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Polio is a potentially life-threatening or disabling illness that spreads from person to person. Thanks to vaccination, the United States has been polio-free since 1979, and the spread of this highly contagious disease has been interrupted in most countries. Yet on June 22, the United Kingdom Health Security Agency announced that it had detected poliovirus in a most unexpected place: the sewers of London.

Over the past several months, scientists at the agency repeatedly found poliovirus in London sewer water. The viruses were genetically similar, suggesting that they were the result of limited spread within a family or close-knit community. Just how concerned should all of us be about this news?

Health clues found in wastewater

Sampling of wastewater for genetic material from viruses is a powerful tool used by epidemiologists to track outbreaks of polio and other diseases. Surges in the amount of SARS-CoV-2 RNA in Boston wastewater have been highly predictive of COVID outbreaks. Wastewater may also help to detect the spread of influenza and antibiotic-resistant bacteria.

Poliovirus infection was once a common and dreaded disease. Most people with poliovirus either had no symptoms or mild gastroenteritis (stomach flu). But one in 100 people developed paralysis, or poliomyelitis. In half of the affected patients, this paralysis was permanent.

In the UK, wild poliovirus has been eliminated since 1984. Although great progress has been made in many parts of the world, complete eradication of polio has been elusive. Pakistan and Afghanistan have never been free from wild-type polio, and outbreaks have recently taken place in Malawi and Mozambique, countries which had previously eliminated polio.

The reasons for this backsliding are complex. Some contributing factors are diversion of scarce resources toward the COVID-19 pandemic, backlogs in vaccine manufacturing, anti-vaccine agitation, and violence directed at vaccine workers.

Another problem is vaccine-derived poliovirus. In the United States and most other countries, injections containing killed viruses are used. While these vaccines are safe, they are less effective than oral vaccines at breaking the chain of polio transmission. Oral vaccines stimulate long-lived immune responses in the lining of the intestines, where polioviruses replicate. Unfortunately, oral vaccines contain weakened but live viruses, which occasionally revert to a more dangerous form. In fact, the poliovirus found in London was a vaccine-derived strain that the infected individual had likely acquired from travel abroad.

Who is at risk for poliovirus stemming from this source?

Vaccine-derived viruses pose little risk to highly vaccinated populations, but they are able to spread in communities with low polio vaccination rates. In some cases, this can even cause paralytic disease. Because of these risks, steps are being taken to gradually phase out the use of oral polio vaccines.

If you’re concerned about polio, the best protection against this disease is vaccination. Children should receive a full series of four shots of inactivated polio vaccine, given at specific intervals, that helps with developing immunity.

Nationwide, rates of childhood polio vaccination in the United States are still high (nearly 93%). However, some infectious disease experts worry that the weakening of vaccine mandates in some areas has created islands of vulnerability in this sea of immunity. Communities in the US with low childhood vaccination rates have been vulnerable to large measles outbreaks in recent years, and might also be vulnerable to polio outbreaks.

With few exceptions, adults who were fully vaccinated as kids do not need booster shots. These exceptions include travel to a country with active polio transmission, laboratory work with poliovirus, or providing health care to polio patients and their close contacts. A single lifetime booster dose of inactivated polio vaccine is adequate for these high-risk scenarios.

About the Author

John Ross, MD, FIDSA, Contributor

Dr. John Ross is an assistant professor of medicine at Harvard Medical School. He is board certified in internal medicine and infectious diseases, and practices hospital medicine at Brigham and Women’s Hospital. He is the author … See Full Bio View all posts by John Ross, MD, FIDSA

Asthma is the most common chronic lung disease in children. In the US, it affects about 6 million children, or about one in every 12 children.

Breathing is key to life, obviously, so asthma can make life very hard. It can make going for a walk outside feel very hard. It leads not just to visits with the doctor or to the emergency room, and to hospitalizations, but also to missed school, missed work for parents, missed events, and missed activities.

The good news is that asthma is very treatable. If parents, children, and doctors work together, a child with asthma can lead a healthy, normal life. Here’s what you need to know and do.

Know your child’s symptoms

Wheezing is definitely a symptom of asthma, but a dry persistent cough can be as well (for some children, this occurs mostly at night).

Watch for signs that a child is working harder to breathe. One sign is skin tugging inward between, on top of, or below the ribs. Difficulty talking in long sentences is another sign of this.

Some children with exercise-induced asthma avoid exercise; if your child is choosing to be less active, talk to them about why.

