'Occupational dermatoses from Personal Protective Equipment during the COVID-19 pandemic in the tropics - A Review'.

The COVID-19 pandemic has enveloped the world and there has been a high incidence of occupational dermatoses related to Personal Protective Equipment (PPE) amongst healthcare workers (HCWs) during this period. Prevention and management of these conditions will not only improve staff morale and quality of life, but will also minimize the risk of breaching PPE protocol due to such symptoms. The tropical climate in Singapore predisposes HCWs to more skin damage and pruritus due to intense heat, high humidity and sun exposure. The effects of friction, occlusion, hyperhidrosis and overheating on the skin in the tropics should not be neglected. Preventive measures can be taken based on our recommendations, and the working environment can be made more conducive for frontline HCWs. We review the literature and discuss various preventive and management strategies for these occupational skin diseases for our frontline HCWs, especially those working in less controlled working environments beyond the hospital in Singapore. Shorter shifts and frequent breaks from PPE are recommended. Duration of continuous PPE-usage should not exceed 6 h, with breaks in non-contaminated areas every 2-3 h to hydrate and mitigate the risk of skin reactions. Other strategies, such as teledermatology, should be considered so that consultations can remain accessible, while ensuring the safety and well-being of our clinical staff.

Photoprotection according to skin phototype and dermatoses: practical recommendations from an expert panel.

Increasing evidence on the impact of the different wavelengths of sunlight on the skin demonstrates the need for tailored recommendations of sunscreen according to skin phototype and dermatoses, which is now possible due to advances in the filters and formulations of sunscreens. A selective literature search was performed by an international expert panel, focusing on the type of sunscreen to recommend for photoaging, skin cancers, photodermatoses, pigmentary disorders and skin inflammatory disorders. Protection against ultraviolet (UV)B is especially important for light skin as there is a high risk of sunburn, DNA damage and skin cancers. Darker skin may be naturally better protected against UVB but is more prone to hyperpigmentation induced by visible light (VL) and UVA. Protection against UVA, VL and infrared A can be helpful for all skin phototypes as they penetrate deeply and cause photoaging. Long-wave UVA1 plays a critical role in pigmentation, photoaging, skin cancer, DNA damage and photodermatoses. Adapting the formulation and texture of the sunscreen to the type of skin and dermatoses is also essential. Practical recommendations on the type of sunscreen to prescribe are provided to support the clinician in daily practice.

Epidemiology of post-adolescence acne and adolescence acne in Singapore: a 10-year retrospective and comparative study.

INTRODUCTION: Acne vulgaris commonly affects adolescents. But recent reports suggest a rising prevalence of post-adolescence acne. While there are few reports on post-adolescence acne, there are even fewer reports comparing adolescence acne and post-adolescence. METHODS: Epidemiological data of adolescence (<25 years) and post-adolescence (≥25 years) acne patients diagnosed between 2004 and 2013 in a tertiary dermatology referral centre was analysed. From the pool of patients seen in 2010, 80 adolescence and 84 post-adolescence acne patients' epidemiological characteristics and treatment responses were analysed. RESULTS: During the 10-year study period, there was an increase in the number and proportion of acne cases. In 2004, 4447 (5.77%) of all new diagnoses made were of acne vulgaris. The proportion rose to 5723 (8.13%) in 2013. There were consistently more female than male acne patients. The proportion of post-adolescent cases remained constant at about 30% of all acne patients seen. Mean age of acne vulgaris patients decreased from 23.1 years in 2004 to 22.6 years in 2013. In the subgroup analysis, there were more males than females with adolescence acne (61.3% vs. 38.8%, P < 0.01) and more females with post-adolescence acne (69.0% vs. 31.0%, P < 0.01). Thirty-four (40.5%) post-adolescence acne patients had acne from adolescence persisting into adulthood. Comedonal acne was more prevalent in the adolescence acne patients (58.8% vs. 40.5%, P = 0.019), whereas cystic acne was more prevalent in post-adolescence patients (18.1% vs. 7.5%, P = 0.044). Systemic retinoids were more often used for treatment in the adolescence acne patients than post-adolescence acne patients (23.8% vs. 10.7%, P = 0.027). CONCLUSION: Acne predominantly affects adolescents but post-adolescence acne is not uncommon. For post-adolescence acne, females predominate over males. Inflammatory and cystic acne tends to be more predominant in post-adolescence acne patients, whereas comedonal acne is more often seen in adolescence acne patients.

