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Capitol siege presents new challenges for psychiatry to help prevent domestic terrorism
On Jan. 6, 2021, Americans and the world witnessed a violent insurrection at the U.S. Capitol inspired by a president and other elected leaders and driven by lies, conspiracy theories, militias, and white supremacy. The violent insurrection was carried out by thousands of citizens, including many with weapons.
Psychiatric organizations condemned the attack and warned about the potential traumatic impact of these events on those directly involved as well as for others in the United States already living under anxiety and fear tied to the surging COVID pandemic.
A major challenge for U.S. society is to prevent other potential future violent attacks. For those who didn’t already know, the Capitol attack made it apparent that the United States faces major problems with white supremacists and domestic terrorism. FBI Director Christopher Wray stipulated that those involved in the Jan. 6 events were violent agitators and extremists.
Addressing the causes and preventing domestic terrorism is also a challenge and opportunity for psychiatry and other mental health professionals. I write as a psychiatrist in academic medicine who has spent more than 10 years advocating for public health approaches to the causes and consequences of violence, especially involving violent extremism. and that psychiatrists have a role to play as part of a whole-of-society coalition with other multidisciplinary practitioners and stakeholders.
Day by day, we learn more and more about those responsible for the insurrection and how to understand their motivations, intentions, and actions. Seditionists incite or commit acts of violence against a lawful authority with the goal of destroying or overthrowing it. Domestic terrorists commit violent, criminal acts to further ideological goals stemming from domestic influences, such as those of a political, religious, social, racial, or environmental nature. The mob that attacked the Capitol contained both. What’s more, the Capitol insurrection might inspire others to take similar actions. The risk for even broader and deeper radicalization to violence is a grave concern.
Aided by more than 100,000 tips, the FBI is conducting a massive nationwide manhunt and thus far, dozens of people have been charged with crimes. Given that the United States has no law that makes domestic terrorism a crime, they are being charged with other crimes. Upholding the rule of law is necessary, but it should not be regarded as sufficient to deal with the white supremacism and domestic terrorism threats.
In many countries all over the world, and to a much lesser extent in the United States, there are successful non–law enforcement programs helping people move away from domestic terrorism and other forms of violence. One example in the United States is Life After Hate, a nongovernmental organization that uses former white supremacist extremists to counsel people to leave the movement. Another example is the Colorado Resilience Collaborative, which takes a socioecological approach to prevent terrorism and targeted violence. At Boston Children’s Hospital, a regional prevention initiative is focused on reducing youth risk for targeted violence and terrorism by reducing mental health problems and increasing social belonging among adolescents. These are but three of several initiatives currently being conducted throughout the United States.
Over the past decade, I have had the opportunity to become familiar with several of these programs domestically and internationally. These include programs aimed at rehabilitating and reintegrating repatriated foreign fighters and their children and other family members all over the world, including in Kazakhstan. I would like to share some of the lessons learned from these programs to aid in preventing domestic terrorism in the United States.
One lesson learned from combating international terrorism is that intelligence and law enforcement strategies (hard counterterrorism) need to be balanced with civil society–led prevention strategies. Overreliance on hard strategies can harm individuals and communities through oversecuritization. Alternatively, we need to build civil society–led initiatives that focus on other levers, such as addressing the underlying conditions, including individual psychosocial and mental health dimensions, or social dimensions (for example, lack of opportunity), that mitigate a person’s involvement in violent extremism.
A second lesson is not to focus exclusively on ideology and deradicalization. Yes, we need to challenge extremist ideology and disinformation, but a wide range of different factors explains involvement in violent extremism and the many pathways into it. Using a socioecological model, we can identify modifiable risk and protective factors that mitigate for or against extremist violence (for example, family support, job prospects, untreated mental health problems). In addition, it is well-established that prevention programs should seek to disengage, not deradicalize, potential violent extremists.
Third, we should leverage existing evidence-based interventions and best practices in mental health and public health, but we should also invest in building and evaluating new models through research approaches, especially for secondary and tertiary prevention. As much as possible, these should be integrated into broader programs to improve individual and community mental health and health.
A fourth lesson is we must vigorously protect the human rights and civil liberties of individuals and communities involved in these programs, and uphold racial equity. We can learn from public health experts about how to engage vulnerable individuals and communities without adding to their stigmatization. One way is to not focus on single communities, and not just on ideologically motivated violence, but to build violence prevention programs that are broad enough to address multiple forms of violence.
Fifth, if we expect community-based organizations to do the work, then they need adequate resources, capacity building, training and supervision, and quality improvement activities to succeed. For example, psychiatrists and other mental health professionals will require additional training to learn how to work effectively and ethically in this space.
Psychiatrists can start by building their knowledge and skills in understanding violent extremism and how it can be assessed and addressed, which is not the same as for suicidality. Psychiatrists can also become involved in established or emerging violence prevention programs, such as threat assessment programs in schools, workplaces, and communities. Across the country, there is a need for building new secondary and tertiary violence prevention initiatives, and they will need psychiatrists to work with them. Academic psychiatrists can become involved in building the models, developing and delivering training, and designing and conducting the program evaluations.
Finally, I suggest that psychiatrists look at domestic terrorism prevention through the lens of public health and not overly “psychiatrize” the issue. A public health approach uses evidence-based programs and policies, addresses underlying causes, and focuses on prevention. Public health builds programs with teams of experts from across disciplines – educators, health care workers, mental health professionals, faith leaders, youth leaders, community advocates, peers, and law enforcement.
As part of a public health–oriented team, psychiatrists can contribute to addressing the grave challenges of domestic terrorism facing our nation today.
Dr. Weine is professor of psychiatry, director of global medicine, and director of the Center for Global Health at the University of Illinois at Chicago. He has no conflicts of interest.
On Jan. 6, 2021, Americans and the world witnessed a violent insurrection at the U.S. Capitol inspired by a president and other elected leaders and driven by lies, conspiracy theories, militias, and white supremacy. The violent insurrection was carried out by thousands of citizens, including many with weapons.
Psychiatric organizations condemned the attack and warned about the potential traumatic impact of these events on those directly involved as well as for others in the United States already living under anxiety and fear tied to the surging COVID pandemic.
A major challenge for U.S. society is to prevent other potential future violent attacks. For those who didn’t already know, the Capitol attack made it apparent that the United States faces major problems with white supremacists and domestic terrorism. FBI Director Christopher Wray stipulated that those involved in the Jan. 6 events were violent agitators and extremists.
Addressing the causes and preventing domestic terrorism is also a challenge and opportunity for psychiatry and other mental health professionals. I write as a psychiatrist in academic medicine who has spent more than 10 years advocating for public health approaches to the causes and consequences of violence, especially involving violent extremism. and that psychiatrists have a role to play as part of a whole-of-society coalition with other multidisciplinary practitioners and stakeholders.
Day by day, we learn more and more about those responsible for the insurrection and how to understand their motivations, intentions, and actions. Seditionists incite or commit acts of violence against a lawful authority with the goal of destroying or overthrowing it. Domestic terrorists commit violent, criminal acts to further ideological goals stemming from domestic influences, such as those of a political, religious, social, racial, or environmental nature. The mob that attacked the Capitol contained both. What’s more, the Capitol insurrection might inspire others to take similar actions. The risk for even broader and deeper radicalization to violence is a grave concern.
Aided by more than 100,000 tips, the FBI is conducting a massive nationwide manhunt and thus far, dozens of people have been charged with crimes. Given that the United States has no law that makes domestic terrorism a crime, they are being charged with other crimes. Upholding the rule of law is necessary, but it should not be regarded as sufficient to deal with the white supremacism and domestic terrorism threats.
In many countries all over the world, and to a much lesser extent in the United States, there are successful non–law enforcement programs helping people move away from domestic terrorism and other forms of violence. One example in the United States is Life After Hate, a nongovernmental organization that uses former white supremacist extremists to counsel people to leave the movement. Another example is the Colorado Resilience Collaborative, which takes a socioecological approach to prevent terrorism and targeted violence. At Boston Children’s Hospital, a regional prevention initiative is focused on reducing youth risk for targeted violence and terrorism by reducing mental health problems and increasing social belonging among adolescents. These are but three of several initiatives currently being conducted throughout the United States.
Over the past decade, I have had the opportunity to become familiar with several of these programs domestically and internationally. These include programs aimed at rehabilitating and reintegrating repatriated foreign fighters and their children and other family members all over the world, including in Kazakhstan. I would like to share some of the lessons learned from these programs to aid in preventing domestic terrorism in the United States.
One lesson learned from combating international terrorism is that intelligence and law enforcement strategies (hard counterterrorism) need to be balanced with civil society–led prevention strategies. Overreliance on hard strategies can harm individuals and communities through oversecuritization. Alternatively, we need to build civil society–led initiatives that focus on other levers, such as addressing the underlying conditions, including individual psychosocial and mental health dimensions, or social dimensions (for example, lack of opportunity), that mitigate a person’s involvement in violent extremism.
A second lesson is not to focus exclusively on ideology and deradicalization. Yes, we need to challenge extremist ideology and disinformation, but a wide range of different factors explains involvement in violent extremism and the many pathways into it. Using a socioecological model, we can identify modifiable risk and protective factors that mitigate for or against extremist violence (for example, family support, job prospects, untreated mental health problems). In addition, it is well-established that prevention programs should seek to disengage, not deradicalize, potential violent extremists.
Third, we should leverage existing evidence-based interventions and best practices in mental health and public health, but we should also invest in building and evaluating new models through research approaches, especially for secondary and tertiary prevention. As much as possible, these should be integrated into broader programs to improve individual and community mental health and health.
A fourth lesson is we must vigorously protect the human rights and civil liberties of individuals and communities involved in these programs, and uphold racial equity. We can learn from public health experts about how to engage vulnerable individuals and communities without adding to their stigmatization. One way is to not focus on single communities, and not just on ideologically motivated violence, but to build violence prevention programs that are broad enough to address multiple forms of violence.
Fifth, if we expect community-based organizations to do the work, then they need adequate resources, capacity building, training and supervision, and quality improvement activities to succeed. For example, psychiatrists and other mental health professionals will require additional training to learn how to work effectively and ethically in this space.
Psychiatrists can start by building their knowledge and skills in understanding violent extremism and how it can be assessed and addressed, which is not the same as for suicidality. Psychiatrists can also become involved in established or emerging violence prevention programs, such as threat assessment programs in schools, workplaces, and communities. Across the country, there is a need for building new secondary and tertiary violence prevention initiatives, and they will need psychiatrists to work with them. Academic psychiatrists can become involved in building the models, developing and delivering training, and designing and conducting the program evaluations.
Finally, I suggest that psychiatrists look at domestic terrorism prevention through the lens of public health and not overly “psychiatrize” the issue. A public health approach uses evidence-based programs and policies, addresses underlying causes, and focuses on prevention. Public health builds programs with teams of experts from across disciplines – educators, health care workers, mental health professionals, faith leaders, youth leaders, community advocates, peers, and law enforcement.
As part of a public health–oriented team, psychiatrists can contribute to addressing the grave challenges of domestic terrorism facing our nation today.
Dr. Weine is professor of psychiatry, director of global medicine, and director of the Center for Global Health at the University of Illinois at Chicago. He has no conflicts of interest.
On Jan. 6, 2021, Americans and the world witnessed a violent insurrection at the U.S. Capitol inspired by a president and other elected leaders and driven by lies, conspiracy theories, militias, and white supremacy. The violent insurrection was carried out by thousands of citizens, including many with weapons.
Psychiatric organizations condemned the attack and warned about the potential traumatic impact of these events on those directly involved as well as for others in the United States already living under anxiety and fear tied to the surging COVID pandemic.
A major challenge for U.S. society is to prevent other potential future violent attacks. For those who didn’t already know, the Capitol attack made it apparent that the United States faces major problems with white supremacists and domestic terrorism. FBI Director Christopher Wray stipulated that those involved in the Jan. 6 events were violent agitators and extremists.
Addressing the causes and preventing domestic terrorism is also a challenge and opportunity for psychiatry and other mental health professionals. I write as a psychiatrist in academic medicine who has spent more than 10 years advocating for public health approaches to the causes and consequences of violence, especially involving violent extremism. and that psychiatrists have a role to play as part of a whole-of-society coalition with other multidisciplinary practitioners and stakeholders.
Day by day, we learn more and more about those responsible for the insurrection and how to understand their motivations, intentions, and actions. Seditionists incite or commit acts of violence against a lawful authority with the goal of destroying or overthrowing it. Domestic terrorists commit violent, criminal acts to further ideological goals stemming from domestic influences, such as those of a political, religious, social, racial, or environmental nature. The mob that attacked the Capitol contained both. What’s more, the Capitol insurrection might inspire others to take similar actions. The risk for even broader and deeper radicalization to violence is a grave concern.
Aided by more than 100,000 tips, the FBI is conducting a massive nationwide manhunt and thus far, dozens of people have been charged with crimes. Given that the United States has no law that makes domestic terrorism a crime, they are being charged with other crimes. Upholding the rule of law is necessary, but it should not be regarded as sufficient to deal with the white supremacism and domestic terrorism threats.
In many countries all over the world, and to a much lesser extent in the United States, there are successful non–law enforcement programs helping people move away from domestic terrorism and other forms of violence. One example in the United States is Life After Hate, a nongovernmental organization that uses former white supremacist extremists to counsel people to leave the movement. Another example is the Colorado Resilience Collaborative, which takes a socioecological approach to prevent terrorism and targeted violence. At Boston Children’s Hospital, a regional prevention initiative is focused on reducing youth risk for targeted violence and terrorism by reducing mental health problems and increasing social belonging among adolescents. These are but three of several initiatives currently being conducted throughout the United States.
Over the past decade, I have had the opportunity to become familiar with several of these programs domestically and internationally. These include programs aimed at rehabilitating and reintegrating repatriated foreign fighters and their children and other family members all over the world, including in Kazakhstan. I would like to share some of the lessons learned from these programs to aid in preventing domestic terrorism in the United States.
One lesson learned from combating international terrorism is that intelligence and law enforcement strategies (hard counterterrorism) need to be balanced with civil society–led prevention strategies. Overreliance on hard strategies can harm individuals and communities through oversecuritization. Alternatively, we need to build civil society–led initiatives that focus on other levers, such as addressing the underlying conditions, including individual psychosocial and mental health dimensions, or social dimensions (for example, lack of opportunity), that mitigate a person’s involvement in violent extremism.
A second lesson is not to focus exclusively on ideology and deradicalization. Yes, we need to challenge extremist ideology and disinformation, but a wide range of different factors explains involvement in violent extremism and the many pathways into it. Using a socioecological model, we can identify modifiable risk and protective factors that mitigate for or against extremist violence (for example, family support, job prospects, untreated mental health problems). In addition, it is well-established that prevention programs should seek to disengage, not deradicalize, potential violent extremists.
Third, we should leverage existing evidence-based interventions and best practices in mental health and public health, but we should also invest in building and evaluating new models through research approaches, especially for secondary and tertiary prevention. As much as possible, these should be integrated into broader programs to improve individual and community mental health and health.
A fourth lesson is we must vigorously protect the human rights and civil liberties of individuals and communities involved in these programs, and uphold racial equity. We can learn from public health experts about how to engage vulnerable individuals and communities without adding to their stigmatization. One way is to not focus on single communities, and not just on ideologically motivated violence, but to build violence prevention programs that are broad enough to address multiple forms of violence.
Fifth, if we expect community-based organizations to do the work, then they need adequate resources, capacity building, training and supervision, and quality improvement activities to succeed. For example, psychiatrists and other mental health professionals will require additional training to learn how to work effectively and ethically in this space.
Psychiatrists can start by building their knowledge and skills in understanding violent extremism and how it can be assessed and addressed, which is not the same as for suicidality. Psychiatrists can also become involved in established or emerging violence prevention programs, such as threat assessment programs in schools, workplaces, and communities. Across the country, there is a need for building new secondary and tertiary violence prevention initiatives, and they will need psychiatrists to work with them. Academic psychiatrists can become involved in building the models, developing and delivering training, and designing and conducting the program evaluations.
Finally, I suggest that psychiatrists look at domestic terrorism prevention through the lens of public health and not overly “psychiatrize” the issue. A public health approach uses evidence-based programs and policies, addresses underlying causes, and focuses on prevention. Public health builds programs with teams of experts from across disciplines – educators, health care workers, mental health professionals, faith leaders, youth leaders, community advocates, peers, and law enforcement.
As part of a public health–oriented team, psychiatrists can contribute to addressing the grave challenges of domestic terrorism facing our nation today.
Dr. Weine is professor of psychiatry, director of global medicine, and director of the Center for Global Health at the University of Illinois at Chicago. He has no conflicts of interest.
Topical tranexamic acid for melasma
By addressing the vascular component of melasma, off-label use of oral tranexamic acid has been a beneficial adjunct for this difficult-to-treat condition. For on-label use treating menorrhagia (the oral form) and short-term prophylaxis of bleeding in hemophilia patients undergoing dental procedures – (the injectable form), tranexamic acid acts as an antifibrinolytic.
By inhibiting plasminogen activation, according to a 2018 review article “tranexamic acid mitigates UV radiation–induced melanogenesis and neovascularization,” both exhibited in the clinical manifestations of melasma.1 In addition to inhibiting fibrinolysis, tranexamic acid has direct effects on UV-induced pigmentation, “via its inhibitory effects on UV light–induced plasminogen activator on keratinocytes and [subsequent] plasmin activity,” the article states. “Plasminogen activator induces tyrosinase activity, resulting in increased melanin synthesis. The presence of plasmin [which dissolves clots by degrading fibrin] results in increased production of both arachidonic acid and fibroblast growth factor, which stimulate melanogenesis and neovascularization, respectively.”