Know your child’s triggers

There are many different triggers for asthma, including:

• Upper respiratory infections, like the common cold. COVID falls into this category, which is why children with asthma should be vaccinated against COVID.
• Allergies, such as
  • outdoor allergens like pollen, which are often worse in the spring and fall
  • indoor allergens like dust mites or mold
  • pet dander.
• Exercise. Some children will struggle with even mild exercise, while others only have trouble with vigorous exercise or exercising when there are other triggers too (like a cold or allergies).
• Weather changes, especially to colder weather. Some children can be triggered by going into a cold, air-conditioned room.
• Stress. Stress affects our bodies in multiple ways, and in some people it can trigger their asthma or make it worse.

Understand your child’s medications

Several kinds of medicines are used to treat asthma, including:

• Bronchodilators. Examples are albuterol, levalbuterol, formoterol, or ipratropium. Known as “rescue medications,” these are inhaled and work by opening up the airways. They are given through metered-dose inhalers or a nebulizer machine. They are used when a person is experiencing symptoms.
• Inhaled steroids. These work by decreasing inflammation in the lungs and making them less likely to react to triggers. They are “controller medications” given regularly to prevent symptoms.
• Combined inhalers. These have both an inhaled steroid and a long-acting bronchodilator. They are very useful for patients with more difficult asthma. Sometimes they are used in SMART (Single Maintenance And Reliever Therapy), in which the same inhaler is used for both rescue and control.
• Oral or injected steroids. These are generally used when someone has a bad asthma attack, but some people need to take them regularly to prevent attacks.
• Allergy medications. Medicines like loratadine, cetirizine, or montelukast can be very helpful when there is an allergic component to asthma.

Some people with severe asthma need other treatments, such as allergy shots for severe allergies, or medications like dupilumab that work in the body to flight inflammation. This is far less common.

Use medication correctly

• Sometimes medications and medication regimens can be confusing. That’s why everyone with asthma should have a written Asthma Action Plan that spells out exactly what they should do and when.
• If your child uses an inhaler, make sure that they are doing it right! For most inhalers, it’s important to use a spacer, which is a tube that attaches to the inhaler and helps to ensure that the medication gets into the lungs and not just the mouth or surrounding air.
• If you have any questions about anything your child is prescribed, call your doctor.

Meet with your doctor regularly

If your child’s asthma is anything more than very mild (a few mild attacks a year), you need to check in more frequently than at the yearly checkup. Extra check-ins give you a chance to talk to your doctor about how things are going — and give your doctor a chance to tweak your child’s regimen so that your child can live the healthiest, happiest life possible.

Which, after all, is totally the point.

Follow me on Twitter @drClaire

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

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

It’s an old line: everyone complains about the weather but no one is doing anything about it.

But if you’re a person with bad allergies or asthma, stormy weather can be more than an annoyance; it can be a serious threat to your health. “Thunderstorm asthma” was first reported in the 1980s in England and Australia, and cases continue to crop up. Just after severe thunderstorms passed through Melbourne, Australia in 2016, more than 9,000 people sought urgent medical care for asthma during one notable event. Medical facilities were overwhelmed and at least eight people died. That’s unusual, but if you do have asthma — or seasonal allergies, as it turns out — understanding this trigger can help you stay well.

What is thunderstorm asthma?

The term describes an attack of asthma that starts or worsens after a thunderstorm. It can occur in anyone with asthma, but it most often affects people with seasonal allergic rhinitis, which many people know as hay fever or allergies. Heralded by a runny nose, sneezing, and itchy eyes, seasonal allergies are often worst in the spring, summer, or early fall.

Rain tends to lower pollen counts by cleansing the air, and many people find that rainy weather tends to reduce asthma symptoms triggered by allergies. But thunderstorms can make asthma worse because of a unique sequence of events:

• Cold downdrafts concentrate air particles, such as pollen and mold
• These air particles are swept up into clouds where humidity is high
• In the clouds, wind, humidity, and lightning break up the particles to a size that can readily enter the nose, sinuses, and lungs
• Wind gusts concentrate these small particles so large amounts can be inhaled.

What raises risk for experiencing thunderstorm asthma?

According to a new study in the Journal of Allergy and Clinical Immunology, a whopping 144 out of 228 people with seasonal allergies reported experiencing thunderstorm asthma — that’s 65%! And many of the asthma attacks set off by thunderstorms weren’t mild. Nearly half of people who had an attack sought emergency hospital treatment.

