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Introduction: Since 2016, several therapies have been approved for treating atopic dermatitis (AD) in Singapore, including biologics, oral Janus kinase (JAK) inhibitors and topical crisaborole. This study supplements the 2016 Singapore treatment guidelines for AD, focusing on newer therapies for moderate-to-severe disease, while revisiting older treatment regimens to accommodate changes in knowledge and practice. Method: A modified Delphi panel was held, led by 2 co-chairs. The voting expert panel consisted of 12 dermatologists experienced in managing AD in Singapore. Delphi survey rounds were conducted between 24 July and 27 October 2023. Panellists indicated their agreement with drafted statements using a 5-point Likert scale. Consensus was defined as ≥80% agreement. An expert meeting was held to facilitate the consensus process between rounds 1 and 2 of voting. Results: All expert panellists participated in both survey rounds, with a 100% response rate. Thirty-nine statements, classified into general principles, conventional treatments, biologics and JAK inhibitors, were proposed. Of these, 27 statements reached consensus at the end of round 1. After the expert meeting, 17 statements were included in round 2, of which 16 statements reached consensus. One statement did not reach consensus. Key updates are the inclusion of dupilumab and JAK inhibitors as potential first-line treatments for moderate-to-severe AD, in certain populations. Conclusion: This modified Delphi study generated consensus among Singapore dermatology experts, to update treatment guidelines in moderate-to-severe atopic dermatitis. The consensus statements developed are intended to supplement the 2016 Singapore treatment guidelines for AD. Further revisions may be required when new evidence and/or treatments become available.

Abstract Introduction Rapid progress made in the management of atopic dermatitis (AD) in recent years and the differences in patient journey between Asian and non-Asian populations call for a review of current atopic dermatitis landscape in Asia. Methods A roundtable meeting with nine regional dermatological experts was held in June 2023 to discuss the optimal management approaches for moderate-to-severe AD, focusing on the use of advanced therapies. Results Disease burden on patients’ quality of life, treatment adherence, and financial constraints were identified as major concerns when managing patients with moderate-to-severe AD in parts of Asia. It was agreed that the Hanifin and Rajka’s criteria or the UK Working Party’s Diagnostic Criteria for Atopic Dermatitis can be used to guide the clinical diagnosis of AD. Meanwhile, patient-reported outcome scales including the Dermatology Life Quality Index and Atopic Dermatitis Control Tool can be used alongside depression monitoring scales to monitor treatment outcomes in patients with AD, allowing a better understanding for individualized treatment. When managing moderate-to-severe AD, phototherapy should be attempted after failure with topical treatments, followed by conventional disease-modifying antirheumatic drugs and, subsequently, biologics or Janus kinase inhibitors. Systemic corticosteroids can be used as short-term therapy for acute flares. Although these advanced treatments are known to be effective, physicians have to take into consideration safety concerns and limitations when prescribing these treatments. Conclusions Treatments in AD have evolved and its management varies country by country. Unique challenges across Asian countries necessitate a different management approach in Asian patients with AD.

Background: Atopic dermatitis (AD) is a prevalent skin disease in Asia. Attitudes and practice vary among the Asian cities. Objectives: This study aimed to survey similarities and differences in dermatologists' attitudes and practice in Asian cities. Methods: A questionnaire survey was sent to 118 dermatologists in Singapore, Malaysia, Thailand, Taiwan, and Hong Kong. Results: About 30.8% of respondents from Taiwan and 44.4% of respondents from Hong Kong saw most of their patients presenting with severe AD. This is significantly higher than respondents from Singapore, Malaysia, and Thailand (4%–12%). Majority of the respondents would use topical corticosteroids in infants and children with AD. About 55.6% of the respondents from Hong Kong used topical calcineurin inhibitors in AD, which is a significantly lower than the other countries. Top 3 most prescribed antibiotics in infected AD were cephalexin, cloxacillin, and amoxicillin/clavulanic acid combination. Most respondents used oral corticosteroids in severe AD. Many respondents from Singapore and Malaysia use cyclosporin (70%–92%), azathioprine (80%–100%), and methotrexate (72%–75%). Fewer respondents from Thailand, Taiwan, and Hong Kong used cyclosporin (22.2%–59%), azathioprine (0%–66.7%), and methotrexate (8%–25.6%). A large majority of respondents from Singapore, Taiwan, and Malaysia use phototherapy in management of AD (90%–100%). About 24% of respondents from Thailand and 33.3% of respondents from Hong Kong use phototherapy in AD. Conclusion: Compared to the previous study, there is improvement in the proportion of dermatologists in Asia using topical calcineurin inhibitors and phototherapy. This may signify better access to these treatment modalities throughout the region. Educational programs that allow a patient-centered approach should be recommended as an adjunct to medical therapy. The management of AD among Asians requires a holistic approach while considering accessibility and cultural differences.

