Ultraviolet-A1 phototherapy in Asian skin: A review of 159 cases in Singapore.

BACKGROUND: Ultraviolet-A1 phototherapy has been used to treat many inflammatory dermatoses. AIMS: To determine the efficacy and safety of ultraviolet-A1 phototherapy in Asian skin. MATERIALS AND METHODS: We performed a review of records of patients undergoing ultraviolet-A1 phototherapy at our dermatology unit in Singapore from January 2007 to January 2011. Their electronic medical records were reviewed and a standardized questionnaire was filled up for data collection and tabulation. Chi-square or Fisher's exact tests were used to compare the difference in response between various groups for each characteristic. P value of < 0.05 was considered statistically significant. RESULTS: Our study comprised of 159 patients, of which 103 were patients with hand and foot eczema, 21 with atopic dermatitis, 17 with scleroderma and the remaining with miscellaneous dermatoses. Of these patients, 47.6% of patients with hand and feet eczema had good response after 10 sessions, which increased to 75% after 20 sessions and to 84.6% after 30 sessions. After 10 sessions, 47.6% of patients with atopic dermatitis had good response, which increased to 66.7% after 20 sessions. After 30 sessions, all the three remaining patients with atopic dermatitis experienced good response. For patients with scleroderma, only 11.8 and 10% had good response after 10 and 20 sessions, respectively, which increased to 40% after 30 sessions. LIMITATIONS: Limitations of our study include its retrospective design and, consequently, the lack of standardized treatment protocol, as well as subjective assessment in terms of clinical improvement. CONCLUSIONS: Ultraviolet-A1 phototherapy appears to be efficacious for the treatment of hand and foot eczema as well as atopic dermatitis. However, in patients with scleroderma, the response was partial and needed a longer duration of treatment.

Treatment of xanthelasma palpebrarum with a 1064-nm, Q-switched Nd:YAG laser.

BACKGROUND: Xanthelasma palpebrarum is the most common cutaneous xanthoma characterized by soft, yellow papules or plaques that arise on the periorbital skin. As these lesions can be cosmetically disfiguring, many patients seek medical help to remove these lesions. OBJECTIVE: To determine the effectiveness and minimum number of treatment sessions with a 1064-nm, Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser for the treatment of xanthelasma. METHODS: A retrospective review of patients with xanthelasma consecutively treated with Q-switched Nd:YAG laser was conducted. Forty-six patients with 103 lesions were identified from January 2012 through August 2015. Photographs taken of patients immediately before treatment and 4-8 weeks after treatment were independently evaluated by 2 dermatologists. RESULTS: After a single treatment session, 93.2% of lesions had some degree of clearance. All lesions had excellent-to-complete clearance after at least 4 treatment sessions. Patients usually required 4 treatment sessions for optimal results. LIMITATIONS: This was a retrospective study. Treatment parameters varied, follow-up periods were not uniform, and response was not assessed with a validated scale. CONCLUSION: The Q-switched Nd:YAG laser is effective and well tolerated in the treatment of xanthelasma in our study population.

Adult Henoch-Schönlein purpura: Clinical and histopathological predictors of systemic disease and profound renal disease.

BACKGROUND: A major challenge in the management of adult Henoch-Schönlein purpura is the difficulty in assessing the risk of systemic involvement. There is currently a paucity of data in this area. AIMS: This study sought to determine specific clinical and histopathological features associated with systemic involvement in adult Henoch-Schönlein purpura. METHODS: We reviewed the records of 99 adult Henoch-Schönlein purpura patients who presented at the National Skin Centre, Singapore, between January 2008 and May 2015. RESULTS: Renal involvement was found in 56 (56.6%) patients, joint involvement in 21 (21.2%) and gastrointestinal involvement in 13 (13.1%). Age > 30 years was an independent predictor of renal involvement with an adjusted odds ratio of 2.97 (95% confidence interval, 1.08-8.16; P = 0.04). Risk factors for significant renal involvement necessitating nephrology referral were further evaluated: the odds were approximately 60% higher for every 10-year increase in age (95% confidence interval, 1.02-2.57; P = 0.04) and patients with cutaneous bullae and/or necrosis had an almost six times higher risk (95% confidence interval, 1.43-25.00; P = 0.01). LIMITATIONS: This study was limited by its retrospective design. We also lacked long-term data to examine how clinical and histopathological characteristics correlated with long-term disease outcomes. CONCLUSIONS: Adult Henoch-Schönlein purpura patients older than 30 years have a threefold increased risk of renal involvement. The risk of profound renal disease necessitating nephrology referral rose significantly with age and the presence of cutaneous bullae and/or necrosis.

