Chronic Spontaneous Urticaria in Adult Patients: Evaluating the Effect of Loratadine on Weight and Metabolic Syndrome (Urtikaria spontan kronik di kalangan pesakit dewasa: penilaian kesan loratadin terhadap berat badan dan sindrom metabolik) / Jurnal Sains Kesihatan Malaysia

@#Antihistamine is standard chronic spontaneous urticaria (CSU) therapy. Weight gain is a side effect of concern as prolonged high dose therapy is common. We investigated the effects of 12-weeks loratadine therapy on weight, appetite and parameters of metabolic syndrome (MetS). A cohort study was performed involving CSU patients aged ≥18 years. Patients with diseases or on drugs affecting weight or appetite were excluded. CSU was treated according to standard management. Weight, height, waist circumference (WC), body mass index (BMI) and blood pressure (BP), Urticaria Activity Score 7 (UAS7), Dermatology Life Quality Index (DLQI), hunger and satiety questionnaire, fasting blood sugar (FBS) and fasting lipid profile (FLP) were obtained at baseline, week 6 and week 12. Loratadine cumulative dose were determined. Thirteen (33.33 %) males and 26 (66.67 %) females aged 33.00 (12.00) years participated. Median weight was 62.55 (18.30) kg, BMI 24.60 (6.80) kg/m2, 13(33.33%) patients had normal weight, 12 (30.77%) overweight, 11 (28.21%) obese and 3 (7.69%) underweight. Significant weight gain was observed at week 6, 67.56 ± 16.14 kg vs 68.16 ± 16.95 kg, p < 0.05 and 67.56 ± 16.14 kg vs 64.73 ± 14.60 kg, p = 0.04 at week 12. Changes in BMI, WC, BP, FBS and FLP were insignificant. Three patients developed MetS. Hunger and satiety scores were unaffected. Loratadine induced weight gain despite no effects on appetite. Weight should be monitored in patients on long term loratadine therapy.

Carcinoma Cuniculatum Masquerading as Wart

@#Carcinoma cuniculatum is a rare, slow growing tumour which is commonly mistaken for warts or corn especially when it presents on the sole. Although it rarely metastasizes, it may cause local invasion affecting the underlying tissue and bone. Early identification provides good prognosis as it can be managed with localized resection. We present a case of carcinoma cuniculatum which was misdiagnosed and treated as a common wart for two years until the diagnosis was confirmed by histopathology. By the time of diagnosis, the lesion had involved the underlying bone and patient required amputation. Carcinoma cuniculatum is rare and easily confused with common warts in the early stages hence, it is important to create awareness to identify and differentiate these two conditions.

Serum Vitamin B12 Level and Dietary intake in Adult Atopic Dermatitis: A Case Control Study

Background@#Vitamin B12 is a contributing factor in pruritus and peripheral nerve regeneration. Its role in atopic dermatitis (AD) is still unclear. This study aimed to compare vitamin B12 level between AD patients and healthy controls, determine its correlation with pruritus and AD severity, and evaluate dietary pattern with energy, macro and micronutrient intakes.@*Methods@#This was a case control study involving adult AD patients and age-, gender-, ethnicity- and body mass index-matched healthy controls. All adult patients who fulfilled UK Working Party AD diagnostic criteria were included. Exclusion criteria include patients on systemic agents, diseases known to affect B12 level and vegan diet. AD severity was determined using SCORing Atopic Dermatitis (SCORAD) index. Serum vitamin B12 level were measured. A three-day 24-hour dietary recall was collected and analyzed.@*Results@#A total of 42 AD patients and 42 controls were recruited. Mean SCORAD index was 39.2±16.6, and AD duration was 12.7 ± 8.1 years. Vitamin B12 was lower among AD (215.6 ± 110.2 pmol/L) versus control (295.1± 119.9 pmol/L), p<0.01 despite similar dietary B12 intake in both groups. There were no significant correlations between AD duration and severity with vitamin B12 level. Energy intake (kcal/ day) was significantly lower in AD (p=0.04). There were no significant differences in proportion of main food groups consumed and other macronutrient and micronutrient intakes.@*Conclusion@#Serum vitamin B12 level was significantly lower in AD patients despite similar dietary pattern and nutrient intake with healthy controls. There were no correlations with AD severity or disease duration. Dietary pattern of AD patients should be routinely assessed to ensure adequate nutrition.

