Clinical Presentation And Outcome Of Herpes Zoster Infection In A Tertiary Dermatology Outpatient Referral Clinic In Malaysia

Introduction: Herpes zoster (HZ) is a common acute, cutaneous viral infection caused by reactivation of latent varicella zoster virus with devastating effects on quality of life. This study aims to describe the demographic and clinical characteristic and complications of HZ. Methodology: This was a retrospective study of 179 HZ patients from the Dermatology department of Penang Hospital between January 2010 and June 2013. Results: The 179 patients had a median age of 53 years. Chinese ethnicity was more affected. Majority of the patients came late to seek treatment with the median of disease duration of 4 days. The commonest presenting complaint was pain (98.9%), followed by itching (25.7%) and fever (9.5%). Single dermatome involvement was seen in 90.5% of the patients, of which the thoracic dermatome (54.9%) being the commonest. The incidence of complications such as secondary bacterial infection, post-herpertic neuralgia, eye complication(s) and scar were 36.3%, 4.5%, 5.6% and 2.8% respectively. The complications were not statistically different between the younger and the older patient. However, it was more common among male patients. Conclusion: Patients with HZ in Penang presented late and tend to have complications. Hence, public education and vaccination should be recommended.

Darier's disease: A review of the clinical features and management pattern in Penang Hospital, Malaysia

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. Method : All 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 confirmed histopathologically in at least one of the family member. Details of the demographic and clinical data including treatment regimen were collected for analysis. Results: 15 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 flexural 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. Conclusion: The clinical profiles of our patients were generally comparable to other Asian published data except rarity of co-occurrence of guttate leucoderma. Our findings add to the increasing bulk of Asian patient data valuable in the management of Darier’s disease.

Adequacy of Care in patient with Psoriasis (ADECAP) Study

Introduction: Psoriasis is a chronic recurrent inflammatory skin disease and poses a lifelong burden. Psoriasis is now considered a systemic inflammatory disease. Increasing epidemiological studies have established the role of psoriasis as an independent risk factor in the development of metabolic syndrome and its components. This has led to changes in standard of care recommendations for patients with psoriasis. We conducted a clinical audit on “adequacy of care in patient with psoriasis”. Objective: To examine current trend of practice in the treatment of adults with psoriasis in Dermatology clinic (tertiary referral centre), Penang Hospital. This study also aims to determine the adequacy of care in psoriasis patients in general, and those on systemic agents in specific. Method: A retrospective study examined all adult psoriasis patients who visited Dermatology Clinic, Penang Hospital within 1st July - 31st July 2009. Only those who have been on follow-up for at least 1 year were included in the study. Demographic characteristics, disease burden and details of psoriasis management were documented and analysed. Standards were derived from recommendations of the British Association of Dermatologists (BAD) and American Academy of Dermatology (AAD). Results: Of the 112 patients, 67 were males (59.8%). The mean age of patients was 48.8 years. Fifty (44.6%) were Chinese, 35 Malay (31.3%), 26 Indians (23.2%) and 1 foreigner (0.9%). The mean frequency of clinic visit was 8.2. Forty-seven patients required systemic agents to achieve better disease control. Eighty-three (74.1%) patients were offered “Psoriasis Education Programme”. Percentage of patients who had their severity scoring done by using the DLQI, BSA & Pain score were 73.2%, 90.2% and 85.7% respectively. Only less than 50% of our patients were offered “Metabolic Syndrome Risk Factors Screening”. Of those on systemic agents, only 87.2% and 46.8% of patients, had their baseline and follow up blood investigations done respectively. Conclusion: The care of psoriasis patients in Dermatology Clinic, Penang Hospital is still not adequate. Particular areas of concern include blood monitoring for those on systemic agents and screening for metabolic syndrome risk factors. Remedial measures: Guidelines have been designed to create awareness and to educate doctors and patients on psoriasis and its association with metabolic syndrome. This includes a flow chart / tables to facilitate monitoring and screening of patients. Patients will be given pamphlets on the general knowledge on psoriasis, treatments and the risk of co-morbidities.

