TOPLINE:

More than half of Mohs surgeons report at least one sharps injury in the past year, mostly self-inflicted, survey finds.

METHODOLOGY:

• Data on the incidence of sharps injuries among dermatologic surgeons is limited.
• In a cross-sectional analysis of anonymous survey responses from members of the American College of , researchers aimed to determine the incidence and types of sharps injuries among Mohs surgeons.
• The researchers used descriptive statistics for continuous and nominal variables (percentage and frequencies) to report survey data and Fisher exact or chi-square analysis of categorical variables to obtain P values.

TAKEAWAY:

• Of the 60 survey respondents, more than half (56.7%) were from single-specialty group practices, 26.6% were from academic practices, and fewer than half (43.3%) had been in practice for 15 or more years.
• In the past year, 56.7% of respondents experienced at least one sharps injury. Of these, 14.7% involved exposure to a blood-borne pathogen, which translated into an annual exposure risk of 7.6% for any given Mohs surgeon.
• The top two types of sharps injuries were self-inflicted suture needlestick (76.5%) and other types of self-inflicted needlestick injuries (26.5%).
• Of respondents who sustained a sharps injury, 44.1% did not report them, while 95% of all survey respondents said they had access to postexposure prophylaxis/protocols at their workplace.
• The researchers determined that the average annual rate of sharps injury was 0.87.

IN PRACTICE:

• “In best practices to prevent sharps injuries, the authors recommend that a standardized sharps handling protocol be developed and disseminated for dermatologic surgeons and their staff,” the researchers wrote.

STUDY DETAILS:

• Faezeh Talebi-Liasi, MD, and Jesse M. Lewin, MD, department of dermatology, Icahn School of Medicine at Mount Sinai, New York, conducted the research. The study was published in Dermatologic Surgery.

LIMITATIONS:

• The study’s cross-sectional observational design and small sample size was skewed toward single-specialty and academic practices.

DISCLOSURES:

• The authors reported having no relevant financial disclosures.

A version of this article appeared on Medscape.com.

TOPLINE:

More than half of Mohs surgeons report at least one sharps injury in the past year, mostly self-inflicted, survey finds.

METHODOLOGY:

• Data on the incidence of sharps injuries among dermatologic surgeons is limited.
• In a cross-sectional analysis of anonymous survey responses from members of the American College of , researchers aimed to determine the incidence and types of sharps injuries among Mohs surgeons.
• The researchers used descriptive statistics for continuous and nominal variables (percentage and frequencies) to report survey data and Fisher exact or chi-square analysis of categorical variables to obtain P values.

TAKEAWAY:

• Of the 60 survey respondents, more than half (56.7%) were from single-specialty group practices, 26.6% were from academic practices, and fewer than half (43.3%) had been in practice for 15 or more years.
• In the past year, 56.7% of respondents experienced at least one sharps injury. Of these, 14.7% involved exposure to a blood-borne pathogen, which translated into an annual exposure risk of 7.6% for any given Mohs surgeon.
• The top two types of sharps injuries were self-inflicted suture needlestick (76.5%) and other types of self-inflicted needlestick injuries (26.5%).
• Of respondents who sustained a sharps injury, 44.1% did not report them, while 95% of all survey respondents said they had access to postexposure prophylaxis/protocols at their workplace.
• The researchers determined that the average annual rate of sharps injury was 0.87.

IN PRACTICE:

• “In best practices to prevent sharps injuries, the authors recommend that a standardized sharps handling protocol be developed and disseminated for dermatologic surgeons and their staff,” the researchers wrote.

STUDY DETAILS:

• Faezeh Talebi-Liasi, MD, and Jesse M. Lewin, MD, department of dermatology, Icahn School of Medicine at Mount Sinai, New York, conducted the research. The study was published in Dermatologic Surgery.

LIMITATIONS:

• The study’s cross-sectional observational design and small sample size was skewed toward single-specialty and academic practices.

DISCLOSURES:

• The authors reported having no relevant financial disclosures.

A version of this article appeared on Medscape.com.

TOPLINE:

More than half of Mohs surgeons report at least one sharps injury in the past year, mostly self-inflicted, survey finds.

METHODOLOGY:

• Data on the incidence of sharps injuries among dermatologic surgeons is limited.
• In a cross-sectional analysis of anonymous survey responses from members of the American College of , researchers aimed to determine the incidence and types of sharps injuries among Mohs surgeons.
• The researchers used descriptive statistics for continuous and nominal variables (percentage and frequencies) to report survey data and Fisher exact or chi-square analysis of categorical variables to obtain P values.

TAKEAWAY:

• Of the 60 survey respondents, more than half (56.7%) were from single-specialty group practices, 26.6% were from academic practices, and fewer than half (43.3%) had been in practice for 15 or more years.
• In the past year, 56.7% of respondents experienced at least one sharps injury. Of these, 14.7% involved exposure to a blood-borne pathogen, which translated into an annual exposure risk of 7.6% for any given Mohs surgeon.
• The top two types of sharps injuries were self-inflicted suture needlestick (76.5%) and other types of self-inflicted needlestick injuries (26.5%).
• Of respondents who sustained a sharps injury, 44.1% did not report them, while 95% of all survey respondents said they had access to postexposure prophylaxis/protocols at their workplace.
• The researchers determined that the average annual rate of sharps injury was 0.87.

IN PRACTICE:

• “In best practices to prevent sharps injuries, the authors recommend that a standardized sharps handling protocol be developed and disseminated for dermatologic surgeons and their staff,” the researchers wrote.

STUDY DETAILS:

• Faezeh Talebi-Liasi, MD, and Jesse M. Lewin, MD, department of dermatology, Icahn School of Medicine at Mount Sinai, New York, conducted the research. The study was published in Dermatologic Surgery.

LIMITATIONS:

• The study’s cross-sectional observational design and small sample size was skewed toward single-specialty and academic practices.

DISCLOSURES:

• The authors reported having no relevant financial disclosures.

A version of this article appeared on Medscape.com.

Key clinical point: The binary outcomes of atopic dermatitis (AD) were most effectively improved up to week 16 by 30 mg upadacitinib daily and 200 mg abrocitinib daily, followed by 15 mg upadacitinib daily, and 600 mg dupilumab and subsequently 300 mg dupilumab every 2 weeks.

Major finding: The odds of achieving 50% improvement in the Eczema Area and Severity Index scores were higher with daily doses of 200 mg abrocitinib (odds ratio [OR] 1.5, 95% credible interval [CrI] 1.1-2.2), 30 mg upadacitinib (OR 2.5, 95% CrI 1.3-5.0), and 15 mg upadacitinib (OR 1.7; 95% CrI 0.9-3.3) and lower with 100 mg abrocitinib daily (OR 0.7; 95% CrI 0.5-1.0) and 4 mg baricitinib daily (OR 0.5; 95% CrI 0.3-0.7) compared with dupilumab every 2 weeks.

Study details: This network meta-analysis of 83 trials included 22,122 patients with moderate-to-severe AD receiving systemic immunomodulatory treatment for ≥8 weeks.

Disclosures: This study was sponsored by a UK National Institute for Health Research Career Development Fellowship held by C Flohr and other funds. Seven authors declared ties with various sources.

Source: Drucker AM et al. Comparing binary efficacy outcomes for systemic immunomodulatory treatments for atopic dermatitis in a living systematic review and network meta-analysis. Br J Dermatol. 2023 (Oct 13). doi: 10.1093/bjd/ljad393

Key clinical point: The binary outcomes of atopic dermatitis (AD) were most effectively improved up to week 16 by 30 mg upadacitinib daily and 200 mg abrocitinib daily, followed by 15 mg upadacitinib daily, and 600 mg dupilumab and subsequently 300 mg dupilumab every 2 weeks.