With oral use, the risk of clot formation, especially in those who have a history of blood clots, clotting disorders (such as factor V Leiden), smoking, or other hypercoagulability risks should be weighed.
Topical tranexamic acid used locally mitigates systemic risk, and according to published studies, has been found to be efficacious for hemostasis in knee and hip arthroplasty surgery and for epistaxis. However, clinical outcomes with the topical treatment have largely not been on par with regards to efficacy for melasma when compared with oral tranexamic acid.
. Topical tranexamic acid, in my experience, when applied immediately after fractional 1927-nm diode laser treatment, not only has been noted by patients to feel soothing, but anecdotally has been found to improve pigmentation.
Moreover, there are now several peer-reviewed studies showing some benefit for treating pigmentation from photodamage or melasma with laser-assisted delivery of topical tranexamic acid. Treatment of these conditions may also benefit from nonablative 1927-nm laser alone.
In one recently published study, 10 female melasma patients, Fitzpatrick skin types II-IV, underwent five full-face low-energy, low-density (power 4-5 W, fluence 2-8 mJ, 2-8 passes) 1927-nm fractional thulium fiber laser treatment.2 Topical tranexamic acid was applied immediately after laser treatment and continued twice daily for 7 days. Seven patients completed the study. Based on the Global Aesthetics Improvement Scale (GAIS) ratings, all seven patients noted improvement at day 180, at which time six of the patients were considered to have improved from baseline, according to the investigator GAIS ratings. Using the Melasma Area Severity Index (MASI) score, the greatest degree of improvement was seen at day 90; there were three recurrences of melasma with worsening of the MASI score between day 90 and day 180.
In a split-face, double-blind, randomized controlled study, 46 patients with Fitzpatrick skin types III-V, with recalcitrant melasma received four weekly treatments of full-face fractional 1927-nm thulium laser; topical tranexamic acid was applied to one side of the face and normal saline applied to the other side under occlusion, immediately after treatment.3 At 3 months, significant improvements from baseline were seen with Melanin Index (MI) and modified MASI (mMASI) scores for the sides treated with tranexamic acid and the control side, with no statistically significant differences between the two. However, at month 6, among the 29 patients available for follow-up, significant differences in MI and mMASI scores from baseline were still evident, with the exception of MI scores on the control sides.
No adverse events from using topical tranexamic acid with laser were noted in either study. Split-face randomized control studies with use of topical tranexamic acid after fractional 1927-nm diode laser in comparison to fractional 1927-nm thulium laser would be notable in this vascular and heat-sensitive condition as well.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
References
1. Sheu SL. Cutis. 2018 Feb;101(2):E7-E8.
2. Wang, JV et al. J Cosmet Dermatol. 2021 Jan;20(1):105-9.
3. Wanitphakdeedecha R. et al. Lasers Med Sci. 2020 Dec;35(9):2015-21.
By addressing the vascular component of melasma, off-label use of oral tranexamic acid has been a beneficial adjunct for this difficult-to-treat condition. For on-label use treating menorrhagia (the oral form) and short-term prophylaxis of bleeding in hemophilia patients undergoing dental procedures – (the injectable form), tranexamic acid acts as an antifibrinolytic.
By inhibiting plasminogen activation, according to a 2018 review article “tranexamic acid mitigates UV radiation–induced melanogenesis and neovascularization,” both exhibited in the clinical manifestations of melasma.1 In addition to inhibiting fibrinolysis, tranexamic acid has direct effects on UV-induced pigmentation, “via its inhibitory effects on UV light–induced plasminogen activator on keratinocytes and [subsequent] plasmin activity,” the article states. “Plasminogen activator induces tyrosinase activity, resulting in increased melanin synthesis. The presence of plasmin [which dissolves clots by degrading fibrin] results in increased production of both arachidonic acid and fibroblast growth factor, which stimulate melanogenesis and neovascularization, respectively.”
With oral use, the risk of clot formation, especially in those who have a history of blood clots, clotting disorders (such as factor V Leiden), smoking, or other hypercoagulability risks should be weighed.
Topical tranexamic acid used locally mitigates systemic risk, and according to published studies, has been found to be efficacious for hemostasis in knee and hip arthroplasty surgery and for epistaxis. However, clinical outcomes with the topical treatment have largely not been on par with regards to efficacy for melasma when compared with oral tranexamic acid.
. Topical tranexamic acid, in my experience, when applied immediately after fractional 1927-nm diode laser treatment, not only has been noted by patients to feel soothing, but anecdotally has been found to improve pigmentation.
Moreover, there are now several peer-reviewed studies showing some benefit for treating pigmentation from photodamage or melasma with laser-assisted delivery of topical tranexamic acid. Treatment of these conditions may also benefit from nonablative 1927-nm laser alone.
In one recently published study, 10 female melasma patients, Fitzpatrick skin types II-IV, underwent five full-face low-energy, low-density (power 4-5 W, fluence 2-8 mJ, 2-8 passes) 1927-nm fractional thulium fiber laser treatment.2 Topical tranexamic acid was applied immediately after laser treatment and continued twice daily for 7 days. Seven patients completed the study. Based on the Global Aesthetics Improvement Scale (GAIS) ratings, all seven patients noted improvement at day 180, at which time six of the patients were considered to have improved from baseline, according to the investigator GAIS ratings. Using the Melasma Area Severity Index (MASI) score, the greatest degree of improvement was seen at day 90; there were three recurrences of melasma with worsening of the MASI score between day 90 and day 180.
In a split-face, double-blind, randomized controlled study, 46 patients with Fitzpatrick skin types III-V, with recalcitrant melasma received four weekly treatments of full-face fractional 1927-nm thulium laser; topical tranexamic acid was applied to one side of the face and normal saline applied to the other side under occlusion, immediately after treatment.3 At 3 months, significant improvements from baseline were seen with Melanin Index (MI) and modified MASI (mMASI) scores for the sides treated with tranexamic acid and the control side, with no statistically significant differences between the two. However, at month 6, among the 29 patients available for follow-up, significant differences in MI and mMASI scores from baseline were still evident, with the exception of MI scores on the control sides.
No adverse events from using topical tranexamic acid with laser were noted in either study. Split-face randomized control studies with use of topical tranexamic acid after fractional 1927-nm diode laser in comparison to fractional 1927-nm thulium laser would be notable in this vascular and heat-sensitive condition as well.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
References
1. Sheu SL. Cutis. 2018 Feb;101(2):E7-E8.
2. Wang, JV et al. J Cosmet Dermatol. 2021 Jan;20(1):105-9.
3. Wanitphakdeedecha R. et al. Lasers Med Sci. 2020 Dec;35(9):2015-21.
By addressing the vascular component of melasma, off-label use of oral tranexamic acid has been a beneficial adjunct for this difficult-to-treat condition. For on-label use treating menorrhagia (the oral form) and short-term prophylaxis of bleeding in hemophilia patients undergoing dental procedures – (the injectable form), tranexamic acid acts as an antifibrinolytic.
By inhibiting plasminogen activation, according to a 2018 review article “tranexamic acid mitigates UV radiation–induced melanogenesis and neovascularization,” both exhibited in the clinical manifestations of melasma.1 In addition to inhibiting fibrinolysis, tranexamic acid has direct effects on UV-induced pigmentation, “via its inhibitory effects on UV light–induced plasminogen activator on keratinocytes and [subsequent] plasmin activity,” the article states. “Plasminogen activator induces tyrosinase activity, resulting in increased melanin synthesis. The presence of plasmin [which dissolves clots by degrading fibrin] results in increased production of both arachidonic acid and fibroblast growth factor, which stimulate melanogenesis and neovascularization, respectively.”
With oral use, the risk of clot formation, especially in those who have a history of blood clots, clotting disorders (such as factor V Leiden), smoking, or other hypercoagulability risks should be weighed.
Topical tranexamic acid used locally mitigates systemic risk, and according to published studies, has been found to be efficacious for hemostasis in knee and hip arthroplasty surgery and for epistaxis. However, clinical outcomes with the topical treatment have largely not been on par with regards to efficacy for melasma when compared with oral tranexamic acid.
. Topical tranexamic acid, in my experience, when applied immediately after fractional 1927-nm diode laser treatment, not only has been noted by patients to feel soothing, but anecdotally has been found to improve pigmentation.
Moreover, there are now several peer-reviewed studies showing some benefit for treating pigmentation from photodamage or melasma with laser-assisted delivery of topical tranexamic acid. Treatment of these conditions may also benefit from nonablative 1927-nm laser alone.
In one recently published study, 10 female melasma patients, Fitzpatrick skin types II-IV, underwent five full-face low-energy, low-density (power 4-5 W, fluence 2-8 mJ, 2-8 passes) 1927-nm fractional thulium fiber laser treatment.2 Topical tranexamic acid was applied immediately after laser treatment and continued twice daily for 7 days. Seven patients completed the study. Based on the Global Aesthetics Improvement Scale (GAIS) ratings, all seven patients noted improvement at day 180, at which time six of the patients were considered to have improved from baseline, according to the investigator GAIS ratings. Using the Melasma Area Severity Index (MASI) score, the greatest degree of improvement was seen at day 90; there were three recurrences of melasma with worsening of the MASI score between day 90 and day 180.
In a split-face, double-blind, randomized controlled study, 46 patients with Fitzpatrick skin types III-V, with recalcitrant melasma received four weekly treatments of full-face fractional 1927-nm thulium laser; topical tranexamic acid was applied to one side of the face and normal saline applied to the other side under occlusion, immediately after treatment.3 At 3 months, significant improvements from baseline were seen with Melanin Index (MI) and modified MASI (mMASI) scores for the sides treated with tranexamic acid and the control side, with no statistically significant differences between the two. However, at month 6, among the 29 patients available for follow-up, significant differences in MI and mMASI scores from baseline were still evident, with the exception of MI scores on the control sides.
No adverse events from using topical tranexamic acid with laser were noted in either study. Split-face randomized control studies with use of topical tranexamic acid after fractional 1927-nm diode laser in comparison to fractional 1927-nm thulium laser would be notable in this vascular and heat-sensitive condition as well.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
References
1. Sheu SL. Cutis. 2018 Feb;101(2):E7-E8.
2. Wang, JV et al. J Cosmet Dermatol. 2021 Jan;20(1):105-9.
3. Wanitphakdeedecha R. et al. Lasers Med Sci. 2020 Dec;35(9):2015-21.
Schools, COVID-19, and Jan. 6, 2021
The first weeks of 2021 have us considering how best to face compound challenges and we expect parents will be looking to their pediatricians for guidance. There are daily stories of the COVID-19 death toll, an abstraction made real by tragic stories of shattered families. Most families are approaching the first anniversary of their children being in virtual school, with growing concerns about the quality of virtual education, loss of socialization and group activities, and additional risks facing poor and vulnerable children. There are real concerns about the future impact of children spending so much time every day on their screens for school, extracurricular activities, social time, and relaxation. While the COVID-19 vaccines promise a return to “normal” sometime in 2021, in-person school may not return until late in the spring or next fall.
After the events of Jan. 6, families face an additional challenge: Discussing the violent invasion of the U.S. Capitol by the president’s supporters. This event was shocking, frightening, and confusing for most, and continues to be heavily covered in the news and online. There is a light in all this darkness. We have the opportunity to talk with our children – and to share explanations, perspectives, values, and even the discomfort of the unknowns – about COVID-19, use of the Internet, and the violence of Jan 6. We will consider how parents can approach this challenge for three age groups. With each group, parents will need to be calm and curious and will need time to give their children their full attention. We are all living through history. When parents can be fully present with their children, even for short periods at meals or at bedtime, it will help all to get their balance back and start to make sense of the extraordinary events we have been facing.
The youngest children (aged 3-6 years), those who were in preschool or kindergarten before the pandemic, need the most from their parents during this time. If they are attending school virtually, their online school days are likely short and challenging. Children at this age are mastering behavior rather than cognitive tasks. They are learning how to manage their bodies in space (stay in their seats!), how to be patient and kind (take turns!), and how to manage frustration (math is hard, try again!). Without the physical presence of their teacher and classmates, these lessons are tougher to internalize. Given their age-appropriate short attention spans, they often walk away from a screen, even if it’s class time. They are more likely to be paying attention to their parents, responding to the emotional climate at home. Even if they are not watching news websites themselves, they are likely to have overheard or noticed the news about recent events. Parents of young children should take care to turn off the television or their own computer, as repeated frightening videos of the insurrection can cause their children to worry that these events continue to unfold. These children need their parents’ undivided attention, even just for a little while. Play a board game with them (good chance to stay in their seats, take turns, and manage losing). Or get them outside for some physical play. While playing, parents can ask what they have seen, heard, or understand about what happened in the Capitol. Then they can correct misperceptions that might be frightening and offer reasonable reassurances in language these young children can understand. They might tell their children that sometimes people get angry when they have lost, and even adults can behave badly and make mistakes. They can focus on who the helpers are, and what they could do to help also. They could write letters of appreciation to their elected officials or to the Capitol police who were so brave in protecting others. If their children are curious, parents can find books or videos that are age appropriate about the Constitution and how elections work in a democracy. Parents don’t need to be able to answer every question, watching “Schoolhouse Rock” videos on YouTube together is a wonderful way to complement their online school and support their healthy development.
School-aged children (7-12 years) are developmentally focused on mastery experiences, whether they are social, academic, or athletic. They may be better equipped to pay attention and do homework than their younger siblings, but they will miss building friendships and having a real audience for their efforts as they build emotional maturity. They are prone to worry and distress about the big events that they can understand, at least in concrete terms, but have never faced before. These children usually have been able to use social media and online games to stay connected to friends, but they are less likely than their older siblings to independently exercise or explore new interests without a parent or teacher to guide and support them. These children are likely to be spending a lot of their time online on websites their parents don’t know about, and most likely to be curious about the events of Jan. 6. Parents should close their own device and invite their school-age children to show them what they are working on in school. Be curious about all of it, even how they are doing gym or music class. Then ask about what they have seen or heard about the election and its aftermath at school, from friends, or on their own. Let them be the teachers about what happened and how they learned about it. Parents can correct misinformation or offer reliable sources of information they can investigate together. What they will need is validation of the difficult feelings that events like these can cause; that is, acknowledgment, acceptance, and understanding of big feelings, without trying to just make those feelings go away. Parents might help them to be curious about what can make people get angry, break laws, and even hurt others, and how we protest injustices in a democracy. These children may be ready to take a deeper dive into history, via a good film or documentary, with their parents’ company for discussion afterward. Be their audience and model curiosity and patience, all the while validating the feelings that might arise.
Teenagers are developmentally focused on building their own identities, cultivating independence, and deeper relationships beyond their family. While they may be well equipped to manage online learning and to stay connected to their friends and teachers through electronic means, they are also facing considerable challenge, as their ability to explore new interests, build new relationships, and be meaningfully independent has been profoundly restrained over the past year. And they are facing other losses, as milestones like proms, performances, and competitions have been altered or missed. Parents still know when their teenager is most likely to talk, and they should check in with them during those times. They can ask them about what classes are working online and which ones aren’t, and what extracurriculars are still possible. They should not be discouraged if their teenager only offers cursory responses, it matters that they are showing up and showing interest. The election and its aftermath provide a meaningful matter to discuss; parents can find out if it is being discussed by any teachers or friends. What do they think triggered the events of Jan. 6? Who should be held responsible? How to reasonably protest injustice? What does a society do when citizens can’t agree on facts? More than offering reassurance, parents should be curious about their adolescent’s developing identity and their values, how they are thinking about complex issues around free speech and justice. It is a wonderful opportunity for parents to learn about their adolescent’s emerging identity, to be tolerant of their autonomy, and an opportunity to offer their perspective and values.
At every age, parents need to be present by listening and drawing their children out without distraction. Now is a time to build relationships and to use the difficult events of the day to shed light on deeper issues and values. This is hard, but far better than having children deal with these issues in darkness or alone.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at [email protected].
The first weeks of 2021 have us considering how best to face compound challenges and we expect parents will be looking to their pediatricians for guidance. There are daily stories of the COVID-19 death toll, an abstraction made real by tragic stories of shattered families. Most families are approaching the first anniversary of their children being in virtual school, with growing concerns about the quality of virtual education, loss of socialization and group activities, and additional risks facing poor and vulnerable children. There are real concerns about the future impact of children spending so much time every day on their screens for school, extracurricular activities, social time, and relaxation. While the COVID-19 vaccines promise a return to “normal” sometime in 2021, in-person school may not return until late in the spring or next fall.
After the events of Jan. 6, families face an additional challenge: Discussing the violent invasion of the U.S. Capitol by the president’s supporters. This event was shocking, frightening, and confusing for most, and continues to be heavily covered in the news and online. There is a light in all this darkness. We have the opportunity to talk with our children – and to share explanations, perspectives, values, and even the discomfort of the unknowns – about COVID-19, use of the Internet, and the violence of Jan 6. We will consider how parents can approach this challenge for three age groups. With each group, parents will need to be calm and curious and will need time to give their children their full attention. We are all living through history. When parents can be fully present with their children, even for short periods at meals or at bedtime, it will help all to get their balance back and start to make sense of the extraordinary events we have been facing.
