A prospective cross-sectional study of anxiety and depression in patients with psoriasis in Singapore.

BACKGROUND: Psoriasis has a negative psychological impact on patients, and may have repercussions on treatment outcomes. Despite this, the degree to which psoriatic patients suffer from psychiatric disorders has not received much attention in Singapore. OBJECTIVE: This prospective cross-sectional study was conducted to determine the frequency of anxiety and depression in a cohort of Singaporean patients with psoriasis, and explore its relationship with regards to physical disease severity and subjective quality of life. METHODS: 100 patients aged 21-60 years old who visited the National Skin Centre, Singapore from 2008 to 2009 were enrolled into the study. Anxiety and depression were quantified using the Hospital Anxiety and Depression Scale (HADS). Disease severity was quantified with the Psoriasis Area Severity Index (PASI) and quality of life measured with the Short Form (36) Health Survey (SF-36). RESULTS: Using the HADS, the mean score for anxiety was 6.9 and that for depression was 4.7. An anxiety disorder was suggested in 17%, while a depressive disorder was suggested in 15% of the study population. All eight domains of the SF-36 were significantly correlated with both anxiety and depression scores. Patients with moderate or severe psoriasis (on PASI) had worse depression scores than those with mild psoriasis. No association was found between anxiety scores and PASI. Neither was any significant correlation seen between anxiety and depression scores vs. patients' age, monthly income and duration of psoriasis. CONCLUSION: This study demonstrates the strong psychiatric morbidity in patients with psoriasis, for which further psychiatric evaluation should be considered.

Filaggrin mutations are associated with recurrent skin infection in Singaporean Chinese patients with atopic dermatitis.

BACKGROUND: Loss-of-function (null) mutations within the filaggrin (FLG) gene are a strong risk factor for atopic dermatitis (AD). We hypothesized that the absence or reduction of the filaggrin protein could compromise skin barrier and increase patients' susceptibility to recurrent skin infection. OBJECTIVES: To investigate the association between FLG-null mutations and the risk of recurrent skin infection among a series of patients with AD in Singapore. METHODS: This study included 228 Singaporean Chinese patients with AD with at least 1year of follow-up at the time of recruitment between January 2008 and December 2009 at the National Skin Centre in Singapore. Each patient had their medical records reviewed for history of skin infection in the preceding year and was genotyped for 22 FLG-null mutations. RESULTS: Compared with those without the FLG-null mutations, patients with AD who had FLG mutation(s) had approximately a seven times increased risk of more than four episodes of skin infection requiring antibiotics in the past year (odds ratio 6·74; 95% confidence interval 2·29-19·79). This risk was much greater in those with mild or moderate disease, and was present in both users and nonusers of oral steroids. CONCLUSION: This study highlights a novel association between FLG-null mutations and an increased susceptibility to recurrent bacterial skin infection among patients with AD.

Juvenile psoriasis in European and Asian children: similarities and differences.

BACKGROUND: The first manifestations of psoriasis begin in childhood in more than one-third of patients. However, epidemiological data of juvenile psoriasis are lacking. OBJECTIVES: To compare Dutch (NL group) and Singaporean (SG group) children with psoriasis with the aim of studying the characteristics of juvenile psoriasis and to highlight similarities and differences between these different ethnic groups. METHODS: Data were collected from 207 patients younger than 18 years diagnosed with psoriasis from Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands and the National Skin Centre, Singapore. RESULTS: A striking difference in familial distribution was found, with more Dutch children having an affected family member (73·3% vs. 13·6%). Presence of itch and triggering factors were more common among Dutch children (80% vs. 14·2% and 33·3% vs. 7·4%, respectively). However, both groups shared similar triggering factors like stress and infections. Other similarities included mean age at presentation (NL group 11·3 years; SG group 14·1 years) and gender ratio (NL group, M/F 1 : 1·1; SG group, M/F 1 : 1·4). Plaque psoriasis was the most common type in both cohorts while guttate and pustular psoriasis were rare. In both groups, the head, followed by the limbs, was the most common site involved. Similar proportions of children in both countries had nail involvement and psoriatic arthritis was rare. CONCLUSIONS: The disparity in familial distribution may point to genetic differences between the two groups. Further studies to evaluate this difference in familial distribution may contribute to the understanding of the pathogenesis of psoriasis.

