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Say my name
Dr. Ben-a-bo?
Nope.
Ben-nabi?
Nope.
Ben-NO-bo?
Also no.
My surname is tricky to pronounce for some people. I sometimes exaggerate to help patients get it right: “Beh-NAAH-bee-oh.” Almost daily someone will reply: “Oh, you’re Italian!” Well, no actually, my friend Enzo who was born in Sicily and lives in Milan, he’s Italian. I’m just a Rhode Islander who knows some Italian words from his grandmother. Most times though, I just answer: ‘Yep, I’m Italian.” It’s faster.
We use names as a shortcut to identify people. In clinic, it can help to find things in common quickly, similar to asking where you’re from. (East Coast patients seem to love that I’m from New England and if they’re Italian and from New York, well then, we’re paisans right from the start.)
However, using names to guess how someone identifies can be risky. In some instances, it could even be seen as microaggressive, particularly if you got it wrong.
Like most of you I’ll bet, I’m pretty good at pronouncing names – we practice thousands of times! Other than accepting a compliment for getting a tricky one right, such as Radivojevic (I think it’s Ra-di-VOI-ye-vich), I hadn’t thought much about names until I heard a great podcast on the topic. I thought I’d share a couple tips.
First, if you’re not particularly good at names or if you struggle with certain types of names, it’s better to ask than to butcher it. Like learning the wrong way to hit a golf ball, you may never be able to do it properly once you’ve done it wrong. (Trust me, I know from both.)
If I’m feeling confident, I’ll give it a try. But if unsure, I ask the patient to pronounce it for me, then I repeat it to confirm I’ve gotten it correct. Then I say it once or twice more during the visit. Lastly, for the knotty tongue-twisting ones, I write it phonetically in their chart.
It is important because mispronouncing names can alienate patients. It might make them feel like we don’t “know” them or that we don’t care about them. and eliminating ethnic disparities in care. Just think how much harder it might be to convince skeptical patients to take their lisinopril if you can’t even get their names right.
Worse perhaps than getting the pronunciation wrong is to turn the name into an issue. Saying: “Oh, that’s hard to pronounce” could be felt as a subtly racist remark – it’s not hard for them to pronounce of course, only for you. Also, guessing a patient’s nationality from the name is risky. Asking “are you Russian?” to someone from Ukraine or “is that Chinese?” to someone from Vietnam can quickly turn a nice office visit down a road named “Awkward.” It can give the impression that they “all look the same” to you, exactly the type of exclusion we’re trying to eliminate in medicine.
Saying a patient’s name perfectly is rewarding and a super-efficient way to connect. It can make salient the truth that you care about the patient and about his or her story, even if the name happens to be Mrs. Xiomara Winyuwongse Khosrowshahi Sundararajan Ngoc. Go ahead, give it a try.
Want more on how properly pronounce names correctly? You might like this episode of NPR’s Life Kit.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com
Dr. Ben-a-bo?
Nope.
Ben-nabi?
Nope.
Ben-NO-bo?
Also no.
My surname is tricky to pronounce for some people. I sometimes exaggerate to help patients get it right: “Beh-NAAH-bee-oh.” Almost daily someone will reply: “Oh, you’re Italian!” Well, no actually, my friend Enzo who was born in Sicily and lives in Milan, he’s Italian. I’m just a Rhode Islander who knows some Italian words from his grandmother. Most times though, I just answer: ‘Yep, I’m Italian.” It’s faster.
We use names as a shortcut to identify people. In clinic, it can help to find things in common quickly, similar to asking where you’re from. (East Coast patients seem to love that I’m from New England and if they’re Italian and from New York, well then, we’re paisans right from the start.)
However, using names to guess how someone identifies can be risky. In some instances, it could even be seen as microaggressive, particularly if you got it wrong.
Like most of you I’ll bet, I’m pretty good at pronouncing names – we practice thousands of times! Other than accepting a compliment for getting a tricky one right, such as Radivojevic (I think it’s Ra-di-VOI-ye-vich), I hadn’t thought much about names until I heard a great podcast on the topic. I thought I’d share a couple tips.
First, if you’re not particularly good at names or if you struggle with certain types of names, it’s better to ask than to butcher it. Like learning the wrong way to hit a golf ball, you may never be able to do it properly once you’ve done it wrong. (Trust me, I know from both.)
If I’m feeling confident, I’ll give it a try. But if unsure, I ask the patient to pronounce it for me, then I repeat it to confirm I’ve gotten it correct. Then I say it once or twice more during the visit. Lastly, for the knotty tongue-twisting ones, I write it phonetically in their chart.
It is important because mispronouncing names can alienate patients. It might make them feel like we don’t “know” them or that we don’t care about them. and eliminating ethnic disparities in care. Just think how much harder it might be to convince skeptical patients to take their lisinopril if you can’t even get their names right.
Worse perhaps than getting the pronunciation wrong is to turn the name into an issue. Saying: “Oh, that’s hard to pronounce” could be felt as a subtly racist remark – it’s not hard for them to pronounce of course, only for you. Also, guessing a patient’s nationality from the name is risky. Asking “are you Russian?” to someone from Ukraine or “is that Chinese?” to someone from Vietnam can quickly turn a nice office visit down a road named “Awkward.” It can give the impression that they “all look the same” to you, exactly the type of exclusion we’re trying to eliminate in medicine.
Saying a patient’s name perfectly is rewarding and a super-efficient way to connect. It can make salient the truth that you care about the patient and about his or her story, even if the name happens to be Mrs. Xiomara Winyuwongse Khosrowshahi Sundararajan Ngoc. Go ahead, give it a try.
Want more on how properly pronounce names correctly? You might like this episode of NPR’s Life Kit.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com
Dr. Ben-a-bo?
Nope.
Ben-nabi?
Nope.
Ben-NO-bo?
Also no.
My surname is tricky to pronounce for some people. I sometimes exaggerate to help patients get it right: “Beh-NAAH-bee-oh.” Almost daily someone will reply: “Oh, you’re Italian!” Well, no actually, my friend Enzo who was born in Sicily and lives in Milan, he’s Italian. I’m just a Rhode Islander who knows some Italian words from his grandmother. Most times though, I just answer: ‘Yep, I’m Italian.” It’s faster.
We use names as a shortcut to identify people. In clinic, it can help to find things in common quickly, similar to asking where you’re from. (East Coast patients seem to love that I’m from New England and if they’re Italian and from New York, well then, we’re paisans right from the start.)
However, using names to guess how someone identifies can be risky. In some instances, it could even be seen as microaggressive, particularly if you got it wrong.
Like most of you I’ll bet, I’m pretty good at pronouncing names – we practice thousands of times! Other than accepting a compliment for getting a tricky one right, such as Radivojevic (I think it’s Ra-di-VOI-ye-vich), I hadn’t thought much about names until I heard a great podcast on the topic. I thought I’d share a couple tips.
First, if you’re not particularly good at names or if you struggle with certain types of names, it’s better to ask than to butcher it. Like learning the wrong way to hit a golf ball, you may never be able to do it properly once you’ve done it wrong. (Trust me, I know from both.)
If I’m feeling confident, I’ll give it a try. But if unsure, I ask the patient to pronounce it for me, then I repeat it to confirm I’ve gotten it correct. Then I say it once or twice more during the visit. Lastly, for the knotty tongue-twisting ones, I write it phonetically in their chart.
It is important because mispronouncing names can alienate patients. It might make them feel like we don’t “know” them or that we don’t care about them. and eliminating ethnic disparities in care. Just think how much harder it might be to convince skeptical patients to take their lisinopril if you can’t even get their names right.
Worse perhaps than getting the pronunciation wrong is to turn the name into an issue. Saying: “Oh, that’s hard to pronounce” could be felt as a subtly racist remark – it’s not hard for them to pronounce of course, only for you. Also, guessing a patient’s nationality from the name is risky. Asking “are you Russian?” to someone from Ukraine or “is that Chinese?” to someone from Vietnam can quickly turn a nice office visit down a road named “Awkward.” It can give the impression that they “all look the same” to you, exactly the type of exclusion we’re trying to eliminate in medicine.
Saying a patient’s name perfectly is rewarding and a super-efficient way to connect. It can make salient the truth that you care about the patient and about his or her story, even if the name happens to be Mrs. Xiomara Winyuwongse Khosrowshahi Sundararajan Ngoc. Go ahead, give it a try.
Want more on how properly pronounce names correctly? You might like this episode of NPR’s Life Kit.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com
Preventing the psychosocial effects of adult ADHD during the pandemic
As some countries brace for yet another possible surge in the COVID-19 pandemic – particularly among young adults who have not yet been vaccinated – clinicians should remain wary of the cardinal symptoms of adult ADHD.
Research from an Israeli study shows that individuals with unmedicated ADHD are 52% more likely to test positive for the virus.1,2
The symptoms of ADHD, including impulsiveness and inability to follow directions, combined with the tendency to leave adults with ADHD on their own to sort out COVID-19–related protocols – make these individuals susceptible to exposure.
As we know, ADHD is a condition characterized by a pervasive pattern of impulsivity and/or inattention, which greatly reduces organizational capabilities by interfering at the developmental level.3 Other key symptoms include short attention span, hyperactivity, restlessness, difficulty in prioritizing tasks, and an absence of time awareness. Symptom presentation of ADHD is contingent upon the nature of the individual’s overall mental health and etiologic issues that may be traced back to the brain’s development.4
Diagnosing ADHD in adults is relatively difficult, because a formal diagnosis generally requires symptoms to show up between the ages of 6 and 12.5 Also, clinicians can interview parents and family members to assess whether the classical features of ADHD were present in childhood for those suspected of having the condition.
Early vs. late presentation
Among the preschool population, it has been observed that emerging ADHD symptoms may progress with time or remain relatively constant with respect to the activities that children partake in. In some instances, impulsive behavior, especially compared with other symptoms, might be identified quickly by the attentive parent or caregiver. However, when ADHD appears in adulthood, it is possible that prior ADHD symptoms escaped detection – only to be diagnosed later in life because of varying presentations and the increased organizational demands of adulthood.
Meanwhile, diagnosis in adolescence can bring a different set of challenges to the forefront as teenagers face problems with self-management and responsibilities of daily living. These young people must cope with academic6 and social pressures – and a host of new societal expectations.
It is essential to understand how all of those societal factors have affected ADHD and its aspects, especially within the context of COVID-19. The coronavirus has introduced myriad challenges at the global level. Individuals with ADHD exhibit neurodevelopmental and corollary attention deficit issues that make them more susceptible to environmental stressors. Physical distancing practices might aggravate existing behavioral problems.
Distance forced by pandemic offers challenges
Despite the widespread adoption of telemedicine during the pandemic, some physicians think that the delivery of optimal care and the ability to adequately address patients’ health-related concerns have been compromised. Certainly, in the case of addressing the needs of patients with ADHD or related learning disorders, in-person examinations and clinical visits are best.
That is also the case for ADHD patients with comorbid sleep disorders. For those patients, it might be prudent to explore lifestyle changes (for example, improvements in sleep hygiene practices) before resorting to the use of pharmacologic agents such as hypnotics and melatonin. Along similar lines, the European ADHD Guideline Group (EAGG) advises the use of pharmacotherapy after the successful completion of a physical exam; patients already adhering to a treatment plan should continue therapy without interruption. Clinicians caring for patients with adult ADHD have faced a dilemma because treatment breaks increase the likelihood of illnesses resulting from the pandemic. Also, the inability to conduct treatment in person because of the pandemic raises concerns about pharmacotherapy.
The pandemic has affected the course of pediatric care and also has presented new challenges for adolescents as they begin to tackle unique problems related to their health concerns. In prepandemic times, teachers played integral roles in the diagnostic process, because they were able to readily identify children and teenagers with mental and physical challenges. In stark contrast, connecting with students online may not allow teachers to identify skill deficits in young patients or in adults with ADHD.
Furthermore, adults with ADHD and medical comorbidities may be at increased risk of disease exposure directly resulting from an inability to address their social and/or emotional well-being adequately. The social distancing and other mitigation measures advised by public health experts ensure safety and protection but also can present numerous hurdles for children, teenagers, adults – and their respective families.
Individuals with adult ADHD and other psychiatric disorders may downplay their psychological distress7 [for example, sleep dysfunction, issues concerning activities of daily living], and view it as being the natural product of the COVID-19 environment. As a result of their misconceptions, they may avoid increasing their medication dose to control emergent symptoms of hyperactivity and impulsivity, instead opting to manage stress without aid from health care professionals. The absence of patient-provider interactivity and the integration of telemedicine has introduced unnecessary obstacles with respect to medication management and therapy as well as general access to expert advice. It is of utmost importance for clinicians to identify at-risk patients and reeducate the adult ADHD patient on issues concerning medication intake and psychological wellness.
Individuals with developmental disorders may experience numerous setbacks when trying to navigate their environments. The lack of correct feedback, supervision, and guidance may adversely affect adults with ADHD, contributing toward a lack of self-esteem and social awareness.
Individuals with adult ADHD are more likely than are their younger counterparts to have medical comorbidities, such as cardiovascular disease8 and type 2 diabetes,9 so it is crucial to prescribe dietary instructions to patients. Sometimes patients with adult ADHD lack support in the form of acceptance by family and peers, so it is critical for the patient to come to terms with his/her condition and seek professional help, incorporating effective strategies wherever needed to maintain day-to-day functioning.
Other possible comorbidities
There can be risk factors associated with isolation of adults who have depression and/or anxiety, poor eating habits, and maladaptive behaviors. Other adverse health-related issues may include substance use disorder.10 Drug use suppresses developmental growth and may induce ADHD symptom exacerbation. Consistent with Khantzian’s self-medication hypothesis, among individuals with ADHD, including those who lack a formal diagnosis, there is a tendency to gravitate toward illicit substances, in particular, stimulants.11
We also know that adolescents are known to engage in normal risk-taking and social experimentation. Given that, the notion of boundary setting becomes a complicated affair during a pandemic. Adults may no longer be involved in the same types of risk-taking behaviors, but enforced self-isolation coupled with unchecked consumption of various social medial platforms continue to take a toll on personal development. Socialization plays an enormous role in maintaining psychological health, and social media is no substitute for in-person interactions. Such platforms can reduce mental growth opportunities and affect ADHD adults unfavorably.
For instance, it has been reported that women with adult ADHD are more likely to present with negative cognitive biases and symptoms of anxiety as a function of social media use.12,13 As clinicians, we should recommend introducing activities with the aim of enhancing self-acceptance, mindfulness, and the ability to engage in healthy lifestyles. A holistic framework that focuses on psychological wellness and physical fitness will ensure treatment success. Medication management may prove to be a challenge because of differences in dosing, response schedules, and agreed-upon diagnostic criteria used for young patients, compared with those needed for adults.
Treatment strategies
Before the pandemic, researchers were observing an increase globally in the ADHD diagnosis,14 and clinicians have been exploring the efficacy of select medications, sometimes with limited success.15 Stimulant medication, combined with behavioral interventions, is supported by evidenced-based medicine and is the treatment of choice for childhood ADHD.
The stimulant remedy considered to be the most efficacious for adult ADHD is methylphenidate or dextroamphetamine.
However, be sure to proceed with caution and prepare a thorough work-up, because there can be cardiovascular risk factors associated with these medications with a pronounced increase in heart rate and blood pressure.
Stimulant medications are known to increase the risk of stroke or myocardial infarction for individuals with preexisting cardiovascular anomalies or structural anomalies. The American Heart Association no longer recommends a baseline EKG before commencing stimulant therapy with the exception of preexisting cardiac risk. Nonstimulant medications such as atomoxetine are available as alternatives.
The process of finding therapies that will reduce symptoms of ADHD takes considerable time, and individuals may fail to notice improvements, at least initially.
Before prescribing any medicine or therapies, it is important to evaluate for factors that are specific to ADHD and rule out the presence of other learning or developmental disorders, to prevent negative consequences.
Health care professionals can introduce nonspecific interventions as a means of tackling complicated cases of adult ADHD, especially those that coincide with underlying medical conditions (for example, cardiovascular disease, seizure disorders, and/or eating disorders). In such cases, stimulant medications may lead to symptom exacerbation, and the health care professional should carry out a systematic evaluation (risks vs. benefits of drug classes), despite the limitations of online appointments over the course of the pandemic.
Moreover, ADHD symptoms can take on a more severe form within the context of preexisting mood and anxiety disorders. Unfortunately, these comorbidities may have a negative prognostic outcome, too, thereby increasing other health-related risk factors. Psychological interventions can be implemented via online assessments because of recent technological advances worldwide, providing a new level of confidence and social engagement. EEG-assisted biofeedback is an example of new technological modalities that may help improve the overall performance and functionality of individuals with adult ADHD.16 Numerous services and resources are available to patients and their families that can improve mental health and well-being.
Other nonpharmacologic choices also play an instrumental role in bringing harmony and organization into a patient’s life through the use of daily planners, alarms, and to-do lists. In addition, therapists can provide treatment that helps individuals get motivated and reduce their anxiety levels. Behavioral therapies support patient initiatives by increasing their productivity, activity management, and satisfaction. Cognitive-behavioral therapy (CBT), and marriage counseling and family therapy are modalities that may help adults with ADHD change underlying thoughts and perceptions and develop coping skills and self-esteem.
Appropriate to the pandemic situation is another treatment, e-therapy, which includes text-based communication, video calling, and phone calls. It is a low-cost and convenient alternative for people. For some patients, traveling to a particular clinic or counseling center can be difficult, and there is a shortage of counselors worldwide, so it is beneficial to talk with a counselor on a video/phone call or through social media. It is crucial for the ADHD coach to be trained with relevant knowledge to make plans, set goals, and manage a patient’s schedule of activities. For the counselor, sharing tips based on personal experience and making the appropriate suggestions allows adults with ADHD to stay motivated and focus on the task at hand. It should be noted that counselors play an important role in reducing stress levels for those diagnosed with ADHD, allowing patients to lead productive lives and achieve career goals.
Various online support communities can provide patients and their parents with educational resources, to address issues connected to ADHD in a professional manner.17
The road to treatment success
Any delays in treating adults with ADHD can lead to a frustrating situation in which the entire family will be affected. As stated earlier, numerous support groups are available to adults with ADHD, and some of those groups can offer valuable tips about addressing stress management and the diverse roles that parents and family members may play in patient care.18 These groups provide a network for people to exchange ideas and recommend strategies. Online support groups may connect patients directly with key opinion leaders and health care providers.
Individuals with ADHD often experience problems with organization and concentration – especially within the context of the pandemic – and receiving guidance from counselors will provide an opportunity to learn valuable coping strategies and manage symptoms, recognizing and mitigating any mood swings associated with anxiety or depression that emerge alongside their ADHD. Psychotherapy is instrumental in patient care, and individuals with adult ADHD should be taught to acknowledge the role of medications (for example, neglect, divert, or self-medicate). A holistic approach to managing ADHD symptoms is necessary for optimal functioning and independence.
Dr. Aman is a faculty member in the biology department of City Colleges of Chicago. She is a postdoctoral researcher at the International Maternal and Child Health Foundation (IMCHF), Montreal; a fellow, medical staff development, from the American Academy of Medical Management; and a Masters Online Teacher, University of Illinois at Chicago. Dr. Aman disclosed no relevant financial relationships. Dr. Islam is a medical adviser for the IMCHF, Montreal, and is based in New York. He is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Islam disclosed no relevant financial relationships. Dr. Karama is a psychiatrist at the Douglas Mental Health University Institute, Montreal. He is an assistant professor at the department of psychiatry, McGill University, also in Montreal. He has no disclosures. Dr. Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the IMCHF. He has no disclosures.
References
1. J Atten Disord. 2020. doi: 10.1177/1087054720943271.
2. ADDitude Magazine. 2020 Jul 23.
3. Management of ADHD in Adults: What the Science Says. 2007 Oct 9. Guilford Press.
4. N Engl J Med. 2013 Nov 14;369(20):1935-44.
5. J Clin Psychiatry. 2002;63 Suppl 12:29-35.
6. J Atten Dis. 2015 Jan 12. doi: 10.1177/1087054144566076.
7. Psychiatry Res. 2020 Oct;292. doi: 10.1016/j.psychres.2020.113345.
8. Case Rep Cardiol. 2016. doi: 10.1155/2016/2343691.
9. Curr Diab Rep. 2019 Jun 27;19(8):46. doi: 10.1007/s11892-019-1174-x.
10. Curr Psychiatry Rep. 2014 Mar;16(3):436. doi: 10.1007/s/11920-013-0436-6.
11. Current Psychiatry. 2014 Dec;13(12):e3-4.
12. BMC Psychiatry. 2020;20(40). doi: 10.1186/s/12888-020-02707-9.
13. Psychol Addict Behav. 2016 Mar;30(2):252–62.
14. ADDitude Magazine. 2017 Apr 6.
15. Harv Mental Health Letter. 2009 Nov.
16. MGM J Med Sci. 2020 Jul 17(3):161-2.
17. J Child Psychol Psychiatry. 2020 Jul 7.
18. Int J Disaster Risk Reduct. 2020 Dec;51. doi: 10.1016/j.ijdrr.2020.101845.
As some countries brace for yet another possible surge in the COVID-19 pandemic – particularly among young adults who have not yet been vaccinated – clinicians should remain wary of the cardinal symptoms of adult ADHD.
Research from an Israeli study shows that individuals with unmedicated ADHD are 52% more likely to test positive for the virus.1,2
The symptoms of ADHD, including impulsiveness and inability to follow directions, combined with the tendency to leave adults with ADHD on their own to sort out COVID-19–related protocols – make these individuals susceptible to exposure.
