Epidemiology of adult patients with atopic dermatitis in AWARE 1: A second international survey.

Background: There are gaps in our understanding of the epidemiology of atopic dermatitis (AD) in adults. Objective: To evaluate the prevalence and severity of AD in adults from countries/regions within Asia, Eurasia, Latin America, Middle East, and Russia. Methods: This international, web-based survey was performed in Argentina, Brazil, China, Colombia, Egypt, Hong Kong, Israel, Malaysia, Mexico, Russia, Kingdom of Saudi Arabia (KSA), Singapore, Taiwan, Thailand, Turkey, and United Arab Emirates. Questionnaires were sent to adult members of online respondent panels for determination of AD and assessment of severity. A diagnosis of AD required respondents to meet the modified United Kingdom (UK) Working Party criteria and to self-report they had a physician diagnosis of AD. Severity of AD was determined using Patient-Oriented Scoring of Atopic Dermatitis (PO-SCORAD), Patient-Oriented Eczema Measure (POEM), and Patient Global Assessment (PGA). Results: Among respondents by country/region the prevalence of AD ranged from 3.4% in Israel to 33.7% in Thailand. The prevalence was generally higher in females versus males. Severity varied by scale, although regardless of scale the proportion of respondents with mild and moderate disease was higher than severe disease. PGA consistently resulted in the lowest proportion of severe AD (range 2.4% China - 10.8% Turkey) relative to PO-SCORAD (range 13.4% China - 41.6% KSA) and POEM (range 5.1% China - 16.6% Israel). Conclusions: This survey highlights the importance of AD in adults, with high prevalence and high morbidity among respondents and emphasizes that AD is not just a disease of childhood-there is disease persistence and chronicity in adults.

Pimecrolimus for the Treatment of Atopic Dermatitis in Infants: An Asian Perspective.

Atopic dermatitis (AD) is a common chronic, multisystem inflammatory skin disease in pediatric patients. There has been an increase in the incidence of AD in the pediatric population of the Asia-Pacific region. Studies have shown that genetic, epigenetic, environmental and cultural factors may lead to differences in the clinical manifestation and prevalence of AD between races. Early treatment of AD is necessary to prevent the atopic march leading to comorbidities such as asthma and allergic rhinitis. Topical corticosteroids (TCS) are used as first-line therapy for the treatment of AD, but their long-term usage poses a risk to the patient's health. Pimecrolimus (1%) is a topical calcineurin inhibitor (TCI) that is indicated for the treatment of mild to moderate AD. Pimecrolimus has no apparent increase in adverse events compared to TCS, and it causes less of a burning sensation than tacrolimus. The safety and efficacy of pimecrolimus has been established through various clinical trials; yet, in many Asian countries, the use of pimecrolimus in infants is still restricted due to safety concerns. Based on the available evidence, the expert panel recommends pimecrolimus in infants between 3 months and 2 years of age in the Asian population.

Dermatology Life Quality Index in Patients with Psoriasis Treated with Biologic Versus Non-biologic Treatment in Malaysia: A Retrospective Cross-Sectional Study.

BACKGROUND: Psoriasis imposes a substantial burden on patients' social, emotional, physical, and family life. Although psoriasis has no complete cure, various treatments are available to control its symptoms and improve a patients' quality of life. OBJECTIVE: We aimed to compare the effectiveness of biologic versus non-biologic treatments on health-related quality of life among patients with psoriasis in Malaysia. METHODS: This retrospective cross-sectional study evaluated data of adult patients diagnosed with psoriasis during 2007-18 from the Malaysian Psoriasis Registry. Baseline demographics, disease, and treatment characteristics were described. For a subset of patients treated with biologics and non-biologics who had baseline and 6-month follow-up data available, changes in the mean Dermatology Life Quality Index scores and the proportion of patients with a clinically relevant improvement (≥ 4 points) post-treatment were assessed. RESULTS: Overall, 15,238 adult patients with psoriasis from the Malaysian Psoriasis Registry were included in the analysis. Patients receiving biologics showed a statistically significant reduction in the mean Dermatology Life Quality Index scores after 6 months compared with those receiving non-biologic treatment (- 5.7 vs - 0.8%; p < 0.001). The proportion of patients who achieved a ≥ 4-point improvement in Dermatology Life Quality Index scores was approximately two times greater in the biologic-treated group versus the non-biologic-treated group (56.4 vs 27.7%). CONCLUSIONS: Biologic treatment showed a greater reduction in the Dermatology Life Quality Index scores of patients with psoriasis versus non-biologic treatment. These results highlight the importance of early treatment with more efficacious treatment options, such as biologic therapies, to improve the overall health-related quality of life of patients with psoriasis.

Position Statement on Secukinumab in the Management of Plaque Psoriasis: The Malaysian Perspective.

