Predictive factors of psoriatic arthritis in a diverse population with psoriasis.

OBJECTIVE: We aimed to analyze the clinical characteristics of patients with psoriasis and determine the predictive factors of psoriatic arthritis (PsA). METHODS: This retrospective cohort study was performed among patients with psoriasis. Demographic and clinical data were collected. Psoriasis treatment was categorized as topical agents, phototherapy, oral therapy, and biologics. Predictive factors of PsA development were determined using logistic regression analyses. RESULTS: We included 330 patients with psoriasis, and 83 (25%) patients developed PsA. Thirty-eight (45.8%) patients who developed PsA were Malay, 24 (28.9%) were Chinese, and 21 (25.3%) were Indian. The mean age of patients with PsA was 54.2 (±15.8) years, and the duration from diagnosis of psoriasis to diagnosis of PsA was 36 (3.5-114) months. Predictive factors for developing PsA were female sex (odds ratio [OR] = 3.33, 95% confidence interval [CI] 1.78-6.22), presence of nail involvement (OR = 5.36, 95% CI 2.50-11.51), severe psoriasis (OR = 27.41, 95% CI 7.58-99.11), and oral systemic therapy prior to PsA diagnosis (OR = 4.09, 95% CI 2.04-8.22). CONCLUSION: Patients with psoriasis who are female, have nail involvement, severe skin psoriasis, and require oral systemic therapy for psoriasis may have an increased risk of developing PsA.

Implementing HLA-B*58:01 testing prior to allopurinol initiation in Malaysian primary care setting: A qualitative study from doctors' and patients' perspective.

INTRODUCTION: Allopurinol, the first-line treatment for chronic gout, is a common causative drug for severe cutaneous adverse reactions (SCAR). HLA-B*58:01 allele was strongly associated with allopurinol-induced SCAR in Asian countries such as Taiwan, Japan, Thailand and Malaysia. HLA-B*58:01 screening before allopurinol initiation is conditionally recommended in the Southeast-Asian population, but the uptake of this screening is slow in primary care settings, including Malaysia. This study aimed to explore the views and experiences of primary care doctors and patients with gout on implementing HLA-B*58:01 testing in Malaysia as part of a more extensive study exploring the feasibility of implementing it routinely. METHODS: This qualitative study used in-depth interviews and focus group discussions to obtain information from patients with gout under follow-up in primary care and doctors who cared for them. Patients and doctors shared their gout management experiences and views on implementing HLA-B*58:01 screening in primary care. Data were coded and analysed using thematic analysis. RESULTS: 18 patients and 18 doctors from three different healthcare settings (university hospital, public health clinics, private general practitioner clinics) participated. The acceptability to HLA-B*58:01 screening was good among the doctors and patients. We discovered inadequate disclosure of severe side effects of allopurinol by doctors due to concerns about medication refusal by patients, which could potentially be improved by introducing HLA-B*58:01 testing. Barriers to implementation included out-of-pocket costs for patients, the cost-effectiveness of this implementation, lack of established alternative treatment pathway besides allopurinol, counselling burden and concern about genetic data security. Our participants preferred targeted screening for high-risk populations instead of universal screening. CONCLUSION: Implementing HLA-B*58:01 testing in primary care is potentially feasible if a cost-effective, targeted screening policy on high-risk groups can be developed. A clear treatment pathway for patients who test positive should be made available.

Dermatological Issues Among Individuals Receiving Palliative Care - A Review.

Skin disorders among individuals receiving palliative care may be associated with the primary condition or underlying comorbidities and patients may experience pruritus, discomfort or pain. Common conditions include xerosis, pressure ulcers, intertrigo, superficial fungal infections, telogen effluvium, pruritus, herpes zoster, eczematous disorders and edema. During end-of-life care, there is reduced skin perfusion and metabolism hence leading to susceptibility to infection, pressure and injury. Other factors affecting the skin include limited mobility, nutritional deficits and immunosuppression. Although treatment strategies for each skin condition are usually aligned with standard protocols, considerations among these patients include limited life-expectancies, potential treatment burden, drug-drug interactions as well as comfort-directed rather than cure-directed therapy. For patients with xerosis cutis, the regular use of moisturisers is recommended. The management and prevention of pressure ulcers include the strategies of skin assessment and care, pressure redistribution, nutrition and hydration and ulcer care. Superficial fungal infections require treatment with appropriate topical and/or systemic antifungals while antivirals and adjunctive treatment can be prescribed for herpes zoster. Treatment and symptom control of skin disorders in this population can improve quality of life and patients' comfort level.

