Dermatology Top Secrets

The Medical Short Case: An examination guide

2011-07-24T00:02:00.000-07:00

We have come out with a book on clinical examination with the emphasis on local experience and cases. These are common examination cases.

This book is designed to meet the need of those preparing for exam (undergraduate or postgraduate).We try to illustrate each case with reasonable approach and share interesting signs. The cases chosen are relevant to our local practice. Commonly asked questions

were discussed in this book.

Topical Timolol Effective for Infantile Hemangioma

2011-05-28T16:55:00.000-07:00

Khunger N and Pahwa M. Dramatic response to topical timolol lotion of a large hemifacial infantile haemangioma associated with PHACE syndrome. Br J Dermatol 2011 Apr; 164:886.

Since 2008, propranolol has been used increasingly for the off-label treatment of infantile hemangiomas. Timolol is a topical beta-blocker commonly used for glaucoma that showed therapeutic promise for hemangiomas in a few case reports and small pilot studies.

Case report from India describe the treatment of an 18-month-old girl with PHACE syndrome and an extensive, disfiguring hemifacial hemangioma complicated by ulceration, palpebral occlusion, and ipsilateral cerebellar hypoplasia.

After systemic corticosteroids failed to produce response, topical timolol ophthalmic solution 0.5% was applied to the hemangioma (10 drops, twice daily). The hemangioma shrank dramatically within a week, and timolol was discontinued at 12 weeks.

Pulse, blood pressure, and serum glucose were monitored closely and remained stable throughout treatment. Local irritation was the only reported adverse effect.

Comments:
Randomized, controlled studies of the safety and efficacy of topical beta-blockers for hemangiomas are under way.

In this case report, systemic absorption of timolol may have been a key factor in the dramatic success. Until we know more, systemic therapy should probably remain first-line therapy for time-sensitive problematic hemangiomas (e.g., those that threaten vision).

Antiretrovirals Protect Partners of HIV-Infected Patients

2011-05-14T05:24:00.000-07:00

Treating HIV-infected People with Antiretrovirals Protects Partners from Infection. Findings Result from NIH-funded International Study

Large-scale clinical study (phase 3 clinical trial) sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health. The clinical trial, known as HPTN 052, was slated to end in 2015 but the findings are being released early as the result of a scheduled interim review of the study data by an independent data and safety monitoring board (DSMB).

The DSMB concluded that it was clear that use of antiretrovirals by HIV-infected individuals with relatively healthier immune systems substantially reduced transmission to their partners.

The results are the first from a major randomized clinical trial to indicate that treating an HIV-infected individual can reduce the risk of sexual transmission of HIV to an uninfected partner.

HPTN 052 Study

Study Objective:

Primary goal: To evaluate whether ARV use by the HIV-infected individual reduced HIV transmission to the uninfected partner and potentially benefited the HIV-infected individual as well.

Secondary goal: To evaluate the optimal time for a person infected with HIV to initiate antiretrovirals in order to reduce HIV-related sickness and death.

Study Period: Began in April 2005; run until 2015

Number of subjects: Enrolled 1,763 couples

Study Population:

1. All at least 18 years of age.
2. The vast majority of the couples were heterosexual(97%).
3. Precludes any definitive conclusions about effectiveness in MSM.
4. At the time of enrollment, the HIV-infected partners (890 men, 873 women) had CD4+ T-cell levels—a key measure of immune system health—between 350 and 550 cells per cubic millimeter (mm³) within 60 days of entering the study.
5. The HIV-uninfected partners had tested negative for the virus within 14 days of entering the study.
6. The sex of the infected partner was close to a 50-50 split between men and women.
7. At the onset of the trial, all the infected partners had CD4 cell counts that did not warrant HIV treatment for their health.

Study Sites:

The study was conducted at 13 sites in Botswana, Brazil, India, Kenya, Malawi, South Africa, Thailand, the United States and Zimbabwe. The U.S. site collected only limited data because of difficulties enrolling participants into the study.

Study Protocol:

1. The investigators randomly assigned the couples to either one of two study groups.
2. In the first group, the HIV-infected partner immediately began taking a combination of three antiretroviral drugs (combination of 3 oral antiretroviral drugs).
3. In the second group (the deferred group / delayed ART), the HIV-infected partners began antiretroviral therapy when their CD4 counts fell below 250 cells/mm³ or an AIDS-related event, such as Pneumocystis pneumonia, occurred.
4. A trigger point set by the World Health Organization that the organization raised to 350 cells/mm3 in the middle of the study.
5. Throughout the study, both groups received HIV-related care that included counseling on safe sex practices, free condoms, treatment for sexually transmitted infections, regular HIV testing, and frequent evaluation and treatment for any complications related to HIV infection.
6. Each group received the same amount of care and counseling.
7. Individuals who became HIV-infected during the course of the study were referred to local services for appropriate medical care and treatment.
8. HIV-infected participants in the deferred treatment group will be offered antiretroviral therapy.
9. The study investigators will continue following the study participants for at least one year.

Study Sponsor:

The study was conducted by the HIV Prevention Trials Network, which is largely funded by NIAID with additional funding from the National Institute on Drug Abuse and the National Institute of Mental Health, both part of the NIH.

Additional support was provided by the NIAID-funded AIDS Clinical Trials Group.

The antiretroviral drugs used in the study were made available by Abbott Laboratories, Boehringer Ingelheim Pharmaceuticals, Inc., Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline/Viiv Healthcare and Merck & Co., Inc.

Background of the study:

Clinicians have long suspected that antiretrovirals that benefit HIV-infected patients also could benefit their partners, but no clinical trial has proven that beyond a reasonable doubt.

Previous data about the potential value of antiretrovirals in making HIV-infected individuals less infectious to their sexual partners came largely from observational and epidemiological studies.

This new finding convincingly demonstrates that treating the infected individual—and doing so sooner rather than later—can have a major impact on reducing HIV transmission.

Starting HIV-infected patients immediately after diagnosis on oral antiretroviral therapy (ART) while their immune systems are still relatively healthy is highly effective in protecting their partners from infection.

HPTN findings provide "a powerful policy argument" to encourage widespread testing of individuals to identify those with HIV and get them started right away on ART, not only for their sake but also for their partners.

Results:

The 11 HIV drugs that were used in various combinations included the following:
•Atazanavir (300 mg once daily)
•Didanosine (400 mg once daily)
•Efavirenz (600 mg once daily)
•Emtricitabine/tenofovir disoproxil fumarate (200 mg emtricitabine/300 mg tenofovir disoproxil fumarate once daily)
•Lamivudine (300 mg once daily)
•Lopinavir/ritonavir 800/200 mg once daily (QD) or lopinavir/ritonavir 400/100 mg twice daily (BID)
•Nevirapine (200 mg taken once daily for 14 days followed by 200 mg taken twice daily)
•Ritonavir (100 mg once daily, used only to boost atazanavir)
•Stavudine (weight-dependent dosage)
•Tenofovir disoproxil fumarate (300 mg once daily)
•Zidovudine/lamivudine (150 mg lamivudine/300 mg zidovudine taken orally twice daily)

In its review, the DSMB found a total of 39 cases of HIV infection among the previously uninfected partners.

Of those, 28 were linked through genetic analysis to the HIV-infected partner as the source of infection. 7 infections were not linked to the HIV-infected partner, and 4 infections are still undergoing analysis.

Of the 28 linked infections, 27 infections occurred among the 877 couples in which the HIV-infected partner did not begin antiretroviral therapy immediately.

Only one case of HIV infection occurred among those couples where the HIV-infected partner began immediate antiretroviral therapy.

This finding was statistically significant and means that earlier initiation of antiretrovirals led to a 96% reduction in HIV transmission to the HIV-uninfected partner. The infections were confirmed by genetic analysis of viruses from both partners.

Additionally, 17 cases of extrapulmonary tuberculosis occurredin the HIV-infected partners in the deferred treatment arm compared with 3 cases in the immediate treatment arm, a statistically significant difference.

There were also 23 deaths during the study. 10 occurred in the immediate treatment group and 13 in the deferred treatment group, a difference that did not reach statistical significance.

Discussions:

The timing of ART gets debated,

With the adverse effects and expense of the therapy prompting some to advocate waiting until a patient's immune system takes a turn toward the worse.

Study results were promising but were not conclusive when it comes to choosing immediate over delayed treatment.Of the 23 deaths among study participants, 13 occurred in the delayed-treatment group compared with 10 in the other group. Some of the deaths were not related to HIV.

When all morbidity and mortality events were tallied, "there was a trend towards benefit" with immediate ART, "but it did not reach the 20% difference between study arms required for statistical significance."

In an ongoing international clinical study called Strategic Timing of Antiretroviral Therapy, NIAID is examining the optimal time for asymptomatic HIV-infected individuals to begin antiretrovirals.

Conclusion:

96% Reduction in HIV Transmission With Immediate ART

The efficacy of ART in preventing HIV transmission should not prompt serodiscordant couples to abandon other safe-sex practices such as condom use.

Anesthesia Reactions May Be More Common Than Thought - at Least in France

2011-05-13T21:34:00.000-07:00

J Allergy Clin Immunol 2011
Dr. Paul Michel Mertes of the University Hospital Center of Nancy in France reported that allergic reactions to anesthesia are rare, but they may be more common than some past studies have suggested.

Using two national databases;
1. Estimated that between 1997 and 2004, there were about 100 allergic reactions for every million anesthesia procedures performed in France. That's somewhat higher,if compared with the earlier estimates from a pair of studies in the 1990s -- including a French study that put the rate at 100 reactions for every 1.3 million anesthesia procedures.

2. Women appeared to be at particular risk
The rate of allergic reaction among women was 155 per million anesthesia procedures, versus 55 per million for men. Unclear is why women in this study had a significantly higher rate of allergic reaction than men.

