Evaluating medical undergraduates' and dermatology faculty members' perception of using three-dimensional images as part of dermatology education in a time of COVID-19: a mixed-methods study.

BACKGROUND: The coronavirus-19 pandemic has impacted the delivery of medical education in dermatology, leading to decreased patient contact. There arose a need to pioneer innovative teaching tools to augment current methods for now and beyond the pandemic. OBJECTIVES: We aimed to assess the utility of three-dimensional (3D) images in the learning and teaching of dermatology by analysing the perceptions of medical undergraduates and faculty members in a qualitative and quantitative study. METHODS: Medical undergraduates (n = 119) and dermatology faculty members (n = 20) were recruited on a voluntary basis to watch a showcase session using a portable 3D imaging system allowing 3D images of skin lesions to be examined and digitally manipulated. After the session, participants filled in an anonymous questionnaire evaluating their perceptions. RESULTS: Of the 119 learners, most (> 84%) strongly agreed/agreed that (i) they would have more confidence in the field of dermatology; (ii) their ability to describe skin lesions would increase; (iii) their understanding of common dermatological conditions would increase; (iv) 3D images allow a greater approximation to real-life encounters than 2D images; and (v) learning with this modality would be useful. Of the 20 faculty members, most (> 84%) strongly agreed/agreed that (i) it is easier to teach with the aid of 3D images, and (ii) they would want access to 3D images during teaching sessions. Skin tumours were perceived to be learnt best via this modality in terms of showcasing topography (P < 0.01) and close approximation to real-life (P < 0.001). Overall, thematic analysis from qualitative analysis revealed that conditions learnt better with 3D images were those with surface changes and characteristic topography. CONCLUSIONS: Our results show that the greatest utility of 3D images lies in conditions where lesions have skin surface changes in the form of protrusions or depressions, such as in skin tumours or ulcers. As such, 3D images can be useful teaching tools in dermatology, especially in conditions where appreciation of surface changes and topography is important.

S2k guidelines on the management of paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome initiated by the European Academy of Dermatology and Venereology (EADV).

BACKGROUND: Paraneoplastic pemphigus (PNP), also called paraneoplastic autoimmune multiorgan syndrome (PAMS), is a rare autoimmune disease with mucocutaneous and multi-organ involvement. PNP/PAMS is typically associated with lymphoproliferative or haematological malignancies, and less frequently with solid malignancies. The mortality rate of PNP/PAMS is elevated owing to the increased risk of severe infections and disease-associated complications, such as bronchiolitis obliterans. OBJECTIVES: These guidelines summarize evidence-based and expert-based recommendations (S2k level) for the clinical characterization, diagnosis and management of PNP/PAMS. They have been initiated by the Task Force Autoimmune Blistering Diseases of the European Academy of Dermatology and Venereology with the contribution of physicians from all relevant disciplines. The degree of consent among all task force members was included. RESULTS: Chronic severe mucositis and polymorphic skin lesions are clue clinical characteristics of PNP/PAMS. A complete assessment of the patient with suspected PNP/PAMS, requiring histopathological study and immunopathological investigations, including direct and indirect immunofluorescence, ELISA and, where available, immunoblotting/immunoprecipitation, is recommended to achieve a diagnosis of PNP/PAMS. Detection of anti-envoplakin antibodies and/or circulating antibodies binding to the rat bladder epithelium at indirect immunofluorescence is the most specific tool for the diagnosis of PNP/PAMS in a patient with compatible clinical and anamnestic features. Treatment of PNP/PAMS is highly challenging. Systemic steroids up to 1.5 mg/kg/day are recommended as first-line option. Rituximab is also recommended in patients with PNP/PAMS secondary to lymphoproliferative conditions but might also be considered in cases of PNP/PAMS associated with solid tumours. A multidisciplinary approach involving pneumologists, ophthalmologists and onco-haematologists is recommended for optimal management of the patients. CONCLUSIONS: These are the first European guidelines for the diagnosis and management of PNP/PAMS. Diagnostic criteria and therapeutic recommendations will require further validation by prospective studies.

Photodynamic Therapy With Topical 5% 5-Aminolevulinic Acid for the Treatment of Truncal Acne in Asian Patients.