As we know, ADHD is a condition characterized by a pervasive pattern of impulsivity and/or inattention, which greatly reduces organizational capabilities by interfering at the developmental level.3 Other key symptoms include short attention span, hyperactivity, restlessness, difficulty in prioritizing tasks, and an absence of time awareness. Symptom presentation of ADHD is contingent upon the nature of the individual’s overall mental health and etiologic issues that may be traced back to the brain’s development.4
Diagnosing ADHD in adults is relatively difficult, because a formal diagnosis generally requires symptoms to show up between the ages of 6 and 12.5 Also, clinicians can interview parents and family members to assess whether the classical features of ADHD were present in childhood for those suspected of having the condition.
Early vs. late presentation
Among the preschool population, it has been observed that emerging ADHD symptoms may progress with time or remain relatively constant with respect to the activities that children partake in. In some instances, impulsive behavior, especially compared with other symptoms, might be identified quickly by the attentive parent or caregiver. However, when ADHD appears in adulthood, it is possible that prior ADHD symptoms escaped detection – only to be diagnosed later in life because of varying presentations and the increased organizational demands of adulthood.
Meanwhile, diagnosis in adolescence can bring a different set of challenges to the forefront as teenagers face problems with self-management and responsibilities of daily living. These young people must cope with academic6 and social pressures – and a host of new societal expectations.
It is essential to understand how all of those societal factors have affected ADHD and its aspects, especially within the context of COVID-19. The coronavirus has introduced myriad challenges at the global level. Individuals with ADHD exhibit neurodevelopmental and corollary attention deficit issues that make them more susceptible to environmental stressors. Physical distancing practices might aggravate existing behavioral problems.
Distance forced by pandemic offers challenges
Despite the widespread adoption of telemedicine during the pandemic, some physicians think that the delivery of optimal care and the ability to adequately address patients’ health-related concerns have been compromised. Certainly, in the case of addressing the needs of patients with ADHD or related learning disorders, in-person examinations and clinical visits are best.
That is also the case for ADHD patients with comorbid sleep disorders. For those patients, it might be prudent to explore lifestyle changes (for example, improvements in sleep hygiene practices) before resorting to the use of pharmacologic agents such as hypnotics and melatonin. Along similar lines, the European ADHD Guideline Group (EAGG) advises the use of pharmacotherapy after the successful completion of a physical exam; patients already adhering to a treatment plan should continue therapy without interruption. Clinicians caring for patients with adult ADHD have faced a dilemma because treatment breaks increase the likelihood of illnesses resulting from the pandemic. Also, the inability to conduct treatment in person because of the pandemic raises concerns about pharmacotherapy.
The pandemic has affected the course of pediatric care and also has presented new challenges for adolescents as they begin to tackle unique problems related to their health concerns. In prepandemic times, teachers played integral roles in the diagnostic process, because they were able to readily identify children and teenagers with mental and physical challenges. In stark contrast, connecting with students online may not allow teachers to identify skill deficits in young patients or in adults with ADHD.
Furthermore, adults with ADHD and medical comorbidities may be at increased risk of disease exposure directly resulting from an inability to address their social and/or emotional well-being adequately. The social distancing and other mitigation measures advised by public health experts ensure safety and protection but also can present numerous hurdles for children, teenagers, adults – and their respective families.
Individuals with adult ADHD and other psychiatric disorders may downplay their psychological distress7 [for example, sleep dysfunction, issues concerning activities of daily living], and view it as being the natural product of the COVID-19 environment. As a result of their misconceptions, they may avoid increasing their medication dose to control emergent symptoms of hyperactivity and impulsivity, instead opting to manage stress without aid from health care professionals. The absence of patient-provider interactivity and the integration of telemedicine has introduced unnecessary obstacles with respect to medication management and therapy as well as general access to expert advice. It is of utmost importance for clinicians to identify at-risk patients and reeducate the adult ADHD patient on issues concerning medication intake and psychological wellness.
Individuals with developmental disorders may experience numerous setbacks when trying to navigate their environments. The lack of correct feedback, supervision, and guidance may adversely affect adults with ADHD, contributing toward a lack of self-esteem and social awareness.
Individuals with adult ADHD are more likely than are their younger counterparts to have medical comorbidities, such as cardiovascular disease8 and type 2 diabetes,9 so it is crucial to prescribe dietary instructions to patients. Sometimes patients with adult ADHD lack support in the form of acceptance by family and peers, so it is critical for the patient to come to terms with his/her condition and seek professional help, incorporating effective strategies wherever needed to maintain day-to-day functioning.
Other possible comorbidities
There can be risk factors associated with isolation of adults who have depression and/or anxiety, poor eating habits, and maladaptive behaviors. Other adverse health-related issues may include substance use disorder.10 Drug use suppresses developmental growth and may induce ADHD symptom exacerbation. Consistent with Khantzian’s self-medication hypothesis, among individuals with ADHD, including those who lack a formal diagnosis, there is a tendency to gravitate toward illicit substances, in particular, stimulants.11
We also know that adolescents are known to engage in normal risk-taking and social experimentation. Given that, the notion of boundary setting becomes a complicated affair during a pandemic. Adults may no longer be involved in the same types of risk-taking behaviors, but enforced self-isolation coupled with unchecked consumption of various social medial platforms continue to take a toll on personal development. Socialization plays an enormous role in maintaining psychological health, and social media is no substitute for in-person interactions. Such platforms can reduce mental growth opportunities and affect ADHD adults unfavorably.
For instance, it has been reported that women with adult ADHD are more likely to present with negative cognitive biases and symptoms of anxiety as a function of social media use.12,13 As clinicians, we should recommend introducing activities with the aim of enhancing self-acceptance, mindfulness, and the ability to engage in healthy lifestyles. A holistic framework that focuses on psychological wellness and physical fitness will ensure treatment success. Medication management may prove to be a challenge because of differences in dosing, response schedules, and agreed-upon diagnostic criteria used for young patients, compared with those needed for adults.
Treatment strategies
Before the pandemic, researchers were observing an increase globally in the ADHD diagnosis,14 and clinicians have been exploring the efficacy of select medications, sometimes with limited success.15 Stimulant medication, combined with behavioral interventions, is supported by evidenced-based medicine and is the treatment of choice for childhood ADHD.
The stimulant remedy considered to be the most efficacious for adult ADHD is methylphenidate or dextroamphetamine.
However, be sure to proceed with caution and prepare a thorough work-up, because there can be cardiovascular risk factors associated with these medications with a pronounced increase in heart rate and blood pressure.
Stimulant medications are known to increase the risk of stroke or myocardial infarction for individuals with preexisting cardiovascular anomalies or structural anomalies. The American Heart Association no longer recommends a baseline EKG before commencing stimulant therapy with the exception of preexisting cardiac risk. Nonstimulant medications such as atomoxetine are available as alternatives.
The process of finding therapies that will reduce symptoms of ADHD takes considerable time, and individuals may fail to notice improvements, at least initially.
Before prescribing any medicine or therapies, it is important to evaluate for factors that are specific to ADHD and rule out the presence of other learning or developmental disorders, to prevent negative consequences.
Health care professionals can introduce nonspecific interventions as a means of tackling complicated cases of adult ADHD, especially those that coincide with underlying medical conditions (for example, cardiovascular disease, seizure disorders, and/or eating disorders). In such cases, stimulant medications may lead to symptom exacerbation, and the health care professional should carry out a systematic evaluation (risks vs. benefits of drug classes), despite the limitations of online appointments over the course of the pandemic.
Moreover, ADHD symptoms can take on a more severe form within the context of preexisting mood and anxiety disorders. Unfortunately, these comorbidities may have a negative prognostic outcome, too, thereby increasing other health-related risk factors. Psychological interventions can be implemented via online assessments because of recent technological advances worldwide, providing a new level of confidence and social engagement. EEG-assisted biofeedback is an example of new technological modalities that may help improve the overall performance and functionality of individuals with adult ADHD.16 Numerous services and resources are available to patients and their families that can improve mental health and well-being.
Other nonpharmacologic choices also play an instrumental role in bringing harmony and organization into a patient’s life through the use of daily planners, alarms, and to-do lists. In addition, therapists can provide treatment that helps individuals get motivated and reduce their anxiety levels. Behavioral therapies support patient initiatives by increasing their productivity, activity management, and satisfaction. Cognitive-behavioral therapy (CBT), and marriage counseling and family therapy are modalities that may help adults with ADHD change underlying thoughts and perceptions and develop coping skills and self-esteem.
Appropriate to the pandemic situation is another treatment, e-therapy, which includes text-based communication, video calling, and phone calls. It is a low-cost and convenient alternative for people. For some patients, traveling to a particular clinic or counseling center can be difficult, and there is a shortage of counselors worldwide, so it is beneficial to talk with a counselor on a video/phone call or through social media. It is crucial for the ADHD coach to be trained with relevant knowledge to make plans, set goals, and manage a patient’s schedule of activities. For the counselor, sharing tips based on personal experience and making the appropriate suggestions allows adults with ADHD to stay motivated and focus on the task at hand. It should be noted that counselors play an important role in reducing stress levels for those diagnosed with ADHD, allowing patients to lead productive lives and achieve career goals.
Various online support communities can provide patients and their parents with educational resources, to address issues connected to ADHD in a professional manner.17
The road to treatment success
Any delays in treating adults with ADHD can lead to a frustrating situation in which the entire family will be affected. As stated earlier, numerous support groups are available to adults with ADHD, and some of those groups can offer valuable tips about addressing stress management and the diverse roles that parents and family members may play in patient care.18 These groups provide a network for people to exchange ideas and recommend strategies. Online support groups may connect patients directly with key opinion leaders and health care providers.
Individuals with ADHD often experience problems with organization and concentration – especially within the context of the pandemic – and receiving guidance from counselors will provide an opportunity to learn valuable coping strategies and manage symptoms, recognizing and mitigating any mood swings associated with anxiety or depression that emerge alongside their ADHD. Psychotherapy is instrumental in patient care, and individuals with adult ADHD should be taught to acknowledge the role of medications (for example, neglect, divert, or self-medicate). A holistic approach to managing ADHD symptoms is necessary for optimal functioning and independence.
Dr. Aman is a faculty member in the biology department of City Colleges of Chicago. She is a postdoctoral researcher at the International Maternal and Child Health Foundation (IMCHF), Montreal; a fellow, medical staff development, from the American Academy of Medical Management; and a Masters Online Teacher, University of Illinois at Chicago. Dr. Aman disclosed no relevant financial relationships. Dr. Islam is a medical adviser for the IMCHF, Montreal, and is based in New York. He is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Islam disclosed no relevant financial relationships. Dr. Karama is a psychiatrist at the Douglas Mental Health University Institute, Montreal. He is an assistant professor at the department of psychiatry, McGill University, also in Montreal. He has no disclosures. Dr. Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the IMCHF. He has no disclosures.
References
1. J Atten Disord. 2020. doi: 10.1177/1087054720943271.
2. ADDitude Magazine. 2020 Jul 23.
3. Management of ADHD in Adults: What the Science Says. 2007 Oct 9. Guilford Press.
4. N Engl J Med. 2013 Nov 14;369(20):1935-44.
5. J Clin Psychiatry. 2002;63 Suppl 12:29-35.
6. J Atten Dis. 2015 Jan 12. doi: 10.1177/1087054144566076.
7. Psychiatry Res. 2020 Oct;292. doi: 10.1016/j.psychres.2020.113345.
8. Case Rep Cardiol. 2016. doi: 10.1155/2016/2343691.
9. Curr Diab Rep. 2019 Jun 27;19(8):46. doi: 10.1007/s11892-019-1174-x.
10. Curr Psychiatry Rep. 2014 Mar;16(3):436. doi: 10.1007/s/11920-013-0436-6.
11. Current Psychiatry. 2014 Dec;13(12):e3-4.
12. BMC Psychiatry. 2020;20(40). doi: 10.1186/s/12888-020-02707-9.
13. Psychol Addict Behav. 2016 Mar;30(2):252–62.
14. ADDitude Magazine. 2017 Apr 6.
15. Harv Mental Health Letter. 2009 Nov.
16. MGM J Med Sci. 2020 Jul 17(3):161-2.
17. J Child Psychol Psychiatry. 2020 Jul 7.
18. Int J Disaster Risk Reduct. 2020 Dec;51. doi: 10.1016/j.ijdrr.2020.101845.
As some countries brace for yet another possible surge in the COVID-19 pandemic – particularly among young adults who have not yet been vaccinated – clinicians should remain wary of the cardinal symptoms of adult ADHD.
Research from an Israeli study shows that individuals with unmedicated ADHD are 52% more likely to test positive for the virus.1,2
The symptoms of ADHD, including impulsiveness and inability to follow directions, combined with the tendency to leave adults with ADHD on their own to sort out COVID-19–related protocols – make these individuals susceptible to exposure.
As we know, ADHD is a condition characterized by a pervasive pattern of impulsivity and/or inattention, which greatly reduces organizational capabilities by interfering at the developmental level.3 Other key symptoms include short attention span, hyperactivity, restlessness, difficulty in prioritizing tasks, and an absence of time awareness. Symptom presentation of ADHD is contingent upon the nature of the individual’s overall mental health and etiologic issues that may be traced back to the brain’s development.4
Diagnosing ADHD in adults is relatively difficult, because a formal diagnosis generally requires symptoms to show up between the ages of 6 and 12.5 Also, clinicians can interview parents and family members to assess whether the classical features of ADHD were present in childhood for those suspected of having the condition.
Early vs. late presentation
Among the preschool population, it has been observed that emerging ADHD symptoms may progress with time or remain relatively constant with respect to the activities that children partake in. In some instances, impulsive behavior, especially compared with other symptoms, might be identified quickly by the attentive parent or caregiver. However, when ADHD appears in adulthood, it is possible that prior ADHD symptoms escaped detection – only to be diagnosed later in life because of varying presentations and the increased organizational demands of adulthood.
Meanwhile, diagnosis in adolescence can bring a different set of challenges to the forefront as teenagers face problems with self-management and responsibilities of daily living. These young people must cope with academic6 and social pressures – and a host of new societal expectations.
It is essential to understand how all of those societal factors have affected ADHD and its aspects, especially within the context of COVID-19. The coronavirus has introduced myriad challenges at the global level. Individuals with ADHD exhibit neurodevelopmental and corollary attention deficit issues that make them more susceptible to environmental stressors. Physical distancing practices might aggravate existing behavioral problems.
Distance forced by pandemic offers challenges
Despite the widespread adoption of telemedicine during the pandemic, some physicians think that the delivery of optimal care and the ability to adequately address patients’ health-related concerns have been compromised. Certainly, in the case of addressing the needs of patients with ADHD or related learning disorders, in-person examinations and clinical visits are best.
That is also the case for ADHD patients with comorbid sleep disorders. For those patients, it might be prudent to explore lifestyle changes (for example, improvements in sleep hygiene practices) before resorting to the use of pharmacologic agents such as hypnotics and melatonin. Along similar lines, the European ADHD Guideline Group (EAGG) advises the use of pharmacotherapy after the successful completion of a physical exam; patients already adhering to a treatment plan should continue therapy without interruption. Clinicians caring for patients with adult ADHD have faced a dilemma because treatment breaks increase the likelihood of illnesses resulting from the pandemic. Also, the inability to conduct treatment in person because of the pandemic raises concerns about pharmacotherapy.
The pandemic has affected the course of pediatric care and also has presented new challenges for adolescents as they begin to tackle unique problems related to their health concerns. In prepandemic times, teachers played integral roles in the diagnostic process, because they were able to readily identify children and teenagers with mental and physical challenges. In stark contrast, connecting with students online may not allow teachers to identify skill deficits in young patients or in adults with ADHD.
Furthermore, adults with ADHD and medical comorbidities may be at increased risk of disease exposure directly resulting from an inability to address their social and/or emotional well-being adequately. The social distancing and other mitigation measures advised by public health experts ensure safety and protection but also can present numerous hurdles for children, teenagers, adults – and their respective families.
Individuals with adult ADHD and other psychiatric disorders may downplay their psychological distress7 [for example, sleep dysfunction, issues concerning activities of daily living], and view it as being the natural product of the COVID-19 environment. As a result of their misconceptions, they may avoid increasing their medication dose to control emergent symptoms of hyperactivity and impulsivity, instead opting to manage stress without aid from health care professionals. The absence of patient-provider interactivity and the integration of telemedicine has introduced unnecessary obstacles with respect to medication management and therapy as well as general access to expert advice. It is of utmost importance for clinicians to identify at-risk patients and reeducate the adult ADHD patient on issues concerning medication intake and psychological wellness.
Individuals with developmental disorders may experience numerous setbacks when trying to navigate their environments. The lack of correct feedback, supervision, and guidance may adversely affect adults with ADHD, contributing toward a lack of self-esteem and social awareness.
Individuals with adult ADHD are more likely than are their younger counterparts to have medical comorbidities, such as cardiovascular disease8 and type 2 diabetes,9 so it is crucial to prescribe dietary instructions to patients. Sometimes patients with adult ADHD lack support in the form of acceptance by family and peers, so it is critical for the patient to come to terms with his/her condition and seek professional help, incorporating effective strategies wherever needed to maintain day-to-day functioning.
Other possible comorbidities
There can be risk factors associated with isolation of adults who have depression and/or anxiety, poor eating habits, and maladaptive behaviors. Other adverse health-related issues may include substance use disorder.10 Drug use suppresses developmental growth and may induce ADHD symptom exacerbation. Consistent with Khantzian’s self-medication hypothesis, among individuals with ADHD, including those who lack a formal diagnosis, there is a tendency to gravitate toward illicit substances, in particular, stimulants.11
We also know that adolescents are known to engage in normal risk-taking and social experimentation. Given that, the notion of boundary setting becomes a complicated affair during a pandemic. Adults may no longer be involved in the same types of risk-taking behaviors, but enforced self-isolation coupled with unchecked consumption of various social medial platforms continue to take a toll on personal development. Socialization plays an enormous role in maintaining psychological health, and social media is no substitute for in-person interactions. Such platforms can reduce mental growth opportunities and affect ADHD adults unfavorably.
For instance, it has been reported that women with adult ADHD are more likely to present with negative cognitive biases and symptoms of anxiety as a function of social media use.12,13 As clinicians, we should recommend introducing activities with the aim of enhancing self-acceptance, mindfulness, and the ability to engage in healthy lifestyles. A holistic framework that focuses on psychological wellness and physical fitness will ensure treatment success. Medication management may prove to be a challenge because of differences in dosing, response schedules, and agreed-upon diagnostic criteria used for young patients, compared with those needed for adults.
Treatment strategies
Before the pandemic, researchers were observing an increase globally in the ADHD diagnosis,14 and clinicians have been exploring the efficacy of select medications, sometimes with limited success.15 Stimulant medication, combined with behavioral interventions, is supported by evidenced-based medicine and is the treatment of choice for childhood ADHD.
The stimulant remedy considered to be the most efficacious for adult ADHD is methylphenidate or dextroamphetamine.
However, be sure to proceed with caution and prepare a thorough work-up, because there can be cardiovascular risk factors associated with these medications with a pronounced increase in heart rate and blood pressure.
Stimulant medications are known to increase the risk of stroke or myocardial infarction for individuals with preexisting cardiovascular anomalies or structural anomalies. The American Heart Association no longer recommends a baseline EKG before commencing stimulant therapy with the exception of preexisting cardiac risk. Nonstimulant medications such as atomoxetine are available as alternatives.
The process of finding therapies that will reduce symptoms of ADHD takes considerable time, and individuals may fail to notice improvements, at least initially.
Before prescribing any medicine or therapies, it is important to evaluate for factors that are specific to ADHD and rule out the presence of other learning or developmental disorders, to prevent negative consequences.
Health care professionals can introduce nonspecific interventions as a means of tackling complicated cases of adult ADHD, especially those that coincide with underlying medical conditions (for example, cardiovascular disease, seizure disorders, and/or eating disorders). In such cases, stimulant medications may lead to symptom exacerbation, and the health care professional should carry out a systematic evaluation (risks vs. benefits of drug classes), despite the limitations of online appointments over the course of the pandemic.
Moreover, ADHD symptoms can take on a more severe form within the context of preexisting mood and anxiety disorders. Unfortunately, these comorbidities may have a negative prognostic outcome, too, thereby increasing other health-related risk factors. Psychological interventions can be implemented via online assessments because of recent technological advances worldwide, providing a new level of confidence and social engagement. EEG-assisted biofeedback is an example of new technological modalities that may help improve the overall performance and functionality of individuals with adult ADHD.16 Numerous services and resources are available to patients and their families that can improve mental health and well-being.
Other nonpharmacologic choices also play an instrumental role in bringing harmony and organization into a patient’s life through the use of daily planners, alarms, and to-do lists. In addition, therapists can provide treatment that helps individuals get motivated and reduce their anxiety levels. Behavioral therapies support patient initiatives by increasing their productivity, activity management, and satisfaction. Cognitive-behavioral therapy (CBT), and marriage counseling and family therapy are modalities that may help adults with ADHD change underlying thoughts and perceptions and develop coping skills and self-esteem.
Appropriate to the pandemic situation is another treatment, e-therapy, which includes text-based communication, video calling, and phone calls. It is a low-cost and convenient alternative for people. For some patients, traveling to a particular clinic or counseling center can be difficult, and there is a shortage of counselors worldwide, so it is beneficial to talk with a counselor on a video/phone call or through social media. It is crucial for the ADHD coach to be trained with relevant knowledge to make plans, set goals, and manage a patient’s schedule of activities. For the counselor, sharing tips based on personal experience and making the appropriate suggestions allows adults with ADHD to stay motivated and focus on the task at hand. It should be noted that counselors play an important role in reducing stress levels for those diagnosed with ADHD, allowing patients to lead productive lives and achieve career goals.