Bringing the Treatment of Atopic Eczema Into a New Era with Janus Kinase Inhibitors: A Position Statement By the Persatuan Dermatologi Malaysia

Abstract@#Atopic eczema (AE) is a complex, chronic and recurrent inflammatory pruritic skin condition that impacts the quality of life and exerts an economic toll on patients and their families. One of the factors contributing to AE is the immune dysregulation of the Janus kinase-signal transducers and activators of transcription (JAK-STAT) inflammatory pathway. This has prompted the conduct of various large clinical trial programs to evaluate the efficacy and safety of Janus kinase inhibitors (JAK-i) for AE. The overall and significant benefit of these drugs from clinical studies resulted in regulatory approvals for JAK-i to treat moderate-to-severe atopic eczema. The objective of this position paper was to evaluate the safety, efficacy and role of upadacitinib, baricitinib and abrocitinib in managing AE and update the current recommended treatment algorithm within the 2018 Malaysian Clinical Practice Guidelines for the Management of Atopic Eczema. The Persatuan Dermatologi Malaysia recommends that these JAK-i can be considered as an option for systemic therapy in severe AE.

Case Report of A Rare Case of Adult-Onset Multi-site Lichen Striatus in an Adult

Summary@#Lichen striatus (LS) is a rare self-limiting inflammatory dermatosis characterized by Blaschkoid distribution. We report a 34-year-old woman with a 1-year history of asymptomatic unilateral rashes on her left trunk and limbs. Physical examination revealed light to dark brown papules, macules, patches and plaques with some erythematous areas in a Blaschkoid pattern with proven skin biopsy as well. Patient received potent topical corticosteroid therapy which resulted in the resolution of the lesion. This case report highlights two rare aspect of lichen striatus; involvement of multiple sites and late adult-onset. It is also a reminder that lichen striatus should be included in the differentials of acquired linear dermatoses.

Dermatoses in Human Immunodeficiency Virus Infected Patients with A Focus on Infections: A 12-month Cross-sectional Study in Hospital Sungai Buloh

Background@#Cutaneous disorders are common clinical manifestations of the Human Immunodeficiency Virus (HIV). In the era of antiretroviral therapy (ART), the spectrum of cutaneous disorders in HIV-infected patients has changed. We assessed the types of dermatoses, including cutaneous infections in HIVpositive patients and the association between the peripheral CD4 cell count and the severity of skin infection.@*Methods@#All HIV-positive patients referred to the Dermatology Department of Hospital Sungai Buloh from January 2021 – December 2021 were enrolled in a prospective cross-sectional study. Patients were subjected to a complete medical and physical examination and appropriate investigation to confirm the diagnosis. @*Results@#A total of 112 (92.6%) male and 9 (7.4%) female patients with a mean age of 38.76 ± SD years participated. The majority of patients were Malay (56.2%), with MSM (54.5%) being the commonest mode of transmission. 65.2% of patients had CD4≥350 cells/ mm3 and 86.7% of patients were on ART. Infections (56.1%) were the most common group of mucocutaneous manifestations, with 45.6% of these due to viral infections. There was no statistically significant correlation between the CD4 count and the severity of skin involvement in bacterial (p=0.302), viral (p=0.145) and fungal (p=0.533) infections.@*Conclusion@#Viral infection were the commonest cutaneous manifestations in HIV- positive patients. The frequency and severity of the cutaneous infections were much more common in patients with more advanced immunosuppression.