Comparison of efficacy and safety of two dosing of oral methotrexate in patients with moderate to severe plaque psoriasis

Background: Methotrexate has been widely used as an effective systemic therapy for psoriasis. Retrospective data showed efficacy rate of 70-80% but recent RCTs using PASI 75 as primary endpoint showed wide variations in efficacy. Different dosing regimens for methotrexate may explain this variation. Objectives: To compare the efficacy and tolerability of two different dosing regimes of oral methotrexate in patients with moderate to severe plaque psoriasis. Methods: A 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 efficacy endpoint was PASI 75. Tolerability and safety were assessed. Results: Forty 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). Significantly 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 significant difference in rate of adverse events was noted. Conclusion: There was no significant difference in efficacy between both regimes at the end of 16 weeks but significant efficacy was observed in patients on ‘step-down dose’ regime as early as week 4. The side effect profile and tolerability were similar.

Churg Strauss Syndrome in a 40 year old woman

Cutaneous vasculitis is a common manifestation of many systemic diseases. In the setting of asthma, eosinophilia and multiple disparate signs and symptoms, more serious cause of vasculitis like Churg-Strauss syndrome (CSS) should always be considered.

An outbreak of Rove Beetle dermatitis in Penang Hospital: A report of 37 cases

Background Rove beetle dermatitis is a peculiar form of acute irritant dermatitis following the contact with body fluid of an insect which is belonging to genus Paederus. This retrospective study is to evaluate the epidemiology and clinical manifestations of rove beetle dermatitis during the outbreak of rove beetle dermatitis in Penang (March 2009 - April 2009). Methods We describe 37 patients with clinical diagnosis of rove beetle dermatitis presented to our department. Only those patients with a definite history of contact with the insect were included in the study. Demographic characteristics, reason for referral and details of skin lesions were documented and analysed. Results Male patients outnumbered female patients - 21 males (56.8%); 16 females (43.2%). The mean age of patients was 28.3 years. Of the 37 patients, 18 patients (48.6%) were Malay, 14 Chinese (37.8%), 4 Indians (10.8%) and 1 foreigner (2.8%). The mean duration of lesions before presentation to our clinic was 3.4 days. The mean duration of lesions before presented to our clinic was 3.4 days. Symptom of burning sensation (25, 67.7%) was more pronounced than itching (6, 16.2%). Fourteen of our patients (37.8%) reported a positive family history. Clinically, the most common presentation consisted of linear, geographic, erythematous plaques with a ‘‘burnt’’ appearance. In 59.5% of patients, more than one lesion was present. Pustules and vesicles were seen in 12 (32.4%) and in 10 (27.1%) of the patients respectively. ‘‘Kissing lesions’’were seen in 5 (13.5%) patients. The neck and arms were the most common sites of involvement. Periorbital involvement occurred in 16.2% of patients. Only 8 patients (21.6%) were diagnosed to have “insect related dermatitis” at initial presentation. No one was referred as “rove beetle dermatitis”. Conclusion Rove beetle dermatitis is a common condition. Awareness of these condition and its clinical features will prevent misdiagnosis and unnecessary worry.

Cetirizine induced bullous fixed drug eruptions

A fixed drug eruption (FDE) is a distinct drug induced reaction pattern that characteristically recurs at the same site on the skin or mucosa. We report a case of bullous FDE following ingestion of cetirizine, a common treatment for allergic disorders but a rare causative agent for cutaneous adverse drug reaction.

