Acne Management Guidelines by the Dermatological Society of Singapore.

Due to the multiethnic patient population with varying skin types in Singapore, clinicians often find the management of acne in their patients to be challenging. The authors developed these guidelines to provide comprehensive advice on individualized acne treatment and to provide a reference guide for all doctors who treat patients of Asian descent. Unique features of acne in Singapore are highlighted. We address concerns such as diet, special population needs, and the benefits, side effects, risks, and cost-effectiveness of currently available acne treatments. These treatment guidelines outline recommendations for the diagnosis, grading, and treatment of children, adolescents, and adults with acne of varying severity, and include advice pertaining to the use of cosmeceuticals and management of scars.

Mycobacterium abscessus Infection During Ustekinumab Treatment in Crohn's Disease: A Case Report and Review of the Literature.

The introduction of ustekinumab, an interleukin [IL]12/23 p40 inhibitor, to the therapeutic armamentarium of Crohn's disease has provided a much needed treatment option for patients who have failed conventional biologics with anti-tumour necrosis factor [TNF] and anti-integrin agents. Despite targeting two major cytokine pathways, the side effect profile of ustekinumab appears to be favourable in clinical trials. In particular, the risk of tuberculosis infection was observed to be lower than in patients who have received anti-TNF agents. The risk of non-tuberculosis mycobacterium infection, however, remains unknown. Here, we report the first case of a patient with Crohn's disease who developed Mycobacterium abscessus infection while on ustekinumab treatment.

Use of an Interferon-γ Release Assay in the Detection of Latent Tuberculosis in Dermatology: A Descriptive Analysis.

With the increasing use of biologic therapy in psoriasis, it is becoming more important to identify and treat latent tuberculosis (TB) infection (LTBI). Tuberculin skin test (TST) has been traditionally used to detect LTBI, but interferon-γ release assays (IGRAs), such as the T-SPOT.TB test (T-Spot), are increasingly being used in its place. The indications and results of 51 T-Spot tests performed at the National Skin Centre in Singapore between 2008 and 2010 were analyzed and compared with TST results, decision on LTBI treatment, and previous use of immunosuppressants. T-Spot was most commonly performed as part of a prebiologic workup in patients with psoriasis. A total of 14 (27.5%) results were positive, and no patients had features of active TB. Ten of these patients also underwent TST, five of whom had negative TST results. Six patients (11.8%) had equivocal results with T-Spot test. This study shows poor concordance between T-Spot test and TST. A high incidence of equivocal results in IGRA may limit the utility of the T-Spot test.

Recurrent and persistent pityriasis rosea: an atypical case presentation.

We report a case of atypical pityriasis rosea in a 24-year-old Malay man. He presented with an 11-month history of three recurrent and persistent episodes of pityriasis rosea associated with oral ulcers. The first episode lasted for one month and recurred within 14 days. The second episode lasted for three months and recurred within nine days. The third episode lasted for seven months. Although all three episodes were not preceded by any prodromal symptoms, a herald patch was noted on three different sites (the left iliac fossa, abdomen and chest) on each successive episode. Recurrent pityriasis rosea and its association with oral ulcers, although quite uncommon, have been reported in the literature. However, reports of multiple recurrences, with prolonged duration of each episode and very short remissions in between, have not been made. To the best of our knowledge, this is the first report of such unique presentation.

Complementary role of a polymerase chain reaction test in the diagnosis of onychomycosis.

BACKGROUND: The successful treatment of onychomycosis depends on accurate diagnosis. Conventional diagnostic methods, including direct microscopy and fungal culture, are non-specific, insensitive and time-consuming. Recently, PCR has shown promise in improving the diagnosis of onychomycosis. We aimed to evaluate a commercially available PCR kit for the in vitro detection of dermatophytes and specifically Trichophyton rubrum in nail specimens with suspected onychomycosis, and to compare the detection rates of PCR with conventional diagnostic methods. METHODS: Nail specimens were prospectively collected from patients with clinically suspected onychomycosis. All nail specimens were positive on direct microscopic examination. PCR and fungal cultures were administered, and the detection rates of dermatophytes were compared. RESULTS: In all, 107 nail specimens were analysed. The fungal culture was positive in 57 (53%) specimens (38 dermatophytes and 19 non-dermatophytes). PCR was positive in 77 (72%) specimens (63 T. rubrum and 14 pan-dermatophyte). A total of 37 specimens (35%) were positive for both fungal culture and PCR. PCR detected dermatophytes in 39 specimens that were missed by the fungal culture, increasing the diagnosis of dermatophyte-positive specimens by 37%. Five dermatophyte-culture-positive specimens were negative for PCR. CONCLUSIONS: This study demonstrates that PCR increases the sensitivity of detection of dermatophytes in nail specimens. Despite its limitations, the use of PCR can complement direct microscopic examination and fungal cultures to aid clinicians in the diagnosis of suspected dermatophytic onychomycosis.

