RSMPD 2018

Abstracts E-Book

ADULT DERMATOLOGY

Content

Case Reports/ Case series

Case Reports/ Case series

(Oral Presentations)

Research Studies

Research Studies
(Oral Presentations)
 DSS 2018
Adult Dermatology
Case Reports/ Case series

Abstract ID Title Author Links

Urticaria and Other Dermal Hypersensitivity Disorders

Hydroa vacciniforme-like lymphoproliferative disorder in an

DSS27 Valencia Long View Abstract
elderly man: a rare case with an indolent course

Connective Tissue Disorders and Autoimmune Bullous Disorders

DSS18 A case of anti-MDA5 dermatomyositis Delwyn Lim View Abstract

Benjamin Ricardo
DSS47 Case Report: Scleroderma in Woman View Abstract
R. L. Tobing

Drug Reactions

Vasculitic Ulcer After Programmed Death-Ligand 1

DSS04 Inhibitor Therapy in a Patient with Metastatic Ovarian Ellie Choi View Abstract
Cancer

A Case Of Imatinib-Related Lichen Planus Pigmentosus Rachel Wen Rui

DSS22 View Abstract
With Oral And Nail Involvement Lim

Acute Localized Exanthematous Pustulosis On The Amitha Chandima

DSS51 View Abstract
Abdomen-A Case Report Ranasinghe

Medical Dermatology

Concurrent Erythema Dyschromicum Perstans And

DSS13 Kaposi’s Sarcoma In A Patient With Human An Jian Leung View Abstract
Immunodeficiency Virus.

DSS55 Acute lipodermatosclerosis: A mimic of cellulitis Yan Ling Kong View Abstract

Viral Infections

Rachel Wenrui
DSS10 Hand Foot And Mouth Disease – A Misnomer In Adults View Abstract
Lim

Long-Standing Painful Hemorrhagic Vesiculobullae Of The

DSS11 Stephanie Sutjipto View Abstract
Lower Leg - Case Of Atypical Zoster

Bacterial Infection
 Amitha Chandima
DSS50 Multifocal Tuberculosis Verrucosa Cutis - A case report View Abstract
Ranasinghe

Fungal Infections

DSS24 Pustular Tinea Manuum from Trichophyton erinacei Ellie Choi View Abstract
Infection

DSS38 Pityriasis Versicolor Mimicking Leprosy: Case Report Tanojo Natalia View Abstract

Parasitic Infections

Cutaneous Larva migrans with combination therapy : A Indira

DSS53 View Abstract
case report Dharmasamitha

Skin Tumours (Benign / Malignant)

A Case Of Metastatic Extramammary Paget's Disease

DSS20 Yisheng Wong View Abstract
Requiring Sigmoid Colostomy

DSS52 Metatypical Basal Cell Carcinoma – not “just a BCC” Jazlyn Read View Abstract

Management of Keratoacanthoma with Elliptical Excision:

DSS54 Venny Tandyono View Abstract
A Case Report

Rayson Rui
DSS59 Acral Melanoma: A Case Study View Abstract
Sheng Lee

Dermatological Surgery

Reagan Grey
DSS12 Merkel Cell Carcinoma in a Filipino Patient: A Case Report View Abstract
Reyes
Dermatopathology

Diagnostic Confirmation Of Primary Cutaneous Diffuse

DSSS15 Silfia Mandasari View Abstract
Large B-Cell Lymphoma-Leg Type : A Case Report

A Rare Case Of Multicentric Reticulohistiocytosis Presents

DSS29 As Epidermotropic Papular Xanthoma And Double Primary Sung-Jen Hung View Abstract
Cancers

Chandrasekharan
DSS36 Grover's disease -An Unusual Presentation View Abstract
Jayasree
 DSS 2018
Adult Dermatology
RESEARCH STUDIES

Abstract ID Title Author Links

Atopic Dermatitis and Other Eczematous Conditions

Safety Profile Of Dupilumab In Treatment Of Moderate To

DSS37 Tanojo Natalia View Abstract
Severe Atopic Dermatitis Patients: Evidence Based Case Report

Acne and Acneiform Disorders

Acne Vulgaris and Quality of Life among Young Adult Students Leny
DSS31 View Abstract
in Yogyakarta, Indonesia Purnamasari

Efficacy and safety of oral azithromycin plus 30% salicylic acid

DSS48 Smita Joshi View Abstract
peel in grade II – III facial acne

Acne fulminans associated with neutrophilic dermatoses: case Wen Yang

DSS61 View Abstract
report Benjamin Ho

Urticaria and Other Dermal Hypersensitivity Disorders

Obstructive Sleep Apnea in Recalcitrant Chronic Spontaneous

DSS17 Min Moon Tang View Abstract
Urticaria: a report of 4 Adults in Hospital Kuala Lumpur

Henoch Schonlein Purpura-A 5 Yr Study From A Tertiary Care Panicker

DSS35 View Abstract
Centre Vanitha

Drug Reactions

Clinicoepidemiological Profile Of Severe Cutaneous Adverse

DSS08 Drug Reaction At Dr. Soetomo Hospital Surabaya Indonesia: A Damayanti- View Abstract
Retrospective Study

Drug Reaction With Eosinophilia And Systemic Symptoms

(DRESS) In Singapore: Clinical Features, Treatment And Chong En Linus
DSS16 View Abstract
Outcomes Of 109 Patients Managed In An Academic Medical Chan
Centre

Lamotrigine-induced Severe Cutaneous Adverse Drug

DSS21 Reactions in a Singapore Population: A Case Series and HLA Laura Hui View Abstracts
genotyping

B.S.D.P.
DSS63 Ocular complications related to high dose intravenous steroid View Abstracts
Keragala
therapy

Hair, Nail And Mucous Membrane Disorders

Rumex japonicus Houttuyn and Arctium lappa Linné promotes Kyung-Hwa

DSS32 View Abstract
hair regrowth in alopecia models Kang
 Skin Tumours (Benign / Malignant)

Spectrum Of Skin Condition Seen In A Dedicated Transplant

DSS09 Zi Teng Chai View Abstract
Clinic In A Tertiary Centre

Radiotherapy for Cutaneous Squamous Cell Carcinoma in Solid

DSS14 Pei MingYeo View Abstract
Organ Transplant Recipients, a Systematic Review

The incidence of basal cell carcinoma appears reduced in

DSS41 patients on anti-Programmed cell death-1 therapy for metastatic Cathy Zhao View Abstract
melanoma

Non-melanoma skin cancer in Africans with oculocutaneous

DSS56 Jazlyn Read View Abstract
albinism: 3 cases and review of factors impacting management

Basic Science

Up-regulation of the expressions of involucrin, filaggrin and

Byeong-Churl
DSS62 TGM1 in UVB-irradiated HaCaT cells by fermented Schisandra View Abstract
Jang
chinensis extract

Dermatological Treatment

Residual melanoma in situ following surgical excision – a role for

DSS58 Jazlyn Read View Abstract
topical imiquimod?

Dermatopathology

Sub-Type Of Epidermolysis Bullosa – Clues Hidden In

DSS39 Priya Bishnoi View Abstract
Histopathology
 DSS 2018
Adult Dermatology
Oral Presenters

Abstract ID Title (Research Studies) Author Links

Connective Tissue Disorders and Autoimmune Bullous Disorders

Pemphigoid And Pemphigus: Comparative Analysis Of Clinical

DSS05 Li Cheng Heng View Abstracts
Epidemiology, Course And Outcome In An Academic Centre

Pigmentary Disorders
Automated Scoring Of Vitiligo Using Superpixel-Generated
DSS25 Computerised Digital Image Analysis Of Clinical Photographs: A Joseph Toh View Abstracts
Novel And Consistent Way To Score Vitiligo

Medical Dermatology

A Dermatology Health Services Study Of Nursing And

DSS34 Adeline Yong View Abstarcts
Community Hostpials In Singapore

Dermatological Treatment

Corticosteroid Phobia – A Questionnaire Study Using Topicop©

DSS19 Ellie Choi View Abstracts
Score

Bacterial Infections

Efficacy Of Platelet Rich Fibrin Clot In Treatment Of Trophic Anugandha

DSS45 View Abstract
Ulcers In Hansen’s Disease Ghatge

Abstract ID Title ( Case Reports/ Case series ) Author Links

Medical Dermatology

Jarische
DSS01 Wells' Syndrome In An 18 Year-Old Female Frances View Abstracts
Lao-Ang

Skin Tumours (Benign / Malignant)

Angiolymphoid Hyperplasia With Eosinophilia With Clinical

DSS02 Calvin Santos View Abstract
Pictures Of Keratoacanthoma: A Rare Case Report

Epstein-Barr Virus-Positive Diffuse Large B-Cell Lymphoma

DSS07 Lynette Lee View Abstract
Presenting With Vaginal Sloughing And Ulcerated Skin Nodule

Drug Reactions

A Case Of Acute Generalised Exanthematous Pustulosis (Agep)

DSS26 Mei Qi May Liau View Abstract
With Remarkable Neutrophilic Leukocytosis
 Abstract ID: DSS27

Track: Skin Tumours (Benign / Malignant)

Contact Author: Valencia Long

Country: Singapore

Organisation: Tan Tock Seng Hospital

Poster View here

Hydroa vacciniforme-like lymphoproliferative disorder in an elderly man: a rare case

with an indolent course

Hydroa vaccinforme-like lymphoproliferative disorder (HVLPD) is a rare T-cell

lymphoproliferative disorder driven by the Epstein-Barr Virus (EBV). It was initially designated
under the 2008 WHO classification of tumors of hematopoietic and lymphoid tissues as a
distinct entity but has been recently reclassified as a lymphoproliferative disorder under the
2016 revision of the 2008 WHO classification of lymphoid malignancies. HVLPD is rarely seen
in adults. Although HVLPD may initially be limited to cutaneous involvement and run an indolent
course, some patients may develop a rapidly aggressive course.

We report a case of an elderly Chinese man with cutaneous-limited HVLPD and a favorable
course. A 77 year old Chinese male presented with photodistributed, erosive vesicular lesions
over his face, the V-neck area of the anterior chest and bilateral forearms for over a year. Skin
biopsy was performed and histopathological features showed dense diffuse non-
epidermotropic dermal infiltrates surrounding the folliculosebaceous units with lymphocytes
extending into the follicular epithelium. The infiltrate was composed of small and medium-sized
lymphocytes with convoluted and hyperchromatic nuclei and moderate cellular atypia.
Immunophenotyping revealed diffuse immunoreactivity of the small to medium atypical cells for
CD2, CD3 and CD4 with focal staining (10%) for cytotoxic markers granzyme B and TIA. About
15-20% of the slightly larger atypical lymphocytes stained positively for CD30. The atypical cells
were negative for CD56 and ALK-1. EBER in-situ hybridization showed diffuse nuclear staining
by the infiltrating cells. Systemic work up including full blood count, and positron emission
tomography scan did not reveal any systemic involvement. A diagnosis of hydroa vacciniforme-
like lymphoproliferative disorder (HVLPD) was made.

He was treated with topical clobetasol and mometasone furoate with good response. He
remains well at 7 years post diagnosis with a single residual lesion on the chin. We highlight
the indolent disease course in this patient who also exhibited a good response to topical
corticosteroids. As HVLPD may present with a spectrum of clinical aggressiveness, we
recommend treatment and management guided by the clinical behavior and to avoid
aggressive treatment particularly in elderly patients.
Poster: DSS27

Hydroa vacciniforme-like lymphoproliferative disorder

in an elderly man: a rare case with an indolent course
V Long1 , M.W.T Liang2 , S.H Tan2 1: Tan Tock Seng Hospital 2: National Skin Centre
Introduction
Immunophenotyping shows that the small to
Hydroavaccinforme-like lymphoproliferative
medium atypical cells stained positive for CD2, CD3
disorder (HVLPD) is a rare T-cell
and CD4 with focal staining (10%) for cytotoxic
lymphoproliferative disorder driven by the
markers granzyme B and TIA. About 15-20% of the
Epstein-Barr Virus (EBV). It was initially slightly larger atypical lymphocytes stained
designated under the 2008 WHO classification
positively for CD30. The atypical cells were negative
of tumors of hematopoietic and lymphoid
for CD56 and ALK-1. EBER in-situ hybridization
tissues as a distinct entity but has been
showed diffuse nuclear staining by the infiltrating
recently reclassified as a lymphoproliferative
cells (Figure 3A-F).
disorder under the 2016 revision of the 2008
WHO classification of lymphoid malignancies.1
HVLPD mainly affects Asian, Central and South
American children2. It is rarely seen in adults.
Although HVLPD may initially be limited to
cutaneous involvement and run an indolent
course, some patients may develop a rapidly
aggressive course.
Case report
We report a case of an elderly Chinese man
with cutaneous-limited HVLPD and a
favorable course. A 77 year old Chinese male
presented with photodistributed, erosive
vesicular lesions over his face, the V-neck area
of the anterior chest and bilateral forearms
for over a year (Figure 1a).

