A randomized controlled trial of the efficacy and safety of a fixed triple combination (fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%) compared with hydroquinone 4% cream in Asian patients with moderate to severe melasma.

BACKGROUND: Melasma is an acquired, chronic hypermelanosis for which therapy remains a challenge. OBJECTIVES: To compare the efficacy and safety of a triple combination [TC: fluocinolone acetonide 0.01%, hydroquinone (HQ) 4%, tretinoin 0.05%] vs. HQ 4% after 8 weeks of treatment of moderate to severe facial melasma in Asian patients. METHODS: This was a multicentre, randomized, controlled, investigator-blinded, parallel comparison study. East and South-East Asian patients aged 18 years or older, with a clinical diagnosis of moderate to severe melasma, were enrolled in this study. Patients were enrolled at baseline and treated daily for 8 weeks with TC cream (one application at bedtime) or HQ cream (twice daily). There were four study visits: at baseline and weeks 2, 4 and 8. The primary efficacy variable was the melasma global severity score (GSS). Other outcome measures included Melasma Area and Severity Index, global improvement and patient satisfaction. Safety was assessed through the reporting of adverse events. RESULTS: TC had superior efficacy to HQ for the primary variable: 77/120 patients (64.2%) on TC had GSS 'none' or 'mild' at week 8 vs. 48/122 patients (39.4%) on HQ (P < 0.001). The secondary efficacy variables confirmed these results. Patient satisfaction was in favour of TC (90/127, 70.8%, vs. 64/129, 49.6%; P = 0.005). More patients had related adverse events on TC (63/129, 48.8%) than on HQ (18/131, 13.7%) but most were mild and none was severe. CONCLUSIONS: Efficacy in Asians and patient satisfaction were superior with the fixed TC than with HQ 4%.

Distributed personal health information management system for dermatology at the homes for senior citizens.

A distributed personal health information management system (D-PHIMS) has been tested at a nursing home for the senior citizens (NHSC) in Singapore. The personal health information management system (PHIMS) from the University of Washington was customized to Singapore's context for teledermatology. A clinical trial commenced in October 2005 is ongoing and the survey results obtained indicate that the participants are satisfied with the D-PHIMS system. The diagnosis and treatment recommendations made by the dermatologists using the D-PHIMS diagnosis module were effective in most cases based on feedback from the nursing staff at the elderly nursing home. The results suggest that a teledermatology system could become a useful tool for the nursing homes and to control increasing healthcare costs for elderly care.

A study of natural rubber latex allergens in gloves used by healthcare workers in Singapore.

BACKGROUND: Allergy to natural rubber latex (NRL) proteins is a well-recognized health problem among subjects using protective gloves and products made of NRL. There is currently no information on NRL allergen levels in gloves used in Singapore. OBJECTIVES: This study aims to quantify the amount of specific allergens (Hev b 1, Hev b 3, Hev b 5 and Hev b 6.02) found in rubber gloves used in Singapore. It also aims to determine if these levels are above thresholds that may cause NRL allergy. It also compares the levels of these specific allergens in gloves used for different purposes, namely gloves used for examination purposes or for surgical procedures. METHODS: Forty-nine rubber gloves were obtained from major hospitals and healthcare departments in Singapore and were analysed for their NRL allergen levels. FITkit, based on the enzyme immunometric assay technique, was used to determine the specific allergen levels of Hev b 1, Hev b 3, Hev b 5 and Hev b 6.02 in the gloves. RESULTS: Examination gloves had higher NRL allergen content compared with surgical gloves, and powdered gloves had higher allergen content compared with nonpowdered gloves. Among the various allergens, Hev b 5 and Hev b 6.02 were present in larger quantities than Hev b 1 and Hev b 3. Only two of 19 (11%) surgical gloves had the sum of the four allergens (Hev b 1, Hev b 3, Hev b 5, Hev b 6.02) in excess of 1 microg g(-1), which is believed to be a clinically relevant threshold. Among the examination gloves, 25 of 30 (83%) exceeded this level. CONCLUSIONS: This study shows that NRL allergen levels are present in the majority of examination gloves used by healthcare workers in Singapore at levels high enough to cause NRL allergy among sensitized persons. The information can serve as evidence for a possible requirement for manufacturers to produce gloves with low NRL allergen levels and to state the allergen level in gloves in the product information.

