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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

When trying intermittent fasting, both the quantity and quality of what you eat during your eating window matter.

Intermittent fasting is a trendy topic that arises repeatedly in my clinic these days. I get it: restrict the time period when you eat, but within that time window eat as you normally would. No calorie counting. No food restrictions. Simple and flexible. In an on-the-go world, intermittent fasting has come into vogue as a potential pathway toward sustainable weight loss.

What is Intermittent fasting?

Intermittent fasting (IF) has become a catch-all term for one of the key levers in our dietary pattern: timing. More accurately, intermittent fasting refers to an eating schedule that is designed to expand the amount of time your body experiences a fasted state. You achieve this by reducing the so-called eating window. The most popular time-restricted eating protocols (typically based on study designs) are explained in these previously published articles:

• Time to try intermittent fasting?
• Intermittent fasting: The positive news continues
• Not so fast: Pros and cons of the newest diet trend

How might time-restricted eating help with weight loss?

To start, consider a fed state that promotes cellular growth versus a fasted state that stimulates cellular breakdown and repair. Both can be beneficial or harmful, depending on the context (consider how cellular growth builds lean muscle mass and also spawns cancer). Many of our genes, particularly those that regulate our metabolism (how we digest and utilize the energy from food), are turned on and off each day in accordance with our innate circadian rhythms (our sleep/wake cycle).

We transition from a fed to an early fasted state several hours — five to six, on average — after our last meal. This often aligns with the time when the sun has set, our metabolism slows, and we sleep. However, in our modern environment with artificial lights, 24-hour convenience stores, and DoorDash, we are persistently primed to eat. Rather than obeying our circadian cues, we are eating at all times of day.

Plenty of research, mainly in animal models but also some human trials, indicates that your body experiences numerous benefits from being in a fasted state, given its impact on cellular processes and function. In a fully fasted state, your metabolism switches its primary source of fuel from glucose to ketones, which triggers a host of cellular signaling to dampen cellular growth pathways and increase cellular repair and recycling mechanisms. Repeated exposure to a fasted state induces cellular adaptations that include increased insulin sensitivity, antioxidant defenses, and mitochondrial function.

Given how much of chronic disease is driven by underlying insulin resistance and inflammation, it’s plausible that fasting may help reduce diabetes, high cholesterol, hypertension, and obesity. And multiple short-term clinical studies provide evidence that intermittent fasting — specifically, time-restricted feeding — can improve markers of cardiometabolic health.

Is intermittent fasting a reliable strategy to achieve weight loss?

To date, the answer has remained murky due to the quality of the evidence, which often involves very small sample sizes, short intervention periods, varied study designs (often lacking control groups), different fasting protocols, and participants of varying shapes and sizes. The data on intermittent fasting and its impact on weight loss largely involves studies that employ the time-restricted eating methodology of intermittent fasting. A recent compilation of the evidence suggests that limiting your eating window might indeed help you shed a few pounds.

New research on IF as a tool for weight loss

To tease out the independent impact of time restriction on weight loss, we need to evaluate a calorie-restricted diet combined with time-restricted eating, compared to time-restricted eating alone. The recent results of a yearlong study assessed this exact question: does time-restricted eating with calorie restriction produce greater effects on weight loss and metabolic risk factors in obese patients, as compared with daily calorie restriction alone?

To answer this question, the trial involved people ages 18 to 75 with BMIs between 28 and 45, notably excluding those who were actively participating in a weight-loss program or using medications that affect weight or calorie intake. Participants were instructed to follow a 25% calorie-reduced diet (1,500 to 1,800 calories per day for men and 1,200 to 1,500 calories per day for women) with a set ratio of calories from protein, carbs, and fats. In order to confirm adherence to the diet (a notorious challenge in diet studies), participants were encouraged to weigh foods and were required to keep a daily dietary log, photograph the food they ate, and note the times at which they ate with the use of a custom mobile app.