Major finding: The odds of achieving 50% improvement in the Eczema Area and Severity Index scores were higher with daily doses of 200 mg abrocitinib (odds ratio [OR] 1.5, 95% credible interval [CrI] 1.1-2.2), 30 mg upadacitinib (OR 2.5, 95% CrI 1.3-5.0), and 15 mg upadacitinib (OR 1.7; 95% CrI 0.9-3.3) and lower with 100 mg abrocitinib daily (OR 0.7; 95% CrI 0.5-1.0) and 4 mg baricitinib daily (OR 0.5; 95% CrI 0.3-0.7) compared with dupilumab every 2 weeks.

Study details: This network meta-analysis of 83 trials included 22,122 patients with moderate-to-severe AD receiving systemic immunomodulatory treatment for ≥8 weeks.

Disclosures: This study was sponsored by a UK National Institute for Health Research Career Development Fellowship held by C Flohr and other funds. Seven authors declared ties with various sources.

Source: Drucker AM et al. Comparing binary efficacy outcomes for systemic immunomodulatory treatments for atopic dermatitis in a living systematic review and network meta-analysis. Br J Dermatol. 2023 (Oct 13). doi: 10.1093/bjd/ljad393

Key clinical point: The binary outcomes of atopic dermatitis (AD) were most effectively improved up to week 16 by 30 mg upadacitinib daily and 200 mg abrocitinib daily, followed by 15 mg upadacitinib daily, and 600 mg dupilumab and subsequently 300 mg dupilumab every 2 weeks.

Major finding: The odds of achieving 50% improvement in the Eczema Area and Severity Index scores were higher with daily doses of 200 mg abrocitinib (odds ratio [OR] 1.5, 95% credible interval [CrI] 1.1-2.2), 30 mg upadacitinib (OR 2.5, 95% CrI 1.3-5.0), and 15 mg upadacitinib (OR 1.7; 95% CrI 0.9-3.3) and lower with 100 mg abrocitinib daily (OR 0.7; 95% CrI 0.5-1.0) and 4 mg baricitinib daily (OR 0.5; 95% CrI 0.3-0.7) compared with dupilumab every 2 weeks.

Study details: This network meta-analysis of 83 trials included 22,122 patients with moderate-to-severe AD receiving systemic immunomodulatory treatment for ≥8 weeks.

Disclosures: This study was sponsored by a UK National Institute for Health Research Career Development Fellowship held by C Flohr and other funds. Seven authors declared ties with various sources.

Source: Drucker AM et al. Comparing binary efficacy outcomes for systemic immunomodulatory treatments for atopic dermatitis in a living systematic review and network meta-analysis. Br J Dermatol. 2023 (Oct 13). doi: 10.1093/bjd/ljad393

Key clinical point: Atopic dermatitis (AD) significantly increases the risk for cognitive dysfunction, particularly that of all-cause dementia and Alzheimer’s disease-related dementia, in middle-aged adults (age 45-59 years) and older adults (age ≥60 years).

Major finding: Patients with AD vs control individuals had a significantly higher risk of developing all-cause dementia (pooled hazard ratio [HR] 1.16; 95% CI 1.10-1.23) and Alzheimer’s disease-related dementia (pooled HR 1.28; 95% CI 1.01-1.63). However, no significant association was observed between AD and vascular dementia (pooled HR 1.42; 95% CI 0.99-2.04).

Study details: Findings are from a meta-analysis of five studies including 8,595,252 patients with AD and a corresponding number of control individuals without AD.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Zhou Q et al. Atopic dermatitis and cognitive dysfunction in middle-aged and older adults: A systematic review and meta-analysis. PLoS One. 2023;18(10):e0292987 (Oct 25). doi: 10.1371/journal.pone.0292987

Key clinical point: Atopic dermatitis (AD) significantly increases the risk for cognitive dysfunction, particularly that of all-cause dementia and Alzheimer’s disease-related dementia, in middle-aged adults (age 45-59 years) and older adults (age ≥60 years).

Major finding: Patients with AD vs control individuals had a significantly higher risk of developing all-cause dementia (pooled hazard ratio [HR] 1.16; 95% CI 1.10-1.23) and Alzheimer’s disease-related dementia (pooled HR 1.28; 95% CI 1.01-1.63). However, no significant association was observed between AD and vascular dementia (pooled HR 1.42; 95% CI 0.99-2.04).

Study details: Findings are from a meta-analysis of five studies including 8,595,252 patients with AD and a corresponding number of control individuals without AD.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Zhou Q et al. Atopic dermatitis and cognitive dysfunction in middle-aged and older adults: A systematic review and meta-analysis. PLoS One. 2023;18(10):e0292987 (Oct 25). doi: 10.1371/journal.pone.0292987

Key clinical point: Atopic dermatitis (AD) significantly increases the risk for cognitive dysfunction, particularly that of all-cause dementia and Alzheimer’s disease-related dementia, in middle-aged adults (age 45-59 years) and older adults (age ≥60 years).

Major finding: Patients with AD vs control individuals had a significantly higher risk of developing all-cause dementia (pooled hazard ratio [HR] 1.16; 95% CI 1.10-1.23) and Alzheimer’s disease-related dementia (pooled HR 1.28; 95% CI 1.01-1.63). However, no significant association was observed between AD and vascular dementia (pooled HR 1.42; 95% CI 0.99-2.04).

Study details: Findings are from a meta-analysis of five studies including 8,595,252 patients with AD and a corresponding number of control individuals without AD.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Zhou Q et al. Atopic dermatitis and cognitive dysfunction in middle-aged and older adults: A systematic review and meta-analysis. PLoS One. 2023;18(10):e0292987 (Oct 25). doi: 10.1371/journal.pone.0292987

Key clinical point: Children with atopic dermatitis (AD) have an increased risk for multiple comorbidities, even beyond atopic disorders, with a positive association between AD severity and the risk for comorbidity onset.

Major finding: In children with vs without AD, the risk for hypersensitivity and allergic disorders was the highest (hazard ratio [HR] 3.87; 95% CI 3.77-3.97), followed by that for malignancies (HR 2.53; 95% CI 1.96-3.26) and immunological and inflammatory disorders (HR 2.36; 95% CI 2.22-2.50). Hypersensitivity onset risk increased in children with mild-to-moderate (adjusted HR 2.71; 95% CI 2.41-3.05) and severe (adjusted HR 3.56; 95% CI 3.10-4.09) AD compared with those in remission.

Study details: This observational, retrospective cohort study included 165,145 children with AD (age < 18 years) who were matched with 165,145 children without AD.

Disclosures: This study was sponsored by Pfizer Inc. Some authors declared receiving research grants or consultancy fees from or serving as advisors, investigators, etc., for Pfizer and others. Six authors declared being employees of or holding stock or stock options in Pfizer.

Source: von Kobyletzki L et al. Comorbidities in childhood atopic dermatitis: A population-based study. J Eur Acad Dermatol Venereol. 2023 (Oct 12). doi: 10.1111/jdv.19569

Key clinical point: Children with atopic dermatitis (AD) have an increased risk for multiple comorbidities, even beyond atopic disorders, with a positive association between AD severity and the risk for comorbidity onset.

Major finding: In children with vs without AD, the risk for hypersensitivity and allergic disorders was the highest (hazard ratio [HR] 3.87; 95% CI 3.77-3.97), followed by that for malignancies (HR 2.53; 95% CI 1.96-3.26) and immunological and inflammatory disorders (HR 2.36; 95% CI 2.22-2.50). Hypersensitivity onset risk increased in children with mild-to-moderate (adjusted HR 2.71; 95% CI 2.41-3.05) and severe (adjusted HR 3.56; 95% CI 3.10-4.09) AD compared with those in remission.

Study details: This observational, retrospective cohort study included 165,145 children with AD (age < 18 years) who were matched with 165,145 children without AD.

Disclosures: This study was sponsored by Pfizer Inc. Some authors declared receiving research grants or consultancy fees from or serving as advisors, investigators, etc., for Pfizer and others. Six authors declared being employees of or holding stock or stock options in Pfizer.