Psoriasis is a chronic inflammatory skin disease affecting nearly 10% of dermatologic patients in Malaysia. Treatment options include topical agents and phototherapy as well as nonbiologic and biologic systemic therapy. Mild psoriasis can often be managed with topical agents. However, managing moderate to severe psoriasis is more challenging and may require systemic treatment with nonbiologics or biologics. Despite the availability of several biologics, there are many unmet clinical needs, which may be addressed by secukinumab, an IL-17A inhibitor. This position statement is based on an expert panel discussion and is intended to provide dermatologists an overview of existing options as well as to provide a better understanding of secukinumab and how it can be integrated into current practice. During the discussion, panel members examined current approaches and the role of secukinumab in plaque psoriasis management. Panel members estimated that up to 30% of patients have moderate to severe psoriasis but only 1-2% receive biologics. Highlights from the discussion were that (i) the threshold for biologic use should be lower, in line with international guidelines; (ii) studies have shown that secukinumab has several advantages over other biologics which are greater efficacy, sustained efficacy over time, rapid onset of action, and early evidence of possible disease-modifying potential; and (iii) ideal candidates for secukinumab are all patients of moderate to severe psoriasis, including those with history of treatment failure, difficult-to-treat patterns of psoriasis (nail, scalp, and palmoplantar psoriasis), psoriatic arthritis, and comorbidities and those aiming for clear skin. Panel members recommend that secukinumab be considered first line option among biologic therapies.

Asian consensus on assessment and management of mild to moderate plaque psoriasis with topical therapy.

A working group of dermatologists in Asian countries assessed the current status of psoriatic management in the region to prepare a consensus report on topical treatment in mild to moderate plaque psoriasis. Even though the association of psoriasis with systemic comorbidities is increasingly acknowledged, psoriasis is still lower in health-care priority lists in the region. The psychosocial impact of psoriasis may be greater in Asian countries due to cultural norms and social discrimination. Non-adherence to treatment is also common among Asians. The current care given to patients with mild to moderate psoriasis needs to be streamlined, enhanced and organized with a patient-centered care approach to achieve better outcomes. A comprehensive assessment of the disease severity and its impact on a patient's life is required before initiating treatment. Education and active involvement of the patient in the treatment plan is an important part of psoriatic management. It is recommended to personalize topical treatment to meet the needs of the patient, depending on disease severity, psychosocial impact, the patient's expectations and, more importantly, the patient's willingness and ability to actively follow the treatment procedure. Fixed-dose combination of corticosteroid and vitamin D analogs is the preferred topical medication for both initial and maintenance phases of treatment. The fast containment of the disease is the goal of the initial phase of 4-8 weeks and it demands a potent fast-acting topical therapy. Satisfactory control of the disease and prevention of relapses should be achieved during the maintenance phase with twice a week or weekend applications.

Socioeconomic and sociocultural determinants of psychological distress and quality of life among patients with psoriasis in a selected multi-ethnic Malaysian population.

Patients with psoriasis may have increased risk of psychological comorbidities. This cross-sectional study aimed at determining associations between sociocultural and socioeconomic factors with the Depression Anxiety Stress Scale (DASS) scores and the Dermatology Life Quality Index (DLQI) scores. Adult patients with psoriasis were recruited from a Dermatology outpatient clinic via convenience sampling. Interviews were conducted regarding socio-demographic factors and willing subjects were requested to complete the DASS and DLQI questionnaires. The Pearson χ2 test, Fisher's exact test and multivariate logistic regression were used for statistical analysis to determine independent predictors of depression, anxiety, stress and severe impairment of quality of life. Unadjusted analysis revealed that depression was associated with Indian ethnicity (p = .041) and severe impairment of quality of life was associated with Indian ethnicity (p = .032), higher education (p = .013), higher income (p = .042), and employment status (p = .014). Multivariate analysis revealed that Indian ethnicity was a predictor of depression (p = .024). For stress, tertiary level of education (p = .020) was an independent risk factor while a higher monthly income was a protective factor (p = .042). The ethnic Indians and Malays were significantly more likely than the ethnic Chinese to suffer reduced quality of life (p = .001 and p = .006 respectively) and subjects with tertiary education were more likely to have severe impairment of quality of life (p = .002). Our study was unique in determining sociocultural influences on psychological complications of psoriasis in a South East Asian population. This has provided invaluable insight into factors predictive of adverse effects of psoriasis on psychological distress and quality of life in our patient population. Future studies should devise interventions to specifically target at risk groups in the development of strategies to reduce morbidity associated with psoriasis.

Methotrexate toxicity presenting as ulcerated psoriatic plaques.

