Cost of Medications in the Treatment of Moderate to Severe Acne in Sarawak, Malaysia

Introduction: Acne is a common problem causing impairment in quality of life requiring topical and oral treatment. The objective of this study is to determine the cost of medications for the treatment of an episode of moderate to severe acne vulgaris in patients attending the dermatology clinics in Sarawak. Materials & Methods: This cross sectional study was conducted between June 2008 and January 2009 in all the 3 dermatology clinics in Sarawak. Data were collected from 165 patients with moderate to severe acne and analysed using SPSS ver 15. Statistical significance was set at p < 0.05. Results: The mean cost of medications to treat 1 episode of acne was RM 1170.48 per patient. The government and patients spent an average of RM 519.41 and RM 651.07 respectively. The cost to treat 1 episode of severe acne (mean RM1861.75) was significantly higher than to treat moderate acne (mean RM 470.79, p < 0.001). Working patients paid more for their acne medications (mean RM 1624) compared to students (mean RM 732.21, p = 0.001). In patients with moderate acne, patients with tertiary education spent more (mean RM 657.54) on their medications compared to those with primary/secondary education (mean RM 338.50, p = 0.04) There was no association between the cost of medications and the socio-demographic variables of gender, ethnic group and economic background. Conclusion: Cost of treating moderate to severe acne in Sarawak is high and comparable to Western societies. This data might help in formulating and optimizing resource allocations for the treatment of acne.

The impact of acne vulgaris on the quality of life in Sarawak,Malaysia

Background There 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. Methods A cross-sectional study of 173 patients in 3 dermatology clinics in Sarawak utilizing the dermatology life quality index (DLQI). Results The 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 significant (4.5 vs. 3.5, p = 0.15). Females were significantly 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 with mild acne (Pearson coefficient = 0.27, p = 0.01) but become insignificant for patients with moderate and severe acne. No correlation was seen between DLQI and age of patients. Conclusion Acne 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.

Efficacy and safety of tacrolimus ointment in patients with moderate to severe atopic dermatitis - Malaysian experience

Objectives To evaluate the efficacy and safety of tacrolimus ointment 0.1% in adult and 0.03% in pediatric patients with moderate to severe atopic dermatitis in Malaysia. Methods This is an open-labeled and single arm multi-center study. 36 adult and 37 pediatric patients were enrolled. Tacrolimus ointment is applied twice daily for four weeks. The primary efficacy outcome is based on the Physician’s Global Evaluation of Clinical Response (PG) at Week 4. The secondary efficacy outcomes are Eczema Area and Severity Index (EASI) score, changes from baseline in individual scores of signs and symptoms and body surface area affected and Patients Assessment of Treatment Effects. Results Overall success rate were 97.1% and 91.2% in the adult and pediatric groups respectively. The decline in EASI, percentage of total BSA affected and patient’s assessment of pruritus were significant (P<0.001). Of adults and pediatric patients, 97.2% and 75.7% respectively reported adverse effect. The most common adverse effect reported was skin burning sensation in 91.7% adult patients and pruritus in 67.6% pediatric patients. Conclusion Tacrolimus ointment 0.1% in adult and 0.03% in pediatric patients is effective for the treatment of moderate to severe atopic dermatitis in Malaysia.

Risk factors for type 1 leprosy reaction in a tertiary skin clinic in Sarawak

Introduction Identifying risk factors for leprosy reactions can preempt clinicians to initiate prompt treatment to prevent associated morbidities. Thus, a retrospective study was done to elucidate the risk factors among 44 newly diagnosed leprosy patients in Sarawak General Hospital from 1993 to 2007. Materials and methods Case folders were searched for demographic data, clinical characteristics, slit skin smear results, and the presence of type 1 leprosy reactions, its treatment and outcome. Analysis was done to determine the relative risks for development of this reaction. Student t test was used for comparison of means. The level of significance was set at 0.05. Results Type 1 reaction was seen in 25% (n=11) of patients. It occurred in 44.4% (n=4) of borderline lepromatous (BL), 33.3% (n=1) of mid borderline (BB), 37.5% (n=3) of borderline tuberculoid (BT) and 30% (n=3) of tuberculoid (TT) patients. Borderline spectrum of disease gave a relative risk of 2 (95% CI 0.3-0.9) and age of 40 gave a relative risk of 1.8 (95% CI 0.3-0.9) for the development of type 1 reaction. Older mean age (mean 53.7 years cf. 37.0 years, p = 0.01) and earlier presentation to health care workers (mean 5.8 months cf. 11.9 months, p = 0.02) was also significant risk factors Extent of disease and gender were not identified as risk factors. Conclusion Risk factors for type 1 leprosy reaction were borderline leprosy, older patients and shorter duration of illness on presentation.