Efficacy and relapse rates of different treatment modalities for progressive macular hypomelanosis.

BACKGROUND: Progressive macular hypomelanosis is an acquired disorder characterized by hypopigmented macules mostly on the trunk and upper extremities. Although many treatment modalities have been proposed for this condition with variable success rates, there are few reports comparing their efficacy and relapse rates. AIM: To compare the efficacy and relapse rates of different treatment modalities for progressive macular hypomelanosis. METHODS: Case records of patients diagnosed with progressive macular hypomelanosis and treated in National Skin Centre for a six year period between 2008 and 2014 were reviewed. Patient demographics, distribution of hypopigmented macules, treatment efficacy and relapse rates were noted. RESULTS: A total of 108 patients were seen for progressive macular hypomelanosis over the study period; of these, 40 opted for no treatment but were followed up. Thirty-six were treated with topical antimicrobials and 32 with phototherapy. Of those untreated, 23% recovered spontaneously while 38% in the antimicrobial group and 90% in the phototherapy had remission of their hypopigmentation. After 2 years of follow-up, relapse occurred only in the phototherapy group. LIMITATIONS: The main limitation is the retrospective design whereby diagnosis is dependent on the attending dermatologist. CONCLUSIONS: Narrow-band ultraviolet B therapy appears to be the most effective treatment for progressive macular hypomelanosis but also has the highest potential for relapse. Response rates for antimicrobial therapy are lower and slower, but patients who responded did not relapse. A combination of topical/systemic antimicrobials with narrow-band ultraviolet B therapy might be the best option to hasten recovery and minimize relapse.

Relation between combining evidence-based medications on mortality following myocardial infarction in patients with and without renal impairment.

BACKGROUND: Antiplatelet agents, beta-blockers, statins and ACE inhibitors have been shown to reduce mortality in patients following myocardial infarction (MI). However, it is uncertain if the combination of these agents has a similar impact on mortality following MI in patients with renal dysfunction. METHODS: We studied 5529 consecutive patients with confirmed MI between January 2000 and December 2003. Data on baseline demographics, co-morbidities and in-hospital management were collected prospectively. Glomerular filtration rate (GFR) was estimated using the 4-component Modification of Diet in Renal Disease equation. Based on discharge use of evidence-based medications, the patients were divided into those using 0, 1, 2, 3 or 4 medications. The impact of medication use on 1-year mortality was then assessed for patients with GFR > or =60 ml/min/1.73 m2 (group I) and GFR < 60 ml/min/1.73 m2 (group 2). RESULTS: Mean age was 63 +/- 13 years with 71% men.The prevalence of reduced GFR was 35% and the adjusted odds ratio for I-year mortality of patients in group 2 compared to those in group I was 1.86 (95% CI 1.54-2.25, P < 0.001). Compared with patients with no medication, the adjusted odds ratio for 1-year mortality was lower in patients with 1, 2, 3 and 4 medications in both groups. There was no significant interaction between the number of medications used and GFR. CONCLUSION: Increased use of combined evidence-based medications was independently associated with a lower 1-year post MI mortality. Such therapies offer similar survival benefit in patients with and without renal dysfunction.

Reperfusion strategy and mortality in ST-elevation myocardial infarction among patients with and without impaired renal function.