Gender differences in partner influences and barriers to condom use among heterosexual adolescents attending a public sexually transmitted infection clinic in Singapore.

OBJECTIVE: To compare gender differences in the factors associated with condom use at most recent voluntary intercourse among heterosexual adolescents attending a public clinic for sexually transmitted infections (STIs). STUDY DESIGN: Between 2008 and 2011, we conducted a cross-sectional survey on 964 never-married adolescents between 14 and 19 years of age who reported having engaged in voluntary intercourse for most recent sexual encounter and were attending the only public STI clinic in Singapore for screening or treatment of STIs. Data were collected using a self-administered questionnaire. RESULTS: The response rate to the questionnaire was 85.2%. In multivariate analysis, condom use at last intercourse for both genders was negatively associated with Malay race and peer connectedness and was positively associated with confidence in the ability to use a condom correctly. Being employed was positively associated with condom use for female respondents only. For male respondents only, condom use showed a positive association with living in better housing, older age at first intercourse, and engaging in sexual intercourse with commercial sex partners. Almost all (90%) commercial sex partners suggested condom use and provided condoms compared with 8.1% of non-sex worker partners. Condom use showed a negative association with inconvenience in its use among male respondents but not female respondents. CONCLUSION: STI prevention programs for adolescents must promote condom use with nonpaying partners, address barriers to condom use, and develop condom application skills, taking into account gender differences. Future research should explore condom use within dating relationships.

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.

Accuracy and user-acceptability of HIV self-testing using an oral fluid-based HIV rapid test.

BACKGROUND: The United States FDA approved an over-the-counter HIV self-test, to facilitate increased HIV testing and earlier linkage to care. We assessed the accuracy of self-testing by untrained participants compared to healthcare worker (HCW) testing, participants' ability to interpret sample results and user-acceptability of self-tests in Singapore. METHODOLOGY/PRINCIPAL FINDINGS: A cross-sectional study, involving 200 known HIV-positive patients and 794 unknown HIV status at-risk participants was conducted. Participants (all without prior self-test experience) performed self-testing guided solely by visual instructions, followed by HCW testing, both using the OraQuick ADVANCE Rapid HIV 1/2 Antibody Test, with both results interpreted by the HCW. To assess ability to interpret results, participants were provided 3 sample results (positive, negative, and invalid) to interpret. Of 192 participants who tested positive on HCW testing, self-testing was positive in 186 (96.9%), negative in 5 (2.6%), and invalid in 1 (0.5%). Of 794 participants who tested negative on HCW testing, self-testing was negative in 791 (99.6%), positive in 1 (0.1%), and invalid in 2 (0.3%). Excluding invalid tests, self-testing had sensitivity of 97.4% (95% CI 95.1% to 99.7%) and specificity of 99.9% (95% CI: 99.6% to 100%). When interpreting results, 96%, 93.1% and 95.2% correctly read the positive, negative and invalid respectively. There were no significant demographic predictors for false negative self-testing or wrongly interpreting positive or invalid sample results as negative. Eighty-seven percent would purchase the kit over-the-counter; 89% preferred to take HIV tests in private. 72.5% and 74.9% felt the need for pre- and post-test counseling respectively. Only 28% would pay at least USD15 for the test. CONCLUSIONS/SIGNIFICANCE: Self-testing was associated with high specificity, and a small but significant number of false negatives. Incorrectly identifying model results as invalid was a major reason for incorrect result interpretation. Survey responses were supportive of making self-testing available.

Sex work and risky sexual behaviors among foreign entertainment workers in urban Singapore: findings from Mystery Client Survey.