Pattern of cutaneous malignancies in a tertiary hospital in Sarawak

Background Most Asian studies have determined that basal cell carcinoma (BCC) is the commonest skin cancer followed by squamous cell carcinoma (SCC), malignant melanoma (MM) and others. The pattern of cutaneous malignancies has never been determined in Sarawak. Thus, this retrospective study was performed to determine the pattern among patients attending the skin clinic in Sarawak General Hospital. Materials and Methods The clinic notes of 87 patients diagnosed to have skin cancer histopathologically between 2000 and 2008 were retrieved and subjected to descriptive analysis. Analysis for the pattern of disease and demographics was performed. Results BCC constituted the main skin cancer with 49.4% (n=43) followed by SCC with 26.4% (n=23), cutaneous lymphomas (CL) with 9.2% (n=8), MM with 4.6% (n=4) and other cutaneous malignancies with 10.3% (n=9). The number of cases detected steadily increased over the 8 year period, with most BCC and SCC diagnosed after 2003. The mean age of presentation was highest in patients suffering from SCC at 62.7 years followed by BCC 60.9 years, MM 59 years, CL 54.3 years and other malignancies 40.6 years. Female predominance was noted in all the malignancies except squamous cell carcinoma. Chinese constituted the majority of cases (50.6%) followed by Malays (29.9%), Bidayuhs (9.2%), Ibans (8.0%) and other indigenous people of Sarawak (2.3%). This pattern of distribution corresponds with the racial distribution of the clinic attendance. Conclusion Cutaneous malignancies in Sarawak differ from regional pattern in that CL is ranked as the third commonest skin cancer and that female predominance was seen in BCC, CL, MM and other skin cancers

Primary cutaneous anaplastic large cell lymphoma in a young woman

Primary cutaneous anaplastic large cell lymphoma (ALCL) constitutes around 1% of all cutaneous lymphomas1. It is defined as predominance (>75%) of large clusters of CD 30+ blast like cells in the skin biopsy with no clinical evidence of lymphomatoid papulosis, extracutaneous localization at presentation or previous or concurrent mycosis fungoides or other cutaneous lymphoma2. It is usually seen in males with a median age of 40 years3. It classically presents as a solitary ulcerated tumour on the trunk or extremities. Twenty two percent of cases are multifocal3. Extracutaneous dissemination occurs in approximately 10%, mainly to regional lymph nodes3. Skin restricted disease has an excellent prognosis with 96% 5 year survival4. Here, we report a case of primary cutaneous anaplastic large cell lymphoma (ALCL) in a 32-year-old woman.

Incontinentia pigmenti: Report of 3 cases from Sarawak

Incontinentia pigmenti, also known as Bloch-Sulzberger syndrome, is a rare X- linked dominant multisystem disease involving ectodermal structures namely cutaneous, ocular, dental, neurological and skeletal systems1. Mutation of the nuclear factor kappa B essential modulator (NEMO) gene in chromosome Xq28 is determined to cause this rare genodermatosis2. The cutaneous manifestations are the most characteristic features of this disorder3. We would like to report 3 cases of incontinentia pigmenti seen in the skin clinic, Sarawak General Hospital.

Predictive values of 10% potassium hydroxide examination for superficial fungal infection of the skin

