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Introduction: Patient eczema severity time (PEST) is a new atopic dermatitis (AD) scoring system based on patients' own perception of their disease. Conventional scales such as SCORing of atopic dermatitis (SCORAD) reflect the clinician's observations during the clinic visit. Instead, the PEST score captures eczema severity, relapse and recovery as experienced by the patient or caregiver on a daily basis, promoting patient engagement, compliance with treatment and improved outcomes. This study aims to determine the correlation between carer-assessed PEST and clinician-assessed SCORAD in paediatric AD patients after 12 weeks of treatment using a ceramide-dominant therapeutic moisturizer., Methods: Prospective, open-label, observational, multi-centre study in which children with AD aged 6 months to 6 years were treated with a ceramide dominant therapeutic moisturizer twice daily for 12 weeks; 58 children with mild-to-moderate AD were included. Correlation between the 7-day averaged PEST and SCORAD scores for assessment of AD severity was measured within a general linear model. PEST and SCORAD were compared in week 4 and week 12., Results: At week 12, a moderate correlation was found between the SCORAD and PEST scores (r = 0.51). The mean change in SCORAD and PEST scores from baseline to week 12 was -11.46 [95% confidence interval (CI) -14.99 to -7.92, p < 0.0001] and -1.33 (95% CI -0.71 to -0.10, p < 0.0001) respectively. PEST demonstrated greater responsiveness to change (33.3% of scale) compared to SCORAD (13.8% of scale)., Conclusion: The PEST score correlates well with the SCORAD score and may have improved sensitivity when detecting changes in the severity of AD. The ceramide-dominant therapeutic moisturizer used was safe and effective in the management of AD in young children., Funding: Hyphens Pharma Pte Ltd., Trial Registration: clinicaltrials.gov identifier, NCT02073591.

Introduction: This study aimed to assess the frequency of anxiety and depression in a cohort of adult patients with atopic dermatitis (AD) in a tertiary dermatological centre, using the Hospital Anxiety and Depression Scale (HADS). We looked for any correlation between anxiety and depression with skin disease severity., Materials and Methods: Patients with AD were recruited from the National Skin Centre, Singapore, from 2008 to 2009 for a prospective cross-sectional study. The scoring atopic dermatitis (SCORAD) grade was determined and the HADS was administered via interviews., Results: A total of 100 patients (78 males, 22 females) were enrolled (92% Chinese, 4% Malays and 4% Indians). Their average age was 25.7 years. Sixty-five percent used topical steroids, 14% had previously taken oral prednisolone for the control of disease flares, and 20% were on concurrent systemic therapy. The mean SCORAD was 55.0, with 99% of patients having moderate or severe AD. The mean HADS anxiety score was 7.2 and the mean depression score was 5.0. The level of anxiety correlated well with that of depression (Spearman's rank correlation coefficient, ρ = 0.59, P <0.05); 18% were considered as cases of anxiety and 5% as cases of depression. These patients also had higher SCORAD values compared to other patients with lower scores for anxiety or depression ( P <0.05). Linear regression demonstrated a statistically significant positive relationship between anxiety and depression scores, and SCORAD scores., Conclusion: Our study identified, by means of the HADS, the frequency of anxiety and depression amongst a cohort of Singaporean patients with AD. More severe skin disease correlated to greater psychological burden. The HADS is a useful screening tool that can constitute part of the overall holistic management of patients with AD so as to improve patient care.

Background: Psoriasis has a negative psychological impact on patients, and may have repercussions on treatment outcomes. Despite this, the degree to which psoriatic patients suffer from psychiatric disorders has not received much attention in Singapore., Objective: This prospective cross-sectional study was conducted to determine the frequency of anxiety and depression in a cohort of Singaporean patients with psoriasis, and explore its relationship with regards to physical disease severity and subjective quality of life., Methods: 100 patients aged 21-60 years old who visited the National Skin Centre, Singapore from 2008 to 2009 were enrolled into the study. Anxiety and depression were quantified using the Hospital Anxiety and Depression Scale (HADS). Disease severity was quantified with the Psoriasis Area Severity Index (PASI) and quality of life measured with the Short Form (36) Health Survey (SF-36)., Results: Using the HADS, the mean score for anxiety was 6.9 and that for depression was 4.7. An anxiety disorder was suggested in 17%, while a depressive disorder was suggested in 15% of the study population. All eight domains of the SF-36 were significantly correlated with both anxiety and depression scores. Patients with moderate or severe psoriasis (on PASI) had worse depression scores than those with mild psoriasis. No association was found between anxiety scores and PASI. Neither was any significant correlation seen between anxiety and depression scores vs. patients' age, monthly income and duration of psoriasis., Conclusion: This study demonstrates the strong psychiatric morbidity in patients with psoriasis, for which further psychiatric evaluation should be considered., (© 2016 European Academy of Dermatology and Venereology.)