Half of the participants (those in the time-restricted eating group) were instructed to consume the prescribed calories within an eight-hour period, whereas the other half in the daily-calorie-restriction group consumed the prescribed calories without time restriction. All participants were also instructed to maintain their usual daily physical activity throughout the trial, to remove this variable and to isolate the timing of food intake as the only difference between the two groups.

After a full year, 118 patients successfully completed the study, with similar rates of adherence to the diet and composition of the diet between the two groups. Both groups lost a significant amount of weight: an average of about 18 pounds for the time-restricted eating group and 14 pounds for the daily-calorie-restriction group. The difference in weight loss between the two groups was not statistically significant, nor was there a significant difference in weight loss among subgroups when sorted by sex, BMI at baseline, or insulin sensitivity. The resulting improvements in blood pressure, lipids, glucose, and cardiometabolic risk factors were also similar between the two groups. This trial provides strong evidence that, all else being equal, restricting the eating window alone does not have a substantive impact on weight loss.

What does the new research on IF mean for you?

For most people (with notable exclusions of those who have diabetes, eating disorders, are pregnant or breastfeeding, or require food with their meds), a time-restricted eating approach appears to be a safe strategy that is likely to produce some weight loss, assuming you are not changing your current dietary pattern (eating more calories).

The weight loss effects of time-restricted eating derive primarily from achieving a negative energy balance. If you maintain your regular diet and then limit the time window during which you eat, it is likely that you will eat a few hundred fewer calories per day. If this is sustainable as a lifestyle, it could add up to modest weight loss (3% to 8% on average, based on current data) that can produce beneficial improvements in cardiometabolic markers such as blood pressure, LDL cholesterol and triglyceride levels, and average blood sugar.

But — and this is a big but — if you are overcompensating for the time restriction by gorging yourself during your eating window, it will not work as a weight loss strategy. And it may indeed backfire. The other two levers in your dietary pattern — the quantity and quality of what you eat during your eating window — still matter immensely!

One downside of IF: Loss of lean muscle mass

While weight loss for cardiometabolic health is a sensible goal, weight loss from any intervention (including intermittent fasting) often entails a concurrent loss of lean muscle mass. This has been a notable finding — what I might even call an adverse side effect — of intermittent fasting protocols. Given the importance of lean muscle mass for revving your metabolic rate, regulating your blood sugar, and keeping you physically able overall, pairing resistance training with an intermittent fasting protocol is strongly advised.

Finally, the weight loss achieved through time-restricted eating (which we often refer to interchangeably with intermittent fasting) is likely different than the cellular adaptations that happen with more prolonged fully fasted states. At this time, it is hard to determine the degree to which the cardiometabolic benefits of fasting derive from weight loss or from underlying cellular adaptations; it is likely an interrelated combination of both.

Nevertheless, it seems clear that in a 24/7 world of around-the-clock eating opportunities, all of us could benefit from aligning with our circadian biology, and spend a bit less time in a fed state and more time in a fasted state each day.

About the Author

Richard Joseph, MD, Contributor

Dr. Richard Joseph is the founder of VIM Medicine, cofounder of Vital CxNs, a practicing clinician in the Center for Weight Management and Wellness at Brigham and Women’s Hospital in Boston, MA, and a faculty member at Harvard … See Full Bio View all posts by Richard Joseph, 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

Inflammatory bowel disease (IBD) is commonly diagnosed when people are in their 20s and 30s, which is also when many people are planning families. Many people who have been diagnosed with IBD (which includes Crohn’s disease and ulcerative colitis) have questions and concerns regarding their fertility, conception, pregnancy, delivery, and breastfeeding.

Thinking about conceiving a child or becoming pregnant?

It is important to make sure that your IBD is well controlled, ideally before you begin trying to have a biological child. This is equally important for patients with male and female reproductive anatomy.

