Morphoea following COVID-19 vaccination.

We present a case of generalized morphoea developing after recent COVID-19 mRNA vaccination and suggest the plausible pathomechanisms.

Patients' Experiences of Telemedicine for Their Skin Problems: Qualitative Study.

BACKGROUND: Teledermatology is a cost-effective treatment modality for the management of skin disorders. Most evaluations use quantitative data, and far less is understood about the patients' experience. OBJECTIVE: This qualitative study aimed to explore patients' perceptions of a teledermatology service linking public primary care clinics to the national specialist dermatology clinic in Singapore. A better understanding of patients' experiences can help refine and develop the care provided. METHODS: Semistructured in-depth interviews were conducted with patients who had been referred to the teledermatology service. The interviews were digitally recorded and transcribed before undergoing thematic content analysis. RESULTS: A total of 21 patients aged between 22 and 72 years were recruited. The following 3 themes were identified from the data of patients' experiences: positive perceptions of teledermatology, concerns about teledermatology, and ideas for improving the teledermatology service. The patients found the teledermatology service convenient, saving them time and expense and liberating them from the stresses incurred when making an in-person visit to a specialist facility. They valued the confidence and reassurance they gained from having a dermatologist involved in deciding their management. The patients' concern included data security and the quality of the images shared. Nonetheless, they were keen to see the service expanded beyond the polyclinics. Their experiences and perceptions will inform future service refinement and development. CONCLUSIONS: This narrative exploration of users' experiences of teledermatology produced rich data enabling a better understanding of the patients' journey, the way they understand and interpret their experiences, and ideas for service refinement. Telemedicine reduces traveling and enables safe distancing, factors that are much needed during pandemics.

Intranasal octenidine for methicillin-resistant Staphylococcus aureus (MRSA) carriers and universal octenidine bathing reduced MRSA acquisition in an acute-care general ward.

In this quasi-experimental before-and-after study in a methicillin-resistant staphylococcus aureus (MRSA) high-prevalence acute-care dermatology ward from August 2016 to November 2018, patients admitted during intervention period who received additional topical intranasal octenidine were 63% less likely to acquire MRSA than those receiving universal daily octenidine bathing alone during baseline period (aOR, 0.37; 95% CI, 0.14-0.98).

Teledermatology in Primary Care in Singapore: Experiences of Family Doctors and Specialists.

Most teledermatology studies focus on patients' satisfaction; fewer focus on the experiences of healthcare professionals. This qualitative study explored healthcare professionals' perceptions of teledermatology used for linking public primary care clinics with the specialist dermatology centre in Singapore. Semi-structured in-depth interviews were conducted with 25 family physicians and dermatologists. Six themes were identified: satisfaction with the service; perceived patient benefits; rationale for introducing teledermatology; educational impact; challenges of virtual consultations; and desirable service refinements for the future. Family physicians and dermatologists were positive about the service, but highlighted a need to streamline referral processes and improve the quality of transmitted images. Reduced need for referral to the specialist centre could be achieved by expanding the polyclinic's pharmacopoeia and treatment modalities. This study highlights the benefits of telemedicine for patient, professionals, and healthcare organizations, and these are reassuring given the widespread and rapid introduction of telemedicine through necessity during the COVID-19 pandemic.

ß-Lactam allergy testing and delabeling-Experiences and lessons from Singapore.

BACKGROUND: ß-Lactam allergy is over-reported and this leads to greater healthcare costs. Allergy testing has inherent risks, yet patients who test negative may continue avoiding ß-lactams. OBJECTIVE: To evaluate the safety and diagnostic value of ß-lactams allergy testing locally and usage of antibiotics following negative testing. METHODS: We performed a retrospective medical record review and follow-up survey of patients who underwent ß-lactam testing between 2010 and 2016 at the National Skin Centre, Singapore. RESULTS: We reviewed the records of 166 patients, with a total of 173 ß-lactam allergy labels. Eighty (46.2%) labels were to penicillin, 75 (43.1%) to amoxicillin/amoxicillin-clavulanic acid, 11 (6.4%) to cephalexin, and 5 (2.9%) to others. Skin tests were performed in 142 patients and drug provocation tests (DPTs) in 141 patients. Eleven (6.6%) patients defaulted DPTs after skin testing. Out of 166 patients, 22 (13.3%) patients were proven allergic by either skin tests (16) or DPTs (6). Patients who tested positive had nonsevere reactions. Out of 155 patients who were conclusively evaluated, 133 (85.8%) were not allergic. Of these patients, 30 (22.6%) used the tested ß-lactam subsequently, with one reporting a mild reaction. Fifty-one (38.3%) patients were uncontactable or uncertain if they consumed a ß-lactam since testing negative. Fifty-two (39.1%) patients had no re-exposure (35 had no indication, 17 were fearful of reactions). CONCLUSION: Drug allergy testing was safe and removed inappropriate labels. CLINICAL IMPLICATION: Allergy testing is efficacious, but fears of subsequent rechallenge should be addressed to maximize the effectiveness of allergy delabeling.