Effective management of atopic dermatitis (AD) involves the treatment of a defective skin barrier. Patients with AD are therefore advised to use moisturizers regularly. To date, there are few comparative studies involving moisturizers in patients with AD, and no classification system exists to objectively determine which types of moisturizers are best suited to specific AD phenotypes. With this in mind, a group of experts from allergy and immunology, adult and pediatric dermatology, and pediatrics centers within Southeast Asia met to review current data and practice, and to develop recommendations regarding the use of moisturizers in patients with AD within the Asia-Pacific region. Chronicity and severity of AD, along with patient age, treatment compliance, and economic background should all be taken into account when selecting an appropriate moisturizer for AD patients. Other considerations include adjuvant properties of the product, cosmetic acceptability, and availability over the counter. Well-defined clinical phenotypes of AD could optimally benefit from specific moisturizers. It is hoped that future studies may identify such differences by means of filaggrin mutation subtypes, confocal microscopic evaluation, pH, transepidermal water loss or presence of allergy specific IgE. Recommendations to improve the regular use of moisturizers among AD patients include measures that focus on treatment compliance, patient and caregiver education, appropriate treatment goals, avoidance of sensitizing agents, and collaboration with other relevant specialists.

Few studies have evaluated Asian children with mycosis fungoides (MF). We report a series of patients from a tertiary dermatologic institution in Singapore. A retrospective review was performed of patients younger than 16 years old diagnosed with MF between 2000 and 2008 at the National Skin Centre, Singapore. Forty-six patients were identified. At initial presentation, a provisional diagnosis of MF was made in 19 patients (41.3%), pityriasis lichenoides chronica (PLC) in 11 (23.9%) and postinflammatory hypopigmentation due to eczema or other causes in 11 (23.9%). After skin biopsy, the hypopigmented variant of MF was diagnosed in 42 patients (91.3%). There was one case each of PLC-like MF, pigmented purpuric dermatosis-like MF, classic MF, and solitary MF. Pityriasis lichenoides coexisted in three cases (6.5%). All except one patient presented with the early patch-plaque stage of disease (stage IA/B). The disease did not progress in any of our patients after a mean follow-up of 71.0 ± 52.5 months. Twenty-seven patients (58.7%) had complete disease clearance after a mean duration of 27.1 ± 28.1 months; 15 (49.7%) of 32 patients who received narrowband ultraviolet B treatment had complete clearance within an average of 8.9 ± 5.3 months, but 7 patients relapsed within 14.9 ± 14.8 months. One patient with solitary MF failed multiple treatment modalities before eventually achieving disease clearance with photodynamic therapy. Hypopigmented MF is the most common MF variant in Asian children. The diagnostic difficulty is in differentiating this from PLC, which may coexist with MF. Long-term prognosis is generally favorable., (© 2014 Wiley Periodicals, Inc.)

Introduction: To evaluate the efficacy and safety of a pseudoceramide-containing moisturizer as maintenance therapy in patients with mild-to-moderate atopic dermatitis (AD)., Methods: This was a prospective, single-arm, open-label clinical trial of a twice-daily application of a pseudoceramide-containing moisturizer for 4 weeks as maintenance therapy in 40 patients with stable, mild-to-moderate AD in a tropical climate. Clinical and skin barrier assessment was done at week 0, week 2 and week 4. Any adverse effects were also recorded during the study period., Results: The objective scoring atopic dermatitis decreased from 29.1 [interquartile range (IQR) 21.9-33.7] at week 0 to 22.0 (IQR 21.2-27.8) at week 4 (p < 0.001). There was no detectable difference in transepidermal water loss after 4 weeks; however, stratum corneum (SC) hydration was significantly increased from 39.7 (IQR 35.3-46.4) at week 0 to 49.2 (IQR 41.2-54.6) after 4 weeks (p < 0.001). Both Dermatology Life Quality Index and patient-oriented eczema measure showed significant improvement at week 4 (p < 0.001). The moisturizer was well tolerated with no serious adverse events recorded., Conclusion: After 4 weeks of barrier maintenance therapy with a pseudoceramide moisturizer, there was a significant improvement in disease severity, SC hydration and quality of life in both pediatric and adult patients with mild-to-moderate AD.

Background: 'Atopic dirty neck' is a poorly understood acquired hyperpigmentation in patients with atopic dermatitis (AD)., Objective: To report a single-centre experience with synthesis of this entity's features., Methods: All patients with AD with dirty neck seen over a 5-month period at the National Skin Centre were invited to participate., Results: Out of 544 AD patients examined, 78 (14.3%) had acquired pigmentation of the neck. The majority had moderate-to-severe underlying eczema. Histopathology showed increased epidermal melanin and dermal melanophages, a thickened basement membrane and a dense superficial perivascular infiltrate., Conclusion: Acquired atopic hyperpigmentation has a high prevalence, particularly in adolescent Asian males. Clinico-pathological correlation suggests it results from both frictional melanosis and post-inflammatory hyperpigmentation. The rippled appearance and the onset in adolescence are probably due to accentuation of the juxta-clavicular beaded lines. Optimal control of eczema may improve and potentially prevent the development, which is of importance considering the psychosocial impact of the condition.