3. 72% of allergic reactions were IgE-mediated. Among adults with IgE-mediated reactions, 60% suffered serious cardiovascular or breathing problems.

4. The common cause of allergic reactions are neuromuscular numbing agents (58%), Latex then followed by antibiotics, which were linked to 13% of allergic reactions.

Different opinion from Dr. Richard P. Dutton, executive director of the Anesthesia Quality Institute -- a U.S. group that was formed in 2008 to create a national registry on anesthesia outcomes.

1. The findings do not mean that the rate of allergic reactions to anesthesia is going up. Traditionally, there has been no systematic reporting of allergic reactions to anesthesia in the U.S., so there is no hard number to compare the French estimate to. The (French study)current findings are based on more-comprehensive reporting of allergic reactions than were the earlier studies.

2. Doubts about how applicable these findings would be in the U.S - "That doesn't match with the American experience," where antibiotics and propofol have been most commonly implicated in allergic reactions during anesthesia.

3. Why female are more prone to develop allergic reactions. But there are two theories, according to Dutton.
a. Strogen plays some role in the reactions to certain anesthesia agents.
b. French women may have been exposed to certain chemicals in cosmetics that primed their immune systems to react to structurally similar chemicals used in anesthesia.

Herpes Shedding Patterns Show Wide Risks for Transmission

2011-04-14T04:51:00.000-07:00

Herpes Shedding Patterns Show Wide Risks for Transmission
JAMA 2011;305(14):1441-1449. doi: 10.1001/jama.2011.420

Among patients seropositive for herpes simplex virus type 2, genital shedding is "likely universal," regardless of symptoms, according to a JAMA study.

Researchers followed some 500 seropositive individuals for 2 months, during which the subjects collected daily swabs from the genital area. Rates of viral shedding were twice as high among symptomatic participants, but even asymptomatic subjects showed shedding on 10% of days. In addition, the number of virus copies shed was similar between symptomatic and asymptomatic participants.

The authors say their findings suggest that clinical management of seropositive — but asymptomatic — patients should include anticipatory guidance on recognizing genital symptoms as well as counseling on condom use, valacyclovir therapy, and the need to disclose serostatus to sexual partners.

Finally, Evidence That Sunscreen Delivers

2011-03-12T05:09:00.000-08:00

Primary melanomas developed less often with daily, rather than discretionary, sunscreen use.

Published in Journal Watch Dermatology March 11, 2011

Citation:
Green AC et al. Reduced melanoma after regular sunscreen use: Randomized trial follow-up. J Clin Oncol 2011 Jan 20; 29:257.
Gimotty PA and Glanz K. Sunscreen and melanoma: What is the evidence? J Clin Oncol 2011 Jan 20; 29:249.

Comment:

This large, community-based sunscreen trial is likely the last of its scope.

The findings won't change sunscreen recommendations but do provide clear support for its use.

Sunscreen alone is insufficient to eliminate melanoma risk, and the effects of all-form sun protection on melanoma mortality are unknown. Also, these findings leave unaddressed sunscreen use in less-sunny locations and in populations with other skin tones.

Nevertheless, this carefully executed and ambitious study is commendable. The same trial has already shown reduced squamous cell carcinoma risk, so its clinical implications are compelling.

One could question the borderline significance of the risk reductions, or note that the incidence of melanoma versus non-melanoma skin cancers undermined the study's power from the beginning, but the author of an accompanying editorial carefully outlines the statistical rigor of this trial.

Penang Dermatology Symposium 2011 - Final Announcement

2011-03-12T04:49:00.000-08:00

Visit web at www.penangdermatologysymposium.blogspot.com or www.dermatologyhpp.blogspots.com

Preliminary Programme of Penang Dermatology Symposium 2011

2011-02-20T08:21:00.000-08:00

Day 1 (2nd April 2011)

11:00 am Registration & Booth Visit

12:30 pm Lunch Symposium “Urticaria in Children”

2:00 pm Hair Loss in Children

2:40 pm Fever and Rash in Children

3:20 pm Coffee Break and Booth Visit

3:40 pm Psoriasis in Children

4:20 pm Ten Should Know Skin Disorders In Children (Quiz)

5:00 pm Adjourn

Day 2 (3rd April 2011)

8:30 am Registration and Booth Visit

9:00 am Neonatal Dermatoses: When to be concern

9:40 am Cutaneous Vascular Lesions in Children: When to Intervene!

10:20 am Coffee Break & Booth Visit

10:50 am Life Threatening Paediatric Skin Disorders

11:30 am Pigmentary Disorder In Children

12:10 pm Lunch symposium “The do’s & don’ts in The Management of Atopic Eczema

2:00 pm Autoimmune Blistering Disorder in Children

2:40 pm Paediatric Skin Nursing (Demonstration)

3:40 pm Genodermatoses: What Can We Offer?

4:20 pm Adjourn (Evaluation & Coffee Break)

Penang Dermatology Symposium 2011

2011-02-20T05:22:00.000-08:00

Theme: Paediatric Dermatology

Department of Dermatology, Penang General Hospital will organise Penang Dermatology Symposium 2011 at Auditorium, Ambulatory Care Center (ACC) Penang General Hospital on 2nd – 3rd April 2011 (Saturday-Sunday).

In collaboration with

Post Graduate Medical Education Society (PGMES)
Dermatological Society of Malaysia (PDM)
Faculty of Dermatology, Academy of Medicine Malaysia

The aims for this event are to provide a regular continuous medical education (CME) programme in dermatology for practicing practitioners and to provide an update of various topics in dermatology / paediatric dermatology.

WHO SHOULD ATTEND THE UPDATE
All physician, paediatrician and
primary care practitioners

For further enquiries, kindly contact the secretariat

CONTACT
Mr Kong Tau Chin
Sister Salmi Bt Ismail

Call: 04-2225250 / 2225247
Fax: 04- 2281737 / 2225246
Mail: Dept of Dermatology, Hospital Pulau Pinang

Closing Date: 14 March 2011

Discrepancies Often Found Between Young Adults' Self-Reported Sexual Histories and Their STDs

2011-01-04T05:45:00.000-08:00

A significant proportion of adolescents and young adults who test positive for sexually transmitted diseases report not having had any sexual activity in the past year, according to a Pediatrics study.

Some 14,000 young adults (mean age, 22) were interviewed in their homes about their sexual activity and provided urine specimens to test for chlamydia, gonorrhea, and trichomoniasis. Roughly 12% of those who tested positive for an STD said they had not had sex the past 12 months, and 6% of the STD-positive participants reported never having had sex. No sociodemographic factors were associated with discrepancies between self-reported history and STD results.

The authors say that relying solely on self-reported penile/vaginal sexual activity to assess STD risk could be imprecise and problematic. They conclude: "If pediatricians and adolescent medicine physicians do not test all young people, there are likely a substantial number of missed cases ... that will go undiagnosed, untreated, and spread to future sex partners."

A New Rapid Test for Detection of HIV

2010-12-16T03:40:00.000-08:00

December 13, 2010 | Rochelle P. Walensky, MD, MPH

Published in Journal Watch HIV/AIDS Clinical Care December 13, 2010

Citation(s):

FDA approves bioLytical Laboratories' INSTITM rapid HIV test [press release]. Vancouver, British Columbia, and Chicago, Illinois: bioLytical Laboratories; Dec 1 , 2010. (http://www.biolytical.com/media.html)

The INSTI HIV-1 antibody test delivers results in as little as 60 seconds.

FDA approved INSTI, a new rapid point-of-care HIV-1 antibody test that can provide results from blood and plasma specimens in as little as 60 seconds, with a minimum sensitivity of 99.8% and a minimum specificity of 99.5%. Previously approved rapid HIV tests take 10 to 20 minutes to generate results.

Positive results on any rapid HIV test require confirmation, which usually takes 1 to 2 weeks using standard Western blot or enzyme-linked immunosorbent assay. However, because this new test was generated using different antigens than those used to develop other rapid tests, it opens the door to the possibility of a "rapid/rapid" algorithm, in which one rapid test is used to detect infection and another to confirm it.

Comment:

INSTI offers the unique attribute of faster test processing with nearly immediate delivery of results. Having results within a minute or two alleviates many of the logistical concerns related to patient flow that have challenged clinic-based point-of-care HIV screening programs.

Other tests will probably still have a role, however; the OraQuick rapid HIV test is currently under FDA review for over-the-counter use.

Novel Drugs with Novel Reaction Patterns

2010-12-06T04:56:00.000-08:00

Marta R, Philippe-Jean B, Pascal D. Curr Opin Allergy Clin Immunol. 2010;10(5):457-462.

New Risk Factor:

1. Sex

Current studies continue to argue in favor of the female sex as a risk factor for
developing ADRs.

Zopf Y, Rabe C, Neubert A, et al. Gender-based differences in drug
prescription: relation to adverse drug reactions. Pharmacology 2009; 84:333–339.

Macy E, Poon K-YT. Self-reported antibiotic allergy incidence and prevalence: age
and sex effects. Am J Med 2009; 122:778.e1–778.e7.

2. Atopy

May be a risk factor for developing sensitization to beta-lactam antibiotics in
tertiary hospital nurses.

Choi IS, Han ER, Lim SW, et al. Beta lactam antibiotic sensitization and its
relationship to allergic diseases in tertiary hospital nurses. Allergy Asthma
Immunol Res 2010; 2:114–122.

Recent findings Traditional and complementary alternate medicines are also causes of adverse drug reactions, and many of them are cataloged as allergy.

Jacobsson I, Jönsson AK, Gerdén B, et al. Spontaneously reported adverse
reactions in association with complementary and alternative medicine substances in Sweden. Pharmacoepidemiol Drug Saf 2009; 18:1039–1047.

