Introduction: Smoking is a risk factor for development of psoriasis. The severity of psoriasis has also been associated with smoking. Smoking may be an important modifiable factor in psoriasis treatment. Reduction or cessation of smoking in psoriasis patients is relevant as psoriasis is also associated with cardiovascular disease. Objectives: This study aims to determine the association between smoking and severity of psoriasis, and to investigate the frequency of concomitant cardiovascular risk factors in our psoriasis patients. Method: A 6-month prospective, controlled study. Consecutive patients with chronic plaque psoriasis attending Dermatology Clinic, Kuala Lumpur Hospital were screened. Smokers were identified, age, gender and ethnic matched non-smokers were recruited. Patients were evaluated for Psoriasis Severity Index (PASI) and body surface area (BSA) affected by psoriasis. Results: A total of 89 chronic plaque psoriasis patients were screened. Twenty four smokers and 24 matched non-smokers were included in the study. There were no significant differences in the presence of medical co-morbidities, blood pressure, body mass index (BMI), age of psoriasis onset and duration of disease in both groups. The mean age patients started smoking was 20.2±5.6 years, the mean duration of smoking was 16.3±11.1 years, the number of cigarette per day 11.9±6.1 sticks and the number of cigarette pack years was 10.7±9.2. BSA affected by psoriasis and PASI score were significantly higher in the subjects who smoked compared to the non smokers. Conclusion: Smoking is associated with more severe psoriasis in terms of BSA and PASI. Cardiovascular risk factors are common in psoriasis patients. These patients (smokers and non-smokers) require interventions to reduce their cardiovascular risks.

Introduction: Photodermatitis had become more common reason for referral to dermatology clinics. In Southeast Asia, research regarding idiopathic photodermatitis is not well established. Photo and photo-patch tests are commonly used diagnostic investigations to support this diagnosis. Objective: To describe the epidemiological and clinical features of idiopathic photodermatitis referred for photo and photo-patch tests. Methods: This retrospective study reviewed the clinical data of patients with idiopathic photodermatitis who were referred for photo and photo-patch tests from January 2009 to July 2011. Patients’ demographics, spectrum of clinical presentations, results of photo and photo-patch tests and clinical outcome were reviewed. Results: 38 patients were included in the analysis. Majority of patients were males. The mean age was 47.2 years. 55.3% were Malays, 26.3% Chinese and 18.4% Indians. Most patients have Fitzpatrick’s skin type IV. The commonest clinical presentations were polymorphic eruptions consisted of erythematous patches, papules and eczema at the sun-exposed areas. On average, the patients have had the cutaneous eruption for more than 1 year prior to the initial clinic visit. 32 patients had photo test and 6 had photo and photo-patch tests. 56.3% had positive photo test and the lowest MED is 50mJ/cm2 in skin type IV. 20% had positive photo and photo-patch tests. Patients were treated with potent topical corticosteroid, physical sunblock and oral antihistamines which managed to control the disease severity. Conclusion: Most patients with idiopathic photodermatitis referred for photo test were middle-aged Malay males with skin type IV. The commonest cutaneous presentations were polymorphic eruptions at the sun exposed sites.

Background: The association between chronic hepatitis C infection with lichen planus (LP) remains controversial. Geographical and immunogenetic factors may play a role in this association. Objectives: We sought to compare the prevalence of hepatitis C in patients with LP with healthy blood donors at our centre. Materials & Methods: We conducted a retrospective study in Hospital Kuala Lumpur, Malaysia. All patients with biopsy- proven LP who had undergone hepatitis C serology screening from January 2007 to June 2012 were recruited. The prevalence of Hepatitis C seropositivity among healthy blood donors in Malaysia was used as comparison. Results: Thirty five patients with LP were included in the study. Majority of the patients were Indians (71.4%) followed by Malays (14.3%), Chinese (8.6%) and other ethnicity (5.7%). 82.6% of patients had classical cutaneous LP out of which 17% had oral involvement. Anti-HCV was reactive in 2.9% patients. Among the healthy blood donors, anti-HCV was positive in 1.5% of patients. There was no significant difference between the prevalence of hepatitis C seropositivity between the two groups (p=0.431). Conclusion: There is no significant association between chronic hepatitis C infection and LP among our patients. We recommend screening for hepatitis C in LP patients should be limited to those with risk factors.

Introduction: Stevens Johnson syndrome (SJS), Stevens Johnson Syndrome - toxic epidermal necrolysis overlap syndrome (SJS-TEN overlap), toxic epidermal necrolysis (TEN) and drug-induced hypersensitivity syndrome (DHS) are well known severe adverse cutaneous drug reactions (SACDRs). All clinicians are responsible for the diagnosis and management of SACDR. Objective: To retrospectively review the clinical patterns, management strategies and outcome of 134 patients with severe adverse cutaneous drug reactions managed at the Department of Dermatology, Kuala Lumpur Hospital between 2006 and 2010. Results: The mean age of presentation was 44.8 years (13-83). The male: female ratio was 1:1. There were 68 cases (50.7%) of SJS, 10 cases (7.5%) SJS-TEN overlap, 32 cases (23.9%) TEN and 24 cases (17.9%) DHS. The five commonest drugs associated with SACDRs were allopurinol (26.9%), carbamazepine (13.4%), phenytoin (9.7%), non-steroidal anti-inflammatory drugs (11.2%) and co-trimoxazole (7.5%). The mean duration of drug exposure before the onset of reaction was 2.8 weeks. A hundred and thirty patients (97%) were managed as in-patient. The mean duration of in-patient stay was 12.4 days. All identified culprit drugs were withheld. Systemic corticosteroids was given to 96% cases of DHS with mean duration of 9.7 weeks; 52.9% of SJS with mean duration of 2.8 weeks; 60% of SJS-TEN overlap with mean duration of 2.3 weeks; and 62.5% of TEN with mean duration of 3.3 weeks. Thirteen patients (42%) with TEN were treated with intravenous immunoglobulin. Eight patients (6%) died, of which 7 were TEN and one DHS. Conclusion: SACDRs are life-threatening emergencies which not only results in significant morbidity and mortality; but also potentially increases the health care cost and burden. Clinicians should recognize high risk medications and prescribe them with great caution.