Systemic involvement was excluded. A diagnosis of

Histopathology
There was dense diffuse non-epidermotropic
dermal infiltrates surrounding the
folliculosebaceous units with lymphocytes
extending into the follicular epithelium. The
infiltrate was composed of small and
medium-sized lymphocytes with convoluted
and hyperchromatic nuclei and moderate
cellular atypia (Figure 2a,b)
HVLPD was made. The patient was treated with
topical clobetasol and mometasone furoate with
good response. He remained well at 7 years post
diagnosis with a single residual lesion on the chin
(Figure 1b). In this report, we highlight the indolent
disease course in this patient who also exhibited a
good response to topical corticosteroids. As HVLPD
may present with a spectrum of clinical
aggressiveness, we recommend treatment and
management guided by the clinical behavior and to
avoid aggressive treatment particularly in elderly
patients.
References
1) Swerdlow SH, Campo E, Pileri SA, Harris NL, Stein H, Siebert R, et al. The 2016 revision of the
2)
World Health Organization (WHO) classification of lymphoid neoplasms. Blood. 2016.
Zhang X, Wang T, Wang L. Hydroa Vacciniforme-Like Lymphoma in Tibetan Children: 2 Cases
and a Literature Review. The American Journal of Dermatopathology. 2017;Publish Ahead of
Print.
 Abstract ID: DSS18

Connective Tissue Disorders and Autoimmune

Track:
Bullous Disorders

Contact Author: Delwyn Lim

Country: Singapore

Organisation: Others

Poster View here

A case of anti-MDA5 dermatomyositis

Case: A previously healthy woman in her sixties presented with a 3 week history of painful
lesions on her fingers, non-healing tongue ulcers and arthralgia of distal upper limbs. Systemic
review was unremarkable. Examination demonstrated tender, erythematous juxta-articular
papules on the lateral aspect of her fingers bilaterally with mild synovitis of the left wrist and
interphalangeal joints of her hands. There was a purpuric necrolytic patch over her olecranon
and 2 oral ulcers, one on each side of the lateral tongue. Respiratory, cardiovascular and
neurological examination were normal. A clinical suspicion of dermatomyositis (DM) of the anti-
melanoma differentiation associated gene 5 (anti-MDA5) phenotype was made. Histology of a
palmar papule revealed apoptotic keratinocytes, subepidermal oedema and superficial to deep
perivascular lymphocytic infiltrate. Alcian blue stain demonstrated dermal mucin. Direct
immunofluorescence showed focal intramural IgM in vessels and granular C3 deposits at the
dermoepidermal junction. Myositis panel returned positive for anti-MDA5 antibodies.
Pulmonary function tests and high resolution computed tomography scan of the thorax did not
show features of interstitial lung disease.

Discussion: Up to 35% of patients with DM have anti-MDA5 antibodies. It is imperative to

recognise this entity given its strong association with rapidly progressive interstitial lung disease
that is largely fatal. Fiorentino et al. typified cutaneous stigmata that strongly suggest anti-
MDA5 DM; hand swelling, arthralgia, cutaneous ulcerations, tender palmar papules, violaceous
erythema of the elbows and knees, along with oral ulcers. Anti-MDA5 DM also tends to be
amyopathic. All these are worth underscoring given that serological testing for anti-MDA5 may
not be readily available, hence preventing delayed diagnosis and treatment. What is unique in
this case was the early recognition of anti-MDA5 DM before overt clinical pulmonary disease
had set in – there has been no literature describing treatment in such a cohort of patients. In
our case, monitoring of disease progression is being assessed through regular pulmonary
indices and ferritin levels, with the latter being shown to correlate with the response to treatment
and prognosis. The patient was started on prednisolone and mycofenolate mofetil.
Poster: DSS18

An instructive case on the cutaneous stigmata of

anti-MDA5 dermatomyositis
DZJ. Lim1, JHL. Lim2,, H.Y. Lee,3
1LeeKong Chian School of Medicine, Nanyang Technological University, Singapore, 2National
Skin Centre, Singapore, 3Department of Dermatology, Singapore General Hospital, Singapore,

Case Presentation

• A previously healthy woman in her 60s presented with a 3-week history of persistent painful lesions on the side of her
fingers, associated with non-healing tongue ulcers and arthralgia of the small joints of her hands.
• Further history did not reveal exposure to any contactants, use of intravenous illicit drugs or ingestion of new
medications. Systemic review was non-contributory.
• Examination demonstrated discrete tender and erythematous juxta-articular papules, devoid of surface change, on the
lateral aspect of her fingers bilaterally (Figure A). There were 2 ulcers, one on each side of lateral tongue (Figure B)
along with mild synovial swelling of the left wrist and interphalangeal joints of the hands. There was an incidental
discovery of a dusky purpuric patch over her left elbow with central necrolysis (Figure C).
• Respiratory, cardiovascular and neurological examination were normal and there was no lymphadenopathy. Preliminary
basic blood tests and a plain chest radiograph were negative.
• Punch biopsies of one digital papule were performed (Figure D).

Figure A Figure B Figure C Figure D

Case Discussion
This patient has dermatomyositis (DM) - anti-MDA5 phenotype. DM is a multi-system chronic Th-1 mediated auto
inflammatory disorder defined by the presence of hallmark cutaneous manifestations and muscle weakness.
Clinical Features
• Anti-MDA5 DM is characterised by cutaneous features of hand swelling, arthralgia, skin ulcerations, palmar papules,
mechanic hands, violaceous erythema of the elbows and knees, along with oral ulcers1.
• Studies have also shown that these patients were more likely to be clinically amyopathic. Of note, patients with the
combination of anti-MDA5 positivity and clinical amyopathy have poorer outcomes due to the association with rapidly
progressing interstitial lung disease (RP-ILD). This group of patients generally do poorly with high mortality rates
despite aggressive immunosuppressive therapy2.
Histology
• Histology of palmar papules in such patients would show vasculopathy characterized by vascular fibrin deposition with
variable perivascular inflammation, as compared to the classical histological features of interface dermatitis with mucin.
Discussion
• What is unique in this case was the early recognition of anti-MDA5 DM before overt clinical pulmonary disease had set
in – there has been no recent literature describing treatment in such patients. For our patient, monitoring of disease
progression is being done through regular pulmonary indices and ferritin levels, with the latter being shown to correlate
with response to treatment and prognosis3.
• The patient was started on prednisolone 1mg/kg/day and mycofenolate mofetil 1g twice daily.
• Advancements in clinical immunology shows that DM is a heterogenous group of diseases that veers from the
traditional understanding and description of classical DM. Thus, it is important to recognise the unique clinical features
of anti-MDA5 phenotype due to its association with RPILD leading to poorer outcomes, and to enable the development
of further studies to determine the optimal treatment for patients with this disease.
References
1) Fiorentino D, Chung L, Zwerner J, Rosen A, Casciola-Rosen L. The mucocutaneous and systemic phenotype of dermatomyositis patients with antibodies to MDA5 (CADM-140): A retrospective study. Journal of the American Academy of Dermatology.
2011;65(1):25-34.
2) Kameda H, Nagasawa H, Ogawa H et al. Combination therapy with corticosteroids, cyclosporin A, and intravenous pulse cyclophosphamide for acute/subacute interstitial pneumonia in patients with dermatomyositis. J Rheumatol 2005;32:1719–1726 

3) Gono T, Sato S, Kawaguchi Y, et al. Anti-MDA5 antibody, ferritin and IL-18 are useful for the evaluation of response to treatment in interstitial lung disease with anti-MDA5 antibody-positive dermatomyositis. Rheumatology 2012;51(9):1563-1570.
 Abstract ID: DSS47

Connective Tissue Disorders and

Track:
Autoimmune Bullous Disorders

Contact Author: Benjamin Ricardo R. L. Tobing

Country: Indonesia

Organization: Others

Poster View here

Case Report: Scleroderma in Woman

"Background : Scleroderma is a rare multisystem disease; characterized by fibrosis,

inflammation and vasculopathy. Women are more commonly affected than men, with ages
ranging from 30-50 years old. Besides occurs in the skin, scleroderma may also involve internal
organs (such as the gastrointestinal tract, lungs, kidneys and heart), which can cause severe
dysfunction in the visceral organs..

Case Presentation : A woman, 26 years old, came with the problem white patches and followed
with thickened skin on the hand since ± 2 years ago. On examination of dermatological,
encountered salt and pepper pigmentation on the regio nuchae, suprascapularis, colli anterior,
colli lateralis, clavicularis, antebrachii posterior dextra, cruris anterior dextra et sinistra, cruris
lateralis sinistra, patellaris dextra, and dorsales digitorum dextra et sinistra. In laboratory tests
found elevated levels of ANA and Anti ds-DNA. Patients treated with cyclosporin 100 mg/day
and topical emollients.

Discussion : Scleroderma is an autoimmune disease that occurs more frequently in women

with onset age of 30-50 years. The most frequent organ involvement esophagus (75%) with
complaints of dysphagia, heartburn due to reflux, nausea, and vomiting, and gastrointestinal
disorders (60%). By administering cyclosporin there is improvement in clinical in these patients.

Keywords : scleroderma, systemic sclerosis, cyclosporin

Poster: DSS47
 Abstract ID: DSS04

Track: Drug Reactions

Contact Author: Ellie Choi

Country: Singapore

Organisation: National University Hospital

Poster View here

Vasculitic Ulcer After Programmed Death-Ligand 1 Inhibitor Therapy in a Patient with

Metastatic Ovarian Cancer

Programmed death-ligand 1 (PD-L1) inhibitors are monoclonal antibodies used in the treatment
of certain cancers by enhancing a patient’s immune system. They are therefore associated with
immune related side effects including cerebral vasculitis. However cutaneous vasculitis has
not been previously reported. We report a patient who developed a cutaneous vasculitic ulcer
likely secondary to PD-L1 inhibitor therapy for metastatic ovarian cancer. She was treated and
improved with prednisolone, colchicine and discontinuation of the drug. This case highlights a
cutaneous manifesation of PD-L1 therapy, which although not life threatening, may allow for
early detection of PD-L1 treatment toxicity.
Poster: DSS04
 Abstract ID: DSS22

Track: Drug Reactions

Contact Author: Rachel Wen Rui Lim

Country: Singapore

Organisation: Singapore General Hospital

Poster View here

A Case of Imatinib-related lichen planus pigmentosus with oral and nail involvement

CASE REPORT

We present a rare case of a 64 year old Chinese male with lichen planus pigmentosus
associated with oral lichen planus and nail involvement five months after the commencement
of Imatinib for Gastro-intestinal stromal tumour (GIST). He presented with ill-defined violaceous
macules over the forehead, temples and neck. There were also lacy white patches with
erosions over the tongue and bilateral buccal mucosa and onychorrhexis of his nails. Histology
of a forehead violaceous macule showed focal interface vacuolar change with prominent
pigmentary incontinence and scant cytoid bodies consistent with the clinical diagnosis of lichen
planus pigmentosus. Biopsy of the buccal mucosa showed basovacuolar degeneration, Civatte
bodies and a band-like lichenoid infiltrate consistent with oral lichen planus. He was treated
supportively with topical steroids, tacrolimus ointment, dexamethasone oral rinse and was able
to continue on Imatinib. The latest staging CT scan showed that the GIST was under control.

DISCUSSION

Imatinib is a tyrosine kinase inhibitor used first line for chronic myeloid leukemia (CML) and
GIST. Cutaneous adverse reactions are common (88.9%) with the most common rash being a
maculopapular eruption (67%) while Imatinib-induced lichenoid drug eruption (LDE) remains
rare. LDE can be differentiated from idiopathic lichen planus, by its symmetrical distribution
over the photo-distributed trunk and limbs instead of flexor aspects, as well as residual
hyperpigmentation and histological findings of focal parakeratosis and eosinophils. In addition,
nail manifestations of lichen planus with Imatinib use are extremely rare and there are currently
no reports of lichen planus pigmentosus related to Imatinib.

This case also illustrates that suspension of the drug is usually not necessary and that patients
may be managed supportively. Early recognition is therefore crucial to prevent the premature
discontinuation of Imatinib, which has radically improved the treatment and prognosis of CML
and GIST in the last decade.
Poster: DSS22
 Abstract ID: DSS51

Track: Drug Reactions

Contact Author: Amitha Chandima Ranasinghe

Country: Singapore

Organization: National Skin Centre

Acute localized exanthematous pustulosis on the abdomen-A case report

Background
Acute localized exanthematous pustulosis (ALEP) is a rare form of sudden onset drug eruption
and is considered as a localized variant of AGEP. Pathogenesis is unknown and believed to
be mediated by drug specific T cells which produce cytokines that triggers accumulation of
neutrophils in the skin. Various medications such as antibiotics, NSAIDS, antifungals and
calcium channel blockers have been identified as possible triggers. The disease is
characterized by sudden onset, superficial, non- follicular, pin head sized and sterile clusters
of pustule over erythematous skin after few days of starting the medication and often affect
face, neck and chest. Spontaneous resolution is known to occur within few days after
discontinuing the offending drug. Herein, we report a case of a post- partum woman with a
pustular drug eruption consistent with ALEP.

Case presentation
A 38 year old postpartum mother was referred from obstetric ward on eighth day of emergency
LSCS for the evaluation of pustular eruption and associated fever for two days. She has been
treated with cefuroxime. Examination revealed multiple clusters of non-follicular tiny pustules
on an erythematous background localized mainly to abdomen and thighs. Her full blood
examination showed neutrophilic leucocytosis (WBC 12.1/109, N-80%) and swab for
bacteriological studies was negative. Serum calcium and electrolytes were normal. Skin biopsy
revealed subcorneal collection of neutrophils together with spongiosis and perivascular
collection of neutrophils and lymphocytes together with red cell extravasation. The clinical
diagnosis of ALEP was made and her skin lesions improved within three days after
discontinuing the culprit drug.

