Moisturisers from birth in at-risk infants of atopic dermatitis - a pragmatic randomised controlled trial.

BACKGROUND: Atopic dermatitis (AD) is a common, chronic dermatosis, with onset of disease often manifesting in early infancy. Past studies evaluating the early use of moisturisers in the prevention of AD had mixed results. OBJECTIVES: To compare the incidence of moderate or severe AD and total incidence of AD in a cohort of 'at-risk' infants treated with moisturisers from the first 2 weeks of life, to a similar group without moisturisers. METHODS: We performed a single-centre, prospective, parallel-group, randomised study in infants with at least 2 first-degree relatives with atopy. Subjects were randomised into either a treatment group with moisturisers or a control group without moisturisers. Participants were assessed at 2, 6, and 12 months for AD and if present, the severity was assessed using SCORAD index. We also compared the overall incidence of AD, trans-epidermal water loss (TEWL), stratum corneum (SC) hydration, pH, and incidence of food and environmental sensitisation and allergies between both groups. Genotyping for loss-of-functions mutations in the FLG gene was conducted. RESULTS: A total of 200 subjects were recruited, with 100 subjects in each arm. There was no significant difference in incidence of moderate or severe AD, and total incidence of AD at 12 months between the treatment and control groups. There was a lower mean SCORAD in the treatment group than in the control group, but no significant difference in TEWL, SC hydration, and skin pH. No significant side-effects were reported. CONCLUSIONS: The early use of moisturisers in 'at-risk' infants does not reduce the incidence of moderate-to-severe AD and overall incidence of AD in infancy.

Recalcitrant psoriasiform dermatosis of the face: Is it related to pityriasis rubra pilaris?

BACKGROUND: There are patients with recalcitrant psoriasiform plaques that do not fit into conventional categories of facial dermatoses. Our study aims to describe the clinicopathological characteristics of several patients with a unique presentation of persistent psoriasiform facial rashes. METHODS: This retrospective cross-sectional study analyzed clinical and histological data of known cases of recalcitrant psoriasiform dermatosis of the face diagnosed at National Skin Centre, Singapore, over 10 years. RESULTS: There were 8 Chinese patients with mean age at onset of 29 years. Majority had pink to pink-orange well-defined plaques with dry scale (n = 6, 75%), distributed mostly on the cheeks (100%) and chin (n = 7, 88%). Hyperkeratosis, parakeratosis, preserved granular layer and psoriasiform hyperplasia were showed in all biopsies. Other common findings included subtle subcorneal acantholysis, "checkerboard" alternating ortho-/parakeratosis, vacuolated keratinocytes and follicular plugging. All patients showed little treatment response. One patient eventually developed features of type II pityriasis rubra pilaris (PRP). Our study was limited by its small sample size and lack of a pre-existing diagnostic code. CONCLUSIONS: This recalcitrant psoriasiform facial dermatosis seems to be a distinct entity, with consistent and reproducible clinical features and a PRP-like histology, bearing some resemblance to the recently described condition-facial discoid dermatosis.

A retrospective clinico-pathological study comparing lichen planus pigmentosus with ashy dermatosis.

BACKGROUND/OBJECTIVES: Controversy persists as to whether lichen planus pigmentosus and ashy dermatosis are separate clinical entities. This study was conducted to examine the clinicopathological features and treatment outcome of the two conditions. METHODS: A retrospective medical chart review of all patients who were diagnosed with lichen planus pigmentosus or ashy dermatosis was conducted. The information collected included the participants' age at onset, site of onset, duration of disease, presence of precipitating factors, distribution of disease, pigmentation and presence of symptoms. In patients from whom a biopsy was taken the histopathological reports were included. RESULTS: Altogether 26 patients with ashy dermatosis and 29 with lichen planus pigmentosus were included in the study. Compared with ashy dermatosis, lichen planus pigmentosus had a more localised distribution with a preponderance for facial involvement, compared with the truncal preponderance in ashy dermatosis. Ashy dermatosis tended to have a more stable clinical course than lichen planus pigmentosus, which was more likely to wax and wane. The utility of histopathology in differentiating between the two conditions is low. CONCLUSION: Ashy dermatosis and lichen planus pigmentosus, as defined in this study, appear to be two separate clinical entities with distinguishable clinical features and natural histories.