The youngest children (aged 3-6 years), those who were in preschool or kindergarten before the pandemic, need the most from their parents during this time. If they are attending school virtually, their online school days are likely short and challenging. Children at this age are mastering behavior rather than cognitive tasks. They are learning how to manage their bodies in space (stay in their seats!), how to be patient and kind (take turns!), and how to manage frustration (math is hard, try again!). Without the physical presence of their teacher and classmates, these lessons are tougher to internalize. Given their age-appropriate short attention spans, they often walk away from a screen, even if it’s class time. They are more likely to be paying attention to their parents, responding to the emotional climate at home. Even if they are not watching news websites themselves, they are likely to have overheard or noticed the news about recent events. Parents of young children should take care to turn off the television or their own computer, as repeated frightening videos of the insurrection can cause their children to worry that these events continue to unfold. These children need their parents’ undivided attention, even just for a little while. Play a board game with them (good chance to stay in their seats, take turns, and manage losing). Or get them outside for some physical play. While playing, parents can ask what they have seen, heard, or understand about what happened in the Capitol. Then they can correct misperceptions that might be frightening and offer reasonable reassurances in language these young children can understand. They might tell their children that sometimes people get angry when they have lost, and even adults can behave badly and make mistakes. They can focus on who the helpers are, and what they could do to help also. They could write letters of appreciation to their elected officials or to the Capitol police who were so brave in protecting others. If their children are curious, parents can find books or videos that are age appropriate about the Constitution and how elections work in a democracy. Parents don’t need to be able to answer every question, watching “Schoolhouse Rock” videos on YouTube together is a wonderful way to complement their online school and support their healthy development.
School-aged children (7-12 years) are developmentally focused on mastery experiences, whether they are social, academic, or athletic. They may be better equipped to pay attention and do homework than their younger siblings, but they will miss building friendships and having a real audience for their efforts as they build emotional maturity. They are prone to worry and distress about the big events that they can understand, at least in concrete terms, but have never faced before. These children usually have been able to use social media and online games to stay connected to friends, but they are less likely than their older siblings to independently exercise or explore new interests without a parent or teacher to guide and support them. These children are likely to be spending a lot of their time online on websites their parents don’t know about, and most likely to be curious about the events of Jan. 6. Parents should close their own device and invite their school-age children to show them what they are working on in school. Be curious about all of it, even how they are doing gym or music class. Then ask about what they have seen or heard about the election and its aftermath at school, from friends, or on their own. Let them be the teachers about what happened and how they learned about it. Parents can correct misinformation or offer reliable sources of information they can investigate together. What they will need is validation of the difficult feelings that events like these can cause; that is, acknowledgment, acceptance, and understanding of big feelings, without trying to just make those feelings go away. Parents might help them to be curious about what can make people get angry, break laws, and even hurt others, and how we protest injustices in a democracy. These children may be ready to take a deeper dive into history, via a good film or documentary, with their parents’ company for discussion afterward. Be their audience and model curiosity and patience, all the while validating the feelings that might arise.
Teenagers are developmentally focused on building their own identities, cultivating independence, and deeper relationships beyond their family. While they may be well equipped to manage online learning and to stay connected to their friends and teachers through electronic means, they are also facing considerable challenge, as their ability to explore new interests, build new relationships, and be meaningfully independent has been profoundly restrained over the past year. And they are facing other losses, as milestones like proms, performances, and competitions have been altered or missed. Parents still know when their teenager is most likely to talk, and they should check in with them during those times. They can ask them about what classes are working online and which ones aren’t, and what extracurriculars are still possible. They should not be discouraged if their teenager only offers cursory responses, it matters that they are showing up and showing interest. The election and its aftermath provide a meaningful matter to discuss; parents can find out if it is being discussed by any teachers or friends. What do they think triggered the events of Jan. 6? Who should be held responsible? How to reasonably protest injustice? What does a society do when citizens can’t agree on facts? More than offering reassurance, parents should be curious about their adolescent’s developing identity and their values, how they are thinking about complex issues around free speech and justice. It is a wonderful opportunity for parents to learn about their adolescent’s emerging identity, to be tolerant of their autonomy, and an opportunity to offer their perspective and values.
At every age, parents need to be present by listening and drawing their children out without distraction. Now is a time to build relationships and to use the difficult events of the day to shed light on deeper issues and values. This is hard, but far better than having children deal with these issues in darkness or alone.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at [email protected].
The first weeks of 2021 have us considering how best to face compound challenges and we expect parents will be looking to their pediatricians for guidance. There are daily stories of the COVID-19 death toll, an abstraction made real by tragic stories of shattered families. Most families are approaching the first anniversary of their children being in virtual school, with growing concerns about the quality of virtual education, loss of socialization and group activities, and additional risks facing poor and vulnerable children. There are real concerns about the future impact of children spending so much time every day on their screens for school, extracurricular activities, social time, and relaxation. While the COVID-19 vaccines promise a return to “normal” sometime in 2021, in-person school may not return until late in the spring or next fall.
After the events of Jan. 6, families face an additional challenge: Discussing the violent invasion of the U.S. Capitol by the president’s supporters. This event was shocking, frightening, and confusing for most, and continues to be heavily covered in the news and online. There is a light in all this darkness. We have the opportunity to talk with our children – and to share explanations, perspectives, values, and even the discomfort of the unknowns – about COVID-19, use of the Internet, and the violence of Jan 6. We will consider how parents can approach this challenge for three age groups. With each group, parents will need to be calm and curious and will need time to give their children their full attention. We are all living through history. When parents can be fully present with their children, even for short periods at meals or at bedtime, it will help all to get their balance back and start to make sense of the extraordinary events we have been facing.
The youngest children (aged 3-6 years), those who were in preschool or kindergarten before the pandemic, need the most from their parents during this time. If they are attending school virtually, their online school days are likely short and challenging. Children at this age are mastering behavior rather than cognitive tasks. They are learning how to manage their bodies in space (stay in their seats!), how to be patient and kind (take turns!), and how to manage frustration (math is hard, try again!). Without the physical presence of their teacher and classmates, these lessons are tougher to internalize. Given their age-appropriate short attention spans, they often walk away from a screen, even if it’s class time. They are more likely to be paying attention to their parents, responding to the emotional climate at home. Even if they are not watching news websites themselves, they are likely to have overheard or noticed the news about recent events. Parents of young children should take care to turn off the television or their own computer, as repeated frightening videos of the insurrection can cause their children to worry that these events continue to unfold. These children need their parents’ undivided attention, even just for a little while. Play a board game with them (good chance to stay in their seats, take turns, and manage losing). Or get them outside for some physical play. While playing, parents can ask what they have seen, heard, or understand about what happened in the Capitol. Then they can correct misperceptions that might be frightening and offer reasonable reassurances in language these young children can understand. They might tell their children that sometimes people get angry when they have lost, and even adults can behave badly and make mistakes. They can focus on who the helpers are, and what they could do to help also. They could write letters of appreciation to their elected officials or to the Capitol police who were so brave in protecting others. If their children are curious, parents can find books or videos that are age appropriate about the Constitution and how elections work in a democracy. Parents don’t need to be able to answer every question, watching “Schoolhouse Rock” videos on YouTube together is a wonderful way to complement their online school and support their healthy development.
School-aged children (7-12 years) are developmentally focused on mastery experiences, whether they are social, academic, or athletic. They may be better equipped to pay attention and do homework than their younger siblings, but they will miss building friendships and having a real audience for their efforts as they build emotional maturity. They are prone to worry and distress about the big events that they can understand, at least in concrete terms, but have never faced before. These children usually have been able to use social media and online games to stay connected to friends, but they are less likely than their older siblings to independently exercise or explore new interests without a parent or teacher to guide and support them. These children are likely to be spending a lot of their time online on websites their parents don’t know about, and most likely to be curious about the events of Jan. 6. Parents should close their own device and invite their school-age children to show them what they are working on in school. Be curious about all of it, even how they are doing gym or music class. Then ask about what they have seen or heard about the election and its aftermath at school, from friends, or on their own. Let them be the teachers about what happened and how they learned about it. Parents can correct misinformation or offer reliable sources of information they can investigate together. What they will need is validation of the difficult feelings that events like these can cause; that is, acknowledgment, acceptance, and understanding of big feelings, without trying to just make those feelings go away. Parents might help them to be curious about what can make people get angry, break laws, and even hurt others, and how we protest injustices in a democracy. These children may be ready to take a deeper dive into history, via a good film or documentary, with their parents’ company for discussion afterward. Be their audience and model curiosity and patience, all the while validating the feelings that might arise.
Teenagers are developmentally focused on building their own identities, cultivating independence, and deeper relationships beyond their family. While they may be well equipped to manage online learning and to stay connected to their friends and teachers through electronic means, they are also facing considerable challenge, as their ability to explore new interests, build new relationships, and be meaningfully independent has been profoundly restrained over the past year. And they are facing other losses, as milestones like proms, performances, and competitions have been altered or missed. Parents still know when their teenager is most likely to talk, and they should check in with them during those times. They can ask them about what classes are working online and which ones aren’t, and what extracurriculars are still possible. They should not be discouraged if their teenager only offers cursory responses, it matters that they are showing up and showing interest. The election and its aftermath provide a meaningful matter to discuss; parents can find out if it is being discussed by any teachers or friends. What do they think triggered the events of Jan. 6? Who should be held responsible? How to reasonably protest injustice? What does a society do when citizens can’t agree on facts? More than offering reassurance, parents should be curious about their adolescent’s developing identity and their values, how they are thinking about complex issues around free speech and justice. It is a wonderful opportunity for parents to learn about their adolescent’s emerging identity, to be tolerant of their autonomy, and an opportunity to offer their perspective and values.
At every age, parents need to be present by listening and drawing their children out without distraction. Now is a time to build relationships and to use the difficult events of the day to shed light on deeper issues and values. This is hard, but far better than having children deal with these issues in darkness or alone.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at [email protected].
Tiger parenting, Earl Woods, and the ABPD template
The Tiger Woods saga, which has been broadcast on HBO, is a “child” of the ESPN Michael Jordan series – which riveted early pandemic America. It is likely to exert a similar vicelike hold on the imagination of Biden transition/Trump impeachment II United States, despite not having the express participation of Woods himself.
The differences in parenting styles of these young African American men, at least superficially, appears in amazingly stark contrast.
Whereas Michael Jordan’s parents appear to have shown good old, red-blooded North Carolina ambitious and hard-driven tough parenting, Earl and Kultida Woods seem to have exerted a textbook example of what we call “achievement by proxy distortion” (ABPD) parenting style.1-5
By deciding, even prior to birth, what their son’s future career would be, Earl, aided by Kultida Woods, created a master plan that came to fruition when Eldrick Tont “Tiger” Woods won his first Masters Tournament at the ripe old age of 21.
His parents’ fine-tuning of the ABPD template for professional sports parenting is often emulated. It had been earlier developed, in an industrial model – especially in women’s gymnastics – where Bela Karolyi and others in the Romanian Eastern Bloc system had developed Nadia Comaneci and others to be prepubescent superstars of the 1970s. When it was transferred to the more financially supportive, fertile base of the U.S., physical and sexual abuse were the acceptable price paid for Olympic gold medals.
When Tiger first appeared on the U.S. radar at the age of 2 on the Mike Douglas show in 1977, he was already definitively on the way to “prodigy” territory. Earl, a retired Vietnam veteran and product of the U.S. Marines, was able to model his own extraordinarily rigorous training where breaking down soldiers psychologically helps them survive special ops behind enemy lines. He trained his son essentially from birth, imprinting through somatic and postural echo these golf skills and habits for playing under pressure, handling annoying distraction, and self-hypnosis. These all clearly accelerated his son’s ability to enter the “zone,” a level of high attunement required, even demanded, at the highest levels of professional golf.
His parents’ ruthless approach, clearly accompanied by undoubted love and enthusiasm, to ending what appears to have been an age-appropriate high school relationship with his then “sweetheart,” appears on the surface a little cruel. But their approach achieved its purpose of sacrificing a distraction on the glorious golden path toward inevitable success and superstardom. This likely also produced a degree of self-objectification and further compartmentalization.
The typical outcome of ABPD is a fairly unidimensional identity defined by the activity, or in this case, the sport. In this case, where Earl was building or imagining a Messianic role for Tiger, multidimensionality was important as the self-described “Cablinasian” moniker suggests, whereby all of Tiger’s background of Caucasian, Black, Indian, and Asian ancestry was acknowledged as they all became lifelong fans.
What most likely saved Tiger Woods from the most debilitating aspects of his father’s master plan was that golfers cannot compete and achieve mega endorsements at the professional level until they have established credentials and grow into their adult bodies, when their stroke making becomes fully competitive and their product image ideal.
Therefore, a 6-year-old JonBenet Ramsey competing in beauty contests, or a 7-year-old Jessica Dubroff flying across country could have been Tiger, but they were not.
While awaiting his preordained career and endorsement deals, Tiger still needed to at least spend some time at college, in his case on a Stanford (Calif.) University golfing scholarship, while he accumulated U.S. amateur titles and fully established his credentials during this crucial time of normal development and “adolescent moratorium.”
According to the documentary,* being exposed to the “secret” extracurricular fringe benefits and sexual proclivities of golf pros with his father is likely to have been part of a traumatic “adultification” and compartmentalizing process. Whereby, one of Tiger’s roles became keeping his parents’ marriage together. That alleged exposure may also have planted the seeds for the “groupie” and sexual acting out challenges he so publicly experienced later in his career.
While Michael Jordan’s career has almost receded into the ancient and “hoary” past, Tiger Woods’s career at age 45, after overcoming significant back injuries and multiple failed surgeries, continues to astonish the golf and sporting world in general.
Most of his now deceased father Earl’s ambitions have indeed been realized despite some hiccups, setbacks, and loss of endorsements.
As parents in these challenging times, we all make sacrifices for our children, and in turn, expect them to step up to the plate and within reason, sacrifice and defer short-term excitement and fun for long-term educational, social, and life goals. How we as parents, and that includes Tiger Woods now, rise to this challenge is often a daily and humbling struggle.
While you watch this series, please keep your psychiatrist and family dynamics eyes wide open.
Dr. Tofler is a child and adolescent, sport psychiatrist, and is affiliated with Kaiser Permanente Psychiatry in West Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.
References
1. Tofler IR et al. N Engl J Med. 1996 Jul 25;335(4):281-3.
2. Jellinek MS et al. J Am Acad Child Adolesc Psychiatry. 1999 Feb;38(2):213-6.
3. Tofler IR and DiGeronimo TF. “Keeping Your Kids Out Front Without Kicking Them From Behind: How to Nurture High-Achieving Athletes, Scholars, and Performing Artists.” (Hoboken, N.J,: Jossey-Bass, 2000).
4. Tofler IR et al. Clin Sports Med. 2005 Oct;24(4):805-28.
5. Clark TP et al. Clin Sports Med. 2005 Oct;24(4):959-71.
*Updated 1/25/2021
The Tiger Woods saga, which has been broadcast on HBO, is a “child” of the ESPN Michael Jordan series – which riveted early pandemic America. It is likely to exert a similar vicelike hold on the imagination of Biden transition/Trump impeachment II United States, despite not having the express participation of Woods himself.
The differences in parenting styles of these young African American men, at least superficially, appears in amazingly stark contrast.
Whereas Michael Jordan’s parents appear to have shown good old, red-blooded North Carolina ambitious and hard-driven tough parenting, Earl and Kultida Woods seem to have exerted a textbook example of what we call “achievement by proxy distortion” (ABPD) parenting style.1-5
By deciding, even prior to birth, what their son’s future career would be, Earl, aided by Kultida Woods, created a master plan that came to fruition when Eldrick Tont “Tiger” Woods won his first Masters Tournament at the ripe old age of 21.
His parents’ fine-tuning of the ABPD template for professional sports parenting is often emulated. It had been earlier developed, in an industrial model – especially in women’s gymnastics – where Bela Karolyi and others in the Romanian Eastern Bloc system had developed Nadia Comaneci and others to be prepubescent superstars of the 1970s. When it was transferred to the more financially supportive, fertile base of the U.S., physical and sexual abuse were the acceptable price paid for Olympic gold medals.
When Tiger first appeared on the U.S. radar at the age of 2 on the Mike Douglas show in 1977, he was already definitively on the way to “prodigy” territory. Earl, a retired Vietnam veteran and product of the U.S. Marines, was able to model his own extraordinarily rigorous training where breaking down soldiers psychologically helps them survive special ops behind enemy lines. He trained his son essentially from birth, imprinting through somatic and postural echo these golf skills and habits for playing under pressure, handling annoying distraction, and self-hypnosis. These all clearly accelerated his son’s ability to enter the “zone,” a level of high attunement required, even demanded, at the highest levels of professional golf.
His parents’ ruthless approach, clearly accompanied by undoubted love and enthusiasm, to ending what appears to have been an age-appropriate high school relationship with his then “sweetheart,” appears on the surface a little cruel. But their approach achieved its purpose of sacrificing a distraction on the glorious golden path toward inevitable success and superstardom. This likely also produced a degree of self-objectification and further compartmentalization.
The typical outcome of ABPD is a fairly unidimensional identity defined by the activity, or in this case, the sport. In this case, where Earl was building or imagining a Messianic role for Tiger, multidimensionality was important as the self-described “Cablinasian” moniker suggests, whereby all of Tiger’s background of Caucasian, Black, Indian, and Asian ancestry was acknowledged as they all became lifelong fans.
What most likely saved Tiger Woods from the most debilitating aspects of his father’s master plan was that golfers cannot compete and achieve mega endorsements at the professional level until they have established credentials and grow into their adult bodies, when their stroke making becomes fully competitive and their product image ideal.