Patients with female reproductive anatomy who conceive in remission tend to remain in remission throughout their pregnancy. Research shows that poorly controlled IBD can lead to decreased fertility, and pregnancy can be complicated by premature loss, preterm labor, low birthweight, and small for gestational age babies.

You may require blood work, imaging, or endoscopy prior to conception to get an idea of whether you have an actively inflamed bowel before pregnancy. Your doctor may also modify your medications to ensure that your disease is as well controlled as possible.

You will require care from different types of health care providers during pregnancy, in addition to a gastroenterologist with expertise in IBD. Depending on the history and severity of your IBD, you may benefit from having a high-risk maternal fetal OB/GYN, colorectal surgeon, pharmacist, IBD nurse, psychologist, or nutritionist as part of your care team.

What should I do before I start trying to conceive or become pregnant?

It is recommended to take a prenatal vitamin and/or folic acid supplement. Vitamin D deficiency is common in IBD, and if your levels are low your doctor may recommend supplementation. It is also important to be up to date on your vaccines and review your medication list with your doctor.

Will I need to change my treatment before conception or pregnancy?

Many IBD medications have favorable safety profiles during conception and pregnancy. However, there are some medications that may impact fertility (such as by decreasing sperm count) or that may be unsafe to continue during pregnancy. For example, it is generally recommended to stop taking the drug methotrexate three months before conception.

As newer drugs are developed, research about the safety of IBD treatments continues. It is important to discuss your medications and any concerns you may have during the pregnancy planning period.

How will I be monitored during pregnancy?

Your gastroenterologist will carefully monitor your symptoms during preconception, pregnancy, and postpartum. You may be asked to provide stool samples to assess fecal calprotectin levels (a marker of inflammation measured in the stool), which can help your doctor monitor IBD activity prior to conception and during each trimester of your pregnancy.

Drug levels of certain IBD medications may be monitored via blood work as well, to ensure proper medication dosing. Monitoring and managing IBD throughout pregnancy is individualized for each patient, and the goal is to increase the chances of a healthy outcome for both you and your baby.

What if I have an IBD flare while pregnant?

During an IBD flare in pregnancy, the goal is to rapidly decrease inflammation and optimize an IBD treatment regimen in order to avoid complications for you and your and baby. This may involve drug level monitoring, adjusting medication dosage, or switching medication types. A short course of steroid medications may be needed in certain cases.

If your blood work indicates iron deficiency anemia (which can be caused by inflammation in the GI tract, but can also occur in pregnancy due to increased iron requirement for the baby), iron supplements, either oral or intravenous, can be used to improve blood counts.

What are my options for delivery?

Most people with IBD can deliver via their preferred method. The decision to have a vaginal or cesarean section delivery sometimes depends on a patient’s medical history. If a patient has Crohn’s disease and active perianal disease, a cesarean section may be recommended. This is because active perianal disease increases the risk of severe tears and trauma to the perineal area (area around the anus and vagina).

Patients with a history of steroid exposure and bone complications (like osteoporosis) may want to avoiding pushing during a vaginal delivery. A cesarean section may also be recommended if there are significant risk factors for injury to the perineal area, or an obstetric complication unrelated to Crohn’s or ulcerative colitis.

What happens after I give birth?

After delivery, it’s important to continue IBD medications. Approximately one-third patients will have an IBD flare within a year following delivery. Patients with poorly controlled IBD during the third trimester or while in de-escalation of therapy (reduction in medications) during or after pregnancy are at the highest risk for a postpartum flare. For this reason, it is important to maintain close follow-up with your IBD doctor during this time.

Can I breastfeed/chestfeed?

Breastfeeding/chestfeeding has many benefits for both the postpartum person and infant. Many IBD treatments have favorable safety profiles for breastfeeding/chestfeeding. Some newer biologic medications have not yet been studied well. Your doctor will discuss the risks and benefits of your individualized IBD treatment to ensure your regimen and breastfeeding goals are both optimized.