Source: von Kobyletzki L et al. Comorbidities in childhood atopic dermatitis: A population-based study. J Eur Acad Dermatol Venereol. 2023 (Oct 12). doi: 10.1111/jdv.19569

Key clinical point: Children with atopic dermatitis (AD) have an increased risk for multiple comorbidities, even beyond atopic disorders, with a positive association between AD severity and the risk for comorbidity onset.

Major finding: In children with vs without AD, the risk for hypersensitivity and allergic disorders was the highest (hazard ratio [HR] 3.87; 95% CI 3.77-3.97), followed by that for malignancies (HR 2.53; 95% CI 1.96-3.26) and immunological and inflammatory disorders (HR 2.36; 95% CI 2.22-2.50). Hypersensitivity onset risk increased in children with mild-to-moderate (adjusted HR 2.71; 95% CI 2.41-3.05) and severe (adjusted HR 3.56; 95% CI 3.10-4.09) AD compared with those in remission.

Study details: This observational, retrospective cohort study included 165,145 children with AD (age < 18 years) who were matched with 165,145 children without AD.

Disclosures: This study was sponsored by Pfizer Inc. Some authors declared receiving research grants or consultancy fees from or serving as advisors, investigators, etc., for Pfizer and others. Six authors declared being employees of or holding stock or stock options in Pfizer.

Source: von Kobyletzki L et al. Comorbidities in childhood atopic dermatitis: A population-based study. J Eur Acad Dermatol Venereol. 2023 (Oct 12). doi: 10.1111/jdv.19569

Key clinical point: Compared with dupilumab, lebrikizumab in less frequent doses shows equal or improved long-term maintenance of efficacy and overall adverse event rates in patients with moderate-to-severe atopic dermatitis (AD).

Major finding: Between weeks 16 and 52, patients receiving lebrikizumab every 4 weeks (Q4W) vs dupilumab weekly or biweekly (QW/Q2W) were more likely to maintain Investigator’s Global Assessment scores of 0 or 1 (risk ratio [RR] 1.334; P  =  .035). Lebrikizumab and dupilumab were comparable in terms of adverse event rates (RR 1.052; P  =  .526) and maintenance of 75% improvement in Eczema Area and Severity Index scores (RR 0.937; P  =  .490).

Study details: This matching-adjusted indirect comparison study analyzed the data of adult patients with moderate-to-severe AD who received lebrikizumab Q4W (n = 101) in ADvocate1 and ADvocate2 or dupilumab QW/Q2W (n = 169) in SOLO-CONTINUE and achieved a treatment response at week 16.

Disclosures: This study was funded by Almirall S.A., Spain. Two authors declared being employees of Almirall S.A. The other authors declared ties with various sources, including Almirall.

Source: Rand K et al. Matching-adjusted indirect comparison of the long-term efficacy maintenance and adverse event rates of lebrikizumab versus dupilumab in moderate-to-severe atopic dermatitis. Dermatol Ther (Heidelb). 2023 (Oct 28). doi: 10.1007/s13555-023-01058-z

Key clinical point: Compared with dupilumab, lebrikizumab in less frequent doses shows equal or improved long-term maintenance of efficacy and overall adverse event rates in patients with moderate-to-severe atopic dermatitis (AD).

Major finding: Between weeks 16 and 52, patients receiving lebrikizumab every 4 weeks (Q4W) vs dupilumab weekly or biweekly (QW/Q2W) were more likely to maintain Investigator’s Global Assessment scores of 0 or 1 (risk ratio [RR] 1.334; P  =  .035). Lebrikizumab and dupilumab were comparable in terms of adverse event rates (RR 1.052; P  =  .526) and maintenance of 75% improvement in Eczema Area and Severity Index scores (RR 0.937; P  =  .490).

Study details: This matching-adjusted indirect comparison study analyzed the data of adult patients with moderate-to-severe AD who received lebrikizumab Q4W (n = 101) in ADvocate1 and ADvocate2 or dupilumab QW/Q2W (n = 169) in SOLO-CONTINUE and achieved a treatment response at week 16.

Disclosures: This study was funded by Almirall S.A., Spain. Two authors declared being employees of Almirall S.A. The other authors declared ties with various sources, including Almirall.

Source: Rand K et al. Matching-adjusted indirect comparison of the long-term efficacy maintenance and adverse event rates of lebrikizumab versus dupilumab in moderate-to-severe atopic dermatitis. Dermatol Ther (Heidelb). 2023 (Oct 28). doi: 10.1007/s13555-023-01058-z

Key clinical point: Compared with dupilumab, lebrikizumab in less frequent doses shows equal or improved long-term maintenance of efficacy and overall adverse event rates in patients with moderate-to-severe atopic dermatitis (AD).

Major finding: Between weeks 16 and 52, patients receiving lebrikizumab every 4 weeks (Q4W) vs dupilumab weekly or biweekly (QW/Q2W) were more likely to maintain Investigator’s Global Assessment scores of 0 or 1 (risk ratio [RR] 1.334; P  =  .035). Lebrikizumab and dupilumab were comparable in terms of adverse event rates (RR 1.052; P  =  .526) and maintenance of 75% improvement in Eczema Area and Severity Index scores (RR 0.937; P  =  .490).

Study details: This matching-adjusted indirect comparison study analyzed the data of adult patients with moderate-to-severe AD who received lebrikizumab Q4W (n = 101) in ADvocate1 and ADvocate2 or dupilumab QW/Q2W (n = 169) in SOLO-CONTINUE and achieved a treatment response at week 16.

Disclosures: This study was funded by Almirall S.A., Spain. Two authors declared being employees of Almirall S.A. The other authors declared ties with various sources, including Almirall.

Source: Rand K et al. Matching-adjusted indirect comparison of the long-term efficacy maintenance and adverse event rates of lebrikizumab versus dupilumab in moderate-to-severe atopic dermatitis. Dermatol Ther (Heidelb). 2023 (Oct 28). doi: 10.1007/s13555-023-01058-z

Key clinical point: Patients with alopecia areata (AA) have an increased risk for atopic dermatitis (AD) and vice versa.

Major finding: Patients with AA vs control individuals had a significantly higher risk of developing AD (adjusted odds ratio [aOR] 4.42; P < .001). Reciprocally, patients with AD vs control individuals also had a significantly higher risk of developing AA (aOR 5.08; P < .001).

Study details: Findings are from a nested case-control study including 984 patients with AA from the All of Us database (USA), who were matched with 3936 control individuals without AA using nearest neighbor propensity-score matching.

Disclosures: This study did not disclose any funding source. E Guttman-Yassky and B Ungar declared receiving institutional grants from, serving as consultants for, or having other ties with various sources. The other authors declared no conflicts of interest.

Source: Diaz MJ et al. Association between alopecia areata and atopic dermatitis: A nested case-control study of the All of Us database. J Am Acad Dermatol. 2023 (Oct 21). doi: 10.1016/j.jaad.2023.10.031

Key clinical point: Patients with alopecia areata (AA) have an increased risk for atopic dermatitis (AD) and vice versa.

Major finding: Patients with AA vs control individuals had a significantly higher risk of developing AD (adjusted odds ratio [aOR] 4.42; P < .001). Reciprocally, patients with AD vs control individuals also had a significantly higher risk of developing AA (aOR 5.08; P < .001).

Study details: Findings are from a nested case-control study including 984 patients with AA from the All of Us database (USA), who were matched with 3936 control individuals without AA using nearest neighbor propensity-score matching.

Disclosures: This study did not disclose any funding source. E Guttman-Yassky and B Ungar declared receiving institutional grants from, serving as consultants for, or having other ties with various sources. The other authors declared no conflicts of interest.

Source: Diaz MJ et al. Association between alopecia areata and atopic dermatitis: A nested case-control study of the All of Us database. J Am Acad Dermatol. 2023 (Oct 21). doi: 10.1016/j.jaad.2023.10.031

Key clinical point: Patients with alopecia areata (AA) have an increased risk for atopic dermatitis (AD) and vice versa.

