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This spring, many parts of United States experienced historic heat waves. Now summer is officially underway, and experts are predicting hotter than normal temperatures across most of the country.

Extreme temperatures increase health risks for people with chronic conditions, including heart problems. If you do have a heart condition, here’s how to keep cool and protect yourself when temperatures rise.

How does hot weather affect the heart?

Not only does exposure to high heat increase the risk for heat exhaustion and heat stroke, but it can also place a particular burden on heart health. It stresses the cardiovascular system and makes the heart work harder. This can increase the chance of heart attacks, heart arrhythmias (irregular heartbeat), and heart failure.

According to the Environmental Protection Agency, the interaction of high heat and cardiovascular disease contributes to about a quarter of heat-related deaths.

And the higher the temperature, the greater the threat. A recent study in the journal Circulation looked at cardiovascular death rates over seven years in Kuwait, where daytime temperatures can reach triple digits in the hottest months. The researchers found a link between rising temperatures and the risk of cardiovascular deaths, with most occurring between temperatures of 95° F to 109° F.

“Climate change is giving us more, and unprecedented, heat that can be deadly, especially for people with heart disease,” says Dr. Aaron Bernstein, interim director of the Center for Climate, Health, and the Global Environment at Harvard T.H. Chan School of Public Health.

How does the body shed heat?

Your body is designed to shed extra heat in two major ways, each of which may affect the heart:

Radiation. When the air around you is cooler than your body, you radiate extra heat into the air. This process requires rerouting blood flow so that more of it goes to the skin.

Evaporation. Evaporating sweat helps cool you down by pulling heat away from your skin. When the air is dry, this works well. But when it’s hot and humid, sweat just sits on the skin as your body temperature rises.

When air temperature approaches or exceeds body temperature, especially in high humidity, the heart has to beat faster and pump harder to help your body shed heat. On a hot and humid day, your heart may circulate two to four times as much blood each minute compared with a cool day.

Some medicines meant to help the heart can add to problems on hot days. For example, beta blockers slow the heartbeat and hinder the heart’s ability to circulate blood fast enough for effective heat exchange. Diuretics (water pills) increase urine output and raise the risk of dehydration.

How can you protect yourself and your heart when temperatures rise?

While exposure to high heat and heat waves affects everyone, having existing heart problems raises your risk for heat-related illness and hospitalization. So it’s especially important to try to follow basic strategies for staying cool, including these:

• Monitor weather forecasts for heat advisories and stay inside on those days. If home is too hot, check with your town or city health department for cooling centers and other options to help you stay cool. If you venture outside, evening and early morning are often the coolest times. Rest in the shade whenever possible.
• When outside, try to drink 8 ounces of water every 20 minutes. Set a timer to remind you. “Never wait until you’re thirsty to drink,” says Dr. Bernstein. If you have heart failure, ask your doctor how much fluid you should drink daily, since fluids can build up and cause swelling. If you take diuretics, ask how much you should drink during hot weather.
• Avoid soda or fruit juice and limit alcohol. Soda and fruit juice may slow the passage of water from the digestive system to the bloodstream. While research is limited, some studies have found that excessive alcohol intake may raise risk for heat stroke during scorching weather.
• Protect your skin. Sunburn affects your body’s ability to cool down and increases dehydration. Wear a wide-brimmed hat, wraparound sunglasses, and lightweight, light-colored, loose-fitting clothing. Also, apply plenty of broad-spectrum or UVA/UVB protection sunscreen with SPF 30 or higher to all exposed skin 30 minutes before going out. Reapply every hour.

About the Author

Matthew Solan, Executive Editor, Harvard Men's Health Watch

Matthew Solan is the executive editor of Harvard Men’s Health Watch. He previously served as executive editor for UCLA Health’s Healthy Years and as a contributor to Duke Medicine’s Health News and Weill Cornell Medical College’s … See Full Bio View all posts by Matthew Solan

If you’ve ever struggled with low back pain, you know that it can be surprisingly debilitating, even if the discomfort is short-term. You may find it difficult to grocery shop, do housework, play sports, or even tie your shoelaces. When back pain is chronic, lasting 12 weeks or longer, it can impair quality of life and physical function, and contribute to or worsen stress, anxiety, and depression.

While people dealing with chronic back pain are often directed to physical therapy, research shows that psychological approaches that teach strategies to manage your experience of pain can help. So, would combining these approaches do more to ease the pain? A recent systematic review of multiple studies suggests that it might.

How big is this problem, and what did this study find?

Worldwide, low back pain is a leading cause of disability and affects more than 560 million people. In the US, four in 10 people surveyed in 2019 had experienced low back pain within the past three months, according to the Centers for Disease Control and Prevention.

Published in TheBMJ, the review drew on 97 studies of adults experiencing chronic, nonspecific low back pain, with or without leg pain. Using statistical modeling, the researchers compared the effectiveness of therapies aimed at improving

• physical function, such as standing, climbing stairs, and managing personal care
• fear avoidance, because fear of pain can lead people to avoid movement, which contributes to the cycle of muscle weakening and further pain
• pain intensity, measured by pain scores from validated rating scales.

The review revealed that physical therapy plus psychological approaches, such as pain education and cognitive behavioral therapy, more effectively improved chronic low back pain than physical therapy alone. More specifically:

• For improving physical function and fear avoidance, pain education programs in conjunction with physical therapy offered the most sustained effects.
• For improving pain intensity, behavioral therapy combined with physical therapy offered the longest-lasting benefits.