INTRODUCTION: Several randomised controlled trials have demonstrated better outcomes with primary percutaneous coronary intervention (PCI) over fibrinolytic therapy in the treatment of patients with ST-segment elevation myocardial infarction (STEMI) and normal renal function. Whether this benefit extends to patients with impaired renal function is uncertain. MATERIALS AND METHODS: We studied 1672 patients with STEMI within 12 hours of symptom onset who were admitted to 2 major public hospitals in Singapore from 2000 to 2002. All patients received either upfront fibrinolytic or PCI as determined by the attending cardiologist. Serum creatinine was measured on admission and the glomerular filtration rate (GFR) was determined using the Modification of Diet in Renal Disease equation. The impact of reperfusion strategy on 30-ay mortality was then determined for patients with GFR > or =60 mL min-(1) 1.73 m-(2) and GFR <60 mL min-(1) 1.73 m-(2). RESULTS: The mean age was 56 +/- 12 years (85% male) and mean GFR was 81 +/- 30 mL min-(1) 1.73 m-(2). Unadjusted 30-day mortality rates for fibrinolytic-treated vs primary PCI-treated patients were 29.4% vs 17.9%, P <0.05, in the impaired renal function group and 5.4% vs 3.1%, P <0.05, in the normal renal function group. After adjusting for covariates, primary PCI was associated with a significantly lower mortality in the normal renal function group [odds ratio (OR), 0.41; 95% confidence interval (CI), 0.19-0.89] but not in the impaired renal function group [OR, 0.70; 95% CI, 0.31-1.60]. CONCLUSIONS: Primary PCI was associated with improved 30-day survival among patients with normal renal function but not among those with impaired renal function. Randomised trials are needed to study the relative efficacy of both reperfusion strategies in patients with impaired renal function.

Impact of combination evidence-based medical therapy on mortality following myocardial infarction in elderly patients.

Antiplatelet drugs, beta-blockers, statins, and angiotensinogen-converting enzyme inhibitors reduce mortality following myocardial infarction (MI). The data on the impact of combination evidence-based medications on mortality following acute MI in elderly patients are limited. In this study, 5529 patients with MI admitted between January 2000 and December 2003 were assessed. Based on discharge use of evidence-based medications, the patients were divided into those using 0, 1, 2, 3, or 4 medications. The impact of medications on 1-year mortality was assessed for patients younger than 75 years and 75 years and older. Mean age of the patients was 63+/-13 years (71% male). The unadjusted 1-year mortality post-MI was 18.3% and 52.7% for young and elderly patients, respectively. Compared with patients with 0 medications, the adjusted odds ratio for 1-year mortality was lower in patients with 1, 2, 3, and 4 medications in both groups. Use of combination evidence-based medications was independently associated with lower 1-year post-MI mortality irrespective of age.

Trends in mortality from acute myocardial infarction in the coronary care unit.

INTRODUCTION: The treatment and outcome of acute myocardial infarction (AMI) has evolved greatly over the past few decades. We compared the mortality and complication rates of patients with AMI admitted to the Coronary Care Unit (CCU) in 2002 to previously reported data. MATERIALS AND METHODS: All data for AMI patients admitted to National Heart Centre CCU in 2002 were collected through the Singapore Cardiac Data Bank, including demographics, in hospital complications and mortality. These were compared to previous reports from the same institution in 1988, 1975 and 1967. RESULTS: A total of 516 cases with AMI were identified. A higher proportion of patients were aged >or=70 years in 2002 (31.8%) compared to 1988 (25%), 1975 (11%) and 1967 (5.6%). Acute percutaneous transluminal coronary angioplasty (PTCA) was performed in 250 of 516 (48%) patients in 2002. The overall in-patient and age-standardised mortality was 14.7% and 10% respectively, compared to 20.6% and 17% respectively in 1988 (P = 0.06). For the 250 patients who underwent acute PTCA, overall mortality was 5.2% compared to 24% in those who did not (P <0.001). Common in-hospital complications included heart failure (38%), non-sustained ventricular tachycardia (8%), atrial fibrillation (8%) and complete heart block (6%). Age, heart failure, bundle branch block and sustained ventricular tachycardia were associated with higher mortality by univariate analysis. On multivariate analysis, older age, heart failure and the absence of percutaneous intervention were independently associated with higher mortality. CONCLUSION: In-hospital mortality for AMI patients admitted to the CCU declined from 1988 to 2002 despite a higher proportion of elderly patients. The introduction of new therapies including drugs and percutaneous intervention may have contributed to this decline.