Globalization has led to a rapid influx of female workers from Asian countries with high prevalence of HIV to Singapore, with many entering the entertainment industry. We assessed the prevalence of sexual services, condom use, and self-initiated screening for sexually transmitted infections (STIs) and associated variables among foreign female entertainment workers in Singapore. A cross-sectional survey of 317 female entertainment workers, using mystery clients, was conducted on a two-stage proportional cluster sample of 93 entertainment establishments stratified by geographical zone in Singapore. We found a high prevalence (71 %) of sexual services in entertainment establishments with 53 % of the female entertainment workers reporting selling sex. Consistent condom use for sex with paying clients in a usual week in the past 3 months was low, ranging from 37.9 % for oral sex, 46.9 % for anal sex, to 51.9 % for vaginal sex. On multivariate logistic regression, consistent condom use for vaginal sex with clients showed a significant independent association with the entertainment worker's behavior of asking clients to use condoms and a borderline association with entertainment worker being a Chinese national. Less than half (48.9 %) of the sex workers had ever been screened for STIs either locally or in their home country. The only independent factor significantly associated with STI screening was having to support one's family. In summary, a high percentage of foreign female entertainment workers in Singapore reported selling sex. Condom use and STI screening were low among them. Access to STI screening, treatment, and education services should be enhanced for foreign female entertainment workers in Singapore.

Identification of the leprosy agent Mycobacterium lepromatosis in Singapore.

BACKGROUND: A new leprosy-causing species, namely Mycobacterium lepromatosis, was discovered recently to be the cause of diffuse lepromatous leprosy (DLL) in Mexico. It is unknown whether this organism exists beyond Mexico. METHODS: We sought to determine the identity of the mycobacteria in the skin tissue of two patients from Singapore who died of DLL. DNA was extracted from archived biopsy tissue, and conserved polymerase chain reaction primers were used to amplify and sequence two to three mycobacterial genes in each skin sample. RESULTS: Both M. lepromatosis and the well-known leprosy agent Mycobacterium leprae were identified in each DLL skin sample. The M. lepromatosis gene sequences from the Singapore cases matched 99.9% with the known Mexican M. lepromatosis strain, but they only matched the corresponding M. leprae sequences by 89.2%. CONCLUSIONS: The new species M. lepromatosis exists beyond Mexico and is the cause of DLL in Singapore. It may cause dual infections along with M. leprae in endemic areas. Archived skin biopsy can be used to differentiate the leprosy agents.

Premarital sexual intercourse among adolescents in an Asian country: multilevel ecological factors.

OBJECTIVE: The goal was to assess personal and environmental factors associated with premarital sex among adolescents. METHODS: We conducted a case-control study. Between 2006 and 2008, we recruited 500 adolescents who reported having engaged in voluntary sex for most recent sex. Five hundred control subjects were matched for age, gender, and ethnicity. RESULTS: Independently significant factors for premarital sex among boys were pornography viewing (adjusted odds ratio [OR]: 5.82 [95% confidence interval [CI]: 2.34-14.43]), lack of confidence to resist peer pressure (OR: 3.84 [95% CI: 2.27-6.50]), perception that more than one half of their friends had engaged in sex (OR: 3.37 [95% CI: 1.92-5.92]), permissiveness regarding premarital sex (OR: 3.41 [95% CI: 2.10-5.55]), involvement in gang activities (OR: 3.45 [95% CI: 1.66-7.15]), drinking (OR: 1.77 [95% CI: 1.07-2.94]), smoking (OR: 1.91 [95% CI: 1.14-3.20]), and living in low-cost housing (OR: 3.25 [95% CI: 1.64-6.43]). For girls, additional factors were previous sexual abuse (OR: 7.81 [95% CI: 2.50-24.41]) and dropping out of school (OR: 2.72 [95% CI: 1.32-5.61]), and stronger associations were found for lack of confidence to resist peer pressure (OR: 5.56 [95% CI: 2.94-10.53]) and permissiveness regarding premarital sex (OR: 6.25 [95% CI: 3.30-11.83]). Exposure to persons with HIV/AIDS or sexually transmitted infections in the media was negatively associated with sex for boys (OR: 0.27 [95% CI: 0.16-0.45]) and girls (OR: 0.24 [95% CI: 0.13-0.47]). CONCLUSION: Sex education programs for adolescents must address social, media, and pornographic influences and incorporate skills to negotiate sexual abstinence.

