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Dermatology for the pediatric skin of color population is the application of dermatology to the genetically diverse and distinctive segment of the pediatric population that includes children of non-White racial and ethnic groups with increased pigmentation including individuals of Asian, LatinX, African, Native American, Pacific Island descent, Indigenous Peoples, among others, with overlap in particular individuals, and mixtures thereof. Treating children of color is a unique skill set within the field of pediatric dermatology, requiring knowledge and sensitivity. The discipline of pediatric skin of color can be challenging. Difficulty in diagnosis of common conditions stems from underlying pigmentation, variations in common hairstyling practices, and differences in demographics of cutaneous disease, whereas some conditions are more common in children of color, other conditions have nuances in clinical appearance and/or therapeutics with regard to skin color. This article is the first in a series of two articles looking at recently published skin-related issues of high concern in children of color. Conditions reviewed in Part 1 include (1) hairstyling hair-related concerns (traction alopecia, central centrifugal cicatricial alopecia, endocrine disruption), (2) autoimmune concerns (cutaneous lupus, vitiligo), and (3) infections (tinea capitis, progressive macular hypomelanosis).

Introduction There is some evidence to suggest that the prevalence of atopic dermatitis (AD) in Asia is rising. We have therefore developed an algorithm for the topical treatment of AD throughout South and East Asia for use by primary care physicians, pediatricians and dermatologists. Methods Nine AD experts from South and East Asia and one from Europe developed the algorithm based upon treatment guidelines, relevant literature and local treatment practices. The algorithm outlines current best practice for the use of emollients, topical corticosteroids (TCS) and topical calcineurin inhibitors (TCI), with the intention of simplifying the treatment regimen of mild-to-moderate AD in South and East Asia. Results Patients with AD should bathe and cleanse affected skin to remove crusts and scales daily. Emollients should also be applied daily as a maintenance treatment. When selecting appropriate topical anti-inflammatory treatment for AD flares, several factors should be taken into consideration, including the patient’s age, attitude to treatment options and site of AD lesions. Given the concerns regarding the risk of skin atrophy with use of TCS, a TCI should be used to treat AD lesions in sensitive skin areas: pimecrolimus is recommended for mild-to-moderate AD in these locations, while tacrolimus should be considered for moderate and severe cases. Either pimecrolimus or tacrolimus is recommended for flares in other, non-sensitive body locations. A proactive or intermittent maintenance treatment strategy involving regular emollient use and twice-weekly application of a TCI to previously affected areas is encouraged to reduce the risk of flares. Conclusions The algorithm proposed here is intended to simplify the topical treatment of mild-to-moderate AD in daily practice in South and East Asian countries.

Dermatology for pediatric skin of color is the application of dermatology to the genetically diverse and distinctive segment of the pediatric population that includes children of non-White racial and ethnic groups with increased pigmentation including individuals of Asian, Hispanic/LatinX, African, Native American, Pacific Island descent, indigenous people among others with overlap in particular individuals, and mixtures thereof. The discipline of pediatric skin of color can be challenging with difficulty in diagnosis of common conditions due to underlying pigmentation, variations in common hair styling practices, and differences in demographics of cutaneous disease. Whereas some conditions are more common in children of color, other conditions have nuances in clinical appearance and therapeutics with regard to skin color. This article, the second of the series, focuses on inflammatory skin disease nuances, melanocytic disorders, and hypopigmented mycosis fungoides.

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.

Atopic dermatitis (AD) is a common, chronic inflammatory skin condition affecting up to 20% of children and 3% of adults worldwide. There is wide variation in the prevalence of AD among different countries. Although the frequency of AD is increasing in developing countries, it seems to have stabilized in developed countries, affecting approximately 1 in 5 schoolchildren. Adult-onset AD is not uncommon and is significantly higher, affecting between 11% and 13% of adults in some countries, for example, Singapore, Malaysia, and Sweden. AD is thus associated with significant health care economic burden in all age groups.

The Health Sciences Authority launched a pharmacogenetics initiative in 2008 to facilitate evaluation of pharmacogenetics associations pertinent for Chinese, Malays and Indians in Singapore. The aim was to reduce the incidence and unpredictability of serious adverse drug reactions, with a focus on serious skin adverse drug reactions. This paper describes the gathering of evidence and weighing of factors that led to different genotyping recommendations for HLA-B*15:02 with carbamazepine and HLA-B*58:01 with allopurinol, despite both having strong genetic associations. Translation of pharmacogenomics at a national level requires careful deliberation of the prevalence of at-risk allele, strength of genetic associations, positive predictive value, cost–effectiveness and availability of alternative therapies. Our experience provides a perspective on translating genomic discoveries in advancing drug safety.

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.

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.