Twelve-month and sixty-month outcomes of noncultured cellular grafting for vitiligo.

BACKGROUND: Noncultured cellular grafting is a known surgical technique for vitiligo. OBJECTIVE: This study evaluated our center's 12-month repigmentation outcome and its maintenance up to 60 months, factors influencing repigmentation and safety data. METHODS: Clinicoepidemiologic and repigmentation data were reviewed for patients with vitiligo who had undergone noncultured cellular grafting from March 2006 to December 2012 at the National Skin Center, Singapore. RESULTS: All 177 patients who received noncultured cellular grafting during the study period were included. For those with available data, good to excellent repigmentation was present in 83% at 60 months. At 12 months, 88% of patients (n = 52) with segmental vitiligo achieved good to excellent repigmentation compared with 71% (n = 55) with nonsegmental vitiligo (P < .05). More patients on collagen dressings (82%) achieved good to excellent repigmentation compared with those who received hyaluronic acid (63%) (P < .05). Sites of lesions and postgrafting phototherapy did not significantly affect repigmentation outcome. Adverse reactions were uncommon and mild. LIMITATIONS: The study is limited by its retrospective nature, the progressive loss to follow-up of patients, the absence of blinding, and the lack of use of standardized assessment tools. CONCLUSION: Noncultured cellular grafting was successful in allowing more than 80% of patients to achieve good to excellent repigmentation for at least 60 months.

Follicular vitiligo: A report of 8 cases.

BACKGROUND: Follicular vitiligo, a recently proposed new subtype of vitiligo, has primary involvement of the hair follicle melanocytic reservoir. OBJECTIVE: We sought to characterize follicular vitiligo through a case series of 8 patients. METHODS: Patients with features of follicular vitiligo who were seen at the vitiligo clinic in the National Center for Rare Skin Disorders in Bordeaux, France, were recruited. A retrospective review of case records and clinical photographs was carried out. RESULTS: There were 8 male patients with a mean age of 48 years. All patients reported significant whitening of their body and, in some, scalp hairs before cutaneous depigmentation. Examination revealed classic generalized depigmented lesions of vitiligo and an impressive presence of leukotrichia, not only in the vitiliginous areas, but also in areas with clinically normal-appearing skin. Punch biopsy specimen of the leukotrichia and vitiligo lesions demonstrated loss of melanocytes and precursors in the basal epidermis and hair follicle. LIMITATIONS: This was a cross-sectional study based on a single-center experience. CONCLUSION: Follicular vitiligo is a distinct entity within the spectrum of vitiligo. This entity may serve as the missing link between alopecia areata and vitiligo, with probable physiopathological similarities between these conditions.

A retrospective review of cutaneous metastases at the National Skin Centre Singapore.

BACKGROUND/OBJECTIVES: Cutaneous metastases occur in up to 10% of all visceral malignancies. This study aims to determine the clinico-epidemiological characteristics of patients diagnosed with cutaneous metastases at a leading Asian tertiary dermatological centre. METHODS: A retrospective chart review was carried out on all patients diagnosed with cutaneous metastases from 2001 to 2010, identified through the National Skin Centre's clinical and histological databases. RESULTS: In all, 35 patients were diagnosed with cutaneous metastases at a mean age of 65 years, with a female: male ratio of 3:2 and with most (97%) being Chinese. Cutaneous metastases were the first presentation of cancer in 34% of patients (n = 12). The two commonest primaries were breast (49%, n = 17) and lung (9%, n = 3). Most had cutaneous metastases on the chest (37%, n = 13) followed by the pelvis (17%, n = 6) and 20% (n = 7) had skin lesions on multiple sites. Clinically, 46% of patients (n = 16) presented with nodule(s), 26% (n = 9) with plaque(s) and 20% (n = 7) with heterogeneous morphologies. Cutaneous metastases were suspected in 72% of patients (n = 25), attributed to clinical features (46%, n = 16) or the presence of active metastatic disease elsewhere (26%, n = 9). All lesions appeared dermal in origin. CONCLUSIONS: Cutaneous metastases are highly variable in presentation and a high index of suspicion is required for prompt diagnosis, especially in patients with a history of cancer, regardless of stage of treatment of the primary tumour.

