, talk with your dentist about the best way to start.
• Visit a dentist to have your teeth checked and cleaned every 6 months.
• Choose a toothpaste with fluoride. GVHD’s symptoms can raise your risk of tooth decay (such as cavities). Fluoride helps prevent this decay.
• If your teeth are sensitive to toothpaste, choose one without lauryl sulfate. You can see if a toothpaste has this chemical by checking the ingredients list. Tom’s of Maine®, Sensodyne®, and hello® are examples of brands that make toothpastes without lauryl sulfate.
• If your teeth are sensitive to toothpaste, choosing one without menthol (mint) can also help. Kingfisher Natural Toothpaste is an example of a brand that makes toothpastes without mint.
• Choose an alcohol-free mouthwash. Mouthwashes with alcohol can irritate your mouth.
  • You can make your own mouthwash by mixing 1 teaspoon of baking soda and 1 teaspoon of salt in 1 quart (4 cups) of warm water. Rinse your mouth with this mouthwash every 2 hours.
  • If you have sores in your mouth, talk with your dentist before using mouthwash.
• Wear a fragrance-free lip balm that has no vitamins. Reapply it as often as you need to.

It’s also helpful to avoid foods and drinks that may irritate your mouth. Talk with a clinical dietitian nutritionist about foods to choose and which to avoid. In general, avoid foods and drinks that are:

• Acidic. Examples include citrus fruit products (such as orange juice and lemonade) and tomato products (such as pasta sauce, tomato juice, or tomato soup).
• Spicy. Examples include foods made with large amounts of spices such as pepper or chili powder.
• Rough or dry. Examples include dry meats; dry breads, crackers and pretzels; and coarse, raw fruits and vegetables.
• Carbonated (fizzy). Examples include sodas and seltzers.
• Hot. Examples include hot tea or coffee and food straight from the oven or microwave.

Skin

When you’re putting products on your skin, use them in this order:

Washing your hands

It’s important to wash your hands, even if your skin is dry. This helps prevent infections.

• Do not wash your hands for longer than 20 seconds. Use lukewarm water.
• Dry your hands with a clean towel or paper towel, but leave some water on your hands. While they’re a little wet, rub a pea-sized amount of a gentle, fragrance-free moisturizer over them. The brands listed above make gentle moisturizers.
• If you’re using hand sanitizer, use a pea-sized amount of a gentle, fragrance-free moisturizer as soon as the sanitizer dries.

Showering or bathing

• Take a short (less than 20 minutes) bath or shower every other day. Use lukewarm or cool water. If you need to shower daily, keep your showers as short as you can.
• Use a gentle, fragrance-free, moisturizing soap or cleanser. Avoid soaps and cleansers that may be harsh on your skin, such as ones labeled “exfoliating.” Avoid antibacterial soaps and cleansers, including ones made with triclosan.
• Rub a moisturizer into your skin right after you get out of the shower or bath, while your skin is still damp.

Moisturizing your skin

• Choose an ointment or cream, not a lotion. They can be more moisturizing and less irritating than lotion. Check the product’s label to be sure.
• Rub a moisturizer into your skin right after you get out of the shower or bath, while your skin is still damp. Use it again at bedtime.
• Rub petroleum jelly (such as Vaseline®) or the moisturizer your care team recommends into your hands and feet at bedtime. Cover them with cotton gloves or socks. This helps the moisturizer sink into your skin.
• Look at your skin often. When your skin is dry, stop using skin care products (including deodorants and soaps) with alcohol, fragrance, retinoids, or alpha-hydroxy acid (AHA). These things can dry out your skin more. Very dry skin can crack or open. If bacteria gets in, it can lead to an infection.

Protecting your skin from the sun

• Put on sunscreen 20 minutes before you go outside.
• Choose a sunscreen labeled “broad spectrum” with a sun protection factor (SPF) of 30 or higher. Broad-spectrum sunscreens protect against both UVA and UVB rays. Examples include:
  • Vanicream™ Sunscreen Broad Spectrum SPF 50+
  • CeraVe® Hydrating Mineral Sunscreen Broad Spectrum SPF 50
  • Neutrogena® Sensitive Skin Sunscreen Lotion Broad Spectrum SPF 60+
• Wear clothing that protects your skin from the sun, such as long-sleeved shirts, wide-brimmed hats, and sunglasses. If you can, choose clothing that has an ultraviolet protection factor (UPF) of 30 or higher. You can find the UPF on the label of some clothes.
• Stay out of the sun between 10 a.m. and 4 p.m. That’s when the sun’s rays are strongest. Stay inside or in the shade during this time.