Discussion
ALEP very rare form of cutaneous drug eruption and the diagnosis is usually clinical. Temporal
relationship of antibiotic usage, abrupt onset of localized pustules associated with fever and
neutrophilic leucocytosis, absence of pruritus and no previous history of psoriasis and rapid
resolution of lesions following discontinuation of cefuroxime favoured the diagnosis of ALEP in
this patient.
 Abstract ID: DSS13

Track: Medical Dermatology

Contact Author: An Jian Leung

Country: Singapore

Organisation: Others

Poster View Here

Concurrent erythema dyschromicum perstans and Kaposi’s sarcoma in a patient with

Human Immunodeficiency Virus.

Introduction:
Erythema dyschromicum perstans (EDP) is a rare benign dermopathy with an unclear
aetiology.

Case presentation:
We report a case of a 41-year-old Chinese gentleman who was HIV positive. He declined
treatment for six years and consequently developed numerous AIDS-defining conditions. These
included oropharyngeal candidiasis, disseminated zoster, salmonella bacteraemia,
disseminated non-tuberculous mycobacteria, pneumocystis pneumonia, cytomegalovirus
myelitis, HIV-related dementia and nephropathy.

Of note, this patient also had unusual skin features. He developed multiple red-brown plaques
and tumors on his elbows and trunk, together with well-circumscribed brown-to-grey patches
symmetrically distributed over his flanks and proximal thighs. These skin changes occurred
over a 6-month timeframe. Both rashes were biopsied separately. The first biopsy from a nodule
revealed Kaposi’s sarcoma, the second biopsy over the trunk demonstrated features consistent
with EDP.

Discussion:
This is the third reported case of a patient with HIV and EDP. Two previous case reports exist
in literature; one described a child with haemophilia B & HIV seroconversion, and another
described a Chinese male on long-term anti-retrovirals and pneumocystis pneumoniae
prophylaxis who developed EDP. Of additional interest, in our case, the concurrent
development of Kaposi Sarcoma was also a feature that coloured the clinical presentation.

Postulated aetiologies for EDP include a genetic susceptibility, infections like hepatitis C,
whipworm infestations, HIV, and toxic ingestion of ammonium nitrate. It can be treated with
topical steroids, lasers, peels with limited to moderate effect. Systemic agents, notably
clofazimine have proven to be promising in treating EDP.

Conclusion:
Firstly, a detailed sexual history and HIV serological testing should be included in the evaluation
of patients suspected to have EDP. Secondly, in HIV positive patients, it is prudent to carefully
evaluate their skin manifestations as concurrent eruptions may complicate the clinical picture.
Poster: DSS13

Concurrent erythema dyschromicumperstansand

Kaposi’s sarcoma in a patient with Human
Immunodeficiency Virus.
An Jian LEUNG1, Sam S YANG2, HC LEE3, Martin TW CHIO3
1. Yong Loo Lin School of Medicine, National University of Singapore
2. National University Hospital, Singapore, 3. National Skin Centre, Singapore

Background Clinical pictures

Erythema dyschromicum perstans (EDP) is a rare benign

dermopathy with an unclear aetiology.

Case presentation
Figure 1 Figure 2 Figure 3
We report a case of a 41-year-old Chinese gentleman who was HIV-
positive. He declined treatment for six years and consequently
developed numerous AIDS-defining conditions. These included Figure 1, 2 and 3:
oropharyngeal candidiasis, disseminated zoster, salmonella Red-brown scaly plaques measuring 3x4cm, 2x2cm, 5x4cm, 3x4cm above
bacteraemia, disseminated non-tuberculous mycobacteria, spine of the right scapula, medial border of left scapula (fig. 1), right elbow
pneumocystis pneumonia, cytomegalovirus myelitis, HIV-related (fig. 2) and right hypochondrium (fig. 3) respectively.
dementia and nephropathy.
Figure 3 and 4:
Well demarcated brown grey
He also had unusual skin features - two distinctive rashes that both patches were disseminated over
appeared and worsened progressively over a 6 month’s duration. the anterior trunk (fig. 3) and
flanks (fig. 4) bilaterally. A red-
Examination revealed developed multiple red-brown plaques and brown plaque was noted over
tumors on his back (fig. 1), right elbow (fig. 2) and trunk (fig. 3). In the right hypochondrium
Figure 4
addition, there were well-circumscribed brown-to-grey patches overlying the patches (fig. 3)
symmetrically distributed over his trunk (fig. 3) and proximal thighs
(fig. 4).
Histology and immunohistochemistry
A skin biopsy was performed over each rash. The first biopsy from CD34 CD31
a nodule revealed Kaposi’s sarcoma (fig. 5), the second biopsy over
the trunk demonstrated features consistent with EDP (fig. 6).
Histology results of 2 punch biopsies are shown in figure 5 and 6.

Discussion KI67 HHV8

This is the third reported case of a patient with HIV and EDP. Two Figure 5
previous case reports exist in literature; one described a child with
haemophilia B & HIV seroconversion, and another described a Results of punch biopsy skin Immunohistochemistry (above):
Chinese male on long-term anti-retrovirals and pneumocystis specimen of the upper abdominal The atypical vascular proliferation
jiroveci pneumoniae (PJP) prophylaxis who developed EDP. In this red-brown plaque (fig. 5): is postive on HHV-8, CD31 and CD
third reported case of EDP in HIV, we have not only described the The epidermis is acanthotic with 34 stains, with a proliferative
presence of EDP, but also illustrated a unique presentation of EDP atypical spindle cell proliferation index of about 10% on ki-67
with concurrent development of Kaposi sarcoma. extending from the superficial stain.
dermis to the lower reticular This is consistent with Kaposi’s
dermis. The tumor forms small sarcoma over the right upper
Postulated etiologies for EDP include a genetic susceptibility,
vessels and slit-like spaces, quadrant.
infections like hepatitis C, whipworm infestations, HIV, and toxic dissecting through the collagen,
ingestion of ammonium nitrate. It can be treated with topical comprising plump endothelial cells
steroids, lasers, peels with limited to moderate effect. Systemic with focally hyperchromatic nuclei.
agents, notably clofazimine have proven to be promising in Some of the slit-like spaces contain
treating EDP. red cells. Few eosinophilic hyaline
globules are seen within the
spindled cells. Focal hemosiderin
deposits are seen, accompanied by
Conclusion
a lymphocytic infiltrate.
This is consistent with Kaposi’s
This is a unique case of a HIV patient presenting with EDP and sarcoma. Figure 6

concomitant Kaposi sarcoma. 3 cases of EDP occurring in HIV-

positive individuals have been reported. We recommend that
Results of punch biopsy skin specimen from right flank (fig. 6):
detailed sexual history and HIV screening be considered in abrupt The epidermis shows mild focal basal vacuolar alteration with a rare
onset of EDP. As other cutaneous conditions may be present with apoptotic keratinocyte. A sparse superficial perivascular lymphocytic
EDP, patients with HIV who develop skin lesions of varying infiltrate, accompanied by melanophages, is present.
morphologies should be thoroughly evaluated. Diagnosis: Focal interface dermatitis with melanin incontinence
 Abstract ID: DSS55

Track: Medical Dermatology

Contact Author: Yan Ling Kong

Country: Singapore

Organization: National Skin Centre

Poster View Here

Acute lipodermatosclerosis: A mimic of cellulitis

A 58-year old lady, with a past medical history of diabetes mellitus and hypothyroidism, was
admitted under orthopaedic surgery for a 1-month history of pain, swelling and redness over
her left shin. She does not recall a history of trauma and there was no associated fever.

On examination, there was an indurated, tender and warm erythematous plaque on her left
anterior shin. There were extensive varicosities on both lower limbs. Her distal pulses were well
felt. Full blood count did not reveal leucocytosis, and C-reactive protein was not elevated. Blood
cultures were negative. The impression was that of cellulitis and she was commenced on
intravenous cefazolin. Her condition remained slow to improve despite multiple changes of
broad-spectrum antibiotics.

The patient was reviewed by dermatology a week into her admission. In view of the failure of
antibiotics, and the presence of varicose veins, a differential of acute lipodermatosclerosis was
considered. Further investigations supported this diagnosis. Left lower limb venous
insufficiency scan demonstrated incompetencies of the long and short saphenous veins and
also along the tributaries on the calf. Skin biopsy revealed lobular panniculitis with microcystic
fat degeneration, associated with foamy histiocytes and neutrophils. The patient was started
on pentoxifylline and danazol, with improvement of her symptoms after a few days of treatment.

In conclusion, we wish to raise cognizance amongst clinicians that acute lipodermatosclerosis

may present similarly to cellulitis, and that there is a need to consider this differential especially
in patients with concomitant varicose veins who fail treatment with antibiotics.
Poster:DSS55

Acute lipodermatosclerosis:
A mimic of cellulitis
Kong YL, Chong WS
National Skin Centre, Singapore
Introduction
Several common conditions can mimic cellulitis, creating
a potential for incorrect management.

Case Report
A 58-year old lady, with a past medical history of well-
controlled diabetes mellitus and hypothyroidism, was
admitted under orthopaedic surgery for a 1-month
history of pain, swelling and redness over her left shin.
She does not recall a preceding history of trauma and
there was no associated fever.

On examination, there was an indurated, tender and

warm erythematous plaque on her left antero-medial
Figure 2: Left lower limb venous insufficiency study demonstrated incompentencies
shin (Figure 1). She also had extensive varicosities on in the distal long and short saphenous veins, and also the presence of incompetent
both lower limbs. Her distal pulses were well felt. Full tributaries distributed along the medial, posterior and anterior aspect of the calf.

blood count did not reveal leucocytosis, and C-reactive

Skin biopsy revealed the presence lobular panniculitis
protein was not elevated. Blood cultures were negative.
with microcystic fat degeneration, associated with
Magnetic resonance imaging (MRI) of her left lower limb
foamy histiocytes and neutrophils (Figures 3). The
demonstrated focal cellulitis at the anteromedial shin,
clinical impression was altered to acute LDS of the left
associated with subcutaneous oedema. In view of the
leg, with concomitant cellulitis. In addition to the
clinical and MRI findings, the impression was that of left
intravenous antibiotics, the patient was started on
lower limb cellulitis and she was commenced on
pentoxifylline and danazol, with improvement of her
intravenous cefazolin. However, her condition remained
symptoms after a few days of treatment.
slow to improve despite multiple changes of broad-
spectrum antibiotics.

Figure 1:
Indurated and
warm plaque on
the anteromedial
aspect of the
patient’s shin, on
background of
multiple varicose
veins.

Figure 3: Microcystic fat degeneration along with foamy histiocytes and neutrophils
in the subcutis. Deep vessel thrombosis and red cell extravasation are seen
(haematoxylin and eosin, original magnification x 400).

Discussion and Conclusion

Distinguishing true cellulitis from its mimickers is
The patient was reviewed by dermatology a week into
challenging but critical if we are to avoid unnecessary
her admission. In view of the presence of varicose veins,
use of antibiotics and delays in treatment. Acute LDS
coupled by the slow resolution despite multiple courses
presents with severe lower-extremity pain above the
of antibiotics, a differential diagnosis of acute
medial malleolus, erythema, oedema, and warmth; this
lipodermatosclerosis (LDS) was considered. Further
can be difficult to distinguish from cellulitis. We wish to
investigations supported this diagnosis. Left lower limb
remind clinicians to consider the diagnosis of acute LDS
venous insufficiency scan demonstrated incompetencies
in patients who fail treatment with antibiotics, especially
of the distal long and short saphenous veins and also
if there are concomitant varicosities associated with
along the tributaries on the calf (Figure 2).
cutaneous changes of stasis dermatitis.
 Abstract ID: DSS10

Track: Viral Infections

Contact Author: Rachel Wenrui Lim

Country: Singapore

Organisation: Singapore General Hospital

Poster View Here

HAND FOOT AND MOUTH DISEASE – A MISNOMER IN ADULTS

A 62-year-old chinese male presented with an asymptomatic palmoplantar rash for 5 days,
preceded by a sore throat. Examination showed purpuric papules on volar fingers/palms and
scaly purpuric papules on forearms. Serosanguineous vesiculobullae overlying scaly plaques
were noted on the dorsum and borders of the feet and soles. There were purpuric vesicles on
the back. There was no mucosal involvement and was apyrexial.

Investigations revealed normal leukocyte count with 23% atypical mononuclear cells. Skin
biopsies over the lower limb and back revealed prominent sub-epidermal oedema with
moderate superficial perivascular lymphocytic infiltration and irregular psoriasiform dermatitis
respectively. No vasculitis was noted and direct immunofluorescence was positive with granular
C3 deposits in superficial dermal vessel walls in both specimens.

Enterovirus polymerase chain reaction (PCR) from respiratory swab and stool returned positive.
Anti-streptolysin-O-titre, BP180, BP230 and indirect immunofluorescence were negative. He
was treated with topical corticosteroids and a retrospective account revealed exposure to
HFMD.

DISCUSSION

Atypical HFMD is distinct from classic HFMD in that it has (1) a myriad of cutaneous
manifestations, (2) is associated with Coxsackie virus A6 (CV-A6) infection instead of
Coxsackie virus A16 or Enterovirus 71, and (3) is more prevalent in adults compared to children
under five years old.