Management of herpes zoster and post-herpetic neuralgia.

Herpes zoster and its sequela post-herpetic neuralgia (PHN) are conditions with significant morbidity. PHN is a chronic, debilitating neuropathic pain that can persist long beyond resolution of visible cutaneous manifestations. This paper provides practical guidelines for management of herpes zoster and PHN. For herpes zoster, antivirals should be started, preferably within 72 h of onset, to reduce the severity and duration of the eruptive phase and to reduce the intensity of acute pain. PHN can be treated with either topical or systemic agents. Topical lidocaine and capsaicin are effective. For patients with more severe pain, the following systemic agents can be considered (in decreasing order of recommendation): the anticonvulsants gabapentin and pregabalin, the tricyclic antidepressants amitriptyline, nortriptyline, and desipramine, and, lastly, the opioid analgesics tramadol, morphine, oxycodone, and methadone. For patients at high risk of developing PHN, early initiation of gabapentin or amitriptyline after the onset of herpes zoster is suggested. The new zoster vaccine has been shown to be effective in reducing the incidence of herpes zoster and PHN.

Therapeutic strategies in psoriasis patients with psoriatic arthritis: focus on new agents.

Psoriatic arthritis affects approximately 6-42 % of patients with psoriasis. It is useful for physicians or dermatologists managing psoriasis patients to be aware of how to concurrently manage the joint manifestations, as it is preferable and convenient to use a single agent in such patients. However, only certain therapies are effective for both. Systemic agents, which can be used for both skin and joint manifestations, include methotrexate and ciclosporin. For the group of biologic agents, the tumor necrosis factor inhibitors such as adalimumab, etanercept, infliximab, golimumab and certolizumab are effective. Ustekinumab is a more recently developed agent belonging to the group of anti-IL-12p40 antibodies and has been shown to be efficacious. Newer drugs in the treatment armamentarium that have shown efficacy for both psoriasis and psoriatic arthritis consist of the anti-IL-17 agent, secukinumab, and a phosphodiesterase-4 inhibitor, apremilast. The other anti-IL-17 agents, ixekizumab and brodalumab, as well as the oral Jak inhibitor, tofacitinib, have very limited but promising data. This review paper provides a good overview of the agents that can be used for the concurrent management of skin and joint psoriasis.

Isotretinoin is safe and efficacious in Asians with acne vulgaris.

BACKGROUND: Oral isotretinoin is effective for acne vulgaris but concerns remain regarding its adverse effects. OBJECTIVES: This study aims to evaluate the safety and efficacy of isotretinoin for acne vulgaris in Asian patients. METHODS: We conducted a 4-year retrospective study on all patients with acne vulgaris treated with isotretinoin, between January 2005 and December 2008 at the National Skin Centre in Singapore. Medical records were reviewed for information on patient demographics, acne severity, isotretinoin dose, duration, adverse effects and outcome. RESULTS: There were 2,255 patients, with a mean age of 22.5 years, male:female ratio of 2.5:1 and 82.3% being Chinese. The mean starting dose of isotretinoin was 0.4 mg/kg and on average, patients received 7.8 months of treatment at a mean dose of 0.5 mg/kg. Mean total cumulative dose was 95.6 mg/kg. Vast majority (93.9%) achieved complete remission or substantial improvement. Thirty-eight (2.2%) and 24 patients (2.7%) developed elevated serum levels of alanine and aspartate aminotransferases subsequent to treatment. There were 194 (12.1%) and 80 (4.8%) patients who developed hyperlipidaemia and hypertriglyceridaemia respectively. Isotretinoin was generally well-tolerated, with 6.4% (n = 145) discontinuing due to side-effects. CONCLUSIONS: This study reaffirms the overall safety and efficacy of oral isotretinoin in Asian patients with acne vulgaris.