Major finding: Patients with AA vs control individuals had a significantly higher risk of developing AD (adjusted odds ratio [aOR] 4.42; P < .001). Reciprocally, patients with AD vs control individuals also had a significantly higher risk of developing AA (aOR 5.08; P < .001).

Study details: Findings are from a nested case-control study including 984 patients with AA from the All of Us database (USA), who were matched with 3936 control individuals without AA using nearest neighbor propensity-score matching.

Disclosures: This study did not disclose any funding source. E Guttman-Yassky and B Ungar declared receiving institutional grants from, serving as consultants for, or having other ties with various sources. The other authors declared no conflicts of interest.

Source: Diaz MJ et al. Association between alopecia areata and atopic dermatitis: A nested case-control study of the All of Us database. J Am Acad Dermatol. 2023 (Oct 21). doi: 10.1016/j.jaad.2023.10.031

Key clinical point: In real-world settings, dupilumab is safe and effective in children with moderate-to-severe atopic dermatitis (AD) who are age > 2 to < 12 years.

Major finding: Dupilumab led to significant improvements in the Eczema Area and Severity Index scores and Body Surface Area scores in children age > 2 to < 6 years (both P < .001) and ≥ 6 to < 12 years (both P < .001) but not in those age ≤ 2 years (P  =  .191 and P  =  .092, respectively). No serious adverse events were reported.

Study details: This multicenter retrospective study included 63 children with moderate-to-severe AD who were classified relative to age: ≤ 2 years (n = 4), > 2 to < 6 years (n = 25), and ≥ 6 to < 12 years (n = 34), with most having received prior systemic immunosuppressive therapies and all being treated with dupilumab.

Disclosures: This study did not disclose any funding source. Several authors declared receiving grants or honoraria from or serving as investigators, advisors, consultants, or speakers for various sources.

Source: Martinez-Cabriales S et al. Multicenter Canadian case series of pediatric patients less than 12 years of age with moderate-to-severe atopic dermatitis treated with dupilumab. Pediatr Dermatol. 2023 (Oct 31). doi: 10.1111/pde.15418

Key clinical point: In real-world settings, dupilumab is safe and effective in children with moderate-to-severe atopic dermatitis (AD) who are age > 2 to < 12 years.

Major finding: Dupilumab led to significant improvements in the Eczema Area and Severity Index scores and Body Surface Area scores in children age > 2 to < 6 years (both P < .001) and ≥ 6 to < 12 years (both P < .001) but not in those age ≤ 2 years (P  =  .191 and P  =  .092, respectively). No serious adverse events were reported.

Study details: This multicenter retrospective study included 63 children with moderate-to-severe AD who were classified relative to age: ≤ 2 years (n = 4), > 2 to < 6 years (n = 25), and ≥ 6 to < 12 years (n = 34), with most having received prior systemic immunosuppressive therapies and all being treated with dupilumab.

Disclosures: This study did not disclose any funding source. Several authors declared receiving grants or honoraria from or serving as investigators, advisors, consultants, or speakers for various sources.

Source: Martinez-Cabriales S et al. Multicenter Canadian case series of pediatric patients less than 12 years of age with moderate-to-severe atopic dermatitis treated with dupilumab. Pediatr Dermatol. 2023 (Oct 31). doi: 10.1111/pde.15418

Key clinical point: In real-world settings, dupilumab is safe and effective in children with moderate-to-severe atopic dermatitis (AD) who are age > 2 to < 12 years.

Major finding: Dupilumab led to significant improvements in the Eczema Area and Severity Index scores and Body Surface Area scores in children age > 2 to < 6 years (both P < .001) and ≥ 6 to < 12 years (both P < .001) but not in those age ≤ 2 years (P  =  .191 and P  =  .092, respectively). No serious adverse events were reported.

Study details: This multicenter retrospective study included 63 children with moderate-to-severe AD who were classified relative to age: ≤ 2 years (n = 4), > 2 to < 6 years (n = 25), and ≥ 6 to < 12 years (n = 34), with most having received prior systemic immunosuppressive therapies and all being treated with dupilumab.

Disclosures: This study did not disclose any funding source. Several authors declared receiving grants or honoraria from or serving as investigators, advisors, consultants, or speakers for various sources.

Source: Martinez-Cabriales S et al. Multicenter Canadian case series of pediatric patients less than 12 years of age with moderate-to-severe atopic dermatitis treated with dupilumab. Pediatr Dermatol. 2023 (Oct 31). doi: 10.1111/pde.15418

Key clinical point: Upadacitinib is effective and well-tolerated in patients with moderate-to-severe atopic dermatitis (AD) and prior failure to multiple systemic immunosuppressive and biologic therapies.

Major finding: At a median follow-up of 37.5 weeks, the median Investigator’s Global Assessment scores and Numerical Rating Scale itch scores reduced significantly from 3.00 to 1.50 and from 7.00 to 2.25, respectively (both P < .001). The adverse events reported were mostly mild in severity, with acne-like eruptions (25%) and nausea (13%) being the most common.

Study details: This prospective observational single-center study included 48 patients with moderate-to-severe AD receiving 15 mg or 30 mg upadacitinib daily, most of whom (n = 39) had failed other targeted therapies, including other Janus kinase inhibitors and biologics.

Disclosures: This study did not receive any funding. DJ Hijnen declared serving as an investigator and consultant for various sources. The other authors declared no conflicts of interest.

Source: Schlösser AR et al. Upadacitinib treatment in a real-world difficult-to-treat atopic dermatitis patient cohort. J Eur Acad Dermatol Venereol. 2023 (Oct 21). doi: 10.1111/jdv.19581

Key clinical point: Upadacitinib is effective and well-tolerated in patients with moderate-to-severe atopic dermatitis (AD) and prior failure to multiple systemic immunosuppressive and biologic therapies.

Major finding: At a median follow-up of 37.5 weeks, the median Investigator’s Global Assessment scores and Numerical Rating Scale itch scores reduced significantly from 3.00 to 1.50 and from 7.00 to 2.25, respectively (both P < .001). The adverse events reported were mostly mild in severity, with acne-like eruptions (25%) and nausea (13%) being the most common.

Study details: This prospective observational single-center study included 48 patients with moderate-to-severe AD receiving 15 mg or 30 mg upadacitinib daily, most of whom (n = 39) had failed other targeted therapies, including other Janus kinase inhibitors and biologics.

Disclosures: This study did not receive any funding. DJ Hijnen declared serving as an investigator and consultant for various sources. The other authors declared no conflicts of interest.

Source: Schlösser AR et al. Upadacitinib treatment in a real-world difficult-to-treat atopic dermatitis patient cohort. J Eur Acad Dermatol Venereol. 2023 (Oct 21). doi: 10.1111/jdv.19581

Key clinical point: Upadacitinib is effective and well-tolerated in patients with moderate-to-severe atopic dermatitis (AD) and prior failure to multiple systemic immunosuppressive and biologic therapies.

Major finding: At a median follow-up of 37.5 weeks, the median Investigator’s Global Assessment scores and Numerical Rating Scale itch scores reduced significantly from 3.00 to 1.50 and from 7.00 to 2.25, respectively (both P < .001). The adverse events reported were mostly mild in severity, with acne-like eruptions (25%) and nausea (13%) being the most common.

Study details: This prospective observational single-center study included 48 patients with moderate-to-severe AD receiving 15 mg or 30 mg upadacitinib daily, most of whom (n = 39) had failed other targeted therapies, including other Janus kinase inhibitors and biologics.

Disclosures: This study did not receive any funding. DJ Hijnen declared serving as an investigator and consultant for various sources. The other authors declared no conflicts of interest.