Various online support communities can provide patients and their parents with educational resources, to address issues connected to ADHD in a professional manner.17
The road to treatment success
Any delays in treating adults with ADHD can lead to a frustrating situation in which the entire family will be affected. As stated earlier, numerous support groups are available to adults with ADHD, and some of those groups can offer valuable tips about addressing stress management and the diverse roles that parents and family members may play in patient care.18 These groups provide a network for people to exchange ideas and recommend strategies. Online support groups may connect patients directly with key opinion leaders and health care providers.
Individuals with ADHD often experience problems with organization and concentration – especially within the context of the pandemic – and receiving guidance from counselors will provide an opportunity to learn valuable coping strategies and manage symptoms, recognizing and mitigating any mood swings associated with anxiety or depression that emerge alongside their ADHD. Psychotherapy is instrumental in patient care, and individuals with adult ADHD should be taught to acknowledge the role of medications (for example, neglect, divert, or self-medicate). A holistic approach to managing ADHD symptoms is necessary for optimal functioning and independence.
Dr. Aman is a faculty member in the biology department of City Colleges of Chicago. She is a postdoctoral researcher at the International Maternal and Child Health Foundation (IMCHF), Montreal; a fellow, medical staff development, from the American Academy of Medical Management; and a Masters Online Teacher, University of Illinois at Chicago. Dr. Aman disclosed no relevant financial relationships. Dr. Islam is a medical adviser for the IMCHF, Montreal, and is based in New York. He is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Islam disclosed no relevant financial relationships. Dr. Karama is a psychiatrist at the Douglas Mental Health University Institute, Montreal. He is an assistant professor at the department of psychiatry, McGill University, also in Montreal. He has no disclosures. Dr. Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the IMCHF. He has no disclosures.
References
1. J Atten Disord. 2020. doi: 10.1177/1087054720943271.
2. ADDitude Magazine. 2020 Jul 23.
3. Management of ADHD in Adults: What the Science Says. 2007 Oct 9. Guilford Press.
4. N Engl J Med. 2013 Nov 14;369(20):1935-44.
5. J Clin Psychiatry. 2002;63 Suppl 12:29-35.
6. J Atten Dis. 2015 Jan 12. doi: 10.1177/1087054144566076.
7. Psychiatry Res. 2020 Oct;292. doi: 10.1016/j.psychres.2020.113345.
8. Case Rep Cardiol. 2016. doi: 10.1155/2016/2343691.
9. Curr Diab Rep. 2019 Jun 27;19(8):46. doi: 10.1007/s11892-019-1174-x.
10. Curr Psychiatry Rep. 2014 Mar;16(3):436. doi: 10.1007/s/11920-013-0436-6.
11. Current Psychiatry. 2014 Dec;13(12):e3-4.
12. BMC Psychiatry. 2020;20(40). doi: 10.1186/s/12888-020-02707-9.
13. Psychol Addict Behav. 2016 Mar;30(2):252–62.
14. ADDitude Magazine. 2017 Apr 6.
15. Harv Mental Health Letter. 2009 Nov.
16. MGM J Med Sci. 2020 Jul 17(3):161-2.
17. J Child Psychol Psychiatry. 2020 Jul 7.
18. Int J Disaster Risk Reduct. 2020 Dec;51. doi: 10.1016/j.ijdrr.2020.101845.
Leveraging the microbiome to enhance cancer treatment
Andrea Facciabene, PhD, of the University of Pennsylvania, Philadelphia, and colleagues conducted a preclinical study in which vancomycin enhanced the efficacy of radiotherapy against melanoma and lung cancer. Now, researchers are conducting a clinical trial to determine if vancomycin can have the same effect in patients with non–small cell lung cancer.
Dr. Facciabene reviewed this research at the AACR Virtual Special Conference: Radiation Science and Medicine.
According to Dr. Facciabene, “gut microbiota” includes the more than 1,000 different strains of bacteria living in human intestines. He indicated that the average human has 10 times more bacteria than cells in the body and 150 times more genes in the gut microbiome than in the human genome.
In healthy individuals, the gut microbiota play a key role in intestinal function and digestive processes, modulation of hormones and vitamin secretion, energy extraction from food, and development and maintenance of a balanced immune system.
“Dysbiosis” is the term applied to a change in the composition, diversity, or metabolites of the microbiome from a healthy pattern to one associated with disease. Antibiotic therapy is a classic cause of dysbiosis, and dysbiosis has been implicated in a variety of inflammatory diseases.
The mechanisms by which the gut microbiome could influence systemic immunity is not known but is relevant to cancer therapy response. Augmenting the frequency and durability of response to immune-targeted treatments – potentially by manipulating the influence of gut microbiota on the immune system – could be highly impactful.
Gut microbiota and radiation-induced cell death
Immunogenic cell death – a process by which tumors die and release their intracellular molecular contents – is one of the mechanisms by which radiotherapy kills cancer cells.
Tumor cells succumbing to immunogenic cell death stimulate antigen presenting cells, such as dendritic cells, that engulf tumor antigens and cross-present them to CD8+ cytotoxic T lymphocytes. This process culminates in the generation of a specific immune response capable of killing the malignant cells in the irradiated area, but it also impacts distant nonirradiated tumors – an abscopal effect.
Dr. Facciabene and colleagues hypothesized that alterations of the gut microbiota could have an impact on the effect of radiotherapy. To investigate this, they studied mouse models of melanoma.
The team allowed B16-OVA tumors to grow for 9-12 days, then delivered a single dose of radiotherapy (21 Gy) to one – but not all – tumors. Simultaneously with the delivery of radiotherapy, the investigators started some animals on oral vancomycin. The team chose vancomycin because its effects are localized and impact the gut microbiota directly, without any known systemic effects.
Results showed that vancomycin significantly augmented the impact of radiotherapy in the irradiated area and was associated with regression of remote tumors.
The effects of the combination treatment on tumor volume were significantly greater than the effects of either treatment alone. Since manipulation of the gut microbiome potentiated radiotherapy effects both locally and distantly, the investigators concluded that immunogenic cell death may be involved in both the local and abscopal effects of radiotherapy.
When the experiment was repeated with a lung tumor model, similar findings were observed.
Involvement of cytotoxic T cells and interferon-gamma
Dr. Facciabene and colleagues found that the irradiated and unirradiated B16 OVA melanoma tumors treated with the radiotherapy-vancomycin combination were infiltrated by CD3+ and CD8+ T cells.
The investigators selectively depleted CD8+ T cells by pretreating the mice with an anti-CD8 monoclonal antibody. Depletion of CD8+ cells prior to administering radiotherapy plus vancomycin abrogated the antitumor effects of the combination treatment, demonstrating that the CD8+ T cells were required.
To characterize the antigen specificity of the tumor-infiltrating CD8+ T cells, Dr. Facciabene and colleagues used OVA MHC class 1 tetramer. Tumors from mice treated with vancomycin alone, radiotherapy alone, or the combination were dissected. Individual dendritic cells were assayed for OVA tetramer by flow cytometry.
The investigators found that tumors from mice treated with radiotherapy plus vancomycin had a significantly higher number of OVA-specific CD8+ T cells, in comparison with untreated tumors or tumors treated with either vancomycin alone or radiotherapy alone. Since antibody that impaired recognition of MHC class I peptides by T cells ablated the effect, it was clear that antigen recognition was vital.
Interferon-gamma (IFN-gamma) is known to play a critical role in both differentiation and effector functions of CD8+ cytolytic T cells in the antitumor immune response. To determine whether IFN-gamma is involved in the antitumor effects of the radiotherapy-vancomycin combination, the investigators measured intratumoral expression of IFN-gamma in the tumors 5 days after radiotherapy.
IFN-gamma messenger RNA expression levels were significantly elevated in the combination treatment group when compared with either treatment alone. In B16-OVA melanoma–challenged knockout mice, the enhancement of the radiotherapy effects by vancomycin was ablated.
The investigators concluded that vancomycin remodels the tumor microenvironment and increases the functionality of tumor-infiltrating, tumor-specific, CD8+ T cells. Furthermore, IFN-gamma is required to augment the radiotherapy-induced immune effect against the tumor.
Potential biochemical mediators of immune effects
The gut microbiota aid host digestion and generate a large repertoire of metabolites after defermentation of fiber. Short-chain fatty acids (SCFAs) constitute the major products of bacterial fermentation.
Acetic acid, propionic acid, and butyric acid represent 95% of total SCFAs present in the intestine. SCFAs are known to directly modulate cytokine production and dendritic cell function.
In their study, Dr. Facciabene and colleagues focused on butyric acid. Using mass spectroscopy, they demonstrated that vancomycin treatment reduces butyrate concentrations in tumor and tumor-draining lymph nodes by eradicating the major families of SCFA-producing Clostridia species.
To test whether supplementing butyrate could influence the synergy of the radiotherapy-vancomycin combination in vivo, the investigators added sodium butyrate to the mice’s drinking water when starting vancomycin treatment. The team then challenged the mice with B16-OVA tumors and treated them with radiotherapy.
In agreement with the group’s prior findings, vancomycin enhanced the tumor-inhibitory effects of radiotherapy, but dietary butyrate inhibited the benefit. The investigators found a significant decrease in the population of B16-OVA–presenting dendritic cells in the lymph nodes of mice receiving the supplemental butyrate.
Dr. Facciabene said these findings were supported by a recent publication. The authors observed that butyrate inhibited type I IFN expression in dendritic cells and radiotherapy-induced, tumor-specific cytotoxic T-cell immune responses without directly protecting tumor cells from the cytotoxic effects of radiotherapy.
Wide-ranging implications
Overall, Dr. Facciabene’s research has shown that:
- Vancomycin significantly enhances the tumor inhibitory effect of targeted radiation, including abscopal effects.
- The synergistic effects are dependent upon IFN-gamma and CD8+ cells.
- Depletion of some gut microbiome species increases antigen presentation by dendritic cells. This is mediated by SCFAs produced by certain bacterial families.
- There are promising new strategies to improve responses to radiotherapy, including targeting gut microbiota.
A clinical trial (NCT03546829) of vancomycin plus stereotactic body radiation in patients with locally advanced non–small cell lung cancer has been launched to investigate these findings further. Early data analysis has shown a significant impact of vancomycin on several species of gut microbiota, according to Dr. Facciabene.
Revolutionary results from immune-targeted therapy in the recent past have highlighted the important role the immune system can play in fighting cancer. Still, up to one-third of cancer patients fail to respond to overtly immune-targeted therapy.
The ability to inhibit cancer cells from evading immune surveillance by using new adjuvants – including those acting on non-traditional targets like gut microbiota – could herald the next major advances in cancer therapy. During his presentation, Dr. Facciabene gave participants an enticing hint of what could be coming for cancer patients in the years ahead.
Dr. Facciabene reported having no relevant disclosures.
Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers, as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.
Andrea Facciabene, PhD, of the University of Pennsylvania, Philadelphia, and colleagues conducted a preclinical study in which vancomycin enhanced the efficacy of radiotherapy against melanoma and lung cancer. Now, researchers are conducting a clinical trial to determine if vancomycin can have the same effect in patients with non–small cell lung cancer.
Dr. Facciabene reviewed this research at the AACR Virtual Special Conference: Radiation Science and Medicine.
According to Dr. Facciabene, “gut microbiota” includes the more than 1,000 different strains of bacteria living in human intestines. He indicated that the average human has 10 times more bacteria than cells in the body and 150 times more genes in the gut microbiome than in the human genome.
In healthy individuals, the gut microbiota play a key role in intestinal function and digestive processes, modulation of hormones and vitamin secretion, energy extraction from food, and development and maintenance of a balanced immune system.
“Dysbiosis” is the term applied to a change in the composition, diversity, or metabolites of the microbiome from a healthy pattern to one associated with disease. Antibiotic therapy is a classic cause of dysbiosis, and dysbiosis has been implicated in a variety of inflammatory diseases.
The mechanisms by which the gut microbiome could influence systemic immunity is not known but is relevant to cancer therapy response. Augmenting the frequency and durability of response to immune-targeted treatments – potentially by manipulating the influence of gut microbiota on the immune system – could be highly impactful.
Gut microbiota and radiation-induced cell death
Immunogenic cell death – a process by which tumors die and release their intracellular molecular contents – is one of the mechanisms by which radiotherapy kills cancer cells.
Tumor cells succumbing to immunogenic cell death stimulate antigen presenting cells, such as dendritic cells, that engulf tumor antigens and cross-present them to CD8+ cytotoxic T lymphocytes. This process culminates in the generation of a specific immune response capable of killing the malignant cells in the irradiated area, but it also impacts distant nonirradiated tumors – an abscopal effect.
Dr. Facciabene and colleagues hypothesized that alterations of the gut microbiota could have an impact on the effect of radiotherapy. To investigate this, they studied mouse models of melanoma.
The team allowed B16-OVA tumors to grow for 9-12 days, then delivered a single dose of radiotherapy (21 Gy) to one – but not all – tumors. Simultaneously with the delivery of radiotherapy, the investigators started some animals on oral vancomycin. The team chose vancomycin because its effects are localized and impact the gut microbiota directly, without any known systemic effects.
Results showed that vancomycin significantly augmented the impact of radiotherapy in the irradiated area and was associated with regression of remote tumors.
The effects of the combination treatment on tumor volume were significantly greater than the effects of either treatment alone. Since manipulation of the gut microbiome potentiated radiotherapy effects both locally and distantly, the investigators concluded that immunogenic cell death may be involved in both the local and abscopal effects of radiotherapy.
When the experiment was repeated with a lung tumor model, similar findings were observed.
Involvement of cytotoxic T cells and interferon-gamma
Dr. Facciabene and colleagues found that the irradiated and unirradiated B16 OVA melanoma tumors treated with the radiotherapy-vancomycin combination were infiltrated by CD3+ and CD8+ T cells.
The investigators selectively depleted CD8+ T cells by pretreating the mice with an anti-CD8 monoclonal antibody. Depletion of CD8+ cells prior to administering radiotherapy plus vancomycin abrogated the antitumor effects of the combination treatment, demonstrating that the CD8+ T cells were required.
To characterize the antigen specificity of the tumor-infiltrating CD8+ T cells, Dr. Facciabene and colleagues used OVA MHC class 1 tetramer. Tumors from mice treated with vancomycin alone, radiotherapy alone, or the combination were dissected. Individual dendritic cells were assayed for OVA tetramer by flow cytometry.
The investigators found that tumors from mice treated with radiotherapy plus vancomycin had a significantly higher number of OVA-specific CD8+ T cells, in comparison with untreated tumors or tumors treated with either vancomycin alone or radiotherapy alone. Since antibody that impaired recognition of MHC class I peptides by T cells ablated the effect, it was clear that antigen recognition was vital.
Interferon-gamma (IFN-gamma) is known to play a critical role in both differentiation and effector functions of CD8+ cytolytic T cells in the antitumor immune response. To determine whether IFN-gamma is involved in the antitumor effects of the radiotherapy-vancomycin combination, the investigators measured intratumoral expression of IFN-gamma in the tumors 5 days after radiotherapy.
IFN-gamma messenger RNA expression levels were significantly elevated in the combination treatment group when compared with either treatment alone. In B16-OVA melanoma–challenged knockout mice, the enhancement of the radiotherapy effects by vancomycin was ablated.
The investigators concluded that vancomycin remodels the tumor microenvironment and increases the functionality of tumor-infiltrating, tumor-specific, CD8+ T cells. Furthermore, IFN-gamma is required to augment the radiotherapy-induced immune effect against the tumor.
Potential biochemical mediators of immune effects
The gut microbiota aid host digestion and generate a large repertoire of metabolites after defermentation of fiber. Short-chain fatty acids (SCFAs) constitute the major products of bacterial fermentation.
Acetic acid, propionic acid, and butyric acid represent 95% of total SCFAs present in the intestine. SCFAs are known to directly modulate cytokine production and dendritic cell function.
In their study, Dr. Facciabene and colleagues focused on butyric acid. Using mass spectroscopy, they demonstrated that vancomycin treatment reduces butyrate concentrations in tumor and tumor-draining lymph nodes by eradicating the major families of SCFA-producing Clostridia species.
To test whether supplementing butyrate could influence the synergy of the radiotherapy-vancomycin combination in vivo, the investigators added sodium butyrate to the mice’s drinking water when starting vancomycin treatment. The team then challenged the mice with B16-OVA tumors and treated them with radiotherapy.
In agreement with the group’s prior findings, vancomycin enhanced the tumor-inhibitory effects of radiotherapy, but dietary butyrate inhibited the benefit. The investigators found a significant decrease in the population of B16-OVA–presenting dendritic cells in the lymph nodes of mice receiving the supplemental butyrate.
Dr. Facciabene said these findings were supported by a recent publication. The authors observed that butyrate inhibited type I IFN expression in dendritic cells and radiotherapy-induced, tumor-specific cytotoxic T-cell immune responses without directly protecting tumor cells from the cytotoxic effects of radiotherapy.
Wide-ranging implications
Overall, Dr. Facciabene’s research has shown that:
- Vancomycin significantly enhances the tumor inhibitory effect of targeted radiation, including abscopal effects.
- The synergistic effects are dependent upon IFN-gamma and CD8+ cells.
- Depletion of some gut microbiome species increases antigen presentation by dendritic cells. This is mediated by SCFAs produced by certain bacterial families.
- There are promising new strategies to improve responses to radiotherapy, including targeting gut microbiota.
A clinical trial (NCT03546829) of vancomycin plus stereotactic body radiation in patients with locally advanced non–small cell lung cancer has been launched to investigate these findings further. Early data analysis has shown a significant impact of vancomycin on several species of gut microbiota, according to Dr. Facciabene.
Revolutionary results from immune-targeted therapy in the recent past have highlighted the important role the immune system can play in fighting cancer. Still, up to one-third of cancer patients fail to respond to overtly immune-targeted therapy.
The ability to inhibit cancer cells from evading immune surveillance by using new adjuvants – including those acting on non-traditional targets like gut microbiota – could herald the next major advances in cancer therapy. During his presentation, Dr. Facciabene gave participants an enticing hint of what could be coming for cancer patients in the years ahead.
Dr. Facciabene reported having no relevant disclosures.
Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers, as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.
Andrea Facciabene, PhD, of the University of Pennsylvania, Philadelphia, and colleagues conducted a preclinical study in which vancomycin enhanced the efficacy of radiotherapy against melanoma and lung cancer. Now, researchers are conducting a clinical trial to determine if vancomycin can have the same effect in patients with non–small cell lung cancer.
Dr. Facciabene reviewed this research at the AACR Virtual Special Conference: Radiation Science and Medicine.
According to Dr. Facciabene, “gut microbiota” includes the more than 1,000 different strains of bacteria living in human intestines. He indicated that the average human has 10 times more bacteria than cells in the body and 150 times more genes in the gut microbiome than in the human genome.
In healthy individuals, the gut microbiota play a key role in intestinal function and digestive processes, modulation of hormones and vitamin secretion, energy extraction from food, and development and maintenance of a balanced immune system.
“Dysbiosis” is the term applied to a change in the composition, diversity, or metabolites of the microbiome from a healthy pattern to one associated with disease. Antibiotic therapy is a classic cause of dysbiosis, and dysbiosis has been implicated in a variety of inflammatory diseases.
The mechanisms by which the gut microbiome could influence systemic immunity is not known but is relevant to cancer therapy response. Augmenting the frequency and durability of response to immune-targeted treatments – potentially by manipulating the influence of gut microbiota on the immune system – could be highly impactful.
Gut microbiota and radiation-induced cell death
Immunogenic cell death – a process by which tumors die and release their intracellular molecular contents – is one of the mechanisms by which radiotherapy kills cancer cells.
Tumor cells succumbing to immunogenic cell death stimulate antigen presenting cells, such as dendritic cells, that engulf tumor antigens and cross-present them to CD8+ cytotoxic T lymphocytes. This process culminates in the generation of a specific immune response capable of killing the malignant cells in the irradiated area, but it also impacts distant nonirradiated tumors – an abscopal effect.
Dr. Facciabene and colleagues hypothesized that alterations of the gut microbiota could have an impact on the effect of radiotherapy. To investigate this, they studied mouse models of melanoma.
The team allowed B16-OVA tumors to grow for 9-12 days, then delivered a single dose of radiotherapy (21 Gy) to one – but not all – tumors. Simultaneously with the delivery of radiotherapy, the investigators started some animals on oral vancomycin. The team chose vancomycin because its effects are localized and impact the gut microbiota directly, without any known systemic effects.
Results showed that vancomycin significantly augmented the impact of radiotherapy in the irradiated area and was associated with regression of remote tumors.
The effects of the combination treatment on tumor volume were significantly greater than the effects of either treatment alone. Since manipulation of the gut microbiome potentiated radiotherapy effects both locally and distantly, the investigators concluded that immunogenic cell death may be involved in both the local and abscopal effects of radiotherapy.
When the experiment was repeated with a lung tumor model, similar findings were observed.
Involvement of cytotoxic T cells and interferon-gamma
Dr. Facciabene and colleagues found that the irradiated and unirradiated B16 OVA melanoma tumors treated with the radiotherapy-vancomycin combination were infiltrated by CD3+ and CD8+ T cells.
The investigators selectively depleted CD8+ T cells by pretreating the mice with an anti-CD8 monoclonal antibody. Depletion of CD8+ cells prior to administering radiotherapy plus vancomycin abrogated the antitumor effects of the combination treatment, demonstrating that the CD8+ T cells were required.