Will my baby have IBD?

While there is a genetic component to IBD, there is usually a low risk of IBD for biologic children of IBD patients. First-degree relatives (and in particular, siblings) of people with IBD do have an increased risk of Crohn’s disease and ulcerative colitis.

The bottom line

It is important to discuss family planning goals with your doctors early, so they can help you optimize your health and focus on achieving remission prior to conception. Fortunately, many IBD medications are considered safe and effective during conception, pregnancy, and postpartum. During pregnancy, proactive monitoring and early treatment of flares is essential. Every pregnancy is different, and close communication with your medical team is important to keep you and your developing baby healthy.

About the Authors

Loren Rabinowitz, MD, Contributor

Dr. Loren Rabinowitz is an instructor in medicine Beth Israel Deaconess Medical Center and Harvard Medical School, and an attending physician in the Inflammatory Bowel Disease Center at BIDMC. Her clinical research is focused on the … See Full Bio View all posts by Loren Rabinowitz, MD

Nisa Desai, MD, Contributor

Dr. Nisa Desai is a practicing hospitalist physician at Beth Israel Deaconess Medical Center, and an instructor in medicine at Harvard Medical School. She completed undergraduate education at Northwestern University, followed by medical school at the … See Full Bio View all posts by Nisa Desai, 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

A study asks whether people who eat a lot of fish have a higher risk for the skin cancer melanoma.

If you’re trying to stick to a healthy diet, fish is a good choice, right? After all, fish is high in protein, low in saturated fat, and a good source of omega-3 fatty acids, vitamin D, and many other nutrients. Eating more fish can mean eating less of foods with harmful fats and higher calorie counts. Indeed, nutritionists commonly recommend more seafood (and fewer cheeseburgers) to improve your diet, and nutrition guidelines promote fish as part of a healthy diet.

So, it seems surprising that a new study in Cancer Causes and Control suggests a link between eating fish and skin cancer, particularly since the biggest known risk factor for melanoma is not dietary ­–– it’s sun exposure. Having five or more sunburns in your life doubles your risk of developing melanoma.

A study links eating fish often with higher risk of melanoma

Melanoma, the most serious type of skin cancer, is responsible for more than 7,500 deaths in the US each year. And cases are on the rise.

In the new study, researchers found a higher risk of melanoma among people who ate the most fish. This study is among the largest and most well-designed to examine this link. Nearly 500,000 people in six US states completed a dietary questionnaire in 1995 or 1996. The average age of participants was 61 and 60% were male. More than 90% were white, 4% were Black, and 2% were Hispanic.

Over the following 15 years, the researchers tallied how many people developed melanoma, and found that:

• The rate of melanoma was 22% higher among people reporting eating the most fish (about 2.6 servings per week) compared with those who ate the least (0.2 servings a week, or about one serving every five weeks). Similar trends were noted for intake of tuna.
• The risk of precancerous skin changes (called melanoma in situ) rose similarly among those in the group that ate the most fish.
• Interestingly, researchers found no increased risk of melanoma among those eating the most fried fish. This is surprising because, if eating fish increases the risk of melanoma as the study suggests, it’s not clear why frying the fish would eliminate the risk.

Does this mean eating fish causes melanoma?

No, it doesn’t. It’s too soon to make definitive conclusions about the relationship between fish in our diets and melanoma. The study had important limitations, including

• Type of study. Observational studies like this one can detect a possible link between diet and cancer but cannot prove it.
• Reliance on self-reported survey data. People self-reported how many servings of fish they ate each week, which may not be accurate. Also, researchers assumed that fish consumption reported on the initial survey persisted for 15 years, which may not have been the case.
• Accounting for other factors. Many factors affect risk for melanoma, such as varied sun exposure depending on where participants lived. The analysis did account for some key factors, yet the study didn’t collect information about sun exposure, past sunburns, or use of sunscreen — all important in melanoma risk. Nor did researchers ask about skin type or number of moles; fair skin or higher numbers of moles raise risk for melanoma.
• Contaminants. Mercury or arsenic in fish may be to blame for its link to melanoma. This study did not record contaminants, but previous studies link mercury exposure with the risk of skin cancers, including melanoma.
• Lack of diversity. It’s not clear if the findings apply broadly to people in different racial and ethnic groups, because nine in 10 study participants were white.