The study shows the advantages of an interdisciplinary approach to chronic low back pain. Integrating behavioral therapy and physical therapy helped people achieve better function, reduce the cycle of avoidant behavior, and reduce the intensity of their pain. In their daily lives, this may lead to more productive workdays and better sleep, as well as enabling people to participate in more social activities, which boosts overall well-being.

What else should you know about this study?

The authors define chronic, nonspecific low back pain as pain between the bottom of the rib cage and buttocks crease, without an identified structural cause like spinal stenosis, cancer, or fracture.

However, “nonspecific” is a controversial term. Many experts on back pain believe that further evaluation might determine specific, multiple factors that contribute to pain.

A physiatrist, also known as a physical medicine and rehabilitation physician, can diagnose a range of pain conditions and help people navigate therapies to manage back pain.

In addition, the authors noted that the reporting of socioeconomic and demographic information was poor and inconsistent across the included studies. This means that the findings of the study may not apply to everyone.

How do psychological therapies help with pain?

Psychological therapies can help people reframe negative thoughts and change pain perception, attitudes, and behaviors. Examples of approaches that aim to reduce pain-related distress are cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), mindfulness-based stress reduction (MBSR), biofeedback, and pain reprocessing therapy (PRT). A recent study evaluating PRT showed that psychological treatment focused on changing beliefs about the causes and consequences of chronic low back pain may provide substantial, long-lasting pain relief.

Neuroscience has demonstrated that the brain and body are always connected, and pain is a combination of medical, cognitive, emotional, and environmental issues. Strategies to manage pain effectively must address your body and brain by integrating physical and psychological therapies, such as with functional restoration programs and working with a pain psychologist. Gaining a better understanding of pain, and treating all factors contributing to your chronic pain, can be empowering and healing.

Follow me on Twitter @DanielleSarnoMD

About the Author

Danielle L. Sarno, MD, Contributor

Dr. Danielle Sarno is the director of interventional pain management in the department of neurosurgery at Brigham and Women’s Hospital, and an instructor of physical medicine and rehabilitation at Harvard Medical School. She is the founding … See Full Bio View all posts by Danielle L. Sarno, MD

 

Proponents of cannabis generally dismiss the idea that there is a cannabis withdrawal syndrome. One routinely hears statements such as, “I smoked weed every day for 30 years and then just walked away from it without any problems. It’s not addictive.” Some cannabis researchers, on the other hand, describe serious withdrawal symptoms that can include aggression, anger, irritability, anxiety, insomnia, anorexia, depression, restlessness, headaches, vomiting, and abdominal pain. Given this long list of withdrawal symptoms, it’s a wonder that anyone tries to reduce or stop using cannabis. Why is there such a disconnect between researchers’ findings and the lived reality of cannabis users?

New research highlights the problems of withdrawal, but provides an incomplete picture

A recent meta-analysis published in JAMA cites the overall prevalence of cannabis withdrawal syndrome as 47% among “individuals with regular or dependent use of cannabinoids.” The authors of the study raise the alarm that “many professionals and members of the general public may not be aware of cannabis withdrawal, potentially leading to confusion about the benefits of cannabis to treat or self-medicate symptoms of anxiety or depressive disorders.” In other words, many patients using medical cannabis to “treat” their symptoms are merely caught up in a cycle of self-treating their cannabis withdrawal. Is it possible that almost half of cannabis consumers are actually experiencing a severe cannabis withdrawal syndrome — to the point that it is successfully masquerading as medicinal use of marijuana — and they don’t know it?

Unfortunately, the study in JAMA doesn’t seem particularly generalizable to actual cannabis users. This study is a meta-analysis: a study which includes many studies that are deemed similar enough to lump together, in order to increase the numerical power of the study and, ideally, the strength of the conclusions. The authors included studies that go all the way back to the mid-1990s — a time when cannabis was illegal in the US, different in potency, and when there was no choice or control over strains or cannabinoid compositions, as there is now. One of the studies in the meta-analysis included “cannabis-dependent inpatients” in a German psychiatric hospital in which 118 patients were being detoxified from cannabis. Another was from 1998 and is titled, “Patterns and correlates of cannabis dependence among long-term users in an Australian rural area.” It is not a great leap to surmise that Australians in the countryside smoking whatever marijuana was available to them illegally in 1998, or patients in a psychiatric hospital, might be substantively different from current American cannabis users.

Medical cannabis use is different from recreational use

Moreover, the JAMA study doesn’t distinguish between medical and recreational cannabis, which are actually quite different in their physiological and cognitive effects, as Harvard researcher Dr. Staci Gruber’s work tells us. Medical cannabis patients, under the guidance of a medical cannabis specialist, are buying legal, regulated cannabis from a licensed dispensary; it might be lower in THC (the psychoactive component that gives you the high) and higher in CBD (a nonintoxicating, more medicinal component), and the cannabis they end up using often results in them ingesting a lower dose of THC.

Cannabis withdrawal symptoms are real

All of this is not to say that there is no such thing as a cannabis withdrawal syndrome. It isn’t life-threatening or medically dangerous, but it certainly does exist. It makes absolute sense that there would be a withdrawal syndrome because, as is the case with many other medicines, if you use cannabis every day, the natural receptors by which cannabis works on the body “down-regulate,” or thin out, in response to chronic external stimulation. When the external chemical is withdrawn after prolonged use, the body is left in the lurch, and forced to rely on natural stores of these chemicals, but it takes time for the natural receptors to grow back to their baseline levels. In the meantime, the brain and the body are hungry for these chemicals, and the result is withdrawal symptoms.