To characterize the antigen specificity of the tumor-infiltrating CD8+ T cells, Dr. Facciabene and colleagues used OVA MHC class 1 tetramer. Tumors from mice treated with vancomycin alone, radiotherapy alone, or the combination were dissected. Individual dendritic cells were assayed for OVA tetramer by flow cytometry.
The investigators found that tumors from mice treated with radiotherapy plus vancomycin had a significantly higher number of OVA-specific CD8+ T cells, in comparison with untreated tumors or tumors treated with either vancomycin alone or radiotherapy alone. Since antibody that impaired recognition of MHC class I peptides by T cells ablated the effect, it was clear that antigen recognition was vital.
Interferon-gamma (IFN-gamma) is known to play a critical role in both differentiation and effector functions of CD8+ cytolytic T cells in the antitumor immune response. To determine whether IFN-gamma is involved in the antitumor effects of the radiotherapy-vancomycin combination, the investigators measured intratumoral expression of IFN-gamma in the tumors 5 days after radiotherapy.
IFN-gamma messenger RNA expression levels were significantly elevated in the combination treatment group when compared with either treatment alone. In B16-OVA melanoma–challenged knockout mice, the enhancement of the radiotherapy effects by vancomycin was ablated.
The investigators concluded that vancomycin remodels the tumor microenvironment and increases the functionality of tumor-infiltrating, tumor-specific, CD8+ T cells. Furthermore, IFN-gamma is required to augment the radiotherapy-induced immune effect against the tumor.
Potential biochemical mediators of immune effects
The gut microbiota aid host digestion and generate a large repertoire of metabolites after defermentation of fiber. Short-chain fatty acids (SCFAs) constitute the major products of bacterial fermentation.
Acetic acid, propionic acid, and butyric acid represent 95% of total SCFAs present in the intestine. SCFAs are known to directly modulate cytokine production and dendritic cell function.
In their study, Dr. Facciabene and colleagues focused on butyric acid. Using mass spectroscopy, they demonstrated that vancomycin treatment reduces butyrate concentrations in tumor and tumor-draining lymph nodes by eradicating the major families of SCFA-producing Clostridia species.
To test whether supplementing butyrate could influence the synergy of the radiotherapy-vancomycin combination in vivo, the investigators added sodium butyrate to the mice’s drinking water when starting vancomycin treatment. The team then challenged the mice with B16-OVA tumors and treated them with radiotherapy.
In agreement with the group’s prior findings, vancomycin enhanced the tumor-inhibitory effects of radiotherapy, but dietary butyrate inhibited the benefit. The investigators found a significant decrease in the population of B16-OVA–presenting dendritic cells in the lymph nodes of mice receiving the supplemental butyrate.
Dr. Facciabene said these findings were supported by a recent publication. The authors observed that butyrate inhibited type I IFN expression in dendritic cells and radiotherapy-induced, tumor-specific cytotoxic T-cell immune responses without directly protecting tumor cells from the cytotoxic effects of radiotherapy.
Wide-ranging implications
Overall, Dr. Facciabene’s research has shown that:
- Vancomycin significantly enhances the tumor inhibitory effect of targeted radiation, including abscopal effects.
- The synergistic effects are dependent upon IFN-gamma and CD8+ cells.
- Depletion of some gut microbiome species increases antigen presentation by dendritic cells. This is mediated by SCFAs produced by certain bacterial families.
- There are promising new strategies to improve responses to radiotherapy, including targeting gut microbiota.
A clinical trial (NCT03546829) of vancomycin plus stereotactic body radiation in patients with locally advanced non–small cell lung cancer has been launched to investigate these findings further. Early data analysis has shown a significant impact of vancomycin on several species of gut microbiota, according to Dr. Facciabene.
Revolutionary results from immune-targeted therapy in the recent past have highlighted the important role the immune system can play in fighting cancer. Still, up to one-third of cancer patients fail to respond to overtly immune-targeted therapy.
The ability to inhibit cancer cells from evading immune surveillance by using new adjuvants – including those acting on non-traditional targets like gut microbiota – could herald the next major advances in cancer therapy. During his presentation, Dr. Facciabene gave participants an enticing hint of what could be coming for cancer patients in the years ahead.
Dr. Facciabene reported having no relevant disclosures.
Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers, as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.
FROM AACR: RADIATION SCIENCE AND MEDICINE
A woman with a history of diabetes, and plaques on both shins
. Women are often more affected than men. Patients often present in their 30s and 40s. The cause of NLD is unknown. Twenty percent of patients with NLD will have glucose intolerance or a family history of diabetes.1 The percentage of patients with NLD who have diabetes varies in reports from 11% to 65%.2 NLD may progress despite the diabetes treatment. Only 0.03% of patient with diabetes will have NLD.3
Lesions most commonly occur on the extremities, with shins being affected in most cases. They vary from asymptomatic to painful. Typically, lesions begin as small, firm erythematous papules that evolve into shiny, well-defined plaques. In older plaques, the center will often appear yellow, depressed, and atrophic, with telangiectasias. The periphery appears pink to violaceous to brown. Ulceration may be present, particularly after trauma, and there may be decreased sensation in the plaques. NLD is clinically distinct from diabetic dermopathy, which appear as brown macules, often in older patients with diabetes.
Ideally, biopsy should be taken at the edge of a lesion. Histologically, the epidermis appears normal or atrophic. A diffuse palisaded and interstitial granulomatous dermatitis consisting of histiocytes, multinucleated giant cells, lymphocytes, and plasma cells is seen in the dermis. Granulomas are often oriented parallel to the epidermis. There is no mucin at the center of the granulomas (as seen in granuloma annulare). Inflammation may extend into the subcutaneous fat. Asteroid bodies (as seen in sarcoid) are absent.
Unfortunately, treatment of NLD is often unsuccessful. Treatment includes potent topical corticosteroids for early lesions and intralesional triamcinolone to the leading edge of lesions. Care should be taken to avoid injecting centrally where atrophy and ulceration may result. Systemic steroids may be helpful in some cases, but can elevate glucose levels. Other reported medical treatments include pentoxifylline, cyclosporine, and niacinamide. Some lesions may spontaneously resolve. Ulcerations may require surgical excision with grafting.
This case and photo are provided by Dr. Bilu Martin, who is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to dermnews@mdedge.com.
References
1. James WD et al. Andrews’ Diseases of the Skin: Clinical Dermatology. Philadelphia: Saunders Elsevier, 2006.
2. Hashemi D et al. JAMA Dermatol. 2019 Apr 1;155(4):455-9.
3. Bolognia JL et al. Dermatology. St. Louis, Mo.: Mosby Elsevier, 2008.
. Women are often more affected than men. Patients often present in their 30s and 40s. The cause of NLD is unknown. Twenty percent of patients with NLD will have glucose intolerance or a family history of diabetes.1 The percentage of patients with NLD who have diabetes varies in reports from 11% to 65%.2 NLD may progress despite the diabetes treatment. Only 0.03% of patient with diabetes will have NLD.3
Lesions most commonly occur on the extremities, with shins being affected in most cases. They vary from asymptomatic to painful. Typically, lesions begin as small, firm erythematous papules that evolve into shiny, well-defined plaques. In older plaques, the center will often appear yellow, depressed, and atrophic, with telangiectasias. The periphery appears pink to violaceous to brown. Ulceration may be present, particularly after trauma, and there may be decreased sensation in the plaques. NLD is clinically distinct from diabetic dermopathy, which appear as brown macules, often in older patients with diabetes.
Ideally, biopsy should be taken at the edge of a lesion. Histologically, the epidermis appears normal or atrophic. A diffuse palisaded and interstitial granulomatous dermatitis consisting of histiocytes, multinucleated giant cells, lymphocytes, and plasma cells is seen in the dermis. Granulomas are often oriented parallel to the epidermis. There is no mucin at the center of the granulomas (as seen in granuloma annulare). Inflammation may extend into the subcutaneous fat. Asteroid bodies (as seen in sarcoid) are absent.
Unfortunately, treatment of NLD is often unsuccessful. Treatment includes potent topical corticosteroids for early lesions and intralesional triamcinolone to the leading edge of lesions. Care should be taken to avoid injecting centrally where atrophy and ulceration may result. Systemic steroids may be helpful in some cases, but can elevate glucose levels. Other reported medical treatments include pentoxifylline, cyclosporine, and niacinamide. Some lesions may spontaneously resolve. Ulcerations may require surgical excision with grafting.
This case and photo are provided by Dr. Bilu Martin, who is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to dermnews@mdedge.com.
References
1. James WD et al. Andrews’ Diseases of the Skin: Clinical Dermatology. Philadelphia: Saunders Elsevier, 2006.
2. Hashemi D et al. JAMA Dermatol. 2019 Apr 1;155(4):455-9.
3. Bolognia JL et al. Dermatology. St. Louis, Mo.: Mosby Elsevier, 2008.
. Women are often more affected than men. Patients often present in their 30s and 40s. The cause of NLD is unknown. Twenty percent of patients with NLD will have glucose intolerance or a family history of diabetes.1 The percentage of patients with NLD who have diabetes varies in reports from 11% to 65%.2 NLD may progress despite the diabetes treatment. Only 0.03% of patient with diabetes will have NLD.3
Lesions most commonly occur on the extremities, with shins being affected in most cases. They vary from asymptomatic to painful. Typically, lesions begin as small, firm erythematous papules that evolve into shiny, well-defined plaques. In older plaques, the center will often appear yellow, depressed, and atrophic, with telangiectasias. The periphery appears pink to violaceous to brown. Ulceration may be present, particularly after trauma, and there may be decreased sensation in the plaques. NLD is clinically distinct from diabetic dermopathy, which appear as brown macules, often in older patients with diabetes.
Ideally, biopsy should be taken at the edge of a lesion. Histologically, the epidermis appears normal or atrophic. A diffuse palisaded and interstitial granulomatous dermatitis consisting of histiocytes, multinucleated giant cells, lymphocytes, and plasma cells is seen in the dermis. Granulomas are often oriented parallel to the epidermis. There is no mucin at the center of the granulomas (as seen in granuloma annulare). Inflammation may extend into the subcutaneous fat. Asteroid bodies (as seen in sarcoid) are absent.
Unfortunately, treatment of NLD is often unsuccessful. Treatment includes potent topical corticosteroids for early lesions and intralesional triamcinolone to the leading edge of lesions. Care should be taken to avoid injecting centrally where atrophy and ulceration may result. Systemic steroids may be helpful in some cases, but can elevate glucose levels. Other reported medical treatments include pentoxifylline, cyclosporine, and niacinamide. Some lesions may spontaneously resolve. Ulcerations may require surgical excision with grafting.
This case and photo are provided by Dr. Bilu Martin, who is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to dermnews@mdedge.com.
References
1. James WD et al. Andrews’ Diseases of the Skin: Clinical Dermatology. Philadelphia: Saunders Elsevier, 2006.
2. Hashemi D et al. JAMA Dermatol. 2019 Apr 1;155(4):455-9.
3. Bolognia JL et al. Dermatology. St. Louis, Mo.: Mosby Elsevier, 2008.
Let me tell you about my vaccine
Welcome to our national obsession: Vaccines! You may have noticed – it’s all talk, all the time, with short breaks to discuss what we’re watching on Netflix.
For months, every session with almost every patient includes a commentary on someone they know who has gotten “the shot.” Before our state expanded eligibility to all adults, the discussion might include thoughts about who deserves to go first, who “cut the line,” how they did it, what vaccine is best, and worries about side effects.
And it’s not just my patients: With every friend, with every acquaintance, and even just walking by strangers who are conversing, the topic of discussion is vaccines. The narratives are similar; people want to talk about who has gotten vaccinated, why they qualified, where they went, which one they got, and what side effects they experienced. This is followed by a discussion about what they are now doing that they weren’t doing before being vaccinated, if anything. Some have returned to indoor restaurant dining, others only dine outdoors, still others continue to avoid public settings. There are the fully vaccinated, the partially vaccinated, and those scheduled for the first shot. In the unvaccinated/unregistered group there are the vaccine-hesitants and vaccine-refusers, with their concerns about everything from the safety of the agent to whether the government is using this as a way to insert tracker chips into all of us. There is enthusiasm, trepidation, anxiety, fear, excitement, relief, and absolute joy.
Recently I opened two emails from old friends I have not communicated with in a long time. Both emails began with, “I am fully vaccinated.” And yes, I heard the status of his wife and two children. In the course of one work day, I received distressed text messages from two patients about vaccines – one was anxious about having received the Janssen vaccine that was paused that morning, another was worried about getting a second dose of the Pfizer vaccine later in the week because he was having a symptom that could be indicative of COVID-19. I suggested that his primary care physician might be a better resource for this, but then added that he should probably get tested and delay having the second dose if positive. It seems I did have thoughts about a course of action after all.
Some psychiatrists have wondered how to handle patient questions about their own vaccination status. I have taken the stance that we are physicians, and that patients who may be seeing us – now or in the future – for in-person appointments are entitled to know if we pose a risk to their health, and so I have chosen to answer, without further exploration, when patients ask if I’ve received that coronavirus vaccine. Some psychiatrists feel it is our responsibility to share this information with our patients as a way of modeling safe behavior, and I have had one patient who said she would not be getting vaccinated until I told her that I thought she should.
“Did you get it?” she asked.
“I did,” I responded.
“Okay, if you got it, I will.” She soon discovered that vaccinations were hard to come by and that in her social group, being vaccinated was something of a status symbol. In addition to the worry about contracting a potentially fatal virus, her hesitancy yielded to “vaccine FOMO” or fear of missing out.
Some psychiatrists have felt uneasy with a question that pertains to their personal health, or have used the question as a springboard for exploration. Nicole Leistikow, MD (fully vaccinated, Moderna), is a psychiatrist in private practice in Baltimore. She notes, “Recently, I was discussing vaccination with a patient who wasn’t sure what information to believe or how much to trust the U.S. government. My careful exploration comparing different risks was not very helpful. I mentioned that I was vaccinated and that if he got vaccinated, he could come for a low-risk, in-person appointment after a year of telephone visits. This proved to be a winning argument and he called back later that day to say he had already had his first shot from leftover vaccine at his pharmacy.”
I grew up in a world that did not question vaccines. You got them and they were good things. No one asked which pharmaceutical company manufactured the vaccine. We trusted the system and our physicians. Schools asked for proof of vaccination, and it never occurred to me not to be vaccinated. Life has grown more complicated in the last 30 years, and the groups of people who are opposed to being vaccinated are more diverse. Those opposed to getting a COVID-19 vaccine are not necessarily the same as the broader group of anti-vaxxers that spawned from the fear that childhood vaccines cause autism. For some, it’s a personal issue related to their own health and risk perception, for others it’s a polarized political issue, and for another group there is the question of where their trust lies.
What lies ahead in our postvaccine world? This will be our next national conversation, and just as we negotiated our own levels of comfort with regard to working and socializing during the pandemic, I imagine the postvaccine world will have the same adjustment. There already are cases of COVID-19 in those who have been fully vaccinated, as well as the rare hospitalizations and deaths – we simply cannot expect a vaccine that did so well in controlled studies of tens of thousands of study subjects to do as well when given to tens of millions of uncontrolled citizens. One of the first deaths in a fully vaccinated person in late March was an older psychologist, and it remains unclear how effective the vaccine is for immunocompromised patients. Some people will play it very safe, eschewing all activities that entail risk, while others will choose to adhere to either their own intuition about what is safe, or to the recommendations of Anthony S. Fauci, MD, and the Centers for Disease Control and Prevention.
I’ll end with a final thought from the Twitter feed of Ashish K. Jha, MD, dean of the School of Public Health at Brown University, Providence, R.I. Dr. Jha tweeted, “Once you get fully vaccinated, it absolutely changes what you can do safely.” It seems our national conversation is not slated to change anytime soon.
Dr. Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.
Welcome to our national obsession: Vaccines! You may have noticed – it’s all talk, all the time, with short breaks to discuss what we’re watching on Netflix.
For months, every session with almost every patient includes a commentary on someone they know who has gotten “the shot.” Before our state expanded eligibility to all adults, the discussion might include thoughts about who deserves to go first, who “cut the line,” how they did it, what vaccine is best, and worries about side effects.
And it’s not just my patients: With every friend, with every acquaintance, and even just walking by strangers who are conversing, the topic of discussion is vaccines. The narratives are similar; people want to talk about who has gotten vaccinated, why they qualified, where they went, which one they got, and what side effects they experienced. This is followed by a discussion about what they are now doing that they weren’t doing before being vaccinated, if anything. Some have returned to indoor restaurant dining, others only dine outdoors, still others continue to avoid public settings. There are the fully vaccinated, the partially vaccinated, and those scheduled for the first shot. In the unvaccinated/unregistered group there are the vaccine-hesitants and vaccine-refusers, with their concerns about everything from the safety of the agent to whether the government is using this as a way to insert tracker chips into all of us. There is enthusiasm, trepidation, anxiety, fear, excitement, relief, and absolute joy.
Recently I opened two emails from old friends I have not communicated with in a long time. Both emails began with, “I am fully vaccinated.” And yes, I heard the status of his wife and two children. In the course of one work day, I received distressed text messages from two patients about vaccines – one was anxious about having received the Janssen vaccine that was paused that morning, another was worried about getting a second dose of the Pfizer vaccine later in the week because he was having a symptom that could be indicative of COVID-19. I suggested that his primary care physician might be a better resource for this, but then added that he should probably get tested and delay having the second dose if positive. It seems I did have thoughts about a course of action after all.
Some psychiatrists have wondered how to handle patient questions about their own vaccination status. I have taken the stance that we are physicians, and that patients who may be seeing us – now or in the future – for in-person appointments are entitled to know if we pose a risk to their health, and so I have chosen to answer, without further exploration, when patients ask if I’ve received that coronavirus vaccine. Some psychiatrists feel it is our responsibility to share this information with our patients as a way of modeling safe behavior, and I have had one patient who said she would not be getting vaccinated until I told her that I thought she should.
“Did you get it?” she asked.
“I did,” I responded.
“Okay, if you got it, I will.” She soon discovered that vaccinations were hard to come by and that in her social group, being vaccinated was something of a status symbol. In addition to the worry about contracting a potentially fatal virus, her hesitancy yielded to “vaccine FOMO” or fear of missing out.
Some psychiatrists have felt uneasy with a question that pertains to their personal health, or have used the question as a springboard for exploration. Nicole Leistikow, MD (fully vaccinated, Moderna), is a psychiatrist in private practice in Baltimore. She notes, “Recently, I was discussing vaccination with a patient who wasn’t sure what information to believe or how much to trust the U.S. government. My careful exploration comparing different risks was not very helpful. I mentioned that I was vaccinated and that if he got vaccinated, he could come for a low-risk, in-person appointment after a year of telephone visits. This proved to be a winning argument and he called back later that day to say he had already had his first shot from leftover vaccine at his pharmacy.”
I grew up in a world that did not question vaccines. You got them and they were good things. No one asked which pharmaceutical company manufactured the vaccine. We trusted the system and our physicians. Schools asked for proof of vaccination, and it never occurred to me not to be vaccinated. Life has grown more complicated in the last 30 years, and the groups of people who are opposed to being vaccinated are more diverse. Those opposed to getting a COVID-19 vaccine are not necessarily the same as the broader group of anti-vaxxers that spawned from the fear that childhood vaccines cause autism. For some, it’s a personal issue related to their own health and risk perception, for others it’s a polarized political issue, and for another group there is the question of where their trust lies.
What lies ahead in our postvaccine world? This will be our next national conversation, and just as we negotiated our own levels of comfort with regard to working and socializing during the pandemic, I imagine the postvaccine world will have the same adjustment. There already are cases of COVID-19 in those who have been fully vaccinated, as well as the rare hospitalizations and deaths – we simply cannot expect a vaccine that did so well in controlled studies of tens of thousands of study subjects to do as well when given to tens of millions of uncontrolled citizens. One of the first deaths in a fully vaccinated person in late March was an older psychologist, and it remains unclear how effective the vaccine is for immunocompromised patients. Some people will play it very safe, eschewing all activities that entail risk, while others will choose to adhere to either their own intuition about what is safe, or to the recommendations of Anthony S. Fauci, MD, and the Centers for Disease Control and Prevention.
I’ll end with a final thought from the Twitter feed of Ashish K. Jha, MD, dean of the School of Public Health at Brown University, Providence, R.I. Dr. Jha tweeted, “Once you get fully vaccinated, it absolutely changes what you can do safely.” It seems our national conversation is not slated to change anytime soon.
Dr. Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.
Welcome to our national obsession: Vaccines! You may have noticed – it’s all talk, all the time, with short breaks to discuss what we’re watching on Netflix.
For months, every session with almost every patient includes a commentary on someone they know who has gotten “the shot.” Before our state expanded eligibility to all adults, the discussion might include thoughts about who deserves to go first, who “cut the line,” how they did it, what vaccine is best, and worries about side effects.
And it’s not just my patients: With every friend, with every acquaintance, and even just walking by strangers who are conversing, the topic of discussion is vaccines. The narratives are similar; people want to talk about who has gotten vaccinated, why they qualified, where they went, which one they got, and what side effects they experienced. This is followed by a discussion about what they are now doing that they weren’t doing before being vaccinated, if anything. Some have returned to indoor restaurant dining, others only dine outdoors, still others continue to avoid public settings. There are the fully vaccinated, the partially vaccinated, and those scheduled for the first shot. In the unvaccinated/unregistered group there are the vaccine-hesitants and vaccine-refusers, with their concerns about everything from the safety of the agent to whether the government is using this as a way to insert tracker chips into all of us. There is enthusiasm, trepidation, anxiety, fear, excitement, relief, and absolute joy.