The study showed that 1.2% of the total reports concerned suspected ADRs were related to 175 different CAM products.

The main reactions were urticaria (8.3%), exanthema (7.4%) and contact dermatitis (5.7%).

The most reported were purple coneflower (Echinacea purpurea) (8.1%), Siberian ginseng (Eleutherococcus senticosus), malabar nut (Adhatoda vasica) (7.3%) and ginkgo leaf (Ginkgo biloba) (6.7%).

Zeng ZP, Jiang JG. Analysis of the adverse reactions induced by natural
product- derived drugs. Br J Pharmacol 2010; 159:1374–1391

Three thousand one hundred twenty-two cases involving 140 different drugs were analyzed. Herba houttuyniae and Shuanghuanglian were the most common drugs involved.

Research in the field of skin and drug provocation test to antibiotics such as beta-lactams and carbapenems has allowed the understanding of cross-reactivity reactions and permitted the use of well tolerated alternate drugs in cases of proper negative drug allergy work-up.

Cross-reactions between Imipenem/Cilastatin and Penicillins

Atanasković-Marković M, Gaeta F, Gavrović-Jankulović M, et al. Tolerability of imipenem in children with IgE-mediated hypersensitivity to penicillins. J Allergy Clin Immunol 2009; 124:167–169.

Work on cross-reactivity between penicillins and carbapenems in children with proven IgE-mediated allergy to penicillins.

The rate of cross-reactivity to imipenem/cilastatin detected by skin tests and drug provocation was 0.8%.

Schiavino D, Nuecera E, Lombardo C, et al. Cross-reactivity and tolerability
of imipenem in patients with delayed-type, cell-mediated hypersensitivity to beta-
lactams. Allergy 2009; 64:1644–1648.

Work on cross-reactivity in proven cell-mediated allergy to beta-lactams.

They found a 5.5% rate of cross-reactivity.

These studies open the opportunity to administer imipenem/cilastatin to those patients with proven allergy to penicillins after performing skin tests(immediate and delayed readings) and drug provocation tests.

Many unique cases have been reported, including diverse drugs as infliximab, succinylcholine, hydroxychloroquine, that widen the spectrum of clinical manifestations of drug hypersensitivity to various drugs.

Summary

As new and old drugs continue to be used, new reports regarding new and known drug hypersensitivity manifestations are made. Advances in mechanisms are enhanced by the use of new in-vitro techniques to detect specific antibodies or T cells. Research in the field of skin and provocation tests has allowed the use of well tolerated alternate drugs in individuals with proven drug allergy.

Psychocutaneous Disorder

2010-11-21T04:49:00.000-08:00

The Current Management of Delusional Parasitosis and Dermatitis Artefacta

Caroline S. Koblenzer, MD

Skin Therapy Letter. 2010

Introduction:

Patients who present with delusional parasitosis or dermatitis artefacta are not easy for dermatologists to work with, whose treatment requires the use of drugs unusual to the dermatologist and a significant investment of the clinician's time.

Each is a skin manifestation of a psychiatric disorder that represents a psychological defense - a way for the patient to avoid the acknowledgment of psychiatric pathology.

Delusions of Parasitosis

The delusions seen in dermatology are "systematized" or non-bizarre - i.e., they are fixed beliefs that, though false, control the patient's feelings and behavior in ways that are wholly consistent with the content of those beliefs. Delusions of parasitosis associated with cutaneous dysesthesia.

The delusional patient is often defensive, angry, and distrusting. The patient desperately wants answers. "We do not know the cause, but we have treatments that are effective" or "We have seen other patients with similar symptoms, and whatever is the cause, there are changes in the skin that we can treat" are possible answers.

Intensive topical measures are helpful (e.g., tar or bleach baths, emollients, and antibiotics as indicated). Topical agents, such as pramoxine hydrogen chloride cream or lotion, may be used to provide temporary relief of any dysesthesia.

Antipsychotic drugs are the first-line treatment (Much smaller doses than those used). Pimozide has long been the drug of choice. Risperidone and aripiprazole are preferable to olanzapine.

50–90% of patients are reported to have near or full symptom resolution, with improved functioning and any psychiatric and physical comorbidities tend to improve in parallel.

Dermatitis Artefacta

Dermatitis artefacta refers to skin lesions produced by the patient, under the veil of secrecy, to satisfy an unconscious need to be taken care of.

Lesions that are morphologically bizarre, often geometric in outline, destructive, and reportedly of sudden, mysterious yet fully formed appearance. Patients with neurotic excoriations usually have depression or anxiety with obsessive-compulsive features; those with Munchausen's syndrome have a sociopathic personality, while patients with dermatitis artefacta are most commonly diagnosed with the borderline personality disorder.

Dermatologic support is important, borderline patients are best treated psychiatrically, though a recommendation for psychiatric referral must be approached very judiciously. The antipsychotics are the drugs of choice and aripiprazole has an advantage in that it also has antidepressant properties.

Discussion:

Because patients with delusional parasitosis and dermatitis artefacta do not accept the need for psychiatric treatment, they fall either to the lot of the dermatologist or receive no help at all.

An optimal approach includes frequent short clinic visits, expression of empathy, affirmation that the skin itself is involved, and low dose antipsychotic drugs. With compliance, remissions of varying length occur, but both disorders are likely to last life-long.

Rebound of plasma viremia following cessation of antiretroviral therapy despite profoundly low levels of HIV reservoir

2010-11-09T03:51:00.000-08:00

Chun T-W et al. Rebound of plasma viremia following cessation of antiretroviral therapy despite profoundly low levels of HIV reservoir: Implications for eradication. AIDS 2010 Oct 19.

The persistence of HIV in CD4 cells despite full virologic suppression in plasma renders the prospect of viral eradication highly unlikely, at least with present strategies. However, initiation of antiretroviral therapy (ART) very early during acute HIV infection limits the size of the viral reservoir, and some studies suggest that it may deplete the pool of HIV-infected CD4 cells over time. In this study, researchers further explore whether early, long-term administration of potent ART might eliminate viral reservoirs.

Using quantitative real-time polymerase chain reaction, the researchers measured genomic HIV DNA in highly purified CD4 cells obtained from 44 patients who had achieved long-term suppression on ART without any episodes of detectable viremia.

Nine of the patients had started ART <6 months after acquiring HIV. These patients were found to have significantly lower levels of HIV proviral DNA (mean, 4.6 copies per million CD4 cells) than the patients who started ART later, and four of them had no proviral DNA detected.

One such patient was found to have an extremely low level of virus after 10.5 years of ART (1 infected cell per 1.7 billion CD4 cells). Under close follow-up, this patient discontinued ART. For 7 weeks, he had no virus detected in his plasma, but then his plasma HIV RNA level rebounded to 1593 copies/mL.

It spontaneously returned to an undetectable level for a brief period, only to rebound again during week 20, reaching 8684 copies/mL. At that time, ART was restarted.

Comment:

In this study and others, initiating long-term effective ART very early rather than later was associated with lower levels of residual HIV. Nonetheless, this seemingly favorable combination of very early ART, long-term consistent virologic suppression, and a very limited viral burden in the reservoir of CD4 cells did not prevent HIV recurrence after withdrawal of ART.

Although reemergence of the virus took longer in the patient described here than in patients in other studies who had less favorable circumstances, viral rebound still occurred in <2 months. Long-term virologic suppression without ART will require novel strategies to target the rare infected cells that rekindle the infection systemically.

22nd World Congress of Dermatology (WCD)

2010-10-29T06:55:00.000-07:00

WCD 2011

Period: May 24 - 29, 2011
Location: Seoul, Korea
Venue: COEX Convention and Exhibition Center

Hosted by International League of Dermatological Societies
Organized by Korean Dermatological Association

Previous World Congresses

(The name of the international congress was changed in 1992 to the World Congress of Dermatology)

No Host City President Secretary-General

1 Paris, 1889 A. Hardy H.Feulard

2 Vienna, 1892 M. Kaposi G.Riehl, Sr.

3 London, 1896 J. Hutchinson J.J. Pringle

4 Paris, 1900 E. Besnier G.Thiebierge

5 Berlin, 1904 E. Lesser O.Rosenthal

6 New York,1907 J.C. White J.Fordyce

7 Rome, 1911 T.deAmicis G.Ciarrocchi

8 Copenhagen,1930 C. Rasch S.Lomholt

9 Budapest, 1935 L. Nekam S.Rothman

10 London, 1952 A. Gray G.B.Mitchell-Heggs

11 Stockholm, 1957 S. Hellerstrom G.H.Floden

12 Washington, 1962 D.M. Pillsbury C.S.Livingood

13 Munich, 1967 W. Jadassohn C.G.Schirren

14 Padua-Venice,1972 F. Flarer F.Serri

15 Mexico City,1977 A. Gonzalez-Ochoa L. Dominquez-Soto

16 Tokyo, 1982 A. Kukita M. Seiji

17 Berlin, 1987 G. Stuttgen C.E. Orfanos

18 New York, 1992 J.S.Strauss S.I. Katz

19 Sydney, 1997 R.Marks A.J. Cooper

20 Paris, 2002 J. Revuz J.-P. Ortonne

21 Buenos Aires,2007 R. Galimberti A.M. Pierini

BLINCK approach

2010-10-18T05:50:00.000-07:00

BLINCK approach is simple and useful algorithm to help clinicians determine if a pigmented lesion warrants biopsy. The use of this algorithm will improve the pickup rate of potentially serious skin cancers as well as reduce the number of unnecessary benign lesion excisions.

BLINCK may be especially helpful to clinicians who have only basic or intermediate dermoscopy skills but who are regularly called upon to assess skin lesions in their practices.