Getting support for withdrawal symptoms

Uncomfortable withdrawal symptoms can prevent people who are dependent on or addicted to cannabis from remaining abstinent. The commonly used treatments for cannabis withdrawal are either cognitive behavioral therapy or medication therapy, neither of which has been shown to be particularly effective. Common medications that have been used are dronabinol (which is synthetic THC); nabiximols (which is cannabis in a mucosal spray, so you aren’t actually treating the withdrawal); gabapentin for anxiety (which has a host of side effects); and zolpidem for the sleep disturbance (which also has a list of side effects). Some researchers are looking at CBD, the nonintoxicating component of cannabis, as a treatment for cannabis withdrawal.

Some people get into serious trouble with cannabis, and use it addictively to avoid reality. Others depend on it to an unhealthy degree. Again, the number of people who become addicted or dependent is somewhere between the 0% that cannabis advocates believe and the 100% that cannabis opponents cite. We don’t know the actual number, because the definitions and studies have been plagued with a lack of real-world relevance that many studies about cannabis suffer from, and because the nature of both cannabis use and cannabis itself have been changing rapidly.

How do you know if your cannabis use is a problem?

The standard definition of cannabis use disorder is based on having at least two of 11 criteria, such as: taking more than was intended, spending a lot of time using it, craving it, having problems because of it, using it in high-risk situations, getting into trouble because of it, and having tolerance or withdrawal from discontinuation. As cannabis becomes legalized and more widely accepted, and as we understand that you can be tolerant and have physical or psychological withdrawal from many medicines without necessarily being addicted to them (such as opiates, benzodiazepines, and some antidepressants), I think this definition seems obsolete and overly inclusive.

For example, if one substituted “coffee” for “cannabis,” many of the 160 million Americans who guzzle coffee on a daily basis would have “caffeine use disorder,” as evidenced by the heartburn and insomnia that I see every day as a primary care doctor. Many of the patients that psychiatrists label as having cannabis use disorder believe that they are fruitfully using cannabis to treat their medical conditions — without problems — and recoil at being labeled as having a disorder in the first place. This is perhaps a good indication that the definition doesn’t fit the disease.

Perhaps a simpler, more colloquial definition of cannabis addiction would be more helpful in assessing your use of cannabis: persistent use despite negative consequences. If your cannabis use is harming your health, disrupting your relationships, or interfering with your job performance, it is likely time to quit or cut down drastically, and consult your doctor. As part of this process, you may need to get support or treatment if you experience uncomfortable withdrawal symptoms, which may make it significantly harder to stop using.

About the Author

Peter Grinspoon, MD, Contributor

Dr. Peter Grinspoon is a primary care physician, educator, and cannabis specialist at Massachusetts General Hospital; an instructor at Harvard Medical School; and a certified health and wellness coach. He is the author of the forthcoming book Seeing … See Full Bio View all posts by Peter Grinspoon, MD

No one is truly allergic to the sun, but some people are quite sensitive to different types of sun rays and may develop mild to serious reactions after spending time in the sun.

There are several types of “sun allergies,” but polymorphous light eruption (PMLE), an autoimmune condition in the skin that occurs after sun exposure, is one of the most common. Other conditions considered as sun allergies are solar urticaria (hives and reddish patches that usually start 30 minutes to two hours after the sun exposure), actinic prurigo (papules and nodules that are intensely itchy on sun-exposed skin areas), and photoallergic reaction (when the UV rays from the sun modify the chemical structure of medications or products applied to the skin, and a person develops an allergy to the newly modified substance).

What causes PMLE?

People who have PMLE have immune cells that are triggered by sun rays, which attack their skin, and they develop a skin reaction to the sun’s the ultraviolet (UV) rays.

PMLE represents 70% of all sun-induced skin eruptions. It can affect both sexes and all skin types, and it usually starts when someone is a teen or young adult. PMLE may be an inherited condition. Being a female, having fair skin, and living in the north are other risk factors.

PMLE is more common in young women who live in temperate climates. People who live in temperate climates spend all winter out of the sun, so when it becomes warmer the sun exposure is intense. People who live in warmer climates are desensitized because they have a higher sun exposure all year.

What does PMLE look like?

PMLE can appear several hours or days after the first major sunlight exposure of the season, usually during spring or at the beginning of summer. The areas of the body generally affected the most are the ones that are covered during wintertime, but not in the summer: the neck, the chest, and the outer parts of the arms.

After exposure to the sun, people with PMLE usually notice reddish patches on their skin. These spots may itch, burn, or sting, but they typically don’t leave a scar. In more severe cases, the patches cover most of the body and may also be associated with headaches, fevers, tiredness, and low blood pressure. (If you experience these symptoms, see an urgent care provider for evaluation.) If you think you have PMLE or another sun allergy, a dermatologist is the best doctor to evaluate and treat your skin condition.

Does PMLE get better?

PMLE lesions often get better in approximately 10 days, and it’s important to avoid sun exposure until you are healed. People who develop PMLE can experience significant discomfort and have their life negatively impacted during the spring and summer months. However, repetitive sun exposure can make PMLE less likely to occur. The hardening effect, as it is called, means that the skin lesions that appear after the first episode are less severe, and they can be better tolerated during subsequent episodes.