Sexually transmissible infection management practices among primary care physicians in Singapore.

BACKGROUND: Primary care physicians manage a significant number of sexually transmissible infections (STI); however, there has not been a survey to assess the standard of medical care, completeness of notifications, provision of counselling and contact tracing by primary care physicians in Singapore. METHODS: An anonymous postal survey was conducted in which 1557 questionnaires were mailed out to general practitioners (GP), and government primary care and emergency department doctors. RESULTS: In all, 736 questionnaires (47.3%) were returned, and the majority of respondents were graduates from the local medical school, worked in solo or group practices and were males. One hundred and thirty doctors (17.7%) indicated they had received training attachments or postings in dermato-venereology departments. Almost one-third (30.8%) had been working as doctors for fewer than 10 years and 87.8% reported that they managed STI in their practice. Almost half did not investigate genital discharge patients, and one-third would still use ciprofloxacin to treat discharges. In the management of ulcers, over half indicated that they would order syphilis serology, and a significant minority would use parenteral penicillin. Most doctors provided history taking, screening for other STI, testing for HIV infection and STI counselling. A small minority of doctors undertook contact tracing, and there was incomplete notification of many STI. CONCLUSIONS: Overall medical management of STI by primary care physicians was acceptable. Skills in contact tracing and reminders on disease notification are areas that need particular attention.

Spectrum of skin disorders in human immunodeficiency virus-infected patients in Singapore and the relationship to CD4 lymphocyte counts.

BACKGROUND: Skin disorders are extremely common and cause significant morbidity in human immunodeficiency virus (HIV)-infected individuals. There are few data on their prevalence and association with CD4 counts in Asians. AIM: To evaluate the prevalence of skin disorders in ambulatory HIV-infected individuals attending a specialized skin clinic in Singapore and the association with the degree of immunosuppression. METHODS: A cross-sectional study on skin disorders in HIV-positive outpatients in the Communicable Disease Centre of Singapore was performed. The association between skin disease prevalence and CD4 count was evaluated using logistic regression. RESULTS: Ninety-six patients (male : female, 8 : 1) were enrolled. The most common mode of HIV transmission was heterosexual (75%), followed by homosexual/bisexual contacts (22%), and intravenous drug abuse (3%). The distribution of patients in terms of current CD4 cell counts was as follows: 38.5% with less than 50 x 10(6)/L, 25% with between 50 and 199/microL, and 36.5% with at least 200 x 10(6)/L. The most common skin disorder was pruritic papular eruption (PPE) of HIV infection (31 cases), followed by psoriasis (24), seborrheic dermatitis (18), xerosis (17), herpes simplex (17), and adverse drug eruptions (17). A CD4 cell count of less than 200 x 10(6)/L was significantly associated with a higher number of skin disorders (P = 0.002) and the development of psoriasis [odds ratio (OR), 8.97; 95% confidence interval (CI), 1.70-47.16; P = 0.010], PPE (OR, 3.40; 95% CI, 1.21-9.53; P = 0.020), and adverse drug eruption (OR, 5.83; 95% CI, 1.21-28.00; P = 0.028). CONCLUSIONS: A preponderance of inflammatory dermatoses and an absence of skin tumors characterized this study. A low CD4 cell count was associated with a higher number of skin disorders and an increased incidence of PPE, psoriasis, and adverse drug eruptions.

User acceptability and feasibility of self-testing with HIV rapid tests.

OBJECTIVE: Because HIV rapid tests are considered for self-testing, this study aims to determine the user acceptability and feasibility of self-testing. METHODS: A cross-sectional study was performed on 350 systematically sampled participants across 2 Singapore HIV testing centers using the Abbott Determine HIV 1/2 blood sample rapid test (Abbott Laboratories, Abbott Park, IL). Participants were surveyed on knowledge of and attitudes toward rapid testing. To determine interrater agreement between self-testing and trained personnel testing, participants performed self-testing with visual instructions, followed by trained personnel testing. Ability to identify test outcomes was determined through interpretation of sample test results. RESULTS: Eighty-nine percent of participants preferred testing in private, but most indicated that confidential counseling by trained counselors was necessary. Almost 90% found the kit easy to use and instructions easy to understand. Nevertheless, 85% failed to perform all steps correctly, especially blood sampling, and 56% had invalid results because of incorrect test performance. Interrater agreement between results from self-testing and trained personnel testing had a kappa value of 0.28. Twelve percent could not correctly determine results using sample tests, including 2% and 7% who read positive and negative samples, respectively, incorrectly. CONCLUSIONS: A substantial proportion could not perform self-testing or identify outcomes. Self-testing with the Determine HIV 1/2 kit in Singapore should be deferred.