BACKGROUND: Photodynamic therapy (PDT) using topical application of aminolevulinic acid (ALA) is an effective treatment for acne vulgaris. However, there is no clear consensus on the treatment regime in Asians.
AIM: To determine the efficacy, safety and tolerability of 5% ALA PDT in the treatment of truncal acne in Asians.
METHODS: Patients with truncal acne were treated with 5%-ALA under occlusion for 3 hours. All were subsequently treated with a red light source at wavelength 630 nm and an irradiance of 38mW/cm2 giving a total dose of 37 J/cm2. The numbers of acne lesions were recorded at baseline and regular intervals after treatment together with any adverse effects.
RESULTS: Fifteen patients were recruited. Overall, there was a 64.2% reduction in the inflammatory lesions count and a 24.3% reduction in the non-inflammatory lesions count at the end of the 12 weeks follow-up. Both mean lesions counts were significantly lower than baseline at all follow-up time points with paired t tests (all P values <0.05). Pain was well tolerated among our patients.
CONCLUSION: A single treatment session of 5%-ALA PDT was effective for the treatment of truncal acne with little side effects and acceptable in our Asian patients.

J Drugs Dermatol. 2016;15(6):727-732.

Retrospective Study on Autoimmune Blistering Disease in Paediatric Patients.

BACKGROUND: Autoimmune blistering diseases (AIBDs) are rare in children and their prevalence in Singapore is unclear. We aimed to investigate the clinical and immunopathologic characteristics of children diagnosed with AIBDs in Singapore. MATERIALS AND METHODS: The clinical and histology databases at the National Skin Centre in Singapore were searched to identify patients younger than 18 years old diagnosed with an AIBD from January 1, 1998, through December 31, 2012. Patient demographic characteristics, presentation, triggers, investigations, treatments, and disease course were analyzed. RESULTS: Twelve patients with AIBDs were identified; five (41.7%) had linear immunoglobulin A disease (LAD); two (16.7%) each had pemphigus vulgaris (PV), bullous pemphigoid, and bullous systemic lupus erythematosus; and one (8.3%) had pemphigus foliaceus. Four (33.3%) were female and eight (66.7%) male. The mean age of onset was 8.7 years (range 2-17 years). Most patients were treated with steroids and adjuvant immunosuppressants. Intravenous rituximab was used effectively in a patient with recalcitrant PV. The mean follow-up was 2.35 years (range 0.17-7.33 years). As of the last follow-up, four (33.3%) patients were in complete remission off therapy, two (16.7%) were in complete remission on therapy, four (33.3%) were in partial remission on therapy, and two (16.7%) were lost to follow-up. CONCLUSION: Consistent with the existing literature, our study shows that LAD is the most common cause of AIBDs in children. Although common in the West, dermatitis herpetiformis was not identified in the current study. Intravenous rituximab may be considered in recalcitrant childhood PV, but vigilant monitoring for side effects is crucial. Immunohistopathologic evaluation is important and repeat biopsies may be of value in patients with atypical disease courses.

Atopic dirty neck or acquired atopic hyperpigmentation? An epidemiological and clinical study from the National Skin Centre in Singapore.

BACKGROUND: 'Atopic dirty neck' is a poorly understood acquired hyperpigmentation in patients with atopic dermatitis (AD). OBJECTIVE: To report a single-centre experience with synthesis of this entity's features. METHODS: All patients with AD with dirty neck seen over a 5-month period at the National Skin Centre were invited to participate. RESULTS: Out of 544 AD patients examined, 78 (14.3%) had acquired pigmentation of the neck. The majority had moderate-to-severe underlying eczema. Histopathology showed increased epidermal melanin and dermal melanophages, a thickened basement membrane and a dense superficial perivascular infiltrate. CONCLUSION: Acquired atopic hyperpigmentation has a high prevalence, particularly in adolescent Asian males. Clinico-pathological correlation suggests it results from both frictional melanosis and post-inflammatory hyperpigmentation. The rippled appearance and the onset in adolescence are probably due to accentuation of the juxta-clavicular beaded lines. Optimal control of eczema may improve and potentially prevent the development, which is of importance considering the psychosocial impact of the condition.