Introduction: Atopic dermatitis is a common, chronic pruritic condition affecting both children and adults, which has a negative impact on the quality of life. These guidelines were developed by an expert workgroup appointed by the Dermatological Society of Singapore, to provide doctors with information to assist in the management of their patients with atopic dermatitis. The workgroup members are experienced dermatologists with interest and expertise in eczemas. Materials and Methods: Workgroup members arrived at a consensus on the topics to be included. Relevant studies from the literature were assessed for best evidence, supplemented by the collective experience of the workgroup. Results: For mild atopic dermatitis, emollients, mild potency topical steroids and topical calcineurin inhibitors are recommended. For moderate-to-severe atopic dermatitis, the use of emollients, moderate-to-potent topical steroids, topical calcineurin inhibitors, wet dressings, antimicrobials for secondary skin infection, phototherapy, and systemic therapy (e.g. prednisolone, cyclosporine, azathioprine or methotrexate) may be warranted. Patients with moderate-to-severe atopic dermatitis should be managed in conjunction with a dermatologist. Conclusion: Good outcomes can be achieved with an individualised therapeutic approach combined with adequate patient and parental education. Key words: Antimicrobials, Calcineurin inhibitors, Corticosteroids, Eczema, Moisturisers

Background Henoch-Schonlein purpura (HSP) is less common in adults and has been linked with a more severe clinical syndrome as well as a higher frequency of renal disease and internal malignancy. Renal involvement in adult HSP has been significantly associated with antecedent infections, pyrexia at time of first presentation, and purpura above the waist. We aim to evaluate the frequency of cutaneous and extra-cutaneous features and identify the predictive factors for renal involvement in Asian adults with HSP. Methods We performed a retrospective study of 48 adult Asian patients diagnosed with HSP based on the European League Against Rheumatism (EULAR) criteria at a tertiary hospital in Singapore between January 2000 and December 2011. Results The most common cutaneous manifestations were palpable purpura (73%), papules (31%), and petechiae (27%). Forty-percent had cutaneous lesions extending above the waist. Fifteen patients (31%) had gastrointestinal symptoms, 21 (44%) had joint involvement, and 27 (56%) had renal disease. Seventy-percent of patients with pyrexia at presentation experienced renal disease, whereas only 30% without pyrexia had renal involvement (P = 0.018). Sixty-six percent of patients with purpura had renal involvement as compared to 31% in those without purpura (P = 0.049). The frequency of renal involvement in patients with purpura above the waist (52%) was similar to those with purpura below the waist (55%). Conclusions Our study confirms that HSP in adults tends to be more severe with a high incidence of extracutaneous manifestations, especially renal disease. Pyrexia at presentation and the presence of purpura were significant predictive factors for renal involvement.

Atopic dermatitis (AD) is a common, chronic inflammatory skin condition affecting up to 20% of children and 3% of adults worldwide. There is wide variation in the prevalence of AD among different countries. Although the frequency of AD is increasing in developing countries, it seems to have stabilized in developed countries, affecting approximately 1 in 5 schoolchildren. Adult-onset AD is not uncommon and is significantly higher, affecting between 11% and 13% of adults in some countries, for example, Singapore, Malaysia, and Sweden. AD is thus associated with significant health care economic burden in all age groups.

This report compares the efficacy of timolol maleate 0.5% eyedrops (TM) with that of timolol maleate 0.5% ophthalmic gel-forming solution in the treatment of infantile hemangiomas (IHs). Sixty-six patients undergoing treatment with topical timolol were retrospectively reviewed; our results revealed similar therapeutic efficacies for both types of timolol formulations. Early treatment initiation (

Generalized pustular psoriasis (GPP) is a rare but serious inflammatory skin disease that may be caused by deficiency of interleukin-36 receptor antagonist in which there is presence of homozygous or compound heterozygous mutations of the IL-36RN gene. Most GPP cases are sporadic, although some may be autosomal recessive.1 A significant proportion of GPP without psoriasis vulgaris (PV) had homozygous or compound heterozygous mutations in IL-36RN. GPP alone is a distinct subtype and is etiologically distinguished from GPP with PV. Most GPP alone is caused by deficiency of the IL-36RN caused by IL-36RN mutations, in contrast to GPP associated with PV, in which this mutation is usually absent.2

Background There are few studies comparing pityriasis lichenoides (PL) in adults and children, with fewer involving Asians. We compared the clinical profile and treatment outcomes of 10 adults and five children diagnosed with PL. Methods We retrospectively reviewed a series of patients diagnosed with PL at our hospital from 2002 to 2008. Results We identified 10 adults and five children (nine adults and four children with pityriasis lichenoides chronica; one adult and one child with pityriasis lichenoides et varioliformis acuta). Mean age of onset of disease was 42.2 years in adults and 12.2 years in children. Median duration of disease before presentation was 5.5 months in adults and 6 months in children. Trunk and limbs were the most common sites of involvement. Itch was present in the majority. Almost all patients did not respond to topical corticosteroids. A good response was seen in three adults and two children treated with oral antibiotics. Three adults and two children responded to treatment with narrow-band ultraviolet B phototherapy. The median time to resolution was 8 months in adults and 21 months in children. Postinflammatory dyspigmentation was seen in six adults and four children. Conclusion PL presents similarly in adults and children; however, it runs a longer course in children. In our series, postinflammatory hyperpigmentation was common, which may be explained by our patients’ darker skin phototypes. We routinely prescribe oral antibiotics initially in patients without contraindications. Phototherapy may be useful in patients not responding to antibiotics.