Trichothiodystrophy (TTD) is an autosomal recessive condition characterized by brittle and sparse sulfur deficient hair. The disorder is due to a known genetic mutation in DNA nucleotide excision repair (NER) in up to 83% of cases. We describe a 13-month-old girl presenting with hair fragility and hair loss since age 3 months, and discuss the overlap between TTD and other NER diseases. This case report highlights the importance of early diagnosis of occult learning disorder in young children with TTD and the need for early assessment and involvement of multidisciplinary team to target the child's educational needs.

Background: Loss-of-function (null) mutations within the filaggrin (FLG) gene are a strong risk factor for atopic dermatitis (AD). We hypothesized that the absence or reduction of the filaggrin protein could compromise skin barrier and increase patients' susceptibility to recurrent skin infection., Objectives: To investigate the association between FLG-null mutations and the risk of recurrent skin infection among a series of patients with AD in Singapore., Methods: This study included 228 Singaporean Chinese patients with AD with at least 1year of follow-up at the time of recruitment between January 2008 and December 2009 at the National Skin Centre in Singapore. Each patient had their medical records reviewed for history of skin infection in the preceding year and was genotyped for 22 FLG-null mutations., Results: Compared with those without the FLG-null mutations, patients with AD who had FLG mutation(s) had approximately a seven times increased risk of more than four episodes of skin infection requiring antibiotics in the past year (odds ratio 6·74; 95% confidence interval 2·29-19·79). This risk was much greater in those with mild or moderate disease, and was present in both users and nonusers of oral steroids., Conclusion: This study highlights a novel association between FLG-null mutations and an increased susceptibility to recurrent bacterial skin infection among patients with AD., (© 2011 The Authors. BJD © 2011 British Association of Dermatologists.)

Background: Null mutations in the filaggrin gene (FLG) cause ichthyosis vulgaris (IV) and predispose to atopic dermatitis (AD). Cohort studies in Europe and Japan have reported an FLG mutation carrier frequency of between 14% and 56%, but the prevalent European FLG mutations are rare or absent in Chinese patients with IV and AD., Objectives: To investigate further the spectrum of FLG-null mutations in Chinese patients and to compare it with that in other populations., Methods: We conducted comprehensive FLG genetic analysis in a discovery cohort of 92 Singaporean Chinese individuals with IV and/or moderate-to-severe AD. All detected FLG mutations were then screened in a cohort of 425 patients with AD and 440 normal controls. Results In total, 22 FLG-null mutations, of which 14 are novel, were identified in this study; the combined null FLG genotype of 17 mutations detected in cases and controls showed strong association with AD [Fisher's exact test; P = 5·3 × 10⁻⁹; odds ratio (OR) 3·3], palmar hyperlinearity (Fisher's exact test; P = 9·0 × 10⁻¹⁵; OR 5·8), keratosis pilaris (Fisher's exact test; P = 0·001; OR 4·7) and with increased severity of AD (permutation test; P = 0·0063)., Conclusions: This study emphasizes the wider genetic landscape of FLG-null mutations in Asia that is slowly emerging., (© 2011 Institute of Medical Biology, Agency of Science, Technology and Research. BJD © 2011 British Association of Dermatologists 2011.)

The skin is increasingly recognized as a component of the innate immune response, in addition to its role as a physical barrier. Although the deleterious effects of solar ultraviolet radiation (UVR), including immunosuppression and cutaneous tumorigenesis, are widely acknowledged, most studies to date have concentrated on adult skin. Despite the more sensitive nature of infant and toddler skin, little is known about its responses to UVR exposure, whether acute or long-term. Accumulating evidence suggests not only that the skin's barrier protection remains immature throughout at least the first 2 years of life but also that accumulation of UVR-induced changes in the skin may begin as early as the first summer of life. Such evidence not only affirms the importance of sun protection during the infant and toddler years but underscores the need for more research to establish evidence-based standards of care in this area. In this article we review recent studies in which differences between the skin properties of infants and young children and those of adults were compared, and we discuss the implications of these differences for sun-protection practices., (Copyright © 2011 by the American Academy of Pediatrics.)