BLINCK checklist is introduced by Dr. Peter Bourne, a founder of the Skin Cancer College of Australia and New Zealand (SCCANZ). The score for the lesion was added up to 4 by criteria as following.

1. B. The lesion was not clearly benign at our first initial evaluation
2. L. The lesion appeared to be lonely without any other similar melanocytic lesion near by
3. I. The lesion appeared to be irregular outline and color on our dermoscopic exam
4. N & C. The patient was nervous about the change in color in past 4-6 months
5. K. The lesion exhibited known clues when viewed with a dermatoscope. See "Chaos and Clues" reference below.

BLINCK Score = 4

According to the BLINCK approach, a lesion should be biopsied if the BLINCK score is 2 or more out of a possible 4. Therefore, the we excised this lesion and sent for a pathologic evaluation.

New Classification Criteria for Rheumatoid Arthritis

2010-10-02T20:11:00.000-07:00

Aletaha D et al. 2010 rheumatoid arthritis classification criteria: An American College of Rheumatology / European League Against Rheumatism collaborative initiative. Arthritis Rheum 2010 Sep; 62:2569. (http://dx.doi.org/10.1002/art.27584)

The American College of Rheumatology (ACR) and the European League Against Rheumatism have collaboratively developed new classification criteria for rheumatoid arthritis (RA); the ACR's previous criteria were published in 1987.

First, a working group analyzed data from several large cohorts of patients with early synovitis to determine predictors of eventual requisite disease-modifying therapy with disease-modifying drugs.

Second, 24 RA experts used a consensus-based decision-analytic approach to reach agreement on key predictors of RA. Both sources of information were used to construct the new classification system, which can be applied to patients who have at least one joint with clinical synovitis that is not explained better by another disease.

Four variables constitute the new criteria:

•The number and size of involved joints (score, 0–5)

•Results of rheumatoid factor and anti–citrullinated protein antibody testing (score, 0–3)

•Abnormal sedimentation rate or elevated C-reactive protein level (1 point)

•Symptom duration >6 weeks (1 point)

Maximal score is 10 points; patients whose scores are 6 points are considered to have "definite RA"

Comment:

The goal of this classification scheme is early identification of patients with undifferentiated synovitis who are likely to progress to erosive RA and thus might benefit from early initiation of disease-modifying therapy.

Subdermal Minimal Surgery for Acne Scars

2010-10-02T03:11:00.000-07:00

Lee JW et al. Treatment of acne scars using subdermal minimal surgery technology. Dermatol Surg 2010 Aug; 36:1281.

Method:

Subdermal minimal surgery technology makes use of an industrial-strength, needleless hypodermic inoculator that delivers medication into the skin through a high-pressure jet.

One shot covers a 1-cm2 area in the dermal and subdermal planes. In a pilot study from South Korea, investigators evaluated the efficacy of this technology for treating acne scars.

Ten patients with facial acne scars underwent a series of three subdermal minimal surgery treatments, 4 weeks apart, under topical EMLA anesthesia (lidocaine, prilocaine topical cream). Hyaluronic acid (HA) was infiltrated into the area of the scar, at 0.15 mL/scar. The HA used in this trial was 90% cross-linked with butanediol diglycidyl ether; according to the authors, it remains active for 6 to 8 weeks.

Result:

At follow-up 3 months after the last treatment, two independent observers found mean scar improvement of 51% to 75%; in patient assessments, the mean rating was 25% to 50% improvement.

Conclusion:

The authors note that the benefit seemed to last for at least 6 months and that ice pick scars improved more than rolling or boxcar-type scars. Pain was described as none to mild, and no complications were noted.

Comment:

Subdermal minimal surgery technology has interesting potential for delivering filler materials and medications into the skin.

It is not clear whether the observed benefit was related to the fleeting presence of HA or to the trauma of infiltration and resulting wound healing and collagen remodeling.

The authors state that the HA is dispersed within the dermis, but given the density of the dermis, it is much more likely that the material is dispersed in the subdermal plane.

Do Antiviral Drugs Taken During Pregnancy Cause Birth Defects?

2010-09-27T09:36:00.000-07:00

Reviewing:

Pasternak B and Hviid A. JAMA 2010 Aug 25; 304:859
Mills JL and Carter TC. JAMA 2010 Aug 25; 304:905

First-trimester use of acyclovir was not associated with excess risk for major birth defects.

Hand Foot Chemotherapy Induced Syndrome

2010-09-26T03:05:00.000-07:00

Chemotherapy-induced acral erythema or palmoplantar erythrodysesthesia syndrome is a well-defined reaction to some of the chemotherapeutic agents such as methotrexate, cytarabine, doxorubicin, fluorouracil (5-FU), cytosine arabinoside and bleomycin.

More recently, HFS has been reported in association with regimens using targeted agents, in particular the multikinase inhibitors (MKI) sorafenib and sunitinib (1). The HFS associated with MKI has a different distribution and clinical appearance than the traditional disorder.

This reaction is characterized by symmetric, well-demarcated, painful erythema of the palms and soles, which may progress to desquamation or blisters.

It appears to be dose dependent. It is likely a direct toxic effect of the drug.

Tingling on the palms and soles is followed in a few days by painful, symmetric, well-defined swelling and erythema.

Histologically, the HFS is characterized by a toxic keratinocyte reaction. Furthermore, there is sub-basal edema with a tendency to bullae, dilated blood and lymph capillaries and usually only mild perivascular lymphocytic infiltration (2).

Depending on the severity, HFS requires dose reduction, interruption or switch in the antineoplastic chemotherapy (2-3).

(1) Degen A, Alter M, Satzger I, et al. The hand-foot-syndrome associated with medical tumor therapy- classification and management. J Dtsch Dermatol Ges. 2010 Sep; 8(9):652-61.

(2) Janusch M, Fischer M, Marsch WCh, et al. The hand-foot syndrome - a frequent secondary manifestation in antineoplastic chemotherapy. Eur J Dermatol. 2006 Sep-Oct; 16(5): 494-9.

(3) Habif TP. Clinical Dermatology. 5th edition. USA: Elsevier Science 2010.

Cryotherapy May Be Most Effective for Removal of Common Warts

2010-09-26T02:46:00.000-07:00

Canadian Medical Association Journal, September 13 2010 (Published online)

A randomized controlled trial that compared the effectiveness of common wart treatments (Liq Nitrogen Vs Salicylic Acid) as well as a wait-and-see approach.

Introduction:

"Cryotherapy is widely used for the treatment of cutaneous warts in primary care"
"However, evidence favours salicylic acid application"

Method:

Between May 1, 2006, and January 26, 2007, all eligible patients with new cutaneous warts were recruited from 30 primary care practices in the Netherlands and were randomly assigned to 1 of 3 groups: cryotherapy with liquid nitrogen every 2 weeks, daily self-application of salicylic acid, or a wait-and-see approach.

The proportion of participants with cure of all warts at 13 weeks was the main study endpoint, and analysis was by intent-to-treat. Treatment adherence, adverse effects, and satisfaction with treatment were secondary endpoints. At 4, 13, and 26 weeks, research nurses evaluated outcomes during home visits.

Results:

Of the 250 participants, 122 (49%) were stratified into the common wart group and 128 (51%) into the plantar wart group.

Age range of the participants was 4 to 79 years.

At 13 weeks, 10 patients (4%) were lost to follow-up, and 240 were included in the analysis.

In the cryotherapy group, cure rate was 39(95% confidence interval [CI], 29% - 51%) vs 24% (95% CI, 16% - 35%) in the salicylic acid group and 16% (95% CI, 9.5% - 25%) in the wait-and-see group.

For participants with common warts (n = 116), these differences in efficacy were most pronounced. Cure rates were 49% with cryotherapy (95% CI, 34% - 64%), 15% with salicylic acid (95% CI, 7% - 30%), and 8% with the wait-and-see approach. The different treatments were not associated with significant differences in cure rates among participants with plantar warts (n = 124).

Limitation:

Limitations of this study include self-application of salicylic acid and lack of blinding of participants, family practices, and research nurses.

Conclusion:

"Although earlier evidence favoured salicylic acid application above cryotherapy, the present randomized controlled trial is the first that provides evidence to support the use of cryotherapy above salicylic acid, however, for common warts only,"

19th Regional Conference of Dermatology 2010

2010-06-18T09:10:00.000-07:00

The 19th RCD presents a unique opportunity for the dermatological profession in Asia to come together in fraternity and fellowship. This conference will also pave way for enhanced regional and international cooperation in the field of dermatology.

This conference will look at innovative medical technology - particularly new
drugs, therapeutic devices and biologics. It will also examine developments
in subspecialties dealing with gene therapy, immunodermatology,
paediatric dermatology, dermatopathology, dermatologic and laser surgery.
An impressive regional and international faculty will be assembled to make
this conference.

You will find Kota Kinabalu, on the mystic island of Borneo a truly exciting
destination full of things to do and to discover, from crystal clear seas to
majestic mountains. Come and enjoy the warm hospitality and the unique
culture of the people. Come and be fascinated by the fauna, the rain forest,
the orang utans, proboscis monkeys and other creatures that you will not see anywhere else in this world.

Malaysia welcomes you.

http://www.asianderm.org/

ECG refresher course 2010

2010-06-18T09:06:00.000-07:00

Dear colleagues,

The Cardiology Society of Hospital Pulau Pinang is organising an ECG refresher course on the 1st Jul 2010 venued at ACC. It is a one-day event with lectures and discussions detailing right from the very fundamental technical issues with ECG, to the complex tracings pertaining to day to day practice.

Please feel free to forward this email and program brochure to your colleagues in your mailing list, who are currently practicing in the northern region ie Penang, Perak, Kedah and Perlis.