Energy and Dietary Intakes in Adult Atopic Dermatitis

@#Introduction: Studies on nutrition among adult AD, a chronic inflammatory skin condition, are lacking. The objective of this cross-sectional study was to investigate the energy, micro and macro nutrient intakes. Methods: Sixty two adult participants defined by the Hanifin-Rajka criteria were included. AD severity was determined using SCORAD index and objective SCORAD. Demographic data and a three-day 24-hour dietary recall were collected and analyzed. Basal metabolic rate (BMR) was estimated using Schofield’s equation. The Energy Intake (EI): BMR ratio was used to identify under reporters (EI:BMR<1.2). To understand food preferences, main food groups consumed, meat (chicken, beef, and pork), seafood (fish, crustaceans, and mollusk), vegetables, fruits, including eggs and milk were examined. To ascertain food avoidance, open ended questions were asked. Results: Significant differences between the severity of AD groups and energy intake, vitamin A, beta carotene, magnesium, and energy intake-basal metabolic rate ratio (EI: BMR) were seen for SCORAD index. Energy intake was significantly lower among severe AD. Vitamin A and magnesium intake was lower among severe AD. Saturated fat intake was higher among mild AD. EI: BMR was inversely correlated with objective SCORAD. Seventy seven percent of participants were under reporters. Almost 10 percent reported avoiding some form of seafood; predominantly form the crustacean or mollusk group. Conclusion: Subjective symptoms, a component of SCORAD index but not objective SCORAD, may have contributed to significant differences seen. Lower energy intake in severe AD was due to reduced dietary intake during flares rather than underreporting.

The Effect of Narrowband Ultraviolet B Phototherapy on Vitamin D Status in Psoriasis Patients with Skin Phototype III, IV and V

Background@#Narrowband ultraviolet-B (NBUVB) is an effective treatment option for psoriasis. Vitamin D insufficiency is common in psoriasis patients. We assessed the effect of NBUVB on vitamin D levels amongst psoriasis patients with skin phototype III, IV and V.@*Methods@#Psoriasis patients planned for NBUVB phototherapy were enrolled in a prospective cohort study in Hospital Putrajaya and Hospital Kuala Lumpur from May 2020-December 2020. NBUVB phototherapy was given twice weekly for 12 weeks. Serum 25 (OH)D level was measured at baseline and at week 12.@*Results@#A total of 21(63.6%) male and 12(36.4%) female patients aged 18-66 years participated. Majority were Fitzpatrick skin phototype (FSP) IV (66.7%) followed by FSP V (21.2%) and FSP III (12.1%). Serum 25(OH)D increased significantly (p<0.001) from 52.09±21.43 nmol/L at baseline to 72.80±19.56 nmol/L at week 12 with the most increment seen in skin type V. There was also a significant improvement seen in Body Surface Area (BSA) involvement after 12 weeks of phototherapy (p<0.001). There was no correlation seen between BSA at week 12 with serum 25(OH)D and percentage of serum 25(OH) D increment.@*Conclusion@#NBUVB phototherapy increases the level of serum 25(OH)D in psoriasis patients with darker skin types while simultaneously clearing psoriasis.

Prick, patch or blood test? A simple guide to allergy testing

@#This article provides information on allergy testing and serves as a simple guide for physicians who are considering using allergy testing as a step in patient management. Basic principles of allergy testing, indications for testing, and how and when to choose a suitable allergy test are discussed. Allergy testing in general refers to evaluation of either type I or type IV hypersensitivity reactions. The type I (immediate) reaction is evaluated using the skin prick test (in vivo) or serum IgE (in vitro) test methods, while the type IV (delayed) reaction is determined via the skin patch test method. The allergens responsible for a specific reaction can be identified from allergy testing, and this information is useful in administering avoidance measures. Appropriate treatment of allergic reactions along with allergen avoidance ensure a successful treatment outcome and prevent future reactions.

Skin eruption induced by dieting – an underdiagnosed skin disease in Malaysia

@#Prurigo pigmentosa is an inflammatory dermatosis characterized by a pruritic, symmetrically distributed erythematous papular or papulo-vesicular eruption on the trunk arranged in a reticulated pattern that resolves with hyperpigmentation. It is typically non-responsive to topical or systemic steroid therapy. The exact etiology is unknown, but it is more commonly described in the Far East countries. Dietary change is one of the predisposing factors. We report on nine young adult patients with prurigo pigmentosa, among whom five were on ketogenic diets prior to the onset of the eruptions. All cases resolved with oral doxycycline with no recurrence. We hope to improve the awareness of this uncommon skin condition among general practitioners and physicians so that disfiguring hyperpigmentation due to delayed diagnosis and treatment can be avoided.