Therefore, a 6-year-old JonBenet Ramsey competing in beauty contests, or a 7-year-old Jessica Dubroff flying across country could have been Tiger, but they were not.
While awaiting his preordained career and endorsement deals, Tiger still needed to at least spend some time at college, in his case on a Stanford (Calif.) University golfing scholarship, while he accumulated U.S. amateur titles and fully established his credentials during this crucial time of normal development and “adolescent moratorium.”
According to the documentary,* being exposed to the “secret” extracurricular fringe benefits and sexual proclivities of golf pros with his father is likely to have been part of a traumatic “adultification” and compartmentalizing process. Whereby, one of Tiger’s roles became keeping his parents’ marriage together. That alleged exposure may also have planted the seeds for the “groupie” and sexual acting out challenges he so publicly experienced later in his career.
While Michael Jordan’s career has almost receded into the ancient and “hoary” past, Tiger Woods’s career at age 45, after overcoming significant back injuries and multiple failed surgeries, continues to astonish the golf and sporting world in general.
Most of his now deceased father Earl’s ambitions have indeed been realized despite some hiccups, setbacks, and loss of endorsements.
As parents in these challenging times, we all make sacrifices for our children, and in turn, expect them to step up to the plate and within reason, sacrifice and defer short-term excitement and fun for long-term educational, social, and life goals. How we as parents, and that includes Tiger Woods now, rise to this challenge is often a daily and humbling struggle.
While you watch this series, please keep your psychiatrist and family dynamics eyes wide open.
Dr. Tofler is a child and adolescent, sport psychiatrist, and is affiliated with Kaiser Permanente Psychiatry in West Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.
References
1. Tofler IR et al. N Engl J Med. 1996 Jul 25;335(4):281-3.
2. Jellinek MS et al. J Am Acad Child Adolesc Psychiatry. 1999 Feb;38(2):213-6.
3. Tofler IR and DiGeronimo TF. “Keeping Your Kids Out Front Without Kicking Them From Behind: How to Nurture High-Achieving Athletes, Scholars, and Performing Artists.” (Hoboken, N.J,: Jossey-Bass, 2000).
4. Tofler IR et al. Clin Sports Med. 2005 Oct;24(4):805-28.
5. Clark TP et al. Clin Sports Med. 2005 Oct;24(4):959-71.
*Updated 1/25/2021
The Tiger Woods saga, which has been broadcast on HBO, is a “child” of the ESPN Michael Jordan series – which riveted early pandemic America. It is likely to exert a similar vicelike hold on the imagination of Biden transition/Trump impeachment II United States, despite not having the express participation of Woods himself.
The differences in parenting styles of these young African American men, at least superficially, appears in amazingly stark contrast.
Whereas Michael Jordan’s parents appear to have shown good old, red-blooded North Carolina ambitious and hard-driven tough parenting, Earl and Kultida Woods seem to have exerted a textbook example of what we call “achievement by proxy distortion” (ABPD) parenting style.1-5
By deciding, even prior to birth, what their son’s future career would be, Earl, aided by Kultida Woods, created a master plan that came to fruition when Eldrick Tont “Tiger” Woods won his first Masters Tournament at the ripe old age of 21.
His parents’ fine-tuning of the ABPD template for professional sports parenting is often emulated. It had been earlier developed, in an industrial model – especially in women’s gymnastics – where Bela Karolyi and others in the Romanian Eastern Bloc system had developed Nadia Comaneci and others to be prepubescent superstars of the 1970s. When it was transferred to the more financially supportive, fertile base of the U.S., physical and sexual abuse were the acceptable price paid for Olympic gold medals.
When Tiger first appeared on the U.S. radar at the age of 2 on the Mike Douglas show in 1977, he was already definitively on the way to “prodigy” territory. Earl, a retired Vietnam veteran and product of the U.S. Marines, was able to model his own extraordinarily rigorous training where breaking down soldiers psychologically helps them survive special ops behind enemy lines. He trained his son essentially from birth, imprinting through somatic and postural echo these golf skills and habits for playing under pressure, handling annoying distraction, and self-hypnosis. These all clearly accelerated his son’s ability to enter the “zone,” a level of high attunement required, even demanded, at the highest levels of professional golf.
His parents’ ruthless approach, clearly accompanied by undoubted love and enthusiasm, to ending what appears to have been an age-appropriate high school relationship with his then “sweetheart,” appears on the surface a little cruel. But their approach achieved its purpose of sacrificing a distraction on the glorious golden path toward inevitable success and superstardom. This likely also produced a degree of self-objectification and further compartmentalization.
The typical outcome of ABPD is a fairly unidimensional identity defined by the activity, or in this case, the sport. In this case, where Earl was building or imagining a Messianic role for Tiger, multidimensionality was important as the self-described “Cablinasian” moniker suggests, whereby all of Tiger’s background of Caucasian, Black, Indian, and Asian ancestry was acknowledged as they all became lifelong fans.
What most likely saved Tiger Woods from the most debilitating aspects of his father’s master plan was that golfers cannot compete and achieve mega endorsements at the professional level until they have established credentials and grow into their adult bodies, when their stroke making becomes fully competitive and their product image ideal.
Therefore, a 6-year-old JonBenet Ramsey competing in beauty contests, or a 7-year-old Jessica Dubroff flying across country could have been Tiger, but they were not.
While awaiting his preordained career and endorsement deals, Tiger still needed to at least spend some time at college, in his case on a Stanford (Calif.) University golfing scholarship, while he accumulated U.S. amateur titles and fully established his credentials during this crucial time of normal development and “adolescent moratorium.”
According to the documentary,* being exposed to the “secret” extracurricular fringe benefits and sexual proclivities of golf pros with his father is likely to have been part of a traumatic “adultification” and compartmentalizing process. Whereby, one of Tiger’s roles became keeping his parents’ marriage together. That alleged exposure may also have planted the seeds for the “groupie” and sexual acting out challenges he so publicly experienced later in his career.
While Michael Jordan’s career has almost receded into the ancient and “hoary” past, Tiger Woods’s career at age 45, after overcoming significant back injuries and multiple failed surgeries, continues to astonish the golf and sporting world in general.
Most of his now deceased father Earl’s ambitions have indeed been realized despite some hiccups, setbacks, and loss of endorsements.
As parents in these challenging times, we all make sacrifices for our children, and in turn, expect them to step up to the plate and within reason, sacrifice and defer short-term excitement and fun for long-term educational, social, and life goals. How we as parents, and that includes Tiger Woods now, rise to this challenge is often a daily and humbling struggle.
While you watch this series, please keep your psychiatrist and family dynamics eyes wide open.
Dr. Tofler is a child and adolescent, sport psychiatrist, and is affiliated with Kaiser Permanente Psychiatry in West Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.
References
1. Tofler IR et al. N Engl J Med. 1996 Jul 25;335(4):281-3.
2. Jellinek MS et al. J Am Acad Child Adolesc Psychiatry. 1999 Feb;38(2):213-6.
3. Tofler IR and DiGeronimo TF. “Keeping Your Kids Out Front Without Kicking Them From Behind: How to Nurture High-Achieving Athletes, Scholars, and Performing Artists.” (Hoboken, N.J,: Jossey-Bass, 2000).
4. Tofler IR et al. Clin Sports Med. 2005 Oct;24(4):805-28.
5. Clark TP et al. Clin Sports Med. 2005 Oct;24(4):959-71.
*Updated 1/25/2021
How do you answer patients’ emails?
The pandemic has isolated our patients to an unprecedented degree, forcing them to find other ways to communicate with us, including email.
Responses varied all over the map. Some refuse the medium entirely. “I politely say that I don’t practice dermatology via email,” said one. “Please schedule a teledermatology appointment and I’d be happy to help.”
Others are ambivalent: “I do email with some patients who have complex situations or quick questions, but if it gets out of hand then I let them know someone will call to make an appointment.” Another office treats them as a one-way street: “We set up one account to receive patients’ emails, but we tell them clearly that we don’t respond ... my staff or I call them back.”
Still others have assimilated it completely. “Patients email through the portal and my MA routes [them] to me. I answer questions and the MA responds ... staff loves it because it’s so much faster than the phone.”
A 1998 study in JAMA was more scientifically designed, but basically reached the same conclusion. The authors found “a striking lack of consensus” on how to deal with patient emails: 50% responded to them, but 31% of responders refused to give advice without seeing the patient, while 59% offered a diagnosis, and a third of that group went on to provide specific advice about therapy. In response to a follow-up questionnaire, 28% said that they tended not to answer any patient emails, 24% said they usually replied with a standard message, and 24% said they answer each request individually. The authors concluded that “standards for physician response to unsolicited patient emails are needed.”
Indeed, my own unscientific survey suggests that, more than 20 years later, there is still nothing resembling a consensus on this issue. In the interim, several groups, including the American Medical Informatics Association and the American Medical Association have proposed standards, but none have been generally accepted. Until that happens, it seems prudent for each individual practice to adopt its own guidelines. For ideas, take a look at the proposals from the groups I mentioned, plus any others you can find. When you’re done, consider running your list past your attorney to make sure you haven’t forgotten anything, and that there are no unique requirements in your state.
Your guidelines may be very simple (if you decide never to answer any queries) or very complex, depending on your situation and personal philosophy. But all guidelines should cover such issues as authentication of correspondents, informed consent, licensing jurisdiction (if you receive emails from states in which you are not licensed), and of course, confidentiality.
Contrary to popular belief, HIPAA does not prohibit email communication with patients, nor require that it be encrypted. The HIPAA website specifically says: “Patients may initiate communications with a provider using email. If this situation occurs, the health care provider can assume (unless the patient has explicitly stated otherwise) that e-mail communications are acceptable to the individual.”
Still, if you are not comfortable with unencrypted communication, encryption software can be added to your practice’s email system. Proofpoint, Tumbleweed, Zix, and many other vendors sell encryption packages. (As always, I have no financial interest in any product or enterprise mentioned in this column.)
Another option is web-based messaging: Patients enter your website and send a message using an electronic template that you design. A designated staffer will be notified by regular email when messages are received, and can post a reply on a page that can only be accessed by the patient. Besides enhancing privacy and security, you can state your guidelines in plain English to preclude any misunderstanding of what you will and will not address online.
Web-based messaging services can be freestanding or incorporated into existing secure websites. Medfusion and klara are among the leading vendors of secure messaging services.
The important thing is to make a firm decision on how you want to deal with emails, and stick with that method. And follow your guidelines.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
The pandemic has isolated our patients to an unprecedented degree, forcing them to find other ways to communicate with us, including email.
Responses varied all over the map. Some refuse the medium entirely. “I politely say that I don’t practice dermatology via email,” said one. “Please schedule a teledermatology appointment and I’d be happy to help.”
Others are ambivalent: “I do email with some patients who have complex situations or quick questions, but if it gets out of hand then I let them know someone will call to make an appointment.” Another office treats them as a one-way street: “We set up one account to receive patients’ emails, but we tell them clearly that we don’t respond ... my staff or I call them back.”
Still others have assimilated it completely. “Patients email through the portal and my MA routes [them] to me. I answer questions and the MA responds ... staff loves it because it’s so much faster than the phone.”
A 1998 study in JAMA was more scientifically designed, but basically reached the same conclusion. The authors found “a striking lack of consensus” on how to deal with patient emails: 50% responded to them, but 31% of responders refused to give advice without seeing the patient, while 59% offered a diagnosis, and a third of that group went on to provide specific advice about therapy. In response to a follow-up questionnaire, 28% said that they tended not to answer any patient emails, 24% said they usually replied with a standard message, and 24% said they answer each request individually. The authors concluded that “standards for physician response to unsolicited patient emails are needed.”
Indeed, my own unscientific survey suggests that, more than 20 years later, there is still nothing resembling a consensus on this issue. In the interim, several groups, including the American Medical Informatics Association and the American Medical Association have proposed standards, but none have been generally accepted. Until that happens, it seems prudent for each individual practice to adopt its own guidelines. For ideas, take a look at the proposals from the groups I mentioned, plus any others you can find. When you’re done, consider running your list past your attorney to make sure you haven’t forgotten anything, and that there are no unique requirements in your state.
Your guidelines may be very simple (if you decide never to answer any queries) or very complex, depending on your situation and personal philosophy. But all guidelines should cover such issues as authentication of correspondents, informed consent, licensing jurisdiction (if you receive emails from states in which you are not licensed), and of course, confidentiality.
Contrary to popular belief, HIPAA does not prohibit email communication with patients, nor require that it be encrypted. The HIPAA website specifically says: “Patients may initiate communications with a provider using email. If this situation occurs, the health care provider can assume (unless the patient has explicitly stated otherwise) that e-mail communications are acceptable to the individual.”
Still, if you are not comfortable with unencrypted communication, encryption software can be added to your practice’s email system. Proofpoint, Tumbleweed, Zix, and many other vendors sell encryption packages. (As always, I have no financial interest in any product or enterprise mentioned in this column.)
Another option is web-based messaging: Patients enter your website and send a message using an electronic template that you design. A designated staffer will be notified by regular email when messages are received, and can post a reply on a page that can only be accessed by the patient. Besides enhancing privacy and security, you can state your guidelines in plain English to preclude any misunderstanding of what you will and will not address online.
Web-based messaging services can be freestanding or incorporated into existing secure websites. Medfusion and klara are among the leading vendors of secure messaging services.
The important thing is to make a firm decision on how you want to deal with emails, and stick with that method. And follow your guidelines.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
The pandemic has isolated our patients to an unprecedented degree, forcing them to find other ways to communicate with us, including email.
Responses varied all over the map. Some refuse the medium entirely. “I politely say that I don’t practice dermatology via email,” said one. “Please schedule a teledermatology appointment and I’d be happy to help.”
Others are ambivalent: “I do email with some patients who have complex situations or quick questions, but if it gets out of hand then I let them know someone will call to make an appointment.” Another office treats them as a one-way street: “We set up one account to receive patients’ emails, but we tell them clearly that we don’t respond ... my staff or I call them back.”
Still others have assimilated it completely. “Patients email through the portal and my MA routes [them] to me. I answer questions and the MA responds ... staff loves it because it’s so much faster than the phone.”
A 1998 study in JAMA was more scientifically designed, but basically reached the same conclusion. The authors found “a striking lack of consensus” on how to deal with patient emails: 50% responded to them, but 31% of responders refused to give advice without seeing the patient, while 59% offered a diagnosis, and a third of that group went on to provide specific advice about therapy. In response to a follow-up questionnaire, 28% said that they tended not to answer any patient emails, 24% said they usually replied with a standard message, and 24% said they answer each request individually. The authors concluded that “standards for physician response to unsolicited patient emails are needed.”
Indeed, my own unscientific survey suggests that, more than 20 years later, there is still nothing resembling a consensus on this issue. In the interim, several groups, including the American Medical Informatics Association and the American Medical Association have proposed standards, but none have been generally accepted. Until that happens, it seems prudent for each individual practice to adopt its own guidelines. For ideas, take a look at the proposals from the groups I mentioned, plus any others you can find. When you’re done, consider running your list past your attorney to make sure you haven’t forgotten anything, and that there are no unique requirements in your state.
Your guidelines may be very simple (if you decide never to answer any queries) or very complex, depending on your situation and personal philosophy. But all guidelines should cover such issues as authentication of correspondents, informed consent, licensing jurisdiction (if you receive emails from states in which you are not licensed), and of course, confidentiality.
Contrary to popular belief, HIPAA does not prohibit email communication with patients, nor require that it be encrypted. The HIPAA website specifically says: “Patients may initiate communications with a provider using email. If this situation occurs, the health care provider can assume (unless the patient has explicitly stated otherwise) that e-mail communications are acceptable to the individual.”
Still, if you are not comfortable with unencrypted communication, encryption software can be added to your practice’s email system. Proofpoint, Tumbleweed, Zix, and many other vendors sell encryption packages. (As always, I have no financial interest in any product or enterprise mentioned in this column.)
Another option is web-based messaging: Patients enter your website and send a message using an electronic template that you design. A designated staffer will be notified by regular email when messages are received, and can post a reply on a page that can only be accessed by the patient. Besides enhancing privacy and security, you can state your guidelines in plain English to preclude any misunderstanding of what you will and will not address online.
Web-based messaging services can be freestanding or incorporated into existing secure websites. Medfusion and klara are among the leading vendors of secure messaging services.
The important thing is to make a firm decision on how you want to deal with emails, and stick with that method. And follow your guidelines.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
An introduction to Naikan
The list of things to be ungrateful for last year is long. You’re not supposed to make this list, though. The best practice is to list what you’re grateful for, even when living in trying times. That’s a long list too, but I find making it similarly unfruitful.
Of course, I’m grateful I don’t have COVID-19, thankful my practice hasn’t been significantly impacted, grateful I got the vaccine. But simply repeating these gratitudes daily seems ineffective. I’ve learned a different “gratefulness practice” that perhaps works better.
It’s a Japanese method called Naikan (pronounced “nye-kan”). The word means introspection and the practice is one of self-reflection. But . Yoshimoto Ishin developed Naikan in the 1940s. He was a Japanese businessman and devout Buddhist who wanted to make a difficult form of meditation more accessible. He removed the ascetic bits like sleep deprivation and refined the exercises such that they better see how others see us. The result is a way to reframe your life experiences and help you understand how much others do for us and how our actions and attitudes impact others. It can be done alone or with a partner. You can do it at the beginning or end of your day.