Are some fish safer to eat than others?

The study did not explore this question. However, if contaminants like mercury in fish are responsible for increasing the risk of melanoma, the FDA offers advice on which fish are safer to eat, particularly for children and those who are pregnant or breastfeeding.

Yet even if fish is confirmed as a contributor to the risk of melanoma, other positive effects of fish consumption (such as cardiovascular benefit) may far outweigh this risk.

The bottom line

The researchers responsible for this study are not recommending a change in how much fish people eat. More study is required to confirm the findings, investigate which types of fish affect melanoma risk, and determine whether certain contaminants in fish are responsible for any added risk.

In the meantime, fish with lower mercury levels (such as salmon and clams) remain better dietary choices than the high-fat, highly processed foods typical of many Western diets.

If you’re planning to spend a lot of time outside this summer, limiting sun exposure and using sunscreen will likely have a bigger impact on skin health and your overall health than avoiding seafood.

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

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

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

You may have noticed nipped-in, hourglass waists among women wearing the celebrity trend du jour: so-called waist trainers. This tummy-tucking shapewear evokes images of buttoned-up corsets and too-tight girdles from a dim past. But does it live up to the hype?

Splashy advertisements suggest these compression devices can help you selectively sculpt inches off your waistline by wearing them during workouts or as part of everyday routines. But the claims largely don’t live up to the evidence, says Michael Clem, a physical therapist with Spaulding Rehabilitation Network.

“People want the quick fix,” Clem says. “Putting something around our waist seems easy — we do it every day with pants and belts. What’s one more thing? Diet and exercise take longer and require more dramatic habit changes. We all know what we need to do, we just don’t want to do it.”

Debunking the hourglass hype

Clem debunks four common claims made about waist trainers — and points out one case where they may prove useful.

• Spot-reduce fat: Compressing fat with a waist trainer and expecting it to stay put once you uncinch the shapewear is a faulty concept. “Fat is a systemic deposit,” Clem says. “Putting something around your waist can’t help you burn the fat in just that place.”
• Sweat away the inches: Similarly, perspiring more profusely in one body area — in this case, under your waist trainer — will not melt fat there. “Sweat is a mechanism for cooling the body. We expend calories when we sweat but we can’t say those calories are going to come from the area we sweat from,” Clem notes.
• Eat less due to belly compression: While orthopedic braces or compression sleeves can heighten awareness of a body part, leading wearers to act differently, the same probably can’t be said of a thick band around the belly. Our awareness of internal organs isn’t as strong, Clem says. And while waist trainers apply pressure to the abdomen, they probably wouldn’t alter the body’s feeling of being full.
• Build a stronger core: Wearing a waist trainer might help if a doctor recommends temporary use after certain surgeries — such as while someone is rebuilding core muscles after a cesarean section, hernia surgery, or appendectomy — by offering tangible “feedback” on abdominal muscle use as a person recovers. “But there are much better ways to teach someone to feel their core,” says Clem, including working with a physical therapist on posture and breathing.

In most cases, there’s probably no harm in trying one of the shape-shifting devices, although anyone who is pregnant should not use them. And if you have any health issues, it’s best to talk to your doctor about whether compressing your core could have any negative effects, including not being able to breathe deeply and comfortably.

Want to shape your waist? Try core strengthening exercises

Listed from least to most challenging, here are three great exercises to strengthen core muscles that help define the waist. Start with one set and work up, paying attention to your form.