Using makeup

• Choose products that are fragrance-free, made for sensitive skin (such as Almay® or Clinique® products), or both.
• It’s best to use products with no more than 10 ingredients, if you can. If a product irritates your skin, this makes it easier to figure out which ingredient your skin reacted to.
• Avoid products that are natural, organic, or unpreserved. They can have germs. You can usually find this information on the label or in the ingredients list.
• Avoid products made with:
  • Botanical (plant-based) ingredients. Arnica, camphor, eucalyptus, ginseng, menthol, tea tree, and wintergreen are examples of botanical ingredients.
  • Talcum powder.
  • Parabens.
• When you first start using makeup after you’re diagnosed with GVHD, try one product at a time every few days. You may have new allergies, even to products you used regularly in the past.
• It’s OK to use makeup to cover a rash if the skin is not broken. Try to only do this when you feel that you need to, such as for social events. Keep in mind that anything you put on your skin may irritate it.
• It’s OK to use concealer to cover dark or light spots. Stronger concealers, such as those made by Make Up For Ever® and MAC Cosmetics®, may work best.
• Throw out your older products and buy new ones regularly. Follow these guidelines.
  • Replace your mascaras every few months.
  • Replace your eyeshadows every year.
  • Replace your foundation every 1½ years.
  • Replace your lipsticks and blushes every 2 years.

Hair and nails

• Wash and condition your hair every 2 to 4 days, depending on your hair type. Use a shampoo and a cream rinse or hair conditioner.
• When you brush or comb your hair, start at the ends. Use a soft-bristle brush, a comb, or your fingers. Wet your fingers with water first.
• Use a nail hardener (such as NailTek® or Sally Hansen® Hard as Nails®) to strengthen your nails. Follow the instructions on the bottle.

Physical activity and exercise

Making exercise and physical activity part of your routine can help prevent and manage GVHD symptoms. Talk with your healthcare provider to plan your exercise routine, especially if you’re new to exercising. Start slowly. Build up the amount of physical activity you do over time.

It’s helpful to include aerobic exercise, resistance exercises, and flexibility exercises in your routine.

• Aerobic exercise makes your heart beat faster. Walking, swimming, jogging, and riding a bike are examples of aerobic exercise.
• Resistance exercises make your muscles stronger. Bodyweight exercises and lifting weights are examples of resistance exercise.
• Flexibility exercises increase your range of motion. Your range of motion is how much you can move a part of your body. Stretching is an example of a flexibility exercise.

Follow the instructions in the resource Stretching Exercises to Help Manage Graft-Versus-Host Disease (GVHD).

Managing GVHD Side Effects

If you have GVHD side effects, the tips in this section may help you manage them. Some of the information may not apply to you. If that’s true, you can skip that section.

If you have questions or need help managing your side effects, contact a member of your care team.

Dry mouth

When your mouth is dry, eating can be hard. Some foods may be hard to chew and swallow. The types of foods you eat can make a difference. Choose foods that have a moist, soft texture and are easy to swallow. Avoid foods that are dry or rough.

Drink plenty of fluids throughout the day. Sipping fluids between bites at meals can make it easier to chew and swallow foods.

Follow the eating and drinking guidelines below if your mouth is dry.

You can also use artificial saliva to help manage dry mouth. You can buy it at your local pharmacy without a prescription. There are many types. If you are not sure which one to use, ask a member of your care team.

A dry mouth may also cause cavities. This is because you’re making less saliva, which protects your teeth against decay. Oral hygiene is very important if your mouth is dry. Follow the instructions in the “Mouth and Teeth” section earlier in this resource.

Mouth pain, such as mucositis or oral ulcers

Mucositis is when the inside of your mouth is sore and inflamed. Oral ulcers are sores in your mouth.