Among people with seasonal allergies, risk factors for experiencing thunderstorm asthma include having

• poorly controlled asthma symptoms (assessed by a standard asthma questionnaire)
• a low score on a rapid exhalation test (a common breathing test for asthma)
• higher levels of a certain antibody (ryegrass pollen-specific IgE)
• higher numbers of certain blood cells (eosinophils, which tend to increase when people have allergic conditions)
• higher levels of exhaled nitric oxide (one measure of lung inflammation among people with asthma).

Not everyone with these risk factors will develop thunderstorm asthma. And even among those who do, asthma attacks won’t necessarily occur with every storm. But it may be useful to know if you’re among those at risk, especially if you live in an area where thunderstorms are common.

The bottom line

Thunderstorm asthma may seem like more of a curiosity than a serious threat to public health. But when it affects a large population area, emergency rooms can become overwhelmed, as happened during the 2016 Melbourne event. A better understanding of when these events are expected could lead to advanced warning systems, enhanced emergency room preparedness, and even preventive treatment.

In the US, 25 million people have asthma and more than 20 million have seasonal allergies. Odds are good that millions have both, which puts large numbers of people at risk for developing thunderstorm asthma.

If you’re among them, the weather forecast may be much more than just a guide on what to wear or whether to bring an umbrella. Knowing thunderstorms are headed your way may serve as an advance warning to double check that you are taking your asthma medicines properly, have a supply of rescue medicine handy, or simply plan to stay indoors until the storm has passed.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

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

For the longest time, your milk choices were whole, 2%, 1%, and fat-free (or skim). Today, refrigerator shelves at grocery stores are crowded with plant-based milks made from nuts, beans, or grains, and include favorites like almond, soy, coconut, cashew, oat, and rice. Yet the fertile ground of the plant-milk business continues to sprout new options, such as pistachio, pea, and even potato milk. It seems if you can grow it, you can make milk out of it.

So, are these new alternatives better nutritionally than the other plant milks — or just more of the same?

A few facts about plant-based milks

Plant-based milks are all made the same way: nuts, beans, or grains are ground into pulp, strained, and combined with water. You end up with only a small percentage of the actual plant — less than 10% for most brands. Nutrients like vitamin D, calcium, potassium, and protein are added in varying amounts. "Still, many alternative milks have similar amounts of these nutrients compared with cow’s milk," says Dr. Walter Willett, professor of epidemiology and nutrition at the Harvard T.H. Chan School of Public Health.

Plant-based milks are considered "greener" than dairy and emit fewer greenhouse gases during production. However, growing some of these plants and making them into milk requires great quantities of water. Most plant-based milks are low-calorie. On average, though, these milk products cost more than dairy.

Nutrition, calories, and other benefits of newer plant-based milks

Here’s a closer look at three new members of the alternative-milk family.

• Pistachio milk is not green like the nut, but rather an off-brown color. Because it contains little actual pistachio, you miss out on the nuts' essential vitamins and minerals, like thiamin, manganese, and vitamin B6. Yet pistachio milk contains less than 100 calories per cup, which is similar to skim cow’s milk and other plant-based milks. One extra benefit of pistachio milk is that it's a bit higher in protein than other plant milks (which can be light in the protein department compared with cow’s milk).
• Pea milk is created from yellow field peas, but has no "pea-like" flavor. Its color, taste, and creamy consistency are close to dairy, so people may find it more appealing than the sometimes-watery texture of other plant milks. Pea milk has a decent protein punch — at least 7 grams per serving — and each serving adds up to about 100 calories. It also requires less water in production than other plant milks, and has a smaller carbon footprint than dairy.
• Potato milk looks more like regular dairy milk than other plant milks because of the potato's starchy nature. It’s arguably the most eco-conscious plant milk, because growing potatoes requires less land and water than dairy and other plants. Potato milk also is low-calorie: 80 to 100 per serving.

What’s the best plant-based milk for you?

There doesn’t appear to be a huge difference between most plant milks. Ultimately, three issues drive your choice: digestion issues, environmental impact, and personal taste.

Digestion issues. Plant-based milks are a quality alternative for people with lactose intolerance or lactose sensitivity whose bodies can't break down and digest lactose, the sugar in milk. This causes digestive problems like diarrhea, gas, and bloating. (However, lactose-free and ultra-filtered dairy milk are available for those who prefer dairy.)