Dermatological manifestations can be typified: (1) herpangina with Gianotti-Crosti–like lesions,

petechiae/purpura or palmoplantar desquamation; (2) generalized vesiculobullous exanthem
involving the trunk, dorsal hands and feet, resembling varicella; and (3) extensive vesiculation
over flexures of the limbs and trunk, leading a misdiagnosis of eczema herpeticum. Our patient
had findings compatible with categories 1 and 2 of atypical HFMD.

Confirmatory investigations include Enterovirus PCR testing from vesicular fluid or throat
swabs for mucosal lesions. Treatment is symptomatic with hydration and pain relief where
necessary. Prevention of spread may be achieved with hand washing and routine disinfection
of surfaces. Having an index of suspicion for atypical HFMD in acute polymorphic acral
eruptions or atypical vesicular exanthems may prevent unnecessary investigations and over
treatment
Poster: DSS10
 Abstract ID: DSS11

Track: Viral Infections

Contact Author: Stephanie Sutjipto

Country: Singapore

Organisation: Tan Tock Seng Hospital

Poster View Here

Long-standing painful hemorrhagic vesiculobullae of the lower leg - Case of Atypical

Zoster

A lady in her 50s, who was pancytopenic from ongoing chemotherapy for metastatic
nasopharyngeal carcinoma, presented with a 3-month history of persistent and intermittently
painful rashes over her right lower limb. She was systemically well and denied other
dermatoses. Examination demonstrated crops of tense hemorrhagic vesicles, each surrounded
by a livid purpuric base over the right plantar aspect of the foot with areas of eschar over right
medial hallux. No dysesthesia/lymphadenopathy. A punch biopsy was performed over an intact
vesicle. Histopathological examination showed full-thickness epidermal necrosis with
ballooning-degeneration resulting in an intra-epidermal blister. Multinucleated keratinocytes
with nuclear moulding seen within the blister cavity. GMS, Ziehl-Neelsen and Gram stains were
negative. Granular IgG, IgM and C3 seen intra-murally. DNA analysis of vesicular fluid positive
for Varicella Zoster Virus (VZV). The diagnosis of Herpes Zoster of the right S1 dermatome
with primary obliterative vasculitis was established.

DISCUSSION Cutaneous VZV reactivation in the immunosuppressed may present atypically

and persist longer. It has been proposed that in atypical presentations, the reactivated VZV
spread trans-axonally from adjacent nerves to the outermost adventitial layer of the arterial wall.
Proposed mechanisms of viral-induced vasculitis include inflammation due to direct infection of
vessel walls, immune complex-mediated, cell-mediated hypersensitivity or inflammation from
immune dysregulation. VZV-induced vasculitis is caused by direct infection of the blood vessels
by the virus instead of vascular damage from secondary inflammatory process. There are
several differentials to consider. Bullous cutaneous vasculitis may present similarly but its
unilaterality and distribution would not be in keeping. Angioinvasive fungal infections may
present with scattered ulceronecrotic lesions to purpuric vesiculobullous dermatoses. However,
the clinical stability and that no fungal organisms were seen on GMS staining of biopsy tissue
dispute fungaemia. Atypical hand-foot-mouth-disease is associated with Coxsackievirus A-6
infection. It may appear as generalized vesiculobullous exanthem resembling varicella. The
chronic nature makes this unlikely. Our patient had oral acyclovir with complete resolution.
Poster:DSS11
Long-standing painful hemorrhagic vesiculobullae of the
lower leg - Case of atypical zoster
Sutjipto Stephanie, Lim Hua-Liang Joel, Tan Siyun Lucinda
Tan Tock seng Hospital, Singapore

Case Presentation
• A lady in her 50s, who was pancytopenic from A B
ongoing chemotherapy for metastatic naso-
pharyngeal carcinoma, presented with a three
month history of persistent and intermittently
painful rashes over her right lower limb (Figure
A-B).
• She was systemically well and denied other
dermatoses.
• Examination demonstrated scattered crops of
tense haemorrhagic vesicles, each surrounded
by a livid purpuric base over the right plantar
aspect of the foot with areas of eschar over
right medial hallux.
• No allodynia, hyperaesthesia or
lymphadenopathy noted.

Discussion
D

Discussion
• A punch biopsy was performed over an intact vesicle
C D
(Figure C-D).
• Histopathological examination showed full-
thickness epidermal necrosis with ballooning
degeneration resulting in an intra-epidermal blister.
Multinucleated keratinocytes with nuclear moulding
seen within the blister cavity.
o Gomori Methamine Silver (GMS), Ziehl-Neelsen
and Gram stains were negative.
o Granular IgG, IgM and C3 were seen intra-murally.
o DNA analysis of vesicular fluid returned positive
for Varicella Zoster Virus (VZV).
• The diagnosis of HZ of the right S1 dermatome with
primary obliterative vasculitis was established.
• Our patient was treated with oral acyclovir with
prompt resolution of rashes.
• Cutaneous VZV reactivation in the immunosuppressed may present atypically and lesions may
persist longer.
o It has been proposed that in these atypical presentations, the reactivated VZV spread trans-axonally
from adjacent nerves to the outermost adventitial layer of the arterial wall1.
o Proposed mechanisms of viral-induced vasculitis include inflammation due to direct infection of vessel
walls, immune complex-mediated reaction, cell-mediated hypersensitivity or inflammation due to
immune dysregulation2.
o VZV-induced vasculitis is caused by direct infection of the blood vessels by the virus instead of
vascular damage from secondary inflammatory process3.
• There are several important differentials to consider in this case.
o Bullous cutaneous vasculitis may present similarly but its unilaterality and distribution would not be in
keeping.
o Angioinvasive fungal infections in immunocompromised patients may present with scattered
ulceronecrotic lesions to purpuric vesiculobullous dermatoses4. However, no fungal organisms were
seen on GMS staining of biopsy tissue
o Atypical HFMD tends to affect adults and is associated with Coxsackievirus A-6 infection5. It may
appear as generalized vesiculobullous exanthem resembling varicella. The chronic nature and
restricted extent of the rash makes this unlikely.

References
1.Uhoda I, Piérard-Franchimont C, Piérard GE. Varicella-zoster virus vasculitis: a case of recurrent varicella without epidermal involvement. Dermatology.
2000;200(2):173-175.
2.Teng GG, Chatham WW. Vasculitis related to viral and other microbial agents. Best Practice & Research Clinical Rheumatology. 2015;29(2):226-243.
3.Nagel MA, Gilden D. Developments in varicella zoster virus vasculopathy. Current neurology and neuroscience reports. 2016;16(2):12.
4.Pfaller MA, Diekema DJ. Epidemiology of invasive mycoses in North America. Critical reviews in microbiology. 2010;36(1):1-53.
5.Lott JP, Liu K, Landry M-L, et al. Atypical hand-foot-and-mouth disease associated with coxsackievirus A6 infection. Journal of the American Academy of
Dermatology. 2013;69(5):736-741.
 Abstract ID: DSS50

Track: Bacterial Infections

Contact Author: Amitha Chandima Ranasinghe

Country: Singapore

Organization: National Skin Centre

Multifocal Tuberculosis Verrucosa Cutis - A case report

Background
Mycobacterium tuberculosis is an acid and alcohol fast bacilli which has affected humans for
centuries.it causes pulmonary as well as extra pulmonary infections in humans. Cutaneous
Tuberculosis constitutes of only 1.5 of all tuberculosis infections. Multifocal involvement of the
skin is even rare. Herein, we report a case of multifocal verrucous Tuberculosis in a 34 year
old male without a primary focus.

Case presentation
A 34 year old manual labourer presented with multiple skin lesions over both legs for 3 years
duration. They have initially started over Right knee as asymptomatic erythematous papules,
later formed verrucous papules and plaques involving both lower limbs. Examination revealed
multiple well defined discrete to coalescent verrucous erythematous papules and plaques over
anterior lateral aspect of both legs, more over the right leg involving the knee. Lesions were not
fixed to the underlying structures. General and systemic examination findings were normal. The
routine investigations including chest radiography was normal. Skin biopsy showed
pseudoepitheliomatous hyperplasia with multiple ill-defined granulomas rimmed by
lymphocytes without necrosis.
Considering the clinical presentation and biopsy findings he was diagnosed as Tuberculosis
verrucosa cutis (TBVC) and started on isoniazid, rifampicin, ethambutol, and pyrazinamide,
daily for 2 months, followed by isoniazid and rifampicin for 4 months for which, he responded
well and his lesions were completely healed after six months of treatment.

Discussion
TBVC is characterized by the presence of verrucous plaque-like lesions, due to direct
inoculation of the organism into the skin of a previously infected patient. However, multifocal
verrucous plaques in an immunocompetent patient without any other tuberculous foci are rare.
Therefore, multifocal pattern of the disease in this patient may be due to either haematogenous
spread of the disease or direct inoculation from unrecognized minor trauma as he is a manual
labourer.
 Abstract ID: DSS24

Track: Fungal Infections

Contact Author: Ellie Choi

Country: Singapore

Organisation: National University Hospital

Poster View Here

Pustular Tinea Manuum from Trichophyton erinacei Infection

Background
Trichophyton erinacei is a zoonotic dermatophyte that is rarely isolated as a human pathogen.
It causes a localized itchy rash at the size of contact, and is typically reported in the context of
hedgehog exposure. We describe the first documented case of T. erinacei in Singapore, in a
patient who developed pustular tinea manuum after contact with a hedgehog.

Case presentation
A 37-year-old lady presented with a 2-week history of an itchy and painful pustular rash over
the left palm. She reported an exposure to cactus sap and getting pricked in the plant nursery
she was working in prior to the rash.

She had a background of HLA-27 positive spondyloarthropathy on methotrexate and

prednisolone.

The initial impression was a contact dermatitis to cactus sap with secondary pyoderma. The
differential diagnosis was pustular psoriasis. A swab was taken for bacterial, mycobacterial and
fungal cultures. She was treated with oral Augmentin, gentrisone, potassium permanganate
compress, and advised avoidance of gardening. On review 6 days later, the lesions were
persistent hence a skin biopsy was performed. The histology showed subcorneal pustules with
spongiotic dermatitis and a neutrophilic infiltrate. Septated fungal hyphae were seen. Fungal
culture from the skin swab and skin biopsy grew T. erinacei.

On further history, it transpired that she had contact with a pet hedgehog in the month prior,
and had been bitten and pricked by its thorns. She was given a two-week course of oral
terbinafine with remarkable resolution of the rash.

Discussion
T. erinacei infection in humans may present as an erosive inflammatory vesiculopustular
eruption, or scaling eczematous plaques mimicking eczema. Infection in hedgehogs may be
asymptomatic, or may present with scaling and loss of quills.

Topical antifungals are rarely adequate and systemic treatment options include terbinafine and
itraconzole. The animal ideally should be treated as well.

Such zoonotic infections are rare and as in our patient, the inoculating event may be only
determined post isolation of the fungus. An index of suspicion is important, especially with the
rising number of exotic domestic pets.
Poster:DSS24

Pustular Tinea Manuum from

Trichophyton erinacei Infection
REPLACE THIS
BOX WITH YOUR
ORGANIZATION’
S
HIGH Ellie Choi1, Jingxiang Huang2 , Ka Lip Chew3 , Huma Jaffar1 , Chris Tan
RESOLUTION
LOGO
1. Division of Dermatology, Department of Medicine, National University Healthcare System, Singapore
2. Department of Pathology, National University Healthcare System, Singapore
3. Department of Laboratory Medicine, National University Hospital, Singapore

ABSTRACT INTRODUCTION
Trichophyton erinacei is a member of
Trichophyton the Trichophyton mentagrophytes
erinacei is a complex, a zoonotic dermatophyte
zoonotic that is rarely isolated as a human
pathogen. It often causes a localized
dermatophyte that is itchy rash at the size of contact, and
rarely isolated as a is typically reported in the context of
human pathogen. hedgehog exposure (1–7).

Epidemiologically, T. erinacei was first

It is typically recognized in New Zealand, followed
reported in the by Europe, Africa and Australia. Case
reports have been reported in East
context of hedgehog Figure 1: Small erythematous papules Figure 2: Small lakes of pustules over the
Asia since early 2000s such as Japan and pustules over the left palm left palm 2 days later
exposure. (7), Korea (1) and Taiwan (5). This
case reports the first case of T.
We describe the first erinacei arising in Southeast Asia
after contact with a hedgehog.
documented case of
T. erinacei in
Singapore, in a CASE REPORT
patient who
developed pustular A 37-year-old lady with a history of
tinea manuum after HLA-27 positive spondyloarthropathy
treated with methotrexate (7.5mg
contact with a OM) and prednisolone (10mg OM)
hedgehog. presented to the emergency Figure 3: Development of small pustular Figure 4. Development of small pustular
department (ED), and subsequently lakes 1 week later lakes 1 week later
dermatology clinic for a pustular rash
over the left hand.

It started two weeks prior as a single

pustule on the thumb, before
spreading to involve the whole palm
and dorsal web space (Figure 1 and
2). It was itchy and painful. She had
intermittent fever for the past 2
weeks.

