Introduction: Xanthogranuloma is a rare, non-Langerhans cell histiocytosis that most commonly presents in infancy or early childhood. It is rare in adults, and when present are usually solitary. We present an unusual case of adult xanthogranuloma with multiple lesions. Case summary Our patient is a 66 year-old lady with a 10-year history of persistent lesions over her eyelids and cheeks. Physical examination revealed confluent yellowish-red plaques and nodules over the periorbital regions as well as yellowish plaques over both sides of the neck. Histological analysis revealed a pattern of diffuse dermatitis in the dermis consisting of foamy histiocytes admixed with a few Touton-type giant cells. She had mild thrombocytopenia but a bone marrow trephine and flow cytometry investigations were normal. Due to the chronic and disfiguring nature of the lesions, intralesional triamcinolone was given with moderate efficacy. Conclusion: Differentiating between adult xanthogranuloma and other xanthomatous disorders has therapeutic implications and requires correlation with the epidemiological, clinical, biochemical and histopathological features. Adult xanthogranuloma

Introduction: Dermatophytic granuloma is uncommonly seen on the leg as Majocchi’s granuloma and in scalp as kerion type of tinea capitis, but it is rare to occur on the face. Case summary A 9 year-old Malay girl presented with itchy skin lesions over body, face and scalp since 1yr. On examination, multiple dry scaly annular patches with well defined border were seen over trunk and limbs. Multiple hyperkeratotic and verrucous papules and plaques were seen over face and scalp. Patches of scarring alopecia of scalp were also seen. Left middle finger nail showed dystrophic changes. Oral mucosa showed no lesions. Scales from body skin scrapping with Potassium hydroxide preparation showed multiple septate hyphae. Culture of scales from skin lesion and hyperkeratotic lesion over face grown Microsporum canis. Biopsy of the granulomatous lesion over the face and skin lesion showed multiple hyphae on PAS staining confirmed the dermatophytic granuloma of the face and scalp and tinea corporis over the trunk. The girl was referred to Paediatric Department to assess her immunological status. The results were inconclusive. According to Paediatrician, the child appears to be immunocompetent. Injection Itraconazole 80mg were given twice a day as inpatient. Within a week, the lesion over face and scalp almost resolved and the lesions over trunk and limbs totally cleared. Patient was discharged and asked to continue syrup Itraconazole 80mg bd. By 3rd week, scalp lesions almost cleared with few scarring alopecia patches. Conclusion: This case has been reported for the rare presentation of verrucous dermatophytic granuloma of face and scalp in immunocompetent child.

Objective The T-Spot.TB is an interferon-gamma release assay (IGRA) which is increasingly used in dermatology as a screen for latent TB before initiation of biologics and for confirming diagnosis of tuberculids. This study aims to explore its concordance with tuberculin skin tests (TST) and eventual diagnosis of latent TB. Study design This is a retrospective review of all patients in NSC who had a TB T-spot test done between 2008 and 2010. We looked at the dermatological diagnosis, results of T-Spot.TB and TST, chest radiograph findings, tuberculosis status and treatment of TB. Result 51 TB T spot tests were ordered in National Skin Centre between 1 January 2008 and 9 June 2010. 31 tests were for patients with psoriasis with the intention of initiating biologics; 5 were for patients with suspected tuberculids and tuberculosis verrucosa cutis; 3 were done as part of work-up for possible erythema nodosum; 3 tests were part of screening for latent TB in hospital staff and 9 tests were performed for other reasons. There were a total of 13 patients eventually diagnosed with latent or active TB infection. All of whom had a positive T-Spot.TB result except for 1 patient with an indeterminate result. On the other hand, out of these 13 patients, only 5 showed a positive TST, 2 had negative TST and 4 patients did not have a TST done. There were a total of 14 positive T-Spot.TB results for which 12 eventually received antituberculous therapy. All patients with erythema induratum had a positive test result. Six patients’ T-Spot.TB tests were borderline, indeterminate or could not be interpreted due to insufficient lymphocyte yield. Conclusion Our study shows the utility of T-Spot. TB test in various conditions seen in dermatology clinics in a local setting. We suggest that the T-spot test can supplant the tuberculin skin test in screening latent TB for psoriasis patients for whom biologics are intended and in erythema induratum. The high incidence of borderline and indeterminate results should not be ignored. This should be taken into account when interpreting the IGRA especially if patients are on immunosuppressive therapy.

