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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.
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Background: Tinea capitis (TC), a fungal infection of the scalp, hair follicles and hair shafts, is common among the paediatric population especially under tropical conditions1. The etiological factors vary between different regions of the world. Clinical presentation of tinea capitis varies widely from non-inflammatory to severe, painful inflammatory lesions. Aim: To look into the clinical manifestations, causative agents and the treatment pattern for tinea capitis in Penang Hospital. Methods: A retrospective study of all patients who were treated clinically for tinea capitis in Penang Hospital from January 2011 to June 2013. Results: There were a total of thirty nine patients treated for tinea capitis during this period. Tinea capitis was found to be most common in the 7-12 year age group (44%) with a male to female ratio of 2:1. Non-inflammatory type (54%) was more common then the inflammatory type. Twenty seven of them (69%) had positive fungal culture of their pluck hair roots. The most common dermatophyte detected was Microsporum canis (92%) followed by Trichophyton rubrum (4%) and Trichophyton metagraphyte (4%). Thirty-one (80%) of them were treated with griseofulvin at a dose of 10-15mg / kg /day. The rest were treated with itraconazole, terbinafine or fluconazole. All of them responded well to the treatment. In this cohort only one patient, has a second episode of infection a year later. He is a child who was concomitantly undergoing chemotherapy for acute lymphoblastic leukaemia. Conclusion: Tinea capitis is predominantly an infection of pre-adolescent children and M. canis was the most common dermatophyte isolated.
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Background Antibiotic therapy directed against Propionibacterium acnes (P. 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. Methods This 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. Results A 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 the highest (15.1%) followed by erythromycin (7.5%), doxycycline (5.7%), tetracycline (1.9%) and minocycline (0%). Isolates of antibiotic resistant P. acnes was significantly 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 significantly 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). Conclusion Antibiotic resistant P. acnes is present locally with clindamycin and erythromycin accounting for 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.
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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.
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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.
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Background Antibiotic 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. Methods This 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. Results A 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 significantly 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 significantly 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). Conclusion Antibiotic 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.
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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.
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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.
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Objective The purpose of this study is to determine the outcome of patients with acne vulgaris treated with oral isotretinoin from January 2003 till January 2008. Methodology This is a 5-year retrospective study of patients with acne vulgaris who were started on oral isotretinoin from January 2003 to January 2008. Only patients who have completed at least 4 months of treatment were included. Case notes were retrieved and analyzed with regards to demographic data, total cumulative dose of oral isotretinoin, duration of treatment, average daily dose of isotretinoin, response, relapse and subsequent treatment. Patients who defaulted follow-up were contacted via phone to ascertain if they had any relapse. Laboratory data that were analyzed included serial liver enzymes, total cholesterol, triglyceride and LDL levels. Results A total of 110 case notes were reviewed but only 83 patients fulfilled the inclusion and exclusion criteria. Average daily dose of isotretinoin was 0.24 mg /kg/day and mean duration of treatment was 9.56 months. Mean total accumulated dose of isotretinoin was 61.96 ± 34.15 mg/kg (range from 11.18 mg/kg to 151.79mg/kg). There were only 6 (7.2%) patients who achieved total accumulated dose of more than 120mg/kg/day. All of our patients responded to treatment with 24 (28.9%) of them were in complete clearance. However, a high percentage (71.2%) of patients developed mucocutaneous side-effects out of which 27.7% required dose reduction. Relapse rate among those who completed treatment and follow up or contactable for at least 6 months post treatment was 24.2% (8 out of 33 patients). There were only 3 (3.6%) patients who developed raised transaminases during treatment but all were less than twice the upper normal limit. Mean total cholesterol, triglyceride and LDL level were significantly raised at 4 months of treatment when compared to the baseline (p<0.05). Conclusion Low dose Isotretinoin (<0.5mg/kg) is an effective treatment for moderate to severe acne vulgaris in our population. All of our patients showed good response to isotretinoin even though some of them relapsed subsequently. Intolerability as a result of mucocutaneous side-effects seems to be a challenging issue when starting isotretinoin in our population.
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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.
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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.
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Cutaneous B-cell pseudolymphoma (CBPL) is a reactive B-cell hyperplasia that clinically and histologically mimics cutaneous B-cell lymphoma (CBCL). Many different terms have been used to describe this condition such as lymphocytoma cutis and cutaneous lymphoid hyperplasia. This condition typically present as a solitary nodule or papule over face (cheek, nose and ear lobe), chest and upper extremities, but multiple lesions may also be present. A variety of stimuli are known to induce this condition but most cases have an unknown cause. We report 2 cases of CBPL, the causes of which could not be ascertained.