Cutaneous tuberculosis in Penang: A 12-year retrospective study

Background Cutaneous tuberculosis (TB) is a form of extrapulmonary tuberculosis. Diagnosis of cutaneous TB is often difficult because of the diverse clinical presentations. The positive yields from cultures are often low. To describe the demographic, clinical, histopathological and bacteriological aspects of cutaneous TB. Materials and Methods This retrospective review looked at cases of cutaneous tuberculosis treated at the Respiratory and Dermatology unit, Penang Hospital from 1996 to 2007. Data were analysed with SPSS 13.0 version. Results A total of 23 cases of cutaneous tuberculosis were reviewed. The male to female ratio was 2.3 to 1. The mean age was 37.7 ± 20.7 years. There were 10 Malays, 9 Chinese, 2 Indians and 2 Indonesian. The types of cutaneous tuberculosis observed were lupus vulgaris (47.8%), tuberculides (17.5%), tuberculosis verrucosa cutis (13.0%), scrofuloderma (13.0%) and primary inoculation TB (8.7%). 43.5% of patients had systemic involvement. Mantoux tests were positive in 85.0% of cases. Skin biopsies were performed in 91.3% of patients and 71.4% of them showed classical histopathologic findings suggestive of tuberculosis. Mycobacterium tuberculosis was isolated in the culture from 28.6% of patients. Localized diseases were found more often in BCG-vaccinated individuals. Regional lymphadenopathy was noted more often in patients with disseminated disease. No correlation was found between Mantoux reactivity and the extent of disease. Conclusion Lupus vulgaris was the commonest form of cutaneous tuberculosis. Cultures were positive in only a small proportion of patients. Almost half of our patients had systemic involvement. The presence of regional lymphadenopathy often indicates disseminated disease. Patients without BCG vaccination were at higher risk of disease dissemination.

Lepra reactions: A 10-year retrospective analysis

Introduction Leprosy is a chronic granulomatous infection caused by Mycobacterium leprae. Drug treatment is effective in eradicating the bacilli but does not prevent lepra reaction. Despite much attention being focused on the problem of lepra reactions, very limited data has been published on the epidemiology of lepra reactions especially this part of the world. The aim of the study is to improve the understanding of lepra reaction and to determine the demographics and clinical patterns of lepra reactions in Penang General Hospital. Materials and Methods This retrospective study covers a 10-year period from 1997 to 2006. Demographic characteristic and clinical patterns of lepra reactions were analysed with SPSS 13.0 version. Results Of the 95 patients who were enrolled in the study, 67 (70.5%) were male and 28 (29.5%) were females. The mean age at presentation was 40.4 ± 17.9 years (range 3-91 years). There were 35 Malays (36.8%), 34 Chinese (35.8%), 5 Indians (5.2%) and 21 foreigners (22.2%). 35.8% of patients presented with LL (n=34), 18.9% BT (n=18), 17.9% TT (n=17), 13.7% BB (n=13) and 13.7% BL (n=13). In our series, the lepra reaction rate among leprosy patient was 51.6% (n=49). Among those with lepra reaction, 53.1% cases were type 1 reaction (n=26), 44.9% cases were type 2 reaction (n=22) and 2.0% cases were Lucio phenomenon (n=1). Common manifestations observed in lepra reaction were worsening of skin lesions (100%), inflammatory oedema of hands, feet and face (53.1%), nerve pain (46.9%), fever (20.8%) and nerve tenderness (20.4%). Only 4 cases had involvement of other organs like the eye and joint. 30.6% of the reactions observed in our cohort were severe. Type 1 reaction commonly involved those in borderline spectrum whereas type 2 reaction commonly involved those in the lepromatous spectrum. Lepra reactions occurred before treatment (24.5%), during treatment (71.4%) or even after treatment has been stopped (4.1%). Most of the lepra reactions occurred during the treatment period especially the first 12 months of therapy. Conclusion Our study showed a more severe and higher reaction rate compared to other studies. Lepra reaction is a common presentation of leprosy. Type 1 reaction commonly involved those with borderline disease but type 2 reaction commonly involved those with lepromatous spectrum of disease. Lepra reaction occurred before, during and even after the treatment has stopped. Most of the lepra reactions occurred during treatment period especially the first 12 months of therapy.

Kaposi’s Sarcoma in a 35-year-old homosexual

Kaposi’s sarcoma (KS) is strongly associated with Human Herpes Virus 8 (HHV8) and Human Immunodeficiency Virus infection (HIV). It was the first malignancy to be linked with Acquired Immunodeficiency Syndrome (AIDS) and it is still the most commonly encountered malignancy associated with HIV. We report a case of Kaposi’s sarcoma in a homosexual man.