Necrobiosis lipoidica with elastophagocytosis on an unusual location.

Necrobiosis lipoidica (NL) is a granulomatous disease of collagen degeneration classically affecting the lower extremities. Elastophagocytosis is a histological finding, whereby multinucleate macrophages demonstrate phagocytosis of elastic fibers commonly associated with sun-damaged skin. Elastophagocytosis is not typically described in NL. The authors present a patient who presented with reddish-yellow plaques on both his forearms. Skin biopsy revealed extensive palisaded granulomas consistent with NL and features of elastophagocytosis in the upper dermis. The unusual site of presentation is a diagnostic pitfall, further complicated by the histological features of elastophagocytosis, for which the differential diagnosis of actinic granuloma needs to be considered. This case highlights the importance of clinicopathological correlation to arrive at a definitive diagnosis in situations where unexpected features on physical examination and histology may confound the clinical picture.

A retrospective review of the therapeutic response with remission in patients with newly diagnosed bullous pemphigoid.

We reviewed the clinical characteristics and therapeutic response in cases of newly diagnosed bullous pemphigoid at the National Skin Centre between June 2009 and December 2010. Most (76%, n = 68/90) achieved clinical remission within 6 months of commencement of therapy. Oral mucosal involvement was identified as a risk factor associated with a prolonged duration of treatment beyond 6 months.

Autoimmune manifestations of CTLA-4 haploinsufficiency in two patients of Southeast Asian ethnicity.

We report 2 patients who first developed cutaneous manifestations, followed by autoimmune phenomena, infections, and hypogammaglobulinemia. They were initially diagnosed with common variable immunodeficiency; however, the diagnosis was revised to cytotoxic T-lymphocyte antigen 4 haploinsufficiency after genetic and functional testing.

Autoimmune Pemphigus: Latest Advances and Emerging Therapies.

Pemphigus represents a group of rare and severe autoimmune intra-epidermal blistering diseases affecting the skin and mucous membranes. These painful and debilitating diseases are driven by the production of autoantibodies that are mainly directed against the desmosomal adhesion proteins, desmoglein 3 (Dsg3) and desmoglein 1 (Dsg1). The search to define underlying triggers for anti-Dsg-antibody production has revealed genetic, environmental, and possible vaccine-driven factors, but our knowledge of the processes underlying disease initiation and pathology remains incomplete. Recent studies point to an important role of T cells in supporting auto-antibody production; yet the involvement of the myeloid compartment remains unexplored. Clinical management of pemphigus is beginning to move away from broad-spectrum immunosuppression and towards B-cell-targeted therapies, which reduce many patients' symptoms but can have significant side effects. Here, we review the latest developments in our understanding of the predisposing factors/conditions of pemphigus, the underlying pathogenic mechanisms, and new and emerging therapies to treat these devastating diseases.

Epidemiology and Factors Associated with Remission of Pemphigus Vulgaris and Foliaceus in Singapore.

INTRODUCTION: Pemphigus is a chronic, relapsing immunobullous disease. There is limited data on the clinical course and prognostic factors of pemphigus in Asian patients. MATERIALS AND METHODS: We conducted a retrospective cohort study of all newly diagnosed pemphigus vulgaris (PV) and pemphigus foliaceus (PF) patients seen at the National Skin Centre from 1 January 2004 to 31 December 2009. Demographic and clinical data on comorbidities, treatment and remission were recorded. Mortality information was obtained from the National Registry of Diseases. Prognostic endpoint was overall remission at last visit. RESULTS: Sixty- one patients (36 PV and 25 PF) were recruited. Among PV patients, higher initial prednisolone dose (P = 0.017) and the use of azathioprine (P = 0.028) were significantly associated with overall remission at last visit. However, higher desmoglein 1 antibody titres at diagnosis (P = 0.024) and the use of dapsone (P = 0.008) were negatively associated with overall remission at last visit. Among PF patients, only higher desmoglein 1 antibody titre at diagnosis (P = 0.041) was found to be associated with lower overall remission at last visit. There was no mortality during the 3-year follow-up period in both PV and PF. CONCLUSION: Higher initial prednisolone dose and the use of azathioprine in PV desmoglein 1 antibody titre at diagnosis in PV and PF might be prognostic markers for achieving remission. Use of dapsone was associated with lower overall remission in PV, but this might be confounded because dapsone was used as an adjuvant therapy in recalcitrant cases. Owing to study methodology and limitations, further evaluation is needed for better prognostication of pemphigus.