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 Neisseria 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 high-dose 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 intra-venous immunoglobulin were useful in TEN and SJS/TEN overlap syndrome.

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.

Background Previous reports regarding the characteristics of patients with drug-induced hypersensitivity syndrome (DIHS) are mostly limited to small case reports and drug-specific case series, mainly involving Caucasian patients. Objective We describe the trends in the clinical presentation and laboratory findings of our patients with DIHS and their response to therapy. Methods This is a retrospective case series. Clinical records of patients treated in the Department of Dermatology, Changi General Hospital, Singapore, with a diagnosis of DIHS from January 2003 to January 2008 were retrieved and analyzed. Results In all, 27 patients were analyzed. The 3 most consistent features in our patients were 1) history of drug exposure (100%); 2) a morbilliform cutaneous eruption in 81.5% of the patients; and 3) systemic involvement with hepatitis (96.3%), hematologic abnormalities (81.5%), and fever (77.8%) being most common. Superficial perivascular dermatitis was the most common skin biopsy specimen findings, with tissue eosinophilia occurring in half the biopsy specimens. Severe complications included renal failure requiring dialysis in two patients and hyperthyroidism and myocarditis occurring in one patient. Limitations This is a retrospective study with a small number of patients during a 5-year period. We did not routinely document the presence of lymphadenopathy and hepatosplenomegaly in our patient's records. We do not measure viral serologies routinely as part of the workup for DIHS. Conclusion DIHS is not uncommon. The presentation in an Asian population is similar to published studies. Treatment includes discontinuation of the offending drug, monitoring for organ involvement, and using systemic steroids.

Ablative carbon dioxide resurfacing is the gold standard for treating atrophic acne scarring but is associated with prolonged recovery and many side effects. To address these limitations, newer modalities employing the principle of fractional photothermolysis have emerged.We undertook a prospective study whereby five Asian patients of skin phototype IV with moderate to severe atrophic acne scarring received two sessions of a fractional carbon dioxide laser 6-8 weeks apart. Treatment parameters were: fluence, 28 J/cm(2); pulse width, 2.5 ms; spot size, 300 microm; penetration depth, up to 500 microm; degree of skin coverage, 20%; single pass. Photographic evaluation was done on the level of improvement according to a quartile grading scale:or=25% (mild), 26-50% (moderate), 51-75% (marked),75% (excellent).At 2 months post-treatment, all five subjects showed some clinical improvement (four: mild improvement; one: moderate improvement). The treatment was well tolerated. All patients had erythema, which lasted for a mean of 6 days. No other complications were observed.Our study has shown that in Asians the fractional ablative carbon dioxide laser produces mild to moderate improvement in acne scarring with the advantage of a quick recovery period with minimal adverse effects.

Background Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but severe drug reactions. There have been few reviews of SJS and TEN in children. Objectives To evaluate the clinical profile and treatment outcomes of 15 pediatric patients with SJS or TEN. Methods We retrospectively reviewed the case notes of all patients diagnosed with SJS or TEN admitted to a tertiary care pediatric hospital from 2001 to 2006. Results We identified 13 cases of SJS, 1 case of SJS/TEN overlap and 1 case of TEN. Four patients were treated with intravenous immunoglobulin (IVIg), 5 patients were treated with systemic corticosteroids, and 6 patients were treated with supportive therapy only. The time to cessation of progression of disease was not significantly different in these 3 groups of patients. The duration of hospital stay was longer for patients treated with IVIG compared with those treated with systemic corticosteroids or supportive therapy. The only death was the patient with TEN treated with IVIG. Limitations This was a retrospective study with a very small number of patients. Conclusion The use of intravenous immunoglobulins or systemic corticosteroids did not improve the outcome of SJS and TEN.