Hansen's Disease in Penang: A 10-year Retrospective Analysis

Background Leprosy is a chronic granulomatous infection caused by Mycobacterium leprae. The principal manifestations are skin lesions and peripheral neuropathy. The aims of the study is to improve the understanding of leprosy cases managed in Penang General Hospital and to analyse the demographics, clinical patterns, treatment regimen and outcome of leprosy in Penang Hospital. Materials and Methods This retrospective study covered a 10-year period from 1997 to 2006. Demographic characteristics, clinical patterns, treatment regimen of leprosy and outcome were analysed. Results A total of 95 patients were diagnosed to have leprosy (prevalence rate of 0.68 per 100,000). The mean age at presentation was 40.4 years ± 17.9 (range from 3 to 91 years old). There were 35 Malays (36.8%), 34 Chinese (35.8%), 5 Indians (5.2%) and 21 others. Patients experienced symptoms for a mean of 21.4 months before being referred to our clinic. Only 29 patients (30.5%) had a family history of leprosy. 34 patients (35.8%) presented with lepromatous leprosy. 95 patients (100%) presented with skin lesions, 61 patients (61.2%) with nerve lesions, 17 patients (17.9%) with deformities and 12 (12.6%) with reactions. The skin lesions occurred predominantly over the lower limbs, face and trunk. 95.8% of skin lesions were hypo/anaesthetic. Common thickened nerves observed were ulnar nerve (40.0%), great auricular nerve (38.9%) and posterior tibialis nerve (25.3%). The lepra reaction rate was 51.6%. Type 1 reaction commonly involved those with borderline spectrum but type 2 reaction commonly involved those with lepromatous spectrum. Common side effects observed with MDT were dapsone induced hemolytic anaemia (10.5%), cutaneous adverse drug reaction (8.4%) and drug induced hepatitis (2.1%). None of them experienced severe drug toxicity. In terms of treatment for leprosy, 71.6% of patients had completed their treatment and 18.9% were still on treatment. 24.1% of patients had their regimen changed because of side effects and drug resistance. 6 patients died (due to unrelated cause) and another 3 patients defaulted treatment. Conclusions Our study showed similar epidemiological findings as other studies except for a higher reaction rate. There was a significant delay in diagnosis in our cohort. Identification of the reasons of delay in diagnosis, and the risk factors of lepra reaction are important in the management of leprosy. Anti-leprotic treatment is relatively safe and effective in treating leprosy.

Cutaneous Adverse Drug Reactions observed in a Dermatology Clinic, Penang General Hospital

Background Cutaneous Adverse Drug Reaction (CADR) is commonly encountered in our daily clinical practice1. Knowledge of the various patterns of CADR and the common offending agents will certainly help the physician in assessing the likelihood of the drug induced eruption as opposed to another dermatological diagnosis. Objectives To improve the understanding of CADRs in Penang General Hospital,To evaluate the incidence of CADR in Dermatology clinic Penang Hospital, to identify the common offending drugs and to describe the characteristics of CADR and to identify the associated risk factors of developing CADR. Materials and Methods This prospective study covers a 12-month period from April 2005 to March 2006. Demographic characteristics, causative drugs, management and treatment outcome were analysed. Results A total of 174 cases were referred to the Dermatology Clinic over 1-year period (Incidence of 4.9% of Dermatology Clinic new case attendees). Chinese comprises of 51.4%, followed by Malay 32.4%, Indian 10.8% and others 5.4%. Male to female ratio was 1.2:1. 74.1 % of CADR occurred between 13 - 59 year age group. The offending drugs included antimicrobials 28.6%, antituberculous 19.7%, analgesics 17.7%, allopurinol 8.4%, anticonvulsants 5.4%, HAART 1.0%, traditional medicines 2.0% and others 17.2%. High proportion of erythema multiforme syndrome cases was observed (23.5%). Toxic epidermal necrolysis has a high mortality rate. It was caused by amoxycillin, sulphonamide and phenytoin. 80.5% of CADR occurred within 2 weeks of drug introduction. Overall mortality rate secondary to CADR was 2.3%. Risk factors identified included poly-pharmacy (37.9%), renal insufficiency (31.0%), personal history of previous drug allergy (19.0%), liver disorder (18.4%), tuberculosis (16.7%), HIV infection (10.3%), autoimmune disorders (6.3%) and hematological malignancy (4.0%). Conclusions Diagnosis of CADR requires a high index of suspicion especially in those having symmetrical eruption within 2 months in relation to initial dose of medication, particularly the high risk groups.