A sore mouth or throat can make eating difficult. The way you eat can make a difference. The following are some tips to avoid irritating your mouth:

• Cook your foods until they’re soft and tender. Use a blender to purée foods.
• Cut your foods into small pieces that are easy for you to chew.
• Rinse your mouth often. Try using a mouth rinse of 1 teaspoon salt, 1 teaspoon baking soda, and 1 quart (4 cups) of warm water. If this does not help, ask your doctor for other mouth rinse recommendations.
• Use a straw to drink. This keeps liquids from touching your sore mouth.
• Brush your teeth and tongue, if your doctor or dentist says it’s OK.
• Drink more liquids to help to keep your mouth clean.

If you have a sore mouth or throat, trying softer, bland, lukewarm, or cool foods can be helpful. Avoid foods that may increase pain, such as dry foods and foods that are spicy, salty, sour, or acidic.

Follow the eating and drinking guidelines below if your mouth or throat is sore.

Taste changes

Your sense of taste is made up of 5 main sensations: salty, sweet, savory, bitter, and sour. Taste changes are different from person to person. The most common changes are having bitter and metallic tastes in your mouth. Sometimes, food may not taste like anything. These changes usually go away after your treatment ends.

Maintaining good oral hygiene is very important to help with taste changes. Follow the instructions in the “Mouth and Teeth” section earlier in this resource.

If your food seems tasteless

• Change the texture of your foods. For example, you may like mashed potatoes more than baked potatoes.
• Change the temperature of your foods. Some foods may taste better cold or at room temperature.
• Choose and make foods that look and smell good to you.
• Use more spices and flavorings, as long as they don’t cause discomfort. For example:
  • Add sauces and condiments (such as soy sauce or ketchup) to your food.
  • Marinate your meats or meat substitutes in salad dressings, fruit juices, or other sauces.
  • Use onion or garlic to flavor your vegetables or meats.
  • Add herbs (such as rosemary, basil, oregano, and mint) to your food.
  • Blend fruit into your milkshakes or yogurt. You can also try mint or coffee-flavored milkshakes.
• Try sour and tart foods. These may help stimulate your taste.
• Try alternating bites of different-tasting foods within a meal. For example, try:
  • Cottage cheese and pineapple.
  • Canned fruit and plain yogurt.
  • Grilled cheese and tomato juice.

If there’s a bitter or metallic taste in your mouth

• Rinse your mouth with water before meals.
• If meats taste bitter, try marinating them in sauces or fruit juices or squeeze lemon juice on them. Only do this if your mouth isn’t sore.
• Include meat substitutes (such as dairy products and beans) for protein.
• Use plastic utensils.
• Try sugar-free mints or gum.
• Avoid canned food items (such as sauces and soups). Choose items in a glass or plastic jar or a box instead.

If foods taste too sweet

• Add some salt to the food.
• Dilute sweet drinks with water.
• If everything tastes sweet, try more acidic foods, such as foods with lemon.

If foods taste or smell different than usual

• Avoid foods with strong odors (smells). Because beef and fish have the strongest odors, try eating poultry, eggs, and dairy products.
• When cooking, open lids of pots and pans away from you so that the smell moves away from you, not towards you.
• Open windows while cooking if the smell of foods cooking bothers you.
• Choose foods that can be eaten cold or at room temperature. Let foods cool down before eating. Room-temperature or cold foods have less smell than warm foods.
• Experiment with different seasonings and food combinations, such as:
  • Adding sauces to foods.
  • Changing the temperature and texture of foods.
• If your mouth isn’t sore, try tart foods (such as lemon wedges or citrus fruits) to stimulate taste.
• Rinse your mouth out before and after you eat.
• Drink small sips of liquid throughout your meals to rinse out the taste of the food.

Losing weight without trying to

You may have good days and bad days when it comes to eating. Large meals can seem overwhelming or unappealing. This can happen when you have a decreased appetite (want to eat less than usual) or early satiety (feel full shortly after you start eating).

The suggestions below can help you get the most from your meals.

• Eat small, frequent meals. For example, have 6 to 8 meals a day instead of 3 main meals.
• Eat every few hours. Don’t wait until you feel hungry.
• Serve smaller food portions on salad plates instead of dinner plates.
• Drink hot chocolate, fruit juices, and nectars that are high in calories.
• Avoid low-calorie drinks (such as water, coffee, tea, and diet drinks). Make Double Milk and milkshakes using the recipes in the “Recipes” section of Eating Well During Your Cancer Treatment.
• Have your favorite snack foods available at home, on the go, and at work.
• Eat your favorite foods at any time of the day. For example, eat breakfast foods (such as pancakes or omelets) for lunch or dinner.
• Include different colors and textures of foods in your meals to make them more appealing.
• Make dining a good experience by eating your meals in a pleasant, relaxing setting with family or friends.
• Make food that smells good (such as baking bread or frying bacon).