Bridge

Reps: 10
Sets: 1–3
Tempo: 3–1–3
Rest: 30–90 seconds between sets

Starting position: Lie on your back with your knees bent and feet flat on the floor, hip-width apart. Place your arms at your sides. Relax your shoulders against the floor.

Movement: Tighten your buttocks, then lift your hips up off the floor until they form a straight line with your knees and shoulders. Hold. Return to the starting position.

Tips and techniques:

• Tighten your buttocks before lifting.
• Keep your shoulders, hips, knees, and feet evenly aligned.
• Keep your shoulders down and relaxed into the floor.

Opposite arm and leg raise

Reps: 10
Sets: 1–3
Tempo: 3–1–3
Rest: 30–90 seconds between sets

Starting position: Kneel on all fours with your hands and knees directly aligned under your shoulders and hips. Keep your head and spine neutral.

Movement: Extend your left leg off the floor behind you while reaching out in front of you with your right arm. Keeping your hips and shoulders squared, try to bring that leg and arm parallel to the floor. Hold. Return to the starting position, then repeat with your right leg and left arm. This is one rep.

Tips and techniques:

• Keep your shoulders and hips squared to maintain alignment throughout.
• Keep your head and spine neutral.
• Think of pulling your hand and leg in opposite directions, lengthening your torso.

Stationary Lunge

 

Reps: 8-12 on each side
Sets: 1-3
Tempo: 3-1-3
Rest: 30-90 seconds between sets

Starting position: Stand up straight with your right foot one to two feet in front of your left foot, hands on your hips. Shift your weight forward and lift your left heel off the floor.

Movement: Bend your knees and lower your torso straight down until your right thigh is about parallel to the floor. Hold, then return to starting position. Finish all reps, then repeat with your left foot forward. This completes one set.

Tips and techniques:

• Keep your front knee directly over your ankle.
• In the lunge position, shoulder, hip, and rear knee should be aligned. Don’t lean forward or back.
• Keep your spine neutral and your shoulders down and back.

About the Author

Maureen Salamon, Executive Editor, Harvard Women's Health Watch

Maureen Salamon is executive editor of Harvard Women’s Health Watch. She began her career as a newspaper reporter and later covered health and medicine for a wide variety of websites, magazines, and hospitals. Her work has … See Full Bio View all posts by Maureen Salamon

More than five million Americans use wheelchairs. Getting one repaired is hard.

Wheelchairs restore mobility to people who are unable to walk or have limited ability to do so. Over a lifetime, this may describe many of us due to changes in health, injuries, neurological conditions, or disabling conditions like arthritis. So, when wheelchair technology or parts quit working, a quick fix would seem essential, right?

I know this firsthand. Unable to walk from decades with multiple sclerosis, I keep small scooters on every floor of my 1911 home, which is further adapted for accessibility with stair lifts and ramps. One day when I turned on my second-floor scooter-type wheelchair, sparks arced from the tiller opening atop the steering column, followed by smoke and the acrid smell of burning electrical wires. It was late on a Friday afternoon. No emergency repair service exists for wheelchairs or scooters. Now what?

Wheelchair repair delays are far more than an annoyance

Wheelchairs allow millions of Americans with mobility disability to participate in daily activities and community life (note: automatic download). We know this improves physical and mental well-being and overall quality of life.

On that Friday, my only option was to have my husband bring my first-floor scooter to the second floor. There I stayed, awaiting repairs on the now-inoperable scooter while my husband brought my meals upstairs. Because I have used the same small assistive technology company for more than 20 years — and have the owner’s cell phone number — by midafternoon on Tuesday, I once again had functional scooters on both floors. My confinement had lasted only four days. I know I was lucky on many levels.

But what if I lived alone, didn’t have another operational scooter, or hadn’t been able to wait four days? And what about people experiencing far longer waits for help with an essential device? While the 1990 Americans with Disabilities Act (ADA) prohibits discriminatory policies and requires physical accessibility in public services and spaces, it says nothing about this issue.