Poor sleep quality in children with atopic dermatitis and its effects on behavior: A multicenter cross-sectional study from a low-middle-income country.

BACKGROUND: Sleep disturbance in children with atopic dermatitis (AD) frequently goes unnoticed and can be associated with behavioral challenges. The aims of this study were to determine (a) the prevalence and factors associated with sleep disturbance and behavioral problems and (b) the correlation between sleep disturbance and behavioral problems in children with AD. METHODS: This cross-sectional study involved children aged 4-12 years old with moderate to severe AD. Age and sex-matched healthy children were recruited as the comparison group. The Children's Sleep Habits Questionnaire (CSHQ) and the Strengths and Difficulties Questionnaire (SDQ) were used to assess sleep disturbance and behavioral problems, respectively. Higher scores in both questionnaires signify more disturbance. RESULTS: Seventy patients and 141 controls were recruited. Median (interquartile range) age of patients was 5 (4,8) years. Patients had later sleep time (p < 0.001), longer night awakening (p < 0.001), and shorter sleep duration (p < 0.001) compared to controls. CSHQ total scores and all its domains, except for sleep-disordered breathing were significantly higher in patients compared to controls. Patients also had significantly higher SDQ total difficulties scores in all domains, except for peer problems. Severity of AD was significantly associated with high CSHQ and SDQ scores. There was a moderate positive correlation between the total CSHQ score and total SDQ score in patients (r = 0.532). CONCLUSIONS: Children with moderate-to-severe AD had significantly more sleep disturbance and more behavioral problems than their healthy peers. Sleep disturbance had a positive correlation with behavioral problems. Severity of AD was associated with sleep disturbance and behavioral problems.

Psychological well-being, quality of life and patient satisfaction among adults with chronic spontaneous urticaria in a multi-ethnic Asian population.

Patients with chronic spontaneous urticaria (CSU) have an increased risk of psychological distress. This cross-sectional study aimed to determine factors associated with psychological burden, quality of life (QoL) and patient satisfaction among adults living with CSU. Participants completed the self-administered Urticaria Activity Score-7 (UAS-7), Depression Anxiety Stress Scale (DASS 21), Dermatology Life Quality Index (DLQI), and Short Assessment Patient Satisfaction (SAPS) questionnaires. Multivariate logistic regression was used to determine the independent predictors of depression, anxiety, stress, QoL and patient satisfaction. From a total of 115 subjects with a median age of 42.6 years, range (19-89 years). 60.9% subjects reported moderate-to-severe CSU, 26.1% reported symptoms of depression, 54.8% had anxiety, 40.0% had stress, and 36.5% reported severely impaired QoL. The median UAS-7 score was 20 (IQR 11-27) while the median score of DLQI was 8 (IQR 4-13). The median score of SAPS was 20 (IQR 17-21). Low-income and severe disease were the significant predictors for depression while severe disease was predictive of impaired QoL and depression. Subjects who were diagnosed at older ages and those who required medical leave due to flares of CSU were less likely to be satisfied with their care. (192 words).

Dermal Cystine Crystals: An Incidental Finding During Mohs Surgery.

ABSTRACT: Cystinosis is an autosomal recessive lysosomal storage disorder with intracellular cystine accumulation caused by mutations in the CTNS gene. We present a case of a 48-year-old woman with a history of cystinosis and squamous cell carcinoma treated with Mohs micrographic surgery where widespread deposition of cystine crystals were noted on frozen sections of the Mohs layers. These were rectangular to polygonal refractile crystals within the cytoplasm of dermal fibroblasts and macrophages which were highlighted by polarized light microscopy. This case illustrates the use of frozen section processing to demonstrate the presence of intracellular cystine crystals. Moreover, because patients with cystinosis may be predisposed to developing carcinomas postrenal transplantation, Mohs surgeons should be aware of this unusual phenomenon when evaluating the slides.