She reported an exposure to cactus

sap and getting pricked in the plant
nursery she was working in prior to
Figure 5. PAS stain and imaged at 600x Figure 6. Complete resolution 2 weeks after
the onset of the rash.
magnification, showing septated fungal initiate of course of terbinafine
hyphae within the stratum corneum.
On dermatology review, there were
pustules coalescing into small lakes PROGRESS
over the palm and dorsal web space
(Figures 3, 4). The nails were Histology from the skin punch biopsy showed spongiotic dermatitis with subcorneal
uninvolved, and there were no other pustules and a neutrophilic infiltrate (Figure 5). Septated fungal hyphae were seen in
rashes on other parts of her body. the stratum corneum. Fungal cultures from both the skin swab and skin biopsy grew
Trichophyton erinacei.

On further history, it transpired that she had been in contact with her friend’s pet
INITIAL IMPRESSION hedgehog on two occasions in the month prior, and had been bitten and pricked by
its thorns. She was given a two-week course of oral terbinafine with remarkable
The initial impression was a contact
dermatitis to cactus sap with resolution of the rash (Figure 6).
secondary pyoderma. The differential
diagnosis was pustular psoriasis in
DISCUSSION AND CONCLUSION
view of her history of HLA 27
Trichophyton erinacei Infection typically occurs at the sites of contact– most
spondyloarthropathy. She was given commonly the hands as in tinea manuum (1,4,6,7), and less frequently as tinea facei
an empiric course of oral augmentin, (2) and tinea kerion barbae (3). They may present as an erosive inflammatory
topical gentrisone, PP compress, and
vesiculopustular eruption (1,5), or scaling eczematous plaques mimicking
advised avoidance of gardening. eczema(1,4). Infection in hedgehogs may be asymptomatic, or may present with
scaling and loss of quills(1).
Skin swabs for fungal,bacterial culture
and a skin punch biopsy was Such zoonotic infections are rare and as in our patient, the inoculating event may be
performed.
only determined post isolation of the fungus (3). An index of suspicion is important,
REFERENCES
especially with the rising number of exotic domestic pets.
Refeerences 4. Schauder S, Kirsch-Nietzki M, Wegener S, Switzer E, Qadripur SA. [From hedgehogs to men.
1.Rhee D-Y, Kim M-S, Chang S-E, Lee M-W, Choi J-H, Moon K-C, et al. A case of tinea manuum Zoophilic dermatophytosis caused by Trichophyton erinacei in eight patients]. Hautarzt Z Dermatol
caused by Trichophyton mentagrophytes var. erinacei: the first isolation in Korea. Mycoses. 2009 Venerol Verwandte Geb. 2007 Jan;58(1):62–7.
May;52(3):287 90. 5. Hsieh C-W, Sun P-L, Wu Y-H. Trichophyton erinacei infection from a hedgehog: a case report
2. Concha M, Nicklas C, Balcells E, Guzmán AM, Poggi H, León E, et al. The first case of tinea from Taiwan. Mycopathologia. 2010 Dec;170(6):417–21.
faciei caused by Trichophyton mentagrophytes var. erinacei isolated in Chile. Int J Dermatol. 2012 6. Philpot CM, Bowen RG. Hazards from hedgehogs: two case reports with a survey of the
Mar;51(3):283–5. epidemiology of hedgehog ringworm. Clin Exp Dermatol. 1992 May;17(3):156–8.
3. Sidwell RU, Chan I, Francis N, Bunker CB. Trichophyton erinacei kerion barbae from a 7. Mochizuki T, Takeda K, Nakagawa M, Kawasaki M, Tanabe H, Ishizaki H. The first isolation in
hedgehog with direct osculatory transfer to another person. Clin Exp Dermatol. 2014 Jan;39(1):38–Japan of Trichophyton mentagrophytes var. erinacei causing tinea manuum. Int J Dermatol. 2005
40. Sep;44(9):765–8
 Abstract ID: DSS38

Track: Fungal Infections

Contact Author: Tanojo Natalia

Country: Indonesia

Organisation: Others

Poster View Here

PITYRIASIS VERSICOLOR MIMICKING LEPROSY: CASE REPORT

Background
Pityriasis versicolor is a common dermatomycosis often characterized by hypopigmented
macules on darker skin patients. Hypopigmented macules are often diagnosed as leprosy in
endemic countries, including Indonesia.

Case Presentation
We report the case of a male patient, aged 26, who was diagnosed with leprosy in a private
practice, was actually affected by Pityriasis versicolor. Physical examinatation reveals 2
hypopigmented macules with irregular borders. The lesions were bright yellow under Wood’s
lamp examination. Mycological examination showed spaghetti meatball appearance.
Treatment with antifungal drugs was entirely successful.

Discussion
In countries endemic of leprosy, a thorough skin examination should be done to ensue correct
diagnosis. Simple examinations such as wood’s lamp and KOH examination should be made
available in private practices, especially in rural areas, to avoid the risk of mistaken diagnosis
and consequent incorrect treatment.
Poster:DSS38

Pityriasis Versicolor Mimicking Leprosy: Case Report

Tanojo N

BACKGROUND

• Pityriasis versicolor is a common

dermatomycosis often characterized by
hypopigmented macules on darker skin
patients.
• Hypopigmented macules are often diagnosed
as leprosy in endemic countries, including
Indonesia.
• Here we present a case of pityriasis versicolor
that was previously diagnosed as leprosy in a
young man.
Figure 1

CASE PRESENTATION
• A 26-year old male came with a chief
complaint of whitish lesions that had been
growing in size for the past 10 months. No
complaint of itchiness.
• Patient were initially referred from private
clinic for screening of leprosy due to high
incidence of leprosy and initial examination of
sensory loss with ballpoint pen. He received
no treatment from the initial clinic.
• Clinical examination showed hypopigmented
macules with irregular border on the neck
(Figure 1). No apparent loss of sensation over
the areas of hypopigmentations. No
abnormality on the eye and peripheral
nerves.
• The lesions were bright yellow under Wood’s
lamp examination. A potassium hydroxide
preparation showed spaghetti meatball
appearance. Routine blood examination,
kidney and liver functions were within normal
limits.
• A diagnosis of pityriasis versicolor was
established.
• Treatment with antifungal drugs over the
course of 2 weeks was entirely successful.
DISCUSSION
• High index of suspicion for leprosy in patients
from endemic area often create overdiagnosis
of leprosy.
• Careful sensory testing is required, in this
case monofilament is prefered than ballpoint
pen. Patient’s cooperation needs to be
ensured as well.
• Further examinations with the help of wood’s
lamp and microscopic examination of
potassium hydroxide preparations often
confirm the diagnosis in relatively short time.
• These will prevent the risk of under and
overdiagnosis and consequent incorrect
treatment.
CONCLUSIONS
• Hypopigmented macules are often caused by
pitiriasis versicolor, although leprosy should
be considered especially in endemic area.
• Further examinations with wood’s lamp and
direct microscopic examination of pottasium
hydroxide preparate help to achieve correct
diagnosis.

References:
1. Gupta AK, et al. Pityriasis versicolor: an update on pharmacological treatment options. Expert Opin Pharmacother. 2014 Aug;15(12):1707-13.
2. Yang S, et al. A case of Hansen Disease presenting as tinea versicolor. Dermatol Online J. 2013 Apr 15;19(4):7.
3. Koelewijn LF, et al. Sensory testing in leprosy: comparison of ballpoint pen and monofilaments. Lepr Rev. 2003 Mar;74(1):42-52.
 Abstract ID: DSS53

Track: Parasitic Infections

Contact Author: Indira Dharmasamitha

Country: Indonesia

Organization: Others

Poster View here

Cutaneous Larva migrans with combination therapy : A case report

Indira Dharmasamitha1*, Nyoman Suryawati1

1Department of Dermatology and Venereology Faculty of Medicine Udayana University
Sanglah Hospital, Bali, Indonesia
*indiradharma@gmail.com

Abstract
Introduction:
Cutaneous larva migrans (CLM) is the most frequent syndrome with serpiginous lesions and
shows a characteristic creeping eruption. Even it’s a self-limiting disease, it can be
misdiagnosed or treated incorrectly and can lead to prolonged morbidity and extension of
lesion. Combination therapy may helpful in reducing the treatment period.

Case:
We present a 25-year-old Asian male, Javanese, seek for medical attention with chief complaint
of itchy and redness on the left ankle and also on the back after traveling from Samarinda, East
Kalimantan. Previously, patient had misdiagnosed and treated incorrectly with topical antibiotic
and as a result the lesion got extensive and more itch. The redness on the left ankle and back
has a serpiginous form. Diagnosis of CLM was achieved from anamnesis and physical
examination. We managed this patient using a combination therapy of topical anthelmintic,
systemic anthelmintic, and cryotherapy with liquid nitrogen. Patient showed improvement on
skin lesion and clinical symptoms after had topical Albendazole 10% ointment application for 4
days combine with 1 cycle of cryotherapy using liquid nitrogen and 5 days of 400 mg
Albendazole. The serpiginious lesion healed by hypopigmentation lesion after combination
therapy.

Discussion:

CLM faces therapeutic challenge. These days, cases are increasingly rare in urban areas, so
mostly patient came already with prolonged and extension of lesion. Systemic anthelmintic
have been the first choice of treatment for CLM. However, a monotherapy seems having a
greater risk to recurrence and a longer treatment period. Alternative approach is needed to
manage CLM to reduce the treatment period and lower risk of recurrences by having a
combination therapy.
Poster: DSS53

Indira Dharmasamitha1*, Nyoman Suryawa 1, Made Swas ka Adiguna1

1Department of Dermatology and Venereology

Faculty of Medicine Udayana University Sanglah Hospital, Bali, Indonesia

*indiradharma@gmail.com

Day 1 : Oct Day 4 : Oct Day 21 : Oct

9th 2017 13th 2017 30th 2017
 Abstract ID: DSS20

Track: Skin Tumours (Benign / Malignant)

Contact Author: Yisheng Wong

Country: Singapore

Organisation: National Skin Centre

Poster View Here

A Case Of Metastatic Extramammary Paget's Disease Requiring Sigmoid Colostomy

A 78 year old Chinese female presented with an enlarging erythematous patch over the groin
area for 15 years. Clinical examination showed an extensive erythematous plaque involving the
lower abdomen, groin, introitus, gluteal and perianal region. Histology revealed evidence of
extramammary Paget's disease (EMPD). Staging studies with magnetic resonance imaging
showed metastatic disease involving the liver. This case demonstrates the challenging nature
of treating extensive EMPD with metastases.
Poster: DSS20
An Uncommon Case Of
Metastatic Extramammary Paget Disease
Yisheng Wong1, Johnny CA Ong2, Martin TW Chio1
1. National Skin Centre, Singapore 2. Singapore General Hospital
Introduction
• Extramammary Paget disease (EMPD) is an intraepithelial
neoplasm affecting cells rich in apocrine glands – often
located in the vulvar, scrotal or perianal region.
• It typically affects older patients, between the ages of 50 and
80 years old, and is most often limited to the epidermis.
• As a rare, slow-growing malignancy with low metastatic
potential, the incidence of metastases is estimated to be 0.11
per 100,000 person-years1.
• Herein, we present an uncommon case of metastatic EMPD.
We would like to use this case to demonstrate the challenges
in differentiating primary EMPD from secondary EMPD, as
well as in managing cases of extensive EMPD.
Case report
• A 78 year-old Indonesian Chinese female presents with a 15
year history of an expanding, asymptomatic erythematous
plaque over the vulva and perianal region.
• A previous punch biopsy done at our tertiary dermatology
centre 3 years ago was consistent with the diagnosis of
EMPD, but she subsequently defaulted follow-up. She also
defaulted screening for any other primary malignancies.
• On examination, extensive erythematous plaque with
irregular border was noted involving the vulva, perineum and
perianal region, extending to bilateral groin folds, superior
thigh, lower abdomen and gluteal cleft. (Fig 1A, B)
Fig 1A, B. Extensive EMPD involving both anterior and posterior
aspects of the patient’s groin
• Extensive disease was noted on MRI pelvis with multiple
masses and nodules along the urogenital tract invading into
the left levator ani, vagina, rectal wall and the external anal
sphincter. There is also invasion into the urethra resulting in
bilateral hydroureteronephrosis. Enlarged bilateral inguinal
and pelvic lymph nodes were suspicious for nodal disease.
• A subsequent staging CT thorax, abdomen and pelvis
showed metastatic disease affecting the pleural cavity,
peritoneum, right inferior pubic ramus and possibly the liver.
• She was referred to our surgical oncology colleagues and
was discussed at the tumour board. She subsequently
underwent a laparoscopic assisted loop sigmoid colostomy
creation to prevent faecal contamination of the perineum with
subsequent referral to the radiation oncology and palliative
team.
• The patient decided to continue medical care back in
Indonesia due to cost issues.
Discussion
• Our case highlights the difficulty of differentiating primary
from secondary EMPD in patients with infrequent screening
and asymptomatic disease.
• In females, EMPD is associated with underlying invasive
adenocarcinomas in 4 to 17 percent of patients, and another
20 to 30 percent will develop adenocarcinoma at another
non-vulvar location.2
• EMPD with distant metastasis exhibit a poor prognosis with
the median overall survival of 1.5 years and 5-year survival
rate of 7% without treatment.3
• Proposed pathophysiology of metastatic Paget cells include
their interaction with other cells, such as lymphatic
endothelial cells and macrophages in a tumour through the
CXCR4–SDF-1 signaling and RANKL–RANK signaling,
establishing a favorable tumour microenvironment to
promote metastasis of Paget cells.4
• Treatment options for metastatic EMPD are limited and
include several chemotherapeutic regimens. However,
tumour recurrence rates remains high despite over half of
patients initially responding to treatment.5
Conclusion
• Evaluation and long-term follow-up for the possibility of
synchronous neoplasms (breast, lung, colorectum, gastric,
pancreas, and ovary) should be recommended for all patients
diagnosed with EMPD in view of the serious clinical
implication of late diagnosis and the possibility of curative
treatment if disease if detected early in its course.
References
1. Parker LP, Parker JR, Bodurka-Bevers D, et al. Paget's disease of the
vulva: pathology, pattern of involvement, and prognosis. Gynecol Oncol
2000; 77:183.
2. Fanning J, Lambert HC, Hale TM, et al. Paget's disease of the vulva:
prevalence of associated vulvar adenocarcinoma, invasive Paget's
disease, and recurrence after surgical excision. Am J Obstet Gynecol
1999; 180:24.
3. Ohara K, Fujisawa Y, Yoshino K, et al. A proposal for a TNM staging
system for extramammary Paget disease: retrospective analysis of 301
patients with invasive primary tumors. J Dermatol Sci 2016; 83:234–9.
4. Fukuda K, Funakoshi T. Metastatic Extramammary Paget's Disease:
Pathogenesis and Novel Therapeutic Approach. Front Oncol 2018;
8:38.
5. Tokuda Y, Arakura F, Uhara H. Combination chemotherapy of low-dose
5-fluorouracil and cisplatin for advanced extramammary Paget’s
disease. Int J Clin Oncol 2015; 20:194–7.
 Abstract ID: DSS52