Atopy patch testing with aeroallergens in patients with atopic dermatitis and controls in Singapore.

The role of allergy in atopic dermatitis is controversial. The atopy patch test (APT) has been used to investigate the association between atopic dermatitis and aeroallergen allergy. To determine the proportion of patients with atopic dermatitis with positive patch tests to common local aeroallergens and to compare this to controls with and without respiratory atopy, we performed APT, skin-prick tests (SPT) and IgE radioallergosorbent tests (RAST) on 73 patients with atopic dermatitis and on 38 nonatopic controls (13 with and 25 without respiratory atopy). The allergens used were house dust mite, cat dander, Bermuda grass and German cockroach. Only the APT for house dust mite showed a significant difference between the two groups. APT for house dust mite correlated with the RAST test, while APT for cat fur correlated with the SPT. The APT may be useful to evaluate aeroallergens in atopic dermatitis, but further work is needed to make it more reliable.

Latex sensitisation in healthcare workers in Singapore.

INTRODUCTION: Epidemiological data on latex sensitisation among Asian healthcare workers is lacking. The aim of the study is to determine the rate of latex sensitisation in our healthcare workers. MATERIALS AND METHODS: We recruited 313 healthcare workers, of which 46.6% were operating theatre staff and 53.4% were non-operating theatre staff. Seventy-one administrative staff served as controls. All participants answered a self-administered questionnaire relating to latex exposure and glove-related symptoms. Latex sensitisation was determined by skin prick testing to latex and latex-specific IgE detection. RESULTS: The prevalence of latex sensitisation among healthcare workers was 9.6%, with no difference between operating theatre and nonoperating theatre staff. Glove-related symptoms were reported in 13.7% of all healthcare workers, of which 22.9% were sensitised to latex. Only 26.7% of latex-sensitised healthcare workers had glove-related symptoms while the rest were asymptomatic. The most common symptoms were itch and hand eczema but the most important discriminating symptom was contact urticaria. Personal history of atopy was more common in sensitised healthcare workers (40.0%) compared to non-sensitised workers (31.8%). Only 1 out of 9 (11.2%) symptomatic latex-sensitised subjects had sought previous medical attention for the problem. CONCLUSIONS: Latex sensitisation among healthcare workers in Singapore should be considered a significant occupational health risk, as it is in the West. Increased screening and awareness of this problem is essential to identify those at risk.

Not all pustules are infective in nature: acute generalised exanthematous pustulosis causing pustular eruptions in an elderly woman.

Acute generalised exanthematous pustulosis (AGEP) is an adverse drug reaction that can occur in any age group. It is commonly mistaken as pustular psoriasis or cutaneous infection, resulting in unnecessary commencement of medications such as methotrexate and antibiotics that can cause harm to the patient or interact and adversely affect the efficacy of other medications. Early diagnosis of AGEP avoids unnecessary investigations and treatment, which not only can harm the patient but also escalate health care, as the condition is self-limiting. This case report illustrates AGEP secondary to Cefaclor occurring in a 72-year-old Chinese woman. Although the literature has documented the occurrence of AGEP with Cefaclor, the unique feature of this case is the occurrence of AGEP following repeated uneventful courses of Cefaclor. This case highlights that AGEP must never be forgotten in the work-up for pustular eruptions in an elderly patient.

Sweet's syndrome associated with Mycobacterium chelonae and herpes simplex virus infections: a case report.

INTRODUCTION: We report a case of Sweet's syndrome associated with Mycobacterium chelonae and herpes simplex virus infection. CLINICAL PICTURE: A 56-year-old Chinese woman presented with a granulomatous subglottic mass and right lung nodules, which responded to a 9-month course of anti-tuberculous treatment. Subsequently, she developed genital herpes simplex virus infection, which was followed by a cutaneous eruption with vesicular plaques associated with fever, bilateral cervical lymph nodes and neutrophilia. Mycobacterium chelonae was isolated from lymph node cultures. The cutaneous presentation of Sweet's syndrome was confirmed on skin biopsy. There was no evidence of underlying immunosuppression, malignancy or connective tissue disease. TREATMENT: She was treated with rifampicin, clarithromycin and oral prednisolone. OUTCOME: There was complete resolution of her cutaneous lesions and cervical lymphadenopathy. CONCLUSION: The association between Sweet's syndrome and Mycobacterium chelonae as well as herpes simplex virus, though rare, should be considered in all patients presenting with Sweet's syndrome.