Recently I opened two emails from old friends I have not communicated with in a long time. Both emails began with, “I am fully vaccinated.” And yes, I heard the status of his wife and two children. In the course of one work day, I received distressed text messages from two patients about vaccines – one was anxious about having received the Janssen vaccine that was paused that morning, another was worried about getting a second dose of the Pfizer vaccine later in the week because he was having a symptom that could be indicative of COVID-19. I suggested that his primary care physician might be a better resource for this, but then added that he should probably get tested and delay having the second dose if positive. It seems I did have thoughts about a course of action after all.
Some psychiatrists have wondered how to handle patient questions about their own vaccination status. I have taken the stance that we are physicians, and that patients who may be seeing us – now or in the future – for in-person appointments are entitled to know if we pose a risk to their health, and so I have chosen to answer, without further exploration, when patients ask if I’ve received that coronavirus vaccine. Some psychiatrists feel it is our responsibility to share this information with our patients as a way of modeling safe behavior, and I have had one patient who said she would not be getting vaccinated until I told her that I thought she should.
“Did you get it?” she asked.
“I did,” I responded.
“Okay, if you got it, I will.” She soon discovered that vaccinations were hard to come by and that in her social group, being vaccinated was something of a status symbol. In addition to the worry about contracting a potentially fatal virus, her hesitancy yielded to “vaccine FOMO” or fear of missing out.
Some psychiatrists have felt uneasy with a question that pertains to their personal health, or have used the question as a springboard for exploration. Nicole Leistikow, MD (fully vaccinated, Moderna), is a psychiatrist in private practice in Baltimore. She notes, “Recently, I was discussing vaccination with a patient who wasn’t sure what information to believe or how much to trust the U.S. government. My careful exploration comparing different risks was not very helpful. I mentioned that I was vaccinated and that if he got vaccinated, he could come for a low-risk, in-person appointment after a year of telephone visits. This proved to be a winning argument and he called back later that day to say he had already had his first shot from leftover vaccine at his pharmacy.”
I grew up in a world that did not question vaccines. You got them and they were good things. No one asked which pharmaceutical company manufactured the vaccine. We trusted the system and our physicians. Schools asked for proof of vaccination, and it never occurred to me not to be vaccinated. Life has grown more complicated in the last 30 years, and the groups of people who are opposed to being vaccinated are more diverse. Those opposed to getting a COVID-19 vaccine are not necessarily the same as the broader group of anti-vaxxers that spawned from the fear that childhood vaccines cause autism. For some, it’s a personal issue related to their own health and risk perception, for others it’s a polarized political issue, and for another group there is the question of where their trust lies.
What lies ahead in our postvaccine world? This will be our next national conversation, and just as we negotiated our own levels of comfort with regard to working and socializing during the pandemic, I imagine the postvaccine world will have the same adjustment. There already are cases of COVID-19 in those who have been fully vaccinated, as well as the rare hospitalizations and deaths – we simply cannot expect a vaccine that did so well in controlled studies of tens of thousands of study subjects to do as well when given to tens of millions of uncontrolled citizens. One of the first deaths in a fully vaccinated person in late March was an older psychologist, and it remains unclear how effective the vaccine is for immunocompromised patients. Some people will play it very safe, eschewing all activities that entail risk, while others will choose to adhere to either their own intuition about what is safe, or to the recommendations of Anthony S. Fauci, MD, and the Centers for Disease Control and Prevention.
I’ll end with a final thought from the Twitter feed of Ashish K. Jha, MD, dean of the School of Public Health at Brown University, Providence, R.I. Dr. Jha tweeted, “Once you get fully vaccinated, it absolutely changes what you can do safely.” It seems our national conversation is not slated to change anytime soon.
Dr. Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.
Goodbye, OTC hydroquinone
In 1972, an over-the-counter drug review process was established by the Food and Drug Administration to regulate the safety and efficacy of over-the-counter (OTC) drugs. This created a book or “monograph” for each medication category that describes the active ingredients, indications, doses, route of administration, testing, and labeling. If a drug meets the criteria in its therapeutic category, it does not have to undergo an FDA review before being marketed to consumers.
As part of this process, drugs are classified into one of three categories: category I: generally recognized as safe and effective (GRASE) and not misbranded; category II: not GRASE; category III: lacking sufficient data on safety and efficacy to permit classification. This methodology was outdated and made it difficult under the old guidelines to make changes to medications in the evolving world of drug development. Some categories of OTC drugs, including hand sanitizers, hydroquinone, and sunscreens, have been marketed for years without a final monograph.
The signing of the “Coronavirus Aid, Relief, and Economic Security” (CARES) Act in March 2020 included reforms in the FDA monograph process for OTC medications. Under this proceeding, a final monograph determination was made for all OTC categories. While drugs in category I and some in category III may remain on the market, if certain specifications are met, category II drugs had to be removed within 180 days of the enactment of the CARES Act.
Hydroquinone was one of those that fell victim to the ban. This ban is similar to hydroquinone bans in other places, including Europe. However, for manufacturers, this issue was under the radar and packaged in a seemingly irrelevant piece of legislation.
Among dermatologists, there is no consensus as to whether 2% hydroquinone is safe or not. However, the unmonitored use and overuse that is common for this type of medication has led to heightened safety concerns. Common side effects of hydroquinone include irritant and allergic contact dermatitis; the most difficult to treat side effect with long-term use is ochronosis. But there are no reported cancer data in humans with the use of topical hydroquinone as previously thought. Hydroquinone used short term is a very safe and effective treatment for hard to treat hyperpigmentation and is often necessary when other topicals are ineffective, particularly in our patients with skin of color.
The bigger problem however is the legislative process involved, as exemplified by this ban, which only came to light because of the CARES act.
Dr. Talakoub and Naissan O. Wesley, MD, are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
In 1972, an over-the-counter drug review process was established by the Food and Drug Administration to regulate the safety and efficacy of over-the-counter (OTC) drugs. This created a book or “monograph” for each medication category that describes the active ingredients, indications, doses, route of administration, testing, and labeling. If a drug meets the criteria in its therapeutic category, it does not have to undergo an FDA review before being marketed to consumers.
As part of this process, drugs are classified into one of three categories: category I: generally recognized as safe and effective (GRASE) and not misbranded; category II: not GRASE; category III: lacking sufficient data on safety and efficacy to permit classification. This methodology was outdated and made it difficult under the old guidelines to make changes to medications in the evolving world of drug development. Some categories of OTC drugs, including hand sanitizers, hydroquinone, and sunscreens, have been marketed for years without a final monograph.
The signing of the “Coronavirus Aid, Relief, and Economic Security” (CARES) Act in March 2020 included reforms in the FDA monograph process for OTC medications. Under this proceeding, a final monograph determination was made for all OTC categories. While drugs in category I and some in category III may remain on the market, if certain specifications are met, category II drugs had to be removed within 180 days of the enactment of the CARES Act.
Hydroquinone was one of those that fell victim to the ban. This ban is similar to hydroquinone bans in other places, including Europe. However, for manufacturers, this issue was under the radar and packaged in a seemingly irrelevant piece of legislation.
Among dermatologists, there is no consensus as to whether 2% hydroquinone is safe or not. However, the unmonitored use and overuse that is common for this type of medication has led to heightened safety concerns. Common side effects of hydroquinone include irritant and allergic contact dermatitis; the most difficult to treat side effect with long-term use is ochronosis. But there are no reported cancer data in humans with the use of topical hydroquinone as previously thought. Hydroquinone used short term is a very safe and effective treatment for hard to treat hyperpigmentation and is often necessary when other topicals are ineffective, particularly in our patients with skin of color.
The bigger problem however is the legislative process involved, as exemplified by this ban, which only came to light because of the CARES act.
Dr. Talakoub and Naissan O. Wesley, MD, are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
In 1972, an over-the-counter drug review process was established by the Food and Drug Administration to regulate the safety and efficacy of over-the-counter (OTC) drugs. This created a book or “monograph” for each medication category that describes the active ingredients, indications, doses, route of administration, testing, and labeling. If a drug meets the criteria in its therapeutic category, it does not have to undergo an FDA review before being marketed to consumers.
As part of this process, drugs are classified into one of three categories: category I: generally recognized as safe and effective (GRASE) and not misbranded; category II: not GRASE; category III: lacking sufficient data on safety and efficacy to permit classification. This methodology was outdated and made it difficult under the old guidelines to make changes to medications in the evolving world of drug development. Some categories of OTC drugs, including hand sanitizers, hydroquinone, and sunscreens, have been marketed for years without a final monograph.
The signing of the “Coronavirus Aid, Relief, and Economic Security” (CARES) Act in March 2020 included reforms in the FDA monograph process for OTC medications. Under this proceeding, a final monograph determination was made for all OTC categories. While drugs in category I and some in category III may remain on the market, if certain specifications are met, category II drugs had to be removed within 180 days of the enactment of the CARES Act.
Hydroquinone was one of those that fell victim to the ban. This ban is similar to hydroquinone bans in other places, including Europe. However, for manufacturers, this issue was under the radar and packaged in a seemingly irrelevant piece of legislation.
Among dermatologists, there is no consensus as to whether 2% hydroquinone is safe or not. However, the unmonitored use and overuse that is common for this type of medication has led to heightened safety concerns. Common side effects of hydroquinone include irritant and allergic contact dermatitis; the most difficult to treat side effect with long-term use is ochronosis. But there are no reported cancer data in humans with the use of topical hydroquinone as previously thought. Hydroquinone used short term is a very safe and effective treatment for hard to treat hyperpigmentation and is often necessary when other topicals are ineffective, particularly in our patients with skin of color.
The bigger problem however is the legislative process involved, as exemplified by this ban, which only came to light because of the CARES act.
Dr. Talakoub and Naissan O. Wesley, MD, are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
Tick talk for families and pediatricians
Spring 2021 has arrived with summer quickly approaching. It is our second spring and summer during the pandemic. Travel restrictions have minimally eased for vaccinated adults. However, neither domestic nor international leisure travel is encouraged for anyone. Ironically, air travel is increasing. For many families, it is time to make decisions regarding summer activities. Outdoor activities have been encouraged throughout the pandemic, which makes it a good time to review tick-borne diseases. Depending on your location, your patients may only have to travel as far as their backyard to sustain a tick bite.
Ticks are a group of obligate, bloodsucking arthropods that feed on mammals, birds, and reptiles. There are three families of ticks. Two families, Ixodidae (hard-bodied ticks) and Argasidae (soft-bodied ticks) are responsible for transmitting the most diseases to humans in the United States. Once a tick is infected with a pathogen it usually survives and transmits it to its next host. Ticks efficiently transmit bacteria, spirochetes, protozoa, rickettsiae, nematodes, and toxins to humans during feeding when the site is exposed to infected salivary gland secretions or regurgitated midgut contents. Pathogen transmission can also occur when the feeding site is contaminated by feces or coxal fluid. Sometimes a tick can transmit multiple pathogens. Not all pathogens are infectious (e.g., tick paralysis, which occurs after exposure to a neurotoxin and red meat allergy because of alpha-gal). Ticks require a blood meal to transform to their next stage of development (larva to nymph to adult). Life cycles of hard and soft ticks differ with most hard ticks undergoing a 2-year life cycle and feeding slowly over many days. In contrast, soft ticks feed multiple times often for less than 1 hour and are capable of transmitting diseases in less than 1 minute.
Rocky Mountain spotted fever was the first recognized tick-borne disease (TBD) in humans. Since then, 18 additional pathogens transmitted by ticks have been identified with 40% being described since 1980. The increased discovery of tickborne pathogens has been attributed to physician awareness of TBD and improved diagnostics. The number of cases of TBD has risen yearly. Ticks are responsible for most vector-transmitted diseases in the United States with Lyme disease most frequently reported.
Mosquito transmission accounts for only 7% of vector-borne diseases. Three species of ticks are responsible for most human disease: Ixodes scapularis (Black-legged tick), Amblyomma americanum (Lone Star tick), and Dermacentor variabilis (American dog tick). Each is capable of transmitting agents that cause multiple diseases.
Risk for acquisition of a specific disease is dependent upon the type of tick, its geographic location, the season, and duration of the exposure.
Humans are usually incidental hosts. Tick exposure can occur year-round, but tick activity is greatest between April and September. Ticks are generally found near the ground, in brushy or wooded areas. They can climb tall grasses or shrubs and wait for a potential host to brush against them. When this occurs, they seek a site for attachment.
In the absence of a vaccine, prevention of TBD is totally dependent upon your patients/parents understanding of when and where they are at risk for exposure and for us as physicians to know which pathogens can potentially be transmitted by ticks. Data regarding potential exposure risks are based on where a TBD was diagnosed, not necessarily where it was acquired. National maps that illustrate the distribution of medically significant ticks and presence or prevalence of tick-borne pathogens in specific areas within a region previously may have been incomplete or outdated. The Centers for Disease Control and Prevention initiated a national tick surveillance program in 2017; five universities were established as regional centers of excellence to help prevent and rapidly respond to emerging vector-borne diseases across the United States. One goal is to standardize tick surveillance activities at the state level. For state-specific activity go to https://www.cdc.gov/ncezid/dvbd/vital-signs/index.html.
Prevention: Here are a few environmental interventions you can recommend to your patients
- Remove leaf litter, clear tall brush, and grass around the home and at edge of lawns. Mow the lawn frequently.
- Keep playground equipment, decks, and patios away from yard edges and trees.
- Live near a wooded area? Place a 3-ft.-wide barrier of gravel or wood chips between the areas.
- Put up a fence to keep unwanted animals out.
- Keep the yard free of potential hiding place for ticks (e.g., mattresses or furniture).
- Stack wood neatly and in a dry area.
- Use pesticides, but do not rely on them solely to prevent ticks exposure.
Personal interventions for patients when outdoors
- Use Environmental Protection Agency–registered insect repellents. Note: Oil of lemon-, eucalyptus-, and para-menthane-diol–containing products should not be used in children aged3 years or less.
- Treat clothing and gear with products containing 0.5% permethrin to repel mosquitoes and ticks.
- Check cloths for ticks. Drying clothes on high heat for 10 minutes will kill ticks. If washing is needed use hot water. Lower temperatures will not kill ticks.
- Do daily body checks for ticks after coming indoors.
- Check pets for ticks.
Tick removal
- Take tweezers, grasp the tick as close to the skin’s surface as possible.
- Pull upward. Do not twist or jerk the tick. Place in a container. Ideally submit for species identification.
- After removal, clean the bite area with alcohol or soap and water.
- Never crush a tick with your fingers.
When should you include TBD in your differential for a sick child?
Headache, fever, arthralgia, and rash are symptoms for several infectious diseases. Obtaining a history of recent activities, tick bite, or travel to areas where these diseases are more prevalent is important. You must have a high index of suspicion. Clinical and laboratory clues may help.
Delay in treatment is more detrimental. If you suspect rickettsia, ehrlichiosis, or anaplasmosis, doxycycline should be started promptly regardless of age. Consultation with an infectious disease specialist is recommended.
The United States recognizes it is not adequately prepared to address the continuing rise of vector-borne diseases. In response, on Jan. 20, 2021, the CDC’s division of vector-borne diseases with input from five federal departments and the EPA developed a joint National Public Health Framework for the Prevention and Control of Vector-Borne Diseases in Humans to tackle issues including risk, detection, diagnosis, treatment, prevention and control of TBD. Stay tuned.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures.
Spring 2021 has arrived with summer quickly approaching. It is our second spring and summer during the pandemic. Travel restrictions have minimally eased for vaccinated adults. However, neither domestic nor international leisure travel is encouraged for anyone. Ironically, air travel is increasing. For many families, it is time to make decisions regarding summer activities. Outdoor activities have been encouraged throughout the pandemic, which makes it a good time to review tick-borne diseases. Depending on your location, your patients may only have to travel as far as their backyard to sustain a tick bite.
Ticks are a group of obligate, bloodsucking arthropods that feed on mammals, birds, and reptiles. There are three families of ticks. Two families, Ixodidae (hard-bodied ticks) and Argasidae (soft-bodied ticks) are responsible for transmitting the most diseases to humans in the United States. Once a tick is infected with a pathogen it usually survives and transmits it to its next host. Ticks efficiently transmit bacteria, spirochetes, protozoa, rickettsiae, nematodes, and toxins to humans during feeding when the site is exposed to infected salivary gland secretions or regurgitated midgut contents. Pathogen transmission can also occur when the feeding site is contaminated by feces or coxal fluid. Sometimes a tick can transmit multiple pathogens. Not all pathogens are infectious (e.g., tick paralysis, which occurs after exposure to a neurotoxin and red meat allergy because of alpha-gal). Ticks require a blood meal to transform to their next stage of development (larva to nymph to adult). Life cycles of hard and soft ticks differ with most hard ticks undergoing a 2-year life cycle and feeding slowly over many days. In contrast, soft ticks feed multiple times often for less than 1 hour and are capable of transmitting diseases in less than 1 minute.
Rocky Mountain spotted fever was the first recognized tick-borne disease (TBD) in humans. Since then, 18 additional pathogens transmitted by ticks have been identified with 40% being described since 1980. The increased discovery of tickborne pathogens has been attributed to physician awareness of TBD and improved diagnostics. The number of cases of TBD has risen yearly. Ticks are responsible for most vector-transmitted diseases in the United States with Lyme disease most frequently reported.
Mosquito transmission accounts for only 7% of vector-borne diseases. Three species of ticks are responsible for most human disease: Ixodes scapularis (Black-legged tick), Amblyomma americanum (Lone Star tick), and Dermacentor variabilis (American dog tick). Each is capable of transmitting agents that cause multiple diseases.
Risk for acquisition of a specific disease is dependent upon the type of tick, its geographic location, the season, and duration of the exposure.
Humans are usually incidental hosts. Tick exposure can occur year-round, but tick activity is greatest between April and September. Ticks are generally found near the ground, in brushy or wooded areas. They can climb tall grasses or shrubs and wait for a potential host to brush against them. When this occurs, they seek a site for attachment.
In the absence of a vaccine, prevention of TBD is totally dependent upon your patients/parents understanding of when and where they are at risk for exposure and for us as physicians to know which pathogens can potentially be transmitted by ticks. Data regarding potential exposure risks are based on where a TBD was diagnosed, not necessarily where it was acquired. National maps that illustrate the distribution of medically significant ticks and presence or prevalence of tick-borne pathogens in specific areas within a region previously may have been incomplete or outdated. The Centers for Disease Control and Prevention initiated a national tick surveillance program in 2017; five universities were established as regional centers of excellence to help prevent and rapidly respond to emerging vector-borne diseases across the United States. One goal is to standardize tick surveillance activities at the state level. For state-specific activity go to https://www.cdc.gov/ncezid/dvbd/vital-signs/index.html.
Prevention: Here are a few environmental interventions you can recommend to your patients
- Remove leaf litter, clear tall brush, and grass around the home and at edge of lawns. Mow the lawn frequently.
- Keep playground equipment, decks, and patios away from yard edges and trees.
- Live near a wooded area? Place a 3-ft.-wide barrier of gravel or wood chips between the areas.
- Put up a fence to keep unwanted animals out.
- Keep the yard free of potential hiding place for ticks (e.g., mattresses or furniture).
- Stack wood neatly and in a dry area.
- Use pesticides, but do not rely on them solely to prevent ticks exposure.
Personal interventions for patients when outdoors
- Use Environmental Protection Agency–registered insect repellents. Note: Oil of lemon-, eucalyptus-, and para-menthane-diol–containing products should not be used in children aged3 years or less.
- Treat clothing and gear with products containing 0.5% permethrin to repel mosquitoes and ticks.
- Check cloths for ticks. Drying clothes on high heat for 10 minutes will kill ticks. If washing is needed use hot water. Lower temperatures will not kill ticks.
- Do daily body checks for ticks after coming indoors.
- Check pets for ticks.
Tick removal
- Take tweezers, grasp the tick as close to the skin’s surface as possible.
- Pull upward. Do not twist or jerk the tick. Place in a container. Ideally submit for species identification.
- After removal, clean the bite area with alcohol or soap and water.
- Never crush a tick with your fingers.
When should you include TBD in your differential for a sick child?
Headache, fever, arthralgia, and rash are symptoms for several infectious diseases. Obtaining a history of recent activities, tick bite, or travel to areas where these diseases are more prevalent is important. You must have a high index of suspicion. Clinical and laboratory clues may help.
Delay in treatment is more detrimental. If you suspect rickettsia, ehrlichiosis, or anaplasmosis, doxycycline should be started promptly regardless of age. Consultation with an infectious disease specialist is recommended.
The United States recognizes it is not adequately prepared to address the continuing rise of vector-borne diseases. In response, on Jan. 20, 2021, the CDC’s division of vector-borne diseases with input from five federal departments and the EPA developed a joint National Public Health Framework for the Prevention and Control of Vector-Borne Diseases in Humans to tackle issues including risk, detection, diagnosis, treatment, prevention and control of TBD. Stay tuned.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures.
Spring 2021 has arrived with summer quickly approaching. It is our second spring and summer during the pandemic. Travel restrictions have minimally eased for vaccinated adults. However, neither domestic nor international leisure travel is encouraged for anyone. Ironically, air travel is increasing. For many families, it is time to make decisions regarding summer activities. Outdoor activities have been encouraged throughout the pandemic, which makes it a good time to review tick-borne diseases. Depending on your location, your patients may only have to travel as far as their backyard to sustain a tick bite.