What are current treatments for any sun allergy, including PMLE?

The best treatment is to prevent sun exposure. Avoid sunlight when it is most intense (from 10 a.m. to 4 p.m.), and use UV-protecting clothing or clothes made of darker and thicker fabrics, as they will prevent the UV rays coming from the sun from reaching your skin. Hats with a wide brim protect your scalp, face, and (partially) the neck.

Broad-spectrum sunscreens that protect your skin from both UVA and UVB rays should be used daily, even if it’s cloudy. Apply sunscreen on your face and any part of your skin that is not covered by a hat or clothing. Reapply sunscreen every two hours, and if you go swimming or get sweaty reapply more frequently (water-resistant sunscreen should also be reapplied).

If you develop PMLE, the areas of skin impacted can be treated with steroid creams. In severe cases, your doctor may recommend a short course of steroid pills. Medications that reduce the immune response, such as azathioprine, are options for treating PMLE, since it is an autoimmune condition (the body is attacking it is own healthy cells).

Antihistamines are medications typically used for allergies that may help shorten the duration of reddish patches that itch or burn, and they also reduce inflammation.

Hydroxychloroquine (a medication also used to treat malaria) can be used in case of flare-ups, or as a prevention method when people travel to sunny locations during winter vacations.

Oral Polypodium leucotomos extract, a natural substance derived from tropical fern leaves, may work as a potent antioxidant, and has anti-inflammatory properties that are beneficial in the prevention of PMLE. Other nutritional supplements containing lycopene and beta-carotene (vitamin A derivatives) have a similar effect. A dermatologist will guide you on the best way to use these medications.

The bottom line

Sun allergies are common in temperate climates, but with a dermatologist’s guidance, vigilant sun prevention, and medications they can be managed throughout the sunny months of the year.

About the Authors

Neera Nathan, MD, MSHS, Contributor

Dr. Neera Nathan is a dermatologist and researcher at Massachusetts General Hospital and Lahey Hospital and Medical Center. Her clinical and research interests include dermatologic surgery, cosmetic dermatology, and laser medicine. She is part of the … See Full Bio View all posts by Neera Nathan, MD, MSHS

Lais Lopes Almeida Gomes, Contributor

Dr. Lais Lopes Almeida Gomes is a dermatology research fellow at Massachusetts General Hospital, and a pediatric dermatologist in Brazil. Her clinical and research interests include atopic dermatitis and global health. She is part of the … See Full Bio View all posts by Lais Lopes Almeida Gomes

While psychiatric medications can be essential for improving mental health and well-being, they often come with unwanted side effects. One particular side effect of many psychiatric medications is weight gain. In this post we will explore how these medications cause weight gain, and what you can do to lessen the impact of this unwanted effect of many psychiatric medications.

What are the different types of psychiatric medications?

There are five main types of psychiatric prescription medications: antidepressants, antipsychotics, anxiolytics (also known as anti-anxiety medications, which can include medications for sleep), mood stabilizers, and stimulants. Stimulants are not likely to cause weight gain. In fact, many of them reduce appetite and can cause weight loss as a side effect. These medications will not be discussed in this post.

Antidepressants can be divided into separate classes:

• SSRIs, or selective serotonin reuptake inhibitors, increase serotonin levels in the brain.
• SNRIs, or serotonin-norepinephrine reuptake inhibitors, increase both serotonin and norepinephrine in the brain.
• TCAs, or tricyclic antidepressants, increase serotonin, norepinephrine, and dopamine in the brain.
• MAOIs, or monoamine oxidase inhibitors, increase serotonin, dopamine, and norepinephrine in the brain.

Why do antidepressants cause weight changes?

All of these medications increase serotonin levels in the brain. Serotonin regulates mood and affects appetite, yet this can have varying results depending on length of treatment. Short-term use reduces impulsivity and increases satiety, which can reduce food intake and cause weight loss. However, long-term use (longer than a year) can cause downregulation of serotonin receptors, which subsequently causes cravings for carbohydrate-rich foods such as bread, pasta, and sweets that ultimately may lead to weight gain. The antidepressants with the highest risk of causing weight gain are amitriptyline, citalopram, mirtazapine, nortriptyline, trimipramine, paroxetine, and phenelzine.

Why do antipsychotic medications worsen obesity-related diseases?

Antipsychotics can also be categorized into two classes: typical and atypical antipsychotics. Both classes can cause weight gain, but they differ in that atypical antipsychotics cause fewer movement disorder side effects. Like antidepressants, antipsychotics affect the chemical messengers in the brain associated with appetite control and energy metabolism, namely serotonin, dopamine, histamine, and muscarinic receptors. In addition to causing weight gain, antipsychotics can also impair glucose metabolism, increase cholesterol and triglyceride levels, and cause hypertension, all of which can lead to metabolic syndrome and worsen obesity-related diseases. The antipsychotics most likely to cause weight gain are olanzapine, risperidone, and quetiapine.

What about anti-anxiety medications and weight changes?

There is no clear link between traditional anti-anxiety medications such as benzodiazepines and weight gain. However, many antidepressants are also used for the treatment of anxiety, and may cause weight gain as discussed above.

Similarly, not all medications for sleep cause weight gain; one that has been associated with weight gain is diphenhydramine (the active ingredient in Benadryl that is also used in many over-the-counter sleep aids). Diphenhydramine can contribute to weight gain by causing increased hunger and tiredness, which can make a person less active. Other sleep aids such as zolpidem (Ambien) or eszopiclone (Lunesta) have not been linked to weight gain.