Radiofrequency devices generate electromagnetic energy to induce dermal heating to a critical temperature of about 65 degrees C, causing collagen to shrink and contract, and this provides a non-ablative means to improve rhytides and lax skin.To evaluate the efficacy and safety of a novel radiofrequency device (Photo Bio Care, Thailand) operating at a frequency of 1.75 MHz for the treatment of rhytides and lax skin in Asian patients.Six female patients (age range, 30-60 years; mean age 48 years) with class I and II facial rhytides and Fitzpatrick skin types III and IV were treated six times at intervals of 2-3 weeks. The forehead, periorbital area, cheeks and nasolabial folds were treated using the following parameters: monopolar mode, pulse duration of 5 s, frequency of 18 Hz, and power of 100 W. No preoperative anesthesia or postoperative treatment were used. The handpiece was applied to the skin in a continuous sweeping motion until the baseline skin temperature was elevated to 40 degrees C, as monitored with a laser thermometer, and this was maintained for 3 minutes. Clinical photographs were taken before, after the sixth treatment and 2 months after the last treatment. Analysis was undertaken through photographic evaluation by non-treating physicians.At 2 months after the last treatment, mild to moderate (25-50%) clinical improvement was noted in all patients compared to baseline, and all patients were somewhat satisfied with the treatment. The procedure was well tolerated with no unexpected side effects. Discomfort was rated as mild and post-treatment erythema resolved within 1-2 hours.Treatment with the radiofrequency device can result in mild to moderate clinical improvement of age-related rhytides and lax skin. The system is safe and inexpensive with no consumables required.

Background Atrophic scars are dermal depressions caused by collagen damage most commonly occurring after inflammatory acne vulgaris. There are little published data regarding the effectiveness and safety of minimally invasive lasers in the treatment of atrophic acne scars in darker skin types. Objective The purpose was to evaluate the efficacy and safety of a low-fluence 2,940-nm erbium:YAG laser in the treatment of atrophic acne scars in Asian patients. Materials and methods Nine patients aged 19 to 45 years with mild to moderate atrophic facial scars and Skin Types IV and V were treated with topical anesthesia and one to two passes with an erbium:YAG laser two times at 1-month intervals. Treatment parameters were 6-mm spot size, fluence of 400 mJ, pulse duration of 300 micros, and repetition rate of 2 Hz. Results At 2 months after the last treatment, mild to moderate clinical improvement was noted in all patients compared to baseline. Treatment was well tolerated. Side effects consisted of posttreatment erythema, peeling, and crusting, which resolved within 1 to 2 weeks. There was no postinflammatory hyper- or hypopigmentation, blistering, or hypertrophic scarring. Conclusion Low-fluence erbium:YAG facial resurfacing was effective and safe in patients with mild to moderately severe atrophic acne scarring.

Background Topical photodynamic therapy (PDT) is based on the principle of targeted tissue destruction using selective photosensitization via a topical porphyrin precursor, followed by light exposure. It is well established for the treatment of actinic keratoses and superficial nonmelanoma skin cancers. Some studies have reported good efficacy when using PDT to treat viral warts in the Western population. Methods We carried out a prospective, single-arm, phase II study of 5-aminolevulinic acid (5-ALA)-PDT in the treatment of recalcitrant viral warts in an Asian population. Recalcitrant viral warts were surgically pared, and then treated with 20% 5-ALA cream (Medac, Hamburg, Germany) under occlusion for 4 hours before irradiation with a red light source (Waldmann PDT1200; wavelength, 590–700 nm) at an irradiance of 50 mW/cm2 and a total dose of 50 J/cm2. PDT was repeated fortnightly for a maximum of four times. Results Twelve adult Asian patients were enrolled into the study (10 males, two females). The mean age of the patients was 32.8 years (range, 18–70 years). They had skin phototypes III–IV. Nine patients had plantar warts and three patients had hand warts (two had warts on the fingers, one had a wart on the palm). Five patients (42%) showed complete disappearance of their warts, one patient (8%) showed partial clearance (greater than 50% decrease in the wart area), five patients (42%) had stable disease (less than 50% decrease in the wart area), and one (8%) showed progressive disease (increase in the wart area). Adverse effects included mild to moderate pain and erythema, which lasted no longer than 48 hours and was well tolerated by all patients. None of the patients withdrew from the study because of side-effects. Conclusion 5-ALA-PDT, given its noninvasiveness, minimal adverse effects, and good cosmetic results, is a promising alternative treatment for recalcitrant viral warts. Further studies with a larger cohort of patients would be of value.

The early inflammatory lesions of morphea may present with erythema or violaceous patches and plaques before evolving into areas of sclerosis. They have been misdiagnosed as acquired port-wine stains (PWSs). We report a previously well 7-year-old Chinese girl presenting with early facial morphea mimicking an acquired PWS with unusual histologic features of perineural inflammation. The presence of cutaneous perineural inflammation may be seen in a small percentage of cases of morphea and appears to be a feature of early inflammatory morphea. We report this case to highlight the importance in recognizing this entity and summarize the reported cases of inflammatory morphea mimicking acquired PWSs.