Source: Schlösser AR et al. Upadacitinib treatment in a real-world difficult-to-treat atopic dermatitis patient cohort. J Eur Acad Dermatol Venereol. 2023 (Oct 21). doi: 10.1111/jdv.19581

Since 1983, when I was a child and fled as a boat refugee from Vietnam with my mother, the international plight of displaced people has only worsened. From 1997 to 2022, the number of forcibly displaced people has more than tripled, growing from 34 million to more than 108 million.¹

Displaced people are designated as refugees only when they cross international borders and meet the United Nations High Commissioner for Refugees’ (UNHCR) definition as “persons outside their countries of origin who are in need of international protection because of a serious threat to their life, physical integrity, or freedom in their country of origin as a result of persecution, armed conflict, violence, or serious public disorder.”² There is a separate mandate by the United Nations for the aid of Palestinian refugees under the United Nations General Assembly’s United Nations Relief and Works Agency for Palestinian Refugees in the Near East (UNRWA).³ Of the displaced in 2022, more than 36 million were recognized as refugees under UNHCR and UNRWA mandates.¹ Of these, almost 50% were children, at 17.5 million.⁴ To make matters worse, worldwide children represent less than one-third of the population.⁴ Since 2022, the increase in refugeeism is mostly driven by Ukraine and Syria, though also significantly Afghanistan, Venezuela, Sudan, Myanmar, Congo, Somalia, and Central African Republic.⁴ Refugeeism is a growing problem that disproportionately impacts children through sheer number, and one suspects, given their greater overall vulnerabilities compared with adults, physical and mental health consequences.
 

Traumas of refugees compared with non-refugee immigrants

In terms of mental health, refugees are distinct from non-refugee immigrants in that they likely experience more severe psychosocial adversities from greater poverty, greater risk of family separation, and uncertainty of the asylum process.^5-8

From my own experience, this stems from the urgent nature of the refugee’s displacement, where they are often fleeing an immediate danger. My family had fled persecution from Communist forces and the social economic collapse that rendered Vietnam, for a time, one of the poorest in the world.⁹ Or, as my mother observed, “We had to leave because even doctors were starving.”

Refugees often have little preparation, have little legal protection since they are often criminalized, and are forced to endure dangerous conditions where they are vulnerable to smugglers and criminals who exploit their unprotected status. Once they arrive in their new country, they often do not have other family as social supports or resources. They themselves become the anchor for future legal and orderly immigration of their remaining family, given that they can extend their refugee status to those left behind.¹⁰ These non-refugee immigrants, unlike their refugee counterparts, are often flown to their new homes with more preparation, protecting them from dangerous conditions, and have the benefit of family who provide them with resources. As such, refugees tend to experience more traumatic life events than non-refugee immigrants. This was true in my family where those of us who initially escaped became the anchors to legally, and more safely, immigrate most of our family in Vietnam. We became their resources, likely making their acclimation smoother.
 

The mental health of refugee children and their caregivers

It is important to understand the stressors affecting the caregivers of children, since effective treatment of their mental health conditions can also benefit the children as well.¹¹ In fact, among the greatest protective factors for refugee children is the presence of an adult caregiver, suggesting that the child’s mental health is dependent on the caregivers.

Those children who are separated show much worse mental health sequalae.¹² As such, an understanding of the caregiver’s stressors is important. For example, when we were escaping Vietnam, my mom would protect me from our hardships by talking about our goals in America, minimizing our dangers by saying that we would be rewarded with things like a hamburger with its seemingly impossible amount of meat. Physically, my mother would always sleep with her arms around me and a knife hidden in order to ward off any attackers at night. When I was starving in the hull of a boat, having not eaten for days, my mother begged for food and gave me what she could get. And post-escape, my family focused on work and applied for aid for shelter and food, while encouraging us to invest in education, likely preventing involvement in criminal activities or gangs. Though overall, my family shielded me from the worst consequences, they also passed on their fears. One of my uncles had been killed by the police when he tried to escape, and so my family passed down a deep suspicion of authorities, whether they were the police or school principals. My mother had vivid memories of Communist re-education camps, which likely gave her a lasting fear that a Communist would find out our identities in America and re-capture us.
 

The mental health risk of refugees

Given that refugees tend to experience greater amounts of traumatic life events and a vast array of stressors sustained across years and even decades before, during, and after migration, it is no wonder they have much higher rates of mental health conditions, most predominantly PTSD and affective disorders.^13,14 They are at particular risk of developing psychoses because they are more likely to experience a range of physical, psychological, and psychosocial problems associated with adversities such as violence, discrimination, economic stress, and social isolation.¹³ For example, the period leading up to my escape consisted of decades of prolonged war: the French-Indochina from 1945 to 1954, then the Vietnam War from 1955 to 1975) as well as the persecution and re-education camps afterward. What my family had to endure created a period of fear and loss into which I was born into in 1976. That year, my family had lost its fortune due to the Communist government seizing of our home and business, plunging us from a comfortable middle- to upper-class life to poverty. There was also widespread fear of systematic rape by the Communist victors. So my family endured great stress and the loss of a way of life leading up to our escape.

For the refugees, the escape itself is often a dangerous journey where, given its emergent nature, they are often exposed to the elements. We know about the current situation in Ukraine and Gaza, where children are fleeing from bombs and bullets. In my situation, we endured weeks of starvation crammed in the hull of boat as we forged through the Indian Ocean to the Philippines. One of my aunts, on a separate trip, perished because her boat had capsized, like so many others. Though impossible to verify, it has been estimated that up to 70% of Vietnamese refugees died during their escape.¹⁵ After the boat, my mother and I still had to brave Malaysian jungles and prisons, and then refugee camps for a year before we reached safety at an American Embassy in the Philippines. After we gained sponsorship to America, the traumas did not abate, but were only replaced by those of culture shock, poverty, and alienation. Taken by themselves, significant traumas exist in each phase of a refugee child’s escape, whether before, during, or after. These traumas are likely compounded since they are continuously layered and sustained across years, even decades. They affect not only the children, but their parents, and sometimes even a whole nation of people.
 

Summary

In recent decades, refugeeism has been a growing problem that disproportionately affects children. Refugee children and their families experience a variety of traumas, often sustained across years and even decades, because of armed conflict, persecution, or social upheavals. It is known that refugees are at greater risk for PTSD and affective and psychotic disorders, presumably due to increased traumatic life events before, during, and after their migration. The writer uses his own experience as a child refugee from Vietnam to elucidate the stressors evident in various phases of forced displacement.

Dr. Nguyen is a second year resident at UCSF Fresno Psychiatry Residency. He was a public high school English teacher for 15 years previously.

References

1. UNHCR. Global Trends. Forced displacement in 2016. Geneva, Switzerland: The UN Refugee Agency, 2022. https://www.unhcr.org/global-trends.

2. Office of the United Nations High Commissioner for Refugees. The refugee concept under international law. Global compact for safe, orderly and regular migration.  https://www.unhcr.org/sites/default/files/legacy-pdf/5aa290937.pdf. Published March 8, 2018.

3. United Nations. (2023, November 11). The Question of Palestine. Un.org. https://www.un.org/unispal/document/un-general-assembly-renews-unrwa-mandate-press-release/

4. UNICEF. (2023, November 11). Child displacement. Data.unicef.org. https://data.unicef.org/topic/child-migration-and-displacement/displacement

5. Kinzie JD. Immigrants and refugees: The psychiatric perspective. Transcult Psychiatry. 2006 Dec;43(4):577-91. doi: 10.1177/1363461506070782.

6. Eaton W and Harrison G. Ethnic disadvantage and schizophrenia. Acta Psychiatr Scand Suppl. 2000:(407):38-43. doi: 10.1034/j.1600-0447.2000.00007.x.

7. Gilliver SC et al. Recent research on the mental health of immigrants to Sweden: a literature review. Eur J Public Health. 2014 Aug:24 Suppl 1:72-9. doi: 10.1093/eurpub/cku101.

8. Rapp MA et al. When local poverty is more important than your income: Mental health in minorities in inner cities. World Psychiatry. 2015 Jun;14(2):249-50. doi: 10.1002/wps.20221.