Background: The first manifestations of psoriasis begin in childhood in more than one-third of patients. However, epidemiological data of juvenile psoriasis are lacking., Objectives: To compare Dutch (NL group) and Singaporean (SG group) children with psoriasis with the aim of studying the characteristics of juvenile psoriasis and to highlight similarities and differences between these different ethnic groups., Methods: Data were collected from 207 patients younger than 18 years diagnosed with psoriasis from Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands and the National Skin Centre, Singapore., Results: A striking difference in familial distribution was found, with more Dutch children having an affected family member (73·3% vs. 13·6%). Presence of itch and triggering factors were more common among Dutch children (80% vs. 14·2% and 33·3% vs. 7·4%, respectively). However, both groups shared similar triggering factors like stress and infections. Other similarities included mean age at presentation (NL group 11·3 years; SG group 14·1 years) and gender ratio (NL group, M/F 1 : 1·1; SG group, M/F 1 : 1·4). Plaque psoriasis was the most common type in both cohorts while guttate and pustular psoriasis were rare. In both groups, the head, followed by the limbs, was the most common site involved. Similar proportions of children in both countries had nail involvement and psoriatic arthritis was rare., Conclusions: The disparity in familial distribution may point to genetic differences between the two groups. Further studies to evaluate this difference in familial distribution may contribute to the understanding of the pathogenesis of psoriasis., (© 2011 The Authors. BJD © 2011 British Association of Dermatologists.)

Sensitization to house dust mites (HDM) is highly prevalent among the young atopic population in Singapore. Previously published data suggest that individuals with skin allergies show preferred sensitization to Dermatophagoides pteronyssinus while individuals with pure respiratory allergies show preferred sensitization to Blomia tropicalis. The aim of our study was to compare the sensitization profiles between children with asthma and those with eczema to D. pteronyssinus and B. tropicalis and their specific allergens. A total of 60 children, 30 with asthma and 30 with eczema were recruited. IgE levels specific for a panel of HDM allergens from the two mite species were measured using enzyme-linked immunosorbent assay. The asthma group showed highest sensitization to Blo t5 while the eczema group showed highest sensitization to Der p5. Comparison between the two disease groups showed that the eczema group had significantly higher IgE levels for Der p (p = 0.042) and its allergens Der p1 (p = 0.019) and Der p5 (p = 0.001). Generally, the eczema group was more sensitized to the panel of allergens compared to the asthma group. Individuals with asthma and those with eczema showed different sensitization profiles to HDM. These findings highlighted possible mechanisms for different manifestation of allergy.

This study examines maternal perceptions of paediatric atopic dermatitis (AD) on family and determines risk factors including severity of AD, maternal physical and mental health (MH), quality of life of patients and sociodemographics which predict a negative family impact. A cross-sectional assessment using the Dermatitis Family Impact Questionnaire Scale to assess the impact of AD on family, Infant's Dermatitis Quality of Life Index (<5-yrs old) or Children's Dermatitis Life Quality Index (5-17 yrs old) was used to measure health-related quality of life (HRQOL) of paediatric patients with AD. A 12-item Short-Form Health Survey (SF-12) was used to assess physical and MH of their mothers. Risk factors of adverse family impact were assessed using multiple regression analysis. One hundred and four patients with AD and their mothers were studied. Their mean ages (+/-s.d.) were respectively 6.4 +/- 4.3 and 37.2 +/- 6.6 yrs. In multiple regression analysis, Severity Scoring of Atopic Dermatitis (SCORAD) appeared to be associated with negative family impact and the association remained significant after adjustment for bio-psycho-social factors and HRQOL of patients. The association remained insignificant after adjustment for physical and MH of the mothers. Our results show that the severity of paediatric AD leads to negative family impact through reduction of physical and MH of the mothers, and is independent of patients' HRQOL and sociodemographics. The current approach for managing paediatric AD in Asian society could include early multidisciplinary intervention, aiming at enhancing physical and MH of mothers while minimizing negative impact on family and social isolation. Further research will be welcomed as the results of this study mainly applied to Asian society which could be different to populations from other geographic areas.

Fish allergy is common in countries where consumption is high. Asian nations are amongst the world's largest consumers of fish but the allergen profiles of tropical fish are unknown. This study sought to evaluate the allergenicity of four commonly consumed tropical fish, the threadfin (Polynemus indicus), Indian anchovy (Stolephorus indicus), pomfret (Pampus chinensis) and tengirri (Scomberomorus guttatus). Immunoglobulin E (IgE) cross-reactivity with parvalbumin of cod fish (Gad c 1), the major fish allergen, was also studied. Detection of tropical fish and cod specific-IgE was performed by UniCap assay, and skin prick tests were also carried out. The IgE-binding components of tropical fish were identified using IgE immunoblot techniques, and cross-reactivity with Gad c 1 was assessed by ELISA inhibition and IgE immunoblot inhibition. Clinically, nine of 10 patients studied were allergic to multiple fish. All patients exhibited detectable specific-IgE to cod fish (10 of 10 skin prick test positive, eight of 10 UniCap assay positive) despite lack of previous exposure. The major allergen of the four tropical fish was the 12-kDa parvalbumin. IgE cross-reactivity of these allergens to Gad c 1 was observed to be moderate to high in the tropical fish studied. Parvalbumins are the major allergens in commonly consumed tropical fish. They are cross-reactive with each other as well as with Gad c 1. Commercial tests for cod fish appear to be sufficient for the detection of tropical fish specific-IgE.