Wide spectrum of filaggrin-null mutations in atopic dermatitis highlights differences between Singaporean Chinese and European populations.

BACKGROUND: Null mutations in the filaggrin gene (FLG) cause ichthyosis vulgaris (IV) and predispose to atopic dermatitis (AD). Cohort studies in Europe and Japan have reported an FLG mutation carrier frequency of between 14% and 56%, but the prevalent European FLG mutations are rare or absent in Chinese patients with IV and AD. OBJECTIVES: To investigate further the spectrum of FLG-null mutations in Chinese patients and to compare it with that in other populations. METHODS: We conducted comprehensive FLG genetic analysis in a discovery cohort of 92 Singaporean Chinese individuals with IV and/or moderate-to-severe AD. All detected FLG mutations were then screened in a cohort of 425 patients with AD and 440 normal controls. Results In total, 22 FLG-null mutations, of which 14 are novel, were identified in this study; the combined null FLG genotype of 17 mutations detected in cases and controls showed strong association with AD [Fisher's exact test; P = 5·3 × 10⁻9; odds ratio (OR) 3·3], palmar hyperlinearity (Fisher's exact test; P = 9·0 × 10⁻¹5; OR 5·8), keratosis pilaris (Fisher's exact test; P = 0·001; OR 4·7) and with increased severity of AD (permutation test; P = 0·0063). CONCLUSIONS: This study emphasizes the wider genetic landscape of FLG-null mutations in Asia that is slowly emerging.

The influence of childhood atopic dermatitis on health of mothers, and its impact on Asian families.

This study examines maternal perceptions of paediatric atopic dermatitis (AD) on family and determines risk factors including severity of AD, maternal physical and mental health (MH), quality of life of patients and sociodemographics which predict a negative family impact. A cross-sectional assessment using the Dermatitis Family Impact Questionnaire Scale to assess the impact of AD on family, Infant's Dermatitis Quality of Life Index (<5-yrs old) or Children's Dermatitis Life Quality Index (5-17 yrs old) was used to measure health-related quality of life (HRQOL) of paediatric patients with AD. A 12-item Short-Form Health Survey (SF-12) was used to assess physical and MH of their mothers. Risk factors of adverse family impact were assessed using multiple regression analysis. One hundred and four patients with AD and their mothers were studied. Their mean ages (+/-s.d.) were respectively 6.4 +/- 4.3 and 37.2 +/- 6.6 yrs. In multiple regression analysis, Severity Scoring of Atopic Dermatitis (SCORAD) appeared to be associated with negative family impact and the association remained significant after adjustment for bio-psycho-social factors and HRQOL of patients. The association remained insignificant after adjustment for physical and MH of the mothers. Our results show that the severity of paediatric AD leads to negative family impact through reduction of physical and MH of the mothers, and is independent of patients' HRQOL and sociodemographics. The current approach for managing paediatric AD in Asian society could include early multidisciplinary intervention, aiming at enhancing physical and MH of mothers while minimizing negative impact on family and social isolation. Further research will be welcomed as the results of this study mainly applied to Asian society which could be different to populations from other geographic areas.

Guidelines of care for cutaneous haemangiomas.

INTRODUCTION: Haemangiomas are common benign tumours of the vascular endothelium. They are extremely heterogenous clinically, with size, location and rate of proliferation having a significant effect on the risk of complications. MATERIALS AND METHODS: The available evidence in the literature was evaluated using the grading system currently employed by the Ministry of Health, Singapore. RESULTS: An uncomplicated haemangioma can be observed for spontaneous involution. However, some haemangiomas may be life- or function-threatening, or have associated structural anomalies. Corticosteroids may be used topically, intralesionally or systematically. Interferon alpha, vincristine and cyclophosphamide are therapeutic options for complicated haemangiomas which do not respond to corticosteroids. Vascular-specific pulse dye laser therapy may be considered for superficial haemangiomas, ulcerated haemangiomas or post-involution sequelae like telangiectasia. The mainstay of therapy for ulcerated haemangiomas is good local wound care, analgesics and treatment of secondary infection. A periorbital haemangioma that obstructs the visual axis or exerts pressure on the globe is an ocular emergency. Systemic corticosteroids and patching of the unaffected eye should be considered. CONCLUSIONS: Medical practitioners should be aware of available therapeutic options for life- or function-threatening haemangiomas. Treatment must be individualised and referral to the relevant specialist should be considered in patients with complicated haemangiomas.