Track: Skin Tumours (Benign / Malignant)

Contact Author: Jazlyn Read

Country: Australia

Organization: Others

Poster View Here

Metatypical Basal Cell Carcinoma – not “just a BCC”

Background
Metatypical basal cell carcinoma is a rare and aggressive form of BCC, and shares clinical and
histopathological features of both BCC and SCC. Compared with other subtypes of BCC,
metatypical BCC exhibits higher recurrence rates and an increased risk of metastasis. It has
also been suggested that this subtype may derive from differentiation of BCC into SCC.

Case Presentation
A 65-year-old female presented with an ulcerated lesion within a split skin graft on her left shin,
in the context of previous incompletely excised BCC treated with adjuvant radiotherapy.
Biopsies of the new ulcerated lesion demonstrated infiltrating and metatypical BCC, with the
metatypical component comprising paler cells with reduced peripheral palisading. The existing
split skin graft was excised with a 20mm margin, taking periosteum of the anterior tibia along
the length of the excision, and bone underlying the biopsy sites. Microscopic assessment
showed foci of moderately differentiated SCC. The defect was reconstructed with an ipsilateral
gracilis muscle free flap and split skin graft.

Discussion
The phrase “just a BCC” refers to the reputation of BCC as a slow growing lesion that almost
never metastasises. However, metatypical BCC may have increased propensity for local
recurrence and also risk of metastasis, and thereby warrants elevated concern for adequate
surgical excision margins and also tolerance of close or involved margins. It is possible that the
biopsied metatypical BCC in this case represents a transitional state between the initial
incompletely excised BCC 9 years prior and the subsequent finding of SCC in the final resection
specimen.
Poster: DSS52

Metatypical Basal Cell Carcinoma – not “just a BCC”

Jazlyn Read1, Brendan Louie 1
1 Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia

Background

Metatypical basal cell carcinoma is a rare and aggressive form

of BCC, and shares clinical and histopathological features of
both BCC and SCC.

Compared with other subtypes of BCC, metatypical BCC

exhibits higher recurrence rates and an increased risk of
metastasis.1 It has also been suggested that this subtype may
derive from differentiation of BCC into SCC.

Case Presentation
A 65 year old female presented with an ulcerated lesion within a
split skin graft on her left shin, in the context of previous
incompletely excised BCC 9 years prior. The original lesion was
a multifocal superficial, micronodular, and sclerosing type BCC
with perineural invasion of nerves up to 0.1mm. The tumour
extended to the deep and peripheral margins, and she received
adjuvant radiotherapy.

Biopsies of the new ulcerated lesion demonstrated infiltrating

and metatypical BCC, with the metatypical component
comprising paler cells with reduced peripheral palisading.
Clinically the lesion was adherent to the underlying tibia, and a
CT scan demonstrated perisoteal thickening but no bony
erosion.

The existing split skin graft was excised with a 20mm margin,
taking periosteum of the anterior tibia along the length of the
excision, and bone underlying the biopsy sites (Figure 1). Figure 1: lesion left anterior shin, pre-operative with 20mm margin marked.
Ulcerated lesions on medial aspect of existing SSG.
Microscopic assessment showed foci of moderately
differentiated SCC. The defect was reconstructed with an
ipsilateral gracilis muscle free flap and split skin graft (Figure 2).
Discussion

The phrase “just a BCC” refers to the reputation of BCC as a slow growing lesion
that almost never metastasizes. However, metatypical BCC may have increased
propensity for local recurrence and also risk of metastasis, with reported local
recurrence rates of 10 – 45% and metastatic rates of 5 – 8.4%. 1 Metatypical
BCC therefore warrants elevated concern for adequate surgical excision margins
and also for tolerance of close or involved margins.

The terms ‘metatypical’ and ‘basosquamous’ are often used interchangeably, and
both are characterised by features of BCC and SCC, with the presence of
‘metatypical’ cells. Metatypical cells are an intermediate type that are larger and
paler than basaloid cells of BCC but smaller and less eosinophilic than those of
SCC. 2

Dermoscopic features that could alert to the possibility of metatypical BCC

include keratinisation in conjunction with morphologic features of BCC. 3
Figure 2: post-operative. Left: defect following 2 weeks of VAC
It is possible that the biopsied metatypical BCC in this case represents a
dressing. Right: immediately post gracilis free flap with SSG.
transitional state between the initial incompletely excised BCC 9 years prior and
the subsequent finding of SCC in the final resection specimen.

References

1. Tan CZ, Rieger KE, Sarin KY. Basosquamous Carcinoma: Controversy, Advances, and
Future Directions. Dermatol Surg. 2017;43(1)23-31.
2. Allen KJ, Cappel MA, Killian JM, Brewer JD. Basosquamous carcinoma and
metatypical basal cell carcinoma: a review of treatment with Mohs micrographic
surgery. Int J Dermatol. 2014;53(11):1395-403.
3. Akay BN, Saral S, Heper AO, Erdem C, Rosendahl C. Basosquamous carcinoma:
Contact Dermoscopic clues to diagnosis. J Dermatol. 2017;44(2):127-134.
Dr Jazlyn Read
Email: uqjread4@uq.edu.au
 Abstract ID: DSS54

Track: Skin Tumours (Benign / Malignant)

Contact Author: Venny Tandyono

Country: Indonesia

Organization: Others

Poster View Here

Management of Keratoacanthoma with Elliptical Excision: A Case Report

Background: Keratoacanthoma is a keratin tumor that may be easily mistaken with squamous
cell carcinoma, both clinically and histopathologically. The accurate management is the biggest
challenge. Many treatment options are available, with surgical treatment still becomes the
mainstay management for keratoacanthoma.

Case Presentation: A 73-year-old Caucasian male reported a painless firm skin nodule of
progressive growth on the right cheek since 6 months ago. Within 3 months, erosion developed
on the surface of the nodul, and several times the patient was treated by dermatologist with
electrosurgery. The patient was exposed to sunlight on a daily basis, and was classified as
skin phototype II. Other past illness histories were unremarkable. Upon dermatologic status,
there was solitary erythematous tumor, round-to-oval-shaped, sized 1 cm in diameter, with
telangiectasia on the surrounding skin. Dermoscopic examination showed central yellowish
structureless mass, surrounded with polymorphic vessels, on a white background. The patient
was treated with elliptical excision with the safety margin of 5 mm. Histopathological
examination showed exoendophytic lesion consisted of predominately large pale pink cells,
nuclear atypia were only seen in the peripheral areas, some infiltrated into the dermis without
extension beyond than eccrine glands. There was also central keratin-filled crater with
overhanging epithelial lips, which suggested the diagnosis of keratoacanthoma.

Discussion: Keratoacanthoma is a cutaneous tumor that usually affects elderly patients. It

commonly appears in hair-bearing regions, central part of the face, and chronic sun-exposed
skin. There are some clinical variants of this tumor, of which the solitary one is the most
common type. The clinical characteristic is mostly a rapidly growing tumor and subsequently
shows a slow involution over a period of months. Though it has a tendency to regress
spontaneously, active management is considered due to potential malignant transformation
and it could clinically mimic invasive squamous cell carcinoma. Surgical treatment with full-
thickness elliptical excision is the gold standard regiment as it provides good esthetic outcome
and optimal specimen for pathologist.

Keywords: Keratoacanthoma, squamous cell carcinoma, excision surgery.

Poster: DSS54

Tandyono Venny, Wardhana Made

Department of Dermatology and Venereology, Udayana University,
Sanglah General Hospital, Denpasar-Bali, Indonesia

BACKGROUND
Keratoacanthoma is a keratin tumor that may be easily mistaken with squamous cell carcinoma, both clinically and
histopathologically. The accurate management is the biggest challenge. Many treatment options are available, with
surgical treatment still becomes the mainstay management for keratoacanthoma.

CASE PRESENTATION
A 73-year-old Caucasian male reported a painless firm skin nodule of progressive growth on the right cheek since
6 months ago. Within 3 months, erosion developed on the surface of the nodul, and several times the patient was
treated by dermatologist with electrosurgery. The patient was exposed to sunlight on a daily basis, and was
classified as skin phototype II. Other past illness histories were unremarkable. Upon dermatologic status, there
was solitary erythematous tumor, round-to-oval-shaped, sized 1 cm in diameter, with telangiectasia on the
surrounding skin. Dermoscopic examination showed central yellowish structureless mass, surrounded with
polymorphic vessels, on a white background. The patient was treated with elliptical excision with the safety margin
of 5 mm. Histopathological examination showed exoendophytic lesion consisted of predominately large pale pink
cells, nuclear atypia were only seen in the peripheral areas, some infiltrated into the dermis without extension
beyond than eccrine gland. There was also central keratin-filled crater with overhanging epithelial lips, which
suggested the diagnosis of keratoacanthoma.

Fig 4. Histopathological features showed lipping, exoendophytic lesion with cellular

Fig 1. Solitary erythematous
tumor on the right cheek
Fig 2. Dermoscopic examination.
Central yellowish structureless mass
and polymorphic vessels. Hairpin &
glomerular vessels (O), branching
vessel ( ), telangiectasia (arrowhead)
atypia without extension beyond eccrine gland.
DISCUSSION
Keratoacanthoma is a cutaneous tumor that usually affects
elderly patients. It commonly appears in hair-bearing
regions, central part of the face, and chronic sun-exposed
skin. There are some clinical variants of this tumor, of
which the solitary one is the most common type. The
clinical characteristic is mostly a rapidly growing tumor and
subsequently shows a slow involution over a period of
months. Though it has a tendency to regress
spontaneously, active management is considered due to
potential malignant transformation and it could clinically
mimic invasive squamous cell carcinoma. Surgical
treatment with full-thickness elliptical excision is the gold
standard regiment as it provides good esthetic outcome
and optimal specimen for pathologist.

References
1. Cerroni L, Kerl H. Keratoacanthoma. In: Goldsmith LA, Katz SI, Gilchrest BA,
Paller AS, Leffel DJ, Wolf K, editors. Fitzpatrick’s Dermatology in General
Medicine. 8th Ed. New York: McGraw-Hill; 2012. p.1312-1318.
2. Kallini JR, Hamed N, Khachemoune A. Squamous cell carcinoma of the skin:
epidemiology, classification, management, and novel trends. International
Journal of Dermatology. 2015; 54: 130-140.
3. Zalaudek I, Cameron A, Rosendahl C. Actinic keratosis, bowen’s disease,
keratoacanthoma, and squamous cell carcinoma. In: Marghoob AA, Malvehy
Fig 3. Elliptical excision and secondary closure with simple interrupted J, Braun RP, editors. Atlas of Dermoscopy. 2nd Ed. USA: Informa Healthcare;
sutures and rule of halves 2012.p.48-57
 Abstract ID: DSS59

Track: Skin Tumours (Benign / Malignant)

Contact Author: Rayson Rui Sheng Lee

Country: Singapore

Organization: Singapore General Hospital

Poster View Here

Acral Melanoma: A Case Study

Introduction
Melanoma incidence within Asia is significantly lower compared to the United States of America
and Europe. In this population, acral lentiginous melanoma (ALM) is the most common
histological variant. This subtype has a longer time to diagnosis, and is typically less aggressive
than other subtypes. While it is prudent to monitor clinically benign appearing lesions, some
acrally located melanomas are not ALM and other more aggressive subtypes have to be
considered as well.