Trazodone, a medication used for depression as well as insomnia, reduces excess serotonin at some sites, while increasing serotonin levels at other sites, thus affecting appetite as previously discussed.

Mood stabilizers are often used to treat bipolar disease, and can increase appetite or cause changes in metabolism. Although some antidepressants and antipsychotics are also used to treat bipolar disease, mood stabilizers such as lithium, valproic acid, divalproex sodium, carbamazepine, and lamotrigine are the mood stabilizers often used for treatment of bipolar disorder, and with the exception of lamotrigine, they are all known to increase the risk of weight gain.

There are effective strategies to minimize weight gain

For people taking psychiatric medications for mental health, there are strategies to minimize weight gain. Optimizing lifestyle and daily habits is important. This includes eating a healthy diet with whole foods and limiting processed foods and added sugars; staying physically active; minimizing stress; and ensuring adequate restful sleep. Physical activity, in particular, can have a double effect of both improving mental health and minimizing weight gain that might otherwise occur. Cognitive and behavioral strategies under the guidance of a psychologist may be useful for avoiding giving in to any increased cravings for sweets and carbohydrates.

Another strategy to minimize weight gain is to work with your healthcare provider to determine if there might be an appropriate alternate medication option with a lower risk of weight gain. In addition, the anti-diabetes medication metformin has been shown to be effective in treating and preventing psychotropic-induced weight gain. Other medications prescribed for weight loss may also be appropriate to help counteract the weight gain experienced by psychotropic medications.

Be aware that almost all medications have a risk of causing side effects, and it is important to ensure that the benefits of taking any medications will outweigh the risks. Speaking to your primary care provider, psychiatrist, or obesity medicine specialist can be useful in determining which options may work best for you.

About the Author

Chika Anekwe, MD, MPH, Contributor

Chika V. Anekwe, MD, MPH is an obesity medicine physician at Massachusetts General Hospital (MGH) Weight Center and Instructor in Medicine at Harvard Medical School (HMS). Her professional interests are in the areas of clinical nutrition, … See Full Bio View all posts by Chika Anekwe, MD, MPH

Melasma is a pigmentation disorder of the skin mostly affecting women, especially those with darker skin. It is commonly seen on the face, and appears as dark spots and patches with irregular borders. Melasma is not physically harmful, but studies have shown that it can lead to psychological problems and poorer quality of life due to the changes it causes in a person’s appearance.

Melasma is a common disorder, with a prevalence of 1% that can increase to 50% in higher-risk groups, including those with darker skin. Melasma is known as the “mask of pregnancy” since hormonal changes caused by pregnancy, as well as hormonal medications such as birth control pills, are major triggers for excessive skin pigment production in melasma. Sun exposure is another important contributor to melasma.

Can melasma be prevented?

Currently, melasma cannot be fully prevented in people who are likely to develop this condition due to their genetics, skin color type, hormones, or sun exposure level. Avoiding direct sun exposure during peak hours (10 a.m. to 4 p.m.), diligently using high-SPF sunscreens, and avoiding hormonal medications when possible may help protect against melasma flares and reduce their recurrence after treatment. Strict sun protection is the mainstay of any melasma treatment regimen.

What sunscreen should melasma patients use?

Choosing an appropriate sunscreen is critical if you develop melasma, and studies have shown that broad-spectrum tinted sunscreens, especially ones containing iron oxide, can lower pigment production in the skin in melasma patients, as they block visible light as well as UVA/UVB rays. Non-tinted sunscreens, on the other hand, do not block visible light.

For some people, it might be more convenient to use cosmetic products such as foundations that contain both UVA/UVB blockers and visible light blockers such as iron oxide. These products can conceal dark spots and therefore alleviate the psychosocial impact of melasma, and at the same time act as a sunscreen to protect against darkening of the lesions.

It is important for people with melasma to know that visible light can go through windows, and therefore even if they are not out in the sun, they can still get melasma flares by exposing themselves to visible light while driving or sitting by a window.

Can melasma be treated?

Currently there is no cure for melasma; however, there are several medications and procedures available to manage this condition. It is important to know that these treatment options may result in an incomplete response, meaning that some of the discolorations become lighter or disappear while some remain unchanged. In addition, frequent relapses are common.

It is also important to be aware of possible side effects of treatment, including darkening of the skin caused by inflammation induced by the treatment, or extra lightening of the skin in a treated area. Using the appropriate medications under the supervision of a dermatologist can help achieve treatment goals and maintain them with fewer relapses.

Common melasma treatments

The most commonly used treatments for melasma are skin lightening medications that are applied topically. These include medications such as hydroquinone, azelaic acid, kojic acid, niacinamide, cysteamine, rucinol, and tranexamic acid. These medications work by reducing pigment production and inflammation, and by reducing excess blood vessels in the skin that contribute to melasma.

Pregnant women (who constitute a big proportion of melasma patients) should avoid most of these medications except for azelaic acid, which is a safe choice during pregnancy. Hydroquinone is a commonly used skin lightener that should only be used for a limited time due to side effects that may happen with prolonged use. It can be used for up to six months for initial treatment and then occasionally if needed.

In most patients a combination therapy is needed for treatment for melasma. A common choice is the combination of hydroquinone with a retinoid that increases skin cell turnover and a steroid that decreases skin inflammation. Oral medications, including tranexamic acid, are usually considered in more severe melasma cases. This medication is thought to help melasma by reducing pigment production and by reducing excess blood vessels in the skin.