The method is simple. You ask three questions:
What have I received today from ___________?
What have I given today to ___________?
What difficulty or trouble have I caused to ___________?
The first question is similar to most gratitude practices. For example, you might ask, “What have I received from (my husband or nurse or friend, etc.)? Today, I received a beautifully tidied-up office from my wife who spent time last night sorting things. This made it easy for me to sit down and start writing this piece.
The second question is better. What have I given today to (my wife, or patient, or mom, etc.)? It can be simple as: Today, I slowed down to let everyone who was in the closed highway lane back into traffic (even though some were clearly undeserving of my generosity). Or last night, I worked to coordinate with anesthesia and scheduling to help a little girl who would benefit from conscious sedation for her procedure.
Combined, these two questions pull you 180 degrees from our default mode, which is complaining. We are wired to find, and talk about, all the inconveniences in our lives: Roadway construction caused a traffic backup that led to running late for clinic. First patient was peeved and had a list of complaints, the last of which was hair loss. Isn’t it much better to rave about how our dermatology nurse volunteered to work the hospital COVID-19 unit to give her colleagues a break? Or how my 10:15 patient came early to be sure she was on time? (It happens.)
The last question is the best. We all spend time thinking about what others think of us. We should spend time thinking about what impact we’ve had on them. Like a cold shower, it’s both briskly awakening and easy to do. Go back through your day and reflect on what you did that made things difficult for others. It can be as simple as I started whining about how a patient waylaid me with her silly complaints. That led to my colleague’s joining in about difficult patients. Or I was late turning in my article, which made my editor have to work harder to get it completed in time.
There’s plenty of things we should be grateful for. In doing these exercises you’ll learn just how much others have cared for you and, I hope, how you might do things to make them grateful for you.
If you’re interested in learning more about Naikan, I discovered this from Brett McKay’s The Art of Manliness podcast and the teaching of Gregg Krech, summarized in his book, “Naikan: Gratitude, Grace, and the Japanese Art of Self-Reflection.”
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected] .
The list of things to be ungrateful for last year is long. You’re not supposed to make this list, though. The best practice is to list what you’re grateful for, even when living in trying times. That’s a long list too, but I find making it similarly unfruitful.
Of course, I’m grateful I don’t have COVID-19, thankful my practice hasn’t been significantly impacted, grateful I got the vaccine. But simply repeating these gratitudes daily seems ineffective. I’ve learned a different “gratefulness practice” that perhaps works better.
It’s a Japanese method called Naikan (pronounced “nye-kan”). The word means introspection and the practice is one of self-reflection. But . Yoshimoto Ishin developed Naikan in the 1940s. He was a Japanese businessman and devout Buddhist who wanted to make a difficult form of meditation more accessible. He removed the ascetic bits like sleep deprivation and refined the exercises such that they better see how others see us. The result is a way to reframe your life experiences and help you understand how much others do for us and how our actions and attitudes impact others. It can be done alone or with a partner. You can do it at the beginning or end of your day.
The method is simple. You ask three questions:
What have I received today from ___________?
What have I given today to ___________?
What difficulty or trouble have I caused to ___________?
The first question is similar to most gratitude practices. For example, you might ask, “What have I received from (my husband or nurse or friend, etc.)? Today, I received a beautifully tidied-up office from my wife who spent time last night sorting things. This made it easy for me to sit down and start writing this piece.
The second question is better. What have I given today to (my wife, or patient, or mom, etc.)? It can be simple as: Today, I slowed down to let everyone who was in the closed highway lane back into traffic (even though some were clearly undeserving of my generosity). Or last night, I worked to coordinate with anesthesia and scheduling to help a little girl who would benefit from conscious sedation for her procedure.
Combined, these two questions pull you 180 degrees from our default mode, which is complaining. We are wired to find, and talk about, all the inconveniences in our lives: Roadway construction caused a traffic backup that led to running late for clinic. First patient was peeved and had a list of complaints, the last of which was hair loss. Isn’t it much better to rave about how our dermatology nurse volunteered to work the hospital COVID-19 unit to give her colleagues a break? Or how my 10:15 patient came early to be sure she was on time? (It happens.)
The last question is the best. We all spend time thinking about what others think of us. We should spend time thinking about what impact we’ve had on them. Like a cold shower, it’s both briskly awakening and easy to do. Go back through your day and reflect on what you did that made things difficult for others. It can be as simple as I started whining about how a patient waylaid me with her silly complaints. That led to my colleague’s joining in about difficult patients. Or I was late turning in my article, which made my editor have to work harder to get it completed in time.
There’s plenty of things we should be grateful for. In doing these exercises you’ll learn just how much others have cared for you and, I hope, how you might do things to make them grateful for you.
If you’re interested in learning more about Naikan, I discovered this from Brett McKay’s The Art of Manliness podcast and the teaching of Gregg Krech, summarized in his book, “Naikan: Gratitude, Grace, and the Japanese Art of Self-Reflection.”
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected] .
The list of things to be ungrateful for last year is long. You’re not supposed to make this list, though. The best practice is to list what you’re grateful for, even when living in trying times. That’s a long list too, but I find making it similarly unfruitful.
Of course, I’m grateful I don’t have COVID-19, thankful my practice hasn’t been significantly impacted, grateful I got the vaccine. But simply repeating these gratitudes daily seems ineffective. I’ve learned a different “gratefulness practice” that perhaps works better.
It’s a Japanese method called Naikan (pronounced “nye-kan”). The word means introspection and the practice is one of self-reflection. But . Yoshimoto Ishin developed Naikan in the 1940s. He was a Japanese businessman and devout Buddhist who wanted to make a difficult form of meditation more accessible. He removed the ascetic bits like sleep deprivation and refined the exercises such that they better see how others see us. The result is a way to reframe your life experiences and help you understand how much others do for us and how our actions and attitudes impact others. It can be done alone or with a partner. You can do it at the beginning or end of your day.
The method is simple. You ask three questions:
What have I received today from ___________?
What have I given today to ___________?
What difficulty or trouble have I caused to ___________?
The first question is similar to most gratitude practices. For example, you might ask, “What have I received from (my husband or nurse or friend, etc.)? Today, I received a beautifully tidied-up office from my wife who spent time last night sorting things. This made it easy for me to sit down and start writing this piece.
The second question is better. What have I given today to (my wife, or patient, or mom, etc.)? It can be simple as: Today, I slowed down to let everyone who was in the closed highway lane back into traffic (even though some were clearly undeserving of my generosity). Or last night, I worked to coordinate with anesthesia and scheduling to help a little girl who would benefit from conscious sedation for her procedure.
Combined, these two questions pull you 180 degrees from our default mode, which is complaining. We are wired to find, and talk about, all the inconveniences in our lives: Roadway construction caused a traffic backup that led to running late for clinic. First patient was peeved and had a list of complaints, the last of which was hair loss. Isn’t it much better to rave about how our dermatology nurse volunteered to work the hospital COVID-19 unit to give her colleagues a break? Or how my 10:15 patient came early to be sure she was on time? (It happens.)
The last question is the best. We all spend time thinking about what others think of us. We should spend time thinking about what impact we’ve had on them. Like a cold shower, it’s both briskly awakening and easy to do. Go back through your day and reflect on what you did that made things difficult for others. It can be as simple as I started whining about how a patient waylaid me with her silly complaints. That led to my colleague’s joining in about difficult patients. Or I was late turning in my article, which made my editor have to work harder to get it completed in time.
There’s plenty of things we should be grateful for. In doing these exercises you’ll learn just how much others have cared for you and, I hope, how you might do things to make them grateful for you.
If you’re interested in learning more about Naikan, I discovered this from Brett McKay’s The Art of Manliness podcast and the teaching of Gregg Krech, summarized in his book, “Naikan: Gratitude, Grace, and the Japanese Art of Self-Reflection.”
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected] .
Family physicians can help achieve national goals on STIs
Among these are the U.S. Department of Health and Human Services’ first “Sexually Transmitted Infections (STIs) National Strategic Plan for the United States,” which has a strong encompassing vision.
“The United States will be a place where sexually transmitted infections are prevented and where every person has high-quality STI prevention care, and treatment while living free from stigma and discrimination. The vision includes all people, regardless of age, sex, gender identity, sexual orientation, race, ethnicity, religion, disability, geographic location, or socioeconomic circumstance,” the new HHS plan states.1
Family physicians can and should play important roles in helping our country meet this plan’s goals particularly by following two important updated clinical guidelines, one from the U.S. Preventive Services Task Force (USPSTF) and another from the Centers for Disease Control and Prevention (CDC).
This strategic plan includes the following five overarching goals with associated objectives:
- Prevent New STIs.
- Improve the health of people by reducing adverse outcomes of STIs.
- Accelerate progress in STI research, technology, and innovation.
- Reduce STI-related health disparities and health inequities.
- Achieve integrated, coordinated efforts that address the STI epidemic.1
In my opinion, family physicians have important roles to play in order for each of these goals to be achieved.Unfortunately, there are approximately 20 million new cases of STIs each year, and the U.S. has seen increases in the rates of STIs in the past decade.
“Sexually transmitted infections are frequently asymptomatic, which may delay diagnosis and treatment and lead persons to unknowingly transmit STIs to others,” according to a new recommendation statement from the USPSTF.2 STIs may lead to serious health consequences for patients, cause harms to a mother and infant during pregnancy, and lead to cases of cancer among other concerning outcomes. As such, following the HHS new national strategic plan is critical for us to address the needs of our communities.
Preventing new STIs
Family physicians can be vital in achieving the first goal of the plan by helping to prevent new STIs. In August 2020, the USPSTF updated its guideline on behavioral counseling interventions to prevent STIs. In my opinion, the USPSTF offers some practical improvements from the earlier version of this guideline.
The task force provides a grade B recommendation that all sexually active adolescents and adults at increased risk for STIs be provided with behavioral counseling to prevent STIs. The guideline indicates that behavioral counseling interventions reduce the likelihood of those at increased risk for acquiring STIs.2
The 2014 guideline had recommended intensive interventions with a minimum of 30 minutes of counseling. Many family physicians may have found this previous recommendation impractical to implement. These updated recommendations now include a variety of interventions, such as those that take less than 30 minutes.
Although interventions with more than 120 minutes of contact time had the most effect, those with less than 30 minutes still demonstrated statistically significant fewer acquisitions of STIs during follow-up. These options include in-person counseling, and providing written materials, websites, videos, and telephone and text support to patients. These interventions can be delivered directly by the family physician, or patients may be referred to other settings or the media interventions.
The task force’s updated recommendation statement refers to a variety of resources that can be used to identify these interventions. Many of the studies reviewed for this guideline were conducted in STI clinics, and the guideline authors recommended further studies in primary care as opportunities for more generalizability.
In addition to behavioral counseling for STI prevention, family physicians can help prevent STIs in their patients through HPV vaccination and HIV pre-exposure prophylaxis (PrEP provision) within their practices. As the first contact for health care for many patients, we have an opportunity to significantly impact this first goal of prevention.
Treating STIs
Within the second goal of the national strategic plan is treatment of STIs, which family physicians should include in their practices as well as the diagnosis of STIs.
In December 2020, an update to the CDC’s treatment guideline for gonococcal infection was released. Prior to the publishing of this updated recommendation, the CDC recommended combination therapy of 250 mg intramuscular (IM) dose of ceftriaxone and either doxycycline or azithromycin. This recommendation has been changed to a single 500-mg IM dose of ceftriaxone for uncomplicated urogenital, anorectal, and pharyngeal gonorrhea. If chlamydia cannot be excluded, then the addition of oral doxycycline 100 mg twice daily for 7 days is recommended for nonpregnant persons, and 1 g oral azithromycin for pregnant persons. The previous treatment was recommended based on a concern for gonococcal resistance.
This updated guideline reflects increasing concerns for antimicrobial stewardship and emerging azithromycin resistance. It does not recommend a test-of-cure for urogenital or rectal gonorrhea, though did recommend a test-of-cure 7-14 days after treatment of pharyngeal gonorrhea. The guideline also recommends testing for reinfection 3-12 months after treatment as the rate of reinfection ranges from 7% to 12% among those previously treated.3
For some offices, the provision of the IM injection may be challenging, though having this medication in stock with the possibility of provision can greatly improve access and ease of treatment for patients. Family physicians can incorporate these updated recommendations along with those for other STIs such as chlamydia and syphilis with standing orders for treatment and testing within their offices.
Accelerating progress in STI research
Family physicians can also support the national strategic plan by participating in studies looking at the impact of behavioral counseling in the primary care office as opposed to in STI clinics. In addition, by following the STI treatment and screening guidelines, family physicians will contribute to the body of knowledge of prevalence, treatment failure, and reinfection rates of STIs. We can also help advance the research by providing feedback on interventions that have success within our practices.
Reducing STI-related health disparities and inequities
Family physicians are also in important places to support the strategic plan’s fourth goal of reducing health disparities and health inequities.
If we continue to ask the questions to identify those at high risk and ensure that we are offering appropriate STI prevention, care, and treatment services within our clinics, we can expand access to all who need services and improve equity. By offering these services within the primary care office, we may be able to decrease the stigma some may feel going to an STI clinic for services.
By incorporating additional screening and counseling in our practices we may identify some patients who were not aware that they were at risk for an STI and offer them preventive services.
Achieving integrated and coordinated efforts
Finally, as many family physicians have integrated practices, we are uniquely poised to support the fifth goal of the strategic plan of achieving integrated and coordinated efforts addressing the STI epidemic. In our practices we can participate in, lead, and refer to programs for substance use disorders, viral hepatitis, STIs, and HIV as part of full scope primary care.
Family physicians and other primary care providers should work to support the entire strategic plan to ensure that we are fully caring for our patients and communities and stopping the past decade’s increase in STIs. We have an opportunity to use this strategy and make a large impact in our communities.
Dr. Wheat is a family physician at Erie Family Health Center in Chicago. She is program director of Northwestern’s McGaw Family Medicine residency program at Humboldt Park, Chicago. Dr. Wheat serves on the editorial advisory board of Family Practice News. You can contact her at [email protected].
References
1. U.S. Department of Health and Human Services. 2020. Sexually Transmitted Infections National Strategic Plan for the United States: 2021-2025. Washington.
2. U.S. Preventive Services Task Force. Behavioral counseling interventions to prevent sexually transmitted infections: U.S. Preventive Services Task Force Recommendation Statement. JAMA. 2020;324(7):674-81. doi: 10.1001/jama.2020.13095.
3. St. Cyr S et al. Update to CDC’s Treatment Guideline for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1911-6. doi: 10.15585/mmwr.mm6950a6external_icon.
Among these are the U.S. Department of Health and Human Services’ first “Sexually Transmitted Infections (STIs) National Strategic Plan for the United States,” which has a strong encompassing vision.
“The United States will be a place where sexually transmitted infections are prevented and where every person has high-quality STI prevention care, and treatment while living free from stigma and discrimination. The vision includes all people, regardless of age, sex, gender identity, sexual orientation, race, ethnicity, religion, disability, geographic location, or socioeconomic circumstance,” the new HHS plan states.1
Family physicians can and should play important roles in helping our country meet this plan’s goals particularly by following two important updated clinical guidelines, one from the U.S. Preventive Services Task Force (USPSTF) and another from the Centers for Disease Control and Prevention (CDC).
This strategic plan includes the following five overarching goals with associated objectives:
- Prevent New STIs.
- Improve the health of people by reducing adverse outcomes of STIs.
- Accelerate progress in STI research, technology, and innovation.
- Reduce STI-related health disparities and health inequities.
- Achieve integrated, coordinated efforts that address the STI epidemic.1
In my opinion, family physicians have important roles to play in order for each of these goals to be achieved.Unfortunately, there are approximately 20 million new cases of STIs each year, and the U.S. has seen increases in the rates of STIs in the past decade.
“Sexually transmitted infections are frequently asymptomatic, which may delay diagnosis and treatment and lead persons to unknowingly transmit STIs to others,” according to a new recommendation statement from the USPSTF.2 STIs may lead to serious health consequences for patients, cause harms to a mother and infant during pregnancy, and lead to cases of cancer among other concerning outcomes. As such, following the HHS new national strategic plan is critical for us to address the needs of our communities.
Preventing new STIs
Family physicians can be vital in achieving the first goal of the plan by helping to prevent new STIs. In August 2020, the USPSTF updated its guideline on behavioral counseling interventions to prevent STIs. In my opinion, the USPSTF offers some practical improvements from the earlier version of this guideline.
The task force provides a grade B recommendation that all sexually active adolescents and adults at increased risk for STIs be provided with behavioral counseling to prevent STIs. The guideline indicates that behavioral counseling interventions reduce the likelihood of those at increased risk for acquiring STIs.2
The 2014 guideline had recommended intensive interventions with a minimum of 30 minutes of counseling. Many family physicians may have found this previous recommendation impractical to implement. These updated recommendations now include a variety of interventions, such as those that take less than 30 minutes.
Although interventions with more than 120 minutes of contact time had the most effect, those with less than 30 minutes still demonstrated statistically significant fewer acquisitions of STIs during follow-up. These options include in-person counseling, and providing written materials, websites, videos, and telephone and text support to patients. These interventions can be delivered directly by the family physician, or patients may be referred to other settings or the media interventions.
The task force’s updated recommendation statement refers to a variety of resources that can be used to identify these interventions. Many of the studies reviewed for this guideline were conducted in STI clinics, and the guideline authors recommended further studies in primary care as opportunities for more generalizability.