Predictive factors of sun protection behaviour among global airline pilots.

BACKGROUND: Airline pilots face significant ultraviolet radiation exposure resulting in an increased risk of sun damage and skin cancers. We aimed to evaluate sun-protective practices and associated factors among airline pilots. METHODS: We disseminated an online questionnaire evaluating the use of sunscreen, sunglasses, hats and protective clothing during daytime hours in the cockpit and during outdoor activities to 346 global commercial airline pilots, and we received 220 completed responses. The Pearson chi-squared test or Fisher's exact test where necessary were used to determine possible factors associated with the use of sun-protective practices. Potential confounders were adjusted for using multivariate analyses. RESULTS: The most common sun protective behaviour was the wearing of sunglasses during daytime flights (89.5%), followed by the use of caps during outdoor activities (47.7%). More pilots applied sunscreen during daytime flights (14.1%) compared with walk-arounds (8.2%). Males were less likely to use sunscreen during flights (adjusted odds ratio, aOR = 0.76), use sunscreen for walk-arounds (aOR = 0.175) and wear long sleeves (aOR = 0.013). Pilots who flew less than 30 h a month in high latitude regions were less likely to use a cap or hat outdoors (aOR = 0.419) or use sunscreen during walk-arounds (aOR = 0.241). Younger pilots were also less likely to use caps or hats outdoors (aOR = 0.446). CONCLUSION: Male pilots and those who spent less time in high latitudes were less likely to practice sun protection. Targeted educational efforts may be implemented to reduce occupational ultraviolet exposure.

Tinea Imbricata among the Indigenous Communities: Current Global Epidemiology and Research Gaps Associated with Host Genetics and Skin Microbiota.

Tinea imbricata is a unique fungal skin disease that mostly affects indigenous populations in Southeast Asia, Oceania, and Central and South America. The control and management of this disease among these communities are challenging given their remote locations, certain traditional practices, and severe malnutrition status. To date, there are only a handful of reports published globally, which highlights the need for a more holistic approach in addressing this skin disease. Several bodies of evidence and reports have shown that host genetic factors have a profound influence on the pathogenesis of tinea imbricata, while skin microbiota is touted to have a role in the pathogenesis of the disease. However, there are limited studies of how host genetics and skin microbiota impact disease susceptibility in the host. To improve the understanding of this disease and to find possible long-term effective treatment among the affected indigenous communities, a comprehensive literature review is needed. Hence, this review paper aims to present the current status of tinea imbricata among the indigenous communities, together with published findings on the possible underlying reasons for its specific distribution among these communities, particularly on the ways in which host skin microbiota and host genetics affect occurrence and disease patterns. This information provides valuable insights for future research by highlighting the current knowledge gaps in these areas.

Sexual difficulties and associated factors among patients with psoriasis in Malaysia: data from the Malaysian Psoriasis registry.

The impact of psoriasis on quality of life may have implications for the sexual function of patients. We aimed to determine the frequency of sexual difficulties and associated factors among adult patients with psoriasis. This cross-sectional study involved 13 673 patients notified to the Malaysian Psoriasis Registry. Sexual function was defined based on the Dermatology Life Quality Index (DLQI). Sexual difficulties were reported among 9.5% of subjects with significant predictors identified as younger age, male gender, married status, ethnicity, nail involvement, face and neck involvement and severity of disease. Smokers were more likely to report experiencing sexual difficulties. However, the presence of either ischemic heart disease, diabetes mellitus, hypertension or dyslipidemia was associated with lower odds of sexual issues due to psoriasis. Clinicians should be aware of factors associated with sexual health in psoriasis to implement targeted interventions. Further studies need to be conducted to delineate the different aspects of sexual function and the magnitude of the problem.