Ticks are a group of obligate, bloodsucking arthropods that feed on mammals, birds, and reptiles. There are three families of ticks. Two families, Ixodidae (hard-bodied ticks) and Argasidae (soft-bodied ticks) are responsible for transmitting the most diseases to humans in the United States. Once a tick is infected with a pathogen it usually survives and transmits it to its next host. Ticks efficiently transmit bacteria, spirochetes, protozoa, rickettsiae, nematodes, and toxins to humans during feeding when the site is exposed to infected salivary gland secretions or regurgitated midgut contents. Pathogen transmission can also occur when the feeding site is contaminated by feces or coxal fluid. Sometimes a tick can transmit multiple pathogens. Not all pathogens are infectious (e.g., tick paralysis, which occurs after exposure to a neurotoxin and red meat allergy because of alpha-gal). Ticks require a blood meal to transform to their next stage of development (larva to nymph to adult). Life cycles of hard and soft ticks differ with most hard ticks undergoing a 2-year life cycle and feeding slowly over many days. In contrast, soft ticks feed multiple times often for less than 1 hour and are capable of transmitting diseases in less than 1 minute.
Rocky Mountain spotted fever was the first recognized tick-borne disease (TBD) in humans. Since then, 18 additional pathogens transmitted by ticks have been identified with 40% being described since 1980. The increased discovery of tickborne pathogens has been attributed to physician awareness of TBD and improved diagnostics. The number of cases of TBD has risen yearly. Ticks are responsible for most vector-transmitted diseases in the United States with Lyme disease most frequently reported.
Mosquito transmission accounts for only 7% of vector-borne diseases. Three species of ticks are responsible for most human disease: Ixodes scapularis (Black-legged tick), Amblyomma americanum (Lone Star tick), and Dermacentor variabilis (American dog tick). Each is capable of transmitting agents that cause multiple diseases.
Risk for acquisition of a specific disease is dependent upon the type of tick, its geographic location, the season, and duration of the exposure.
Humans are usually incidental hosts. Tick exposure can occur year-round, but tick activity is greatest between April and September. Ticks are generally found near the ground, in brushy or wooded areas. They can climb tall grasses or shrubs and wait for a potential host to brush against them. When this occurs, they seek a site for attachment.
In the absence of a vaccine, prevention of TBD is totally dependent upon your patients/parents understanding of when and where they are at risk for exposure and for us as physicians to know which pathogens can potentially be transmitted by ticks. Data regarding potential exposure risks are based on where a TBD was diagnosed, not necessarily where it was acquired. National maps that illustrate the distribution of medically significant ticks and presence or prevalence of tick-borne pathogens in specific areas within a region previously may have been incomplete or outdated. The Centers for Disease Control and Prevention initiated a national tick surveillance program in 2017; five universities were established as regional centers of excellence to help prevent and rapidly respond to emerging vector-borne diseases across the United States. One goal is to standardize tick surveillance activities at the state level. For state-specific activity go to https://www.cdc.gov/ncezid/dvbd/vital-signs/index.html.
Prevention: Here are a few environmental interventions you can recommend to your patients
- Remove leaf litter, clear tall brush, and grass around the home and at edge of lawns. Mow the lawn frequently.
- Keep playground equipment, decks, and patios away from yard edges and trees.
- Live near a wooded area? Place a 3-ft.-wide barrier of gravel or wood chips between the areas.
- Put up a fence to keep unwanted animals out.
- Keep the yard free of potential hiding place for ticks (e.g., mattresses or furniture).
- Stack wood neatly and in a dry area.
- Use pesticides, but do not rely on them solely to prevent ticks exposure.
Personal interventions for patients when outdoors
- Use Environmental Protection Agency–registered insect repellents. Note: Oil of lemon-, eucalyptus-, and para-menthane-diol–containing products should not be used in children aged3 years or less.
- Treat clothing and gear with products containing 0.5% permethrin to repel mosquitoes and ticks.
- Check cloths for ticks. Drying clothes on high heat for 10 minutes will kill ticks. If washing is needed use hot water. Lower temperatures will not kill ticks.
- Do daily body checks for ticks after coming indoors.
- Check pets for ticks.
Tick removal
- Take tweezers, grasp the tick as close to the skin’s surface as possible.
- Pull upward. Do not twist or jerk the tick. Place in a container. Ideally submit for species identification.
- After removal, clean the bite area with alcohol or soap and water.
- Never crush a tick with your fingers.
When should you include TBD in your differential for a sick child?
Headache, fever, arthralgia, and rash are symptoms for several infectious diseases. Obtaining a history of recent activities, tick bite, or travel to areas where these diseases are more prevalent is important. You must have a high index of suspicion. Clinical and laboratory clues may help.
Delay in treatment is more detrimental. If you suspect rickettsia, ehrlichiosis, or anaplasmosis, doxycycline should be started promptly regardless of age. Consultation with an infectious disease specialist is recommended.
The United States recognizes it is not adequately prepared to address the continuing rise of vector-borne diseases. In response, on Jan. 20, 2021, the CDC’s division of vector-borne diseases with input from five federal departments and the EPA developed a joint National Public Health Framework for the Prevention and Control of Vector-Borne Diseases in Humans to tackle issues including risk, detection, diagnosis, treatment, prevention and control of TBD. Stay tuned.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures.
Adolescent substance use and the COVID-19 pandemic
During the past year, adolescents, families, educators, and health care providers have had to press forward through myriad challenges and stressors with flexibility and adaptability. With appropriate concern, we ask ourselves how children and youth are coping emotionally with the unprecedented changes of the past year.
Adolescent substance use represents an important area of concern. What has happened during the pandemic? Has youth substance use increased or decreased? Has access to substances increased or decreased, has monitoring and support for at-risk youth increased or decreased?
The answers to these questions are mixed. If anything, the pandemic has highlighted the heterogeneity of adolescent substance use. Now is a key time for assessment, support, and conversation with teens and families.
Monitoring the Future (MTF), a nationally representative annual survey, has provided a broad perspective on trends of adolescent substance use for decades.1 The MTF data is usually collected from February to May and was cut short in 2020 because of school closures associated with the pandemic. The sample size, though still nationally representative, was about a quarter of the typical volume. Some of the data are encouraging, including a flattening out of previous years’ stark increase in vaping of both nicotine and cannabis products (though overall numbers remain alarmingly high). Other data are more concerning including a continued increase in misuse of cough medicine, amphetamines, and inhalants among the youngest cohort surveyed (eighth graders). However, these data were largely representative of prepandemic circumstances.
The COVID-19 pandemic has significantly affected risk and protective factors for teen drug and alcohol use. Most notably, it has had a widely observed negative impact on adolescent mental health, across multiple disease categories.2 In addition, the cancellation of in-person academic and extracurricular activities such as arts and athletics markedly increased unstructured time, a known associated factor for higher-risk activities including substance use. This has also led to decreased contact with many supportive adults such as teachers and coaches. On the other hand, some adolescents now have more time with supportive parents and caregivers, more meals together, and more supervision, all of which are associated with decreased likelihood of substance use disorders.
The highly variable reasons for substance use affect highly variable pandemic-related changes in use. Understanding the impetus for use is a good place to start conversation and can help providers assess risk of escalation during the pandemic. Some teens primarily use for social enhancement while others use as a means of coping with stress or to mask or escape negative emotions. Still others continue use because of physiological dependence, craving, and other symptoms consistent with use disorders.
Highlighting the heterogeneity of this issue, one study assessing use early in the pandemic showed a decrease in the percentage of teens who use substances but an increase in frequency of use for those who are using.3 Though expected, an increase in frequency of use by oneself as compared with peers was also notable. Using substances alone is associated with more severe use disorders, carries greater risk of overdose, and can increase shame and secrecy, further fueling use disorders.
The pandemic has thus represented a protective pause for some experimental or socially motivated substance-using teens who have experienced a period of abstinence even if not fully by choice. For others, it has represented an acute amplification of risk factors and use has accelerated. This latter group includes those whose use represents an effort to cope with depression, anxiety, and loneliness or for whom isolation at home represents less monitoring, increased access, and greater exposure to substances.
Over the past year, in the treatment of adolescents struggling with substance use, many clinicians have observed a sifting effect during these unprecedented social changes. Many youth, who no longer have access to substances, have found they can “take it or leave it”. Other youth have been observed engaging in additional risk or going to greater lengths to access substances and continue their use. For both groups and everyone in between, this is an important time for screening, clinical assessment, and support.
While anticipating further research and data regarding broad substance use trends, including MTF data from 2021, recognizing that the impact of the COVID-19 pandemic is individual, with marked differences from adolescent to adolescent, will help us continue to act now to assess this important area of adolescent health. The first step for primary care providers is unchanged: to routinely screen for and discuss substance use in clinical settings.
Two brief, validated, easily accessible screening tools are available for primary care settings. They can both be self-administered and take less than 2 minutes to complete. Screening, Brief Intervention and Referral to Treatment and the Brief Screener for Tobacco, Alcohol and other Drugs can both be used for youth aged 12-17 years.4,5 Both screens are available online at drugabuse.gov.6
Routine screening will normalize conversations about substance use and healthy choices, provide opportunities for positive reinforcement, identify adolescents at risk, increase comfort and competence in providing brief intervention, and expedite referrals for additional support and treatment.
A false assumption that a particular adolescent isn’t using substances creates a missed opportunity to offer guidance and treatment. An oft-overlooked opportunity is that of providing positive reinforcement for an adolescent who isn’t using any substances or experimenting at all. Positive reinforcement is a strong component of reinforcing health maintenance.
Parent guidance and family assessment will also be critical tools. Parents and caregivers play a primary role in substance use treatment for teens and have a contributory impact on risk through both genes and environment. Of note, research suggests a moderate overall increase in adult substance use during the pandemic, particularly substances that are widely available such as alcohol. Adolescents may thus have greater access and exposure to substance use. A remarkably high percentage, 42%, of substance-using teens surveyed early in the pandemic indicated that they were using substances with their parents.3 Parents, who have equally been challenged by the pandemic, may need guidance in balancing compassion and support for struggling youth, while setting appropriate limits and maintaining expectations of healthy activities.
Unprecedented change and uncertainty provide an opportunity to reassess risks and openly discuss substance use with youth and families. Even with much on our minds during the COVID-19 pandemic, we can maintain focus on this significant risk to adolescent health and wellness. Our efforts now, from screening to treatment for adolescent substance use should be reinforced rather than delayed.
Dr. Jackson is assistant professor of psychiatry at the University of Vermont, Burlington.
References
1. Monitoringthefuture.org
2. Jones EAK et al. Int J Environ Res Public Health, 2021;18(5):2470.
3. Dumas TM et al. J Adolesc Health, 2020;67(3):354-61.
4. Levy S et al. JAMA Pediatr. 2014;168(9):822-8.
5. Kelly SM et al. Pediatrics. 2014;133(5):819-26.
6. National Institute on Drug Abuse. Adolescent Substance Use Screening Tools. 2016 Apr 27. https://www.drugabuse.gov/nidamed-medical-health-professionals/screening-tools-prevention/screening-tools-adolescent-substance-use/adolescent-substance-use-screening-tools
During the past year, adolescents, families, educators, and health care providers have had to press forward through myriad challenges and stressors with flexibility and adaptability. With appropriate concern, we ask ourselves how children and youth are coping emotionally with the unprecedented changes of the past year.
Adolescent substance use represents an important area of concern. What has happened during the pandemic? Has youth substance use increased or decreased? Has access to substances increased or decreased, has monitoring and support for at-risk youth increased or decreased?
The answers to these questions are mixed. If anything, the pandemic has highlighted the heterogeneity of adolescent substance use. Now is a key time for assessment, support, and conversation with teens and families.
Monitoring the Future (MTF), a nationally representative annual survey, has provided a broad perspective on trends of adolescent substance use for decades.1 The MTF data is usually collected from February to May and was cut short in 2020 because of school closures associated with the pandemic. The sample size, though still nationally representative, was about a quarter of the typical volume. Some of the data are encouraging, including a flattening out of previous years’ stark increase in vaping of both nicotine and cannabis products (though overall numbers remain alarmingly high). Other data are more concerning including a continued increase in misuse of cough medicine, amphetamines, and inhalants among the youngest cohort surveyed (eighth graders). However, these data were largely representative of prepandemic circumstances.
The COVID-19 pandemic has significantly affected risk and protective factors for teen drug and alcohol use. Most notably, it has had a widely observed negative impact on adolescent mental health, across multiple disease categories.2 In addition, the cancellation of in-person academic and extracurricular activities such as arts and athletics markedly increased unstructured time, a known associated factor for higher-risk activities including substance use. This has also led to decreased contact with many supportive adults such as teachers and coaches. On the other hand, some adolescents now have more time with supportive parents and caregivers, more meals together, and more supervision, all of which are associated with decreased likelihood of substance use disorders.
The highly variable reasons for substance use affect highly variable pandemic-related changes in use. Understanding the impetus for use is a good place to start conversation and can help providers assess risk of escalation during the pandemic. Some teens primarily use for social enhancement while others use as a means of coping with stress or to mask or escape negative emotions. Still others continue use because of physiological dependence, craving, and other symptoms consistent with use disorders.
Highlighting the heterogeneity of this issue, one study assessing use early in the pandemic showed a decrease in the percentage of teens who use substances but an increase in frequency of use for those who are using.3 Though expected, an increase in frequency of use by oneself as compared with peers was also notable. Using substances alone is associated with more severe use disorders, carries greater risk of overdose, and can increase shame and secrecy, further fueling use disorders.
The pandemic has thus represented a protective pause for some experimental or socially motivated substance-using teens who have experienced a period of abstinence even if not fully by choice. For others, it has represented an acute amplification of risk factors and use has accelerated. This latter group includes those whose use represents an effort to cope with depression, anxiety, and loneliness or for whom isolation at home represents less monitoring, increased access, and greater exposure to substances.
Over the past year, in the treatment of adolescents struggling with substance use, many clinicians have observed a sifting effect during these unprecedented social changes. Many youth, who no longer have access to substances, have found they can “take it or leave it”. Other youth have been observed engaging in additional risk or going to greater lengths to access substances and continue their use. For both groups and everyone in between, this is an important time for screening, clinical assessment, and support.
While anticipating further research and data regarding broad substance use trends, including MTF data from 2021, recognizing that the impact of the COVID-19 pandemic is individual, with marked differences from adolescent to adolescent, will help us continue to act now to assess this important area of adolescent health. The first step for primary care providers is unchanged: to routinely screen for and discuss substance use in clinical settings.
Two brief, validated, easily accessible screening tools are available for primary care settings. They can both be self-administered and take less than 2 minutes to complete. Screening, Brief Intervention and Referral to Treatment and the Brief Screener for Tobacco, Alcohol and other Drugs can both be used for youth aged 12-17 years.4,5 Both screens are available online at drugabuse.gov.6
Routine screening will normalize conversations about substance use and healthy choices, provide opportunities for positive reinforcement, identify adolescents at risk, increase comfort and competence in providing brief intervention, and expedite referrals for additional support and treatment.
A false assumption that a particular adolescent isn’t using substances creates a missed opportunity to offer guidance and treatment. An oft-overlooked opportunity is that of providing positive reinforcement for an adolescent who isn’t using any substances or experimenting at all. Positive reinforcement is a strong component of reinforcing health maintenance.
Parent guidance and family assessment will also be critical tools. Parents and caregivers play a primary role in substance use treatment for teens and have a contributory impact on risk through both genes and environment. Of note, research suggests a moderate overall increase in adult substance use during the pandemic, particularly substances that are widely available such as alcohol. Adolescents may thus have greater access and exposure to substance use. A remarkably high percentage, 42%, of substance-using teens surveyed early in the pandemic indicated that they were using substances with their parents.3 Parents, who have equally been challenged by the pandemic, may need guidance in balancing compassion and support for struggling youth, while setting appropriate limits and maintaining expectations of healthy activities.
Unprecedented change and uncertainty provide an opportunity to reassess risks and openly discuss substance use with youth and families. Even with much on our minds during the COVID-19 pandemic, we can maintain focus on this significant risk to adolescent health and wellness. Our efforts now, from screening to treatment for adolescent substance use should be reinforced rather than delayed.
Dr. Jackson is assistant professor of psychiatry at the University of Vermont, Burlington.
References
1. Monitoringthefuture.org
2. Jones EAK et al. Int J Environ Res Public Health, 2021;18(5):2470.
3. Dumas TM et al. J Adolesc Health, 2020;67(3):354-61.
4. Levy S et al. JAMA Pediatr. 2014;168(9):822-8.
5. Kelly SM et al. Pediatrics. 2014;133(5):819-26.
6. National Institute on Drug Abuse. Adolescent Substance Use Screening Tools. 2016 Apr 27. https://www.drugabuse.gov/nidamed-medical-health-professionals/screening-tools-prevention/screening-tools-adolescent-substance-use/adolescent-substance-use-screening-tools
During the past year, adolescents, families, educators, and health care providers have had to press forward through myriad challenges and stressors with flexibility and adaptability. With appropriate concern, we ask ourselves how children and youth are coping emotionally with the unprecedented changes of the past year.
Adolescent substance use represents an important area of concern. What has happened during the pandemic? Has youth substance use increased or decreased? Has access to substances increased or decreased, has monitoring and support for at-risk youth increased or decreased?
The answers to these questions are mixed. If anything, the pandemic has highlighted the heterogeneity of adolescent substance use. Now is a key time for assessment, support, and conversation with teens and families.
Monitoring the Future (MTF), a nationally representative annual survey, has provided a broad perspective on trends of adolescent substance use for decades.1 The MTF data is usually collected from February to May and was cut short in 2020 because of school closures associated with the pandemic. The sample size, though still nationally representative, was about a quarter of the typical volume. Some of the data are encouraging, including a flattening out of previous years’ stark increase in vaping of both nicotine and cannabis products (though overall numbers remain alarmingly high). Other data are more concerning including a continued increase in misuse of cough medicine, amphetamines, and inhalants among the youngest cohort surveyed (eighth graders). However, these data were largely representative of prepandemic circumstances.
The COVID-19 pandemic has significantly affected risk and protective factors for teen drug and alcohol use. Most notably, it has had a widely observed negative impact on adolescent mental health, across multiple disease categories.2 In addition, the cancellation of in-person academic and extracurricular activities such as arts and athletics markedly increased unstructured time, a known associated factor for higher-risk activities including substance use. This has also led to decreased contact with many supportive adults such as teachers and coaches. On the other hand, some adolescents now have more time with supportive parents and caregivers, more meals together, and more supervision, all of which are associated with decreased likelihood of substance use disorders.
The highly variable reasons for substance use affect highly variable pandemic-related changes in use. Understanding the impetus for use is a good place to start conversation and can help providers assess risk of escalation during the pandemic. Some teens primarily use for social enhancement while others use as a means of coping with stress or to mask or escape negative emotions. Still others continue use because of physiological dependence, craving, and other symptoms consistent with use disorders.
Highlighting the heterogeneity of this issue, one study assessing use early in the pandemic showed a decrease in the percentage of teens who use substances but an increase in frequency of use for those who are using.3 Though expected, an increase in frequency of use by oneself as compared with peers was also notable. Using substances alone is associated with more severe use disorders, carries greater risk of overdose, and can increase shame and secrecy, further fueling use disorders.
The pandemic has thus represented a protective pause for some experimental or socially motivated substance-using teens who have experienced a period of abstinence even if not fully by choice. For others, it has represented an acute amplification of risk factors and use has accelerated. This latter group includes those whose use represents an effort to cope with depression, anxiety, and loneliness or for whom isolation at home represents less monitoring, increased access, and greater exposure to substances.
Over the past year, in the treatment of adolescents struggling with substance use, many clinicians have observed a sifting effect during these unprecedented social changes. Many youth, who no longer have access to substances, have found they can “take it or leave it”. Other youth have been observed engaging in additional risk or going to greater lengths to access substances and continue their use. For both groups and everyone in between, this is an important time for screening, clinical assessment, and support.
While anticipating further research and data regarding broad substance use trends, including MTF data from 2021, recognizing that the impact of the COVID-19 pandemic is individual, with marked differences from adolescent to adolescent, will help us continue to act now to assess this important area of adolescent health. The first step for primary care providers is unchanged: to routinely screen for and discuss substance use in clinical settings.
Two brief, validated, easily accessible screening tools are available for primary care settings. They can both be self-administered and take less than 2 minutes to complete. Screening, Brief Intervention and Referral to Treatment and the Brief Screener for Tobacco, Alcohol and other Drugs can both be used for youth aged 12-17 years.4,5 Both screens are available online at drugabuse.gov.6
Routine screening will normalize conversations about substance use and healthy choices, provide opportunities for positive reinforcement, identify adolescents at risk, increase comfort and competence in providing brief intervention, and expedite referrals for additional support and treatment.
A false assumption that a particular adolescent isn’t using substances creates a missed opportunity to offer guidance and treatment. An oft-overlooked opportunity is that of providing positive reinforcement for an adolescent who isn’t using any substances or experimenting at all. Positive reinforcement is a strong component of reinforcing health maintenance.
Parent guidance and family assessment will also be critical tools. Parents and caregivers play a primary role in substance use treatment for teens and have a contributory impact on risk through both genes and environment. Of note, research suggests a moderate overall increase in adult substance use during the pandemic, particularly substances that are widely available such as alcohol. Adolescents may thus have greater access and exposure to substance use. A remarkably high percentage, 42%, of substance-using teens surveyed early in the pandemic indicated that they were using substances with their parents.3 Parents, who have equally been challenged by the pandemic, may need guidance in balancing compassion and support for struggling youth, while setting appropriate limits and maintaining expectations of healthy activities.
Unprecedented change and uncertainty provide an opportunity to reassess risks and openly discuss substance use with youth and families. Even with much on our minds during the COVID-19 pandemic, we can maintain focus on this significant risk to adolescent health and wellness. Our efforts now, from screening to treatment for adolescent substance use should be reinforced rather than delayed.