Attitudes and behaviors regarding sun exposure in Japan compared to Europe and North America.

The objective of our study was to assess the attitudes and behaviors in Japan regarding sun exposure and compare them to those in Europe and North America. The study population was a representative sample of individuals aged >18 years from Ipsos panels in Japan (N = 1000), North America (N = 1000), and Europe (N = 6000) using the quota method. Questionnaires covered habits, practices, and perceptions regarding sun exposure. Results revealed that the majority of people (80.1%) believed that the sun gives them energy, and 61.1% considered that being tanned made them look healthier. However, there was a significant difference between men and women regarding the appeal of tanned skin, with 54.95% of men versus 34.67% (p < 0.001) of women seeing a tan as an aesthetic asset. People aged <40 years were less likely to find a tan attractive (30.3%) compared to those aged ≥40 years (48.9%) (p < 0.001). Of those questioned, 45.70% of used sunscreen with a much higher use among women (70.10%) than men (18.74%) (p < 0.001). Almost 54% of people said they stayed in the shade to protect themselves from the sun with this behavior being more prevalent among women (67.05%) and fair-skinned individuals (56.13%). Fear of the risks of sun exposure was more common among women, with 84.8% fearing premature skin aging, compared to 71.8% of men (p < 0.001). In Japan, 44.30% of those questioned said tanned skin was attractive (p < 0.001); for Europeans and North Americans the proportions were 81.1% and 77.6%, respectively. Only a quarter (25.80%) thought it essential to return from vacation with a tan. On the other hand, Europeans showed a strong recognition of the energy the sun brings (83.18%), and widely believed that tanned skin is attractive (82.32%) and healthy (73.15%). In North America, attitudes were similar to those in Europe regarding the attractiveness of tanned skin (77.65%) and the importance of returning tanned from vacation (48.15%). Compared to Europeans and North Americans, the Japanese seemed to be more cautious about sun-induced hazards and considered lighter skin to be more attractive.

Genetic variants associated with predisposition to prostate cancer and potential clinical implications.

Prostate cancer is the commonest cancer in the developed world. There is an inherited component to this disease as shown in familial and twin studies. However, the discovery of these variants has been difficult. The emergence of genome-wide association studies has led to the identification of over 46 susceptibility loci. Their clinical utility to predict risk, response to treatment, or treatment toxicity, remains undefined. Large consortia are needed to achieve adequate statistical power to answer these genetic-clinical and genetic-epidemiological questions. International collaborations are currently underway to link genetic with clinical/epidemiological data to develop risk prediction models, which could direct screening and treatment programs.

Variation in allergen content over time of acrylates/methacrylates in patch test preparations.

BACKGROUND: Acrylates/methacrylates are volatile substances. There might be a gradual decrease in acrylate/methacrylate allergen content over time in patch test preparations but this has not yet been documented. OBJECTIVES: To determine the allergen content of acrylates/methacrylates in patch test preparations over time under different storage conditions. METHODS: Five acrylate/methacrylate allergens [2-hydroxyethyl methacrylate (2-HEMA), methyl methacrylate (MMA), ethylene glycol dimethacrylate (EGDMA), triethylene glycol diacrylate (TREGDA) and 2-hydroxypropyl acrylate (2-HPA)] in syringes and IQ™ chambers (Chemotechnique Diagnostics, Vellinge, Sweden) were analysed using gel permeation chromatography and high-performance liquid chromatography to measure the allergen content over time in samples stored in the freezer, refrigerator and under room temperature. RESULTS: The concentration of allergens in syringes decreased with time. Those stored at room temperature had the fastest rate of decrease, followed by those in the refrigerator and freezer. In most cases, in syringes or IQ™ chambers under all storage conditions, the MMA decreased most rapidly, followed by 2-HPA, 2-HEMA, EGDMA and TREGDA. The allergens in the IQ™ chambers rapidly disappeared, with almost all samples reaching nondetectable levels by day 8. MMA was the first to reach a nondetectable level--at day 2. CONCLUSIONS: Acrylate/methacrylate allergens are lost rapidly from IQ™ chambers especially if stored at room temperature. Allergens in syringes remain above 80% of their initial concentrations for longer periods compared with IQ™ chambers. In syringes and IQ™ chambers there is a slower rate of decrease in concentration when the storage temperature is lower. Allergens should be stored refrigerated, replaced regularly, and freshly applied on to test patches on the day of use.