Methotrexate toxicity is known to cause erosions of existing psoriatic plaques, although rare. We describe two patients who developed painful ulcerated psoriatic plaques as an early presenting sign of methotrexate toxicity and review the risk factors associated with this manifestation.

Invasive squamous cell carcinoma arising from chromoblastomycosis.

Chromoblastomycosis is a chronic subcutaneous mycosis seen mainly in tropical regions. While malignant transformation rarely occurs, the present report describes a 69-year-old man with a 21-year history of chromoblastomycosis complicated by invasive squamous cell carcinoma requiring amputation of the affected limb. A review of previous reported cases shows malignancy arising after 20-30 years of infection in ≥60-year-old males who have received inadequate treatment of chromoblastomycosis and have had relapses. An immunocompromised state is not an associated feature of such cases. The extremities are commonly affected as carcinomas occur from the most chronic lesions which are generally found on these limbs.

Penicillium marneffei infection in an African man.

Penicilliosis is a systemic fungal infection caused by Penicillium marneffei. The infection is most commonly seen in Southeast Asia, Southern China, Hong Kong, and Taiwan. It is rarely seen among individuals of African descent. Here, we report a case of penicilliosis in an African man from Namibia who was studying in Malaysia. He presented with multiple umbilicated papules associated with cough, fever, loss of appetite, and weight. He also had urethral discharge and admitted to unprotected sexual intercourse with multiple partners. Histopathological examination of a skin papule showed the presence of multiple 2 to 4 microm intracellular yeast cells. Culture of the papule revealed Penicillium marneffei. The serology for human immunodeficiency virus (HIV) was positive. This case illustrates the need to recognize penicilliosis in any individuals staying or travelling to Southeast Asia and the need to look for underlying HIV infection in adults with umbilicated papules.

Cutaneous blood flow in dermatomyositis and its association with disease severity.

BACKGROUND: Several studies using nailfold capillary microscopes have demonstrated capillary changes in patients with dermatomyositis (DM); however, no previous study has examined cutaneous blood flow in this disease. PURPOSE: To determine cutaneous blood flow in involved and non-involved skin surfaces of patients with DM and to assess possible correlation with clinical measures of disease severity. METHODS: Using a Laser Doppler perfusion imager, cutaneous blood flow was measured at six targeted sites of involved and apparently non-involved skin of 13 DM patients and the corresponding non-involved sites of 13 healthy controls. Overall disease severity of DM patients was determined by physician's global assessment (PGA), creatinine phosphokinase (CPK) levels, medical research council (MRC) scores, and the DM skin severity index (DSSI). RESULTS: Skin blood flow was significantly elevated in involved vs. non-involved skin of DM patients at all anatomic sites measured: periungual (P=0.001), knuckle (P=0.001), elbow (P=0.013), periorbital (P=0.015), chest (P=0.028), and back (P=0.001). Blood flow was also higher in apparently non-involved skin of DM patients vs. skin of healthy controls at all anatomic sites, although statistical significance was not achieved. A significant negative correlation was observed between the DSSI and blood flow in involved skin of the chest (P=0.003), back (P=0.002), and knuckle (P=0.026). CONCLUSION: DM is associated with significantly increased cutaneous blood flow, even at sites where no erythema is evident. This suggests significant involvement of the skin vasculature in this disease process.

Trends in prescription of acne medication in the US: shift from antibiotic to non-antibiotic treatment.

AIM: To describe trends in the prescription of medication for acne vulgaris in the USA from 1990 to 2002 with particular reference to the shift from antibiotic to non-antibiotic treatment. METHODS: Retrospective cross-sectional observational study which analysed the data from the 4922 patient visits for acne vulgaris from the 1990-2002 National Ambulatory Medical Care Survey (NAMCS) to assess medications mentioned or prescribed at office visits for acne vulgaris. We specifically analysed visits for benzoyl peroxide or combination benzoyl peroxide products, topical retinoids, clindamycin, erythromycin, tetracycline group antibiotics and isotretinoin. A priori predictions were made for changes in physician behaviour over time, and were tested by regression. Multivariate regression also assessed the impact of demographic variables such as patient age, gender, race and type of physician seen on prescribing behaviour. RESULTS: From 1990 to 2002 there were significant declines (p<0.01) in the likelihood of use of several drug classes that are reliant on antimicrobial mechanisms for acne including the following: benzoyl peroxide, topical clindamycin, oral erythromycin and tetracycline group antibiotics. There were significant increases in likelihood of utilization for agents not reliant on antimicrobial mechanisms including topical retinoids and oral isotretinoin during this period. These changes in utilization were not affected by controlling for demographic factors in multivariate analysis. CONCLUSION: There has been a shift towards non-antibiotic treatment in acne management. Growing awareness of antibiotic-resistant Propionibacterium species may contribute to increased use of topical and systemic retinoid agents.