Introduction Hansen’s disease is chronic systemic and granulomatous disease by Mycobacterium Leprae. It principally affects peripheral nerves, skin and mucous membrane. Lepromatous leprosy harbors large numbers of bacilli. Objective To review the effectiveness of leprosy contact tracing programme in Kelantan. Methods This is a 10 year retrospective analytical study of new leprosy cases in Kelantan, Malaysia from 2001 to 2010. Routine contact tracing plus 2 intensive home visit surveys were performed in year 2002 and 2006. Results 108 and 87 home visits were made in 2002 and 2006 respectively. 638 adults and 416 child contacts were examined in 2002 while 512 adults and 403 children were examined in 2006. 90% contact tracing were achieved. 127 new leprosy cases were detected from 2001 to 2010 of which 108 (87%) were adults and 16 (13%) children. In adults 63 (58%) and 45 (42%) had multibacillary and paucibacillary respectively. In children, 4 and 12 had multibacillary and paucibacillary leprosy respectively. 90% of the new leprosy in children were detected through contact tracing. One family had 5 children who developed leprosy from contact to index. 2 children had ulnar palsy and another child had type 1 MDT reaction. Conclusion The increased risk of contacts getting leprosy especially in paediatric patients, neccessitate yearly contact tracing for early detection treatment in children and reduce deformity in children. Management to include counselling, surveillance to all leprosy patients and insist on regular slit smear.

Case summary A 62 year old gentleman was admitted to medical ward for 2 months history of generalized body weakness, anorexia, vague abdominal pain, fatigue and multiple erythematous, non-pruritic, scaly patches and plaques scattered throughout his body associated with nasal stuffiness. These lesions were hypoaesthetic. Blood investigations revealed a high corrected calcium level at 3.24 mmol/L which explained his acute medical complaints. Slit skin smear revealed Bacteriological Index (BI) of 1.2 and Morphological Index (MI) of 3.9. Skin biopsy confirmed the diagnosis of Borderline Lepromatous Leprosy. Institution of systemic steroids, vigorous intravenous fluid infusion and the implementation of multi-drug therapy for his leprosy resulted in a relatively swift decrease in reduction of calcium level. Conclusion This case report highlights the rare but important association of hypercalcaemia with leprosy. However, other granulomatous diseases such as sarcoidosis and tuberculosis have higher association with hypercalcaemia.

Introduction: Fusarium spp is an opportunistic fungal pathogen which is being isolated with increasing frequency as a pathogen in oncohematologic patients who are immunocompromised, particularly those who are neutropenic. Case summary: We herein report a case of a 21 year-old old lady with refractory Acute Lymphoblastic Leukaemia on chemotherapy who presented to us with multiple erythematous plaques with central necrosis for past 10 days involving the bilateral upper limb and lower limb. Diagnosis of disseminated fusariosis was made by positive blood cultures and skin biopsy for fungal culture to Fusarium spp. She was treated with intravenous voriconazole for one month. The patient was in complete remission with no signs of clinical activity of the Fusarium infection. Conclusion: There is a need to exclude the other causes of cutaneous plaques occurring in leukaemic patients.

Introduction: Infantile haemangioma (IH) is a common benign vascular tumour which is characterised by rapid proliferation in early infancy period followed by slow involution for years. The initial rapid growth and the location of haemangioma may result in significant morbidity. The introduction of oral Propranolol for the treatment of IH in recent years has seen many promising results though with potential risks. Objective: To review the demography, clinical pattern, management and outcome of patients with IH treated with propranolol in a paediatric dermatology referral centre. Methodology: A retrospective observational study of medical records of patients with IH treated with oral propranolol (maximum dose 2mg/kg/day) from May 2009 to May 2011 in Paediatric Institute, Kuala Lumpur Hospital. Results: A total of 17 patients (14 girls, 3 boys) were studied. They were 12 Malays (70.6%), 2 Chinese(11.8%), 2 Indians(11.8%) and 1 Indonesian (5.9%). Mostly term babies (88%). The age of presentation is from birth to 2 months old. The location of haemangiomas involve periocular (35.3%), perioral (17.6%), facial segmental (17.6%), nasal (5.9%), multiple (17.6%) and spinal (5.9%). They were started on Propranolol at a mean age of 5 months old except one at 2 years old. Five patients had concurrent adjunctive therapies. 70.6% had significant reduction of the size and colour of haemangiomas, 11.8% not significant, 11.8% unclear, and one patient defaulted follow up. Some patients developed wheezing episodes (29.4%), diarrhoea (17.6%), regurgitation (5.9%); but no serious consequences. Conclusion: Low dose oral propranolol is a safe and effective treatment with minor side effects from our experience.