Filaggrin is an abundant protein of the outer epidermis that is essential for terminal differentiation of keratinocytes and formation of an effective barrier against water loss and pathogen/allergen/irritant invasion. Recent investigations in Europe and Japan have revealed null mutations in the filaggrin gene (FLG) as the underlying cause of ichthyosis vulgaris (IV), a common skin disorder characterised by dry skin, palmar hyperlinearity and keratosis pilaris. Following the development of a strategy for the comprehensive analysis of FLG, we have identified five unique mutations and one recurrent mutation in Singaporean Chinese IV patients. Mutation 441delA is located in the profilaggrin S100 domain, whereas two additional frameshift mutations, 1249insG and 7945delA, occur in the first partial filaggrin repeat ("repeat 0") and in filaggrin repeat 7, respectively. Both nonsense mutations Q2147X and E2422X are found in filaggrin repeat 6, whereas R4307X was found on one of the longer size variant alleles of FLG, within duplicated repeat 10.2. Mutation E2422X, previously found in a single Dutch patient, was found in one Singaporean IV patient and at a low frequency in Asian population controls. Our study confirms the presence of population-specific as well as recurrent FLG mutations in Singapore.

This study surveyed the prescription patterns of adrenaline auto-injectors (AAs) in Singapore to examine the frequency, triggers, and demographic pattern of anaphylaxis requiring such prescriptions. A 6-year retrospective review of 417 consecutive patients prescribed AAs in Singapore from January 1999 to December 2004, as identified from hospital pharmacy records. There were 417 patients identified, consisting of 295 (70.7%) Singaporeans with the remaining being non-Singaporean residents. Based on population census, the frequency of AA prescriptions was estimated at 1 per 10,000 Singaporeans. Demographic factors associated with AA prescriptions were male gender (OR = 1.361; p = 0.002); minority ethnic groups, which included Eurasians, Caucasians, Koreans, and Japanese (OR = 15.873; p < 0.001); and children <15 years of age (OR = 2.593; p < 0.001). The most common food allergens resulting in AA prescriptions were peanut (41.9%) and shellfish allergy (28.5%). Multiple logistic regression analysis showed that peanut allergy was independently associated with Eurasian ethnicity (OR = 5.045; p = 0.021); and shellfish allergy with Indian ethnicity (OR = 2.757; p = 0.034). The estimated frequency of AA prescriptions in Singapore is relatively low at 0.01%. The incidence of peanut and shellfish allergy in the Asian population appears to differ from that seen in Western populations.

Linear immunoglobulin A bullous disease is an autoimmune subepidermal blistering disease that has been described in both children and adults. Reports have shown that as many as two-thirds of occurrences may be drug-induced. The offending drugs include antibiotics, predominantly vancomycin, nonsteroidal anti-inflammatory agents and diuretics. We report childhood linear immunoglobulin A bullous dermatosis developing following amoxicillin-clavulanic acid administration. The patient presented with characteristic blisters in an annular fashion, likened to a ''crown of jewels.'' The diagnosis was confirmed by the presence of a linear band of immunoglobulin A at the dermoepidermal junction on direct immunofluorescence. The lesions resolved with withdrawal of the drug, and systemic therapy was not required. We review the current literature and concepts of drug-induced linear immunoglobulin A bullous disease.

Introduction: Non-melanoma skin cancer is one of the commonest cancers in Singapore and worldwide. The aim of our study was to evaluate the demographic and clinicopathological patterns of squamous cell carcinoma (SCC) and Bowen's disease (BD) of the skin, in order to better understand the characteristics of these tumours in our population., Materials and Methods: Histologically proven cases of SCC and BD seen at our centre between 2002 and 2003 were retrospectively analysed according to age, sex, race, predisposing factors such as immunosuppression and ultraviolet therapy, site and size of tumour, histological differentiation and subtype, and treatment method., Results: A total of 161 patients were studied--81 with SCC, 68 with BD, and 12 with both tumours. There were 199 tumours in total--105 SCC and 94 BD. For both SCC and BD, males outnumbered females (ratio of 2.4:1 and 1.5:1 respectively); patient age averaged 72.9 years and 66.8 years respectively; and Chinese were the majority race. The mean duration to presentation was 21.2 months for SCC compared with 39.9 months for BD, and common symptoms were itch, pain and bleeding for both. The mean tumour size was 19.0 mm and 18.5 mm, and the commonest site was the head and neck for both., Conclusions: SCC and BD show rather similar patient characteristics, with a predominance among males, having a predilection for the head and neck region, and with a tendency towards slow growth. As incidences increase worldwide, it is important for healthcare providers to be adept at recognising and managing nonmelanoma skin cancers.