Case Presentation
A 38-year-old male reported a painless melanocytic lesion on the sole of his right foot that
gradually increased in size and intensity of colour over 6 to 12 months. The lesion started
ulcerating a week prior to his medical consult. Examination revealed an ulcerated, oviod lesion
measuring 2cm by 1.3cm at the head of the second metatarsal on the plantar surface of the
right foot. A wide excision and sentinel lymph node biopsy was performed, revealing Stage IIIA
nodular melanoma with involvement of one lymph node.

Discussion
Reasons cited by patients for delaying medical consult include a perception that their lesions
were benign and insufficient understanding about the urgency of their condition. Similarly, this
case study delayed seeking treatment because he perceived his lesion as benign. More
effective education measures need be put in place to educate the public about melanoma and
to do self-skin exams.

The delay in making the diagnosis of melanoma by doctors is largely due to its mimicry of other
lesions. Moreover, while ALM is the most common melanoma in Asian population, not all acral
lesions are ALM. Superficial spreading and nodular melanoma also present on volar surfaces.
Nodular melanomas are more aggressive so more caution should be taken in making
diagnoses. Closer follow up can be enforced and there should be a lower threshold for biopsy
of suspicious lesions.
Poster: DSS59

Acral M elanoma, Not What It Seems:

A Case St udy
Rayson RS Lee, Martin TW Chio

Introduction A positron emission tomography (PET) computed tomography

Melanoma incid ence within Asia is significantly lower
compared to USA and Europe. Incid ence rates in the US
average 18.3 per 100,000 patients yearly1. Incid ence rates in
Singapore are significantly lower at 0.2 to 0.5 per 100,000
patient years2. In the Asian population, acral lentiginous
melanoma (ALM) is the most common histological variant,
ranging from 50 to 58% of all d iagnosed melanoma3-5.
This subtype has a longer lead time to discovery and has a
longer delay before patients pursue medical attention 3. This is
because lesions are:
1. Relatively obscure
2. More insidious in onset than other subtypes6
While it is prudent to monitor clinically b enign appearing
lesions, some acrally located melanomas are not ALM and
other aggressive subtypes have to be consid ered as well7.
Case
(CT) scan revealed no nodal or distant metastases. The patient
then underwent wide excision and sentinel lymph node biopsy
and right medial plantar artery flap reconstruction of right
forefoot plantar defect. An elliptical piece of skin measuring
6.4cm by 4.5cm was excised. Frozen sections taken from 8
equally spaced out regions on the specimen showed no
evidence of malignancy. Of the 2 sentinel lymph nodes
biopsied, one lymph node showed infiltration by multiple foci
of malignant spindle and epithelioid cells at the subcapsular
and intramedullary region. The other lymph node showed no
signs of malignancy. The final diagnosis of Stage IIIA nodular
melanoma was established and the patient was started on
nivolumab adjuvant therapy.
Discussion
Reasons cited by patients for d elaying medical consult include:
1. A perception that their lesions were benign
2. A lack of understanding about the urgency of their
condition 8.

The case presented above was a young and educated

A 38-year-old male was seen at the National Skin Centre (NSC)
for a painless melanocytic lesion on the sole of his right foot
that gradually increased in both size and intensity of colour
over the course of 6 to 12 months. The lesion started ulcerating
about a week prior to his appointment at NSC. He reported no
constitutional symptoms and did not seek treatment p rior to
presentation at NSC.
On p resentation (Fig 1), the p atient
was alert and comfortable. Gross
inspection showed a patient who
had sparse melanocytic nevi on his
trunk and extremities (cause risk
factor). The lesion was located at
the head of the second metatarsal
on the p lantar surface of the right
foot. It was an ovoid nodule that
measured 2cm by 1.3cm. The
surface was ulcerated and
Fig 1: Melanocytic lesion
peripheries were verrucuous. There
at first presentation
were no clinically detectable
popliteal or inguinal lymph nodes.
gentleman. Similarly, he delayed diagnosis because he
perceived his lesion as benig n.
Solutions:
1. More effective education measures need be put in place to
educate the public about melanoma and to d o self-skin
exams.
2. Routine medicals should include a skin exam as well.
The delay in making the diagnosis of melanoma by doctors is
largely due to its mimicry of other lesions9. Acral lesions in
general have poorer prognosis10,11 and so special care needs
to b e taken to id entify these. Moreover, while ALM is the most
common melanoma in Asian population, not all acral lesions
are ALM. Superficial spreading and nodular melanoma can
present on volar surfaces as well 7. Nodular melanomas tend to
be more aggressive and have deeper Breslow thickness at
presentation so more caution should be taken in making
diagnoses.
Solutions:
1. Closer follow up should b e enforced
2. Lower threshold for biopsy of suspicious lesions.

Fig 1: Melanoma post
excisional biopsy
The patient subsequently
underwent an excisional biopsy (Fig
2). Histology revealed an ulcerated
nodular melanoma with spindled
and epithelioid cells.
Immunohistochemistry showed that
the tumor was positive on
melanoma triple marker stain. The
Breslow thickness was 4.6mm, and
the tumour was Clarks level IV,
putting the tumour at a minimum of
Stage IIC, based on the AJCC7.
References
1. Wu, X., Eide, M. J., King, J., Saraiya, M., Huang, Y., Wiggins, C., . . . Kim, J. (2011, 11). Racial and ethnic variations in incidence
and survival of cutaneous melanoma in the United States, 1999-2006. Journal of the American Academy of Dermatology, 65(5).
doi:10.1016/j.jaad.2011.05.034
2. Sng, J., Koh, D., Siong, W. C., & Choo, T. B. (2009, 09). Skin cancer trends among Asians living in Singapore from 1968 to 2006.
Journal of the American Academy of Dermatology, 61(3), 426-432. doi:10.1016/j.jaad.2009.03.031
3. Lee, H. Y., Chay, W. Y., Tang, M. B., Chio, M. T., & Tan, S. H. (2012, January). Melanoma: Differences between Asian and
Caucasian patients. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22499476
4. Luk, N. M., Ho, L. C., Choi, C. L., Wong, K. H., Yu, K. H., & Yeung, W. K. (2004, 11). Clinicopathological features and prognostic
factors of cutaneous melanoma among Hong Kong Chinese. Clinical and Experimental Dermatology, 29(6), 600-604.
doi:10.1111/j.1365-2230.2004.01644.x
5. Chen, Y., Wu, C., Chen, J., Shen, J., Chen, C., & Wang, H. (1999, 12). Clinicopathologic analysis of malignant melanoma in
Taiwan. Journal of the American Academy of Dermatology, 41(6), 945-949. doi:10.1016/s0190-9622(99)70251-3
6. Albreski, D., & Sloan, S. B. (2009, 11). Melanoma of the feet: Misdiagnosed and misunderstood. Clinics in Dermatology, 27(6),
556-563. doi:10.1016/j.clindermatol.2008.09.014
7. Kuchelmeister, C., Schaumburg-Lever, G., & Garbe, C. (2000, 08). Acral cutaneous melanoma in caucasians: Clinical features,
histopathology and prognosis in 112 patients. British Journal of Dermatology, 143(2), 275-280. doi:10.1046/j.1365-
2133.2000.03651.x
8. Richard, M. A., Grob, J. J., Avril, M. F., Delaunay, M., Gouvernet, J., Wolkenstein, P., . . . Chemaly, P. (2000, 05). Delays in
diagnosis and melanoma prognosis (I): The role of patients. International Journal of Cancer, 89(3), 271-279. doi:10.1002/1097-
0215(20000520)89:33.3.co;2-z
9. Richard, M. A., Grob, J. J., Avril, M. F., Delaunay, M., Gouvernet, J., Wolkenstein, P., . . . Chemaly, P. (2000). Delays in diagnosis
and melanoma prognosis (II): The role of doctors. International Journal of Cancer, 89(3), 280-285. doi:10.1002/1097-
0215(20000520)89:33.0.co;2-2
10. Bennett, D. R., Wasson, D., MacArthur, J. D., & McMillen, M. A. (1994, September). The effect of misdiagnosis and delay in
diagnosis on clinical outcome in melanomas of the foot. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/8069422
11. Kuchelmeister, C., Schaumburg-Lever, G., & Garbe, C. (2000, 08). Acral cutaneous melanoma in caucasians: Clinical features,
histopathology and prognosis in 112 patients. British Journal of Dermatology, 143(2), 275-280. doi:10.1046/j.1365-
2133.2000.03651.x
 Abstract ID: DSS12

Track: Dermatological Surgery

Contact Author: Reagan Grey Reyes

Country: Philippines

Organisation: Others

Poster View Here

Merkel Cell Carcinoma in a Filipino Patient: A Case Report

This is a case of a 68-year-old Filipino male with a 6-month history of a solitary, erythematous,
firm, non-tender nodule approximately 1.0 x 1.0cm in size located on the radial aspect of the
right posterior forearm with no associated pain or pruritus. He initially self-medicated with
Tretinoin cream with no noted resolution. With the gradual increase in size of the lesion, the
patient consulted with a Dermatologist who assessed him with Lipoma and advised excision
biopsy. The patient eventually had the lesion excised by a General Surgeon which on routine
histopathology turned out to be Merkel Cell Carcinoma.

Special stains done showed CK20 positive, LCA (CD25) negative, NSE positive, CK PAN
positive which are all consistent for Merkel Cell Carcinoma. PET Scan was also done which
showed negative for any regional or distant metastases. The patient then consulted with a
trained Dermatologic Surgeon who then performed Mohs Micrographic Surgery with Full
Thickness Skin Graft Repair. Sentinel Lymph Node Biopsy was also performed by a General
Surgeon and a Nuclear Medicine Specialist.The patient tolerated the procedure with no noted
complications. Pain medications and antibiotics were given. He was then discharged the
following day. Home instructions were advised and regular follow-up was done to monitor
disease progression. The patient was also referred to Radiation Oncology for other treatment
options.
Poster: DSS12
 Abstract ID: DSS15

Track: Dermatopathology

Contact Author: Silfia Mandasari

Country: Indonesia

Organisation: Others

Poster View Here

DIAGNOSTIC CONFIRMATION OF PRIMARY CUTANEOUS DIFFUSE LARGE B-CELL

LYMPHOMA-LEG TYPE : A CASE REPORT

Abstract

Background: Primary cutaneous diffuse large B-cell lymphoma-leg type (PCDLBCL-LT) is a

rare and aggressive lymphoma subtype with the worst prognosis. The incidence of PCDLBCL-
LT is about 0.1/100,000 per year. Diagnostic confirmation for PCDLBCL-LT is difficult, it
requires a combination of clinical, histopathological, and advance immunohistochemical
examination.

Case Presentation: A 73-year-old man complained multiple purplish-red lumps, on the right
lower leg since one year before consultation. Dermatological examination showed multiple
purplish-red nodules and tumors, well-defined, irregular shape, vary in size. Histopathological
examination revealed monoton proliferation of round shape cells, with coarse chromatin,
diffusely arranged from the dermis to subcutis. Immunohistochemical examination revealed
strong expression of CD20 and bcl-2, and high proliferation index of KI-67. Laboratories
examination are within normal limits except lactate dehydrogenase 539 mg/dl. Chest X-Ray
and abdominal ultrasonography showed no metastasis and no other organ involvement. Patient
was treated with one cycle of Cyclophosphamide, Oncovine, Prednisone (COP) regiment,
followed by Rituximab-COP regiment for 7 cycles. Therapeutical goals were achieved after 8
cycles of chemotherapy. The lesions were decrease in size, and histopathological confirmation
showed no existence of lymphoproliferative cells.

Discussion : Due to the poor prognosis, it is imperative to confirm the diagnosis as early as
possible. Immunohistochemical examination using cellular identification techniques oriented
towards identification of cells specific markers currently is the golden standard. Diagnosing a
cutaneous B-cell lymphoma is a three step process. The first step is to determine whether the
infiltrate is benign or malignant through histopathological examination. Second, identifying cells
derived by using CD3, CD20 and CD79a markers; and the last step, determining the subtype
of cutaneous B-cell lymphoma using bcl-2, bcl-6 and KI-67. Strong expressions of CD20, bcl-
2, and high proliferation index of KI-67, confirmed the diagnosis of PCDLBCL-LT in our patient.

Keywords: primary cutaneous diffuse large b-cell lymphoma, leg type, immunohistochemical,
diagnostic confirmation
Poster: DSS15
 Abstract ID: DSS29
Track: Dermatopathology
Contact Author: Sung-Jen Hung
Country: Taiwan
Organisation: Other
Poster View Here

A rare case of multicentric reticulohistiocytosis presents as epidermotropic papular

xanthoma and double primary cancers

Background
Multicentric reticulohistiocytosis (MRH) is a rare disease of non-Langerhans cell histiocytosis
(n-LCH) involving the skin and joints. Approximately half of the patients with MRH have mucosal
involvement and arthritis mostly affects the hands.

Case presentation
A 64-year-old woman presented with facial skin lesions and interphalangeal joints pain for 6
months. She had a history of hypertension and Sjogren's syndrome. The physical exam
revealed multiple pinkish to erythematous papules and nodules over her scalp, face, buccal
mucosa, distal and proximal interphalangeal (DIP and PIP) areas (Fig. 1a-c). The radiographs
of the fingers showed punch-out erosions over the DIP and PIP joints (Fig. 1d). Endoscopic
exam found multiple papules on the posterior pharyngeal wall (Fig. 1e). The pathologic findings
showed epidermotropic foamy histiocytes infiltration (Fig. 1f, g). Foamy cells were CD68
positive (Fig. 1h), while S100, CD-1a and factor XIIIa were negative. Acid fast and periodic
acid-schiff stains were negative. Blood panels revealed positive antinuclear and anti-Ro
antibody. The diagnosis was consistent with MRH according to typical mucocutaneous lesions
and destructive arthritis. Subsequently, Underlying malignancies were screened to find
papillary thyroid carcinoma and thymic squamous cell carcinoma. After surgical resections of
the double primary cancers, her symptoms of skin and joint improved without any specific
treatment.