Neurofibromatosis 1 (NF1) is a neurocutaneous syndrome characterized by multiple café-au-lait macules, cutaneous neurofibromas or plexiform neurofibromas, iris Lisch nodules, axillary and inguinal freckling. Mosaicism in NF1 can either present as a generalized disease, or in a localized (segmental) manner. Mosaic generalized NF1 may have presentations that are similar to generalized NF1 or have a milder phenotype and hence may be under-recognised in clinical practice. We report a nonsense mutation in the NF1 gene in a 55-year old Chinese male with the mosaic generalized phenotype. He reported noticing increasing numbers of skin-colored papules over his face, neck, back and abdomen when he was about 40 years old. From both next-generation and Sanger sequencing data, the variant appeared to be mosaic and present at about 24%. It is in exon 39 and has not been reported in any database or published literature.

Neurofibromatosis 1 (NF1) is a neurocutaneous syndrome characterized by multiple café-au-lait macules, cutaneous neurofibromas or plexiform neurofibromas, iris Lisch nodules, axillary and inguinal freckling. Mosaicism in NF1 can either present as a generalized disease, or in a localized (segmental) manner. Mosaic generalized NF1 may have presentations that are similar to generalized NF1 or have a milder phenotype and hence may be under-recognised in clinical practice. We report a nonsense mutation in the NF1 gene in a 55-year old Chinese male with the mosaic generalized phenotype. He reported noticing increasing numbers of skin-colored papules over his face, neck, back and abdomen when he was about 40 years old. From both next-generation and Sanger sequencing data, the variant appeared to be mosaic and present at about 24%. It is in exon 39 and has not been reported in any database or published literature.

Background: Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disease. Objective: We report the profile and outcome of 100 cases of BP seen at our center. Patients and Methods: This was a retrospective study of patients with BP seen at Changi General Hospital, Singapore from 2004 to 2012. Results: There were 57 female and 43 male patients. Other than the usual comorbidities such as diabetes mellitus and neurological diseases, there were a high incidence of osteoporosis (29%), hypothyroidism (6%), malignancy (6%), and hepatitis B carrier (3%). Peripheral blood eosinophilia is seen in almost half of the patients. The study results showed the higher sensitivity of direct immunofluorescence (93.5%) as compared to indirect immunofluorescence (89.1%). Topical and systemic corticosteroids were the standard treatment (96%). The duration to remission ranged from 2 weeks to 34 months, with a mean age of 7 months. Doxycycline and nicotinamide were effective for localized BP. The mortality rate was 35%. Conclusion: In Singapore, BP is associated with significant morbidity and mortality. High mortality of BP is related to the advanced age of the patients, associated medical conditions and complications from the treatment.

Background: Carbamazepine (CBZ) is often implicated in drug-induced Stevens–Johnson syndrome/toxic epidermal necrolysis (SJS/TEN). CBZ-induced SJS/TEN is strongly associated with the HLA-B*1502 allele in Southeast Asia. Objectives: The objective was to determine the prevalence of HLA-B*1502 allele in patients with CBZ-induced SJS/TEN and in their first-degree relatives. Materials and Methods: Ten cases of CBZ-induced SJS/TEN from a single center were contacted and offered HLA-B*1502 genotyping for themselves and their first-degree relatives. Eight patients and 12 relatives consented for genotyping. Results: HLA-B *1502 was positive in all patients who were tested, of whom 50% of them were Malay and 50% were Chinese. The frequency of the HLA-B*1502 allele in the first-degree relatives was 58%. Conclusion: HLA-B*1502 is common in first-degree relatives of patients with CBZ-induced SJS/TEN.

Epidermolysis bullosa simplex-Dowling–Meara (EBS-DM) variant is an autosomal dominant blistering genodermatosis due to mutations in genes coding for keratin 5 (K5) or keratin 14 (K14), specifically at the rod domain. Postinflammatory dyspigmentation can arise at sites of blistering, sometimes in a reticulate or mottled configuration. This mimics EBS with mottled pigmentation (EBS-MP), usually due to mutation in the head domain of K5, for which the pigmentation is not preceded by blisters. We report a case of an adult Malay male with recurrent blisters and mottled hyperpigmentation over his trunk and limbs, consistent with EBS-DM clinically, and confirmed on genetic mutation sequencing. Different K5 or K14 mutations, by altering keratinocyte adhesion and interfering with melanin pigment transport, can lead to variable phenotypes of skin fragility and/or hyperpigmentation, possibly modulated by other genetic or environmental factors.