Occupational allergic contact dermatitis in Singapore.

Singapore has a resident population of 3,000,000 and a workforce of 1,780,000. Most are employed in manufacturing, services and commerce (245,000). From 1996 to 1998, 3472 cases were notified to the Ministry of Manpower and confirmed as occupational diseases. Noise-induced hearing loss accounted for 82% of cases, while only 11% of cases were industrial dermatitis. Occupational allergic contact dermatitis was not common, comprising approximately one third of the 369 cases of industrial dermatitis that were notified. However, we believe that the majority of cases are not notified to the authorities. The main occupational contact allergens were chromates, nickel, rubber chemicals, cutting fluids and resins. Most affected workers were from the construction, electronics and metalworking industries. Case series of occupational dermatoses among electronics and metal workers have been published. Of the cases of occupational dermatoses among electronics workers seen at a tertiary dermatological centre, 41% of 149 had allergic contact dermatitis (ACD). The commonest allergens were nickel, resins and rubber chemicals. In another case series of 252 metalworkers seen at the same dermatological centre, 23% suffered from ACD. The common allergens were metals and cutting fluids. Besides the common causes of ACD, unusual allergens have also been described. One example is ACD to grasses, which is seen mainly among military personnel. Population studies have been conducted in several industries. A survey of 2567 electronics workers revealed a 2% point prevalence of ACD. Of the occupationally relevant cases, 46 were nickel sensitive, 7 reacted to colophony, and 1 case to epoxy resin. A study of 272 prefabrication construction workers showed a 14% prevalence rate of occupational dermatitis. Of the 38 cases, 42% were ACD to chromates and rubber chemicals. Occupational ACD in Singapore is not as uncommon as the reported statistics suggest. Population-based reports, which overcome the problem of under-notification, show that the prevalence is variable in different industries.

A review of inpatients with adverse drug reactions to allopurinol.

Allopurinol is still an effective uric-acid lowering drug since its introduction in 1963. However it has been frequently incriminated for severe adverse drug reactions. From our retrospective review of 13 inpatients with allopurinol adverse reactions seen over 3 years, fever and rash were the commonest presenting symptoms, occurring several weeks after initiation of the drug. Other associated abnormalities included leukocytosis (62% of patients), eosinophilia (54%), renal impairment (54%) and liver dysfunction (69%). Although 12 patients (92%) met the criteria for allopurinol hypersensitivity syndrome, there was no mortality recorded. The indications for initiating allopurinol therapy were frequently unclear. In view of the severe adverse reactions experienced with allopurinol, we propose that it should only be prescribed when truly indicated.

The therapeutic efficacy of mometasone furoate cream 0.1% applied once daily vs clobetasol propionate cream 0.05% applied twice daily in chronic eczema.

BACKGROUND: Mometasone furoate [9a, 21-dichloro-llb, 17dihydroxy-16a-methyl-pregna-14-dione-3, 20-dione-17-(2furoate)] is a synthetic, 17-heterocyclic corticosteroid which has been shown to be highly effective as an anti-inflammatory agent which is approximately half as potent is suppressing hypothalamic-pituitary-adrenal (HPA) axis function as betamethasone valerate. METHOD: The present open, randomised, third party blinded, left-right sided study was designed to compare the therapeutic efficacy of mometasone furoate cream 0.1% with clobetasol propionate cream 0.05% applied twice daily in chronic eczema following a 3-week course of therapy. PATIENTS/RESULTS: Sixty consecutive patients with moderate to severe bilateral chronic eczema on the limbs were recruited into the study. The mean scores of various signs/symptoms including erythema, induration, crusting, scaling, excoriation and pruritus before and after 3 weeks treatment with mometasone furoate (MF) and clobetasol propionate (CP) cream, were compared. The baseline scores for MF and CP treated sites were almost identical. There was significant decrease in the mean scores of all signs/symptoms after 3 weeks treatment with MF and CP. There was also a significant difference in the mean scores between MF and CP treated sites after 3 weeks of treatment. The mean scores were significantly lower for CP treated sites than MF treated sites. More CP treated sites achieved "cleared" or "marked improvement" response than MF treated sites. There were more "excellent" or "good" grades on CP treated sites than MF treated sites at the end of 3 weeks of treatment. None of the patients showed any side-effects after 4 weeks of treatment. CONCLUSION: Overall, 53% of patients considered the MF treated sites to be good or excellent vs 88% for CP treated sites.