Background: The lifetime risk of developing melanoma in Caucasian patients with large congenital melanocytic nevi (LCMN) is estimated to be between 4.5% and 10%. Cohort studies of LCMN and the risk of melanoma development in an Asian population are not available., Objective: We sought to determine the risk of melanoma development in a retrospective cohort of patients presenting with LCMN to a dermatology tertiary referral center in Singapore from January 1989 to December 2004., Methods: Patients with congenital melanocytic nevi (CMN) that covered at least 5% of the body surface area were included in the study. Data were obtained from electronic records and photographic documentation. A search for malignancy was done using the National Cancer Registry database., Results: In all, 39 patients (23 male and 16 female) met the study criteria of LCMN; 15 of 39 patients also met the criteria of having a giant CMN (ie, a CMN that is predicted to be at least 20-cm diameter in adulthood). There were 29 Chinese, 6 Malay, 1 Indian, and 3 Caucasian patients. Their ages ranged from 23 months to 60 years (mean 18.8 years). They presented at a mean age of 26 months and were followed up for an average of 16.9 years. The size of the LCMN ranged from 5% to 40% of body surface area, with a mean of 12.2%. The most common sites were the back (54%), lower limb (28%), and abdomen (26%). Satellite lesions were present in 22 patients. Magnetic resonance imaging of the head or thoracolumbar spine was performed in 7 patients with LCMN on the scalp/face or back, respectively; all produced normal findings. Only one patient was treated: he had carbon-dioxide laser ablation and Q-switched neodymium:yttrium-aluminum-garnet laser treatment of a small part of his LCMN. Skin biopsies were done in 5 patients who had developed nodules; histology showed no evidence of malignancy. No patients had developed any form of malignancy., Limitations: The addition of 3 adult patients born before the start of the cancer registry may have led to survivor bias. The small sample size did not allow a precise estimate of the risk of melanoma development in our study population., Conclusion: The risk of melanoma development in LCMN within a predominantly Southeast Asian cohort appears to be very low. Prophylactic complete excision of LCMN is ideal, but seldom achievable. Hence, patient education, regular melanoma surveillance, and biopsy of suspicious lesions are very important.

Introduction: Haemangiomas are common benign tumours of the vascular endothelium. They are extremely heterogenous clinically, with size, location and rate of proliferation having a significant effect on the risk of complications., Materials and Methods: The available evidence in the literature was evaluated using the grading system currently employed by the Ministry of Health, Singapore., Results: An uncomplicated haemangioma can be observed for spontaneous involution. However, some haemangiomas may be life- or function-threatening, or have associated structural anomalies. Corticosteroids may be used topically, intralesionally or systematically. Interferon alpha, vincristine and cyclophosphamide are therapeutic options for complicated haemangiomas which do not respond to corticosteroids. Vascular-specific pulse dye laser therapy may be considered for superficial haemangiomas, ulcerated haemangiomas or post-involution sequelae like telangiectasia. The mainstay of therapy for ulcerated haemangiomas is good local wound care, analgesics and treatment of secondary infection. A periorbital haemangioma that obstructs the visual axis or exerts pressure on the globe is an ocular emergency. Systemic corticosteroids and patching of the unaffected eye should be considered., Conclusions: Medical practitioners should be aware of available therapeutic options for life- or function-threatening haemangiomas. Treatment must be individualised and referral to the relevant specialist should be considered in patients with complicated haemangiomas.

Generalized lentigines associated with multiple noncutaneous features, as in the LEOPARD syndrome and the Carney complex, have been well reported in the literature. Reports of patients with generalized lentigines without systemic abnormalities (termed "generalized lentiginosis") are increasing as well. Despite the lack of systemic features, patients with generalized lentigines only should be monitored for further development of other noncutaneous features, especially cardiac anomalies. We present two patients with generalized lentiginosis and propose a working algorithm in the approach to a child with this finding.

Incontinentia pigmenti is a rare X-linked dominant disease that affects the ectodermal tissues and is usually lethal in males. Two girls, 1 Malay and 1 Chinese, with incontinentia pigmenti of the Bloch-Sulzberger type had a whorled pattern of scarring alopecia. This phenomenon, hitherto unreported in association with this disorder, corresponded to the lines of Blaschko. The mother and maternal grandmother of the Malay girl also had whorled scarring alopecia. This phenomenon is permanent and can be used as a marker to ascertain affected adult women who may no longer have cutaneous manifestations. X chromosome inactivation in females during early embryogenesis results in a mosaic population of cells, which explains the linear and patchy cutaneous manifestations of incontinentia pigmenti.