Infantile hemangiomas (IHs) are the most common benign soft tissue tumor of infancy and childhood. Many patients seek early treatment to halt progression of tumor growth and accelerate regression to achieve quick resolution with good cosmetic outcomes. We reviewed literature through PubMed search on the treatment strategies for IH and share our experience in the field of laser treatment of IH. Treatment strategies for IH include both pharmacological, laser, and surgical interventions depending on the stage and severity of the lesion. Various laser beams have been attempted with varying effects and effectiveness. The 595-nm pulsed dye laser therapy has been most widely utilized owing to its great efficacy but minimal adverse effects. It works by targeting oxyhemoglobin chromophore in blood vessels located within the dermis, causing photothermal damage of these target vessels stimulating quick involution without damaging surrounding healthy skin. It is especially useful in treating ulcerated superficial facial hemangiomas that necessitate rapid healing to avoid unsightly scarring. It has a good safety profile but small risk of epidermal burn, blistering, postinflammatory pigment changes, and scarring remains in those with darker skin types treated with higher fluences and short-pulsed duration. Combination treatment with 1064 nm neodymium-doped yttrium aluminum garnet laser, oral propranolol, and even corticosteroids remains an option, especially in treatment of deep, large, and functionally threatening IH. Careful consideration in consultation with the child's parents given the complexities and potential complications surrounding treatment should always be considered. Laser treatment remains an appropriate treatment for rapidly growing IH in exposed locations at early presentation.

Mastocytosis is characterized by a proliferation of mast cells in the skin and extracutaneous organs. Cutaneous mastocytoma is the second most common presentation of mastocytosis in children and has been reported to arise post-trauma. We report herein the second case of solitary mastocytoma resulting from application of an excessively tight infant identification bracelet and the first in the English literature.

Abstract Clinicians should be aware that cutaneous PAN can present with significant extracutaneous and constitutional symptoms which make it hard to differentiate from systemic PAN. The condition can also rarely be associated with NTM infections.

Background: Pyoderma ga ngrenosum (PG) is a rare, inflammatory, destructive neutrophilic dermatosis, which mimics other ulcerative conditions. Materials and Methods: In a retrospective study based on patients diagnosed with PG over a 3-year period (2010-2013), we evaluated demographics, anatomical sites, number of lesions, subtypes, histopathology, associated conditions, treatment regimens, healing time, and recurrence. Results: Of our five patients, there were three males and two females, age ranging between 19 and 58 years (mean age 38 years). Four had single lesions localized to the lower limbs while one had multiple lesions (more than five) over bilateral hands and legs. Ulcerative subtype was observed in all the patients. One exhibited pathergy. Skin biopsies were done in four patients, revealing dense neutrophilic infiltrates in three cases and leukocytoclastic vasculitis in one. Associated systemic diseases were observed in all patients, four having inflammatory bowel disease and one having both systemic lupus erythematosus and anti-phospholipid syndrome. The patients were all treated with systemic corticosteroids either alone or in combination with immunosuppressants (e.g., azathioprine, mycophenolate mofetil, tacrolimus), and wound dressing. Split-thickness skin graft was done in one patient. Complete healing was achieved in all patients, ranging from one to 3 months after diagnosis. No recurrence was reported. Conclusions: Systemic corticosteroids, either alone or in combination with steroid-sparing agents are the mainstay of treatment. Should family physicians encounter a rapidly progressing ulcer that has poor response to usual wound management, timely referral to dermatology should be made.

The article presents case study of 49‑year‑old woman who is diagnosed with painful leg rash of polyarteritis nodosa disease. Topics discussed include the necrotizing inflammation of the disease affects medium‑sized and small muscular arteries; eosinophilic granulomatosis with polyangiitis diagnosis affects small‑ to medium‑sized vessels; and mention about extent of organ involvement and disease progression guides as treatment of the disease.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, but potentially life-threatening, reactions to medications. Both conditions have significant morbidity and mortality. The aim of this study was to document the epidemiological features, aetiologies, treatment and clinical outcomes of retrospectively reviewed data of all patients with SJS or TEN treated from January 2004 to November 2010 in a general hospital. There were 18 cases of SJS, seven cases of SJS/TEN overlap and three cases of TEN. Mean age was 50.6 years, with a range of 13-85 years. The male/female ratio was 1. Drugs accounted for 26 cases; one case was caused by Neissena gonorrhoea infection. Anti-convulsants (35.7%) were the most common implicated drugs followed by antibiotics (28.5%), non-steroidal anti-inflammatory drugs (NSAIDS) (14.3%), allopurinol (7.1%) and traditional Chinese medication (7.1%). In seven cases, multiple drugs were implicated. Most SJS cases (88%) were treated with corticosteroids, of which 61% were given highdose systemic corticosteroids. No infective complications were observed. Six out of the seven SJS/TEN overlap syndrome and all three TEN cases were given intravenous immunoglobulins. One patient with TEN died. In conclusion, anti-convulsants, especially carbamazepine, were the most frequently implicated drugs, followed by antibiotics and NSAIDS. High-dose corticosteroids were effective in SJS, whereas intravenous immunoglobulin were useful in TEN and SJS/TEN overlap syndrome. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which features a case report involving a 46-year old Chinese man with sporotrichoid nodules caused by Mycobacterium abscessus and treated with doxycycline.