Dr. Jackson is assistant professor of psychiatry at the University of Vermont, Burlington.
References
1. Monitoringthefuture.org
2. Jones EAK et al. Int J Environ Res Public Health, 2021;18(5):2470.
3. Dumas TM et al. J Adolesc Health, 2020;67(3):354-61.
4. Levy S et al. JAMA Pediatr. 2014;168(9):822-8.
5. Kelly SM et al. Pediatrics. 2014;133(5):819-26.
6. National Institute on Drug Abuse. Adolescent Substance Use Screening Tools. 2016 Apr 27. https://www.drugabuse.gov/nidamed-medical-health-professionals/screening-tools-prevention/screening-tools-adolescent-substance-use/adolescent-substance-use-screening-tools
I sent my suicidal teen patient to the ED: Whew?
You read “thoughts of being better off dead” on your next patient’s PHQ-9 screen results and break into a sweat. After eliciting the teen’s realistic suicide plan and intent you send him to the ED with his parent for crisis mental health evaluation. When you call the family that evening to follow-up you hear that he was discharged with a “mental health counseling” appointment next week.
Have you done enough to prevent this child from dying at his own hand? I imagine that this haunts you as it does me. It is terrifying to know that, of youth with suicidal ideation, over one-third attempt suicide, most within 1-2 years, and 20%-40% do so without having had a plan.
We now know that certain kinds of psychotherapy have evidence for preventing subsequent suicide in teens at high risk due to suicidal ideation and past attempts. Cognitive behavioral therapy (CBT) has the best evidence including its subtypes for youth with relevant histories: for both suicide and substance use (integrated, or I-CBT), trauma focused (TF-CBT), traumatic grief (CTG-CBT), and CBT-I, for the potent risk factor of insomnia. The other treatment shown to reduce risk is dialectical behavioral therapy–adolescent (DBT-A) focused on strengthening skills in interpersonal effectiveness, mindfulness, distress tolerance, and emotion regulation adapted to youth by adding family therapy and multifamily skills training. Interpersonal psychotherapy (IPT) adapted for suicidal and self-harming adolescents (IPT-SA) also has evidence.
Some school programs have shown moderate efficacy, for example (IPT-A-IN) addresses the social and interpersonal context, and Youth Aware of Mental Health, a school curriculum to increase knowledge, help-seeking, and ways of coping with depression and suicidal behavior, that cut suicide attempts by half.
You may be able to recommend, refer to, or check to see if a youth can be provided one of the above therapies with best evidence but getting any counseling at all can be hard and some, especially minority families may decline formal interventions. Any therapy – CBT, DBT, or IPT – acceptable to the youth and family can be helpful. You can often determine if the key components are being provided by asking the teen what they are working on in therapy.
It is clear that checking in regularly with teens who have been through a suicide crisis is crucial to ensure that they continue in therapy long and consistently enough, that the family is involved in treatment, and that they are taught emotion regulation, distress tolerance, and safety planning. Warm, consistent parenting, good parent-child communication, and monitoring are protective factors but also skills that can be boosted to reduce future risk of suicide. When there is family dysfunction, conflict, or weak relationships, getting help for family relationships such as through attachment-based family therapy (ABFT) or family cognitive behavioral therapy is a priority. When bereavement or parental depression is contributing to youth suicidal thoughts, addressing these specifically can reduce suicide risk.
Sometimes family members, even with counseling, are not the best supporters for a teen in pain. When youths nominated their own support team to be informed about risk factors, diagnosis, and treatment plans and to stay in contact weekly there was a 6.6-fold lower risk of death than for nonsupported youth.
But how much of this evidence-based intervention can you ensure from your position in primary care? Refer if you can but regular supportive contacts alone reduce risk so you, trusted staff, school counselors, or even the now more available teletherapists may help. You can work with your patient to fill out a written commitment-to-safety plan (e.g. U. Colorado, CHADIS) of strategies they can use when having suicidal thoughts such as self-distractions, problem-solving, listing things they are looking forward to, things to do to get their mind off suicidal thoughts, and selecting support people to understand their situation with whom to be in regular contact. Any plan needs to take into account how understanding, supportive, and available the family is, factors you are most likely to be able to judge from your ongoing relationship, but that immediate risk may change. Contact within 48 hours, check-in within 1-2 weeks, and provision of crisis hotline information are essential actions.
Recommending home safety is part of routine anticipatory guidance but reduction of lethal means is essential in these cases. Guns are the most lethal method of suicide but discussing safe gun storage has been shown to be more effective than arguing in vain for gun removal. Medication overdose, a common means, can be reduced by not prescribing tricyclics (ineffective and more lethal), and advising parents to lock up all household medications.
You can ask about and coach teens on how to avoid the hazards of participating in online discussion groups, bullying, and cyberbullying (with risk for both perpetrator and victim), all risk factors for suicide. Managing insomnia can improve depression and is within your skills. While pediatricians can’t treat the suicide risk factors of family poverty, unemployment, or loss of culture/identity, we can refer affected families to community resources.
Repeated suicide screens can help but are imperfect, so listen to the child or parent for risk signs such as the youth having self-reported worthlessness, low self-esteem, speaking negatively about self, anhedonia, or poor emotion regulation. Children with impulsive aggression, often familial, are at special risk of suicide. This trait, while more common in ADHD, is not confined to that condition. You can help by optimizing medical management of impulsivity, when appropriate.
Most youth who attempt suicide have one or more mental health diagnoses, particularly major depressive disorder (MDD), eating disorder, ADHD, conduct, or intermittent explosive disorder. When MDD is comorbid with anxiety, suicides increase 9.5-fold. Children on the autism spectrum are more likely to have been bullied and eight times more likely to commit suicide. LGBTQ youth are five times more often bullied and are at high risk for suicide. The more common issues of school failure or substance use also confer risk. While we do our best caring for children with these conditions we may not be thinking about, screening, or monitoring for their suicide risk. It may be important for us to explain that, despite black-box warnings, rates of SSRI prescribing for depression are inversely related to suicides.
Child maltreatment is the highest risk factor for suicide (population attributed risk, or PAR, 9.6%-14.5%), particularly sexual misuse. All together, adverse childhood experiences have a PAR for suicide of 80%. Continuity allows you to monitor for developmental times when distress from past experiences often reemerges, e.g., puberty, dating onset, or divorce. Getting consent and sharing these highly sensitive but potentially triggering factors as well as prior diagnoses with a newly assigned therapist can be helpful to prioritize treatments to prevent a suicide attempt, because they may be difficult to elicit and timeliness is essential.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.
References
Brent DA. J Am Acad Child Adolesc Psychiatry. 2019;58(1):25-35.
Cha CB et al. J Child Psychol Psychiatry. 2018;59(4):460-82.
You read “thoughts of being better off dead” on your next patient’s PHQ-9 screen results and break into a sweat. After eliciting the teen’s realistic suicide plan and intent you send him to the ED with his parent for crisis mental health evaluation. When you call the family that evening to follow-up you hear that he was discharged with a “mental health counseling” appointment next week.
Have you done enough to prevent this child from dying at his own hand? I imagine that this haunts you as it does me. It is terrifying to know that, of youth with suicidal ideation, over one-third attempt suicide, most within 1-2 years, and 20%-40% do so without having had a plan.
We now know that certain kinds of psychotherapy have evidence for preventing subsequent suicide in teens at high risk due to suicidal ideation and past attempts. Cognitive behavioral therapy (CBT) has the best evidence including its subtypes for youth with relevant histories: for both suicide and substance use (integrated, or I-CBT), trauma focused (TF-CBT), traumatic grief (CTG-CBT), and CBT-I, for the potent risk factor of insomnia. The other treatment shown to reduce risk is dialectical behavioral therapy–adolescent (DBT-A) focused on strengthening skills in interpersonal effectiveness, mindfulness, distress tolerance, and emotion regulation adapted to youth by adding family therapy and multifamily skills training. Interpersonal psychotherapy (IPT) adapted for suicidal and self-harming adolescents (IPT-SA) also has evidence.
Some school programs have shown moderate efficacy, for example (IPT-A-IN) addresses the social and interpersonal context, and Youth Aware of Mental Health, a school curriculum to increase knowledge, help-seeking, and ways of coping with depression and suicidal behavior, that cut suicide attempts by half.
You may be able to recommend, refer to, or check to see if a youth can be provided one of the above therapies with best evidence but getting any counseling at all can be hard and some, especially minority families may decline formal interventions. Any therapy – CBT, DBT, or IPT – acceptable to the youth and family can be helpful. You can often determine if the key components are being provided by asking the teen what they are working on in therapy.
It is clear that checking in regularly with teens who have been through a suicide crisis is crucial to ensure that they continue in therapy long and consistently enough, that the family is involved in treatment, and that they are taught emotion regulation, distress tolerance, and safety planning. Warm, consistent parenting, good parent-child communication, and monitoring are protective factors but also skills that can be boosted to reduce future risk of suicide. When there is family dysfunction, conflict, or weak relationships, getting help for family relationships such as through attachment-based family therapy (ABFT) or family cognitive behavioral therapy is a priority. When bereavement or parental depression is contributing to youth suicidal thoughts, addressing these specifically can reduce suicide risk.
Sometimes family members, even with counseling, are not the best supporters for a teen in pain. When youths nominated their own support team to be informed about risk factors, diagnosis, and treatment plans and to stay in contact weekly there was a 6.6-fold lower risk of death than for nonsupported youth.
But how much of this evidence-based intervention can you ensure from your position in primary care? Refer if you can but regular supportive contacts alone reduce risk so you, trusted staff, school counselors, or even the now more available teletherapists may help. You can work with your patient to fill out a written commitment-to-safety plan (e.g. U. Colorado, CHADIS) of strategies they can use when having suicidal thoughts such as self-distractions, problem-solving, listing things they are looking forward to, things to do to get their mind off suicidal thoughts, and selecting support people to understand their situation with whom to be in regular contact. Any plan needs to take into account how understanding, supportive, and available the family is, factors you are most likely to be able to judge from your ongoing relationship, but that immediate risk may change. Contact within 48 hours, check-in within 1-2 weeks, and provision of crisis hotline information are essential actions.
Recommending home safety is part of routine anticipatory guidance but reduction of lethal means is essential in these cases. Guns are the most lethal method of suicide but discussing safe gun storage has been shown to be more effective than arguing in vain for gun removal. Medication overdose, a common means, can be reduced by not prescribing tricyclics (ineffective and more lethal), and advising parents to lock up all household medications.
You can ask about and coach teens on how to avoid the hazards of participating in online discussion groups, bullying, and cyberbullying (with risk for both perpetrator and victim), all risk factors for suicide. Managing insomnia can improve depression and is within your skills. While pediatricians can’t treat the suicide risk factors of family poverty, unemployment, or loss of culture/identity, we can refer affected families to community resources.
Repeated suicide screens can help but are imperfect, so listen to the child or parent for risk signs such as the youth having self-reported worthlessness, low self-esteem, speaking negatively about self, anhedonia, or poor emotion regulation. Children with impulsive aggression, often familial, are at special risk of suicide. This trait, while more common in ADHD, is not confined to that condition. You can help by optimizing medical management of impulsivity, when appropriate.
Most youth who attempt suicide have one or more mental health diagnoses, particularly major depressive disorder (MDD), eating disorder, ADHD, conduct, or intermittent explosive disorder. When MDD is comorbid with anxiety, suicides increase 9.5-fold. Children on the autism spectrum are more likely to have been bullied and eight times more likely to commit suicide. LGBTQ youth are five times more often bullied and are at high risk for suicide. The more common issues of school failure or substance use also confer risk. While we do our best caring for children with these conditions we may not be thinking about, screening, or monitoring for their suicide risk. It may be important for us to explain that, despite black-box warnings, rates of SSRI prescribing for depression are inversely related to suicides.
Child maltreatment is the highest risk factor for suicide (population attributed risk, or PAR, 9.6%-14.5%), particularly sexual misuse. All together, adverse childhood experiences have a PAR for suicide of 80%. Continuity allows you to monitor for developmental times when distress from past experiences often reemerges, e.g., puberty, dating onset, or divorce. Getting consent and sharing these highly sensitive but potentially triggering factors as well as prior diagnoses with a newly assigned therapist can be helpful to prioritize treatments to prevent a suicide attempt, because they may be difficult to elicit and timeliness is essential.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.
References
Brent DA. J Am Acad Child Adolesc Psychiatry. 2019;58(1):25-35.
Cha CB et al. J Child Psychol Psychiatry. 2018;59(4):460-82.
You read “thoughts of being better off dead” on your next patient’s PHQ-9 screen results and break into a sweat. After eliciting the teen’s realistic suicide plan and intent you send him to the ED with his parent for crisis mental health evaluation. When you call the family that evening to follow-up you hear that he was discharged with a “mental health counseling” appointment next week.
Have you done enough to prevent this child from dying at his own hand? I imagine that this haunts you as it does me. It is terrifying to know that, of youth with suicidal ideation, over one-third attempt suicide, most within 1-2 years, and 20%-40% do so without having had a plan.
We now know that certain kinds of psychotherapy have evidence for preventing subsequent suicide in teens at high risk due to suicidal ideation and past attempts. Cognitive behavioral therapy (CBT) has the best evidence including its subtypes for youth with relevant histories: for both suicide and substance use (integrated, or I-CBT), trauma focused (TF-CBT), traumatic grief (CTG-CBT), and CBT-I, for the potent risk factor of insomnia. The other treatment shown to reduce risk is dialectical behavioral therapy–adolescent (DBT-A) focused on strengthening skills in interpersonal effectiveness, mindfulness, distress tolerance, and emotion regulation adapted to youth by adding family therapy and multifamily skills training. Interpersonal psychotherapy (IPT) adapted for suicidal and self-harming adolescents (IPT-SA) also has evidence.
Some school programs have shown moderate efficacy, for example (IPT-A-IN) addresses the social and interpersonal context, and Youth Aware of Mental Health, a school curriculum to increase knowledge, help-seeking, and ways of coping with depression and suicidal behavior, that cut suicide attempts by half.
You may be able to recommend, refer to, or check to see if a youth can be provided one of the above therapies with best evidence but getting any counseling at all can be hard and some, especially minority families may decline formal interventions. Any therapy – CBT, DBT, or IPT – acceptable to the youth and family can be helpful. You can often determine if the key components are being provided by asking the teen what they are working on in therapy.
It is clear that checking in regularly with teens who have been through a suicide crisis is crucial to ensure that they continue in therapy long and consistently enough, that the family is involved in treatment, and that they are taught emotion regulation, distress tolerance, and safety planning. Warm, consistent parenting, good parent-child communication, and monitoring are protective factors but also skills that can be boosted to reduce future risk of suicide. When there is family dysfunction, conflict, or weak relationships, getting help for family relationships such as through attachment-based family therapy (ABFT) or family cognitive behavioral therapy is a priority. When bereavement or parental depression is contributing to youth suicidal thoughts, addressing these specifically can reduce suicide risk.
Sometimes family members, even with counseling, are not the best supporters for a teen in pain. When youths nominated their own support team to be informed about risk factors, diagnosis, and treatment plans and to stay in contact weekly there was a 6.6-fold lower risk of death than for nonsupported youth.
But how much of this evidence-based intervention can you ensure from your position in primary care? Refer if you can but regular supportive contacts alone reduce risk so you, trusted staff, school counselors, or even the now more available teletherapists may help. You can work with your patient to fill out a written commitment-to-safety plan (e.g. U. Colorado, CHADIS) of strategies they can use when having suicidal thoughts such as self-distractions, problem-solving, listing things they are looking forward to, things to do to get their mind off suicidal thoughts, and selecting support people to understand their situation with whom to be in regular contact. Any plan needs to take into account how understanding, supportive, and available the family is, factors you are most likely to be able to judge from your ongoing relationship, but that immediate risk may change. Contact within 48 hours, check-in within 1-2 weeks, and provision of crisis hotline information are essential actions.
Recommending home safety is part of routine anticipatory guidance but reduction of lethal means is essential in these cases. Guns are the most lethal method of suicide but discussing safe gun storage has been shown to be more effective than arguing in vain for gun removal. Medication overdose, a common means, can be reduced by not prescribing tricyclics (ineffective and more lethal), and advising parents to lock up all household medications.
You can ask about and coach teens on how to avoid the hazards of participating in online discussion groups, bullying, and cyberbullying (with risk for both perpetrator and victim), all risk factors for suicide. Managing insomnia can improve depression and is within your skills. While pediatricians can’t treat the suicide risk factors of family poverty, unemployment, or loss of culture/identity, we can refer affected families to community resources.
Repeated suicide screens can help but are imperfect, so listen to the child or parent for risk signs such as the youth having self-reported worthlessness, low self-esteem, speaking negatively about self, anhedonia, or poor emotion regulation. Children with impulsive aggression, often familial, are at special risk of suicide. This trait, while more common in ADHD, is not confined to that condition. You can help by optimizing medical management of impulsivity, when appropriate.
Most youth who attempt suicide have one or more mental health diagnoses, particularly major depressive disorder (MDD), eating disorder, ADHD, conduct, or intermittent explosive disorder. When MDD is comorbid with anxiety, suicides increase 9.5-fold. Children on the autism spectrum are more likely to have been bullied and eight times more likely to commit suicide. LGBTQ youth are five times more often bullied and are at high risk for suicide. The more common issues of school failure or substance use also confer risk. While we do our best caring for children with these conditions we may not be thinking about, screening, or monitoring for their suicide risk. It may be important for us to explain that, despite black-box warnings, rates of SSRI prescribing for depression are inversely related to suicides.
Child maltreatment is the highest risk factor for suicide (population attributed risk, or PAR, 9.6%-14.5%), particularly sexual misuse. All together, adverse childhood experiences have a PAR for suicide of 80%. Continuity allows you to monitor for developmental times when distress from past experiences often reemerges, e.g., puberty, dating onset, or divorce. Getting consent and sharing these highly sensitive but potentially triggering factors as well as prior diagnoses with a newly assigned therapist can be helpful to prioritize treatments to prevent a suicide attempt, because they may be difficult to elicit and timeliness is essential.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.
References
Brent DA. J Am Acad Child Adolesc Psychiatry. 2019;58(1):25-35.
Cha CB et al. J Child Psychol Psychiatry. 2018;59(4):460-82.
Seaweed and other marine-derived products in skin care, part 1: Current indications
Marine algae are relatively common raw sources for cosmeceutical products.1 The photoprotective compounds identified among marine algae range from mycosporinelike amino acids, sulfated polysaccharides, and carotenoids to polyphenols, all of which are noted for absorbing UV and conferring antioxidant, matrix metalloproteinase–suppressing, anti-aging, and immunomodulatory effects.2 Such biologic activities understandably account for the interest in harnessing their potential in the skin care realm. Indeed, marine ingredients have been steadily flowing into the market for skin care, and research has proliferated – so much so, in fact, that I’ll take two columns to cover some of the most recent research on various marine species and some of the indications or potential uses for these products in skin care.
Key activities and potential uses
Kim and associates note that carbohydrates are the primary components of marine algae, with copious amounts delivering a moisturizing and thickening effect when incorporated into cosmetic products. They add that marine carbohydrates are also known to impart antioxidant, antimelanogenic, and anti-aging activities.3
In 2017, Colantonio and Rivers reviewed the evidence supporting the use of seaweed, among other plants, for dermatologic purposes. The researchers considered four plants and algae (seaweed, witch hazel, bearberry, and mayapple) used in traditional First Nations approaches to skin disease. They found that seaweed shows promise for clinical use in treating acne and wrinkles and could deliver healthy benefits when included in biofunctional textiles.4
Atopic dermatitis
Found in the seaweed Fucus vesiculosus, fucoidan is known to impart anti-inflammatory, antioxidant, and antitumor activity.5 In a 2019 BALB/c mouse study, Tian and associates showed that fucoidan, which is rich in polysaccharides, significantly improved ear swelling and skin lesions and reduced inflammatory cell infiltration. Given the resolution of the 2,4-dinitrofluorobenzene–induced atopic dermatitis symptoms, the investigators suggested that fucoidan may have potential as an anti-AD agent.5
Also that year, Gil and associates studied the effects of Seaweed fulvescens, a chlorophyll-rich green alga (also called Maesaengi) known to have antioxidant properties, in a mouse model of Dermatophagoides farinae body-induced AD and in tumor necrosis factor–alpha and interferon-gamma–stimulated HaCaT keratinocytes. They observed that 200-mg/mouse treatment hindered AD symptom development, compared with controls, with enhanced dorsal skin lesions, diminished thickness and infiltration of inflammation, and decreased proinflammatory cytokines. In addition, the investigators reported the dose-dependent inhibition of proinflammatory cytokine synthesis in HaCaT keratinocytes. They concluded that Seaweed fulvescens shows promise as a therapeutic option for AD treatment.6
Alopecia
In 2017, Kang and associates studied the impact and mechanism of Undariopsis peterseniana, an edible brown alga, and determined that the extract promotes hair growth by activating the Wnt/beta-catenin and ERK pathways. Specifically, they found that U. peterseniana significantly enhanced hair-fiber length ex vivo and in vivo. They also concluded that the brown alga has potential to treat alopecia as it accelerated anagen initiation.7
Skin protection potential of Ishige okamurae
In 2015, Piao and associates demonstrated that diphlorethohydroxycarmalol (DPHC), a phlorotannin isolated from Ishige okamurae, protected human keratinocytes from UVB-induced matrix metalloproteinase (MMP) expression by inactivating ERK and JNK. MMPs are known to contribute to photoaging and tumor promotion.8
Early in 2020, Wang and associates demonstrated that DPHC, isolated from the marine brown alga I. okamurae, exerted protective effects against UVB-induced photodamage in vitro in human dermal fibroblasts and in vivo in zebrafish by suppressing collagenase and elastase production and the expression of matrix metalloproteinases. In vivo, the brown alga extract lowered cell death by decreasing lipid peroxidation and inflammatory response. The investigators concluded that DPHC warrants consideration as an ingredient in cosmeceutical formulations intended to protect against the effects of UVB radiation.9
The same team also reported on their study of the protective effects of DPHC against skin damage in human dermal fibroblasts caused by particulate matter. They found that DPHC dose-dependently exerted significant decreases in intracellular synthesis of reactive oxygen species. The seaweed product also stimulated collagen production and suppressed collagenase activity, as well as matrix metalloproteinases. The researchers concluded that DPHC may be an effective skin-protective ingredient against particulate matter for use in cosmeceutical products.10
Skin protection mouse studies using various marine species
The last 3 years alone have featured several studies in mice that may have significant implications in accelerating our understanding of how to harness the bioactive properties of multiple marine species.