Kindly take note that the "Stump the cardiologist" session is held with the main purpose of stimulating discussions between the "frontline" ECG interpreters and us. Please feel free to post ECGs during the day.

We'll see you all during the meeting!

Sincerely,
Dr SK Ma
MD, MRCP(UK)
Clinical Cardiologist,
Dept of Cardiology
Hospital Pulau Pinang
sootkeng@gmail.com

4TH PENANG MRCP PACES PREPARATORY COURSE

2010-06-12T08:50:00.000-07:00

This preparartory course is jointly organized by Penang Medical College, MOH Penang General Hospital and Seberang Jaya Hospital.

It is a 2 day intensive and examination orientated course.

Date : 31 July - 1 Aug 2010
Venue : ACC,Hospital Pulau Pinang

THE INSIDER'S GUIDE TO PASSING MRCP(UK) PACES

2010-06-12T08:18:00.000-07:00

Dear all,

Please forward to those who are sitting for the PACES exam soon. I think it is useful since it is a Saturday and it is free.

Folliculitis Decalvans

2010-06-12T07:35:00.000-07:00

Folliculitis decalvans is a rare inflammatory scarring scalp disorder.

It is characterized by follicular pustules, lack of ostia, diffuse perifollicular erythema, follicular tufting and sometimes, hemorrhagic crusts and erosions.

It is believed that this type of scarring alopecia is the end stage of various inflammatory processes resulting in fibrosis and constriction of multiple hair follicles within a common trajectory.

It is also known as cicatricial alopecia or tufted folliculitis.

Treatment is mainly focused on the eradication of S. aureus and the anti-inflammatory agents.

Combination of antibiotic (Oral Rifampicin and Oral Clindamycin) is useful for this rare inflammatory scarring scalp disorder. But patient might need to be on antibiotic for long term.

The scarring, alopecia and tufting persisted but there was no further active inflammation.

Early aggressive treatment should be instituted to prevent scarring.

Please find the poster presentation during Regional Conference of Dermatology 2010 for the details.

Cutaneous Effects of Epidermal Growth Factor Receptor Inhibitors

2010-05-29T03:15:00.000-07:00

The use of TKI is associated with unique and dramatic dermatologic side effects.

1. Abnormal scalp, face hair, and/or eyelash growth (Isolated reports)

2. Anaphylactic infusion reaction (cetuximab)

3. Papulopustular eruption 60%-80%

4. Paronychia with/without pyogenic granulomas 6%-12%

5. Telangiectasias

6. Xerosis 4%-35%

Although these new targeted therapies have low systemic toxicity, cutaneous side effects are common and may be serious.

Proper pre-treatment counseling and management will improve the treatment compliance and avoid unnecessary interruption of the TKI use.

TKI induced skin rash appears to be a visible marker of anti-tumor activity and therapeutic efficacy.

Cross-sensitivity of skin rashes with antiepileptic drug use

2010-05-26T00:00:00.000-07:00

NEUROLOGY 2008;71:1527-1534
© 2008 American Academy of Neurology

Cross-sensitivity of skin rashes with antiepileptic drug use

L. J. Hirsch, MD, H. Arif, MD, E. A. Nahm, BA, R. Buchsbaum, S. R. Resor, Jr, MD and C. W. Bazil, MD, PhD

Objective:

To determine rates of cross-sensitivity of rash among commonly used antiepileptic drugs (AEDs) in patients with epilepsy.

Methods:

The incidence of AED-related rash was determined in 1875 outpatients (12 years), taking carbamazepine (CBZ), clobazam (CLB), felbamate (FBM), gabapentin (GBP), levetiracetam (LEV), lamotrigine (LTG), oxcarbazepine (OXC), phenobarbital (PB), phenytoin (PHT), primidone (PRM), tiagabine (TGB), topiramate (TPM), vigabatrin (VGB), valproic acid (VPA), or zonisamide (ZNS).

We compared rates of rash for each AED in patients with vs those without a rash to 1) another specific AED; 2) any other AED; 3) any two other AEDs; and 4) any non-epilepsy medication.

Results:

A total of 14.3% (269/1,875) of patients had a rash attributed to at least one AED; 2.8% had a rash to two or more AEDs.

Of patients who had a rash to CBZ and were also prescribed PHT (n = 59), 57.6% had a rash to PHT (abbreviated as CBZ PHT: 57.6%); of patients who had a rash to PHT and were also prescribed CBZ (n = 81), rate of rash was 42% (i.e., PHT CBZ: 42%). Other results: CBZ LTG: 20% (n = 50); LTG CBZ: 26.3% (n = 38); CBZ OXC: 33% (n = 15); OXC CBZ: 71.4% (n = 7); CBZ PB: 26.7% (n = 30); PB CBZ: 66.7% (n = 12); LTG PHT: 38.9% (n = 36); PHT LTG: 18.9% (n = 74); PB PHT: 53.3% (n = 15); PHT PB: 19.5% (n = 41); OXC LTG: 37.5% (n = 8); LTG OXC: 20% (n = 15).

There was evidence of specific cross-sensitivity between CBZ and PHT, and between CBZ and PB.

Conclusion:

Cross-sensitivity rates between certain antiepileptic drugs (AEDs) are high, especially when involving carbamazepine and phenytoin.

Specific cross-sensitivity rates provided here may be useful for AED selection and counseling in individual patients.

Abbreviations: AED = antiepileptic drug; CBZ = carbamazepine; CLB = clobazam; FBM = felbamate; GBP = gabapentin; LEV = levetiracetam; LTG = lamotrigine; OXC = oxcarbazepine; PB = phenobarbital; PHT = phenytoin; PRM = primidone; TGB = tiagabine; TPM = topiramate; VGB = vigabatrin; VPA = valproic acid; ZNS = zonisamide.

Drug Cross Sensitivty Reaction Part 2

2010-05-25T23:29:00.000-07:00

Cross-reactivity of beta-lactam antibiotics

Beta-lactam antibiotics = penicillins, cephalosporins, carbapenems, and monobactams.

The safety of administering beta-lactam antibiotics to penicillin-allergic patients is highly debated and is based mainly on anecdotal information regarding the incidence of cross-reactivity.

CEPHALOSPORINS

Anne et al demonstrated a high incidence of in vitro cross-reactivity (up to 20%) between penicillins and cephalosporins. Cephalosporins involved in these reports included cephalothin and cephaloridine.

Petz et al demonstrated a 4-fold increase in the incidence of cephalosporin reactivity--including cephaloridine, cephalothin, and cephalexin--in patients allergic to penicillins (8.1%) compared with patients not allergic to penicillins (1.9%). When this incidence is compared with the overall incidence of allergic reactions to cephalosporins (4%), there is a 2-fold increase of reactivity in patients allergic to penicillins.

CARBAPENEMS

Already discussued in part 1

MONOBACTAMS

To date, aztreonam has not demonstrated clinical cross-reactivity in penicillin-allergic patients.

Ceftazidime has a side chain identical to that of aztreonam and clinical cross-reactivity has been demonstrated in vitro.

The clinical significance of this has not been studied; however, patients who are allergic to aztreonam should not be administered agents with similar side chains.

References
1. Saxon A, Beall GN, Rohr AS, Adelman DC. Immediate hypersensitivity reactions to beta-lactam antibiotics. Ann Intern Med 1987;107:204-215.
2. Neftel KA, Cerny A. Beta-lactam antibiotics other than penicillins and cephalosporins. In Dukes MNG, ed. Meyler's Side Effects of Drugs, 12th ed. Amsterdam: Elsevier, 1992:632-634.
3. Kishiyama JL, Adelman DC. The cross-reactivity and immunology of beta-lactam antibiotics. Drug Saf 1994;10:318-327.
4. Anne S, Reisman RE. Risk of administering cephalosporin antibiotics to patients with histories of penicillin allergy. Ann Allergy Asthma Immunol 1995;74:167-170.
5. Petz LD. Immunologic cross-reactivity between penicillins and cephalosporins: a review. J Infect Dis 1978;137(Suppl):S74-S79.
6. Preston SL, Briceland LL, Lesar TS. Accuracy of penicillin allergy reporting. Am J Hosp Pharm 1994;51:79-84.

Drug Cross Sensitivity

2010-05-25T22:24:00.000-07:00

Cross-reactivity with drugs is an important clinical problem in drug hypersensitivity. Once a patient is labeled 'drug-allergic' all drugs of the same class are withheld and future therapeutic interventions are limited.

Antiepileptics
Development of drug hypersensitivity is one of the major complication of their usage. Antiepileptics are blamed for 20% of all drug rashes and are commonly incriminated drugs in severe cutaneous adverse reactions like Stevens-Johnson syndrome(SJS) or toxic epidermal necrolysis (TEN). The overall prevalence of rash is 2-3% due to antiepileptic drugs in epilepsy patients.

Cross-reactivity between phenytoin, phenobarbital and carbamazepine is thought to exceed 50%.

In patients suspected of having Anticonvulsant Hypersensitivity Syndrome (AHS), anticonvulsant therapy should be discontinued immediately; seizure control may be attempted with a benzodiazepine.

Another alternative for patients with partial or secondarily generalized seizures is gabapentin, which is thought to be safe for administration during the acute phase of AHS.

Valproic acid reportedly has been successful as well but should not be administered during the acute phase of AHS as it is metabolized hepatically.

Refenrence
Cross-Sensitivity between Phenytoin and Carbamazepine. Pharmacotherapy. 2001;21(4) © 2001 Pharmacotherapy Publications. http://www.medscape.com/viewarticle/409706_4.

Penicillin
The risk of cross-reactivity to carbapenems among patients with documented or self-reported penicillin allergy is more than five times higher in patients with a history of penicillin allergy than in those without such a history.