Penile Ulcer due to Leukemia Cutis-A Rare Diagnosis Not to Be Missed.

We present a rare case of leukemia cutis presenting with an ulcer on the ventral penis. A 60-year-old Chinese man was referred for a penile ulcer of 10 days. He was diagnosed with acute myelomonocytic leukemia 6 months earlier and had received 2 cycles of venetoclax with azacitidine. He developed a spontaneous penile blister. It ulcerated after the patient pricked it with a needle. This enlarged after traditional medicated ointment was applied. He denied pain, itch, urethral discharge, systemic symptoms, or rashes elsewhere.

Actinic Prurigo in Singaporean Chinese: A Positive Association with HLA-DRB1*03:01.

Studies have reported the association of human leukocyte antigen (HLA) genes with susceptibility to develop actinic prurigo (AP) in Caucasians, but there were no studies in Asian populations, including the Chinese. Our study was performed to determine if AP is associated with susceptibility or protective HLA alleles or haplotypes in Singaporean Chinese. All Chinese patients diagnosed with AP at National Skin Center, Singapore, from January 2002 to April 2015 were invited to participate in the study. Clinical data and phototesting results were collated, and HLA typing was performed. Among 14 patients included, 11 were male and the mean age was 49.6 (37.9-61.3) years. All patients did not have a family history of AP and none had mucosal involvement, as such these clinical features differed from Caucasian AP patients. The frequency of DRB1*03:01 in AP patients was significantly higher compared to healthy controls (43% vs 16%, P = 0.022, odds ratio (OR) 3.89). Concurrently, the frequency of HLA-B*58:01-DRB1*03:01 haplotype was also significantly increased (25% vs 7%, P = 0.004, OR 4.23). In conclusion, HLA-DRB1*03:01 was associated with AP in Singaporean Chinese patients. This novel allelic association may possibly be utilized as a biological marker to aid in the diagnosis of AP in Chinese patients.

Cutaneous adverse drug reactions in the elderly.

PURPOSE OF REVIEW: Population ageing is a worldwide phenomenon. The presence of multiple comorbidities, polypharmacy, age-related changes in pharmacokinetics and pharmacodynamics, as well as skin changes in the elderly contribute to a unique diagnostic and management problem. This article reviews the epidemiology of cutaneous adverse drug reactions in the elderly and elaborates on a few specific types of reactions which are more relevant to the elderly. RECENT FINDINGS: Chronic dermatoses, for example, eczema, have been reported to be associated with the use of long-term medications such as calcium channel blockers and hydrochlorothiazide. Elderly patients receiving treatment for cancers may develop chemotherapy-related cutaneous side effects, including those associated with newer 'targeted' molecular therapies. Elderly patients who develop severe cutaneous adverse drug reactions, such as Stevens-Johnson syndrome and toxic epidermal necrolysis, have worse prognosis in terms of mortality. SUMMARY: Persons of advanced age often have multiple comorbidities and are on multiple medications. This can result in higher probability of an elderly person developing drug eruptions. It is important for the clinician to be aware of the range of drug-related eruptions and their implications.

Lichen nitidus presenting with nail changes--case report and review of the literature.

Lichen nitidus of the nail is rare and can precede the onset of skin lesions. Delayed diagnosis is common. We present an unusual case of lichen nitidus-associated nail changes that preceded the onset of skin lesions in a 4-year-old Indian girl. We also conduct a review of six other cases of lichen nitidus with nail involvement from the English-language literature. Clues to the diagnosis of lichen nitidus include violaceous or pigmentary changes of the nail fold and subtle lichenoid papules on the affected digits. Lichen nitidus of the nails appears to be less severe than nail changes of lichen planus and is generally self-limiting. Understanding the natural history of lichen nitidus of the nails will help physicians better counsel patients and their families.

Eccrine syringofibroadenomatosis of the reactive subtype occurring in chronic poorly-controlled psoriasis.