In addition to behavioral counseling for STI prevention, family physicians can help prevent STIs in their patients through HPV vaccination and HIV pre-exposure prophylaxis (PrEP provision) within their practices. As the first contact for health care for many patients, we have an opportunity to significantly impact this first goal of prevention.
Treating STIs
Within the second goal of the national strategic plan is treatment of STIs, which family physicians should include in their practices as well as the diagnosis of STIs.
In December 2020, an update to the CDC’s treatment guideline for gonococcal infection was released. Prior to the publishing of this updated recommendation, the CDC recommended combination therapy of 250 mg intramuscular (IM) dose of ceftriaxone and either doxycycline or azithromycin. This recommendation has been changed to a single 500-mg IM dose of ceftriaxone for uncomplicated urogenital, anorectal, and pharyngeal gonorrhea. If chlamydia cannot be excluded, then the addition of oral doxycycline 100 mg twice daily for 7 days is recommended for nonpregnant persons, and 1 g oral azithromycin for pregnant persons. The previous treatment was recommended based on a concern for gonococcal resistance.
This updated guideline reflects increasing concerns for antimicrobial stewardship and emerging azithromycin resistance. It does not recommend a test-of-cure for urogenital or rectal gonorrhea, though did recommend a test-of-cure 7-14 days after treatment of pharyngeal gonorrhea. The guideline also recommends testing for reinfection 3-12 months after treatment as the rate of reinfection ranges from 7% to 12% among those previously treated.3
For some offices, the provision of the IM injection may be challenging, though having this medication in stock with the possibility of provision can greatly improve access and ease of treatment for patients. Family physicians can incorporate these updated recommendations along with those for other STIs such as chlamydia and syphilis with standing orders for treatment and testing within their offices.
Accelerating progress in STI research
Family physicians can also support the national strategic plan by participating in studies looking at the impact of behavioral counseling in the primary care office as opposed to in STI clinics. In addition, by following the STI treatment and screening guidelines, family physicians will contribute to the body of knowledge of prevalence, treatment failure, and reinfection rates of STIs. We can also help advance the research by providing feedback on interventions that have success within our practices.
Reducing STI-related health disparities and inequities
Family physicians are also in important places to support the strategic plan’s fourth goal of reducing health disparities and health inequities.
If we continue to ask the questions to identify those at high risk and ensure that we are offering appropriate STI prevention, care, and treatment services within our clinics, we can expand access to all who need services and improve equity. By offering these services within the primary care office, we may be able to decrease the stigma some may feel going to an STI clinic for services.
By incorporating additional screening and counseling in our practices we may identify some patients who were not aware that they were at risk for an STI and offer them preventive services.
Achieving integrated and coordinated efforts
Finally, as many family physicians have integrated practices, we are uniquely poised to support the fifth goal of the strategic plan of achieving integrated and coordinated efforts addressing the STI epidemic. In our practices we can participate in, lead, and refer to programs for substance use disorders, viral hepatitis, STIs, and HIV as part of full scope primary care.
Family physicians and other primary care providers should work to support the entire strategic plan to ensure that we are fully caring for our patients and communities and stopping the past decade’s increase in STIs. We have an opportunity to use this strategy and make a large impact in our communities.
Dr. Wheat is a family physician at Erie Family Health Center in Chicago. She is program director of Northwestern’s McGaw Family Medicine residency program at Humboldt Park, Chicago. Dr. Wheat serves on the editorial advisory board of Family Practice News. You can contact her at [email protected].
References
1. U.S. Department of Health and Human Services. 2020. Sexually Transmitted Infections National Strategic Plan for the United States: 2021-2025. Washington.
2. U.S. Preventive Services Task Force. Behavioral counseling interventions to prevent sexually transmitted infections: U.S. Preventive Services Task Force Recommendation Statement. JAMA. 2020;324(7):674-81. doi: 10.1001/jama.2020.13095.
3. St. Cyr S et al. Update to CDC’s Treatment Guideline for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1911-6. doi: 10.15585/mmwr.mm6950a6external_icon.
Among these are the U.S. Department of Health and Human Services’ first “Sexually Transmitted Infections (STIs) National Strategic Plan for the United States,” which has a strong encompassing vision.
“The United States will be a place where sexually transmitted infections are prevented and where every person has high-quality STI prevention care, and treatment while living free from stigma and discrimination. The vision includes all people, regardless of age, sex, gender identity, sexual orientation, race, ethnicity, religion, disability, geographic location, or socioeconomic circumstance,” the new HHS plan states.1
Family physicians can and should play important roles in helping our country meet this plan’s goals particularly by following two important updated clinical guidelines, one from the U.S. Preventive Services Task Force (USPSTF) and another from the Centers for Disease Control and Prevention (CDC).
This strategic plan includes the following five overarching goals with associated objectives:
- Prevent New STIs.
- Improve the health of people by reducing adverse outcomes of STIs.
- Accelerate progress in STI research, technology, and innovation.
- Reduce STI-related health disparities and health inequities.
- Achieve integrated, coordinated efforts that address the STI epidemic.1
In my opinion, family physicians have important roles to play in order for each of these goals to be achieved.Unfortunately, there are approximately 20 million new cases of STIs each year, and the U.S. has seen increases in the rates of STIs in the past decade.
“Sexually transmitted infections are frequently asymptomatic, which may delay diagnosis and treatment and lead persons to unknowingly transmit STIs to others,” according to a new recommendation statement from the USPSTF.2 STIs may lead to serious health consequences for patients, cause harms to a mother and infant during pregnancy, and lead to cases of cancer among other concerning outcomes. As such, following the HHS new national strategic plan is critical for us to address the needs of our communities.
Preventing new STIs
Family physicians can be vital in achieving the first goal of the plan by helping to prevent new STIs. In August 2020, the USPSTF updated its guideline on behavioral counseling interventions to prevent STIs. In my opinion, the USPSTF offers some practical improvements from the earlier version of this guideline.
The task force provides a grade B recommendation that all sexually active adolescents and adults at increased risk for STIs be provided with behavioral counseling to prevent STIs. The guideline indicates that behavioral counseling interventions reduce the likelihood of those at increased risk for acquiring STIs.2
The 2014 guideline had recommended intensive interventions with a minimum of 30 minutes of counseling. Many family physicians may have found this previous recommendation impractical to implement. These updated recommendations now include a variety of interventions, such as those that take less than 30 minutes.
Although interventions with more than 120 minutes of contact time had the most effect, those with less than 30 minutes still demonstrated statistically significant fewer acquisitions of STIs during follow-up. These options include in-person counseling, and providing written materials, websites, videos, and telephone and text support to patients. These interventions can be delivered directly by the family physician, or patients may be referred to other settings or the media interventions.
The task force’s updated recommendation statement refers to a variety of resources that can be used to identify these interventions. Many of the studies reviewed for this guideline were conducted in STI clinics, and the guideline authors recommended further studies in primary care as opportunities for more generalizability.
In addition to behavioral counseling for STI prevention, family physicians can help prevent STIs in their patients through HPV vaccination and HIV pre-exposure prophylaxis (PrEP provision) within their practices. As the first contact for health care for many patients, we have an opportunity to significantly impact this first goal of prevention.
Treating STIs
Within the second goal of the national strategic plan is treatment of STIs, which family physicians should include in their practices as well as the diagnosis of STIs.
In December 2020, an update to the CDC’s treatment guideline for gonococcal infection was released. Prior to the publishing of this updated recommendation, the CDC recommended combination therapy of 250 mg intramuscular (IM) dose of ceftriaxone and either doxycycline or azithromycin. This recommendation has been changed to a single 500-mg IM dose of ceftriaxone for uncomplicated urogenital, anorectal, and pharyngeal gonorrhea. If chlamydia cannot be excluded, then the addition of oral doxycycline 100 mg twice daily for 7 days is recommended for nonpregnant persons, and 1 g oral azithromycin for pregnant persons. The previous treatment was recommended based on a concern for gonococcal resistance.
This updated guideline reflects increasing concerns for antimicrobial stewardship and emerging azithromycin resistance. It does not recommend a test-of-cure for urogenital or rectal gonorrhea, though did recommend a test-of-cure 7-14 days after treatment of pharyngeal gonorrhea. The guideline also recommends testing for reinfection 3-12 months after treatment as the rate of reinfection ranges from 7% to 12% among those previously treated.3
For some offices, the provision of the IM injection may be challenging, though having this medication in stock with the possibility of provision can greatly improve access and ease of treatment for patients. Family physicians can incorporate these updated recommendations along with those for other STIs such as chlamydia and syphilis with standing orders for treatment and testing within their offices.
Accelerating progress in STI research
Family physicians can also support the national strategic plan by participating in studies looking at the impact of behavioral counseling in the primary care office as opposed to in STI clinics. In addition, by following the STI treatment and screening guidelines, family physicians will contribute to the body of knowledge of prevalence, treatment failure, and reinfection rates of STIs. We can also help advance the research by providing feedback on interventions that have success within our practices.
Reducing STI-related health disparities and inequities
Family physicians are also in important places to support the strategic plan’s fourth goal of reducing health disparities and health inequities.
If we continue to ask the questions to identify those at high risk and ensure that we are offering appropriate STI prevention, care, and treatment services within our clinics, we can expand access to all who need services and improve equity. By offering these services within the primary care office, we may be able to decrease the stigma some may feel going to an STI clinic for services.
By incorporating additional screening and counseling in our practices we may identify some patients who were not aware that they were at risk for an STI and offer them preventive services.
Achieving integrated and coordinated efforts
Finally, as many family physicians have integrated practices, we are uniquely poised to support the fifth goal of the strategic plan of achieving integrated and coordinated efforts addressing the STI epidemic. In our practices we can participate in, lead, and refer to programs for substance use disorders, viral hepatitis, STIs, and HIV as part of full scope primary care.
Family physicians and other primary care providers should work to support the entire strategic plan to ensure that we are fully caring for our patients and communities and stopping the past decade’s increase in STIs. We have an opportunity to use this strategy and make a large impact in our communities.
Dr. Wheat is a family physician at Erie Family Health Center in Chicago. She is program director of Northwestern’s McGaw Family Medicine residency program at Humboldt Park, Chicago. Dr. Wheat serves on the editorial advisory board of Family Practice News. You can contact her at [email protected].
References
1. U.S. Department of Health and Human Services. 2020. Sexually Transmitted Infections National Strategic Plan for the United States: 2021-2025. Washington.
2. U.S. Preventive Services Task Force. Behavioral counseling interventions to prevent sexually transmitted infections: U.S. Preventive Services Task Force Recommendation Statement. JAMA. 2020;324(7):674-81. doi: 10.1001/jama.2020.13095.
3. St. Cyr S et al. Update to CDC’s Treatment Guideline for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1911-6. doi: 10.15585/mmwr.mm6950a6external_icon.
Circadian rhythms, part 2: Can treating cutaneous conditions at different times of the day improve outcomes?
We continue with a focus on when possible, as well as clinical studies that may shed light on how to time skin care treatments.
It is important to remember that several studies in the last 20 years have revealed cutaneous tendencies based on the time of day. For instance, sebum production is known to be highest around noon, and pH also peaks during the day and is at its lowest at night.1-5
Skin aging
In 2019, Dong and associates showed that blue light at 410 nm reduces PER1 transcription in keratinocytes, indicating that epidermal cells have the capacity to directly sense light and regulate their own clock gene expression. With the introduction of blue light at night, circadian rhythm is disrupted as epidermal skin cells act as if it is daytime. The investigators also considered blue light–induced damage to skin cells at various doses and exposure times in comparison with cells that remained unexposed to light. The production of reactive oxygen species increased in the exposed cells, as did DNA impairment and the emergence of inflammatory mediators, all of which have the potential to hasten aging.6
Early this year, Dong and associates demonstrated that melatonin can dose-dependently stimulate PER1 clock gene expression in normal human dermal fibroblasts and normal human epidermal keratinocytes, and verified that the MT-1 melatonin receptor in such fibroblasts manifests a marked decline with age. The researchers concluded that the melatonin pathway contributes significantly in cutaneous aging and impairment, and that its relationship with skin circadian rhythm points to a possible role in slowing the rate of skin aging through the modulation of cutaneous melatonin receptors.7
Wound healing
In 2019, Walker and associates investigated the effects of dim artificial light at night on wound healing in female C57BL/6 mice, and found that those conditions prior to wounding reduced healing. They concluded that such information might warrant consideration in prescribing treatment.8
Atopic dermatitis
Vaughn and associates contended that alterations in circadian rhythm may contribute to the development of atopic dermatitis.9 A good example of the impact of circadian rhythms on cutaneous health is the nocturnal exacerbation of atopic dermatitis, particularly in children.10
Psoriasis
According to Plikus and associates, recent evidence has emerged showing that the circadian clock regulates UVB-induced DNA damage and cutaneous cancers, and it is also associated with the immune-mediated disorder psoriasis.11
Clinical studies
In 2018, Deshayes and associates conducted a clinical study to evaluate the precursors and stem cell attributes of hHF (human hair follicle keratinocytes), hEpi (human interfollicular epidermal keratinocytes), and hHFDP (hair follicle dermal papilla stem cells) in response to clock pathway changes caused by long-term deregulation of circadian rhythms. A total of 20 women participated in the study, 10 in each group (day workers were the control group and compared with shift workers). Two 3-mm fresh punch biopsies were collected from the occipital region of each participant. The investigators reported that chronic circadian rhythm deregulation influenced clock pathway protein expression and correlated with changes in hHF, hEpi, and hHFDP. They concluded that their findings represented the first data in humans suggesting that deregulation of the clock pathway modulates regenerative activity in human cutaneous and hair precursor cells.12
Later that year, Wu and associates reported on the role of the circadian clock in the transcriptional regulation of human epidermis. Investigators sampled 20 human participants through a 24-hour period and a population of 219 people once, finding a potent circadian oscillator in human epidermis at the population level, hundreds of rhythmically expressed genes, as well as a biomarker set for human epidermis that can, with one sample, highlight circadian phase within a 3-hour time frame. The team concluded that rhythms in human epidermis persist at the population level, and that they were able to present an effective single-sample circadian biomarker.13 This is important, as Morris pointed out, because the standard practice for measuring an individual’s internal clock is to use a dim-light melatonin onset assay over the course of a day.14 In 2019, Jia and associates studied the skin surface lipid profiles of young women to evaluate and characterize circadian human facial surface lipid composition. The investigators identified significant markers of circadian rhythm, with glycerolipids most affected. They ascribed changes in skin barrier function, such as variable pH and transepidermal water loss, to alterations in triacylglycerol levels as well as free fatty acid chain lengths and content that were affected by variations in circadian rhythm.15
Sleep and the timing of topicals
Based on their recent review of the literature on circadian rhythm and skin, Lyons and associates argued that an understanding of circadian rhythm helps dermatologists in recommending the optimal times for patients to apply topical medications. They added that urging patients to get sufficient sleep is important because DNA repair of the skin occurs best at that time.16
Conclusions
Doctors have known for half a century that timing drug delivery to a patient’s circadian clock can enhance outcomes. Chronobiological research into how circadian rhythms work at the cellular level, and in cutaneous cells in particular, is a fascinating and expanding area of inquiry that could help dermatologists more accurately recommend timing for skin care regimens. Much more research, especially in clinical trials, is necessary to further elucidate how to best work with the skin’s natural rhythms.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions, a company that independently tests skin care products and makes recommendations to physicians on skin care technologies. Write to her at [email protected].
References
1. Mehling A et al. Skin Pharmacol Physiol. 2006;19(4):182-9.
2. Latreille J et al. Skin Pharmacol Physiol. 2004 May-Jun;17(3):133-40.
3. Le Fur I et al. J Invest Dermatol. 2001 Sep;117(3):718-24.
4. Verschoore M et al. Chronobiol Int. 1993 Oct;10(5):349-59.
5. Yosipovitch G et al. J Invest Dermatol. 1998 Jan;110(1):20-3.
6. Dong K et al. Int J Cosmet Sci. 2019 Dec;41(6):558-62.
7. Dong K et al. Int J Mol Sci. 2020 Jan 3;21(1):326.
8. Walker WH II et al. Arch Dermatol Res. 2019 Sep;311(7):573-6.
9. Vaughn AR et al. Pediatr Dermatol. 2018 Jan;35(1):152-7.
10. Fishbein AB et al. J Allergy Clin Immunol. 2015 Nov;136(5):1170-7.
11. Plikus MV et al. J Biol Rhythms. 2015 Jun;30(3):163-82.
12. Deshayes N et al. Eur J Dermatol. 2018 Aug 1;28(4):467-75.
13. Wu G et al. Proc Natl Acad Sci U S A. 2018 Nov 27;115(48):12313-8.
14. Morris A. Nat Rev Endocrinol. 2018 Dec;15(1):3.
15. Jia Y et al. Exp Dermatol. 2019 Jul;28(7):858-62.
16. Lyons AB et al. J Clin Aesthet Dermatol. 2019 Sep;12(9):42-5.
We continue with a focus on when possible, as well as clinical studies that may shed light on how to time skin care treatments.
