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.

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.