Fibroblast-derived matrices-based human skin equivalent as an in vitro psoriatic model for drug testing.

Psoriasis is a chronic skin disease characterized by thickening and disorganization of the skin's protective barrier. Although current models replicate some aspects of the disease, development of therapeutic strategies have been hindered by absence of more relevant models. This study aimed to develop and characterize an in vitro psoriatic human skin equivalent (HSE) using human keratinocytes HaCat cell line grown on fibroblasts-derived matrices (FDM). The constructed HSEs were treated with cytokines (IL-1α, TNF-α, IL-6, and IL22) to allow controlled induction of psoriasis-associated features. Histological stainings showed that FDMHSE composed of a fully differentiated epidermis and fibroblast-populated dermis comparable to native skin and rat tail collagen-HSE. Hyperproliferation (CK16 and Ki67) and inflammatory markers (TNF-α and IL-6) expression were significantly enhanced in the cytokine-induced FDM- and rat tail collagen HSEs compared to non-treated HSE counterparts. The characteristics were in line with those observed in psoriasis punch biopsies. Treatment with all-trans retinoic acid (ATRA) has shown to suppress these effects, where HSE models treated with both ATRA and cytokines exhibit histological characteristics, hyperproliferation and differentiation markers expression like non-treated control HSEs. Cytokine-induced FDM-HSE, constructed entirely from human cell lines, provides an excellent opportunity for psoriasis research and testing new therapeutics.

Ocular surface disease in psoriatic patients in a developing country.

PURPOSE: To evaluate ocular surface changes among patients with psoriasis in Malaysia, a developing country in Southeast Asia. METHODS: An interdisciplinary case-control study (60 psoriasis patients and 40 control subjects) to look at the differences in ocular surface manifestations between patients with psoriasis and a group of age-, gender- and ethnicity-matched healthy controls. RESULTS: One hundred and twenty eyes of 60 patients with psoriasis and 80 eyes of 40 healthy controls without psoriasis were included in the study. Mild-to-moderate psoriasis was found in 42 patients (70%), while 18 patients (30%) had severe psoriasis. Psoriatic arthritis was found in 19 patients (32%). Of the 60 psoriatic patients, the prevalence of ocular involvement was 65% (39/60), in which 32% (19/60) had dry eyes, 27% (16/60) had lid margin abnormalities, 33% (20/60) had cataract, and one had history of anterior uveitis. Compared to controls, ocular surface of psoriatic patients showed more eyelid margin abnormalities, higher meibomian gland loss and lower tear film break-up time. The estimated odds ratio for dry eyes in the psoriasis group was 2.2 (95% CI: 0.8-6.9). CONCLUSION: Ocular surface disorders encompassing eyelid margin abnormalities, meibomian gland loss and tear dysfunction occur at an earlier and higher rate among psoriatic patients.

Cutaneous manifestations of patients with Human Immunodeficiency Virus (HIV) Infection: A retrospective review of a tertiary referral centre with clinicopathological correlation.

INTRODUCTION: The majority of patients with Human Immunodeficiency Virus (HIV) will have cutaneous manifestation during their disease course. We report the spectrum of cutaneous manifestations and clinicopathological concordance in the diagnosis of skin diseases in patients with HIV. METHODS: A retrospective review of all cutaneous manifestations of HIV-infected patients with skin biopsy-proven histopathological confirmation, treated in the University of Malaya Medical Centre, from 2016 till 2018, was performed. Clinical characteristics and histopathological correlation of these patients were reviewed. RESULTS: A total of 38 cases were included where the median age was 40.5 (interquartile range (IQR) 13.3). The median duration of HIV diagnosis to the development of skin disease was 3 years (IQR 7.8). Majority of our patients were male (89.5%, n = 34), and the commonest mode of transmission is men who have sex with men (36.8%, n = 14). Most patients (92.1%, n = 35) had Acquired Immunodeficiency Syndrome when they presented with skin diseases, predominantly non-infectious types (51.4%, n = 19). Commonest skin diseases include eczema (n = 7) and pruritic papular eruption of HIV (n = 6). Papules and plaques were the commonest morphology for both infectious and non-infectious skin diseases. Duration of HIV diagnosis (P = 0.018) and non-compliance to Highly Active Antiretroviral Therapy (HAART) (P = 0.014) were significantly associated with the development of non-infectious skin diseases. Overall, clinicopathological concordance was 84.2% in our centre. CONCLUSION: A wide spectrum of cutaneous diseases can occur in HIV patients depending on the degree of immunosuppression. skin biopsy along with appropriate stains, and microbiological cultures are important in helping clinicians clinch the right diagnosis.