Physicians to be cautious when administering a carbapenem to patients with a history of penicillin allergy, particularly if the allergy has been documented by a health care professional. Cephalosporins should be used cautiously as well.

Penicillins, carbapenems, and cephalosporins are alike in that they have a characteristic bicyclic core structure, which is believed to play a large role in β-lactam hypersensitivity.

Physician should consider a different type of antibiotic, such as a fluoroquinolone, for patients with a history of penicillin sensitivity.

References
1. Apter AJ, Kinman JL, Bilker WB, et al. Represcription of penicillin after allergic-like events. J Allergy Clin Immunol. 2004;113:764-770.
2. Prescott WA, DePestel DD, Ellis JJ, Regal RE. Incidence of carbapenem-associated allergic-type reactions among patients with versus patients without a reported penicillin allergy. Clin Infect Dis. 2004;38:1102-1107.

Are topical anti-fungals all the same?

2010-05-17T06:13:00.000-07:00

1. Whitfield's ointment (benzoic acid) - useful for web intertrigo
2. Polyenes (ineffective for dermatophyte infection)
Nystatin (Nilstat®; Mycostatin®)
3. Imidazoles
Clotrimazole (Canesten®; Clocreme®; Clomazol®, Fungizid®)
Econazole (Ecreme®; Pevaryl®)
Ketoconazole (Daktagold®; Ketopine®, Nizoral®; Sebizole®)
Miconazole (Daktarin®; Micreme®; Resolve®; Tinasolve®)
Tioconazole
4. Allylamine (higher cure rates & more rapid responses)
Terbinafine (Lamisil®)

Topical Anti-fungal

2010-05-17T06:10:00.000-07:00

Topical antifungal creams can be used
1. As monotherapy to treat Dermatophyte, Yeast infections & mould skin infections.
2. As an adjunct to oral therapy for tinea capitis and tinea barbae.

The creams are applied to the affected area 2x / day for 2-4 weeks, including a margin of several centimetres of normal skin.

Continue for 1-2 weeks after the last visible rash has cleared. Repeated treatment is often necessary

Principle of Prescribing Topical Dermatological Therapy

2010-05-17T05:59:00.000-07:00

1. Correct diagnosis is the key to correct treatment
2. Be familiar with the treatment & their preparation
3. Know the do’s & don’ts of each topical medications
4. Give clear instructions to patient &alert them the possible events / side effect
5. Cure Sometimes; Relief Often; Comfort Always; Harm Never

HIV & SKIN

2010-05-05T04:09:00.000-07:00

HIV infection leads to progressive failure of cell-mediated immunity due to HIV- mediated loss of CD4 helper T cells. Virtually all HIV infected persons will develop some skin disorder during the course of their illness.

Dermatological manifestations can be the first sign of asymptomatic HIV disease. They can be important markers for the diagnosis of HIV infection. Certain skin diseases typically appear at certain stages of HIV infection, sometimes allowing the physician to predict the stage of HIV infection.

The skin changes in HIV / AIDS can be classified into 4 categories:
I. Infections
II. Inflammatory diseases
III. Neoplasms
IV. Cutaneous Adverse Drug Reactions (CADR)

Penang Dermatology Symposium 2010

2010-04-08T07:00:00.000-07:00

Department of Dermatology, Penang General Hospital will organise Penang Dermatology Symposium at Auditorium, Ambulatory Care Center (ACC) Penang General Hospital on 8th – 9th May 2010 (Saturday-Sunday).

This workshop is organised in collaboration with PGMES Hospital Pulau Pinang, Dermatological Society of Malaysia (PDM) and Faculty of Dermatology, Academy of Medicine, Malaysia.

Penang Dermatology Symposium is specially dedicated to doctors with special interest in Dermatology. This symposium is opened to all doctors (both government & private).

The aims for this event are to provide a regular continuous medical education (CME) programme in dermatology for practicing practitioners and to provide an update of various topics in dermatology.

For those interested, pls email me (tanwooichiang@yahoo.com). I will send you the detail and registration form.

The 3 "P"s of small vessel vasculitis

2010-04-08T06:43:00.000-07:00

1 P = Painful
2 P = Palpable
3 P = Purpura

Minocycline induced hyperpigmentation

2009-10-11T06:50:00.000-07:00

Minocycline (MCN) is a second-generation semisynthetic tetracycline derivative first introduced in 1967. It inhibits protein synthesis by binding to the 30s ribosomal subunit in bacteria. MCN is highly lipid soluble and turns black upon oxidation. Pigmentation is asymptomatic and is the most commonly observed cutaneous side effect of MCN therapy (2.4-14% incidence). Other reported sites of pigment deposition include thyroid gland, oral mucosa, nails, teeth, bone, conjunctiva, gingiva, substantia nigra, heart valves, atherosclerotic plaques, lymph nodes, and breast milk. MCN-induced hyperpigmentation is generally observed after prolonged therapy (after cumulative dose of 50-100 grams) but can occur regardless of dosage or treatment duration. It has been reported to occur as soon as 3 weeks after initiation of MCN therapy.

Cornoid Lamella

2009-09-15T09:17:00.000-07:00

Found in

Porokeratosis
Solitary inflammatory lesions
Seborrheic keratosis
Scar
Verrucae vulgares
Milia
Actinic keratoses / squamous cell carcinoma in situ
Basal cell carcinoma

Granuloma annulare

2009-01-17T03:53:00.001-08:00

6 clinical variants:

localized
generalized or disseminated
subcutaneous (pseudo-rheumatoid nodules)
perforating
arcuate
linear

Childhood BCC

2009-01-17T02:49:00.000-08:00

Albinism, Bazex syndrome, BCC nevus syndrome, nevus sebaceous, solid organ transplants, xeroderma pigmentosum and radiotherapy-treated cancers 32 M. de la Luz Orozco-Covarrubias, L. Tamayo-Sanchez, C. Duran-Mckinster, C. Ridaura and R. Ruiz-Maldonado, Malignant cutaneous tumors in children. Twenty years of experience at a large pediatric hospital, J Am Acad Dermatol 30 (1994), pp. 243–249.

Reed's syndrome

2009-01-16T05:07:00.000-08:00

Multiple cutaneous and uterine leiomyomatosis
Autosomal dominant disease
Chromosome 1q42.3-43 and the gene encoding fumarate hydratase
Uterine and cutaneous leiomyomas
Ass with papillary renal-cell carcinoma

Erosions in a newborn

2009-01-16T04:07:00.000-08:00

Infections: Staphylococcal scalded skin syndrome, HSV and varicella zoster virus infection,
Drug: Toxic epidermal necrolysis
Congenital: Aplasia cutis congenita, genetic blistering disorders such as epidermolysis bullosa, Autoimmune disorders: Pemphigus
Others: Incontinentia pigmenti and neonatal Behçet disease.

Baboon syndrome

2009-01-13T02:13:00.000-08:00

SDRIFE

Symmetrical Drug-Related Intertriginous (buttock and groin folds) and Flexural (other folds) Erythema (redness)

LASER TISSUE INTERACTION

2008-07-09T06:16:00.000-07:00

The role of lasers in dermatology has increased dramatically over the past two decades. A fundamental understanding of laser-tissue interactions is vital for the proper and appropriate use in clinical practice.

1. Light can interact with tissue in four key ways:

Transmission

Reflection

Scattering

Absorption

2. Selective photothermolysis

The theory of selective photothermolysis refers to laser energy absorption by a target chromophore without significant thermal damage to surrounding tissue.

To achieve selective photothermolysis, 3 main factors:
A. The laser must produce a beam of light with a wavelength preferentially absorbed by the chromophore in the lesion.
B. The pulse duration of the laser beam must be shorter than the thermal relaxation time of the chromophore to prevent the spread of thermal energy beyond the targeted chromophore.
C. The energy delivered to the site (fluence) must be high enough to destroy the chromophore within the pulse duration.

Classification of photodermatoses

2008-07-03T04:59:00.000-07:00

Photodermatoses ass diff age group

2008-07-03T04:57:00.000-07:00

Photogenodermatoses

2008-07-03T04:44:00.001-07:00

ARA criteria for SLE

2008-06-29T12:22:00.001-07:00

The ARA published criteria for the diagnosis of lupus in 1982. These criteria serve as a guide to information that is useful on history and physical examination. The following are criteria for the classification of systemic lupus erythematosus (SLE).

1. Malar rash
2. Discoid lupus erythematosus lesions
3. Photosensitivity (by history or observation)
4. Oral ulcers, usually painless, observed by physician
5. Arthritis-nonerosive, involving two or more joints
6. Serositis-pleuritis or pericarditis
7. Renal disorder-proteinuria (>500 mg/day) or cellular casts
8. Central nervous system disorder-seizures or psychosis (absence of known cause)
9. Hematologic disorder-hemolytic anemia, leukopenia (<4000/mm2) or thrombocytopenia (< 100,000/mm2)
10. Immunologic disorder-positive LE prep, abnormal titers of antinative (n) DNA, and anti-Sm, false-positive VDRL
11. Antinuclear antibody

If four or more criteria are present serially or simultaneously during any period of observation, the patient is considered to have SLE.

Shingles Vaccine Recommended for All Older Adults

2008-06-07T23:41:00.000-07:00

The Centers for Disease Control and Prevention is now recommending that all adults age 60 and older receive a dose of the zoster vaccine (Zostavax), even if they have had shingles previously.

MMWR 2008

In subjects age 60 and older, use of Zostavax was found to reduce the overall occurrence of herpes zoster by roughly 50%.

For people in their 60s, the risk reduction was 64%.