How often do wheelchairs break down?

Ideally, a wheelchair should be safe, reliable, and match your activity goals and functional needs. It should provide strong postural support and seating that protects against pressure injuries. Depending on strength and endurance, you might wish to self-propel a manual wheelchair. Or you might need a mobility scooter or power wheelchair propelled by a battery-powered motor, one that might even have sip-and-puff operational assistance or a chin-operated trackball.

Regardless of complexity, however — from basic manual wheelchairs to sophisticated rehab power chairs — all wheelchairs can break down, leaving their users stranded. Factors like broken pavement, inadequate curb cuts or soft terrain, steep inclines and inclement weather, and poor wheelchair design pretty much guarantee this.

In one study of 591 wheelchair users with spinal cord injury, 64% reported needing at least one wheelchair repair in the past six months. Among users requiring just one repair, wheels and casters posed the most difficulties for manual wheelchairs (46%). Electrical systems (29%) and power/control systems (27%) caused most problems for power wheelchair users. Rates of wheelchair breakdowns have increased in recent years, and vary across wheelchair manufacturers.

Repairs are costly, in more than one way. A survey of 533 wheelchair users with spinal cord injury found:

• Out-of-pocket repair costs ranged from $50 to $620 (the median, or midpoint, cost was $150).
• Time spent experiencing adverse consequences from wheelchair breakdown before repair ranged from two to 17 days (five days was the median).
• Among those reporting adverse consequences, 27% were stranded inside their home, 12% were stuck in bed, and 9% were stranded outside their home.

Wheelchair repair delays are lengthening: Could right to repair laws help?

Lengthening repair delays (automatic download) that heighten risks to consumers’ physical and mental health have caused many wheelchair users across the US to voice their outrage. However, reducing repair wait times isn’t simple. Medicare moved to competitive bidding in 2011, causing most small vendors — like my assistive technology company — to leave the business.

The two behemoths owned by private equity firms that now dominate the marketplace focus on boosting profits and cutting costs. By reducing technician hours and parts inventories, restricting consumers’ access to parts and software passcodes, requiring pre-approvals from insurers for repairs, and other practices, these companies virtually ensure delayed repairs.

Furthermore, Medicare and other insurers do not pay for preventive maintenance such as tightening loose bolts and cleaning casters, allowing problems to go undetected until breakdowns occur. Training can allow some wheelchair users to perform preventive maintenance tasks, but such training programs are not widely available.

Trying to reduce repair delays, Colorado’s governor recently signed the first “right to repair” law in the US for power wheelchair users. Complex software programs control many functions of power wheelchairs, and by holding this software as trade secrets, the manufacturers and large vendors have forced consumers needing repairs to use their services.

Much like recent right to repair laws for cars, the Colorado law mandates that power wheelchair owners and independent repair shops have access to the embedded software tools, parts, and other resources required to diagnose, maintain, or repair power wheelchairs. Other states, such as Massachusetts, may follow. Power wheelchair users in Massachusetts are testifying at public hearings about their repair horror stories to motivate the legislature to act.

Given the complexities of the wheelchair industry, it’s not clear whether right to repair laws will shorten repair times for power wheelchairs. Additionally, this law does not address manual wheelchairs or scooters like mine. Clearly, much more remains to be done to ensure timely wheelchair repairs. As wheelchair use surges, with growing numbers of baby boomers with mobility disability wanting to remain active in their communities, solving the wheelchair repair crisis is increasingly urgent.

About the Author

Lisa I. Iezzoni, MD, MSc, Contributor

Lisa I. Iezzoni, MD, MSc, is a professor of medicine at Harvard Medical School, and is based at Massachusetts General Hospital in Boston. Dr. Iezzoni studies health care experiences of persons with disability. She is a … See Full Bio View all posts by Lisa I. Iezzoni, MD, MSc