Harlequin ichthyosis is a rare and severe congenital erythrodermic ichthyosis characterized at birth by hyperkeratotic plates covering the entire body, ectropion, eclabium, poorly developed ears, and contractures of the hands and feet. Two Chinese children, a 2-year-old boy and an 11-year-old girl, presented with these classic features as well as alopecia and loss of eyebrows and eyelashes. The boy was small for his age and was found to have hypothyroidism at the age of 18 months; he is currently on thyroxine replacement therapy. At 6 years of age, the girl developed symmetrical polyarthritis associated with positive rheumatoid factor and radiologic evidence of erosive arthritis, suggestive of juvenile rheumatoid arthritis. She received prednisolone, nonsteroidal anti-inflammatory drugs (NSAIDs), and subsequently methotrexate for her arthritis, with clinical and radiologic improvement. Early therapy with oral retinoids in both children accelerated shedding of the hyperkeratotic plates as well as improved ectropion and eclabium. There was no major adverse reaction to oral retinoids. The development of juvenile rheumatoid arthritis in survivors with harlequin ichthyosis has not been previously described. The use of prednisolone and NSAIDs in the girl did not affect the skin condition, but the addition of methotrexate led to a decrease in erythema. The association with autoimmune disease is probably coincidental. The psychosocial impact of this severe lifelong disease on the two families was enormous. Early retinoid therapy may improve the disorder and help increase survival rates. A multidisciplinary approach, including psychosocial support of the affected families, is vital in the management of this lifelong disease.

Folliculitis decalvans is a rare condition affecting mainly the scalp leading to scarring alopecia. Aetiology of the condition is still unknown, abnormal host response to Staphylococcus aureus has been postulated. We present a retrospective analysis of six cases of folliculitis decalvans presented to National Skin Centre (NSC), Singapore for the past five years, 1995-2000. The mean age of presentation was 39 years and ages ranged from 17 to 62 years. There were five male patients and one female patient. Duration of symptoms at presentation varied from six months to seven years. Occipital and vertex areas of the scalp were the only regions involved. Staphylococcus aureus was isolated in three patients; in one patient culture yielded negative results and no culture was done in the other two patients. All our patients were treated with several separate courses of systemic antibiotics which include doxycycline, erythromycin, minocycline, co-trimoxazole, cloxacillin, erythromycin, rifampicin and clindamycin. In addition one patient was treated with fucidic acid and zinc sulphate. The disease ran a protracted course with temporary improvement while on antibiotic and flare up of disease when antibiotics were stopped. The effectiveness of early treatment with rifampicin has been highlighted in some case reports in the past. We did use rifampicin in one of our patients. Our concern over emergence of antibiotic resistance, if used widely, may not permit us to use rifampicin on a wide scale.

Alopecia areata (AA) is a common cause of nonscarring alopecia. The aim of this epidemiologic study is to review the clinical characteristics and treatment of childhood alopecia areata in a mixed ethnic population. The study population consisted of a total of 392 children seen over a 4-year period with AA diagnosed before the age of 16 years. The female:male ratio was 1:1.4. There were 309 Chinese (78.8%), 51 Malays (13.0%), and 32 Indians (8.2%). The mean age at the time of diagnosis was 11.2 years. The majority of patients (71.7%) had alopecia of less than 6-months duration and 6% had previous episodes of AA. Females appeared to have more severe involvement. A familial history of AA was observed in 33 patients (8.4%). Associated atopy was found in 26.6% of patients and in 32.3% of their first-degree relatives. Other associations such as vitiligo or Down syndrome were rare. For limited AA, topical and/or intralesional corticosteroid was the first-line treatment used and squaric acid dibutyl ester was the choice of treatment for patients with extensive involvement. The profile of the poor respondents to therapy included young age of onset, past history of AA, Down syndrome, and extensive involvement.

Marie Unna hypotrichosis is a rare, autosomal dominant hypotrichosis characterized by sparse or absent hair at birth with regrowth of coarse, wiry hair from childhood, followed by progressive loss on approaching puberty. We report a Chinese mother and child seen at our skin center with features of Marie Unna hypotrichosis. The family pedigree showed two affected sisters and one affected brother, consistent with an autosomal dominant mode of inheritance. The clinical, genetic, histologic, and ultrastructural features were consistent with the diagnosis of Marie Unna hypotrichosis. This is the first Chinese family reported.

Temporal triangular alopecia (TTA) is a nonscarring alopecia first described in 1905. We report five cases of TTA in Asian children and review the literature.