Cyclosporin in the treatment of severe atopic dermatitis: a retrospective study.

INTRODUCTION: The aims of this study were to determine the clinical profile of patients with atopic dermatitis who were treated with cyclosporin, and to assess the treatment duration, dose and response to cyclosporin therapy. MATERIALS AND METHODS: Casenotes of patients with atopic dermatitis treated with cyclosporin from January 2000 to February 2002 were analysed. RESULTS: There were 15 patients (9 males and 6 females) (age range, 1 to 58 years). All had severe disease. The mean initiating dose of cyclosporin was 2.8 mg/kg/day and the mean maximum dose was 3.3 mg/kg/day. Average duration of treatment was 6 months. Rapid improvement was seen within the first 2 weeks and maximum benefit was attained at a mean of 10 weeks. At the end of treatment, 73 % of patients had improved from severe to none, mild or moderate disease. Five patients had a flare of eczema during therapy, 3 related to decrease in dose of medication. All patients relapsed within 3 months of cessation of cyclosporin. One patient with borderline hypertension developed worsening of blood pressure, which returned to baseline after cessation of cyclosporin and treatment with atenolol. No patient had sustained rises in serum creatinine. CONCLUSION: Cyclosporin is very useful in patients with severe, recalcitrant atopic dermatitis who have failed conventional therapy. It offers rapid relief of an otherwise disabling skin disease, but its effect is not long-lasting and relapses occur in almost all cases if followed up for long enough.

Viral warts in children seen at a tertiary referral centre.

INTRODUCTION: This study aims to determine the epidemiology of viral warts in children seen at a tertiary referral centre and the treatments used. MATERIALS AND METHODS: This is a retrospective study of viral warts in children aged 12 years and below seen at the National Skin Centre in the year 2000. RESULTS: There were 302 cases of viral warts, 187 (61.9%) in boys and 115 (38.1%) in girls. The greatest number was seen at age 12 and none were noted in those below 1 year of age. The racial breakdown was as follows: 69.9% Chinese, 13.9% Malays, 11.3% Indians and 4.9% of other ethnic groups. Treatment with liquid nitrogen was used most commonly in 267 (88.4%) cases, with a clearance rate of 48.3%. Electrocautery was used in 11 cases with complete clearance in 8 cases. CONCLUSION: Viral warts are common in children, but uncommon in infants. There is no difference in distribution of warts among the races in Singapore. Liquid nitrogen and electrocautery are effective treatments of viral warts in children.

Lymphomatoid papulosis associated with recurrent cutaneous T-cell lymphoma.

INTRODUCTION: Lymphomatoid papulosis is a chronic benign disease which may be associated with malignant lymphomas. This case illustrates the relapsing and remitting nature of both lymphomatoid papulosis and its potential of developing cutaneous T-cell lymphoma and narrow-band ultraviolet B (NB-UVB) phototherapy as a new modality of treatment of early-stage mycosis fungoides in these patients. CLINICAL PICTURE: A 44-year-old woman has had recurrent crops of papules and nodules of lymphomatoid papulosis on the limbs for 15 years. Histological features are consistent with the type B lesions of lymphomatoid papulosis. Eight years after the initial onset of these lesions she developed cutaneous T-cell lymphoma (mycosis fungoides). Since then, she has had recurrence of mycosis fungoides following the cessation of phototherapy, but had no evidence of systemic involvement. TREATMENT: The lesions of lymphomatoid papulosis responded to intermittent courses of oral methotrexate. Mycosis fungoides was treated with oral psoralen and ultraviolet A phototherapy with good response. Unfortunately, the lesions relapsed, whenever phototherapy was discontinued. The most recent recurrence of mycosis fungoides was treated with NB-UVB therapy. OUTCOME: The papules of lymphomatoid papulosis continue to appear but she remains free of lesions of mycosis fungoides, 10 months after cessation of NB-UVB therapy. CONCLUSION: Long-term surveillance is essential in all cases of lymphomatoid papulosis as accurate predictors for the development of malignant lymphoma in these individuals are still lacking.