In 2018, Wiraguna and associates studied the protective effects of 0.2% and 0.4% Caulerpa sp. (a genus of seaweed native to the Indo-Pacific region) extract gels on photoaging in the UVB-irradiated skin of Wistar mice, finding that topical applications of both concentrations of the seaweed extract protected mouse skin from UVB-induced photoaging, with treated mice revealed to have higher collagen expression and preserved collagen structure and decreased MMP-1 levels, compared with vehicle controls.11
The next year, Prasedya and associates showed that the brown macroalgae Sargassum cristafolium exerted photoprotective activity against UVA in mice. Mice pretreated with the seaweed before exposure displayed intact collagen formation and no increases in epidermal thickness, compared with controls.12
At the same time, Santos and associates demonstrated that mice fed a diet supplemented with the red seaweed Porphyra umbilicalis experienced significant decreases in the incidence of human papillomavirus type 16–induced premalignant dysplastic skin lesions.13
Also that year, Zhen and associates evaluated the protective effects of eckol, a phlorotannin isolated from brown seaweed, on human HaCaT keratinocytes against PM2.5-induced cell damage. They showed that eckol (30 mcm) reduced reactive oxygen species production and protected cells from apoptosis by hampering the MAPK signaling pathway.14Earlier that year, Kim and associates studied the viability of the microalga Nannochloropsis oceanica, considered most often as a possible biofuel, for potential photoprotective activity against UVB-irradiated human dermal fibroblasts. They determined that pigment extracts (violaxanthin was identified as the main pigment) were not cytotoxic to the fibroblasts and that treatment with the pigment extract upregulated collagen expression and significantly inhibited UVB-induced damage. Further study revealed that violaxanthin significantly mitigated UVB-induced G1 phase arrest, senescence-associated beta-galactosidase activation, and p16 and p21 up-regulation, among other functions, suggesting its consideration, according to the authors, as a possible antiphotoaging agent.15
Finally, early in 2020, Bellan and associates evaluated the antitumor characteristics of the sulfated heterorhamnan derived from the green seaweed Gayralia brasiliensis as seen on the biological activities in the B16-F10 murine melanoma cell line. The polysaccharidic fraction was found to be effective in reducing melanoma cell migration and invasion capacity.16
Conclusion
. Evidence suggests widespread potential across several species for dermatologic purposes. Indeed, data indicate that some species appear to be suited for treating AD, alopecia, and wrinkles and may possibly render effective photoprotection. More research is necessary, of course, to ascertain the extent to which such ingredients can adequately address cutaneous health and how truly effective the marine ingredients are in currently marketed products.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions, a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at dermnews@mdedge.com.
References
1. Fabrowska J et al. Acta Pol Pharm. 2017 Mar;74(2):633-41.
2. Pangestuti R et al. Mar Drugs. 2018 Oct 23;16(11):399.
3. Kim JH et al. Mar Drugs. 2018 Nov 21;16(11):459.
4. Colantonio S & Rivers JK. J Cutan Med Surg. Jul/Aug 2017;21(4):299-307.
5. Tian T et al. Int Immunopharmacol. 2019 Oct;75:105823.
6. Gil TY et al. Mediators Inflamm. 2019 Mar 17;2019:3760934.
7. Kang JI et al. Mar Drugs. 2017 May 5;15(5):130.
8. Piao MJ et al. Biomol Ther (Seoul). 2015 Nov;23(6):557-63.
9. Wang L et al. Food Chem Toxicol. 2020 Feb;136:110963.
10. Wang L et al. Molecules. 2020 Feb 26;25(5):1055.
11. Wiraguna AAGP et al. Dermatol Reports. 2018 Oct 1;10(2):7597.
12. Prasedya ES et al. Biomedicines. 2019 Sep 27;7(4):77.
13. Santos S et al. Mar Drugs. 2019 Oct 29;17(11):615.
14. Zhen AX et al. Mar Drugs. 2019 Jul 27;17(8):444.
15. Kim HM et al. Photochem Photobiol. 2019 Mar;95(2):595-604.
16. Bellan DL et al. Mar Biotechnol. 2020 Apr;22(2):194-206.
Marine algae are relatively common raw sources for cosmeceutical products.1 The photoprotective compounds identified among marine algae range from mycosporinelike amino acids, sulfated polysaccharides, and carotenoids to polyphenols, all of which are noted for absorbing UV and conferring antioxidant, matrix metalloproteinase–suppressing, anti-aging, and immunomodulatory effects.2 Such biologic activities understandably account for the interest in harnessing their potential in the skin care realm. Indeed, marine ingredients have been steadily flowing into the market for skin care, and research has proliferated – so much so, in fact, that I’ll take two columns to cover some of the most recent research on various marine species and some of the indications or potential uses for these products in skin care.
Key activities and potential uses
Kim and associates note that carbohydrates are the primary components of marine algae, with copious amounts delivering a moisturizing and thickening effect when incorporated into cosmetic products. They add that marine carbohydrates are also known to impart antioxidant, antimelanogenic, and anti-aging activities.3
In 2017, Colantonio and Rivers reviewed the evidence supporting the use of seaweed, among other plants, for dermatologic purposes. The researchers considered four plants and algae (seaweed, witch hazel, bearberry, and mayapple) used in traditional First Nations approaches to skin disease. They found that seaweed shows promise for clinical use in treating acne and wrinkles and could deliver healthy benefits when included in biofunctional textiles.4
Atopic dermatitis
Found in the seaweed Fucus vesiculosus, fucoidan is known to impart anti-inflammatory, antioxidant, and antitumor activity.5 In a 2019 BALB/c mouse study, Tian and associates showed that fucoidan, which is rich in polysaccharides, significantly improved ear swelling and skin lesions and reduced inflammatory cell infiltration. Given the resolution of the 2,4-dinitrofluorobenzene–induced atopic dermatitis symptoms, the investigators suggested that fucoidan may have potential as an anti-AD agent.5
Also that year, Gil and associates studied the effects of Seaweed fulvescens, a chlorophyll-rich green alga (also called Maesaengi) known to have antioxidant properties, in a mouse model of Dermatophagoides farinae body-induced AD and in tumor necrosis factor–alpha and interferon-gamma–stimulated HaCaT keratinocytes. They observed that 200-mg/mouse treatment hindered AD symptom development, compared with controls, with enhanced dorsal skin lesions, diminished thickness and infiltration of inflammation, and decreased proinflammatory cytokines. In addition, the investigators reported the dose-dependent inhibition of proinflammatory cytokine synthesis in HaCaT keratinocytes. They concluded that Seaweed fulvescens shows promise as a therapeutic option for AD treatment.6
Alopecia
In 2017, Kang and associates studied the impact and mechanism of Undariopsis peterseniana, an edible brown alga, and determined that the extract promotes hair growth by activating the Wnt/beta-catenin and ERK pathways. Specifically, they found that U. peterseniana significantly enhanced hair-fiber length ex vivo and in vivo. They also concluded that the brown alga has potential to treat alopecia as it accelerated anagen initiation.7
Skin protection potential of Ishige okamurae
In 2015, Piao and associates demonstrated that diphlorethohydroxycarmalol (DPHC), a phlorotannin isolated from Ishige okamurae, protected human keratinocytes from UVB-induced matrix metalloproteinase (MMP) expression by inactivating ERK and JNK. MMPs are known to contribute to photoaging and tumor promotion.8
Early in 2020, Wang and associates demonstrated that DPHC, isolated from the marine brown alga I. okamurae, exerted protective effects against UVB-induced photodamage in vitro in human dermal fibroblasts and in vivo in zebrafish by suppressing collagenase and elastase production and the expression of matrix metalloproteinases. In vivo, the brown alga extract lowered cell death by decreasing lipid peroxidation and inflammatory response. The investigators concluded that DPHC warrants consideration as an ingredient in cosmeceutical formulations intended to protect against the effects of UVB radiation.9
The same team also reported on their study of the protective effects of DPHC against skin damage in human dermal fibroblasts caused by particulate matter. They found that DPHC dose-dependently exerted significant decreases in intracellular synthesis of reactive oxygen species. The seaweed product also stimulated collagen production and suppressed collagenase activity, as well as matrix metalloproteinases. The researchers concluded that DPHC may be an effective skin-protective ingredient against particulate matter for use in cosmeceutical products.10
Skin protection mouse studies using various marine species
The last 3 years alone have featured several studies in mice that may have significant implications in accelerating our understanding of how to harness the bioactive properties of multiple marine species.
In 2018, Wiraguna and associates studied the protective effects of 0.2% and 0.4% Caulerpa sp. (a genus of seaweed native to the Indo-Pacific region) extract gels on photoaging in the UVB-irradiated skin of Wistar mice, finding that topical applications of both concentrations of the seaweed extract protected mouse skin from UVB-induced photoaging, with treated mice revealed to have higher collagen expression and preserved collagen structure and decreased MMP-1 levels, compared with vehicle controls.11
The next year, Prasedya and associates showed that the brown macroalgae Sargassum cristafolium exerted photoprotective activity against UVA in mice. Mice pretreated with the seaweed before exposure displayed intact collagen formation and no increases in epidermal thickness, compared with controls.12
At the same time, Santos and associates demonstrated that mice fed a diet supplemented with the red seaweed Porphyra umbilicalis experienced significant decreases in the incidence of human papillomavirus type 16–induced premalignant dysplastic skin lesions.13
Also that year, Zhen and associates evaluated the protective effects of eckol, a phlorotannin isolated from brown seaweed, on human HaCaT keratinocytes against PM2.5-induced cell damage. They showed that eckol (30 mcm) reduced reactive oxygen species production and protected cells from apoptosis by hampering the MAPK signaling pathway.14Earlier that year, Kim and associates studied the viability of the microalga Nannochloropsis oceanica, considered most often as a possible biofuel, for potential photoprotective activity against UVB-irradiated human dermal fibroblasts. They determined that pigment extracts (violaxanthin was identified as the main pigment) were not cytotoxic to the fibroblasts and that treatment with the pigment extract upregulated collagen expression and significantly inhibited UVB-induced damage. Further study revealed that violaxanthin significantly mitigated UVB-induced G1 phase arrest, senescence-associated beta-galactosidase activation, and p16 and p21 up-regulation, among other functions, suggesting its consideration, according to the authors, as a possible antiphotoaging agent.15
Finally, early in 2020, Bellan and associates evaluated the antitumor characteristics of the sulfated heterorhamnan derived from the green seaweed Gayralia brasiliensis as seen on the biological activities in the B16-F10 murine melanoma cell line. The polysaccharidic fraction was found to be effective in reducing melanoma cell migration and invasion capacity.16
Conclusion
. Evidence suggests widespread potential across several species for dermatologic purposes. Indeed, data indicate that some species appear to be suited for treating AD, alopecia, and wrinkles and may possibly render effective photoprotection. More research is necessary, of course, to ascertain the extent to which such ingredients can adequately address cutaneous health and how truly effective the marine ingredients are in currently marketed products.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions, a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at dermnews@mdedge.com.
References
1. Fabrowska J et al. Acta Pol Pharm. 2017 Mar;74(2):633-41.
2. Pangestuti R et al. Mar Drugs. 2018 Oct 23;16(11):399.
3. Kim JH et al. Mar Drugs. 2018 Nov 21;16(11):459.
4. Colantonio S & Rivers JK. J Cutan Med Surg. Jul/Aug 2017;21(4):299-307.
5. Tian T et al. Int Immunopharmacol. 2019 Oct;75:105823.
6. Gil TY et al. Mediators Inflamm. 2019 Mar 17;2019:3760934.
7. Kang JI et al. Mar Drugs. 2017 May 5;15(5):130.
8. Piao MJ et al. Biomol Ther (Seoul). 2015 Nov;23(6):557-63.
9. Wang L et al. Food Chem Toxicol. 2020 Feb;136:110963.
10. Wang L et al. Molecules. 2020 Feb 26;25(5):1055.
11. Wiraguna AAGP et al. Dermatol Reports. 2018 Oct 1;10(2):7597.
12. Prasedya ES et al. Biomedicines. 2019 Sep 27;7(4):77.
13. Santos S et al. Mar Drugs. 2019 Oct 29;17(11):615.
14. Zhen AX et al. Mar Drugs. 2019 Jul 27;17(8):444.
15. Kim HM et al. Photochem Photobiol. 2019 Mar;95(2):595-604.
16. Bellan DL et al. Mar Biotechnol. 2020 Apr;22(2):194-206.
Marine algae are relatively common raw sources for cosmeceutical products.1 The photoprotective compounds identified among marine algae range from mycosporinelike amino acids, sulfated polysaccharides, and carotenoids to polyphenols, all of which are noted for absorbing UV and conferring antioxidant, matrix metalloproteinase–suppressing, anti-aging, and immunomodulatory effects.2 Such biologic activities understandably account for the interest in harnessing their potential in the skin care realm. Indeed, marine ingredients have been steadily flowing into the market for skin care, and research has proliferated – so much so, in fact, that I’ll take two columns to cover some of the most recent research on various marine species and some of the indications or potential uses for these products in skin care.
Key activities and potential uses
Kim and associates note that carbohydrates are the primary components of marine algae, with copious amounts delivering a moisturizing and thickening effect when incorporated into cosmetic products. They add that marine carbohydrates are also known to impart antioxidant, antimelanogenic, and anti-aging activities.3
In 2017, Colantonio and Rivers reviewed the evidence supporting the use of seaweed, among other plants, for dermatologic purposes. The researchers considered four plants and algae (seaweed, witch hazel, bearberry, and mayapple) used in traditional First Nations approaches to skin disease. They found that seaweed shows promise for clinical use in treating acne and wrinkles and could deliver healthy benefits when included in biofunctional textiles.4
Atopic dermatitis
Found in the seaweed Fucus vesiculosus, fucoidan is known to impart anti-inflammatory, antioxidant, and antitumor activity.5 In a 2019 BALB/c mouse study, Tian and associates showed that fucoidan, which is rich in polysaccharides, significantly improved ear swelling and skin lesions and reduced inflammatory cell infiltration. Given the resolution of the 2,4-dinitrofluorobenzene–induced atopic dermatitis symptoms, the investigators suggested that fucoidan may have potential as an anti-AD agent.5
Also that year, Gil and associates studied the effects of Seaweed fulvescens, a chlorophyll-rich green alga (also called Maesaengi) known to have antioxidant properties, in a mouse model of Dermatophagoides farinae body-induced AD and in tumor necrosis factor–alpha and interferon-gamma–stimulated HaCaT keratinocytes. They observed that 200-mg/mouse treatment hindered AD symptom development, compared with controls, with enhanced dorsal skin lesions, diminished thickness and infiltration of inflammation, and decreased proinflammatory cytokines. In addition, the investigators reported the dose-dependent inhibition of proinflammatory cytokine synthesis in HaCaT keratinocytes. They concluded that Seaweed fulvescens shows promise as a therapeutic option for AD treatment.6
Alopecia
In 2017, Kang and associates studied the impact and mechanism of Undariopsis peterseniana, an edible brown alga, and determined that the extract promotes hair growth by activating the Wnt/beta-catenin and ERK pathways. Specifically, they found that U. peterseniana significantly enhanced hair-fiber length ex vivo and in vivo. They also concluded that the brown alga has potential to treat alopecia as it accelerated anagen initiation.7
Skin protection potential of Ishige okamurae
In 2015, Piao and associates demonstrated that diphlorethohydroxycarmalol (DPHC), a phlorotannin isolated from Ishige okamurae, protected human keratinocytes from UVB-induced matrix metalloproteinase (MMP) expression by inactivating ERK and JNK. MMPs are known to contribute to photoaging and tumor promotion.8
Early in 2020, Wang and associates demonstrated that DPHC, isolated from the marine brown alga I. okamurae, exerted protective effects against UVB-induced photodamage in vitro in human dermal fibroblasts and in vivo in zebrafish by suppressing collagenase and elastase production and the expression of matrix metalloproteinases. In vivo, the brown alga extract lowered cell death by decreasing lipid peroxidation and inflammatory response. The investigators concluded that DPHC warrants consideration as an ingredient in cosmeceutical formulations intended to protect against the effects of UVB radiation.9
The same team also reported on their study of the protective effects of DPHC against skin damage in human dermal fibroblasts caused by particulate matter. They found that DPHC dose-dependently exerted significant decreases in intracellular synthesis of reactive oxygen species. The seaweed product also stimulated collagen production and suppressed collagenase activity, as well as matrix metalloproteinases. The researchers concluded that DPHC may be an effective skin-protective ingredient against particulate matter for use in cosmeceutical products.10
Skin protection mouse studies using various marine species
The last 3 years alone have featured several studies in mice that may have significant implications in accelerating our understanding of how to harness the bioactive properties of multiple marine species.
In 2018, Wiraguna and associates studied the protective effects of 0.2% and 0.4% Caulerpa sp. (a genus of seaweed native to the Indo-Pacific region) extract gels on photoaging in the UVB-irradiated skin of Wistar mice, finding that topical applications of both concentrations of the seaweed extract protected mouse skin from UVB-induced photoaging, with treated mice revealed to have higher collagen expression and preserved collagen structure and decreased MMP-1 levels, compared with vehicle controls.11
The next year, Prasedya and associates showed that the brown macroalgae Sargassum cristafolium exerted photoprotective activity against UVA in mice. Mice pretreated with the seaweed before exposure displayed intact collagen formation and no increases in epidermal thickness, compared with controls.12
At the same time, Santos and associates demonstrated that mice fed a diet supplemented with the red seaweed Porphyra umbilicalis experienced significant decreases in the incidence of human papillomavirus type 16–induced premalignant dysplastic skin lesions.13
Also that year, Zhen and associates evaluated the protective effects of eckol, a phlorotannin isolated from brown seaweed, on human HaCaT keratinocytes against PM2.5-induced cell damage. They showed that eckol (30 mcm) reduced reactive oxygen species production and protected cells from apoptosis by hampering the MAPK signaling pathway.14Earlier that year, Kim and associates studied the viability of the microalga Nannochloropsis oceanica, considered most often as a possible biofuel, for potential photoprotective activity against UVB-irradiated human dermal fibroblasts. They determined that pigment extracts (violaxanthin was identified as the main pigment) were not cytotoxic to the fibroblasts and that treatment with the pigment extract upregulated collagen expression and significantly inhibited UVB-induced damage. Further study revealed that violaxanthin significantly mitigated UVB-induced G1 phase arrest, senescence-associated beta-galactosidase activation, and p16 and p21 up-regulation, among other functions, suggesting its consideration, according to the authors, as a possible antiphotoaging agent.15
Finally, early in 2020, Bellan and associates evaluated the antitumor characteristics of the sulfated heterorhamnan derived from the green seaweed Gayralia brasiliensis as seen on the biological activities in the B16-F10 murine melanoma cell line. The polysaccharidic fraction was found to be effective in reducing melanoma cell migration and invasion capacity.16
Conclusion
. Evidence suggests widespread potential across several species for dermatologic purposes. Indeed, data indicate that some species appear to be suited for treating AD, alopecia, and wrinkles and may possibly render effective photoprotection. More research is necessary, of course, to ascertain the extent to which such ingredients can adequately address cutaneous health and how truly effective the marine ingredients are in currently marketed products.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions, a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at dermnews@mdedge.com.
References
1. Fabrowska J et al. Acta Pol Pharm. 2017 Mar;74(2):633-41.
2. Pangestuti R et al. Mar Drugs. 2018 Oct 23;16(11):399.
3. Kim JH et al. Mar Drugs. 2018 Nov 21;16(11):459.
4. Colantonio S & Rivers JK. J Cutan Med Surg. Jul/Aug 2017;21(4):299-307.
5. Tian T et al. Int Immunopharmacol. 2019 Oct;75:105823.
6. Gil TY et al. Mediators Inflamm. 2019 Mar 17;2019:3760934.
7. Kang JI et al. Mar Drugs. 2017 May 5;15(5):130.
8. Piao MJ et al. Biomol Ther (Seoul). 2015 Nov;23(6):557-63.
9. Wang L et al. Food Chem Toxicol. 2020 Feb;136:110963.
10. Wang L et al. Molecules. 2020 Feb 26;25(5):1055.
11. Wiraguna AAGP et al. Dermatol Reports. 2018 Oct 1;10(2):7597.
12. Prasedya ES et al. Biomedicines. 2019 Sep 27;7(4):77.
13. Santos S et al. Mar Drugs. 2019 Oct 29;17(11):615.
14. Zhen AX et al. Mar Drugs. 2019 Jul 27;17(8):444.
15. Kim HM et al. Photochem Photobiol. 2019 Mar;95(2):595-604.
16. Bellan DL et al. Mar Biotechnol. 2020 Apr;22(2):194-206.