A study of the sensitization rate to sesquiterpene lactone mix in Singapore.

We report a study of the sensitization rate to sesquiterpene lactone (SL) mix at the National Skin Centre, Singapore. This is a retrospective review of 1256 patients who were patch tested to SL mix (0.1%) from January 1995 to December 1997. 18 out of 1256 patients (1.43%) reacted positively to SL mix. Their ages ranged from 13 to 58 years (average 33.8 years). There were 15 Chinese, 2 Indian and 1 Malay patients. There was a female preponderance, with a female: male ratio of 3.5:1. The most common clinical presentation were dermatitis of the hands (8; 44%), face (5; 28%), and generalized involvement (5; 28%). After extensive evaluation, only 2 patients had a positive patch test reaction that was of current clinical relevance. 13 patients had concomitant sensitization to other allergens. The 3 commonest concomitant allergens were nickel, balsam of Peru and fragrance mix. In our series, SL allergy is observed to be more common in females and the mean age is lower compared to the classical Compositae dermatitis. The sensitization rate is comparable to other studies, although the clinical relevance is only 11%.

Contact allergy in Singapore.

Contact allergy, viz. allergic contact dermatitis, photo-allergic contact dermatitis and contact urticaria, is a well-studied sub-specialty of dermatology in Singapore. Over the years, numerous studies and anecdotal reports on the subject have been published in both international and local refereed journals. This article reviews the epidemiological data on patch testing and photo-patch testing in Singapore. It also summarizes published clinical reports on important contact allergens that are found in both non-occupational and occupational setting.

Human barrier recovery after acute acetone perturbation: an irritant dermatitis model.

The efficacy of a topical agent in barrier recovery was evaluated after acetone-induced acute water loss barrier disruption in vivo in humans. The upper back of several volunteers was rubbed with acetone-soaked cotton balls until elevated rates of transepidermal water loss (TEWL) occurred (> 20 g/m2h, or greater). The topical agent was then applied to the acetone-treated skin sites once daily for 5 days. Resolution evaluation used TEWL measurements and the data were expressed as the percentage recovery in water barrier function. In comparison with placebo control the topical agent significantly enhanced barrier recovery, especially within the first 72 h (P < 0.05). This model offers a simple method of examining chemicals accelerating (or inhibiting) repair of this form of acute skin damage in man.

Corticosteroid contact hypersensitivity screening in Singapore.

BACKGROUND: Topical corticosteroids have been in use since 1957. Two percent to 5% of patients attending patch test (PT) clinics have problems with corticosteroid contact hypersensitivity. Controversies abound with regard to the choice of steroids in the standard battery, the method of patch testing and reading, and the ideal concentration and vehicle. OBJECTIVE: To assess betamethasone 17-valerate (1% pet.), fluocinolone acetonide (0.25% petrolatum [pet.]), and tixocortol pivalate (1% pet.) used in the authors' standard battery. METHODS: Data were analyzed for patients seen between January 1994 and December 1996 who had positive PT reactions to one or more of these steroids. RESULTS: 3,603 patients had standard PTs, of which 20 had positive reactions to one or more of these steroids. There were three positive reactions to betamethasone 17-valerate, 17 to tixocortol, and none to fluocinolone. On further patch testing to the authors' steroid battery, only one tixocortol-positive patient had a positive reaction to hydrocortisone (1% ethanol/ dimethyl sulfoxide [DMSO]). CONCLUSIONS: Corticosteroid allergy is found to be relatively uncommon in Singapore on the basis of this screening series. The frequency of negative reactions to fluocinolone acetonide is sufficiently low for this corticosteroid to be excluded from the authors standard series. The significance of positive tixocortol reactions remains unknown. From the review of other relevant literature, the authors recommend that budesonide be added to their present series. Testing betamethasone 17-valerate in 1% ethanol may yield more positive allergic reactions. Individuals with a positive allergic PT reaction to one corticosteroid should subsequently be tested to a full corticosteroid series.