Background: Atopic dermatitis is a common disease that appears to be increasing in frequency during recent decades. Most of the studies are based on the Western population, and there are few data in the Asian population., Objectives: To determine the prevalence and descriptive epidemiology of atopic dermatitis among school children in the general community in Singapore., Methods: This is a questionnaire study of 12 323 students done over a 1-year period, comprising 7 year olds (4605), 12 year olds (3940) and 16 year olds (3778) from 19 primary and 17 secondary schools randomly selected in Singapore. All children had a complete cutaneous examination. The diagnosis of atopic dermatitis was based on the U.K. Working Party diagnostic criteria. The questionnaire was translated into Chinese and both the English and Chinese versions were issued simultaneously to the students., Results: The 1-year period prevalence of atopic dermatitis was 20.8%. Atopic dermatitis was present in 22.7% of 7 year olds, 17.9% of 12 year olds and 21.5% of 16 year olds. The overall sex ratio was equal. There were slightly more boys with atopic dermatitis among the younger children (6 and 12 year olds, 1.18 : 1 and 1.19 : 1, respectively) but more girls were affected (1.57 : 1) among the 16 year olds. Atopic dermatitis was more common among the Chinese (21.6%) and Malays (19.8%) compared with the Indians (16%) and other races (14%). The onset of the disease occurred before the age of 10 years in 49.5% of the 16 year olds. "Pure" atopic dermatitis without concomitant respiratory allergies was noted in 788 respondents (30.7%); 1775 (69.3%) suffered from a "mixed" type, with 34.3% having allergic rhinitis, 9.5% having asthma and 25.5% having both asthma and allergic rhinitis. More boys had atopic dermatitis and concomitant respiratory allergies whereas more girls were affected with "pure" atopic dermatitis alone (1.4 : 1). At least one first-degree family member with atopy was noted in 1435 children (56%): atopic dermatitis (70%), asthma (62%) and allergic rhinitis (68%). Among siblings with one parent with atopic dermatitis, 37% had either a father or a mother with atopic dermatitis. Common aggravating factors reported included exercise, heat and sweating, grass intolerance, thick clothing and stress. Pityriasis alba was noted in 25% of the study population, keratosis pilaris in 13% and ichthyosis vulgaris in 8%. Most respondents had mild to moderate atopic dermatitis that could be controlled with a fairly simple regimen of moisturizers, topical steroids, antihistamines and antibiotics., Conclusions: The high prevalence of atopic dermatitis in Singapore is similar to that observed in developed countries, suggesting that environmental factors may be important in determining the expression of the disease.

Introduction: Incontinentia pigmenti is a rare X-linked dominant disease which affects the ectodermal tissues, usually lethal in males., Materials and Methods: A retrospective analysis of clinical data obtained from the photographic documentation and casenotes of patients diagnosed to have incontinentia pigmenti at the National Skin Centre. The study covered the period from January 1990 to December 1999., Results: Twenty-six patients were diagnosed to have incontinentia pigmenti of the Bloch-Sulzberger type; 23 (88.5%) were females and 3 (11.5%) were males. There were 20 Chinese, 3 Malay and 3 Indian patients. Most patients had cutaneous manifestations at birth or within the first week of life. Cutaneous features included vesicles, papules, verrucous plaques and splash-like hyperpigmentation along the lines of Blaschko. The cutaneous lesions were widespread in 21 (81%) and localised in 5 (19%) patients. In some cases, hypopigmented atrophic streaks (2 patients) or whorled scarring alopecia (4 patients) were seen. Extracutaneous manifestations, seen in 5 (19%) patients, included neurological, dental and ocular defects. One Malay girl had severe neurological involvement associated with ocular abnormalities. A positive family history was present in 6 (23%) patients. The 3 male patients were Chinese without any family history., Conclusions: Each stage of the disease comes with its own set of differential diagnosis, including infections e.g. herpes virus infection and other types of genodermatoses e.g. linear and whorled nevoid hypermelanosis. The phenomenon of whorled scarring alopecia, hitherto unreported in the literature, corresponded to the lines of Blaschko. In the 3 Chinese male patients, the disorder probably originated from a new mutation. X chromosome inactivation in females during early embryogenesis results in a mosaic population of cells and this explains the linear and patchy manifestations of incontinentia pigmenti.

Introduction: A retrospective study of melanocytic naevi was undertaken to assess the degree of clinico-pathological correlation and incidence of histological atypia., Materials and Methods: The case records from January to March 1996 of all patients with histologically diagnosed melanocytic naevi at the National Skin Centre were analysed., Results: Of the 240 lesions removed from 167 patients, the majority being women (111/167 patients), it was found that 55% (132/240) were correctly diagnosed. Fourteen per cent were mistaken for non-melanocytic lesions, namely skin tag, neurofibroma, syringoma cylindroma, epidermal naevus, naevus sebaceous and basal cell carcinoma. Most of the lesions were located on the cheeks and eyelids. Junctional naevi, followed by compound naevi were often missed. Histological dysplasia were seen in 7 naevi; 6 compound and 1 congenital naevi. There was a lack of clinico-pathological concordance in dysplastic naevi., Conclusions: The clinico-pathological concordance of melanocytic naevi was high, with low incidence of atypia on histology.

We report pseudopili annulati for the first time in a dark-haired Chinese girl. The hair was elliptical in shape and twisted along its long axis. The banded or ringed appearance was due to incident light being reflected by the flattened segments. Banding was also noted under polarized light but was not present under transmitted light. Under transmitted light the whole length of the hair appeared dark and the thickness varied at regular intervals, giving rise to fusiform segments due to the twisted nature of the hair shaft. Scanning and transmission electron microscopic examinations revealed no abnormalities in the cuticle and cortex.