It is important to remember that several studies in the last 20 years have revealed cutaneous tendencies based on the time of day. For instance, sebum production is known to be highest around noon, and pH also peaks during the day and is at its lowest at night.1-5
Skin aging
In 2019, Dong and associates showed that blue light at 410 nm reduces PER1 transcription in keratinocytes, indicating that epidermal cells have the capacity to directly sense light and regulate their own clock gene expression. With the introduction of blue light at night, circadian rhythm is disrupted as epidermal skin cells act as if it is daytime. The investigators also considered blue light–induced damage to skin cells at various doses and exposure times in comparison with cells that remained unexposed to light. The production of reactive oxygen species increased in the exposed cells, as did DNA impairment and the emergence of inflammatory mediators, all of which have the potential to hasten aging.6
Early this year, Dong and associates demonstrated that melatonin can dose-dependently stimulate PER1 clock gene expression in normal human dermal fibroblasts and normal human epidermal keratinocytes, and verified that the MT-1 melatonin receptor in such fibroblasts manifests a marked decline with age. The researchers concluded that the melatonin pathway contributes significantly in cutaneous aging and impairment, and that its relationship with skin circadian rhythm points to a possible role in slowing the rate of skin aging through the modulation of cutaneous melatonin receptors.7
Wound healing
In 2019, Walker and associates investigated the effects of dim artificial light at night on wound healing in female C57BL/6 mice, and found that those conditions prior to wounding reduced healing. They concluded that such information might warrant consideration in prescribing treatment.8
Atopic dermatitis
Vaughn and associates contended that alterations in circadian rhythm may contribute to the development of atopic dermatitis.9 A good example of the impact of circadian rhythms on cutaneous health is the nocturnal exacerbation of atopic dermatitis, particularly in children.10
Psoriasis
According to Plikus and associates, recent evidence has emerged showing that the circadian clock regulates UVB-induced DNA damage and cutaneous cancers, and it is also associated with the immune-mediated disorder psoriasis.11
Clinical studies
In 2018, Deshayes and associates conducted a clinical study to evaluate the precursors and stem cell attributes of hHF (human hair follicle keratinocytes), hEpi (human interfollicular epidermal keratinocytes), and hHFDP (hair follicle dermal papilla stem cells) in response to clock pathway changes caused by long-term deregulation of circadian rhythms. A total of 20 women participated in the study, 10 in each group (day workers were the control group and compared with shift workers). Two 3-mm fresh punch biopsies were collected from the occipital region of each participant. The investigators reported that chronic circadian rhythm deregulation influenced clock pathway protein expression and correlated with changes in hHF, hEpi, and hHFDP. They concluded that their findings represented the first data in humans suggesting that deregulation of the clock pathway modulates regenerative activity in human cutaneous and hair precursor cells.12
Later that year, Wu and associates reported on the role of the circadian clock in the transcriptional regulation of human epidermis. Investigators sampled 20 human participants through a 24-hour period and a population of 219 people once, finding a potent circadian oscillator in human epidermis at the population level, hundreds of rhythmically expressed genes, as well as a biomarker set for human epidermis that can, with one sample, highlight circadian phase within a 3-hour time frame. The team concluded that rhythms in human epidermis persist at the population level, and that they were able to present an effective single-sample circadian biomarker.13 This is important, as Morris pointed out, because the standard practice for measuring an individual’s internal clock is to use a dim-light melatonin onset assay over the course of a day.14 In 2019, Jia and associates studied the skin surface lipid profiles of young women to evaluate and characterize circadian human facial surface lipid composition. The investigators identified significant markers of circadian rhythm, with glycerolipids most affected. They ascribed changes in skin barrier function, such as variable pH and transepidermal water loss, to alterations in triacylglycerol levels as well as free fatty acid chain lengths and content that were affected by variations in circadian rhythm.15
Sleep and the timing of topicals
Based on their recent review of the literature on circadian rhythm and skin, Lyons and associates argued that an understanding of circadian rhythm helps dermatologists in recommending the optimal times for patients to apply topical medications. They added that urging patients to get sufficient sleep is important because DNA repair of the skin occurs best at that time.16
Conclusions
Doctors have known for half a century that timing drug delivery to a patient’s circadian clock can enhance outcomes. Chronobiological research into how circadian rhythms work at the cellular level, and in cutaneous cells in particular, is a fascinating and expanding area of inquiry that could help dermatologists more accurately recommend timing for skin care regimens. Much more research, especially in clinical trials, is necessary to further elucidate how to best work with the skin’s natural rhythms.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions, a company that independently tests skin care products and makes recommendations to physicians on skin care technologies. Write to her at [email protected].
References
1. Mehling A et al. Skin Pharmacol Physiol. 2006;19(4):182-9.
2. Latreille J et al. Skin Pharmacol Physiol. 2004 May-Jun;17(3):133-40.
3. Le Fur I et al. J Invest Dermatol. 2001 Sep;117(3):718-24.
4. Verschoore M et al. Chronobiol Int. 1993 Oct;10(5):349-59.
5. Yosipovitch G et al. J Invest Dermatol. 1998 Jan;110(1):20-3.
6. Dong K et al. Int J Cosmet Sci. 2019 Dec;41(6):558-62.
7. Dong K et al. Int J Mol Sci. 2020 Jan 3;21(1):326.
8. Walker WH II et al. Arch Dermatol Res. 2019 Sep;311(7):573-6.
9. Vaughn AR et al. Pediatr Dermatol. 2018 Jan;35(1):152-7.
10. Fishbein AB et al. J Allergy Clin Immunol. 2015 Nov;136(5):1170-7.
11. Plikus MV et al. J Biol Rhythms. 2015 Jun;30(3):163-82.
12. Deshayes N et al. Eur J Dermatol. 2018 Aug 1;28(4):467-75.
13. Wu G et al. Proc Natl Acad Sci U S A. 2018 Nov 27;115(48):12313-8.
14. Morris A. Nat Rev Endocrinol. 2018 Dec;15(1):3.
15. Jia Y et al. Exp Dermatol. 2019 Jul;28(7):858-62.
16. Lyons AB et al. J Clin Aesthet Dermatol. 2019 Sep;12(9):42-5.
We continue with a focus on when possible, as well as clinical studies that may shed light on how to time skin care treatments.
It is important to remember that several studies in the last 20 years have revealed cutaneous tendencies based on the time of day. For instance, sebum production is known to be highest around noon, and pH also peaks during the day and is at its lowest at night.1-5
Skin aging
In 2019, Dong and associates showed that blue light at 410 nm reduces PER1 transcription in keratinocytes, indicating that epidermal cells have the capacity to directly sense light and regulate their own clock gene expression. With the introduction of blue light at night, circadian rhythm is disrupted as epidermal skin cells act as if it is daytime. The investigators also considered blue light–induced damage to skin cells at various doses and exposure times in comparison with cells that remained unexposed to light. The production of reactive oxygen species increased in the exposed cells, as did DNA impairment and the emergence of inflammatory mediators, all of which have the potential to hasten aging.6
Early this year, Dong and associates demonstrated that melatonin can dose-dependently stimulate PER1 clock gene expression in normal human dermal fibroblasts and normal human epidermal keratinocytes, and verified that the MT-1 melatonin receptor in such fibroblasts manifests a marked decline with age. The researchers concluded that the melatonin pathway contributes significantly in cutaneous aging and impairment, and that its relationship with skin circadian rhythm points to a possible role in slowing the rate of skin aging through the modulation of cutaneous melatonin receptors.7
Wound healing
In 2019, Walker and associates investigated the effects of dim artificial light at night on wound healing in female C57BL/6 mice, and found that those conditions prior to wounding reduced healing. They concluded that such information might warrant consideration in prescribing treatment.8
Atopic dermatitis
Vaughn and associates contended that alterations in circadian rhythm may contribute to the development of atopic dermatitis.9 A good example of the impact of circadian rhythms on cutaneous health is the nocturnal exacerbation of atopic dermatitis, particularly in children.10
Psoriasis
According to Plikus and associates, recent evidence has emerged showing that the circadian clock regulates UVB-induced DNA damage and cutaneous cancers, and it is also associated with the immune-mediated disorder psoriasis.11
Clinical studies
In 2018, Deshayes and associates conducted a clinical study to evaluate the precursors and stem cell attributes of hHF (human hair follicle keratinocytes), hEpi (human interfollicular epidermal keratinocytes), and hHFDP (hair follicle dermal papilla stem cells) in response to clock pathway changes caused by long-term deregulation of circadian rhythms. A total of 20 women participated in the study, 10 in each group (day workers were the control group and compared with shift workers). Two 3-mm fresh punch biopsies were collected from the occipital region of each participant. The investigators reported that chronic circadian rhythm deregulation influenced clock pathway protein expression and correlated with changes in hHF, hEpi, and hHFDP. They concluded that their findings represented the first data in humans suggesting that deregulation of the clock pathway modulates regenerative activity in human cutaneous and hair precursor cells.12
Later that year, Wu and associates reported on the role of the circadian clock in the transcriptional regulation of human epidermis. Investigators sampled 20 human participants through a 24-hour period and a population of 219 people once, finding a potent circadian oscillator in human epidermis at the population level, hundreds of rhythmically expressed genes, as well as a biomarker set for human epidermis that can, with one sample, highlight circadian phase within a 3-hour time frame. The team concluded that rhythms in human epidermis persist at the population level, and that they were able to present an effective single-sample circadian biomarker.13 This is important, as Morris pointed out, because the standard practice for measuring an individual’s internal clock is to use a dim-light melatonin onset assay over the course of a day.14 In 2019, Jia and associates studied the skin surface lipid profiles of young women to evaluate and characterize circadian human facial surface lipid composition. The investigators identified significant markers of circadian rhythm, with glycerolipids most affected. They ascribed changes in skin barrier function, such as variable pH and transepidermal water loss, to alterations in triacylglycerol levels as well as free fatty acid chain lengths and content that were affected by variations in circadian rhythm.15
Sleep and the timing of topicals
Based on their recent review of the literature on circadian rhythm and skin, Lyons and associates argued that an understanding of circadian rhythm helps dermatologists in recommending the optimal times for patients to apply topical medications. They added that urging patients to get sufficient sleep is important because DNA repair of the skin occurs best at that time.16
Conclusions
Doctors have known for half a century that timing drug delivery to a patient’s circadian clock can enhance outcomes. Chronobiological research into how circadian rhythms work at the cellular level, and in cutaneous cells in particular, is a fascinating and expanding area of inquiry that could help dermatologists more accurately recommend timing for skin care regimens. Much more research, especially in clinical trials, is necessary to further elucidate how to best work with the skin’s natural rhythms.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions, a company that independently tests skin care products and makes recommendations to physicians on skin care technologies. Write to her at [email protected].
References
1. Mehling A et al. Skin Pharmacol Physiol. 2006;19(4):182-9.
2. Latreille J et al. Skin Pharmacol Physiol. 2004 May-Jun;17(3):133-40.
3. Le Fur I et al. J Invest Dermatol. 2001 Sep;117(3):718-24.
4. Verschoore M et al. Chronobiol Int. 1993 Oct;10(5):349-59.
5. Yosipovitch G et al. J Invest Dermatol. 1998 Jan;110(1):20-3.
6. Dong K et al. Int J Cosmet Sci. 2019 Dec;41(6):558-62.
7. Dong K et al. Int J Mol Sci. 2020 Jan 3;21(1):326.
8. Walker WH II et al. Arch Dermatol Res. 2019 Sep;311(7):573-6.
9. Vaughn AR et al. Pediatr Dermatol. 2018 Jan;35(1):152-7.
10. Fishbein AB et al. J Allergy Clin Immunol. 2015 Nov;136(5):1170-7.
11. Plikus MV et al. J Biol Rhythms. 2015 Jun;30(3):163-82.
12. Deshayes N et al. Eur J Dermatol. 2018 Aug 1;28(4):467-75.
13. Wu G et al. Proc Natl Acad Sci U S A. 2018 Nov 27;115(48):12313-8.
14. Morris A. Nat Rev Endocrinol. 2018 Dec;15(1):3.
15. Jia Y et al. Exp Dermatol. 2019 Jul;28(7):858-62.
16. Lyons AB et al. J Clin Aesthet Dermatol. 2019 Sep;12(9):42-5.
What's the diagnosis?
Nipple eczema is a dermatitis of the nipple and areola with clinical features such as erythema, fissures, scaling, pruritus, and crusting.1,2 It is classically associated with atopic dermatitis (AD), though it may occur as an isolated condition less commonly. While it may affect female adolescents, nipple eczema has also been reported in boys and breastfeeding women.3,4 The overall risk of incidence of nipple dermatitis has also been shown to increase with age.5 Nipple eczema is considered a cutaneous finding of AD, and is listed as a minor diagnostic criteria for AD in the Hanifin-Rajka criteria.6 The patient had not related his history of AD, which was elicited after finding typical antecubital eczematous dermatitis, and he had not been actively treating it.
Diagnosis and differential
Nipple eczema may be a challenging diagnosis for various reasons. For example, a unilateral presentation and the changes in the eczematous lesions overlying the nipple and areola’s varying textures and colors can make it difficult for clinicians to identify.3 Many children and adolescents, including our patient, are initially diagnosed as having impetigo and treated with antibiotics. The diagnosis of nipple eczema is made clinically, and management straightforward (see below). However, additional testing may be appropriate including patch testing for allergic contact dermatitis or bacterial cultures if bacterial infection or superinfection is considered.7,8 The differential diagnosis for nipple eczema includes impetigo, gynecomastia, scabies, and allergic contact dermatitis.
Impetigo typically presents with honey-colored crusts or pustules caused by infection with Staphylococcus aureus or Streptococcus. Patients with AD have higher rates of colonization with S. aureus and impetiginized eczema in common. Impetigo of the nipple and areola is more common in breastfeeding women as skin cracking from lactation can lead to exposure to bacteria from the infant’s mouth.9 Treatments involve topical or oral antibiotics.
Gynecomastia is the development of male breast tissue with most cases hypothesized to be caused by an imbalance between androgens and estrogens.10 Some other causes include direct skin contact with topical estrogen sprays and recreational use of marijuana and heroin.11 It is usually a benign exam finding in adolescent boys. However, clinical findings such as overlying skin changes, rapidly enlarging masses, and constitutional symptoms are concerning in the setting of gynecomastia and warrant further evaluation.
Scabies, which is caused by the infestation of scabies mites, is a common infectious skin disease. The classic presentation includes a rash that is intensely itchy, especially at night. Crusted scabies of the nipples may be difficult to distinguish from nipple eczema. Areas of frequent involvement of scabies include palms, between fingers, armpits, groin, between toes, and feet. Treatments include treating all household members with permethrin cream and washing all clothes and bedding in contact with a scabies-infected patient in high heat, or oral ivermectin in certain circumstances.12
Allergic contact dermatitis is a common cause of breast and nipple dermatitis and should be considered within the differential diagnosis of nipple eczema with atopic dermatitis, or as an exacerbator.7,9 Patients in particular who present with bilateral involvement extending to the periareolar skin, or unusual bilateral focal patterns suggestive for contact allergy should be considered for allergic contact dermatitis evaluation with patch tests. A common causative agent for allergic contact dermatitis of the breast and nipple includes Cl+Me-isothiazolinone, commonly found in detergents and fabric softeners.7 Primary treatment includes avoidance of the offending agents.
Treatment
Topical corticosteroids are first-line treatment for treating nipple eczema. Low-potency topical steroids can be used for maintenance and mild eczema while more potent steroids are useful for more severe cases. In addition to topical medication therapy, frequent emollient use to protect the skin barrier and the elimination of any irritants are essential to a successful treatment course. Unilateral nipple eczema can also be secondary to inadequate treatment of AD, demonstrating the importance of addressing the underlying AD with therapy.3
Our patient was diagnosed with nipple eczema based on clinical presentation of an eczematous left nipple in the setting of active atopic dermatitis and minimal improvement on topical antibiotic. He was started on a 3-week course of fluocinonide 0.05% topical ointment (a potent topical corticosteroid) twice daily for 2 weeks with plans to transition to triamcinolone 0.1% topical ointment several times a week.
Ms. Park is a pediatric dermatology research associate in the division of pediatric and adolescent dermatology, University of California, San Diego, and Rady Children’s Hospital, San Diego. Dr. Eichenfield is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego, and Rady Children’s Hospital. Neither Ms. Park nor Dr. Eichenfield have any relevant financial disclosures.
References
1. Pediatr Dermatol. 2005;22(1):64-6.
2. Am J Dermatopathol. 2015;37(4):284-8.
3. Pediatr Dermatol. 2015;32(5):718-22.
4. J Cutan Med Surg. 2004;8(2):126-30.
5. Pediatr Dermatol. 2012;29(5):580-3.
6. Dermatologica. 1988;177(6):360-4.
7. Ann Dermatol. 2014;26(3):413-4.
8. BMJ Case Rep. 2020;13(8).
9. J Am Acad Dermatol. 2019;80(6):1483-94.
10. Pediatr Endocrinol Rev. 2017;14(4):371-7.
11. JAMA. 2010;304(9):953.
12. JAMA. 2018;320(6):612.
Nipple eczema is a dermatitis of the nipple and areola with clinical features such as erythema, fissures, scaling, pruritus, and crusting.1,2 It is classically associated with atopic dermatitis (AD), though it may occur as an isolated condition less commonly. While it may affect female adolescents, nipple eczema has also been reported in boys and breastfeeding women.3,4 The overall risk of incidence of nipple dermatitis has also been shown to increase with age.5 Nipple eczema is considered a cutaneous finding of AD, and is listed as a minor diagnostic criteria for AD in the Hanifin-Rajka criteria.6 The patient had not related his history of AD, which was elicited after finding typical antecubital eczematous dermatitis, and he had not been actively treating it.