Tips for adding more protein to your diet

Your body needs a balance of calories and protein to work best. Your doctor or clinical dietitian nutritionist may tell you to temporarily increase the amount of protein in your diet. The suggestions below will help you do this.

• Eat foods rich in protein, such as chicken, fish, pork, beef, lamb, eggs, milk, cheese, beans, nuts or nut butters, and soy foods.
• Drink Double Milk and use it in recipes that call for milk or water, such as instant pudding, cocoa, omelets, and pancake mixes. To make Double Milk, mix 1 envelope (about 1 cup) of non-fat dry milk powder and 1 quart of whole milk in a blender. Store it in the refrigerator.
• Use Double Milk or ready-to-drink nutritional supplements (such as Ensure®) in hot or cold cereals.
• Add cheese and diced, cooked meats to your omelets or quiches.
• Add unflavored protein powder to creamy soups, mashed potatoes, shakes, and casseroles.
• Snack on cheese or nut butters (such as peanut butter, cashew butter, and almond butter) with crackers.
• Spread nut butters on apples, bananas, or celery.
• Try apple slices with cheese wedges and honey drizzled on top.
• Blend a nut butter into your shakes or smoothies.
• Snack on nuts, sunflower, or pumpkin seeds.
• Add nuts and seeds to breads, muffins, pancakes, cookies, and waffles.
• Try hummus with pita bread. Use hummus as a spread on sandwiches or add a spoonful to your salad.
• Add cooked meats to soups, casseroles, and salads.
• Add wheat germ, ground nuts, chia seeds, or ground flax seeds to cereals, casseroles, and yogurt.
• Choose Greek style yogurts over regular yogurt.
• Eat desserts made with eggs, such as pound cake, puddings, custards, and cheesecakes.
• Add extra eggs or egg whites to custards, puddings, quiches, pancake batter, French toast egg wash, scrambled eggs, or omelets.
• Add grated cheese to sauces, vegetables, and soups. You can also add it to baked or mashed potatoes, casseroles, and salads.
• Add cottage cheese or ricotta cheese to casseroles, pasta dishes, or egg dishes.
• Melt cheese on hamburgers and breaded cutlets.
• Add chickpeas, kidney beans, tofu, hard-boiled eggs, nuts, seeds, and cooked meats or fish to your salads.
• Use pasteurized bone broth for soups and stews.

Tips for adding more calories to your diet

The suggestions below can help you eat more calories. They may seem to go against what you already know about healthy eating. But during your treatment and while you’re healing, the most important thing is that you get enough calories and protein.

• Avoid food and drink labels that say “low-fat,” “non-fat,” or “diet.” For example, use whole milk instead of skim.
• Snack on dried fruits, nuts, or dried seeds. Add them to hot cereals, ice cream, or salads.
• Drink fruit nectars or fruit shakes.
• Add butter, ghee, or oils to potatoes, rice, and pasta. Also add them to cooked vegetables, sandwiches, toast, and hot cereals.
• Add cream cheese or nut butters to toast or bagels or use it as a spread on vegetables.
• Spread cream cheese, jam, and peanut butter on crackers.
• Add jelly or honey to breads and crackers.
• Mix jam with diced fruit and use it as a topping over ice cream or cake.
• Snack on tortilla chips with guacamole or sour cream dips.
• Use high-calorie dressings on salads, baked potatoes, and vegetables (such as green beans or asparagus).
• Add sour cream, coconut milk, half and half, or heavy cream to mashed potatoes, cake, and cookie recipes. You can also add it to pancake batter, sauces, gravies, soups, and casseroles.
• Top baked potatoes with cheese or sour cream.
• Top cakes, waffles, French toast, fruits, puddings, and hot chocolate with whipped cream.
• Make vegetables or pasta with cream sauces or drizzle olive oil over these foods before eating.
• Use mayonnaise, creamy salad dressing, or aioli sauce in salads, sandwiches, and vegetable dips.
• Mix granola with yogurt or put it on top of ice cream or fruits. Use granola in cookie, muffin, and bread batters.
• Top your ice cream or unfrosted cakes with sweetened condensed milk. Combine the condensed milk with peanut butter to add more calories and flavor.
• Add croutons to your salads.
• Include stuffing as a side dish with your meals.
• Drink homemade shakes. Try the shake recipes in the “Recipes” section of Eating Well During Your Cancer Treatment. You can also drink high-calorie, high-protein drinks (such as Carnation® Breakfast Essentials or Ensure®).
• Add avocado to smoothies, soups, salads, omelets, and as a spread on toast.
• Add mayonnaise or sour cream to salads (such as tuna or egg salad) or use it as a spread on sandwiches.