Some figures for atopic eczema

2008-05-19T16:19:00.000-07:00

1. Concordance rate is 80% and 20% in monozygotic and dizygotic twins respectively.
2. If both parents have atopic eczema, 75% chance the child with develope atopic eczema.
3. 75% develope before 6/12, 80-90% develope before 5 yrs old
4. 66% remit before age of 10.

Genetic facts of psoriasis

2008-05-19T16:07:00.000-07:00

1. Concordant in 70% monozygotic twins and only 20% in dizygotic twins
2. One parent affected, 16% child will be affected
3. Both parents affected, 50% child will be affected
4. If none of parents affected, but one sibling affected, the subsequent child is 10% affected

Mimicker of angioedema

2008-05-15T13:25:00.000-07:00

CT ds: LE, DM, vasculitis
Granuloma: silicone, sarcoid, granulomatous cheilitis, MR syndrome
Infection: Erysipelas
Neoplasm: Myeloma, SVC
Inflammation: ACD, Rosacea
Drug induced: Fixed drug eruption
Fat

Annular lesions

2008-05-10T16:15:00.001-07:00

Source: http://www.aafp.org

Malassezia furfur

2008-05-10T16:07:00.000-07:00

Causal relationship with:
1. Pityriasis vesicolor
2. Seborrheic dermatitis
3. Pitysporum folliculitis
4. Confluent and reticulate papillomatosis

Types of porokeratosis

2008-04-24T14:03:00.001-07:00

Classic porokeratosis of Mibelli (PM)
Disseminated superficial actinic porokeratosis (DSAP)
Porokeratosis palmaris et plantaris disseminata (PPPD)
Linear porokeratosis (LP)
Punctate porokeratosis (PP)

Differentials of linear lesions

2008-04-24T13:43:00.000-07:00

# Linear Contact Dermatitis

* Phytophotodermatitis
* Contact allergic or irritant dermatitis
* Artifact or factitial

# Koebner Phenomenon

* Lichen planus
* Psoriasis
* Auto-inoculation: Verruca, Molluscum contagiosum

# Developmental Linear Lesions

* Epidermal nevi
* Incontinentia pigmenti

# Linear Vascular or Lymphatic Lesions

* Thrombophlebitis
* Sporotrichosis
* Coccidioidomycosis

# Linear Lesions of Childhood (

* Porokeratosis
* Lichen striatus
* Epidermal nevi -
o Nevus unis lateris
o Verrucous nevi
* Linear verrucae vulgaris
* Linear lichen planus
* Linear psoriasis
* Incontinentia pigmenti
* Linear morphea
* Erythrokeratoderma variabilis

# Linear - Others not otherwise specified.

* Lichen striatus
* Lichen simplex
* Lichen sclerosus
* Morphea - childhood
* Porokeratosis of Mibelli
* Herpes zoster

OSLER WEBER RENDU SYNDROME

2008-01-24T22:24:00.000-08:00

TEACH

Telengiectasia
Epistaxis
AV malformation
Cerebral abscess
Haemorrhages-pulmonary,GIT

WARNING SIGNS IN MELANOMA

2008-01-24T22:20:00.000-08:00

"ABCDE"

A symmetry
B order irregular
C olour irregular
D iameter > 0.5 cm
E levation

DAYS OF APPEARANCE OF RASHES

2008-01-24T21:05:00.000-08:00

Very Sick Patients Must Take Double Exercise

Varicella (chicken pox)- 1st day
Scarlet fever - 2nd day
Pox (small pox) - 3rd day
Mumps - 4th day
Typhus - 5th day
Dengue - 6th day
Enteric fever (typhoid) - 7th day

TIMING OF VIRAL EXANTHEM

2008-01-24T20:45:00.001-08:00

Many Similar Rashes Develop In Submarines

1st day-measles
2nd day-scarlet fever
3rd day-rubella
4th day-duke's disease/scarletinella
5th day-erythema infectiosum
6th day-exanthem subitum

CUTANEOUS MANIFESTATION OF CANDIDIASIS

2008-01-23T21:57:00.000-08:00

THE CANDIDA

Thrush
Hypodermal granulomatosis
Erosions interdigital
Chronic paronychia
Angular chelitis/perleche
Nail-onchomycosis
Diabetic female-vulvovaginitis
Intertrigo
Diabetic male-balanitis/balanoposthitis
Anal-pruritis ani

Primary Cicatricial Alopecia

2008-01-22T16:23:00.000-08:00

North American Hair Research Societyv(NAHRS) Classification System 2001
1. Lymphocytic

Chronic cutaneous lupus erythematosus
Lichen planopilaris (LLP)

Classic LLP
Graham-Little syndrome
Frontal fibrosing alopecia

Pseudopelade of Brocq
Central centrifugal cicatricial alopecia
Alopecia mucinosa
Keratosis follicularis spinulosa decalvans

2. Neutrophilic

Folliculitis decalvans
Dissecting cellulitis

3. Mixed

Acne keloidalis
Acne necrotica
Erosive pustular dermatosis

4. Nonspecific/ end stage cicatricial alopecia

DERMATOMYOSITIS

2008-01-19T20:12:00.000-08:00

MUSCLE PAINS

Malignancy (breast, lung, ovary, GI)
Ungual telangiectasias
Subcutaneous calcinosis
Cardiac
Liver
Eyes (heliotrope lids, photosensitivity, retinopathy)
Poikiloderma / Polyarthritis
Aldolase
Interstitial pneumonitis
Needle biopsy
Sclerodermatomyositis

14 P's
Pruritis
Purple
Periocular rash
Poikiloderma
Palms - mechanic's hands
Peritoneal-ovarian cancer
Paraneoplastic
Photosensitive
Photodermatitis
Periungual telangiectasia
Papules-Gottron
Polyarthritis
Pneumonitis
Polyphasic potentials on EMG

RISK FACTORS FOR DEVELOPMENT OF LATEX ALLERGY

2008-01-18T20:43:00.000-08:00

1. Occupational exposure to latex (HCW / food handlers)
2. Multiple surgical procedures (patients with spinal bifida / congenital abn)
3. Frequent mucosal exposure to natural latex products (dental/contraceptive)
4. Pre-existing hand eczema
5. Atopy
6. Female
7. Fruit allergy

FOOD ALLERGIES ASSOCIATED WITH LATEX ALLERGY

2008-01-18T20:21:00.000-08:00

FRUIT LATEX CROSS REACTIVITY MAY OCCUR

1. Avocado
2. Banana
3. Chestnut
4. Kiwi
5. Mango
6. Pineapple
7. Apple
8. Papaya
9. Potato
10.Tomato
11.Spinach
12.Celery

MULTIPLE LENTIGINES SYNDROME

2008-01-10T02:43:00.000-08:00

CLAMP

Centrofacial Lentiginosis
LEOPARD Syndrome
Adolescent Eruptive Len.
Moynahan's Syndrome
Peutz-Jegher's

LICHENOID DISEASE

2008-01-10T02:34:00.000-08:00

LLLL AQ CAT

Lichen planus
Lichen planus-like GVHD
Lichenoid Discoid Lupus
Lichenoid Drug Eruption

Au (gold)
Quinidine
Captopril and color developers
Amino salicylic acid (PAS) & arsenicals
Thiazides

Types of Cutaneous TB

2008-01-08T18:32:00.000-08:00

Exogenous infection

PIT : Primary inoculation tuberculosis
TVC : Tuberculosis verrucosa cutis

Endogenous infection

LV : Lupus vulgaris
SD : Scrofuloderma
AMT : Acute miliary tuberculosis
MTA : Metastatic tuberculosis abscess
OT : Orificial tuberculosis

Tuberculid

EI : Erythema induratum
PNT : Papulonecrotic tuberculid
LS : Lichen scrofulosorum

GRANULOCYTIC DERMATITIS

2007-12-16T08:55:00.000-08:00

COMMONLY BIOPSIED LESIONS IN MALAYSIA

1. Subcorneal Pustular Dermatosis
2. Sweet's Syndrome
3. Eosinophilic Cellulitis
4. Pyoderma Gnagrenosum
5. Pustular Folliculitis
6. Hidradenitis Suppurativa
7. Arthropod Reaction

VASCULITIS

2007-12-16T08:52:00.000-08:00

COMMONLY BIOPSIED LESIONS IN MALAYSIA

1. Leukocytoclastic Vasculitis
2. Lymphocytic Vasculitis
3. Perniosis
4. Atrophie Blanche
5. PAN
6. Nodular Vasculitis (+lobular panniculitis)
7. Angiolymphoid Hyperplasia with Eosinophilia

GRANULOMATOUS DERMATITIS

2007-12-16T08:49:00.000-08:00

COMMONLY BIOPSIED LESIONS IN MALAYSIA

1. Foreign Body Granuloma
2. Sarcoidosis
3. Granuloma Annulare
4. Rheumatoid Nodule
5. Necrobiosis Lipoidica Diabeticorum
6. Leprosy
7. Rosacea
8. Atypical Mycobacterial Infection

VESICULOBULLOUS DERMATITIS

2007-12-16T08:46:00.000-08:00

COMMONLY BIOPSIED LESIONS IN MALAYSIA

1. Pemphigus
2. Bullous Pemphigoid
3. Epidermolysis Bullosa (Weber-Cockayne)
4. Epidermolysis Bullosa Simplex
5. Epidermolysis Bullosa Acquisita
6. Darier's Disease
7. Dermatitis Herpetiformis
8. Grover's Disease
9. Hailey Hailey Disease

SPONGIOTIC DERMATITIS

2007-12-16T08:39:00.000-08:00

COMMONLY BIOPSIED LESIONS IN MALAYSIA

1. Spongiotic Dermatitis / Eczema
2. Allergic Contact Dermatitis
3. Pityriasis Rosea
4. Miliaria
5. Spongiosis associated with other pattern like erythema multiforme