Anticipating local flaps closed-form solution on 3D face models using finite element method.

A realistic three-dimensional (3D) computational model of skin flap closures using Asian-like head templates from two different genders, male and female, has been developed. The current study aimed to understand the biomechanics of the local flap designs along with the effect of wound closures on the respective genders. Two Asian head templates from opposite genders were obtained to use as base models. A third-order Yeoh hyperelastic model was adapted to characterize as skin material properties. A single layer composed of combined epidermis and dermis was considered, and the models were thickened according to respective anatomical positions. Each model gender was excised with a fixed defect size which was consequently covered by three different local flap designs, namely advancement, rotation, and rhomboid flaps. Post-operative simulation presented various scenarios of skin flap closures. Rotation and rhomboid flaps demonstrated maximal tension at the apex of the flap for both genders as well as advancement flap in the female face model. However, advancement flap closure in the male face model was presented otherwise. Yet, the deformation patterns and the peak tension of the discussed flaps were consistent with conventional local flap surgery. Moreover, male face models generated higher stresses compared to the female face models with a 70.34% mean difference. Overall, the skin flap operations were executed manually, and the designed surgery model met the objectives successfully while acknowledging the study limitations. NOVELTY FILE: 3D head templates were considered to address the gap as 3D face models were uncommonly employed in understanding the biomechanics of the local flaps realistically. Most of the existing studies focus on the 2D and 3D planar geometry in their models. As gender comparison has yet to be addressed, we intended to fill this gap by exploring the stress contours of the local flap designs in different genders. Create a 3D face model from two opposite genders which is capable of simulating closure of wounds using local flaps with a focus on advancement, rotation, and rhomboid flaps.

Self-reported generalised pruritus among community-dwelling older adults in Malaysia.

BACKGROUND: The ageing skin is more susceptible to pruritic dermatoses, which are associated with adverse psychosocial effects and reduced quality of life among older adults. This cross-sectional study aimed to identify the burden of pruritus and factors associated with its presence and severity among older adults recruited to the Malaysian Elders Longitudinal Research study. METHODS: Seven hundred seventy individuals aged 55 years (lower age limit) and above were interviewed as to whether they experienced pruritus during the preceding week and the locations involved if present. The association between generalised pruritus, sleep quality, and major systemic risk factors were explored. RESULTS: 5.97% of respondents reported generalised pruritus. Generalised pruritus was associated with poorer sleep quality, with Pittsburgh Sleep Quality Index score above 6. Mean haemoglobin level was lower in subjects with generalised pruritus (13.14 g/dL) but there was no significant difference in the frequency of generalised pruritus and severe generalized pruritus between subjects with clinically defined anaemia. Also, there were no significant associations between other major systemic risk factors and generalised pruritus in this population-based study. There was no association between generalised pruritus with depression, anxiety or stress. CONCLUSION: The negative effect of pruritus on sleep quality suggests a possible deleterious effect of pruritus on health and quality of life. Further prospective research on the longer-term effects of pruritus on health status is now warranted. (222 words).

Analysis of Internet searches using Google Trends to measure interest in sun protection and skin cancer in selected South-East Asian populations.