Background: Methotrexate has been widely used as an effective systemic therapy for psoriasis. Retrospective data showed efficacy rate of 70-80% but recent RCTs using PASI 75 as primary endpoint showed wide variations in efficacy. Different dosing regimens for methotrexate may explain this variation. Objectives: To compare the efficacy and tolerability of two different dosing regimes of oral methotrexate in patients with moderate to severe plaque psoriasis. Methods: A prospective comparative study was conducted from October 2009 to June 2010. Patients with moderate-to-severe plaque psoriasis were randomized to receive either a ‘step-up dose’ regime (starting dose 7.5mg) or a ‘step-down dose’ regime (starting dose 20mg) of oral methotrexate for 16 weeks. The primary efficacy endpoint was PASI 75. Tolerability and safety were assessed. Results: Forty patients received oral methotrexate with equal numbers in each arm. After 16-week, 55% (11) of patients in ‘step-up dose’ group and 65% (13) of patients in ‘step-down dose’ group achieved PASI 75 (p > 0.05). Significantly higher number of patients in ‘step-down dose’ group achieved PASI 75 at week 4 and week 8 (p < 0.05) compared to ‘step-up dose’ group. One patients from ‘step-down dose’ group discontinued study prematurely due to adverse effect but no significant difference in rate of adverse events was noted. Conclusion: There was no significant difference in efficacy between both regimes at the end of 16 weeks but significant efficacy was observed in patients on ‘step-down dose’ regime as early as week 4. The side effect profile and tolerability were similar.

Background: Individuals with AD have an increased susceptibility to colonization with Staphylococcus aureus (S. aureus), contributing to the exacerbation of the disease. Sodium hypochlorite (bleach) has both in vitro and in vivo antimicrobial activity against S.aureus. Objectives: To evaluate the efficacy and safety of diluted sodium hypochlorite (bleach) baths in patients with moderate to severe atopic dermatitis in our Malaysian population. Methods: This was a prospective randomized, investigator-blinded, placebo-controlled study. Patients were randomly assigned through computer generated simple randomized numbers to treatment (bleach baths) or placebo (distilled water baths). Patients were instructed to soak in the baths neck down for 10 minutes, twice a week for 2 months. The efficacy outcome measures were the Eczema Area and Severity Index (EASI) score, percentage body surface area involved, quantitative S. aureus counts and patient’s assessment of overall response (including itch scores). Safety outcomes were also assessed. Results: A total of 36 patients completed the study. EASI scores and body surface area showed significant improvement between treatment and placebo groups at 2 months (p=0.02, p=0.02). At baseline, 88% of patients yielded S. aureus from lesional skin. Although most cultures in the treatment group continued to yield S. aureus, there was a reduction in the density over time, although not statistically significant. Five patients reported burning/stinging and dry skin in the treatment arm which did not differ significantly compared to placebo. Conclusion: Diluted sodium hypochlorite baths as an adjunctive treatment decreased the clinical severity of patients with moderate to severe atopic dermatitis and may reduce S. aureus density. This treatment was well tolerated with minimal adverse effects.

Background Antibiotic therapy directed against Propionibacterium acnes has been a mainstay of treatment in acne vulgaris for more than 40 years. Prolonged antibiotic usage has been associated with emergence of antibiotic-resistant P. acnes and is linked to treatment failure. Little work has been done in Malaysia on drug resistance in P. acnes and there is no surveillance data on this aspect to guide the clinical decision. Objective This study aims to evaluate antibiotic sensitivity of P. acnes isolated from patients with acne vulgaris in Kuala Lumpur Hospital, Malaysia. Methods This is a non interventional, single centered, cross-sectional hospital-based survey of antibiotic sensitivity of P. acnes isolated from patients with acne vulgaris in Kuala Lumpur Hospital from January 2010 to June 2010. Results A total of 100 patients were recruited in our study. P. acnes was isolated in 53% of patients and 11% had gram negative organism. Antibiotic resistant P. acnes was found in 15.1% of positive isolates. Clindamycin resistance was most common (15.1%) followed by erythromycin (7.5%), doxycycline (5.7%), tetracycline (1.9%) and minocycline (0%). Isolates of antibiotic resistant P. acnes was significantly higher in patients treated with antibiotics within the last 6 months (29%) as compared with non antibiotic treated patients (0%) (p<0.05). The mean duration of prior antibiotic treatment was significantly longer in the group of antibiotic resistant P. acnes as compared with antibiotic sensitive P. acnes (17.13 weeks vs 5.74 weeks, p<0.05). Conclusion Antibiotic resistant P. acnes is present locally with clindamycin and erythromycin conferring the highest resistance. Longer duration of antibiotic treatment predisposes to antibiotic resistant P. acnes and may also induce emergence of gram negative organisms. Strategies to reduce antibiotic resistance should be emphasized when prescribing antibiotic for acne vulgaris in order to achieve optimal therapeutic results while reducing the potential for antibiotic resistance.