PSORIASIFORM DERMATITIS

2007-12-16T08:23:00.000-08:00

COMMONLY BIOPSIED LESIONS IN MALAYSIA

1. Psoriasis
2. Picker's Nodule
3. Lichen Simplex Chronicus
4. Prurigo Nodularis
5. Pityriasis Rubra Pillaris
6. Pityriasis Rosea
7. Mycosis Fungoides

LICHENOID DERMATITIS

2007-12-16T08:20:00.000-08:00

COMMONLY BIOPSIED LESION IN MALAYSIA

1. Erythema Multiforme
2. Pityriasis Lichenoides Chronicum
3. PLEVA
4. Lupus Erythematosus
5. Lichen Planus
6. Lichen Nitidus
7. Lichenoid Drug Eruption
8. Lichen Planopilaris

MAJOR TISSUE REACTIONS

2007-12-16T08:09:00.000-08:00

1. Lichenoid Dermatitis
2. Psoriasiform Dermatitis
3. Spongiotic Dermatitis
4. Vesicobullous Dermatitis
5. Granulomatous Dermatitis
6. Vasculitis
7. Panniculitis
8. Granulocytic Dermatitis (Neutrophilic / eosinophilic)

DRUG INDUCED LE

2007-12-11T21:48:00.000-08:00

PASCHA ALI

Penicillamine, Procainamide
Antihypertensives (ACE-I., Atenolol)
Sulfonamides
Chlorpromazine
Hydralazine
Antibiotics (Griseofulvin, Sulfa)
Anticonvulsants (Phenytoin, Phenobarbital)
Lithium
Isoniazid

CAUSES OF PERIPHERAL EOSINOPHILIA

2007-12-11T21:34:00.000-08:00

CHINA

Connective tissue disease (SLE, DM, Sjogren's, CSS)
Helminths (All worms, parasites, Giardia)
Idiopathic hypereosinophilic syndrome
Neoplasms (Leukaemia)
Allergies, Asthma

SCARRING ALOPECIA

2007-12-11T21:28:00.000-08:00

ALOPECIAS

Autoimmune (DLE, Morphea, Cicatricial pemphigoid)
Lichen Planus (Lichen planopilaris)
pseudOpelada de Brocq
Physical damage (chemicals, trauma, radiation)
Epidermal Nevus and Neoplasms (BCC, SCC, metastases)
Congenital (Aplasia cutis)
Infectious (Bacterial, Fungal, Viral - Herpes zoster)
Alopecia mucinosa (Sometimes associated with mycosis fungoides)
Sarcoidosis

DRUG INDUCED PEMPHIGUS

2007-12-11T05:31:00.000-08:00

CRAP

Captopril
Rifampicin
ACE Inhibitor
Piroxicam; Penicillamine

CAUSES OF BLUE SCLERA

2007-12-11T05:23:00.000-08:00

A POEM

Anaemia
Pseudoxanthoma elasticum
Osteogenesis imperfect
Ehlers Danlos syndrome
Marfan syndrome

GENERALIZED SKIN HYPERPIGMENTATION

2007-12-11T05:11:00.000-08:00

"Generalized mean none of the skin is SPARED"

Sunlight
Pregnancy
Addison's Disease
Renal failure
Excess iron (haemochromatosis)
Drugs (e.g. amiodarone, minocycline)

HENOCH-SCHONLEIN PURPURA

2007-12-11T05:08:00.000-08:00

NAPA

Nephritis
Arthritis, arthralgias
Purpura, palpable (especially on lower extremities)
Abdominal pain (intussusception to be ruled out)

INCONTINENTIA PIGMENTI (BLOCH-SULZBERGER'S DISEASE)

2007-12-11T05:00:00.000-08:00

BLOCH

Bony abnormalities; Bullae/vesicles (I)
Loss or dystrophy of hair, nails or teeth
Ocular (blindness, strabismus, cataracts)
Central Nervous System (seizures, mental retardation)
Heart malformations (uncommon);

Stages:

Bullae/vesicles (I),
Hyperkeratotic plaques (II),
Hyperpigmentation (III),
Hypopigmentation- (IV)

LEUKOCYTOCLASTIC VASCULITIS

2007-12-11T04:51:00.000-08:00

VASCULITIS

Viral hepatitis B, C
Anaphylactoid purpura, Autoimmune (SLE, PSS, DM)
Systemic lupus & other autoimmune Disease, Staph/Strep Sepsis
Cryoglobulins
Urticarial Vasculitis, ulcerative colitis
Lymphoproliferative Disease (Hairy Cell leukemia)
Idiopathic
Thiazides, PhenoThiazines, Lasix
Immune Sera, & Iodides
Sulfa (& other antibiotics)

Hair shaft abnormalities

2007-12-09T07:28:00.000-08:00

1) Increased fragility - monilethrix, pili torti,trichorrhexis invaginata, trichorrhexis nodosa, trichoschisis
2) Without fragility - pili annulati, uncombable hair, loose anagen hair

Pili torti - twisting of hair, flattened hair with rotation of 180 degree around long axis at irregular interval
eg. Menkes' syndrome, Bjornstard syndrome
Trichorrhexis nodosa is the fraying of hair ends so that the resemble a "broom-stick" or "paint brush".
eg. argininosuccinic aciduria

Trichoschisis or clean fracture of the hair shaft.
eg. Tay's syndrome is also known as trichothiodystrophy

Trichorrhexis invaginata or bamboo hair.
eg. Netherton's syndrome

Monilethrix means beading of hairs, it is an Autosomal Dominant condition.
Abnormality is in gene coding for human hair keratins hHb1 and hHb6.
Pili Annulati is the alternating light and dark bands secondary to air-spaces seen in normal light and has been associated with alopecia areata.

CLASSIFICATION OF HYPERSENSITIVITY REACTION

2007-12-09T07:21:00.000-08:00

ACID

A = Type 1 Anaphylactic
C = Type 2 Cytotoxic
I = Type 3 Immune complex
D = Type 4 Delayed

Modified sebaceous glands

2007-12-09T07:12:00.000-08:00

Fordyce spots = lips
Montgomery's tubecles = nipples
Meibomian glands = eyelids
Tyson glands = genitalia

KOEBNER'S PHENOMENON

2007-12-09T07:01:00.000-08:00

Very Low Density Lipo-ProteinS

V = Vitiligo; Viral wart
L = Lichen planus / Lichen striatus
D = DLE
L = Molluscum contagiosum
P = Psoriasis
S = Sarcoidosis

LICHEN PLANUS

2007-12-09T06:55:00.000-08:00

"7P"

Pruritic, Papules, Plaques, Purple, Polygonal, Plain top, Peripheral

LYMPHOGRANULOMA VENEREUM

2007-12-09T06:47:00.000-08:00

ABCDEFG

A = Asymptomatic in early stage
B = Bilateral buboes
C = Causative organism Chlamydia trachomatis
D = Drug of choice doxycycline
E = Estheomine
F = Frei's test
G = Groove's sign

Important HPV types

2007-12-08T15:16:00.000-08:00

Plantar warts 1,2
Common warts 1,2
Flat warts 3,10
Butcher's warts 7
Epidermodysplasia verruciformis 5,8,9
Condyloma acuminatum (CA) 6,11
Bushke Lowenstein tumour (Giant CA) 6,11
Focal epithelial hyperplasia of Heck 13,32
Bowenoid papulosis 16
Intraepithelial neoplasias 11,16,31,33

Classification of cutaneous TB

2007-12-08T15:12:00.000-08:00

1.Exogenous
- Primary inoculation TB (nonsensitized)
- TB verrucosa cutis (sensitized)

2.Endogenous
- Lupus vulgaris
- Scrofuloderma
- Metastatic TB abscess
- Acute miliary TB
- Orificial TB

3.Tuberculid
- Erythema induratum
- Papulonecrotic tuberculid
- Lichen scrofulosorum

Blueberry Muffin spots

2007-12-08T08:06:00.000-08:00

Causes:
Prenatal infections (e.g. TORCH)
Severe anemia (e.g. Hemolytic Disease of the newborn, Hereditary spherocytosis)
Neoplastic diseases (e.g. rhabdomyosarcoma, Neuroblastoma)

Indicate extramedullary erythropoiesis

AGEP

2007-12-08T03:58:00.000-08:00

Acute generalized Examthematous Pustulosis

Drugs: Ampicilin, cephalosporins, macrolides, Ca channel blockers, hydrochloroquine, paracetamol
Infections: Enterococcus, Parvo virus 19, CMV, Chlamydia, spider bites

MHC molecules

2007-12-07T16:10:00.001-08:00

MHC Class I molecules are on ALL nucleated cells
MHC Class II molecules are on B cells, monocytes, dendritic cells, and are inducible on keratinocytes and endothelial cells.

TH relation of skin diseases

2007-12-07T15:46:00.000-08:00

TH1: psoriasis, contact dermatitis, tuberculoid leprosy
TH2: atopic dermatitis, lepromatous leprosy, SLE

TH1:IL1, IL2, IL12, IL15, IL18, IL23, IFN alpha, IFN gamma, TNF alpha, TNF beta
TH2:IL4, IL5, IL6, IL9, IL10, IL13

Sutures

2007-12-07T15:27:00.001-08:00

Absorbable: Catgut, Vicryl, Maxon, Monocryl, PDS, Dexon

Non-absorbable: Polypropylene, Nylon, Navafil, Silk

Waardenburg's syndrome gene

2007-12-06T17:46:00.000-08:00

"pack your mittens and pack your socks"

PAX-3
MITF
SOX10

POEMS syndrome

2007-12-03T15:13:00.000-08:00

Polyneuropathy
Organomegaly
Endocrinopathy
Monoclonal gammopathy
Skin lesions - gromeruloid hemangioma