9. Cima, Ronald, ed. Vietnam: A Country Study. Washington: GPO for the Library of Congress, 1987.

10. United States Citizenship & Immigration Services (2023, November 12). Refugees. Uscis.gov. https://www.uscis.gov/humanitarian/refugees-and-asylum/refugees

11. Fazel M and Betancourt TS. (2018). Preventive mental health interventions for refugee children and adolescents in high-income settings. Lancet Child Adolesc Health. 2018 Feb;2(2):121-32. doi: 10.1016/S2352-4642(17)30147-5.

12. Fazel M et al. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet. 2012 Jan 21;379(9812):266-82. doi: 10.1016/S0140-6736(11)60051-2.

13. Dapunt J et al. Refugees and psychosis: A review of the literature. Transl Psychiatry. 2017 Jun 13;7(6):e1149. doi: 10.1038/tp.2017.119.

14. Fazel M et al. Prevalence of serious mental disorder in 7,000 refugees resettled in western countries: a systematic review. Lancet. 2005 Apr;365(9467):1309-14. doi: 10.1016/S0140-6736(05)61027-6.

15. Rummel R. Statistics of Vietnamese Democide, in his Statistics of Democide. 1997. Table 6.1B,lines 730, 749-51.

Since 1983, when I was a child and fled as a boat refugee from Vietnam with my mother, the international plight of displaced people has only worsened. From 1997 to 2022, the number of forcibly displaced people has more than tripled, growing from 34 million to more than 108 million.¹

Displaced people are designated as refugees only when they cross international borders and meet the United Nations High Commissioner for Refugees’ (UNHCR) definition as “persons outside their countries of origin who are in need of international protection because of a serious threat to their life, physical integrity, or freedom in their country of origin as a result of persecution, armed conflict, violence, or serious public disorder.”² There is a separate mandate by the United Nations for the aid of Palestinian refugees under the United Nations General Assembly’s United Nations Relief and Works Agency for Palestinian Refugees in the Near East (UNRWA).³ Of the displaced in 2022, more than 36 million were recognized as refugees under UNHCR and UNRWA mandates.¹ Of these, almost 50% were children, at 17.5 million.⁴ To make matters worse, worldwide children represent less than one-third of the population.⁴ Since 2022, the increase in refugeeism is mostly driven by Ukraine and Syria, though also significantly Afghanistan, Venezuela, Sudan, Myanmar, Congo, Somalia, and Central African Republic.⁴ Refugeeism is a growing problem that disproportionately impacts children through sheer number, and one suspects, given their greater overall vulnerabilities compared with adults, physical and mental health consequences.
 

Traumas of refugees compared with non-refugee immigrants

In terms of mental health, refugees are distinct from non-refugee immigrants in that they likely experience more severe psychosocial adversities from greater poverty, greater risk of family separation, and uncertainty of the asylum process.^5-8

From my own experience, this stems from the urgent nature of the refugee’s displacement, where they are often fleeing an immediate danger. My family had fled persecution from Communist forces and the social economic collapse that rendered Vietnam, for a time, one of the poorest in the world.⁹ Or, as my mother observed, “We had to leave because even doctors were starving.”

Refugees often have little preparation, have little legal protection since they are often criminalized, and are forced to endure dangerous conditions where they are vulnerable to smugglers and criminals who exploit their unprotected status. Once they arrive in their new country, they often do not have other family as social supports or resources. They themselves become the anchor for future legal and orderly immigration of their remaining family, given that they can extend their refugee status to those left behind.¹⁰ These non-refugee immigrants, unlike their refugee counterparts, are often flown to their new homes with more preparation, protecting them from dangerous conditions, and have the benefit of family who provide them with resources. As such, refugees tend to experience more traumatic life events than non-refugee immigrants. This was true in my family where those of us who initially escaped became the anchors to legally, and more safely, immigrate most of our family in Vietnam. We became their resources, likely making their acclimation smoother.
 

The mental health of refugee children and their caregivers

It is important to understand the stressors affecting the caregivers of children, since effective treatment of their mental health conditions can also benefit the children as well.¹¹ In fact, among the greatest protective factors for refugee children is the presence of an adult caregiver, suggesting that the child’s mental health is dependent on the caregivers.

Those children who are separated show much worse mental health sequalae.¹² As such, an understanding of the caregiver’s stressors is important. For example, when we were escaping Vietnam, my mom would protect me from our hardships by talking about our goals in America, minimizing our dangers by saying that we would be rewarded with things like a hamburger with its seemingly impossible amount of meat. Physically, my mother would always sleep with her arms around me and a knife hidden in order to ward off any attackers at night. When I was starving in the hull of a boat, having not eaten for days, my mother begged for food and gave me what she could get. And post-escape, my family focused on work and applied for aid for shelter and food, while encouraging us to invest in education, likely preventing involvement in criminal activities or gangs. Though overall, my family shielded me from the worst consequences, they also passed on their fears. One of my uncles had been killed by the police when he tried to escape, and so my family passed down a deep suspicion of authorities, whether they were the police or school principals. My mother had vivid memories of Communist re-education camps, which likely gave her a lasting fear that a Communist would find out our identities in America and re-capture us.
 

The mental health risk of refugees

Given that refugees tend to experience greater amounts of traumatic life events and a vast array of stressors sustained across years and even decades before, during, and after migration, it is no wonder they have much higher rates of mental health conditions, most predominantly PTSD and affective disorders.^13,14 They are at particular risk of developing psychoses because they are more likely to experience a range of physical, psychological, and psychosocial problems associated with adversities such as violence, discrimination, economic stress, and social isolation.¹³ For example, the period leading up to my escape consisted of decades of prolonged war: the French-Indochina from 1945 to 1954, then the Vietnam War from 1955 to 1975) as well as the persecution and re-education camps afterward. What my family had to endure created a period of fear and loss into which I was born into in 1976. That year, my family had lost its fortune due to the Communist government seizing of our home and business, plunging us from a comfortable middle- to upper-class life to poverty. There was also widespread fear of systematic rape by the Communist victors. So my family endured great stress and the loss of a way of life leading up to our escape.

For the refugees, the escape itself is often a dangerous journey where, given its emergent nature, they are often exposed to the elements. We know about the current situation in Ukraine and Gaza, where children are fleeing from bombs and bullets. In my situation, we endured weeks of starvation crammed in the hull of boat as we forged through the Indian Ocean to the Philippines. One of my aunts, on a separate trip, perished because her boat had capsized, like so many others. Though impossible to verify, it has been estimated that up to 70% of Vietnamese refugees died during their escape.¹⁵ After the boat, my mother and I still had to brave Malaysian jungles and prisons, and then refugee camps for a year before we reached safety at an American Embassy in the Philippines. After we gained sponsorship to America, the traumas did not abate, but were only replaced by those of culture shock, poverty, and alienation. Taken by themselves, significant traumas exist in each phase of a refugee child’s escape, whether before, during, or after. These traumas are likely compounded since they are continuously layered and sustained across years, even decades. They affect not only the children, but their parents, and sometimes even a whole nation of people.
 

Summary

In recent decades, refugeeism has been a growing problem that disproportionately affects children. Refugee children and their families experience a variety of traumas, often sustained across years and even decades, because of armed conflict, persecution, or social upheavals. It is known that refugees are at greater risk for PTSD and affective and psychotic disorders, presumably due to increased traumatic life events before, during, and after their migration. The writer uses his own experience as a child refugee from Vietnam to elucidate the stressors evident in various phases of forced displacement.

Dr. Nguyen is a second year resident at UCSF Fresno Psychiatry Residency. He was a public high school English teacher for 15 years previously.

References

1. UNHCR. Global Trends. Forced displacement in 2016. Geneva, Switzerland: The UN Refugee Agency, 2022. https://www.unhcr.org/global-trends.

2. Office of the United Nations High Commissioner for Refugees. The refugee concept under international law. Global compact for safe, orderly and regular migration.  https://www.unhcr.org/sites/default/files/legacy-pdf/5aa290937.pdf. Published March 8, 2018.