Environmental impact. One study in Science found that dairy milk production creates almost three times more greenhouse gas than plant-based milk. However, some plant milks, predominantly almond, demand much water to produce. (Some research suggests the water demands of almond milk are about equal to cow’s milk, according to Dr. Willet.)

Still, if you want to do your part to fight climate change, buying plant-based instead of dairy is the greener choice.

Personal taste. Plant-based milks can be an acquired taste, but with multiple choices, there is a good chance you can find one that satisfies your taste buds. Manufacturers try to overcome the taste dilemma by pouring in extra sugar, sweeteners like vanilla and chocolate, and other additives. So always check the total and added sugar amounts and keep the amount per serving below 10%. Of course, the lower the amount, the better.

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

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

Acne can be frustrating, especially when it does not go away after your teenage years. Believe it or not, acne can continue to affect adults beyond adolescence, or develop for the very first time in adulthood. This may be particularly distressing for adult women, who are more likely to get acne after the age of 20 compared to men.

What is adult female acne?

Adult female acne can look very similar to teenage acne. While adult acne is commonly thought to affect the jawline and chin, it can appear on any part of the face or trunk. Adult women can have clogged pores, inflamed pus-filled bumps, or deep-seated cysts. Unfortunately, treatment options that worked well in the teenage years may not work as well in adult females with acne, due to triggering factors such as hormonal imbalance, stress, and diet.

There are many reasons adult females can get acne. Hormonal disturbances caused by pregnancy, menstrual cycle, menopause, and oral contraceptives can contribute to acne by modifying the production of certain hormones. These hormones stimulate oil production within the skin, promoting the growth of acne-causing bacteria. Stress can increase the production of substances that activate oil glands within the skin of acne patients. Consumption of dairy and high-glycemic foods is also linked to acne. Certain hair or skin products can clog pores and cause comedonal acne (blackheads and whiteheads). A board-certified dermatologist can help determine the appropriate treatment for the type of acne you have.

Consequences of adult acne and scarring

The extent to which acne causes emotional distress varies, and is not related to the severity of the acne or acne scars. Some women with acne may experience disruption in their personal and professional lives as they fear stigmatization in relationships and employment. Adult females may also be more likely to seek treatment for active acne when acne bumps and scarring persist.

Acne scarring can be disfiguring. Permanent changes in skin texture in the form of pits or raised scars may not be easily concealed with makeup. Raised scars may also lead to skin picking and worsening skin texture and pigment.

Acne can also heal with red or dark spots that may not resolve for weeks to months. The dark spots may persist even longer without proper sun protection, especially on darker skin. Having both acne and dark spots may negatively impact one’s quality of life and self-perception.

The emotional toll associated with acne may include an elevated risk of developing depression compared to patients who do not have acne. Clinical studies show that having severe acne can negatively affect quality of life on par with long-term diseases such as arthritis, diabetes, back pain, and asthma. If you have acne, extensive scarring, or dark spots of any severity that are affecting your mental health, you may benefit from earlier intervention with oral medications.

What are options for treatment and support?

Acne is a medical condition, but it only needs to be treated if the acne or marks left behind from it are bothersome to you. Please see a board-certified dermatologist (in person or virtually) for the best available options if you wish to seek treatment.

Your dermatologist may prescribe a combination of topical (skin) and oral treatments. Some of these medications may not be appropriate if you are pregnant or breastfeeding, or carry risks. Ask your dermatologist about hair and skin products that may be irritating, clogging pores, or promoting oil production in the skin, making your acne worse. Also, avoid skin picking to prevent scarring, and try to minimize emotional and physical stressors.

For individuals with dark spots or scarring, consult a board-certified dermatologist to get a personalized treatment geared to your skin concerns. Use a broad-spectrum, tinted sunscreen daily and reapply it every two hours to help prevent acne marks from worsening. If your acne is causing you significant mental distress, ask your doctor about mental health resources. Additionally, seeking treatment for your acne may help you feel better. Consider joining online or in-person support groups in your area.

For more information, visit the American Academy of Dermatology Acne Resource Center.

Follow Dr. Nathan on Twitter @NeeraNathanMD
Follow Dr. Patel on Twitter @PayalPatelMD

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

Payal Patel, MD, Contributor

Dr. Payal Patel is a dermatology research fellow at Massachusetts General Hospital. Her clinical and research interests include autoimmune disease and procedural dermatology. She is part of the Cutaneous Biology Research Center, where she investigates medical … See Full Bio View all posts by Payal Patel, MD

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

Editor’s note: in honor of Pride Month, we’re re-publishing a 2019 post by Dr. Cecil Webster.