Diagnostic Biopsy Site in Cutaneous Angiosarcoma: Reflections from 3 Cases

Angiosarcoma is a rare, malignant vascular endothelium neoplasm with poor prognosis. Cutaneousangiosarcoma makes up a majority of its presentation. Diagnosis is often delayed due to the nature ofits clinical presentation. We report 3 cases of cutaneous angiosarcoma to focus on the importance ofbiopsy site selection in securing the histopathological diagnosis.

Doctor Shopping Behaviour and Its Predisposing Factors amongst Dermatology Patients / Jurnal Sains Kesihatan Malaysia

@#Doctor shopping increases health economic burden and morbidities. Its prevalence and predisposing factors have to beidentified in order to formulate preventive measures. We aimed to determine the prevalence of doctor shopping, its reasonsand predisposing factors by conducting a cross sectional study of new patients at the Dermatology Clinic, UniversitiKebangsaan Malaysia Medical Centre (UKMMC). Doctor shopping was defined as having consultation with ≥3 healthcareproviders without a referral for the same illness prior to the patients’ visit to UKMMC. Reasons and contributing factorswere classified as disease, healthcare provider, logistic and cost related. Data was collected by a face to face interview.Dermatology Life Quality Index (DLQI) questionnaire determined disease impact on the patients. A total of 58 (55.8%)female and 46 (44.2%) male patients participated. Referral was patient-initiated in 51.9% while 40.4% were doctorshopping. Age, gender, ethnicity, income, occupation and type of health finance provider were not associated with thisbehaviour. About 95% doctor shopped due to disease factors: searching for a cure (95.2%), lack of improvement (88.1%),worsening disease (50.0%), dissatisfaction with treatment (31.0%), seeking other opinions (26.2%) and exploringtreatment options (26.2%). Impaired DLQI (OR 1.17; 95% CI 1.08,1.38), p 0.04, and disease related factors (OR 6.57; 95%CI 1.52, 7.72), p 0.041 were significant independent risk factors. Doctor shopping is very common among our patients.Reasons and predisposing factors are predominantly disease related. Patient education and counselling is important inmanagement of dermatological diseases to prevent doctor shopping.

Acitretin an Additional Treatment Option for Elephantiasis Nostras Verrucosa: A Case Report

Elephantiasis nostras verrucosa occurs due to chronic lymphedema, characterized by cutaneous changes consisting of papillomatous, verrucous, and hyperkerototic lesions. Treatment of elephantiasis nostras verrucosa is challenging and results are often disappointing. We report our experience with a patient who was successfully treated with oral acitretin.

Cardiac Abnormalities in Psoriasis

Introduction: Psoriasis is considered an independent cardiovascular risk factor. This study aims to determine and describe the cardiac abnormalities using echocardiography and electrocardiography in patients with plaque psoriasis. Methods: This is a case control study of psoriasis patients with no previous history of cardiac disease. One hundred and thirty-five patients attending the Dermatology Clinic, Hospital Kuala Lumpur were recruited over one year. A full history, physical examination, echocardiogram and electrocardiogram were done. The controls were 135 age and sex matched healthy individuals. Results: The psoriasis group had a significantly higher body mass index and blood pressure. The echocardiogram showed that the mean left ventricular wall diastolic thickness, aortic annulus diameter and isovolumetric relaxation time of the left ventricle was significantly prolonged, and a higher prevalence of tricuspid regurgitation in psoriasis. On the electrocardiogram, more psoriasis patients had left ventricular hypertrophy, ischaemia and right bundle branch block. The QRS interval was significantly shorter in these patients. The tricuspid valve E/A ratio was significantly lower in patients with psoriatic arthropathy. The mitral valve early filling velocity deceleration time, tricuspid valve E/A ratio and QRS interval were significantly higher among systemic therapy naïve patients. The mean mitral and tricuspid valve E/A ratio were significantly lower; and the mean ascending aorta diameter larger, in those with psoriasis for more than ten years. Conclusion: Psoriasis may be associated with an increased risk of cardiac abnormalities suggesting diastolic dysfunction and tricuspid regurgitation. These abnormalities appear to be related to disease duration. Further studies employing newer echocardiographic and cardiac imaging techniques are needed to validate this.