Prevalence of body dysmorphic features in patients undergoing cosmetic procedures at the National Skin Centre, Singapore.

BACKGROUND: Body dysmorphic disorder (BDD) is characterised by an obsessive preoccupation with a slight defect in appearance, and recognition is essential. OBJECTIVE: To screen by a previously developed questionnaire the prevalence of BDD in an aesthetics clinic in Singapore. This questionnaire has a positive predictive value of 70% and a negative predictive value of 100%; patients answering that they were preoccupied with their appearance and having answered 'yes' in part A, answered 8 further questions (part B) grading the degree of distress (B4) and impairment (B5) of social functioning. METHODS: The questionnaire was given to 396 patients: 198 attending Mandalay Aesthetics Clinic and 198 controls at a general outpatient clinic. The screen was considered suggestive of BDD if the patients: were preoccupied by their defect (question A) and qualified the degree of stress (question B4) or impairment of functioning (question B5) as moderate to severe. RESULTS: 58.1% of patients undergoing cosmetic procedures answered 'yes' to question A (odds ratio = 18.21, 95% confidence interval = 9.87-33.59). 41.74 and 26.96% of those qualified the distress (question B4) and impairment (question B5) as moderate to severe. CONCLUSION: A calculated prevalence of 29.4% in an aesthetics centre warrants systematic screening for BDD.

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.

Hepatitis B infection in prostitutes.

The prevalence of HBV markers in prostitutes is known to be higher than that of the normal population of similar age range in previous studies. This study showed a significant correlation between the duration of prostitution and the prevalence of HBV antibodies amongst the prostitutes. The prevalence of HBV antibodies doubled after the first year of prostitution. A two-year follow-up study of these prostitutes showed that 37% of HBsAg positive prostitutes lost the HBsAg. The seroconversion rate of HBsAg negative prostitutes was 10% during this two-year period. Early immunization against HBV infection should be considered in this high risk group in view of these findings.

Chemoprophylaxis and gonococcal infections in prostitutes.

The influence of chemoprophylaxis on gonorrhoea has not been reported recently. 777 prostitutes were interviewed and checked for evidence of chemoprophylaxis. The study showed that chemoprophylaxis does reduce the risk of gonococcal infections and that those who took penicillin chemoprophylaxis had a higher risk of Penicillinase producing Neisseria gonorrhoeae (PPNG) infections compared to those who took non-penicillin chemoprophylaxis and those who did not take any prophylaxis.

Parasitic skin infections in the elderly: recognition and drug treatment.

There are many parasitic infections of medical importance, which can produce both systemic disease as well as skin lesions. For the most part, treatment of these infections in the elderly does not differ very much from that of younger patients. However, one must be aware that the geriatric population can present with certain challenges with regard to diagnosis of these diseases because history taking may be more difficult and patients often already have a set of other medical problems, which may overshadow the skin lesions. In addition, the clinical manifestations of these infections may not appear classical and may be altered. Dosages of drugs used to treat these infections, even topical agents, may require adjustments in this population. The recognition of scabies in elderly people living together is important and early treatment with topical scabiecides, including oral ivermectin, will help to control the spread of the infestation. Pediculosis may be a cause of pruritus in the elderly and can be treated with malathione, lindane or permethrin. Less common parasitic infections in the elderly, including cutaneous larva migrans and cutaneous leishmaniasis, present with a characteristic clinical picture and can be effectively treated with oral thiabendazole and intravenous antimonials.