Rising trends of STIs and HIV infection in Singapore-- a review of epidemiology over the last 10 years (1994 to 2003).

INTRODUCTION: This is a review of the epidemiology and trends of sexually transmitted infections (STIs) in Singapore from 1994 to 2003. MATERIALS AND METHODS: Data collated for both notifiable and non-notifiable STIs from 1994 to 2003 were analysed. This data consisted of STI notifications from medical practitioners in Singapore as well as from the Department of STI Control clinic itself. RESULTS: There was a decline in the overall STI incidence in Singapore in the first half of the last decade from 215 cases per 100,000 population (7,200 cases) in 1994 to 162 cases per 100,000 population (6,318 cases) in 1999, followed by an increasing trend in the number of acute STIs (both bacterial and viral) over the past 5 years to 195 cases per 100,000 population (8,175 cases) in 2003 (P <0.001). The incidence of HIV has risen sharply over the last decade whilst that of other viral STIs has not decreased. Singaporeans are becoming sexually active at a younger age, with casual partners constituting the main primary contacts. CONCLUSIONS: Although there has been a significant decline in the overall incidence of STIs in Singapore over the last decade, a rise in acute STIs over the last 5 years has resulted in the need to identify the causal factors, and to intensify existing as well as develop new STI/HIV prevention programmes for the general population and certain core groups.

Viral infections affecting the skin in organ transplant recipients: epidemiology and current management strategies.

Viral skin infections are common findings in organ transplant recipients. The most important etiological agents are the group of human herpesviruses (HHV), human papillomaviruses (HPV), and molluscum contagiosum virus. HHV that are important in this group of patients are herpes simplex virus (HSV) types 1 and 2, varicella-zoster virus (VZV), cytomegalovirus (CMV), Epstein-Barr virus (EBV), HHV-6 and -7, and HHV-8, which causes Kaposi sarcoma (KS). HSV infections are characterized by their ability to establish latency and then reactivate at a later date. The most common manifestations of HSV infection in organ transplant recipients are mucocutaneous lesions of the oropharynx or genital regions. Treatment is usually with acyclovir, valaciclovir, or famciclovir. Acyclovir resistance may arise although the majority of acyclovir-resistant strains have been isolated from AIDS patients and not organ transplant recipients. In such cases, alternatives such as foscarnet, cidofovir, or trifluridine may have to be considered. VZV causes chickenpox as well as herpes zoster. In organ transplant recipients, recurrent herpes zoster can occur. Acute chickenpox in organ transplant patients should be treated with intravenous acyclovir. CMV infection occurs in 20-60% of all transplant recipients. Cutaneous manifestations, which include nonspecific macular rashes, ulcers, purpuric eruptions, and vesiculobullous lesions, are seen in 10-20% of patients with systemic infection and signify a poor prognosis. The present gold standard for treatment is ganciclovir, but newer drugs such as valganciclovir appear promising. EBV is responsible for some cases of post-transplant lymphoproliferative disorder, which represents the greatest risk of serious EBV disease in transplant recipients. HHV-6 and HHV-7 are two relatively newly discovered viruses and, at present, the body of information concerning these two agents is still fairly limited. KS is caused by HHV-8, which is the most recently discovered lymphotrophic HHV. Iatrogenic KS is seen in solid-organ transplant recipients, with a prevalence of 0.5-5% depending on the patient's country of origin. HPV is ubiquitous, and organ transplant recipients may never totally clear HPV infections, which are the most frequently recurring infections in renal transplant recipients. HPV infection in transplant recipients is important because of its link to the development of certain skin cancers, in particular, squamous cell carcinoma. Regular surveillance, sun avoidance, and patient education are important aspects of the management strategy.