Identifying the Core Content of a Dermatology Module for Malaysian Medical Undergraduate Curriculum Using a Modified Delphi Method

Background: Dermatology is a minor module in internal medicine undergraduate curriculum. Limited time is allocated for its teaching. Most graduates are inadequately prepared to diagnose and manage skin diseases. We aimed to identify the core content of a more effective dermatology module. Methods: A modified Delphi method was used to reach a consensus. A questionnaire was developed by a selected panel and sent to 20 dermatologists, family physicians and general practitioners (GPs), respectively. They were asked to rate diseases according to importance. The participants then answered the questionnaire again with results of the first round made available to them. The final module content was identified based on the panel’s collective opinions. Results: Eleven topics had mode and median values of 1 with an agreement level of more than 70%. They were as follows: (1) skin structure and function; (2) infections and infestations; (3) the skin in systemic diseases; (4) dermatology emergencies; (5) drug eruptions; (6) psoriasis; (7) eczema; (8) sexually transmitted infections; (9) leprosy; (10) acne; and (11) clinical skills and diagnostic procedures. A total of 56 diseases were identified as important. Conclusion: Results of this study reflect the importance of understanding the influence of regional factors on common and important skin diseases. These topics may be used to develop a more effective dermatology module for the Malaysian undergraduate medical curriculum.

Developing A Dermatology Curriculum For Malaysian Medical Undergraduates: Initial Results Of The Delphi Method

Background: Dermatology in the Malaysian undergraduate medical curriculum is included as a subspecialty subject in Internal Medicine. The dermatology course content for undergraduate varies among the different teaching institutions. A standardized curriculum is required to prepare graduates for clinical dermatological practices in a tropical country and also applicable worldwide. Methods: The Delphi method is used to reach a consensus on the curriculum’s core content. A questionnaire with lists of dermatological conditions was developed by a panel of dermatologists and family physician. A total of 60 participants comprising of 20 dermatologists, 20 family physicians and 20 general practitioners are asked to rate the importance of each dermatological conditions stated in the questionnaire. The same participants then answers the questionnaire again with results of the first round made available to them. The final curriculum content will be identified based on the panel’s collective opinions. Results: We present the results of the first part of the study which is the (questionnaire development). Section 1 of the questionnaire lists 20 topics according to the classification of dermatological diseases and common dermatological diseases. Section 2 expands each classification by listing specific diseases or conditions. There are 4 to 13 diseases identified under each classification. This provides a total of 171 options to be graded by each participant. Section 1 aimed to identify important topics based on the classification and common dermatological diseases. The list of specific diseases aimed to identify the important dermatological conditions or diseases under each classification. Conclusion: A standardized appropriate curriculum in dermatology is required for the Malaysian undergraduate teaching curriculum which is acceptable both locally and internationally. The finding of the study may be used to recommend a standard Malaysian medical undergraduate dermatology curriculum.

Association between smoking and the severity of psoriasis

Introduction: Smoking is a risk factor for development of psoriasis. The severity of psoriasis has also been associated with smoking. Smoking may be an important modifiable factor in psoriasis treatment. Reduction or cessation of smoking in psoriasis patients is relevant as psoriasis is also associated with cardiovascular disease. Objectives: This 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. Method: A 6-month prospective, controlled study. Consecutive patients with chronic plaque psoriasis attending Dermatology Clinic, Kuala Lumpur Hospital were screened. Smokers were identified, 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. Results: A 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 significant 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 significantly higher in the subjects who smoked compared to the non smokers. Conclusion: Smoking 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.