STD/AIDS knowledge and risk behaviour among masseuses and bar hostesses in Singapore.

Sex workers are not confined to brothels, they also include a variety of individuals who practise part-time in establishments conductive to sexual liaisons. We undertook to study the extent of sex work among masseuses and nightclub hostesses and the level of AIDS and STD knowledge in these 2 groups. The studies were conducted in 1993 and 1996. Altogether 1244 masseuses and 746 hostesses attended educational sessions at the STD clinic, during which they were also surveyed for knowledge on AIDS and STDs, and practices which may put them at risk of infection; they were also offered tests for HIV and syphilis. Knowledge on AIDS transmission was good, knowledge of other aspects of AIDS and STDs was not. Sexual activities resulting from the conduct of their work was practised by only a minority of masseuses (13.5%) and hostesses (7.9%). Among those who engaged in sexual activities at work, masseuses practised safe sex more commonly than hostesses (83.5% vs 27.6%). The prevalence of HIV (0.175% in hostesses, 0% in masseuses) and syphilis (0.87% in hostesses and 1.7% in masseuses) was very low in both groups.

Evaluation of a safe-sex intervention programme among sex workers in Singapore.

The purpose of this study was to evaluate the effects of a brief intervention programme on STD knowledge, condom use and gonorrhoea incidence among sex workers in Singapore. A controlled before-and-after study design with non-random assignment of sex workers was used, supplemented by multivariate analysis to adjust for baseline differences. Control (n = 221, denoted C1) and experimental (n = 221, denoted E1) groups were interviewed on 2 occasions 3 months apart. Two supplementary groups were interviewed once each at the end of the 3-month period (n = 145 who had received the intervention and n = 151 who had not). Basic knowledge of STD symptoms and HIV transmission was high in all groups. There were misconceptions about casual transmission of HIV which improved dramatically at the second interview for group E1 (from 37-56% correct responses to 82-90%). Overall condom use was high (about 75%) and did not change after the intervention. Gonorrhoea rates were correspondingly low (0.4 episodes/worker/year) and also did not change. This brief intervention improved the STD knowledge of sex workers. However, behaviour as measured by reported condom use and gonorrhoea incidence did not change. Implications for future intervention programmes are discussed.

Comparative study on a single treatment response to long pulse Nd:YAG lasers and intense pulse light therapy for hair removal on skin type IV to VI--is longer wavelengths lasers preferred over shorter wavelengths lights for assisted hair removal.

OBJECTIVE: To investigate the safety and effectiveness of a long pulsed Nd:YAG (1064nm) laser compared to a shorter wavelength intense pulse light system for assisted hair removal in volunteers with skin type 1V, V and VI. METHODS: Eleven patients of Fitzpatrick skin type IV-VI were recruited into the study. The area treated included the face (upper lips, chin and jaw area), axillae and legs. One half of the body was treated with the long pulse Nd:YAG laser and the other half was treated with the IPL system randomly under topical anesthesia. Degree of pain experienced during treatment, the treatment outcome and any complications were observed. Patients were reviewed at 2 weeks and 6 weeks post-treatment. RESULTS: Volunteers generally described pain from the IPL system as "prolonged burning sensation" but tolerable. Pain from Nd:YAG laser treatment was described as "pinprick" and more intense but tolerable. "Slowing of hair growth"was reported with IPL and Nd:YAG, but with a greater effect from Nd:YAG. Sixty-four percent and 73%(8/11) noticed hair reduction <20% after 6 weeks on IPL and Nd:YAG treated side respectively (ns). Post-inflammatory pigmentation occurred in some volunteers on the IPL treated sides whereas this was not seen on any Nd:YAG treated side, and three of these patients experienced blistering, followed by post-inflammatory pigmentation. CONCLUSION: In our experience the long pulse width 1064 nm Nd:YAG laser, which can penetrate 5-7 mm into the dermis depths to reach the whole length of the hair follicle, would be expected to produce sufficient follicular injury with less epidermal damage in patients with darker skin type compared to shorter wavelength laser and light system.