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Herpes simplex virus (HSV) infection is one of the common opportunistic viral infections that may occur in human immunodeficiency virus (HIV) - infected patients. The natural history of HSV infection is often altered in this group of patients. Characteristically, genital herpes presents with multiple painful vesicles and erosions in immunocompetent patients. However, clinical presentations in immunocompromised patients are frequently severe and atypical which may lead to a delay in diagnosis and treatment. Genital herpes enhances transmission of HIV infection and hence early detection of this condition is important to reduce transmission of HIV and HSV.
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Background Atopic eczema is a common dermatological condition seen in our practice in which the mainstay of treatment is topical medications. One of the main reasons for poor clinical response to therapy in atopic eczema is the lack of understanding of topical preparation usage and thus poor adherence to treatment. Objectives The aim of this study is to determine the effect of explanation and demonstration of topical medication on the clinical response of atopic eczema. Methodology Twenty newly diagnosed patients with atopic eczema who fulfilled the study criteria were recruited and randomized consecutively into 2 groups - A & B. All patients were assessed on the severity of the eczema using the six area, six sign atopic dermatitis severity score (SASSAD) and patients’ assessment of itch, sleep disturbance and irritability were recorded on 10-cm visual analogue scales. They were also assessed on their level of understanding on the proper usage of topical medications using a questionnaire. Group A then received explanation and demonstration on how to apply the topical medications while Group B was not educated on these. They were followed up 2 weeks after treatment and were re-evaluated on their understanding and the severity of their skin condition. This was followed by education by a dermatology nurse on the proper usage of topical medications for both groups. A third evaluation was done 2 weeks later. Results At baseline, 70% of the patients did not understand the potency of topical corticosteroid and between 20-30% of them did not know the correct sites, frequency, time and duration of each topical application prescribed. About two thirds of the patients claimed that they did not receive any explanation or demonstration from either their doctors or the pharmacy dispensers. After education on the proper usage of topical medications, the level of understanding improved to 100% for group A at visit 2 and group B at visit 3. A clinical improvement as measured by SASSAD score reduction was seen in both groups. In group A, a significant SASSAD score reduction of 49.5% (P=0.003) was seen after 2 weeks and it was sustainable, as evidenced by a further reduction to 67% (p=0.001) by week 4. In group B, a significant SASSAD score reduction (64.8%; p=0.002) was seen only at week 4 after patient education and demonstration. The magnitude of improvement in patients’ symptoms which included itch, sleep disturbance and irritability, measured by the patient using visual analog score, were only significant for group A after 4 weeks. Conclusions This study reinforces the importance of explanation and demonstration on the proper usage of topical medications in achieving better clinical response. Failure to explain on the use of topical medications may lead to patient dissatisfaction, poor compliance and lack of treatment efficacy.
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Background Autoimmune bullous diseases (ABD) represent a group of chronic blistering dermatoses in which management is often challenging. Epidemiologic data on these diseases in Malaysia has been limited. Objectives Our purpose was to study the spectrum of the various ABD presented to the Department of Dermatology, Ipoh Hospital, and to determine the clinico-epidemiological pattern of the 2 main ABD, namely pemphigus and bullous pemphigoid. Methodology We performed a retrospective review of records for all patients who were diagnosed with ABD confirmed by histopathology and direct immunofluorescence test in this centre between 2001 and 2005. The data were analyzed with regard to age, sex, ethnicity, subtypes of ABD, treatment provided and outcome. Results There were a total of 79 cases of ABD presented to us during this period. Bullous pemphigoid was observed to be the commonest (60.8%) followed by the pemphigus group (36.7%) with the mean incidence of 0.45/100,000/year and 0.28/100,000/year respectively.44% of patients were of ethnic Chinese origin. There was an overall female preponderance. The mean age of presentation was 65.5 years for bullous pemphigoid and 55 years for pemphigus group. The mean duration of disease before presentation was 1.6 months for bullous pemphigoid and 6.3 months for pemphigus. Various combinations of immunosuppressive agents were used to treat the patients. 48% of bullous pemphigoid cases were controlled with prednisolone alone while 67.9% of pemphigus group required at least 2 immunosuppressive agents to achieve disease control. Conclusion In our study population, bullous pemphigoid was more frequently seen than pemphigus.