BACKGROUND: Analysis of Internet search trends has been performed to evaluate interest in sun protection, artificial tanning, and skin cancers among the public, particularly in Western countries. This observational study aimed to investigate the relative popularity of search terms relating to sun protection, sunburn, skin cancers, and tanning used in Google Trends® in three South-East Asian countries (Malaysia, Singapore, and Indonesia). METHODS: The relevant search terms were queried using the Google Trends® in each location and worldwide. The search volume indices were compared between locations and over a time period from January 1, 2004, to January 31, 2019. Correlations between "sunblock" and "sunburn" as well as "sunblock" and search terms relating to skin cancers ("skin cancer," "melanoma," "basal cell carcinoma," and "squamous cell carcinoma") were evaluated. RESULTS: The favored search term relating to sun protection in this region was "sunblock" despite the term itself being a misnomer. The relative popularity of searches for "sunblock" also showed an increase over time and was generally higher compared with interest in sunburn, skin cancers, and artificial tanning practices. Positive correlations were noted between "sunblock" and "sunburn" in Malaysia and "sunblock" and "melanoma" in Singapore. CONCLUSION: Insights into search trends may assist public health promotion to raise awareness regarding sun protection and skin cancers in the region by targeting commonly used terms for each geographical location.

Characteristics of skin cancers among adult patients in an urban Malaysian population.

There has been a rising incidence of skin cancers among Asians in recent years. We present a retrospective analysis of 106 skin cancers and analysed the demography, clinical subtypes of skin cancers and surgical techniques used for skin cancer treatment. In our population, skin cancers were most frequently basal cell carcinomas and diagnosed among ethnic Chinese patients.

Metformin as an adjunct therapy for the treatment of moderate to severe acne vulgaris: A randomized open-labeled study.

Insulin, insulin-like growth factor-1 (IGF-1) and essential amino acids activate the mechanistic target of rapamycin complex 1 (mTORC1), the main nutrient-sensitive kinase. Metformin, through inhibition of mTORC1 may improve acne. A 12-week, randomized, open-labeled study evaluated the efficacy and safety of metformin as an adjunct for moderate to severe facial acne. In total, 84 patients received either oral tetracycline 250 mg bd and topical benzoyl peroxide 2.5% with or without metformin 850 mg daily. Evaluations constituted lesion counts, the Cardiff Acne Disability Index (CADI), metabolic parameters and treatment success rate (Investigators Global Assessment score of 0 or 1 or improvement of two grades). Treatment success rates were higher in the metformin group (66.7% vs. 43.2%; p = .04). The mean percentage reduction from baseline in total lesion counts at Week 12 was greater in the metformin group (71.4% vs. 65.3%; p = .278). The CADI scores showed a greater mean reduction in the metformin group (4.82 vs. 4.22; p = .451). Metformin was equally efficacious in improving acne in lean and overweight subjects. Gastrointestinal symptoms were noted in 31.7% of subjects on metformin. This study presents favorable data for metformin as an adjunct for acne treatment. Further randomized placebo-controlled studies are required.

Determinants of quality of life and psychological status in adults with psoriasis.

We investigated whether disease severity and clinical manifestations were associated with depression, anxiety, stress and quality of life in adults with psoriasis. Participants were recruited from a dermatology outpatient clinic at a teaching hospital. Information on sociodemographic characteristics, disease severity, presence of arthropathy and head involvement was specifically recorded. Disease severity was assessed using the Psoriasis Area and Severity Index (PASI). Quality of life and psychological symptoms were measured using the Dermatology Life Quality Index (DLQI) and the Depression Anxiety Stress Scale (DASS), respectively. One hundred individuals were recruited. Unadjusted analysis revealed that head involvement was associated with depression [odds ratio (OR) 8.509; 95% confidence interval (CI) 1.077-67.231] and anxiety (OR 6.46; 95% CI 1.401-29.858). Severe disease was associated with a poorer quality of life compared to mild disease (OR 3.750; 95% CI 1.330-10.577). Younger age was associated with an increased risk of depression [mean difference (MD) - 8.640; 95% CI - 16.390 to - 0.890], anxiety (MD - 11.553; 95% CI - 18.478 to- 4.628), stress (MD - 11.440; 95% CI - 19.252 to - 3.628) and severely impaired quality of life (MD - 12.338; 95% CI - 19.548 to - 5.127). Following adjustments for age and disease severity, anxiety, stress and depression remained associated with severely impaired quality of life.