3. United Nations. (2023, November 11). The Question of Palestine. Un.org. https://www.un.org/unispal/document/un-general-assembly-renews-unrwa-mandate-press-release/

4. UNICEF. (2023, November 11). Child displacement. Data.unicef.org. https://data.unicef.org/topic/child-migration-and-displacement/displacement

5. Kinzie JD. Immigrants and refugees: The psychiatric perspective. Transcult Psychiatry. 2006 Dec;43(4):577-91. doi: 10.1177/1363461506070782.

6. Eaton W and Harrison G. Ethnic disadvantage and schizophrenia. Acta Psychiatr Scand Suppl. 2000:(407):38-43. doi: 10.1034/j.1600-0447.2000.00007.x.

7. Gilliver SC et al. Recent research on the mental health of immigrants to Sweden: a literature review. Eur J Public Health. 2014 Aug:24 Suppl 1:72-9. doi: 10.1093/eurpub/cku101.

8. Rapp MA et al. When local poverty is more important than your income: Mental health in minorities in inner cities. World Psychiatry. 2015 Jun;14(2):249-50. doi: 10.1002/wps.20221.

9. Cima, Ronald, ed. Vietnam: A Country Study. Washington: GPO for the Library of Congress, 1987.

10. United States Citizenship & Immigration Services (2023, November 12). Refugees. Uscis.gov. https://www.uscis.gov/humanitarian/refugees-and-asylum/refugees

11. Fazel M and Betancourt TS. (2018). Preventive mental health interventions for refugee children and adolescents in high-income settings. Lancet Child Adolesc Health. 2018 Feb;2(2):121-32. doi: 10.1016/S2352-4642(17)30147-5.

12. Fazel M et al. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet. 2012 Jan 21;379(9812):266-82. doi: 10.1016/S0140-6736(11)60051-2.

13. Dapunt J et al. Refugees and psychosis: A review of the literature. Transl Psychiatry. 2017 Jun 13;7(6):e1149. doi: 10.1038/tp.2017.119.

14. Fazel M et al. Prevalence of serious mental disorder in 7,000 refugees resettled in western countries: a systematic review. Lancet. 2005 Apr;365(9467):1309-14. doi: 10.1016/S0140-6736(05)61027-6.

15. Rummel R. Statistics of Vietnamese Democide, in his Statistics of Democide. 1997. Table 6.1B,lines 730, 749-51.

Since 1983, when I was a child and fled as a boat refugee from Vietnam with my mother, the international plight of displaced people has only worsened. From 1997 to 2022, the number of forcibly displaced people has more than tripled, growing from 34 million to more than 108 million.¹

Displaced people are designated as refugees only when they cross international borders and meet the United Nations High Commissioner for Refugees’ (UNHCR) definition as “persons outside their countries of origin who are in need of international protection because of a serious threat to their life, physical integrity, or freedom in their country of origin as a result of persecution, armed conflict, violence, or serious public disorder.”² There is a separate mandate by the United Nations for the aid of Palestinian refugees under the United Nations General Assembly’s United Nations Relief and Works Agency for Palestinian Refugees in the Near East (UNRWA).³ Of the displaced in 2022, more than 36 million were recognized as refugees under UNHCR and UNRWA mandates.¹ Of these, almost 50% were children, at 17.5 million.⁴ To make matters worse, worldwide children represent less than one-third of the population.⁴ Since 2022, the increase in refugeeism is mostly driven by Ukraine and Syria, though also significantly Afghanistan, Venezuela, Sudan, Myanmar, Congo, Somalia, and Central African Republic.⁴ Refugeeism is a growing problem that disproportionately impacts children through sheer number, and one suspects, given their greater overall vulnerabilities compared with adults, physical and mental health consequences.
 

Traumas of refugees compared with non-refugee immigrants

In terms of mental health, refugees are distinct from non-refugee immigrants in that they likely experience more severe psychosocial adversities from greater poverty, greater risk of family separation, and uncertainty of the asylum process.^5-8

From my own experience, this stems from the urgent nature of the refugee’s displacement, where they are often fleeing an immediate danger. My family had fled persecution from Communist forces and the social economic collapse that rendered Vietnam, for a time, one of the poorest in the world.⁹ Or, as my mother observed, “We had to leave because even doctors were starving.”

Refugees often have little preparation, have little legal protection since they are often criminalized, and are forced to endure dangerous conditions where they are vulnerable to smugglers and criminals who exploit their unprotected status. Once they arrive in their new country, they often do not have other family as social supports or resources. They themselves become the anchor for future legal and orderly immigration of their remaining family, given that they can extend their refugee status to those left behind.¹⁰ These non-refugee immigrants, unlike their refugee counterparts, are often flown to their new homes with more preparation, protecting them from dangerous conditions, and have the benefit of family who provide them with resources. As such, refugees tend to experience more traumatic life events than non-refugee immigrants. This was true in my family where those of us who initially escaped became the anchors to legally, and more safely, immigrate most of our family in Vietnam. We became their resources, likely making their acclimation smoother.
 

The mental health of refugee children and their caregivers

It is important to understand the stressors affecting the caregivers of children, since effective treatment of their mental health conditions can also benefit the children as well.¹¹ In fact, among the greatest protective factors for refugee children is the presence of an adult caregiver, suggesting that the child’s mental health is dependent on the caregivers.

Those children who are separated show much worse mental health sequalae.¹² As such, an understanding of the caregiver’s stressors is important. For example, when we were escaping Vietnam, my mom would protect me from our hardships by talking about our goals in America, minimizing our dangers by saying that we would be rewarded with things like a hamburger with its seemingly impossible amount of meat. Physically, my mother would always sleep with her arms around me and a knife hidden in order to ward off any attackers at night. When I was starving in the hull of a boat, having not eaten for days, my mother begged for food and gave me what she could get. And post-escape, my family focused on work and applied for aid for shelter and food, while encouraging us to invest in education, likely preventing involvement in criminal activities or gangs. Though overall, my family shielded me from the worst consequences, they also passed on their fears. One of my uncles had been killed by the police when he tried to escape, and so my family passed down a deep suspicion of authorities, whether they were the police or school principals. My mother had vivid memories of Communist re-education camps, which likely gave her a lasting fear that a Communist would find out our identities in America and re-capture us.
 

The mental health risk of refugees

Given that refugees tend to experience greater amounts of traumatic life events and a vast array of stressors sustained across years and even decades before, during, and after migration, it is no wonder they have much higher rates of mental health conditions, most predominantly PTSD and affective disorders.^13,14 They are at particular risk of developing psychoses because they are more likely to experience a range of physical, psychological, and psychosocial problems associated with adversities such as violence, discrimination, economic stress, and social isolation.¹³ For example, the period leading up to my escape consisted of decades of prolonged war: the French-Indochina from 1945 to 1954, then the Vietnam War from 1955 to 1975) as well as the persecution and re-education camps afterward. What my family had to endure created a period of fear and loss into which I was born into in 1976. That year, my family had lost its fortune due to the Communist government seizing of our home and business, plunging us from a comfortable middle- to upper-class life to poverty. There was also widespread fear of systematic rape by the Communist victors. So my family endured great stress and the loss of a way of life leading up to our escape.

For the refugees, the escape itself is often a dangerous journey where, given its emergent nature, they are often exposed to the elements. We know about the current situation in Ukraine and Gaza, where children are fleeing from bombs and bullets. In my situation, we endured weeks of starvation crammed in the hull of boat as we forged through the Indian Ocean to the Philippines. One of my aunts, on a separate trip, perished because her boat had capsized, like so many others. Though impossible to verify, it has been estimated that up to 70% of Vietnamese refugees died during their escape.¹⁵ After the boat, my mother and I still had to brave Malaysian jungles and prisons, and then refugee camps for a year before we reached safety at an American Embassy in the Philippines. After we gained sponsorship to America, the traumas did not abate, but were only replaced by those of culture shock, poverty, and alienation. Taken by themselves, significant traumas exist in each phase of a refugee child’s escape, whether before, during, or after. These traumas are likely compounded since they are continuously layered and sustained across years, even decades. They affect not only the children, but their parents, and sometimes even a whole nation of people.
 