Additional treatment procedures may help

If your melasma does not improve with topical or oral medications, adding procedures such as chemical peels and laser therapies to a treatment regimen could be beneficial.

Chemical peels use substances like glycolic acid, alpha-hydroxy acids, and salicylic acid to remove the superficial layer of the skin that contains excess pigment in melasma patients. The effects of a chemical peel are temporary, since this procedure removes a layer of skin without reducing the production of pigment in regenerating deeper layers.

Laser therapies can destroy pigment cells in skin and therefore lighten the dark spots in melasma. However, as with any other treatment option for melasma, there is considerable risk of relapse post-treatment.

Maintenance therapy and prevention

After achieving improvement of melasma lesions, strict sun protection and maintenance therapy need to be continued. Skin lighteners other than hydroquinone can be used in combination with retinoids to maintain the results, and hydroquinone therapy may be used intermittently if needed.

Takeaway message about melasma

The key point in management of melasma is to use sun protection all the time, and to avoid other triggers such as hormonal medications when possible. Since none of the available treatments are a cure, prevention is the best option. People with melasma should see a board-certified dermatologist for evaluation and appropriate treatment regimens to manage melasma and maintain the treatment results.

About the Authors

Lilit Garibyan, MD, PhD, Contributor

Dr. Lilit Garibyan is an assistant professor of dermatology at Harvard Medical School, and a physician-scientist at the Wellman Center for Photomedicine at Massachusetts General Hospital. Her research focuses on innovative biomedical discoveries aimed at identifying … See Full Bio View all posts by Lilit Garibyan, MD, PhD

Sara Moradi Tuchayi, MD, MPH, Contributor

Dr. Sara Moradi Tuchayi is a dermatology research fellow at Massachusetts General Hospital. Her research at the Wellman Center for Photomedicine at MGH is focused on the development of novel therapies for skin disorders. See Full Bio View all posts by Sara Moradi Tuchayi, MD, MPH

Loud snoring, grunts, and gasps can be a sign of obstructive sleep apnea, a serious disorder that causes repeated, brief pauses in breathing (apneas) throughout the night. It can leave people drowsy and depressed, and put them at risk for high blood pressure, heart disease, and other health problems.

If this sounds like you or a bed partner, a recent spate of advertisements for a mask-free treatment for the disorder may catch your attention. Known medically as a hypoglossal nerve stimulator, the pacemaker-like device moves the tongue forward during sleep. That helps reopen a collapsed airway — the root cause of obstructive sleep apnea. But how does it compare with other treatments, and who might be a good candidate?

A second-choice therapy for sleep apnea

Marketed under the name Inspire, the device was approved by the FDA in 2014. It’s a second-choice therapy intended only for people who can’t tolerate positive airway pressure (known as PAP or CPAP), according to Dr. Rohit Budhiraja, a pulmonary and sleep specialist at Harvard-affiliated Brigham and Women’s Hospital.

“Sleep apnea causes the muscles in the back of the throat to collapse, which leads to pauses in breathing that wake you up again and again,” he says. PAP, the gold standard therapy for sleep apnea, prevents airway collapse by using a small bedside machine attached to tubing that blows air through a face mask.

This can improve a measurement called the apnea-hypoxia index (AHI) by approximately 90%, lowering it below 5 in most people. The AHI is a score that gauges the severity of sleep apnea. An AHI between 5 and 14 is considered mild; between 15 and 29 is moderate; 30 and higher is severe.

Targeting tongue muscles is less effective

Inspire targets only the muscles of the tongue rather than the entire airway, so it isn’t as effective as PAP. In fact, the company’s stated treatment goal is to lower a person’s AHI by just 50% (or below 20), although some people may do better.

Because PAP is more effective, sleep specialists encourage people to stick with it by trying different strategies. But research suggests a quarter to a third of people have a hard time using PAP (see here and here). When that’s the case, Inspire may be an alternative, says Dr. Budhiraja.

Who might consider hypoglossal nerve stimulation?

In addition to trying PAP without success, you also must

• have moderate to severe sleep apnea (an AHI score of 15 to 65)
• have a body mass index (BMI) of 32 or lower (although some centers allow BMI values as high as 35), which means the device is not right for people in some weight ranges.

If you meet these criteria, you can ask your doctor for a referral to a sleep specialist or an ear, nose, and throat surgeon. The next step is sleep endoscopy. While you are sedated, a doctor passes a small tube with a light and a tiny video camera on one end through a nostril to examine your upper airway. Up to a quarter of people have an airway collapse pattern that can’t be remedied with Inspire, Dr. Budhiraja notes. And, as noted, others have too high an AHI score to try it.

A surgical procedure requiring general anesthesia

The device is implanted during a short, same-day procedure done under general anesthesia. A generator is placed just below the collarbone, a breathing sensor at the side of the chest by the ribs, and a stimulation electrode around the hypoglossal nerve under the tongue.

As with all surgery, possible risks include bleeding and infection. Some people experience tongue weakness, which can cause slightly slurred speech and minor swallowing problems. But this usually resolves within a few days, or for most people, within a few weeks.

The device must be activated a month after surgery at a sleep laboratory. The breathing sensor monitors your breathing and, when necessary, it tells the generator to send a small electrical pulse to the electrode to make the tongue muscles contract. The stimulation moves your tongue forward so you can breathe normally.