Diagnosis and differential
Nipple eczema may be a challenging diagnosis for various reasons. For example, a unilateral presentation and the changes in the eczematous lesions overlying the nipple and areola’s varying textures and colors can make it difficult for clinicians to identify.3 Many children and adolescents, including our patient, are initially diagnosed as having impetigo and treated with antibiotics. The diagnosis of nipple eczema is made clinically, and management straightforward (see below). However, additional testing may be appropriate including patch testing for allergic contact dermatitis or bacterial cultures if bacterial infection or superinfection is considered.7,8 The differential diagnosis for nipple eczema includes impetigo, gynecomastia, scabies, and allergic contact dermatitis.
Impetigo typically presents with honey-colored crusts or pustules caused by infection with Staphylococcus aureus or Streptococcus. Patients with AD have higher rates of colonization with S. aureus and impetiginized eczema in common. Impetigo of the nipple and areola is more common in breastfeeding women as skin cracking from lactation can lead to exposure to bacteria from the infant’s mouth.9 Treatments involve topical or oral antibiotics.
Gynecomastia is the development of male breast tissue with most cases hypothesized to be caused by an imbalance between androgens and estrogens.10 Some other causes include direct skin contact with topical estrogen sprays and recreational use of marijuana and heroin.11 It is usually a benign exam finding in adolescent boys. However, clinical findings such as overlying skin changes, rapidly enlarging masses, and constitutional symptoms are concerning in the setting of gynecomastia and warrant further evaluation.
Scabies, which is caused by the infestation of scabies mites, is a common infectious skin disease. The classic presentation includes a rash that is intensely itchy, especially at night. Crusted scabies of the nipples may be difficult to distinguish from nipple eczema. Areas of frequent involvement of scabies include palms, between fingers, armpits, groin, between toes, and feet. Treatments include treating all household members with permethrin cream and washing all clothes and bedding in contact with a scabies-infected patient in high heat, or oral ivermectin in certain circumstances.12
Allergic contact dermatitis is a common cause of breast and nipple dermatitis and should be considered within the differential diagnosis of nipple eczema with atopic dermatitis, or as an exacerbator.7,9 Patients in particular who present with bilateral involvement extending to the periareolar skin, or unusual bilateral focal patterns suggestive for contact allergy should be considered for allergic contact dermatitis evaluation with patch tests. A common causative agent for allergic contact dermatitis of the breast and nipple includes Cl+Me-isothiazolinone, commonly found in detergents and fabric softeners.7 Primary treatment includes avoidance of the offending agents.
Treatment
Topical corticosteroids are first-line treatment for treating nipple eczema. Low-potency topical steroids can be used for maintenance and mild eczema while more potent steroids are useful for more severe cases. In addition to topical medication therapy, frequent emollient use to protect the skin barrier and the elimination of any irritants are essential to a successful treatment course. Unilateral nipple eczema can also be secondary to inadequate treatment of AD, demonstrating the importance of addressing the underlying AD with therapy.3
Our patient was diagnosed with nipple eczema based on clinical presentation of an eczematous left nipple in the setting of active atopic dermatitis and minimal improvement on topical antibiotic. He was started on a 3-week course of fluocinonide 0.05% topical ointment (a potent topical corticosteroid) twice daily for 2 weeks with plans to transition to triamcinolone 0.1% topical ointment several times a week.
Ms. Park is a pediatric dermatology research associate in the division of pediatric and adolescent dermatology, University of California, San Diego, and Rady Children’s Hospital, San Diego. Dr. Eichenfield is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego, and Rady Children’s Hospital. Neither Ms. Park nor Dr. Eichenfield have any relevant financial disclosures.
References
1. Pediatr Dermatol. 2005;22(1):64-6.
2. Am J Dermatopathol. 2015;37(4):284-8.
3. Pediatr Dermatol. 2015;32(5):718-22.
4. J Cutan Med Surg. 2004;8(2):126-30.
5. Pediatr Dermatol. 2012;29(5):580-3.
6. Dermatologica. 1988;177(6):360-4.
7. Ann Dermatol. 2014;26(3):413-4.
8. BMJ Case Rep. 2020;13(8).
9. J Am Acad Dermatol. 2019;80(6):1483-94.
10. Pediatr Endocrinol Rev. 2017;14(4):371-7.
11. JAMA. 2010;304(9):953.
12. JAMA. 2018;320(6):612.
Nipple eczema is a dermatitis of the nipple and areola with clinical features such as erythema, fissures, scaling, pruritus, and crusting.1,2 It is classically associated with atopic dermatitis (AD), though it may occur as an isolated condition less commonly. While it may affect female adolescents, nipple eczema has also been reported in boys and breastfeeding women.3,4 The overall risk of incidence of nipple dermatitis has also been shown to increase with age.5 Nipple eczema is considered a cutaneous finding of AD, and is listed as a minor diagnostic criteria for AD in the Hanifin-Rajka criteria.6 The patient had not related his history of AD, which was elicited after finding typical antecubital eczematous dermatitis, and he had not been actively treating it.
Diagnosis and differential
Nipple eczema may be a challenging diagnosis for various reasons. For example, a unilateral presentation and the changes in the eczematous lesions overlying the nipple and areola’s varying textures and colors can make it difficult for clinicians to identify.3 Many children and adolescents, including our patient, are initially diagnosed as having impetigo and treated with antibiotics. The diagnosis of nipple eczema is made clinically, and management straightforward (see below). However, additional testing may be appropriate including patch testing for allergic contact dermatitis or bacterial cultures if bacterial infection or superinfection is considered.7,8 The differential diagnosis for nipple eczema includes impetigo, gynecomastia, scabies, and allergic contact dermatitis.
Impetigo typically presents with honey-colored crusts or pustules caused by infection with Staphylococcus aureus or Streptococcus. Patients with AD have higher rates of colonization with S. aureus and impetiginized eczema in common. Impetigo of the nipple and areola is more common in breastfeeding women as skin cracking from lactation can lead to exposure to bacteria from the infant’s mouth.9 Treatments involve topical or oral antibiotics.
Gynecomastia is the development of male breast tissue with most cases hypothesized to be caused by an imbalance between androgens and estrogens.10 Some other causes include direct skin contact with topical estrogen sprays and recreational use of marijuana and heroin.11 It is usually a benign exam finding in adolescent boys. However, clinical findings such as overlying skin changes, rapidly enlarging masses, and constitutional symptoms are concerning in the setting of gynecomastia and warrant further evaluation.
Scabies, which is caused by the infestation of scabies mites, is a common infectious skin disease. The classic presentation includes a rash that is intensely itchy, especially at night. Crusted scabies of the nipples may be difficult to distinguish from nipple eczema. Areas of frequent involvement of scabies include palms, between fingers, armpits, groin, between toes, and feet. Treatments include treating all household members with permethrin cream and washing all clothes and bedding in contact with a scabies-infected patient in high heat, or oral ivermectin in certain circumstances.12
Allergic contact dermatitis is a common cause of breast and nipple dermatitis and should be considered within the differential diagnosis of nipple eczema with atopic dermatitis, or as an exacerbator.7,9 Patients in particular who present with bilateral involvement extending to the periareolar skin, or unusual bilateral focal patterns suggestive for contact allergy should be considered for allergic contact dermatitis evaluation with patch tests. A common causative agent for allergic contact dermatitis of the breast and nipple includes Cl+Me-isothiazolinone, commonly found in detergents and fabric softeners.7 Primary treatment includes avoidance of the offending agents.
Treatment
Topical corticosteroids are first-line treatment for treating nipple eczema. Low-potency topical steroids can be used for maintenance and mild eczema while more potent steroids are useful for more severe cases. In addition to topical medication therapy, frequent emollient use to protect the skin barrier and the elimination of any irritants are essential to a successful treatment course. Unilateral nipple eczema can also be secondary to inadequate treatment of AD, demonstrating the importance of addressing the underlying AD with therapy.3
Our patient was diagnosed with nipple eczema based on clinical presentation of an eczematous left nipple in the setting of active atopic dermatitis and minimal improvement on topical antibiotic. He was started on a 3-week course of fluocinonide 0.05% topical ointment (a potent topical corticosteroid) twice daily for 2 weeks with plans to transition to triamcinolone 0.1% topical ointment several times a week.
Ms. Park is a pediatric dermatology research associate in the division of pediatric and adolescent dermatology, University of California, San Diego, and Rady Children’s Hospital, San Diego. Dr. Eichenfield is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego, and Rady Children’s Hospital. Neither Ms. Park nor Dr. Eichenfield have any relevant financial disclosures.
References
1. Pediatr Dermatol. 2005;22(1):64-6.
2. Am J Dermatopathol. 2015;37(4):284-8.
3. Pediatr Dermatol. 2015;32(5):718-22.
4. J Cutan Med Surg. 2004;8(2):126-30.
5. Pediatr Dermatol. 2012;29(5):580-3.
6. Dermatologica. 1988;177(6):360-4.
7. Ann Dermatol. 2014;26(3):413-4.
8. BMJ Case Rep. 2020;13(8).
9. J Am Acad Dermatol. 2019;80(6):1483-94.
10. Pediatr Endocrinol Rev. 2017;14(4):371-7.
11. JAMA. 2010;304(9):953.
12. JAMA. 2018;320(6):612.
A 12-year-old boy presents to the dermatology clinic with a 1-month history of crusting and watery sticky drainage from the left nipple. Given concern for a possible skin infection, the patient was initially treated with mupirocin ointment for several weeks but without improvement. The affected area is sometimes itchy but not painful. He reports no prior history of similar problems.
On physical exam, he is noted to have an eczematous left nipple with edema, xerosis, and scaling overlying the entire areola. There is no evidence of visible discharge, pustules, or honey-colored crusts in the area. The extensor surfaces of his arms bilaterally have skin-colored follicular papules, and his antecubital fossa display erythematous scaling plaques with mild lichenification and excoriations.
Coping with vaccine refusal
Do you accept new families into your practice who have already chosen to not have their children immunized? What about families who have been in your practice for several months or years? In 2016 the American Academy of Pediatrics published a clinical report in which it stated that, under some circumstances, dismissing families who refuse to vaccinate is permissible. Have you felt sufficiently supported by that statement and dismissed any families after multiple attempts at education on your part?
In a Pediatrics Perspective article in the December issue of Pediatrics, two philosophers and a physician make the argument that, while in some situations dismissing a family who refuses vaccines may be “an ethically acceptable option” refusing to accept a family with the same philosophy is not. It is an interesting paper and worth reading regardless of whether or not you already accept and continue to tolerate vaccine deniers in your practice.
The Pediatrics Perspective is certainly not the last word on the ethics of caring for families who deny their children care that we believe is critical to their health and the welfare of the community at large. There has been a lot of discussion about the issue but little has been written about how we as the physicians on the front line are coping emotionally with what the authors of the paper call the “burdens associated with treating” families who refuse to follow our guidance.
It is hard not to feel angry when a family you have invested valuable office time in discussing the benefits and safety of vaccines continues to disregard what you see as the facts. The time you have spent with them is not just income-generating time for your practice, it is time stolen from other families who are more willing to follow your recommendations. In how many visits will you continue to raise the issue? Unless I saw a glimmer of hope I would usually stop after two wasted encounters. But, the issue would still linger as the elephant in the examination room for as long as I continued to see the patient.
How have you expressed your anger? Have you been argumentative or rude? You may have been able maintain your composure and remain civil and appear caring, but I suspect the anger is still gnawing at you. And, there is still the frustration and feeling of impotence. You may have questioned your ability as an educator. You should get over that notion quickly. There is ample evidence that most vaccine deniers are not going to be convinced by even the most carefully presented information. I suggest you leave it to others to try their hands at education. Let them invest their time while you tend to the needs of your other patients. You can try being a fear monger and, while fear can be effective, you have better ways to spend your office day than telling horror stories.
If vaccine denial makes you feel powerless, you should get over that pretty quickly as well and accept the fact that you are simply an advisor. If you believe that most of the families in your practice are following your recommendations as though you had presented them on stone tablets, it is time for a wakeup call.
Finally, there is the most troubling emotion associated with vaccine refusal and that is fear, the fear of being sued. Establishing a relationship with a family is one that requires mutual trust and certainly vaccine refusal will put that trust in question, particularly if you have done a less than adequate job of hiding your anger and frustration with their unfortunate decision.
For now, vaccine refusal is just another one of those crosses that those of us in primary care must bear together wearing the best face we can put forward. That doesn’t mean we can’t share those emotions with our peers. Misery does love company.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
Do you accept new families into your practice who have already chosen to not have their children immunized? What about families who have been in your practice for several months or years? In 2016 the American Academy of Pediatrics published a clinical report in which it stated that, under some circumstances, dismissing families who refuse to vaccinate is permissible. Have you felt sufficiently supported by that statement and dismissed any families after multiple attempts at education on your part?
In a Pediatrics Perspective article in the December issue of Pediatrics, two philosophers and a physician make the argument that, while in some situations dismissing a family who refuses vaccines may be “an ethically acceptable option” refusing to accept a family with the same philosophy is not. It is an interesting paper and worth reading regardless of whether or not you already accept and continue to tolerate vaccine deniers in your practice.
The Pediatrics Perspective is certainly not the last word on the ethics of caring for families who deny their children care that we believe is critical to their health and the welfare of the community at large. There has been a lot of discussion about the issue but little has been written about how we as the physicians on the front line are coping emotionally with what the authors of the paper call the “burdens associated with treating” families who refuse to follow our guidance.
It is hard not to feel angry when a family you have invested valuable office time in discussing the benefits and safety of vaccines continues to disregard what you see as the facts. The time you have spent with them is not just income-generating time for your practice, it is time stolen from other families who are more willing to follow your recommendations. In how many visits will you continue to raise the issue? Unless I saw a glimmer of hope I would usually stop after two wasted encounters. But, the issue would still linger as the elephant in the examination room for as long as I continued to see the patient.
How have you expressed your anger? Have you been argumentative or rude? You may have been able maintain your composure and remain civil and appear caring, but I suspect the anger is still gnawing at you. And, there is still the frustration and feeling of impotence. You may have questioned your ability as an educator. You should get over that notion quickly. There is ample evidence that most vaccine deniers are not going to be convinced by even the most carefully presented information. I suggest you leave it to others to try their hands at education. Let them invest their time while you tend to the needs of your other patients. You can try being a fear monger and, while fear can be effective, you have better ways to spend your office day than telling horror stories.
If vaccine denial makes you feel powerless, you should get over that pretty quickly as well and accept the fact that you are simply an advisor. If you believe that most of the families in your practice are following your recommendations as though you had presented them on stone tablets, it is time for a wakeup call.
Finally, there is the most troubling emotion associated with vaccine refusal and that is fear, the fear of being sued. Establishing a relationship with a family is one that requires mutual trust and certainly vaccine refusal will put that trust in question, particularly if you have done a less than adequate job of hiding your anger and frustration with their unfortunate decision.
For now, vaccine refusal is just another one of those crosses that those of us in primary care must bear together wearing the best face we can put forward. That doesn’t mean we can’t share those emotions with our peers. Misery does love company.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
Do you accept new families into your practice who have already chosen to not have their children immunized? What about families who have been in your practice for several months or years? In 2016 the American Academy of Pediatrics published a clinical report in which it stated that, under some circumstances, dismissing families who refuse to vaccinate is permissible. Have you felt sufficiently supported by that statement and dismissed any families after multiple attempts at education on your part?
In a Pediatrics Perspective article in the December issue of Pediatrics, two philosophers and a physician make the argument that, while in some situations dismissing a family who refuses vaccines may be “an ethically acceptable option” refusing to accept a family with the same philosophy is not. It is an interesting paper and worth reading regardless of whether or not you already accept and continue to tolerate vaccine deniers in your practice.
The Pediatrics Perspective is certainly not the last word on the ethics of caring for families who deny their children care that we believe is critical to their health and the welfare of the community at large. There has been a lot of discussion about the issue but little has been written about how we as the physicians on the front line are coping emotionally with what the authors of the paper call the “burdens associated with treating” families who refuse to follow our guidance.
It is hard not to feel angry when a family you have invested valuable office time in discussing the benefits and safety of vaccines continues to disregard what you see as the facts. The time you have spent with them is not just income-generating time for your practice, it is time stolen from other families who are more willing to follow your recommendations. In how many visits will you continue to raise the issue? Unless I saw a glimmer of hope I would usually stop after two wasted encounters. But, the issue would still linger as the elephant in the examination room for as long as I continued to see the patient.
How have you expressed your anger? Have you been argumentative or rude? You may have been able maintain your composure and remain civil and appear caring, but I suspect the anger is still gnawing at you. And, there is still the frustration and feeling of impotence. You may have questioned your ability as an educator. You should get over that notion quickly. There is ample evidence that most vaccine deniers are not going to be convinced by even the most carefully presented information. I suggest you leave it to others to try their hands at education. Let them invest their time while you tend to the needs of your other patients. You can try being a fear monger and, while fear can be effective, you have better ways to spend your office day than telling horror stories.
If vaccine denial makes you feel powerless, you should get over that pretty quickly as well and accept the fact that you are simply an advisor. If you believe that most of the families in your practice are following your recommendations as though you had presented them on stone tablets, it is time for a wakeup call.
Finally, there is the most troubling emotion associated with vaccine refusal and that is fear, the fear of being sued. Establishing a relationship with a family is one that requires mutual trust and certainly vaccine refusal will put that trust in question, particularly if you have done a less than adequate job of hiding your anger and frustration with their unfortunate decision.
For now, vaccine refusal is just another one of those crosses that those of us in primary care must bear together wearing the best face we can put forward. That doesn’t mean we can’t share those emotions with our peers. Misery does love company.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].