Summary

In recent decades, refugeeism has been a growing problem that disproportionately affects children. Refugee children and their families experience a variety of traumas, often sustained across years and even decades, because of armed conflict, persecution, or social upheavals. It is known that refugees are at greater risk for PTSD and affective and psychotic disorders, presumably due to increased traumatic life events before, during, and after their migration. The writer uses his own experience as a child refugee from Vietnam to elucidate the stressors evident in various phases of forced displacement.

Dr. Nguyen is a second year resident at UCSF Fresno Psychiatry Residency. He was a public high school English teacher for 15 years previously.

References

1. UNHCR. Global Trends. Forced displacement in 2016. Geneva, Switzerland: The UN Refugee Agency, 2022. https://www.unhcr.org/global-trends.

2. Office of the United Nations High Commissioner for Refugees. The refugee concept under international law. Global compact for safe, orderly and regular migration.  https://www.unhcr.org/sites/default/files/legacy-pdf/5aa290937.pdf. Published March 8, 2018.

3. United Nations. (2023, November 11). The Question of Palestine. Un.org. https://www.un.org/unispal/document/un-general-assembly-renews-unrwa-mandate-press-release/

4. UNICEF. (2023, November 11). Child displacement. Data.unicef.org. https://data.unicef.org/topic/child-migration-and-displacement/displacement

5. Kinzie JD. Immigrants and refugees: The psychiatric perspective. Transcult Psychiatry. 2006 Dec;43(4):577-91. doi: 10.1177/1363461506070782.

6. Eaton W and Harrison G. Ethnic disadvantage and schizophrenia. Acta Psychiatr Scand Suppl. 2000:(407):38-43. doi: 10.1034/j.1600-0447.2000.00007.x.

7. Gilliver SC et al. Recent research on the mental health of immigrants to Sweden: a literature review. Eur J Public Health. 2014 Aug:24 Suppl 1:72-9. doi: 10.1093/eurpub/cku101.

8. Rapp MA et al. When local poverty is more important than your income: Mental health in minorities in inner cities. World Psychiatry. 2015 Jun;14(2):249-50. doi: 10.1002/wps.20221.

9. Cima, Ronald, ed. Vietnam: A Country Study. Washington: GPO for the Library of Congress, 1987.

10. United States Citizenship & Immigration Services (2023, November 12). Refugees. Uscis.gov. https://www.uscis.gov/humanitarian/refugees-and-asylum/refugees

11. Fazel M and Betancourt TS. (2018). Preventive mental health interventions for refugee children and adolescents in high-income settings. Lancet Child Adolesc Health. 2018 Feb;2(2):121-32. doi: 10.1016/S2352-4642(17)30147-5.

12. Fazel M et al. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet. 2012 Jan 21;379(9812):266-82. doi: 10.1016/S0140-6736(11)60051-2.

13. Dapunt J et al. Refugees and psychosis: A review of the literature. Transl Psychiatry. 2017 Jun 13;7(6):e1149. doi: 10.1038/tp.2017.119.

14. Fazel M et al. Prevalence of serious mental disorder in 7,000 refugees resettled in western countries: a systematic review. Lancet. 2005 Apr;365(9467):1309-14. doi: 10.1016/S0140-6736(05)61027-6.

15. Rummel R. Statistics of Vietnamese Democide, in his Statistics of Democide. 1997. Table 6.1B,lines 730, 749-51.

Key clinical point: Lebrikizumab monotherapy for 16 weeks significantly reduced itch and itch-associated sleep loss in patients with moderate-to-severe atopic dermatitis (AD).

Major finding: At 16 weeks, a significantly higher number of patients from the ADvocate1 and ADvocate2 trials treated with lebrikizumab vs placebo achieved a ≥ 3-point improvement in the Pruritus Numeric Rating Scale scores (ADvocate1 54.6% vs 19.2%; ADvocate2 49.4% vs 14.0%; both P < .001) and ≥ 1-point improvement in Sleep-Loss Scale scores (ADvocate1 64.1% vs 27.2%; ADvocate2 58.1% vs 21.7%; both P < .001).

Study details: Findings are from a study including patients from the ADvocate1 (n = 424) and ADvocate2 (n = 427) trials who had moderate-to-severe AD and were randomized to receive subcutaneous lebrikizumab or placebo every 2 weeks.

Disclosures: This study was sponsored by Dermira, a wholly owned subsidiary of Eli Lilly and Company. Several authors declared receiving research grants or honoraria from, serving as employees and shareholders of, or having other ties with various sources, including Eli Lilly and Dermira.

Source: Yosipovitch G et al. Lebrikizumab improved itch and reduced the extent of itch interference on sleep in patients with moderate-to-severe atopic dermatitis: Two randomized, placebo-controlled, phase III trials. Br J Dermatol. 2023 (Nov 6). doi: 10.1093/bjd/ljad435

Key clinical point: Lebrikizumab monotherapy for 16 weeks significantly reduced itch and itch-associated sleep loss in patients with moderate-to-severe atopic dermatitis (AD).

Major finding: At 16 weeks, a significantly higher number of patients from the ADvocate1 and ADvocate2 trials treated with lebrikizumab vs placebo achieved a ≥ 3-point improvement in the Pruritus Numeric Rating Scale scores (ADvocate1 54.6% vs 19.2%; ADvocate2 49.4% vs 14.0%; both P < .001) and ≥ 1-point improvement in Sleep-Loss Scale scores (ADvocate1 64.1% vs 27.2%; ADvocate2 58.1% vs 21.7%; both P < .001).

Study details: Findings are from a study including patients from the ADvocate1 (n = 424) and ADvocate2 (n = 427) trials who had moderate-to-severe AD and were randomized to receive subcutaneous lebrikizumab or placebo every 2 weeks.

Disclosures: This study was sponsored by Dermira, a wholly owned subsidiary of Eli Lilly and Company. Several authors declared receiving research grants or honoraria from, serving as employees and shareholders of, or having other ties with various sources, including Eli Lilly and Dermira.

Source: Yosipovitch G et al. Lebrikizumab improved itch and reduced the extent of itch interference on sleep in patients with moderate-to-severe atopic dermatitis: Two randomized, placebo-controlled, phase III trials. Br J Dermatol. 2023 (Nov 6). doi: 10.1093/bjd/ljad435

Key clinical point: Lebrikizumab monotherapy for 16 weeks significantly reduced itch and itch-associated sleep loss in patients with moderate-to-severe atopic dermatitis (AD).

Major finding: At 16 weeks, a significantly higher number of patients from the ADvocate1 and ADvocate2 trials treated with lebrikizumab vs placebo achieved a ≥ 3-point improvement in the Pruritus Numeric Rating Scale scores (ADvocate1 54.6% vs 19.2%; ADvocate2 49.4% vs 14.0%; both P < .001) and ≥ 1-point improvement in Sleep-Loss Scale scores (ADvocate1 64.1% vs 27.2%; ADvocate2 58.1% vs 21.7%; both P < .001).

Study details: Findings are from a study including patients from the ADvocate1 (n = 424) and ADvocate2 (n = 427) trials who had moderate-to-severe AD and were randomized to receive subcutaneous lebrikizumab or placebo every 2 weeks.

Disclosures: This study was sponsored by Dermira, a wholly owned subsidiary of Eli Lilly and Company. Several authors declared receiving research grants or honoraria from, serving as employees and shareholders of, or having other ties with various sources, including Eli Lilly and Dermira.

Source: Yosipovitch G et al. Lebrikizumab improved itch and reduced the extent of itch interference on sleep in patients with moderate-to-severe atopic dermatitis: Two randomized, placebo-controlled, phase III trials. Br J Dermatol. 2023 (Nov 6). doi: 10.1093/bjd/ljad435