How does it feel?

“Some people describe a mild tingling sensation, but most say the feeling is hard to describe,” says Dr. Budhiraja.

At home, you use a small remote control to turn the device on at night and off in the morning. The remote is set to gradually increase the level of stimulation once or twice a week as tolerated until you reach the highest level. You then return to the sleep lab for a study to determine your optimal range. The remote is then programmed to that range.

Some people start noticing a difference in their sleep quality even at the lowest levels of stimulation. Yearly checks are recommended thereafter, and the replaceable battery lasts about 11 years. Medicare and most major insurance plans cover Inspire.

Once it’s working, hypoglossal nerve stimulation is definitely convenient: no maintenance, cleaning, or buying supplies as required with a PAP machine. “But because Inspire is less effective, it’s not considered a replacement for PAP,” says Dr. Budhiraja.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

Julie Corliss is the executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She … See Full Bio View all posts by Julie Corliss

Active surveillance for prostate cancer has its tradeoffs. Available to men with low- and intermediate-risk prostate cancer, the process entails monitoring a man’s tumor with periodic biopsies and prostate-specific antigen (PSA) tests, and treating only when — or if — the disease shows signs of progression.

Active surveillance allows men to avoid (at least for a while) the side effects of invasive therapies such as surgery or radiation, but men often feel anxious wondering about the state of their cancer as they spend more time untreated. Is there a middle path between not treating the cancer at all and aggressive therapies that might have lasting side effects? Emerging evidence suggests the answer might be yes.

During a newly-published phase 2 clinical trial, researchers evaluated whether a drug called enzalutamide might delay cancer progression among men on active surveillance. Enzalutamide interferes with testosterone, a hormone that drives prostate tumors to grow and spread. Unlike other therapies that block synthesis of the hormone, enzalutamide prevents testosterone from interacting with its cellular receptor.

A total of 227 men were enrolled in the study. The investigators randomized half of them to a year of daily enzalutamide treatment plus active surveillance, and the other half to active surveillance only. After approximately two years of follow-up, the investigators compared findings from the two groups.

The results showed benefits from enzalutamide treatment. Specifically, tumor biopsies revealed evidence of cancer progression in 32 of the treated men, compared to 42 men who did not get the drug. The odds of finding no cancer in at least some biopsy samples were 3.5 times higher in the enzalutamide-treated men. And it took six months longer for PSA levels to rise (suggesting the cancer is growing) in the treated men, compared to men who stayed on active surveillance only.

Enzalutamide was generally well tolerated. The most common side effects were fatigue and breast enlargement, both of which are reversible when men go off treatment.

In an accompanying editorial, Susan Halabi, a statistician who specializes in prostate cancer at Duke University, described the data as encouraging. But Halabi also sounded a cautionary note. Importantly, differences between the two groups were evident only during the first year of follow-up. By the end of the second year, signs of progression in the treated and untreated groups “tended to be very similar,” she wrote, suggesting that enzalutamide is beneficial only for as long as men stay on the drug. Longer studies lasting a decade or more, Halabi added, may be necessary to determine if early enzalutamide therapy changes the course of the disease, such that the need for more invasive treatments among some men can be delayed or prevented.

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, editor of the Harvard Health Publishing Annual Report on Prostate Diseases, and editor in chief of HarvardProstateKnowledge.org, said the study points to a new way of approaching active surveillance, either with enzalutamide or perhaps other drugs. “An option that further decreases the likelihood that men on active surveillance will need radiation or surgery is important to consider,” he says. “This was a pilot study, and now we need longer-term research.”

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt

If you’re in your 80s or 70s and you’ve noticed that you’re having some memory loss, it might be reasonable to be concerned that you could be developing Alzheimer’s disease or another form of dementia. But what if you’re in your 60s, 50s, or 40s… surely those ages would be too young for Alzheimer’s disease or dementia, right?

About 10% of Alzheimer’s disease is young onset, starting before age 65

Not necessarily. Of the more that 55 million people living with dementia worldwide, approximately 60% to 70% of them have Alzheimer’s disease. And of those 33 to 38.5 million people with Alzheimer’s disease, memory loss or other symptoms began before age 65 in 10% of them. Alzheimer’s is, in fact, the most common cause of young onset dementia. A recent study from the Netherlands found that of those with a known classification of their young onset dementia, 55% had Alzheimer’s disease, 11% vascular dementia, 3% frontotemporal dementia, 3% Parkinson’s disease dementia, 2% dementia with Lewy bodies, and 2% primary progressive aphasia.

Young onset dementia is uncommon

To be clear, young onset dementia (by definition starting prior to age 65, and sometimes called early onset dementia) is uncommon. One study in Norway found that young onset dementia occurred in 163 out of every 100,000 individuals; that’s in less than 0.5% of the population. So, if you’re younger than 65 and you’ve noticed some trouble with your memory, you have a 99.5% chance of there being a cause other than dementia. (Whew!)

There are a few exceptions to this statement. Because they have an extra copy of the chromosome that carries the gene for the amyloid found in Alzheimer’s plaques, more than half of people with Down syndrome develop Alzheimer’s disease, typically in their 40s and 50s. Other genetic abnormalities that run in families can also cause Alzheimer’s disease to start in people’s 50s, 40s, or even 30s — but you would know if you are at risk because one of your parents would have had young onset Alzheimer’s disease.