Folliculitis decalvans--a retrospective study in a tertiary referred centre, over five years.

Folliculitis decalvans is a rare condition affecting mainly the scalp leading to scarring alopecia. Aetiology of the condition is still unknown, abnormal host response to Staphylococcus aureus has been postulated. We present a retrospective analysis of six cases of folliculitis decalvans presented to National Skin Centre (NSC), Singapore for the past five years, 1995-2000. The mean age of presentation was 39 years and ages ranged from 17 to 62 years. There were five male patients and one female patient. Duration of symptoms at presentation varied from six months to seven years. Occipital and vertex areas of the scalp were the only regions involved. Staphylococcus aureus was isolated in three patients; in one patient culture yielded negative results and no culture was done in the other two patients. All our patients were treated with several separate courses of systemic antibiotics which include doxycycline, erythromycin, minocycline, co-trimoxazole, cloxacillin, erythromycin, rifampicin and clindamycin. In addition one patient was treated with fucidic acid and zinc sulphate. The disease ran a protracted course with temporary improvement while on antibiotic and flare up of disease when antibiotics were stopped. The effectiveness of early treatment with rifampicin has been highlighted in some case reports in the past. We did use rifampicin in one of our patients. Our concern over emergence of antibiotic resistance, if used widely, may not permit us to use rifampicin on a wide scale.

Marie Unna hypotrichosis in a Chinese family.

Marie Unna hypotrichosis is a rare, autosomal dominant hypotrichosis characterized by sparse or absent hair at birth with regrowth of coarse, wiry hair from childhood, followed by progressive loss on approaching puberty. We report a Chinese mother and child seen at our skin center with features of Marie Unna hypotrichosis. The family pedigree showed two affected sisters and one affected brother, consistent with an autosomal dominant mode of inheritance. The clinical, genetic, histologic, and ultrastructural features were consistent with the diagnosis of Marie Unna hypotrichosis. This is the first Chinese family reported.

The prevalence and descriptive epidemiology of atopic dermatitis in Singapore school children.

BACKGROUND: Atopic dermatitis is a common disease that appears to be increasing in frequency during recent decades. Most of the studies are based on the Western population, and there are few data in the Asian population. OBJECTIVES: To determine the prevalence and descriptive epidemiology of atopic dermatitis among school children in the general community in Singapore. METHODS: This is a questionnaire study of 12 323 students done over a 1-year period, comprising 7 year olds (4605), 12 year olds (3940) and 16 year olds (3778) from 19 primary and 17 secondary schools randomly selected in Singapore. All children had a complete cutaneous examination. The diagnosis of atopic dermatitis was based on the U.K. Working Party diagnostic criteria. The questionnaire was translated into Chinese and both the English and Chinese versions were issued simultaneously to the students. RESULTS: The 1-year period prevalence of atopic dermatitis was 20.8%. Atopic dermatitis was present in 22.7% of 7 year olds, 17.9% of 12 year olds and 21.5% of 16 year olds. The overall sex ratio was equal. There were slightly more boys with atopic dermatitis among the younger children (6 and 12 year olds, 1.18 : 1 and 1.19 : 1, respectively) but more girls were affected (1.57 : 1) among the 16 year olds. Atopic dermatitis was more common among the Chinese (21.6%) and Malays (19.8%) compared with the Indians (16%) and other races (14%). The onset of the disease occurred before the age of 10 years in 49.5% of the 16 year olds. "Pure" atopic dermatitis without concomitant respiratory allergies was noted in 788 respondents (30.7%); 1775 (69.3%) suffered from a "mixed" type, with 34.3% having allergic rhinitis, 9.5% having asthma and 25.5% having both asthma and allergic rhinitis. More boys had atopic dermatitis and concomitant respiratory allergies whereas more girls were affected with "pure" atopic dermatitis alone (1.4 : 1). At least one first-degree family member with atopy was noted in 1435 children (56%): atopic dermatitis (70%), asthma (62%) and allergic rhinitis (68%). Among siblings with one parent with atopic dermatitis, 37% had either a father or a mother with atopic dermatitis. Common aggravating factors reported included exercise, heat and sweating, grass intolerance, thick clothing and stress. Pityriasis alba was noted in 25% of the study population, keratosis pilaris in 13% and ichthyosis vulgaris in 8%. Most respondents had mild to moderate atopic dermatitis that could be controlled with a fairly simple regimen of moisturizers, topical steroids, antihistamines and antibiotics. CONCLUSIONS: The high prevalence of atopic dermatitis in Singapore is similar to that observed in developed countries, suggesting that environmental factors may be important in determining the expression of the disease.