Diarrhea

Diarrhea is loose or watery bowel movements (poop). The following guidelines can help you manage diarrhea.

• Eat small, frequent meals. For example, have 6 to 8 small meals a day instead of 3 main meals.
• Drink at least 8 to 10 (8-ounce) glasses of liquids daily. Avoid foods and drinks with caffeine, such as coffee, chocolate, and cola.
• Avoid foods that are:
  • Greasy
  • Fatty
  • Fried
  • Spicy
  • Sugary
  • Very hot
  • Very cold
• Choose well-cooked, peeled and puréed, or canned fruits and vegetables. Avoid raw fruits and vegetables.
• Avoid vegetables that can cause gas, such as:
  • Broccoli
  • Cauliflower
  • Cabbage
  • Beans
  • Onions
• Choose high-potassium foods and drinks, such as:
  • Fruit juices
  • Fruit nectars
  • Sports drinks
  • Potatoes with the skin
  • Bananas
• Try limiting dairy products, including milk and cheese. Dairy products have lactose. Some people have trouble digesting lactose. If you do, it can cause diarrhea. Try plant-based and lactose-free products (such as nut milks and Lactaid®) instead.

For more information, read Managing Diarrhea.

Nausea and vomiting

Nausea is feeling like you’re going to throw up. Vomiting is throwing up.

If your doctor recommends an antiemetic medication, take it before meals or whenever you need to. An antiemetic is a medication to prevent nausea and vomiting.

Following the eating and drinking tips below can also help you manage nausea and vomiting.

General tips

• Pay attention to the amount of food you eat. Eating too much can stress your stomach.
• Try ready-made foods (such as take-out foods or frozen dinners) to prevent nausea while you cook or make foods. If you need to, ask others to cook for you.
• If food odors make you nauseated:
  • Try cold foods, such as a sandwich or salad. These foods don’t smell as strong as hot foods.
  • Leave the area while hot foods are cooking, if you can.
  • Have someone else plate your food for you.
  • Let your food cool down for a few minutes before eating.
  • Avoid places with strong odors.
• Eat small, frequent meals. This can stop you from getting too full and help you take in more food throughout the day.
• Drink most liquids between your meals. This will help you keep from feeling full too fast or feeling bloated.
• Eat slowly and chew your foods well. Avoid activity right after meals. These things help with digestion.
• Eat your meals in a pleasant setting. For example:
  • Choose a relaxing place that has a comfortable temperature.
  • Eat with friends or family. This may help distract you from your nausea.
  • Wear loose-fitting clothing to stay comfortable.
• If you have nausea in the morning, keep crackers or dry toast next to your bed. Eat them before getting out of bed.
• Avoid eating your favorite foods right before or after treatments. If you’re often nauseous during or after treatments, you may start to dislike these foods.

If nausea is a lasting problem for you, it may be useful to keep a food diary. A food diary is a record of the foods you eat, the time you ate them, and the setting in which you ate them. Record any situations when you became nauseated. Discuss this with your doctor, nurse, or clinical dietitian nutritionist.

More Resources

Blood & Marrow Transplant Information Network (BMT InfoNet)
www.bmtinfonet.org
847-433-3313
888-597-7674 (toll free)
This organization offers emotional support and information about stem cell transplants. It covers all types of stem cell transplants: bone marrow, peripheral blood stem cell, and cord blood transplants.

Look Good Feel Better
www.lookgoodfeelbetter.org
www.lookgoodfeebetter.org/programs/men
800-395-5665 (800-395-LOOK)
This program helps people cope with the effects that cancer treatment can have on their appearance. They also offer weekly sessions led by makeup artists. During these sessions, makeup artists teach makeup techniques, skin and nail care, and hair styling and head-covering options. To register for a class, visit their website or call the number above.