Generally speaking, discussing what happens in our bedrooms outside of the bedroom can be anxiety-provoking. Let’s try to make your doctor’s office an exception. Why is this important? People in the LGBTQ+ community contend not only with a full range of health needs, but also with environments that may lead to unique mental and physical health challenges. Whether or not you have come out in general, doing so with your doctor may prove critical in managing your health. Sexual experiences, with their impact on identity, varied emotional significance, and disease risk, are a keystone for helping your doctor understand how to personalize your healthcare.

Admittedly, talking about your intimate sexual experiences or your gender identity may feel uncomfortable. Many LGBTQ+ patients worry that their clinicians may not be knowledgeable about their needs, or that they’ll to have to educate them. Finding a LGBTQ+ adept doctor, preparing ahead of time for your next appointment, and courageously asking tough questions can give you and your health the best shot.

Finding a skilled clinician who is LGBTQ+ adept

Many large cities have healthcare institutions whose mission centers on care for LGBTQ+ peoples. However, these organizations may prove inaccessible to many for a variety of reasons. Regardless of your location, asking friends, family, or others to recommend a clinician may be a game changer. If your trans friend had a relatively painless experience visiting an area gynecologist, perhaps your Pap smear may go smoothly there as well. If your coworker has a psychiatrist who regularly asks him about his Grindr use, perhaps it may be easier to navigate your gay relationship questions with her.

Word of mouth is often an undervalued method of finding someone skilled and attentive to the needs of LGBTQ+ individuals. Online, many clinicians offer a short bio with their areas of expertise, and there are provider directories featuring trusted clinicians. Further, some doctors regularly write articles and give talks that may offer clues about desired knowledge. A simple Google search of your provider may yield a bounty.

Next, give your doctor or healthcare organization a call. Don’t be shy about requesting someone whose practice matches your specific needs. Your health information is protected, and generally, physicians hold your clinical privacy dear. Keep in mind that not all clinics will know or share whether or not your doctor is, for example, also a lesbian, but they may pair you with someone well suited to your request or point you in the right direction.

Preparing for your appointment

Let’s say you are nervous about coming out to your doctor. A little preparation may ease this burden. Here are some quick tips:

• Let them know you’re nervous at the start of the conversation.
• Be as bold as you can tolerate.
• Write down what you are excited about, nervous about, and/or curious about.
• Go in with a few goals and start with what’s most important.
• Maximize your comfort. If your partner is calming, bring them. If Beyoncé soothes what ails you, bring her along too.
• Lightly correct or update your clinician if they get something wrong.

Ask tough questions, give clear answers

As a psychiatrist who works with kids and adults, I often hear questions like, “I don’t know really how to say this, but I started experimenting with other guys. Does this mean I’m gay?” I may start by asking if you’ve enjoyed it. My colleagues in health care might begin with the same question.

Pleasurable experiences come in all sorts of constellations, and healthy exploration is part of being human. Additionally, clinicians need to assess and address your safety. Many LGBTQ+ people are at higher risk of intimate partner violence. We may ask about your use of condoms, how many partners you’ve had recently, your use of substances during sex, and how these experiences may shift how you see yourself. Give clear answers if possible, but don’t fret if you’re uncertain. Your doctor will not likely provide a label or pry unnecessarily. They may offer constructive information on the use of condoms, reasons to consider using PrEP (which can effectively prevent HIV), and places you can go for more guidance. Physicians enjoy giving personalized information so that you may make informed healthcare decisions.

There is no end to what is on people’s minds. Be bold. Will tucking reduce my sperm count? Maybe. Does binding my breasts come with risk? Likely. Was Shangela robbed of her RuPaul’s Drag Race: All Stars 3 crown? Utterly, but let’s get back to your cholesterol, shall we?

Remember that it is often impossible to squeeze everything into one appointment. Afterward, take time to catch your breath, reflect on what you’ve learned, and come up with more questions for next time. We’re here for that.

About the Author

Cecil R. Webster, Jr., MD, Contributor

Dr. Cecil R. Webster, Jr. is a child, adolescent, and adult psychiatrist in Boston. He is a lecturer in psychiatry at McLean Hospital and Harvard Medical School, and consultant for diversity health outreach programs at the … See Full Bio View all posts by Cecil R. Webster, Jr., MD