Introduction Ten percent potassium hydroxide examination is one of the most frequently performed tests in dermatology. It is usually supplemented by fungal culture for detection of superficial fungal infection of the skin and its appendages. We aim to determine the predictive values of 10% potassium hydroxide examination in Sarawak General Hospital. Materials and Methods A retrospective review of 292 skin scraping results for 10% potassium hydroxide examination and culture was done between October 2003 and December 2004. Data for all the scrapings were analysed for predictive values, specificity, sensitivity and likelihood ratio with fungal culture as the gold standard investigation. Separate data analysis was done for those with onychomycosis. Results Positive cultures were noted in 80.8% of skin scrapping cases and 85.4% of onychomycosis cases. For the skin scrapping cases, the positive predictive value of 10% potassium hydroxide examination was 67.4%, negative predictive value of 16.9%, sensitivity of 12.3% and specificity of 75%. For those with onychomycosis, the positive predictive value was 75%, negative predictive value 13.6%, specificity 85.7% and sensitivity was 7.3%. The positive likelihood ratio for all cases and onychomycosis cases was 0.5 whereas the negative likelihood ratio was 0.9. Conclusion Ten percent potassium hydroxide examination has a very low negative predictive value and sensitivity, making it a poor investigative tool in Sarawak General Hospital. Thus, culture of the skin scraping for suspected superficial fungal infection of the skin and its appendages is of utmost importance. Steps to improve the quality of 10% potassium hydroxide examination are important as it is an easy and inexpensive test.

Comparison of multiple drug therapy in leprosy

Introduction Multiple drug therapy (MDT) was utilized for the treatment of Hansen’s disease in Sarawak since 1989. MDT Sungai Buloh and MDT Sarawak were the 2 major MDT regimens used. Hence, we aim to compare the outcomes of MDT Sungai Buloh and MDT Sarawak. Materials and Methods A retrospective review of 40 cases receiving MDT Sungai Buloh and MDT Sarawak from 1993 to 2006 was performed. Data regarding demographics and outcomes were collected and analysed. Primary outcome was cure and secondary outcomes were relapse, reactivation, death, leprosy reactions and deformities. Results There were no statistically significant differences in the primary outcome among patients on MDT Sungai Buloh and MDT Sarawak (p=0.41) after adjustment for surveillance rate. We noted that significantly more patients on MDT Sarawak (40.9%) were still under surveillance compared to MDT Sungai Buloh (5.6%, p=0.01). We also noted a higher rate of erythema nodosum leprosum (ENL) (16.7%) and deformities (22.2%) in patients receiving MDT Sungai Buloh compared to 9.1% ENL and 9.1% deformity rate among those on MDT Sarawak. However, this did not reach statistical significance. Other secondary outcomes were not significantly different between the two regimens. No recurrence was reported with the two treatment regimens. Subanalysis for multibacillary patients did not reveal any significant differences between the two regimens in the primary outcome of cure after adjustment for surveillance rate (p=0.35). Both ENL and deformity rates of 25% each for MDT Sungai Buloh were higher than the rate of 13.3% each for MDT Sarawak although they did not reach statistical significance. Analysis for paucibacillary patients did not show superiority of any one regimen. Conclusion Both the MDT Sungai Buloh and MDT Sarawak were effective in leprosy treatment. Selection of the best treatment regimens will depend on the cost effectiveness, ease of administration and duration of treatment that patients can tolerate.

A 4-year retrospective study of Stevens-Johnson syndrome and toxic epidermal necrolysis

Background Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare bullous mucocutaneous disease usually caused by drugs. We aim to determine the demographics, causes and outcomes of patients admitted with SJS, TEN and SJS-TEN overlap in Sarawak General Hospital. Materials and Methods A retrospective review of cases admitted to Sarawak General Hospital with SJS, TEN and SJS-TEN overlap from January 2004 to December 2007 was undertaken. Data regarding the demographic, causes and outcomes were collected from the case folders and subjected to descriptive statistical analysis using Microsoft Excel. Results Twenty four cases were admitted with 54.2% having SJS, 25% having SJS-TEN Overlap and 20.8% having TEN. With the mean ages of more than 40 years, patients with SJS and SJS-TEN overlap were older than patients with TEN, with a mean age of only 25.4 years. Seventy nine percent of cases were drugs induced. Anticonvulsants were the main culprit constituting 29.2% followed by allopurinol with 20.8%. Cases with SJS had the longest incubation period with mean of 21.6 days whereas cases with TEN had the longest mean hospital stay with 12.4 days. A 12.5% mortality rate was recorded with 2 deaths in the SJS-TEN overlap group and one death in the TEN group. All cases who were given intravenous immunoglobulin (IVIg) survived. Conclusion SSJS, SJS-TEN Overlap and TEN were mainly drug induced and have high mortality. IVIg treatment seems promising. Early recognition and optimal care in institution with dermatology service is essential in reducing morbidities and mortalities.