Background Leprosy is often complicated by deformities, disabilities and intermittent hypersensitivity reactions. In the course of management, the physical impact of this disease is often assessed thoroughly but its psychological impact and quality of life is often left unaddressed. Objective To assess the effect of leprosy on the quality of life (QOL) among our patients. Methods This cross sectional study was conducted on patients diagnosed with leprosy in Kuala Lumpur Hospital. The patients were interviewed using World Health Organization Quality of Life Assessment - abbreviated version (WHOQOL-BREF) questionnaire which consists of 26 questions exploring four domains: physical, psychological, social relationships and environmental. Patient’s perception towards diagnosis was also assessed. Results Out of the 26 respondents, 19 (73.1%) were males and 7 females with the mean age of 41 years. 84.6% were of Malay descent and 14 (53.8%) patients were foreigners. Twenty three patients (88.5%) were diagnosed multibacillary and 3 (11.5%) had paucibacillary leprosy. Mean QOL scores by domains were: physical 13.0, psychological 12.5, social relationships 13.4 and environmental 14.2. The mean total QOL score among males were 52.9 and 54 for females but the difference was not statistically significant. Fear was the commonest reaction to initial diagnosis. Conclusion Quality of life is reduced among our patients with leprosy. Early detection and treatment can prevent deformities and disabilities but the importance of incorporating counselling and patient education in overall management cannot be overemphasized.

Background: Psoriasis is a common dermatological condition affecting both adults and children. It causes significant physical and psychological burden on patients and adversely affect their quality of life. Aim: To evaluate the clinical characteristics of paediatric patients with psoriasis in Malaysia. Materials & Methods: Data were obtained from the Malaysian Psoriasis Registry (MPR). All paediatric patients aged <18 years notified to the registry from July 2007 to December 2012 were included in this study. Results: A total of 677 patients were notified from 18 participating centres. There was a slight female preponderance (ratio 1.3:1). Malay accounted for 70.6%, followed by Chinese (8.9%), Indian (12.3%) and others (8.1%). Mean age of onset was 9.8 ± 4.4 years. Positive family history was noted in 19.1%. Plaque psoriasis was the commonest type of psoriasis (79.6%), followed by guttate psoriasis (7.4%), pustular psoriasis (1.6%), erythrodermic (1.2%) and flexural psoriasis (1.2%). Psoriatic arthropathy was reported in only 2.2% of patients. Nail involvement is common, affecting 38.1%. Pitting was the commonest (89.9%). Topical treatment remains the most popular choice of treatment and was given in 95.1% of our patients. Topical steroid was the commonest prescribed (81.4%), followed by tar preparations (78.7%) and emollients (51.6%). Only 1.2% of our patients received phototherapy. Of the patients who had phototherapy, narrowband UVB (NBUVB) was the commonest used (87.5%). Systemic therapy was given in 5.3% of paediatric patients. The most frequently used systemic therapy was methotrexate (50%) and acitretin (27.8%). The mean CDLQI score for paediatric patients with psoriasis was 7.7 ± 5.5. Conclusion: Data from the Malaysian Psoriasis Registry highlights the clinical features of paediatric patients with psoriasis in Malaysia. We hope to get more participation from other centres in the future, especially from private sectors, so that our results can represent the Malaysian data more accurately.

Introduction: Cumulative Sum (CUSUM) technique is an objective statistical method used in assessing and monitoring doctor’s performance. It has been incorporated into quality improvement strategies in clinical services by the Ministry of Health, Malaysia. A pilot study was aimed at evaluating its usefulness in monitoring the performance of specialists in conducting skin biopsy. Methods: All skin biopsies performed by specialists in the Department of Dermatology, Kuala Lumpur Hospital from September 2009 to April 2011 were included in the prospective observational study. Outcomes monitored were wound complications within 14 days post-biopsy, and tissue sample being adequate and representative for histopathological interpretation. CUSUM scores of each consecutive biopsy performed by individual specialist were calculated and charted with the eCUSUM web application (https://app.acrm.org.my/eCUSUM). Results: A total of 870 skin biopsies were performed by 15 clinical specialists and three consultant dermatologists during the study period. Wound infection or dehiscence were reported in 13 (4.1%) of the 318 biopsy wounds evaluated. Tissue samples were inadequate in 10 (1.2%) and non-representative in 11 (1.3%) of the 817 histopathological reports evaluated. No learning curve was observed in all CUSUM charts indicating that all specialists had been adequately trained for the procedure. However, out-of-control signals indicating unacceptable wound complication rates and either inadequate or non-representative tissue samples were detected in three clinical specialists. Feedback and counseling were given while monitoring was continued. Conclusions: The CUSUM method is a useful performance monitoring tool which is able to promptly detect unacceptable outcomes in skin biopsy. It is invaluable in the supervision of junior doctors and trainees as well as self-monitoring for the trained specialists.