A retrospective study of incontinentia pigmenti seen at the National Skin Centre, Singapore over a 10-year period.

INTRODUCTION: Incontinentia pigmenti is a rare X-linked dominant disease which affects the ectodermal tissues, usually lethal in males. MATERIALS AND METHODS: A retrospective analysis of clinical data obtained from the photographic documentation and casenotes of patients diagnosed to have incontinentia pigmenti at the National Skin Centre. The study covered the period from January 1990 to December 1999. RESULTS: Twenty-six patients were diagnosed to have incontinentia pigmenti of the Bloch-Sulzberger type; 23 (88.5%) were females and 3 (11.5%) were males. There were 20 Chinese, 3 Malay and 3 Indian patients. Most patients had cutaneous manifestations at birth or within the first week of life. Cutaneous features included vesicles, papules, verrucous plaques and splash-like hyperpigmentation along the lines of Blaschko. The cutaneous lesions were widespread in 21 (81%) and localised in 5 (19%) patients. In some cases, hypopigmented atrophic streaks (2 patients) or whorled scarring alopecia (4 patients) were seen. Extracutaneous manifestations, seen in 5 (19%) patients, included neurological, dental and ocular defects. One Malay girl had severe neurological involvement associated with ocular abnormalities. A positive family history was present in 6 (23%) patients. The 3 male patients were Chinese without any family history. CONCLUSIONS: Each stage of the disease comes with its own set of differential diagnosis, including infections e.g. herpes virus infection and other types of genodermatoses e.g. linear and whorled nevoid hypermelanosis. The phenomenon of whorled scarring alopecia, hitherto unreported in the literature, corresponded to the lines of Blaschko. In the 3 Chinese male patients, the disorder probably originated from a new mutation. X chromosome inactivation in females during early embryogenesis results in a mosaic population of cells and this explains the linear and patchy manifestations of incontinentia pigmenti.

A retrospective study of melanocytic naevi at the National Skin Centre.

INTRODUCTION: A retrospective study of melanocytic naevi was undertaken to assess the degree of clinico-pathological correlation and incidence of histological atypia. MATERIALS AND METHODS: The case records from January to March 1996 of all patients with histologically diagnosed melanocytic naevi at the National Skin Centre were analysed. RESULTS: Of the 240 lesions removed from 167 patients, the majority being women (111/167 patients), it was found that 55% (132/240) were correctly diagnosed. Fourteen per cent were mistaken for non-melanocytic lesions, namely skin tag, neurofibroma, syringoma cylindroma, epidermal naevus, naevus sebaceous and basal cell carcinoma. Most of the lesions were located on the cheeks and eyelids. Junctional naevi, followed by compound naevi were often missed. Histological dysplasia were seen in 7 naevi; 6 compound and 1 congenital naevi. There was a lack of clinico-pathological concordance in dysplastic naevi. CONCLUSIONS: The clinico-pathological concordance of melanocytic naevi was high, with low incidence of atypia on histology.

Pseudopili annulati in a dark-haired individual: a light and electron microscopic study.

We report pseudopili annulati for the first time in a dark-haired Chinese girl. The hair was elliptical in shape and twisted along its long axis. The banded or ringed appearance was due to incident light being reflected by the flattened segments. Banding was also noted under polarized light but was not present under transmitted light. Under transmitted light the whole length of the hair appeared dark and the thickness varied at regular intervals, giving rise to fusiform segments due to the twisted nature of the hair shaft. Scanning and transmission electron microscopic examinations revealed no abnormalities in the cuticle and cortex.