How does young onset Alzheimer’s disease differ from late onset disease?

The first thing that should be clearly stated is that, just as no two people are the same, no two individuals with Alzheimer’s disease show the same symptoms, even if the disease started at the same age. Nevertheless, there are some differences between young onset and late onset Alzheimer’s disease.

People with typical, late onset Alzheimer’s disease starting at age 65 or older show the combination of changes in thinking and memory due to Alzheimer’s disease plus those changes that are part of normal aging. The parts of the brain that change the most in normal aging are the frontal lobes. The frontal lobes are responsible for many different cognitive functions, including working memory — the ability to keep information in one’s head and manipulate it — and insight into the problems that one is having.

This means that, in relation to cognitive function, people with young onset Alzheimer’s disease may show relatively isolated problems with their episodic memory — the ability to form new memories to remember the recent episodes of their lives. People with late onset Alzheimer’s disease show problems with episodic memory, working memory, and insight. So, you would imagine that life is tougher for those with late onset Alzheimer’s disease, right?

Depression and anxiety are more common in young onset Alzheimer’s disease

People with late onset Alzheimer’s disease do show more impairment, on average, in their cognition and daily function than those with young onset Alzheimer’s disease, at least when the disease starts. However, because their insight is also impaired, those with late onset disease don’t notice these difficulties that much. Most of my patients with late onset Alzheimer’s disease will tell me either that their memory problems are quite mild, or that they don’t have any memory problems at all!

By contrast, because they have more insight, patients with young onset Alzheimer’s disease are often depressed about their situation and anxious about the future, a finding that was recently confirmed by a group of researchers in Canada. And as if having Alzheimer’s disease at a young age wasn’t enough to cause depression and anxiety, recent evidence suggests that in those with young onset Alzheimer’s disease, the pathology progresses more quickly.

Another tragic aspect of young onset Alzheimer’s disease is that, by affecting individuals in the prime of life, it tends to disrupt families more than late onset disease. Teenage and young adult children are no longer able to look to their parent for guidance. Individuals who may be caring for children in the home now need to care for their spouse as well — perhaps in addition to caring for an aging parent and working a full-time job.

What should you do if you’re younger than 65 and having memory problems?

As I’ve discussed, if you’re younger than 65 and you’re having memory problems, it’s very unlikely to be Alzheimer’s disease. But if it is, there are resources available from the National Institute on Aging that can help.

What else could be causing memory problems at a young age? The most common cause of memory problems below age 65 is poor sleep. Other causes of young onset memory problems include perimenopause, medication side effects, depression, anxiety, illegal drugs, alcohol, cannabis, head injuries, vitamin deficiencies, thyroid disorders, chemotherapy, strokes, and other neurological disorders.

Here are some things that everyone at any age can do to improve their memory and reduce their risk of dementia:

• Perform aerobic exercise.
• Eat Mediterranean-style meals.
• Avoid alcohol, cannabis, and drugs.
• Sleep well.
• Participate in social activities.
• Pursue novel, cognitively stimulating activities, listen to music, practice mindfulness, and keep a positive mental attitude.

About the Author

Andrew E. Budson, MD, Contributor

Dr. Andrew E. Budson is chief of cognitive & behavioral neurology at the Veterans Affairs Boston Healthcare System, lecturer in neurology at Harvard Medical School, and chair of the Science of Learning Innovation Group at the … See Full Bio View all posts by Andrew E. Budson, MD

In the aftermath of the killing of 19 children and two adults in an elementary school in Uvalde, Texas, there is a lot of discussion — and argument — about what we should do to prevent shootings like this from happening.

In the midst of all the back and forth between banning guns and arming teachers, there is an important question that cannot be lost: what does it do to a generation of children to grow up knowing that there is nowhere they are safe?

There is increasing research that growing up amidst violence, poverty, abuse, chronic stress, or even chronic unpredictability affects the brains and bodies of children in ways that can be permanent. These adverse childhood experiences put the body on high alert, engaging the flight-or-fight responses of the body in an ongoing way. This increases the risk of depression, anxiety, and substance abuse, but it does so much more: the stress on the body increases the risk of cancer, heart disease, chronic disease, chronic pain, and even shortens the lifespan. The stress on the brain can literally change how it is formed and wired.

Long-term effects on a generation

Think for a moment about what this could mean: an entire generation could be forever damaged in ways we cannot change. The ramifications, not just for their well-being but for future generations and our work force and health care system, are staggering: stress like this can be passed on, and affects parenting.

As we talk about arming teachers and increasing armed police at schools, it is important to remember that research shows that the more guns, the higher the risk of homicide. It’s also important to remember that many children die every year from unintentional shootings in the home. In fact, guns have overtaken motor vehicle accidents as the leading cause of death in children. The idea of “arming the good guys” is an understandable response to horrible events like Uvalde, Parkland, and Sandy Hook, but the data would suggest that it may not be the most successful one. Violence begets violence, and guns aren’t reliably used the way we want them to be.

It’s not just guns, of course. There are other stressors, like poverty, community violence, child abuse, racism and all the other forms of intolerance, and lack of access to health care and mental health care. The pandemic has likely forever altered this generation in ways we cannot change, too.

The communities our children are growing up in and the world they are growing up in are increasingly becoming scary places. If we care about our children, if we care about our future, we need to stop fighting among ourselves and come together to create solutions that support the health and well-being of children, families, and communities. We need to nurture our children, not terrify them.

About the Author

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD