Malaysian Journal of Dermatology 2011B.pdf · am pleased to announce that under the stewardship of Dr Rohna Ridzwan, it ... Najeeb Ahmad Safda ... A retrospective analysis of tuberculosis

Volume 27 | Jul 2011 | ISSN: 1511-5356

www.dermatology.org.my

PERSATUAN DERMATOLOGI MALAYSIA DERMATOLOGICAL SOCIETY OF MALAYSIA

S P E C I A L E D I T I O N

DermatologyM a l a y s i a n J o u r n a l o f

J U R N A L D E R M A T O L O G I M A L A Y S I A

ABSTRACTSOF THE

35th MALAYSIANDERMATOLOGY CONGRESSO R A L & P O S T E R P R E S E N TAT I O N S

22nd - 23rd September 2011

EditorialThe Dermatological Society of Malaysia started from humble beginnings in 1974 when a group of Dermatologist gathered together and decided to form the Persatuan Dermatologi Malaysia (Dermatological Society of Malaysia in Malay language). Apart from having our Annual General Meeting and Annual Congress where the entire dermatologists all over the country comes together to share and fellowship together, we have our own journal called Jurnal Dermatologi Malaysia.

Originally it was a yearly publication with original articles and case reports. I am pleased to announce that under the stewardship of Dr Rohna Ridzwan, it is now published twice a year and is Index Linked.

In this age of electronic renaissance, we have made it available on line. Currently it is limited to only a few recent few issues, we will be including past issues as well.

This journal helps to disseminate dermatological research and activities in Malaysia to the dermatological fraternity around Malaysia, Asian region and the world. It is distributed not only to members but to the various Universities and academic institutions in Malaysia and to our colleagues in the Asian region namely Singapore, Thailand, Philippines, Indonesia and lately Vietnam.

I would like to encourage our budding colleagues in dermatology and other specialties to continue writing original articles; cases reports and submit it to us. Your contribution no matter how small will play an important role in enhancing Dermatology in Malaysia.

Dr. Koh Chuan KengPresident Dermatological Society Malaysia

35th Malaysian Dermatology Congress

Editor-in-Chief (Administrative)Rohna Ridzwan MRCPEmail:[email protected]

Editorial Offi ce Malaysian Dermatological Society Rumah Dermatology2-16, 16th fl oor, Blk 2(Remis)Pantai Panorama CondominiumJln 112 Off Kerinchi59200 Kuala LumpurMalaysia

Advertisement CommitteeIndependent team members

Executive StaffKoh Chuan Keng, MRCP | PresidentMardziah Alias, MMed | Past President Najeeb Ahmad Safda, MRCP | Vice PresidentHenry Foong Boon Bee, FRCP | SecretaryAgnes Heng Yoke Hui, MRCP | TreasurerMohd Nor, MRCPChan Lee Chin, MMedNoor Zalmy Azizan, MRCPRohna Ridzwan, MRCP

Editorial BoardGangaram Hemandas FRCP, Kuala LumpurHenry Foong Boon Bee FRCP, Ipoh PerakChan Lee Chin MMed, PenangAgnes Heng Yoke Hui MRCP, Ipoh Perak

Editor EmeritusSuraiya Hani Hussein FRCP, Kuala Lumpur

Founding EditorSteven Chow Kim Wing FRCPI

Malaysian Dermatological SocietyRumah Dermatolgy2-16, 16th fl oor, Blk 2(Remis)Pantai Panorama CondominiumJln 112 Off Kerinchi59200 Kuala LumpurMalaysia

Dermatological Society of Malaysia | Persatuan Dermatologi Malaysia

Published by Dermatological Society of Malaysia twice a year from year 2009(July and December issues)

Printed by Cetak Sri Jaya, Jalan Ambong Kanan 3, Kepong Baru, 52100 Kuala Lumpur, Malaysia

©Persatuan Dermatologi Malaysia. All rights reserved.No part of this journal can be reproduced without the written permission from editorial board

The inclusion of an advertisement in MJD is not to be construed or publicized as an endorsement or approval by the Society of any product, service, or company; nor may the advertiser represent that its advertising claims have been approved or endorsed by the Society.

Notice to Authors

The Malaysian Journal of Dermatology welcomes manuscripts on all aspects of cutaneous medicine and surgery in the form of original articles, research papers, case reports and correspondence. Contributions are accepted for publication on condition that they are submitted exclusively to the Malaysian Journal of Dermatology. The Publisher and Editors cannot be held responsible for errors or any consequences arising from the use of information contained in this journal; the views and opinions expressed do not necessarily refl ect those of the publisher and Editors, neither does the publication of advertisements constitute any endorsement by the publisher.

Manuscripts should be submitted via email:[email protected]

Questions regarding the Malaysian Journal of Dermatologycan be sent to me [email protected]

Contributions should be written for one of the following categories:

Case Report*A report of 400-600 words, illustrated by no more than three illustrations. This category offers a means for rapid communication about a single subject.

Clinical TrialAn article of 700-1200 words concerning a drug evaluation. This category provides rapid publications and is meant to be a succinct presentation with a minimum of graphs and tables.

Commentary*An editorial 700-1200 words in length with approximately fi ve references. The author may express his or her opinion without complete documentation.

Clinicopathological ChallengeA photographic essay that includes both clinical and pathological photographs in colour. The diagnosis and legends for the photographs should be listed after the references in the article. The article should be no more than 2-3 pages in length.

Correspondence*Letters to the editor and short notes. Contributions should not exceed 600 words, two fi gures, and 10 references.

Dermatological Surgery An article relating to the surgical aspects of treatment. Article types may include Review, Report or Case Report Format.

Original ArticleAn original article including, whenever possible, an Introduction, Materials and Methods, Results, Comment, and References. A Structured Abstract of not more than 240 words must be included. It should consist of four paragraphs, labelled Background, Methods, Results, and Conclusions. It should describe the problem studies, how the study was performed, the main results, and what the author(s) concluded from the results.

ReviewBy invitation only. A major didactic article that clarifi es and summarizes the existing knowledge in a particular fi eld. It should not be an exhaustive review of the literature, and references should not exceed 100 in number. Tables, diagrams, and selected fi gures are often helpful. The length is left to the judgment of the author, although it generally should not exceed 5000 words. Topics may include updates in clinically relevant basic science and cutaneous biology.

*No abstract required

Manuscripts should include a title page bearing the title of the paper, the author(s)’ name(s), degrees, and affi liation(s), the category of the article, the number of fi gures and tables, and three key words for indexing purposes. The name and full postal address (including a street address), phone and fax numbers and an email address of the corresponding author who will be responsible for reading the proofs must also be given on the title page. The author(s) must also declare any affi liation or signifi cant fi nancial involvement in any organizations or entity with a direct fi nancial interest in the subject matter or materials discussed in the manuscript on this page.

All measurements should be according to the metric system. If confusion could result, please include other measurement systems in parentheses.

Refer to patients by number or letters; names or initials should not be used.

References must be listed in the order in which they appear in the manuscript. References from journals should include: (1) name(s) followed by the initials of the author(s), up to four authors: if more than four authors, include the fi rst three authors followed by et al.; (2) title of paper; (3) title of the journal as abbreviated in the Index Medicus; (4) year of publication; (5) volume number; (6) fi rst and fi nal page numbers of the article.

For example:Ambrose D, Gangaram HB, Hussein SH. Sporotrichosis: A Hospital Kuala Lumpur experience. M J Dermatol 2006;19:52-55.

References to books should include: (1) author(s) or editor(s); (2) chapter (if any) book titles; (3) edition, volume, etc.; (4) place of publication; (5) publisher; (6) year; (7) page(s) referred to.

For example: Foong HBB. Transcontinental Dermatology: Virtual Grand Rounds. In: Wootton R and Oakley A, editors. Teledermatology. London. Royal Society of Medicine 2002. p.127-134.

The author is responsible for the accuracy and completeness of all references; incomplete references may result in a delay to publication.

Tables should be typed, double-spaced with a heading, each on a separate sheet, and should only include essential information. Drawings, graphs, and formulas should be submitted on separate pages.

Send illustrations as tiff or jpeg fi les. In the case of photomicrographs, the stain type and original magnifi cation should be stated. Each fi gure should bear a reference number corresponding to a similar number in the text.

To minimise the publication time of your manuscript it is important that all electronic artwork is supplied to the Editorial Offi ce in the correct format and resolution.

DisclaimerThe Publisher and Editors cannot be held responsible for errors or any consequences arising from the use of information contained in this journal; the views and opinions expressed do not necessarily refl ect those of the publisher and Editors, neither does the publication of advertisements constitute any endorsement by the publisher and Editors of the products advertised.

GENERAL DERMATOLOGY

Darier’s disease: A review of the clinical features and management patternin Penang Hospital, MalaysiaTan WC, Chan LC

A 7 years retrospective review of skin cancers: A University Malayamedical experienceCh’ng CC, Lee YY, Wong SM et al

Review of idiopathic photodermatitis at dermatology tertiary centre,Hospital Kuala LumpurNorazirah Md Nor, Mazlin MB, Asmah J

Study between cutaneous disease severity and systemic disease severity inSLE (Systemic lupus erythematosus patients) Tarita Taib, Suganthi T, Roshidah B

Association between smoking and the severity of psoriasisAdawiyah Jamil, Asmah J

Metabolic syndrome amongst patients with psoriasis in a tertiarydermatology centre, MalaysiaLee YY, Lim SS, Lee CK et al

Demographic and clinical characteristics for infantile haemangiomain a tertiary centre in MalaysiaNg SY, Heah SS, Sabeera BKI

An unusual case of adult xanthogranulomaChia KY, Tey HL

Dermatophytic granuloma of face and scalp - a case reportNazelia Thibroni, Balakrishnan M

CUTANEOUS INFECTION

A retrospective analysis of tuberculosis screening by interferon-gammarelease assay at National Skin Centre, SingaporeHazel H Oon, Lim KS, Chong WS et al Prevalence of toe nail onychomycosis among diabetics at primary careLeelavathi M, Kharuddin NF, Azimah MN et al

Le prosy in paediatrics and increasing rate of contacts developing leprosy- 10 year surveyRangaigowder Muthulakshmi

Hypercalcaemia and Leprosy: A rare associationKartini F Rahim, Agnes H, Felix Yap BB

Disseminated Fusariosis in patient with ALL:A Case Report and Literature ReviewAng Tick Sheng

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THERAPEUTICS & INVESTIGATIONS IN DERMATOLOGY

A retrospective observational study of propanolol use in the treatmentof infantile haemangioma : A single centre experienceHeah SS, Ng SY, Leong KF et al Comparison of effi cacy and safety of two dosing of oral methotrexatein patients with moderate to severe plaque psoriasisChong YT, Tang JJ, Tan WC et al

Effi cacy and safety of sodium hypochlorite (bleach) baths in patientswith moderate to severe atopic dermatitis.Wong Su-ming, Ng TG, Roshidah B

Antibiotic sensitivity of Propionibacterium acnes isolated from patientswith acne vulgaris in Kuala Lumpur Hospital, MalaysiaTang Jyn Jong

Five years retrospective study of effectiveness of NBUVB in the treatmentof chronic plaque psoriasis in Hospital Tuanku Ja’afar SerembanKhor Yek Huan, Najeeb MS

Patch testing with different series: Retrospective study from Selayang Hospital, MalaysiaPeter Ch’ng Wee Bing, Rohna R

ADVERSE REACTIONS & EVENTS

Severe adverse cutaneous drug reactions:The 5 year Kuala Lumpur Hospital experienceTang MM, Gill P, Chang CC et al

Lipid lowering drugs induced adverse cutaneous drug reactionsLee Chew Kek, Lee YY, Roshidah B

Narrowband UVB-induced lichen planus pemphigoidesChan WMM, Joyce SSL, Colin Theng CT et al

Tattoo-induced pseudolymphomaHazel H Oon and Joyce SSL

QUALITY ISSUES IN DERMATOLOGY

Monitoring performance of specialists in conducting skin biopsy using Cumulative Sum (CUSUM) technique: results of a pilot study in Kuala Lumpur HospitalChang CC, Noor Addillah S, Ambrose DA et al

A clinical appraisal of adult psoriasis patients in Serdang Hospital Shalini Devi P, Quek SL, Siti Farah M et al

The impact of acne vulgaris on the quality of life in Sarawak, MalaysiaFelix Yap BB, Pubalan M, Chang CC et al

The impact of leprosy on quality of lifeMazlin MB, Norazirah MN, Leelavathi M et al

Opportunity for improvement in monitoring of dermatological patients by nurses Norhasmie Ramli, Kasmawati T, Noradiah J et al

Patients’ knowledge on skin disease and nursing careNoradiah Jalal, Rohna R, Raoul S

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35TH MALAYSIAN DERMATOLOGY CONGRESS

G E N E R A L D E R M AT O L O G Y

DARIER’S DISEASE: A REVIEW OF THE CLINICAL FEATURES AND MANAGEMENT PATTERN IN PENANG HOSPITAL, MALAYSIA

Tan WC, Chan LC Department of Dermatology, Pulau Pinang Hospital, Penang, Malaysia

ABSTRACT

Background Darier’s disease (DD) is a rare autosomal dominant genodermatosis, characterized by abnormal keratinization and acantholysis. Although the clinical and genetic features of this inherited skin disorder have been well studied in the Caucasian population, very little is known about the clinical spectrum of the disorder in Asian populations. This retrospective study aimed to characterize the demographic and clinical features of multi-ethnic Malaysian patients with DD.

MethodAll new cases of DD seen in Department of Dermatology, Hospital Pulau Pinang over the 25-year period 1986–2010 were retrieved. Diagnosis was based on clinical features and was confi rmed histopathologically in at least one of the family member. Details of the demographic and clinical data including treatment regimen were collected for analysis.

Results15 affected patients from 6 unrelated families (60% female; mean age of onset 15.1; 60% Chinese, 40% Malays) were studied, of whom 14 (93.3%) were predominantly seborrhoeic involvement and only 1 (6.7%) had fl exural predominant. Hand involvement was common (60%) which included 7 (46.7%) with nail changes, 6 (40.0%) with palmar pits and 4 (26.7%) patients had acrokeratosis verruciformis. Only 3 patients had oral mucosal involvement. No guttate leucoderma and hemorrhagic macules were noted in our cohort. Factors that exacerbate the disease in descending order of frequency were heat, sun exposure, infections and trauma. Neuropsychiatric abnormalities, including mental retardation, epilepsy and psychosis, have been observed in 4 (26.7%) patients. Nine (60%) patients were given systemic retinoid to control the disease.

ConclusionThe clinical profi les of our patients were generally comparable to other Asian published data except rarity of co-occurrence of guttate leucoderma. Our fi ndings add to the increasing bulk of Asian patient data valuable in the management of Darier’s disease.

Keywords: genodermatosis, guttate leucoderma, Malaysia


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A 7 YEARS RETROSPECTIVE REVIEW OF SKIN CANCERS:A UNIVERSITY MALAYA MEDICAL EXPERIENCE

Ch’ng CC1, Lee YY1, Wong SM1, Pailoor J2

1 Dermatology Unit, Department of Medicine, Faculty of Medicine, Universiti Malaya2 Department of Pathology, Faculty of Medicine, Universiti Malaya

ABSTRACT

BackgroundSkin cancer is ranked the ninth commonest cancer among male and tenth among female in Malaysia.

ObjectiveTo determine the pattern of skin cancers and demography of skin cancer sufferers in University Malaya Medical Centre (UMMC).

MethodsThis is a retrospective review of all histo-pathologically confi rmed skin cancers in UMMC from 2004 to 2010. Patients with incomplete or missing data were excluded.

ResultsA total of 155 patient records were reviewed. The commonest skin cancer was basal cell carcinoma (BCC) (44.5%), followed by squamous cell carcinoma (SCC) (27.1%) and malignant melanoma (MM) (11.6%). The other skin cancers included dermatofi brosarcoma protuberans and cutaneous lymphoma (5.2% each), extramammary Paget’s disease 3.2% and Kaposi sarcoma 2.6%. A majority (78%) of BCC was of nodulo-ulcerative subtype while 50% of MM was of acral lentiginous melanoma subtype. BCC had a signifi cantly higher number of patients from the older age group (>60 years old) compared to other skin cancers (p=0.003). SCC had signifi cantly more male patients than other skin cancers (p=0.006). With the exception of MM, a majority of skin cancers were found on the head and neck.

ConclusionsBCC was the commonest skin cancer followed by SCC and MM. Patients with BCC were older with a female preponderance and mainly located on the head and neck. MM was the least common of the three major skin cancers, but has the highest risk of metastasis and mortality.

Keywords: basal cell carcinoma, malignant melanoma, squamous cell carcinoma, Malaysia

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REVIEW OF IDIOPATHIC PHOTODERMATITIS AT DERMATOLOGYTERTIARY CENTRE, HOSPITAL KUALA LUMPUR

Norazirah Md Nor1, Mazlin Mohd Baseri1, Asmah Johar2

1 Dermatology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur2 Dermatology Department, Hospital Kuala Lumpur

ABSTRACT

IntroductionPhotodermatitis had become more common reason for referral to dermatology clinics. In Southeast Asia, research regarding idiopathic photodermatitis is not well established. Photo and photo-patch tests are commonly used diagnostic investigations to support this diagnosis.

ObjectiveTo describe the epidemiological and clinical features of idiopathic photodermatitis referred for photo and photo-patch tests.

MethodsThis retrospective study reviewed the clinical data of patients with idiopathic photodermatitis who were referred for photo and photo-patch tests from January 2009 to July 2011. Patients’ demographics, spectrum of clinical presentations, results of photo and photo-patch tests and clinical outcome were reviewed.

Results38 patients were included in the analysis. Majority of patients were males. The mean age was 47.2 years.55.3% were Malays, 26.3% Chinese and 18.4% Indians. Most patients have Fitzpatrick’s skin type IV. The commonest clinical presentations were polymorphic eruptions consisted of erythematous patches, papules and eczema at the sun-exposed areas. On average, the patients have had the cutaneous eruption for more than 1 year prior to the initial clinic visit.32 patients had photo test and 6 had photo and photo-patch tests. 56.3% had positive photo test and the lowest MED is 50mJ/cm2 in skin type IV. 20% had positive photo and photo-patch tests. Patients were treated with potent topical corticosteroid, physical sunblock and oral antihistamines which managed to control the disease severity.

ConclusionMost patients with idiopathic photodermatitis referred for photo test were middle-aged Malay males with skin type IV. The commonest cutaneous presentations were polymorphic eruptions at the sun exposed sites.

Keywords: Phototest, idiopathic photodermatitis, Kuala Lumpur


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CORRELATION STUDY BETWEEN CUTANEOUS DISEASE SEVERITYAND SYSTEMIC DISEASE SEVERITY IN SLE (SYSTEMIC LUPUS ERYTHEMATOSUS) PATIENTS

T.Taib1, Thevarajah S2, R. Baba2 1 Dermatology Unit. Medical Dept., Faculty of Medicine and Health Science, UPM2 Department of Dermatolgy, Hospital Kuala Lumpur

ABSTRACT

IntroductionSkin is the second most commonly affected organ in SLE. Lupus-specifi c cutaneous LE(CLE) is classifi ed according to Gilliam Classifi cation into acute CLE (ACLE), subacute CLE(SCLE), chronic CLE(CCLE). CLASI (CLE Disease Activity and Severity Index) is an outcome measures to asses cutaneous activity

ObjectivesTo study the correlation between cutaneous disease severity and severity of systemic disease using SLEDAI (SLE Disease Severity Index) and SLICC / ACR (Systemic Lupus International Collaborating Clinics) outcome measures.

MethodsStudy design: Cross-sectional A total of 71 patients were recruited from Dermatology and Rheumatology Clinic from Hospital Kuala Lumpur, Hospital Selayang and Pusat Perubatan UKM. Study period was from December 2009 to August 2010. Study data were obtained from clinical history, examination, investigations and medical record review.

ResultsThe mean CLASI activity/damage scores in patients with ACLE, SCLE and CCLE were 11.8 / 8.1, 22.6 / 17.2 and 21.1 / 22.1 respectively. The mean SLEDAI/SLICC scores in similar group of patients were 12.3 / 2.1, 6.8 / 1.6, 13.2 / 1.7 respectively. The cutaneous disease activity in patients with SCLE was found to be inversely correlated to systemic disease activity. The cutaneous damage in patients with CCLE was positively correlated with systemic disease damage

ConclusionsPatients with SCLE, despite having high cutaneous disease activity, had mild systemic disease. Patients with CCLE whom had high cutaneous damage scores were more likely to have higher systemic damage, hence more thorough investigations to seek other organs damage, should be offered.

Keywords: Malaysia, CLASI activity, SLEDAI / SLICC scores

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ASSOCIATION BETWEEN SMOKING AND THE SEVERITY OF PSORIASIS

Adawiyah Jamil1, Asmah Johar2

1 Dermatology Unit, Department of Medicine,Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur2 Dermatology Department, Hospital Kuala Lumpur

ABSTRACT

IntroductionSmoking is a risk factor for development of psoriasis. The severity of psoriasis has also been associated with smoking. Smoking may be an important modifi able factor in psoriasis treatment. Reduction or cessation of smoking in psoriasis patients is relevant as psoriasis is also associated with cardiovascular disease.

ObjectivesThis study aims to determine the association between smoking and severity of psoriasis, and to investigate the frequency of concomitant cardiovascular risk factors in our psoriasis patients.

MethodA 6-month prospective, controlled study. Consecutive patients with chronic plaque psoriasis attending Dermatology Clinic, Hospital Kuala Lumpur were screened. Smokers were identifi ed, and age, gender and ethnic matched non-smokers were recruited. Patients were evaluated for Psoriasis Severity Index (PASI) and body surface area (BSA) affected by psoriasis.

ResultsA total of 89 chronic plaque psoriasis patients were screened. Twenty four smokers and 24 matched non-smokers were included in the study. There were no signifi cant differences in the presence of medical co-morbidities, blood pressure, body mass index (BMI), age of psoriasis onset and duration of disease in both groups. The mean age patients started smoking was 20.2±5.6 years, the mean duration of smoking was 16.3±11.1 years, the number of cigarette per day 11.9±6.1 sticks and the number of cigarette pack years was 10.7±9.2. BSA affected by psoriasis and PASI score were signifi cantly higher in the subjects who smoked compared to the non smokers.

ConclusionSmoking is associated with more severe psoriasis in terms of BSA and PASI. Cardiovascular risk factors are common in psoriasis patients. These patients (smokers and non-smokers) require interventions to reduce their cardiovascular risks.

Keywords: cardiovascular risk, PASI score, Malaysia


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METABOLIC SYNDROME AMONGST PATIENTS WITH PSORIASIS INA TERTIARY DERMATOLOGY CENTRE, MALAYSIA

YY Lee, SS Lim, CK Lee, ATB Tan, V Ananda, R Pendek, SP ChanDepartment of Medicine, University of Malaya

ABSTRACT

BackgroundPsoriasis has been shown to be associated with a higher risk of metabolic syndrome and cardiovascular disease.

ObjectiveTo investigate the prevalence of metabolic syndrome among patients with psoriasis and study the association between psoriasis and cardiovascular risk factors.

MethodsThis was a hospital based case-control study conducted at the Dermatology Clinic, University Malaya Medical Centre (UMMC) from May 2010 to March 2011. A total of 131 adult patients with psoriasis and 129 age-, gender- and race-matched controls were recruited. All subjects answered a standardised cardiovascular risks questionnaire and had anthropometric measurements recorded. Laboratory investigations included fasting glucose / lipid profi le, erythrocyte sedimentation rate (ESR), c-reactive protein (CRP), urine microalbumin:creatinine ratio and an electrocardiogram. The diagnosis of metabolic syndrome was made using the harmonised criteria for metabolic syndrome in South East Asians. Statistical analysis was performed using statistical processing software (SPSS-17).

ResultsMetabolic syndrome was signifi cantly higher among patients with psoriasis (64.9% versus 51.9%) (p = 0.034). The presence of metabolic syndrome was associated with low high density lipoprotein (HDL) (p=0.002) and high triglyceride (TG) levels (p = 0.014). The prevalence of diabetes mellitus was also signifi cantly higher among patients with psoriasis (46.6% versus 27.1%) (p = 0.001). Hypertension, ischaemic heart disease, low density lipoprotein (LDL) levels, smoking and obesity were not signifi cantly higher among patients with psoriasis.

ConclusionOur results demonstrate an association between psoriasis and metabolic syndrome which was primarily due to diabetes mellitus and dyslipidaemia.

Keywords: diabetes mellitus, dyslipidaemia, dermatology clinic

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DEMOGRAPHIC AND CLINICAL CHARACTERISTICS FOR INFANTILE HAEMANGIOMA IN A TERTIARY CENTRE IN MALAYSIA

SY Ng, SS Heah, Sabeera BKIInstitut Pediatrik, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

ABSTRACT

IntroductionInfantile haemangioma is the most common tumor in infancy. They are extremely heterogenous clinically. Established risk factors for infantile haemangioma include female sex, white ethnicity, prematurity, low birth weight and multiple gestation. There is a lack of demographic studies in the Asian population especially in the Malay ethnic group.

ObjectiveTo describe the demographics and clinical characteristics of infantile haemangioma in a tertiary centre in Malaysia. To describe associated complications and the need for therapeutic intervention. To determine whether there is any difference in demographics and clinical characteristics of infantile hemangiomas in a Malaysian population comprising predominantly Malay ethnic group with published reports of Western population.

DesignRetrospective review of patients with infantile haemangioma referred to the Pediatric Dermatology unit, Hospital Kuala Lumpur between January 2009 and May 2011.

Main Outcome Measures:Demographic and clinical characteristics were summarized and compared with data from previous studies. The study included 50 patients (38 females and 12 males) with a mean age of 6.23 months (range 0.1 to 16 months) at presentation. 11(22%) patients were premature. The mean age of onset was 20 days (range 0 to 5 months). 18(37%) patients had a premonitory mark at birth.

Of 62 hemangiomas in 50 patients, 45(72.5%) were localized, 5(8.1%) were segmental, 11(17.7%) indeterminate and 1(1.6%) multifocal. The most frequent location of the haemangiomas was in the face with 29(46.8%) lesions, followed by 10(16.1%) lesions in the head and neck, 10(16.1%) lesions in the extremities, 8(12.9%) lesions in the trunk and 5(8.1%) in the perineum. Complications that occurred included ulceration in 8(16%) patients, threat to vision in 7(14%), infection in 2 (4%) and bleeding in 6(12%) patients.

Of the 50 patients, 24(48%) patients required interventions. These interventions included propranolol only in 12(24%) patients, prednisolone only in 4(8%), both propranolol and prednisolone in 5(10%), wound care in 2(4%) and pulse dye laser in 1(2%).

ConclusionThe demographics and clinical characteristics of infantile haemangiomas in Malaysia are similar to published reports.

Keywords: propranolol, prednisolone, pulse dye laser


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AN UNUSUAL CASE OF ADULT XANTHOGRANULOMA

KY Chia1, Tey HL2

1 Department of General Medicine, Tan Tock Seng Hospital, Singapore2 Department of Dermatology, National Skin Centre, Singapore

ABSTRACT

IntroductionXanthogranuloma is a rare, non-Langerhans cell histiocytosis that most commonly presents in infancy or early childhood. It is rare in adults, and when present are usually solitary. We present an unusual case of adult xanthogranuloma with multiple lesions.

Case summaryOur patient is a 66 year-old lady with a 10-year history of persistent lesions over her eyelids and cheeks. Physical examination revealed confl uent yellowish-red plaques and nodules over the periorbital regions as well as yellowish plaques over both sides of the neck. Histological analysis revealed a pattern of diffuse dermatitis in the dermis consisting of foamy histiocytes admixed with a few Touton-type giant cells. She had mild thrombocytopenia but a bone marrow trephine and fl ow cytometry investigations were normal. Due to the chronic and disfi guring nature of the lesions, intralesional triamcinolone was given with moderate effi cacy.

ConclusionDifferentiating between adult xanthogranuloma and other xanthomatous disorders has therapeutic implications and requires correlation with the epidemiological, clinical, biochemical and histopathological features. Adult xanthogranuloma

Keywords: histiocytosis, plaques and nodules, Singapore

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DERMATOPHYTIC GRANULOMA OF FACE AND SCALP

Nazelia Thibroni, M BalakrisnanHospital Sultanah Bahiyah, Alor Setar, Kedah

ABSTRACT

IntroductionDermatophytic granuloma is uncommonly seen on the leg as Majocchi’s granuloma and in scalp as kerion type of tinea capitis, but it is rare to occur on the face.

Case summaryA 9yrs old Malay girl presented with itchy skin lesions over body, face and scalp since 1yr.On examination, multiple dry scaly annular patches with well defi ned border were seen over trunk & limbs. Multiple hyperkeratotic and verrucous papules and plaques were seen over face and scalp. Patches of scarring alopecia of scalp were also seen. Left middle fi nger nail showed dystrophic changes. Oral mucosa showed no lesions.

Scales from body skin scrapping with KOH preparation showed multiple septate hyphae. Culture of scales from skin lesion and hyperkeratotic lesion over face grown Microsporum canis. Biopsy of the granulomatous lesion over the face and skin lesion showed multiple hyphae on PAS staining confi rmed the dermatophytic granuloma of the face and scalp and tinea corporis over the trunk.

The girl was referred to Paediatric Department to assess immunology status. The results were inconclusive. According to Paediatrician, the child appears to be immunocompetent.Injection Itraconazole 80 mg bd was given as in-patient. Within a week, the lesion over face and scalp almost resolved and the lesions over trunk and limbs totally cleared. Patient was discharged and asked to continue syrup Itraconazole 80mg bd. By 3rd week, scalp lesions almost cleared with few scarring alopecia patches.

ConclusionThis case has been reported for the rare presentation of verrucous dermatophytic granuloma of face and scalp in immunocompetent child.

Keywords: microsporum canis, immunocompetent, Malaysia


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C U TA N E O U S I N F E C T I O N

A RETROSPECTIVE ANALYSIS OF TUBERCULOSIS SCREENING BY INTERFERON-GAMMA RELEASE ASSAY AT NATIONAL SKIN CENTRE, SINGAPORE

Hazel H Oon1, Lim KS2, Chong WS1, Colin CT Theng1, Tan HH1, Benson Yeo1

1 National Skin Centre, 1 Mandalay Road, Singapore 3082052 Dermatology Associates, 290 Orchard Road, #15-05/06, Singapore 238859

ABSTRACT

ObjectiveThe T-Spot.TB is an interferon-gamma release assay (IGRA) which is increasingly used in dermatology as a screen for latent TB before initiation of biologics and for confi rming diagnosis of tuberculids. This study aims to explore its concordance with tuberculin skin tests (TST) and eventual diagnosis of latent TB.

Study designThis is a retrospective review of all patients in NSC who had a TB T-spot test done between 2008 and 2010. We looked at the dermatological diagnosis, results of T-Spot.TB and TST, chest radiograph fi ndings, tuberculosis status and treatment of TB.

Result51 TB T spot tests were ordered in National Skin Centre between 1 January 2008 and 9 June 2010. 31 tests were for patients with psoriasis with the intention of initiating biologics; 5 were for patients with suspected tuberculids and tuberculosis verrucosa cutis; 3 were done as part of work-up for possible erythema nodosum; 3 tests were part of screening for latent TB in hospital staff and 9 tests were performed for other reasons.

There were a total of 13 patients eventually diagnosed with latent or active TB infection. All of whom had a positive T-Spot.TB result except for 1 patient with an indeterminate result. On the other hand, out of these 13 patients, only 5 showed a positive TST, 2 had negative TST and 4 patients did not have a TST done.

There were a total of 14 positive T-Spot.TB results for which 12 eventually received antituberculous therapy. All patients with erythema induratum had a positive test result. Six patients’ T-Spot.TB tests were borderline, indeterminate or could not be interpreted due to insuffi cient lymphocyte yield.

ConclusionOur study shows the utility of T-Spot.TB test in various conditions seen in dermatology clinics in a local setting. We suggest that the T-spot test can supplant the tuberculin skin test in screening latent TB for psoriasis patients for whom biologics are intended and in erythema induratum. The high incidence of borderline and indeterminate results should not be ignored. This should be taken into account when interpreting the IGRA especially if patients are on immunosuppressive therapy.

Keywords: T-Spot.TB, TST, erythema induratum, tuberculid, erythema nodosum

11



PREVALENCE OF TOE NAIL ONYCHOMYCOSIS AMONG DIABETICSAT PRIMARY CARE

Leelavathi M1, Kharuddin NF1, MN Azimah1, Tzar MN2

1 Department of Family Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Malaysia2 Department of Medical Microbiology and Immunology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Malaysia

ABSTRACT

ObjectiveThis study was done to determine the prevalence of onychomycosis among diabetics, identify common causative pathogens and associated factors.

MethodsA cross sectional study was done among type I and II diabetic patients attending the primary care facility of Universiti Kebangsaan Malaysia (UKM) from January to March 2011. A total of 151diabetic patients were included. Samples were taken from clinically abnormal nail and from the fi rst right toe nail in the absence of nail abnormality.

ResultsA total of 151 nail samples were cultured of which 81.5% (n=123) were positive for fungal elements. Female constituted 51.7% (n=78) while males 48.3% (n=73) with a mean age of 60.68 ± 9.10. About 58.9% (n=89) had clinically abnormal nail. The most common fungal element isolated was non-dermatophytes moulds (39.7%, n=60), followed by yeast (20.5%, n=31) and dermatophytes (0.7%, n=1). Aspergillus spp. was the commonest (12.6%, n=19) non-dermatophytes mould isolated. A positive correlation was found between onychomycosis and age (p=0.011) and clinically abnormal nail (p< 0.05). However, there was no signifi cant correlation with gender, ethnic group, duration of diabetes, types of diabetes or HbA1c level.

ConclusionThe prevalence of onychomycosis among diabetics is high. Diabetics above age 61 years with clinically abnormal nails should be screened for onychomycosis.

Keywords: dermatophytid, moulds, Malaysia


12


HANSEN’S DISEASE IN PAEDIATRIC AND INCREASING RATE OF CONTACTS DEVELOPING LEPROSY - A 10 YEAR REVIEW

Rangaigowder MuthulakshimiDermatology Department, Hospital Raja Perempuan Zainab11, Kota Bharu, Kelantan

ABSTRACT

IntroductionHansen’s disease is chronic systemic and granulomatous disease by Mycobacterium Leprae. It principally affects peripheral nerves, skin and mucous membrane. Lepromatous leprosy harbors large numbers of bacilli.

ObjectiveTo review the effectiveness of leprosy contact tracing programme in Kelantan.

MethodsThis is a 10 year retrospective analytical study of new leprosy cases in Kelantan, Malaysia from 2001 to 2010. Routine contact tracing plus 2 intensive home visit surveys were performed in year 2002 and 2006.

Results108 and 87 home visits were made in 2002 and 2006 respectively. 638 adults and 416 child contacts were examined in 2002 while 512 adults and 403 children were examined in 2006. 90% contact tracing were achieved.

127 new leprosy cases were detected from 2001 to 2010 of which 108 (87%) were adults and 16 (13%) children. In adults 63 (58%) and 45 (42%) had multibacillary and paucibacillary respectively. 4 and 12 children had multibacillary and paucibacillary leprosy. 90% of the new leprosy in children were detected through contact tracing. One family had 5 children developed leprosy from contact to index.

2 children had ulnar palsy and another child had type 1 MDT reaction.

ConclusionIncreased risk of contacts getting leprosy in paediatric patients.More number of paucibacillary indicates increased immunity to leprosy in children.Early detection and treatment in children to reduce deformity by yearly contact tracing.Counseling to all leprosy patients and surveillance, insist regular slit skin smear and contact tracing.

Keywords: ulnar palsy, MDT reaction, Malaysia

13



HYPERCALCAEMIA AND LEPROSY: A RARE ASSOCIATION

Rahim KF, Heng A, Yap FBB1 Dept. Of Dermatology, Hospital Kuala Lumpur2 Dept of Dermatology, Hospital Raja Permaisuri Bainun, Ipoh

ABSTRACT

Case summaryA 62 year old gentleman was admitted to medical ward for 2 months history of generalized body weakness, anorexia, vague abdominal pain, fatigue and multiple erythematous, non-pruritic, scaly patches and plaques scattered throughout his body associated with nasal stuffi ness. These lesions were hypoaesthetic.

Blood investigations revealed a high corrected calcium level at 3.24 mmol/L which explained his acute medical complaints. Slit skin smear revealed Bacteriological Index (BI) of 1.2 and Morphological Index (MI) of 3.9. Skin biopsy confi rmed the diagnosis of Borderline Lepromatous Leprosy.

Institution of systemic steroids, vigorous intravenous fl uid infusion and the implementation of multi-drug therapy for his leprosy resulted in a relatively swift decrease in reduction of calcium level.

ConclusionThis case report highlights the rare but important association of hypercalcaemia with leprosy. However, other granulomatous diseases such as sarcoidosis and tuberculosis have higher association with hypercalcaemia.

Keywords: plaques, granulomatous disease, Malaysia


14


DISSEMINATED FUSARIOSIS IN PATIENT WITH ACUTE LYMPHOBLASTIC LEUKAEMIA: A CARE REPORT AND LITERATURE REVIEW

Ang Tick ShengDepartment of Dermatology, Hospital Raja Permaisuri Bainun

ABSTRACT

IntroductionFusarium spp is an opportunistic fungal pathogen which is being isolated with increasing frequency as a pathogen in oncohematologic patients who are immunocompromised, particularly those who are neutropenic.

Case summaryWe herein report a case of a 21 years old lady with refractory Acute Lymphoblastic Leukaemia on chemotherapy who presented to us with multiple erythematous plaques with central necrosis for past 10 days involving the bilateral upper limb and lower limb. Diagnosis of disseminated fusariosis was made by positive blood cultures and skin biopsy for fungal culture to Fusarium spp. She was treated with intravenous voriconazole for one month. The patient was in complete remission with no signs of clinical activity of the Fusarium infection.

ConclusionThere is a need to exclude other causes other than skin metastasis for cutaneous plaques occurring in leukaemic patients.

Keywords: fungaemia, plaques, Malaysia

15


T H E R A P E U T I C S & I N V E S T I G AT I O N S I N D E R M AT O L O G Y

A RETROSPECTIVE OBSERVATIONAL STUDY OF PROPRANOLOL USE IN TREATMENT OF INFANTILE HAEMANGIOMA: A SINGLE CENTRE EXPERIENCE

Heah SS, Ng SY, Leong KF, Sabeera BegumPaediatric Institute, Kuala Lumpur Hospital

ABSTRACT

IntroductionInfantile haemangioma(IH) is a common benign vascular tumour which is characterised by rapid proliferation in early infancy period followed by slow involution for years. The initial rapid growth and the location of haemangioma may result in signifi cant morbidity. The introduction of Oral Propranolol for the treatment of IH in recent years has seen many promising results though with potential risks.

ObjectiveTo review the demography, clinical pattern, management and outcome of patients with IH treated with propranolol in a paediatric dermatology referral centre.

MethodologyA retrospective observational study of medical records of patients with IH treated with oral propranolol (maximum dose 2mg/kg/day) from May 2009 to May 2011 in Paediatric Institute, Kuala Lumpur Hospital.

ResultsA total of 17 patients (14 girls, 3 boys) were studied. They were 12 Malays (70.6%), 2 Chinese(11.8%), 2 Indians(11.8%) and 1 Indonesian(5.9%).Mostly term babies (88%). The age of presentation is from birth to 2 months old. The location of haemangiomas involve periocular (35.3%), perioral (17.6%), facial segmental (17.6%), nasal (5.9%), multiple (17.6%) and spinal(5.9%). They were started on Propranolol at a mean age of 5 months old except one at 2 years old. Five patients had concurrent adjunctive therapies. 70.6% had signifi cant reduction of the size and colour of haemangiomas, 11.8% not signifi cant, 11.8% unclear, and one patient defaulted follow up. Some patients developed wheezing episodes (29.4%), diarrhoea (17.6%), regurgitation (5.9%); but no serious consequences.

ConclusionLow dose oral propranolol is a safe and effective treatment with minor side effects from our experience.

Keywords: vascular tumour, Malaysia


16


COMPARISON OF EFFICACY AND SAFETY OF TWO DOSING REGIMENS OF ORAL METHOTREXATE IN PATIENTS WITH MODERATE TO SEVERE PLAQUE PSORIASIS

YT Chong1, JJ Tang1, WC Tan2, LC Chan2, KE Tey3, SE Choon3

1 Hospital Kuala Lumpur, 2 Hospital Pulau Pinang, 3 Hospital Sultanah Aminah, Johor Bahru

ABSTRACT

BackgroundMethotrexate has been widely used as an effective systemic therapy for psoriasis. Retrospective data showed effi cacy rate of 70-80% but recent RCTs using PASI 75 as primary endpoint showed wide variations in effi cacy. Different dosing regimens for methotrexate may explain this variation.

ObjectivesTo compare the effi cacy and tolerability of two different dosing regimes of oral methotrexate in patients with moderate to severe plaque psoriasis.

MethodsA prospective comparative study was conducted from October 2009 to June 2010. Patients with moderate-to-severe plaque psoriasis were randomized to receive either a ‘step-up dose’ regime (starting dose 7.5mg) or a ‘step-down dose’ regime (starting dose 20mg) of oral methotrexate for 16 weeks. The primary effi cacy endpoint was PASI 75. Tolerability and safety were assessed.

ResultsForty patients received oral methotrexate with equal numbers in each arm. After 16-week, 55% (11) of patients in ‘step-up dose’ group and 65% (13) of patients in ‘step-down dose’ group achieved PASI 75 (p > 0.05). Signifi cantly higher number of patients in ‘step-down dose’ group achieved PASI 75 at week 4 and week 8 (p < 0.05) compared to ‘step-up dose’ group. One patients from ‘step-down dose’ group discontinued study prematurely due to adverse effect but no signifi cant difference in rate of adverse events was noted.

ConclusionThere was no signifi cant difference in effi cacy between both regimes at the end of 16 weeks but signifi cant effi cacy was observed in patients on ‘step-down dose’ regime as early as week 4. The side effect profi le and tolerability were similar.

Keywords: PASI chronic skin disease, Malaysia

17



EFFICACY AND SAFETY OF SODIUM HYPOCHLORITE (BLEACH) BATHSIN PATIENTS WITH MODERATE TO SEVERE ATOPIC DERMATITIS

Wong Su-ming, Ng Ting Guan, Roshidah BabaDermatology Department, Hospital Kuala Lumpur

ABSTRACT

BackgroundIndividuals with AD have an increased susceptibility to colonization with Staphylococcus aureus (S.aureus), contributing to the exacerbation of the disease. Sodium hypochlorite (bleach) has both in vitro and in vivo antimicrobial activity against S.aureus.

ObjectivesTo evaluate the effi cacy and safety of diluted sodium hypochlorite (bleach) baths in patients with moderate to severe atopic dermatitis in our Malaysian population.

MethodsThis was a prospective randomized, investigator-blinded, placebo-controlled study. Patients were randomly assigned through computer generated simple randomized numbers to treatment (bleach baths) or placebo (distilled water baths). Patients were instructed to soak in the baths neck down for 10 minutes, twice a week for 2 months. The effi cacy outcome measures were the Eczema Area and Severity Index (EASI) score, percentage body surface area involved, quantitative S.aureus counts and patient’s assessment of overall response (including itch scores). Safety outcomes were also assessed.

ResultsA total of 36 patients completed the study. EASI scores and body surface area showed signifi cant improvement between treatment and placebo groups at 2 months (p=0.02, p=0.02). At baseline, 88% of patients yielded S.aureus from lesional skin. Although most cultures in the treatment group continued to yield S.aureus, there was a reduction in the density over time, although not statistically signifi cant. Five patients reported burning/stinging and dry skin in the treatment arm which did not differ signifi cantly compared to placebo.

ConclusionDiluted sodium hypochlorite baths as an adjunctive treatment decreased the clinical severity of patients with moderate to severe atopic dermatitis and may reduce S.aureus density. This treatment was well tolerated with minimal adverse effects.

Keywords: Staphylococcus aureus, EASI score Malaysia


18


ANTIBIOTIC SENSITIVITY OF PROPIONIBACTERIUM ACNES ISOLATED FROM PATIENTS WITH ACNE VULGARIS IN KUALA LUMPUR HOSPITAL, MALAYSIA

Dr Tang Jyh JongHospital Raja Permaisuri Bainun, Ipoh

ABSTRACT

BackgroundAntibiotic therapy directed against Propionibacterium acnes has been a mainstay of treatment in acne vulgaris for more than 40 years. Prolonged antibiotic usage has been associated with emergence of antibiotic-resistant P. acnes and is linked to treatment failure. Little work has been done in Malaysia on drug resistance in P. acnes and there is no surveillance data on this aspect to guide the clinical decision.

Objective This study aims to evaluate antibiotic sensitivity of P. acnes isolated from patients with acne vulgaris in Kuala Lumpur Hospital, Malaysia.

MethodsThis is a non interventional, single centered, cross-sectional hospital-based survey of antibiotic sensitivity of P. acnes isolated from patients with acne vulgaris in Kuala Lumpur Hospital from January 2010 to June 2010.

ResultsA total of 100 patients were recruited in our study. P. acnes was isolated in 53% of patients and 11% had gram negative organism. Antibiotic resistant P. acnes was found in 15.1% of positive isolates. Clindamycin resistance was most common (15.1%) followed by erythromycin (7.5%), doxycycline (5.7%), tetracycline (1.9%) and minocycline (0%). Isolates of antibiotic resistant P. acnes was signifi cantly higher in patients treated with antibiotics within the last 6 months (29%) as compared with non antibiotic treated patients (0%) (p<0.05).The mean duration of prior antibiotic treatment was signifi cantly longer in the group of antibiotic resistant P. acnes as compared with antibiotic sensitive P. acnes (17.13 weeks vs 5.74 weeks, p<0.05).

ConclusionAntibiotic resistant P. acnes is present locally with clindamycin and erythromycin conferring the highest resistance. Longer duration of antibiotic treatment predisposes to antibiotic resistant P. acnes and may also induce emergence of gram negative organisms. Strategies to reduce antibiotic resistance should be emphasized when prescribing antibiotic for acne vulgaris in order to achieve optimal therapeutic results while reducing the potential for antibiotic resistance.

Keywords: Clindamycin, erythromycin, doxycyline, Malaysia

19



5 YEARS RETROSPECTIVE STUDY OF EFFECTIVENESS OF NBUVB INTHE TREATMENT OF CHRONIC PLAQUE PSORIASIS IN HOSPITALTUANKU JA’AFAR SEREMBAN

Khor Yek Huan, Najeeb MS

ABSTRACT

ObjectiveThe aim of the study is to determine the demographic data of local psoriasis patients treated with NBUVB, their responses and complication to the treatment, factors which affect the effectiveness of NBUVB; and duration of remission post treatment.

Material and MethodsA retrospective analysis of patients with chronic plaque psoriasis treated with NBUVB between January 2005 to December 2009 was conducted at the dermatology clinic, Tuanku Ja’afar Seremban Hospital. Patients’ demographic data and clinical characteristics, concurrent topical treatment, responses to NBUVB, complications and recurrences were reviewed.

ResultsA total of 33 chronic plaque psoriasis patients treated with NBUVB were reviewed. There were 14 female patients and 19 male patients in the group. Their ages ranged from 27 to 78 years old (mean age = 51.8, sd = 12.7). 16 of them were Malays (Fitzpatrick skin phototype IV generally), 12 of them were Chinese (skin phototype III) and only 5 of them were Indians (skin phototype V and VI). The duration of disease before starting phototherapy ranged from 3 to 30 years (mean = 12.3, sd = 6.5). All patients had improvement after phototherapy where 9 of them achieved grade 4 response (complete fl attening of plaque), 12 had grade 3 response (complete fl attening except border of plaque), 11 had grade 2 response (partial fl attening, less scale and erythema) while 1 with grade 1 response(slightly less scale and erythema). Only 1 of the patients had adverse reaction from phototherapy with pruritus post phototherapy. Durations of remission of plaque in response to phototherapy ranges from 1 month to 60 months (mean = 10, sd = 12.9).

ConclusionNBUVB is a good treatment option for patients with chronic plaque psoriasis as most of the patients have some remission of plaques. It is safe and well tolerable with only 1 patient from our study had adverse reaction from the treatment.

Keywords: Phototherapy, Malaysia


20


PATCH TESTING WITH DIFFERENT ALLERGEN SERIES:RETROSPECTIVE STUDY FROM SELAYANG HOSPITAL, MALAYSIA

Peter Ch’ng, Rohna RHospital Selayang, Selangor, Malaysia

ABSTRACT

BackgroundMajority of the hospitals in Malaysia has limited allergen series for patch testing. Since January 2011, Department of Dermatology in Hospital Selayang has extended its number of allergen series available for testing.

ObjectivesThe aim of this study was to evaluate whether other series besides the European baseline series (EBS) deserve to be tested on suspected patient with contact dermatitis.

Methodology Patch test results of patients visiting dermatology clinic in Hospital Selayang from January 2001 to June 2011 were reviewed retrospectively.

Results Out of 129 patients who were patch tested, 98(76%) patients had positive patch test, 30(23.3%) patients had negative patch test and 1(0.7%) patient had ‘Angry back’ reaction. The most commonly positive allergens were Nickel sulfate 45(34.9%), Cobalt chloride 21(16.3%), Potassium dichromate 15(11.6%) and Balsam Peru 15(11.6%). None of the patient had positive patch test to Mercaptobenzothiazole, Sesquiterpene lactone mix, Fragrance mix II and Lyral in the (EBS). The number of patient that will be missed if certain series are not tested were Textile Colours & Finish (TF) (n=4/7, 57.1%), Plastic & Glues (PG) (n=4/19, 21.1%), Hairdressing (n=1/5, 20%), Cosmetic(n=2/12, 16.7%), Rubber Additives (n=12/77, 15.6%), Medicament (n=1/9, 11.1%), Plant (n=0/5, 0%), Cutaneous Adverse Drug Reaction(n=0/3, 0%) and Leg Ulcer (n=0/1, 0%).

Conclusion The absence of positive patch test to Mercaptobenzothiazole, Sesquiterpene lactone mix, Fragrance mix II and Lyral does not support inclusion in the EBS in our region. Additional series especially TF and PG are important series to be tested in suspected patient.

Keywords: contact dermatitis, plastic and glues, textile colour and fi nish, Malaysia

21


A D V E R S E R E A C T I O N S & E V E N T S

SEVERE ADVERSE CUTANEOUS DRUG REACTIONS:THE 5-YEAR HOSPITAL KUALA LUMPUR EXPERIENCE

MM Tang, P Gill, CC Chang, A JoharDepartment of Dermatology, Hospital Kuala Lumpur

ABSTRACT

IntroductionStevens–Johnson syndrome (SJS), Steven-Johnson syndrome-toxic epidermal necrolysis overlap syndrome (SJS-TEN overlap), toxic epidermal necrolysis (TEN) and drug-induced hypersensitivity syndrome (DHS) are well known severe adverse cutaneous drug reactions (SACDRs). All clinicians are responsible for the diagnosis and management of SACDR.

ObjectiveTo retrospectively review the clinical patterns, management strategies and outcome of 134 patients with severe adverse cutaneous drug reactions managed at the Department of Dermatology Hospital Kuala Lumpur between 2006 and 2010.

ResultsThe mean age of presentation was 44.8 years (13-83). The male: female ratio was 1:1. There were 68 cases (50.7%) of SJS, 10 cases (7.5%) SJS-TEN overlap, 32 cases (23.9%) TEN and 24 cases (17.9%) DHS. The fi ve commonest drugs associated with SACDRs were allopurinol (26.9%), carbamazepine (13.4%), phenytoin (9.7%), non-steroidal anti-infl ammatory drugs (11.2%) and co-trimoxazole (7.5%). The mean duration of drug exposure before the onset of reaction was 2.8 weeks. A hundred and thirty patients (97%) were managed as in-patient. The mean duration of in-patient stay was 12.4 days. All identifi ed culprit drugs were withheld. Systemic corticosteroids was given to 96% cases of DHS with mean duration of 9.7 weeks; 52.9% of SJS with mean duration of 2.8 weeks; 60% of SJS-TEN overlap with mean duration of 2.3 weeks; and 62.5% of TEN with mean duration of 3.3 weeks. Thirteen patients (42%) with TEN were treated with intravenous immunoglobulin. Eight patients (6%) died, of which 7 were TEN and one DHS.

ConclusionSACDRs are life-threatening emergencies which not only results in signifi cant morbidity and mortality; but also potentially increases the health care cost and burden. Clinicians should recognize high risk medications and prescribe them with great caution.

Keywords: allopurinol, carbamazepine, phenytoin, co-trimoxazole, Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis, Drug Hypersensitivity, Malaysia


22


LIPID LOWERING DRUGS INDUCED ADVERSE CUTANEOUSDRUG REACTIONS

Chew Kek Lee1,2, Yin Yin Lee2, Baba Roshidah1

1 Department of Dermatology, Hospital Kuala Lumpur2 Department of Medicine, Universiti Malaya, Malaysia

ABSTRACT

BackgroundLipid lowering drugs (LLDs) are widely used. However, reports on its adverse cutaneous drug reactions (ACDRs) are scarce.

ObjectivesThe study objective was to review the patterns of LLD induced ACDRs.

MethodsWe reviewed all LLDs induced ACDRs reported to MADRAC (Malaysian Adverse Drug Reaction Advisory Committee) from January 2005 till December 2009.

ResultsLLD induced ACDRs (124 patients) comprised of 2.07% of all ACDRs reported during the study period. Statins were responsible for most cases (81.5%), followed by fi brates (15.8%), selective cholesterol-absorption inhibitors (1.4%) and combination therapies (statin/selective cholesterol-absorption inhibitors and selective prostaglandin-2 receptor inhibitor/niacin) in 1.4%. Majority were due to lovastatin (42.5%), simvastatin (28.1%) and gemfi brozil (8.9%). The three commonest ACDRs reported with statins usage were non-specifi c dermatitis (45.0%), pruritus/stinging (25.0%) and urticaria/angioedema (10.0%) while fi brates caused non-specifi c dermatitis (52.2%), urticaria/angioedema (13.0%) and photodermatitis (9.7%). There was no reported case of photodermatitis associated with statin usage. Interestingly, statins were the offending drugs resulting in all the fi ve cases of vesiculobullous eruptions, two cases of Stevens-Johnson syndrome and one case of dermatomyositis. No mortalities were reported to be associated with LLD induced ACDRs.

ConclusionsLLD induced ACDRs were not uncommon. Statins were the main putative drugs implicated in those reactions. Spectrum of ACDRs differed between statin and fi brate although non-specifi c dermatitis remained the main ACDRs in both classes. The unavailability of guided and classifi ed ACDRs reporting accounted for the large number of non-specifi c dermatitis. Although most LLD induced ACDRs were mild, statins were reported to cause severe ACDRs.

Keywords: Adverse Drug Reaction, Antilipemic Agents, Anticholesteremic Agents, Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis, Drug Hypersensitivity, Simvastatin, Lovastatin, Gemfi brozil

23



NARROWBAND UVB-INDUCED LICHEN PLANUS PEMPHIGOIDES

W M M Chan, Joyce SS Lee, Colin C T Theng, S H Chua, Hazel H OonNational Skin Centre, 1 Mandalay Road, Singapore 308205

ABSTRACT

IntroductionLichen planus pemphigoides (LPP) is a rare acquired autoimmune disease characterised by the evolution of subepidermal blisters on normal and lichen planus affected skin.

Case summaryWe describe a case of lichen planus pemphigoides in a 54-year-old Chinese woman. The patient presented initially with scaly psoriasiform plaques and was diagnosed to have with guttate psoriasis. She was treated with narrowband ultraviolet (NBUVB) therapy twice weekly. Within a month of starting phototherapy, she experienced a fl are up of her skin lesions with a generalised eruption of violaceous papules, tense bullae over the lower limbs as well as Wickham’s striae over the buccal mucosa. Histology of the violaceous papule over abdomen revealed interface dermatitis, while the specimen from a blister showed subepidermal bulla with linear deposition of IgG and C3 along the basement membrane zone. A diagnosis of LPP was made on clinicopathological grounds. The patient subsequently responded well to oral prednisolone at a dose of 0.5 mg/kg/day.

ConclusionThis is the fi rst case report of NBUVB alone unmasking LPP. In the presentation, we will describe the pathological mechanism of NBUVB in the development of LPP and the key features distinguishing LPP from bullous lichen planus (BLP), psoriasis and bullous pemphigoid (BP).

Keywords: acquired autoimmune disease, subepiderma blister, phototherapy, plaques, Singapore


24


TATTOO-INDUCED PSEUDOLYMPHOMA

Hazel H Oon, Joyce SS LeeNational Skin Centre, 1 Mandalay Road, Singapore 308205, Singapore

ABSTRACT

IntroductionPseudolymphoma is a rare complication of tattooing, presenting with infi ltrated areas often at the site of a red tattoo and postulated to be an allergic reaction to mercury salt. When present, it may be mistaken for the more commonly occurring tattoo-associated granuloma.

Case summaryWe describe a 47-year old female who developed nodular areas on her tattoo four months after placement by a professional tattoo artist. The nodules were restricted to the red regions and spared the blue-black areas of tattoed skin. Initial differentials included a foreign body or sarcoidal granuloma and contact dermatitis to the red dye.

Histology revealed a top-heavy lymphocytic infi ltrate spanning most of the dermis, with numerous eosinophils. Dark red, non-polarisable exogenous pigment was scattered throughout the dermis, in association with the infl ammatory infi ltrate. The epidermis showed intense spongiosis and eosinophilic exocytosis. A fi nal diagnosis of tattoo-induced pseudolymphoma was made.

Pseudolymphoma, foreign body and sarcoidal granulomatous reaction patterns from tattoos occur more commonly in red tattoos. Biopsy with histology is required to differentiate these three disorders with divergent management. We review the literature on tattoo-induced pseudolymphoma and highlight the pitfalls associated with the diagnosis.

Keywords: nodules, red pigment, granuloma, Singapore

25


Q U A L I T Y I S S U E S I N D E R M AT O L O G Y

MONITORING PERFORMANCE OF SPECIALISTS IN CONDUCTING SKIN BIOPSY USING CUMULATIVE SUM (CUSUM) TECHNIQUE: RESULTS OF A PILOT STUDY IN HOSPITAL KUALA LUMPUR

Chang CC, Noor Addillah S, Ambrose DA, Azizan NZ, Johar A, Baba RDepartment of Dermatology, Hospital Kuala Lumpur

ABSTRACT

IntroductionCumulative Sum (CUSUM) technique is an objective statistical method used in assessing and monitoring doctor’s performance. It has been incorporated into quality improvement strategies in clinical services by the Ministry of Health, Malaysia. A pilot study was aimed at evaluating its usefulness in monitoring the performance of specialists in conducting skin biopsy.

MethodsAll skin biopsies performed by specialists in the Department of Dermatology, Hospital Kuala Lumpur from September 2009 to April 2011 were included in the prospective observational study. Outcomes monitored were wound complications within 14 days post-biopsy, and tissue sample being adequate and representative for histopathological interpretation. CUSUM scores of each consecutive biopsy performed by individual specialist were calculated and charted with the eCUSUM web application (https://app.acrm.org.my/eCUSUM).

ResultsA total of 870 skin biopsies were performed by 15 clinical specialists and three consultant dermatologists during the study period. Wound infection or dehiscence were reported in 13 (4.1%) of the 318 biopsy wounds evaluated. Tissue samples were inadequate in 10 (1.2%) and non-representative in 11 (1.3%) of the 817 histopathological reports evaluated. No learning curve was observed in all CUSUM charts indicating that all specialists had been adequately trained for the procedure. However, out-of-control signals indicating unacceptable wound complication rates and either inadequate or non-representative tissue samples were detected in three clinical specialists. Feedback and counseling were given while monitoring was continued.

ConclusionsThe CUSUM method is a useful performance monitoring tool which is able to promptly detect unacceptable outcomes in skin biopsy. It is invaluable in the supervision of junior doctors and trainees as well as self-monitoring for the trained specialists.

Keywords: Infection, histopathological reports, Dermatology, Quality improvement, Malaysia


26


A CLINICAL APPRAISAL OF ADULT PSORIASIS PATIENTSIN HOSPITAL SERDANG

P Shalini Devi, SL Quek, Siti Farah M, YJ Tan , Norashikin S, Norhafi zah MFaculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia

ABSTRACT

ObjectivesTo determine the socio-demographic profi le, clinical characteristics and quality of life of adult psoriasis patients as well as the association between the fi rst two variables with the latter.

MethodsA cross-sectional study of 30 adult psoriasis patients was conducted in the Dermatology Clinic, Hospital Serdang from 9th to 23rd May 2011. A questionnaire regarding clinical data and containing multilingual Dermatology Life Quality Index (DLQI) was used in a face-to-face interview.

ResultsMale-to-female ratio was 1:1.5. Psoriasis was more common in Malays (76.7%) compared to Chinese (10%) and Indians (10%), however this ethnic distribution was proportionate to that of the clinic attendance. The onset of psoriasis was during the second to third decade of life in most patients (53.3%) with a mean of 31 years (range 7 - 62). Nine (30%) patients had positive family history of psoriasis. The main aggravating factors were stress and sunlight. Hyperlipidemia was the commonest associated co-morbidity. Plaque psoriasis was the commonest clinical type (66.7%) and majority (66.7%) had <10% body surface area affected. Nail changes were present in 15 (50%) patients and psoriatic arthropathy occurred in 11 (36.7%), with mono/oligoarticular type being as common as symmetrical polyarthropathy. All patients were treated with topical therapy, six were on systemic medication and only one underwent phototherapy. The mean DLQI score was 10.77 ± 6.22. The duration of disease and the age group were negatively correlated with the DLQI scores (r= - 0.45 and -0.42 respectively, p < 0.05).

ConclusionThe clinical fi ndings are similar to previous local studies and are valuable to improve patient care.

Keywords: DLQI, hyperlipidaemia, sunlight, stress, arthropathy, Malaysia

27



THE IMPACT OF ACNE VULGARIS ON THE QUALITY OF LIFEIN SARAWAK, MALAYSIA

Felix Yap Boon Bin1, Pubalan Muniandy2, Chang Choong Chor1, Roshidah Baba1

1 Department of Dermatology, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur2 Department of Dermatology, Sarawak General Hospital, Jalan Hospital, 93586 Kuching, Sarawak

ABSTRACT

BackgroundThere is lack of data on the impact of acne vulgaris on the quality of life in Malaysia. Thus, this study was done to determine the impact of acne vulgaris on the quality of life in Sarawak, Malaysia and to examine its relationship with the severity of acne.

MethodsA cross-sectional study of 173 patients in 3 dermatology clinics in Sarawak utilizing the dermatology life quality index (DLQI).

ResultsThe mean DLQI score was 4.1. Patients with family income < RM 3000 had higher mean DLQI scores (4.8 vs. 3.2, p = 0.02). There was also a tendency for indigenous groups to have higher DLQI scores compared to Chinese although it was not statistically signifi cant (4.5 vs. 3.5, p = 0.15). Females were signifi cantly more impaired in the domains of symptoms and feelings (2.1 vs. 1.5, p = 0.02); and work and school (0.3 vs. 0.2, p = 0.04). DLQI was weakly correlated with acne severity in patients mild acne (Pearson coeffi cient = 0.27, p = 0.01) but become insignifi cant for patients with moderate and severe acne. No correlation was seen between DLQI and age of patients.

ConclusionAcne vulgaris has a quality of life impact similar to that of psoriasis in Sarawak and must be addressed. Health care providers and administrators should view acne as a psychologically disabling disease requiring optimal management and resource allocation. Education of junior doctors and medical student on this issue is also important.

Keywords: psychologically disabling, indigenous group


28


THE IMPACT OF LEPROSY ON QUALITY OF LIFE

Mazlin MB1, Norazirah MN1, Leelavathi M2, Yap BB3, Johar A3

1 Dermatology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre2 Department of Family Medicine, Universiti Kebangsaan Malaysia Medical Centre3 Department of Dermatology, Hospital Kuala Lumpur

ABSTRACT

Background“Health is often measured in terms of low mortality; nevertheless, merely being alive is not a measure of the quality of life” - H. Méndez Castellanos.

Leprosy is a slowly progressive infectious disease caused by Mycobacterium leprae and is often complicated by deformities, disabilities and intermittent hypersensitivity reactions. In the course of diagnosis and treatment, the physical impact of this disease is often assessed thoroughly but the assessment on its psychological impact and quality of life are sorely lacking.

Objective Our purpose was to quantify the effect of leprosy on the quality of life of our patients.

MethodsThis cross sectional study was conducted on patients who attended the Hansen’s Clinic in Hospital Kuala Lumpur. The patients were interviewed using World Health Organization Quality of Life Assessment - abbreviated version (WHOQOL-BREF) questionnaire. Medical records were examined to evaluate disability grades and impairment. The patients were also questioned about their attitude towards the diagnosis and treatment.

Results & Conclusions The quality of life of patients with leprosy was found to be considerably impaired and comparison with other studies from other parts of the world will be highlighted.

Keywords: Hansen’s disease, Mycobacterium leprae, Malaysia

29



OPPORTUNITY FOR IMPROVEMENT IN MONITORINGOF DERMATOLOGICAL PATIENTS BY NURSES

Norhasmie Ramli, Kasmawati Taib, Noradiah Jalal, Rohna RidzwanDepartment of Dermatology, Selayang Hospital, Malaysia

ABSTRACT

BackgroundNursing progress notes in Selayang Hospital was found to be non-compliance according to Malaysian local accreditation bodies in 2007. In June 2008, Department of Dermatology were assigned with dedicated nurses.

AimTo look into the quality of monitoring of Dermatology patients by nurses which is refl ected by the content in nursing progress notes before and after being taught by Dermatology nurses.

MethodologyA retrospective comparative audit of the quality of nursing progress notes in ward patients that required Dermatology management in May 2006 and May 2009 in Selayang Hospital was performed. Parameters assessed include the patient’s general condition, skin symptoms and signs, alerting doctor whenever there is change in skin condition and nursing intervention. Exclusion criteria include documentation by the same nurse at different times.

Results 325 nursing progress notes were reviewed in 2006 and also in 2009. 70% of nurses described the symptoms and signs of skin lesions at that point of time whereas only 5% of nurses did that in 2006. Documentation of intervention performed for the current skin lesions in 2009 and 2006 were 81% and 48% respectively. Only 4% of nurses informed doctor on fi nding a change in skin condition 2006 as compared to 71% in 2009.

ConclusionThe audit shows that designated skin nurses can assist the ward nurses to improve their clinical documentation.

Keywords: nursing, progress notes, patient monitoring


30


PATIENTS KNOWLEDGE ON SKIN DISEASE AND NURSING CARE

Noradiah J, Rohna R, Raoul SDepartment of Dermatology, Selayang Hospital

ABSTRACT

ObjectiveTo assess adequacy of patients’ knowledge on their own dermatological conditions and skin care.

MethodologyThis is a non-experimental and cross-sectional quantitative descriptive study. The population studied consists of 105 patients on follow-up at Dermatology Clinic from 1st until 17th March 2011, chosen using convenience sampling methods. Questionnaires were given to them to assess their knowledge on their illness and corresponding skin care. Data analysis was performed using SPSS version 16.

ResultsAnalysis showed the average age of respondent were 42.33 + 16.61, with 60% in the category 20 to 40 years scored highest knowledge (p = 0.001). 65% of female respondents had more knowledge about the care of dermatological problems compared with the male respondents.

Respondents with college or university education had the highest knowledge pertaining to their own skin conditions and care (p = 0.001).

55% of respondents who had no family history of similar skin problems appear to know more about dermatological conditions and care than those patients with family history of similar illness. Respondents who had received information about skin diseases and care had higher knowledge (75% score) compared to those who had never received the same information.

ConclusionPatients’ knowledge about their own dermatological condition and care is still inadequate. This study indicates that patient education should be modifi ed by increasing staff participation in educating patients, using pamphlets and giving demonstration of skin nursing so that more patients are aware of their skin conditions enabling them to perform self care at home.

Keywords: patient’s education, dermatological care, compliance

33


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Malaysian Journal of Dermatology 2011B.pdf · am pleased to announce that under the stewardship of Dr Rohna Ridzwan, it ... Najeeb Ahmad Safda ... A retrospective analysis of tuberculosis