Eccrine syringofibroadenomatosis (ESFA) is a rare adnexal tumor with acrosyringeal differentiation. Clinically, it can be mistaken for granulomatous infections or malignancies such as squamous cell carcinoma. Despite the rarity of the condition, we recently encountered two cases of the reactive subtype, which occurred in patients with poorly controlled chronic psoriasis. Both patients presented with long-standing, thick verrucous lesions on the lower legs. The diagnosis was made after histological examination and exclusion of infectious and neoplastic disorders. As this is a reactive disorder, management is focused on treating the underlying condition. Unfortunately, psoriasis was difficult to manage in both our patients and they defaulted further treatment. It is important to recognize ESFA as it can be confused with infectious or malignant disorders.

Pediatric mycosis fungoides in Singapore: a series of 46 children.

Few studies have evaluated Asian children with mycosis fungoides (MF). We report a series of patients from a tertiary dermatologic institution in Singapore. A retrospective review was performed of patients younger than 16 years old diagnosed with MF between 2000 and 2008 at the National Skin Centre, Singapore. Forty-six patients were identified. At initial presentation, a provisional diagnosis of MF was made in 19 patients (41.3%), pityriasis lichenoides chronica (PLC) in 11 (23.9%) and postinflammatory hypopigmentation due to eczema or other causes in 11 (23.9%). After skin biopsy, the hypopigmented variant of MF was diagnosed in 42 patients (91.3%). There was one case each of PLC-like MF, pigmented purpuric dermatosis-like MF, classic MF, and solitary MF. Pityriasis lichenoides coexisted in three cases (6.5%). All except one patient presented with the early patch-plaque stage of disease (stage IA/B). The disease did not progress in any of our patients after a mean follow-up of 71.0 ± 52.5 months. Twenty-seven patients (58.7%) had complete disease clearance after a mean duration of 27.1 ± 28.1 months; 15 (49.7%) of 32 patients who received narrowband ultraviolet B treatment had complete clearance within an average of 8.9 ± 5.3 months, but 7 patients relapsed within 14.9 ± 14.8 months. One patient with solitary MF failed multiple treatment modalities before eventually achieving disease clearance with photodynamic therapy. Hypopigmented MF is the most common MF variant in Asian children. The diagnostic difficulty is in differentiating this from PLC, which may coexist with MF. Long-term prognosis is generally favorable.

Staphylococcus aureus and topical fusidic acid use: results of a clinical audit on antimicrobial resistance.

BACKGROUND: Fusidic acid (FA) resistance in Staphylococcus aureus poses a problem for treating systemic methicillin-resistant S. aureus infection, in which FA may otherwise remain a viable option. It can also result in treatment failure of common dermatological conditions such as impetigo and infected atopic eczema. Several studies have linked trends in prescribing medication and topical use of FA to development of resistance. However, few case-control studies have evaluated risk factors for developing FA resistance in S. aureus. METHODS: A clinical audit for antimicrobial resistance was performed in dermatology patients from the National Skin Centre who were admitted for inpatient care from 2006 to 2008 and had positive bacterial cultures for S. aureus. Each FA-resistant S. aureus (FRSA) case was compared with four randomly selected FA-susceptible (FSSA) cases. Medical records were reviewed retrospectively, and potential risk factors for development of resistance were analyzed. RESULTS: Thirteen of 37 patients with FRSA (35.1%) had used FA topically compared with 11 of 148 patients with FSSA (7.4%). Findings from multivariate analysis indicate that previous use of topical FA was the only independent risk factor of FA resistance (adjusted OR 7.46, 95% CI [2.60-21.41], P < 0.001). Patients' coexisting illnesses, recent hospitalization, or systemic antibiotic use were not significant risks. CONCLUSIONS: Previous recent topical FA use correlated positively with FA resistance in S. aureus. Prescribing physicians must be vigilant of the rise of FA resistance and its resultant problems and prescribe topical FA discerningly.

Congenital combined melanocytic nevus of the scalp with associated alopecia areata.

We report a case of a 20-year-old Chinese man with an alopecic congenital combined compound and blue melanocytic nevus of the scalp, associated with alopecia areata. The diagnosis of a combined melanocytic nevus was confirmed by histopathological examination and immunohistochemical stains, with exclusion of neurocristic hamartoma, which can have a similar clinical and histopathological appearance but different prognosis. In addition, we explore the association of this large melanocytic lesion with alopecia areata.