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.

Tailoring of recommendations to reduce serious cutaneous adverse drug reactions: a pharmacogenomics approach.

The Health Sciences Authority launched a pharmacogenetics initiative in 2008 to facilitate evaluation of pharmacogenetics associations pertinent for Chinese, Malays and Indians in Singapore. The aim was to reduce the incidence and unpredictability of serious adverse drug reactions, with a focus on serious skin adverse drug reactions. This paper describes the gathering of evidence and weighing of factors that led to different genotyping recommendations for HLA-B*15:02 with carbamazepine and HLA-B*58:01 with allopurinol, despite both having strong genetic associations. Translation of pharmacogenomics at a national level requires careful deliberation of the prevalence of at-risk allele, strength of genetic associations, positive predictive value, cost-effectiveness and availability of alternative therapies. Our experience provides a perspective on translating genomic discoveries in advancing drug safety.

Guidelines for the Management of Atopic Dermatitis in Singapore.

INTRODUCTION: Atopic dermatitis is a common, chronic pruritic condition affecting both children and adults, which has a negative impact on the quality of life. These guidelines were developed by an expert workgroup appointed by the Dermatological Society of Singapore, to provide doctors with information to assist in the management of their patients with atopic dermatitis. The workgroup members are experienced dermatologists with interest and expertise in eczemas. MATERIALS AND METHODS: Workgroup members arrived at a consensus on the topics to be included. Relevant studies from the literature were assessed for best evidence, supplemented by the collective experience of the workgroup. RESULTS: For mild atopic dermatitis, emollients, mild potency topical steroids and topical calcineurin inhibitors are recommended. For moderate-to-severe atopic dermatitis, the use of emollients, moderate-to-potent topical steroids, topical calcineurin inhibitors, wet dressings, antimicrobials for secondary skin infection, phototherapy, and systemic therapy (e.g. prednisolone, cyclosporine, azathioprine or methotrexate) may be warranted. Patients with moderate-to-severe atopic dermatitis should be managed in conjunction with a dermatologist. CONCLUSION: Good outcomes can be achieved with an individualised therapeutic approach combined with adequate patient and parental education.

Anxiety and Depression in Patients with Atopic Dermatitis in a Southeast Asian Tertiary Dermatological Centre.

INTRODUCTION: This study aimed to assess the frequency of anxiety and depression in a cohort of adult patients with atopic dermatitis (AD) in a tertiary dermatological centre, using the Hospital Anxiety and Depression Scale (HADS). We looked for any correlation between anxiety and depression with skin disease severity. MATERIALS AND METHODS: Patients with AD were recruited from the National Skin Centre, Singapore, from 2008 to 2009 for a prospective cross-sectional study. The scoring atopic dermatitis (SCORAD) grade was determined and the HADS was administered via interviews. RESULTS: A total of 100 patients (78 males, 22 females) were enrolled (92% Chinese, 4% Malays and 4% Indians). Their average age was 25.7 years. Sixty-five percent used topical steroids, 14% had previously taken oral prednisolone for the control of disease flares, and 20% were on concurrent systemic therapy. The mean SCORAD was 55.0, with 99% of patients having moderate or severe AD. The mean HADS anxiety score was 7.2 and the mean depression score was 5.0. The level of anxiety correlated well with that of depression (Spearman's rank correlation coefficient, ρ = 0.59, P <0.05); 18% were considered as cases of anxiety and 5% as cases of depression. These patients also had higher SCORAD values compared to other patients with lower scores for anxiety or depression (P <0.05). Linear regression demonstrated a statistically significant positive relationship between anxiety and depression scores, and SCORAD scores. CONCLUSION: Our study identified, by means of the HADS, the frequency of anxiety and depression amongst a cohort of Singaporean patients with AD. More severe skin disease correlated to greater psychological burden. The HADS is a useful screening tool that can constitute part of the overall holistic management of patients with AD so as to improve patient care.