Discussion
Our patient disclosed the typical clinical presentations of MRH, but the pathologic exam showed
epidermotropic and xanthomatized histiocytes. To our knowledge, there were only two
documented cases of MRH presenting as papular xanthoma (PX) and destructive arthritis.
Variable microenvironments such as age and immune status result in different phenotypes of
cells in n-LCH to show a disease spectrum with overlapping features of n-LCH, such as MRH
and PX in this case.
Etiology of MRH is unknown and supposed to be associated with autoimmune diseases,
infections and malignancies.15-31% of patients are associated with diverse neoplasms.
There’s no specific treatment for MRH due to its rarity. Here, we report a rare variant of MRH
presenting double primary cancers and a parallel course.
Poster: DSS29
 Abstract ID: DSS36

Track: Dermatopathology

Contact Author: Chandrasekharan Jayasree

Country: India

Organisation: Others

Poster View Here

Grover's disease -An Unusual Presentation

Grover’s Disease is a self-limiting, non-immune mediated, non -familial acantholytic disorder

usually seen in elderly males. When it was first described in 1970, the term Grover’s disease
was synonymous with transient acantholytic dermatosis and later it has been expanded to
include persistent acantholytic dermatosis as well. Although the exact pathogenesis of the
Grover’s disease is still unknown, various studies have postulated the occlusion of the sweat
ducts as the causative factor for the clinical manifestations. Clinically, it is characterized by the
presence of pruritic papulovesicular rash and occasionally as eroded keratotic plaques mainly
on the trunk and proximal extremities. Grover’s disease is characterized by different
acantholytic histological patterns and also associated with various dermatological as well as
non-dermatologic disease including malignancies. Here by, we report the case of a 68-year-old
male, who presented with pruritic papulovesicular rash and crusted plaque like lesions on the
trunk and extensor aspect of upper and lower extremities of 5 years duration. A diagnosis of
Grover’s disease was confirmed by histological and immunological findings. Though it has been
commonly described in western literature, very few cases have been reported in South Asian
countries. We are presenting this case because of the rarity of the condition in our population
as well as its atypical presentation.
Poster: DSS36

GROVER’S DISEASE – A RARE PRESENTATION

Dr:Jayasree Chandrasekharan1, Dr:Vinitha G Krishnan1, Dr P S Mathew1
Dr Malini Eapen2
Sree Narayana Institute of Medical Sciences, Kochi,India 1
AIMS, Kochi, India2

Introduction Histopathology
• First described by Dr.Ralph Grover in • Epidermis shows acantholysis,
1970. intraepidermal and suprabasal
• Syn: Transient acantholytic dermatosis. cleft with areas showing
• Self limiting, non familial, non immune ‘Dilapidated brick wall
mediated acantholytic disorder appearance’.( Fig 3)
characterized clinically by pruritic • No corp ronds or grains were
papules and papulovesicular lesions, seen.
commonly seen in elderly males. • DIF was negative .
• Histopathologic hallmark is acantholysis
with or without dyskeratosis ,often
resembling the patterns of Pemphigus
foliaceous, Pemphigus vulgaris , Darier’s
Disease, Hailey –Hailey Disease.

Clinical History
• A 68 year old male presented with history
of recurrent pruritic papulovesicular Fig 3
eruption over the trunk and extremities of Discussion
5 years duration. • Grover’s disease is a benign,
• No history of mucosal lesions. transient truncal eruption
• There was no family history of similar associated with heat and
complaints. xerosis.
• Frequent exacerbation during sun • Our case varies from the classic
exposure and excessive sweating. pattern as the skin lesions were
atypical, extensive and
Cutaneous examination
persistent.
• Multiple papulo nodular lesions ,vesiculo
• Extensive involvement may be
bullous lesions (Fig 1) and crusted
associated with malignancy and
plaques over the trunk and extremities.
immune suppression.
(Fig 2)
• No association with
• No flexural and mucosal involvement.
malignancy in our case so far.

References
• J .Weaver, Wilma Bergfield. Grover Disease(Transient
Acantholytic Dermatosis). Arch Pathol Lab
Med.2009;133:1490-1494.
• M Gantz, D Butler, M Goldberg .Atypical features
and systemic associations in extensive cases of
Grover disease: A systematic review .JAAD
Fig 2 2017;77:952-7
Fig 1
Abstract ID: DSS37

Track: Atopic Dermatitis and Other Eczematous Conditions

Contact Author: Tanojo Natalia

Country: Indonesia

Poster View Here

SAFETY PROFILE OF DUPILUMAB IN TREATMENT OF MODERATE TO SEVERE ATOPIC

DERMATITIS PATIENTS: EVIDENCE BASED CASE REPORT

Background
Dupilumab has been approved by the U.S. Food and Drug Administration (FDA) as treatment
of moderate to severe atopic dermatitis that cannot be adequately controlled by topical
therapies. However, further study about the safety profile should be done as the drug is
relatively new to the field.

Method
The present study collected meta-analysis and systemic reviews from PubMed, Cochrane, and
Sciencedirect with “dupilumab” and “atopic dermatitis” as keywords. EBM toolkits were used to
test the validity and relevancy of the articles. Three out of 371 articles underwent further
analysis.

Results
Dupilumab decreases the incidence of diseases that usually follow the exacerbation of atopic
dermatitis, such as skin infection, herpes infection, and non-skin infection. There is no statistical
difference between the occurrences of upper respiratory tract infection, nasopharyngitis, urinary
tract infection, and injection site reaction in dupilumab and placebo.

Conclusion
Dupilumab is safe for the treatment of moderate to severe atopic dermatitis in adults.
Poster: DSS37
The Adverse Effect Of Dupilumab As A Treatment Of Moderate To
Severe Atopic Dermatitis: Evidence Based Case Report
Tanojo N
BACKGROUND
• Dupilumab has been approved by U.S. Food and
Drug Administration (FDA) as treatment of
moderate to severe atopic dermatitis that cannot
be adequately controlled by topical therapies.
• However the novelty of Dupilumab necessitates
this drug to be subjected to continual
investigation for probable adverse effects
• Thus, this study aims to examine the side effects
of dupilumab observed from the available studies.
METHOD
• Literature search using the keywords “dupilumab”
and “atopic dermatitis” identified 371 relevant
meta-analysis and systemic reviews from
PubMed, Cochrane, and Sciencedirect on January
8th, 2018.
• Filters limited the search into systematic review,
full text, human, and English literature, resulting
in 5 studies.
• Title and abstract screening with doubles
elimination identified three eligible studies.
• EBM toolkits were used to test the validity and
relevance of the studies.
RESULTS
• The studies are valid and relevant to this review.
• Each study analysed about 7-8 Randomised
Controlled Trials (RCTs) collected from 2000 to
2017. Nevertheless, the studies were done on
about the same RCTs.
• Dupilumab is able to decrease the incidence of
diseases that usually follow the exacerbation of
atopic dermatitis, such as skin infection, herpes
infection, and non-skin infection.
• There is no significant difference between the
occurrences of upper respiratory tract infection,
nasopharyngitis, urinary tract infection, and
injection site reaction in dupilumab and placebo.
• Little to no variation in the conclusions among
these studies may be related to the similarity of
the sources.
CONCLUSIONS
• No notable adverse events were reported.
• Dupilumab is a safe option for moderate to severe
atopic dermatitis, especially for short term usage.
• Further studies are needed to prove the safety
profiles of dupilumab for long term therapies.
REFERENCES
1. Osinka K, Dumycz K, Kwiek B, Feleszko W. Novel
Therapeutic Approaches to Atopic Dermatitis.
Arch Immunol Ther Exp (Warsz). 2017 Aug 31.
2. Han Y, Chen Y, Liu X, et al. Efficacy and safety of
dupilumab for the treatment of adult atopic
dermatitis: A meta-analysis of randomized
clinical trials. J Allergy Clin Immunol. 2017
Sep;140(3):888-891.e6.
3. Ou Z, Chen C, Chen A, Yang Y, Zhou W. Adverse
events of Dupilumab in adults with moderate-to-
severe atopic dermatitis: A meta-analysis. Int
Immunopharmacol. 2018 Jan;54:303-310.
4. Fleming P, Drucker AM. Risk of infection in
patients with atopic dermatitis treated with
dupilumab: A meta-analysis of randomized
controlled trials. J Am Acad Dermatol. 2018
Jan;78(1):62-69.e1.
 Abstract ID: DSS31

Track: Acne and Acneiform Disorders

Contact Author: Leny Purnamasari

Country: Indonesia

Organisation: Others

Poster View Here

Acne Vulgaris and Quality of Life among Young Adult Students in Yogyakarta, Indonesia

Introduction and objectives:

Acne vulgaris is a common inflammatory disease of the pilosebaceous glands in adolescents
and young adults. Acne can interfere with and affect physical appearance, self-esteem, and
quality of life (QoL) both psychologically, emotionally and socially, particularly in active young
adult students. This study was aimed to understand relationship between acne vulgaris severity
with QoL among active students of Universitas Islam Indonesia.

Materials and methods:

This study was conducted using cross-sectional method. Acne severity were assessed using
Physician’s Global Assessment (PGA) method from facial photographs, while QoL were
assessed using Cardiff Acne Disability Index (CADI). Data were analyzed using Spearman dan
Kruskal-Wallis statistic tests.

Results:
Forty seven students, 23 (48.9%) male and 24 (51.1%) female, were participated in this study.
Acne severity were found to be almost clean in 18 subjects (38.8%), moderate in 11 (23.4%)
subjects, and mild in 18 (38.8%). Quality of life were normal in 26 subjects (55.3%), moderately
impaired in 19 (40.4%) and severely impaired in 2 (4.3%). The CADI score means were 4.85
in almost clean acne subjects, 4.83 in mild acne, and 4.85 in moderate acne (p=0.029, Kruskal
Wallis test). Spearman correlation test between quality of life and acne severity degrees found
r=0.255 and p=0.083.
Conclusion :
There was no correlation between acne vulgaris severity degrees with quality of life
categories in young adult students of Universitas Islam Indonesia.
Poster:DSS31

Acne Vulgaris and Quality of Life among

Young Adult Students in Yogyakarta, Indonesia
Purnamasari L1, Firngadi MSK2, Rosmelia3
1Faculty of Medicine Universitas Islam Indonesia, Yogyakarta, Indonesia, 2Department of Psychiatry, Faculty of Medicine, Universitas Islam Indonesia,
Yogyakarta, Indonesia, 3Department of Dermatology and Venereology, Faculty of Medicine, Universitas Islam Indonesia, Yogyakarta, Indonesia

INTRODUCTION RESULTS
The incidence of acne vulgaris usually begins at puberty, i.e. at The study was conducted in July - September 2017 with forty
the age of 12-24 years with a prevalence rate of 85% USA, and a seven students, 23 (48.9%) male and 24 (51.1%) female, were
prevalence of 68.2% in Palembang, Indonesia[1,2]. Acne was the 3rd participated in this study. Acne severity were found to be almost
most frequent cases admitted for treatment at General Hospital in clean in 18 subjects (38.8%), moderate in 11 (23.4%) subjects, and
Indonesia[3]. Acne vulgaris is an inflammatory condition of the mild in 18 (38.8%). QoL were normal in 26 subjects (55.3%),
pilosebaceous unit, manifested as lesions of blackhead or whitehead moderately impaired in 19 (40.4%) and severely impaired in 2
comedones, papules, pustules or nodules on predilection areas such (4.3%). The CADI score means were 4.85 in almost clean acne
as face, shoulders, neck, chest, and upper back [4, 5, 6]. subjects, 4.83 in mild acne, and 4.85 in moderate acne (p=0.029,
Acne can interfere and affect the physical appearance, self- Kruskal Wallis test). Post hoc analysis performed with Mann-
esteem, and quality of life (QoL) both psychologically, emotionally Whitney test to find out influent group and obtained result as in
and socially[7]. Therefore, it is important to evaluate the table 3. Spearman correlation test between quality of life and acne
psychological status and quality of life in patients with acne, because severity degrees found r =0.255 and p=0.083.
poor quality of life can increase the risk of anxiety and depression [8].
QoL is defined as “individual's perception of their position in life in Table 1. Subject characteristics
the context of the culture and value systems in which they live and Characteristics Man Woman Total
in relation to their goals, expectations, standards and concerns” [9]. Acne (Subjective)
Skin problems may have an effect on a person's appearance that Yes 17 (36.2%) 22 (46.8%) 39 (83%)
may affect the QoL. This study was conducted to determine the No 6 (12.8%) 2 (4.3%) 8 (17%)
Acne treatment
correlation of the severity of acne vulgaris with the quality of life of Yes 7 (14.9%) 12 (25.5%) 19 (40.4%)
the sufferer. No 16 (34.0%) 12 (25.5%) 28 (59.6%)
PGA acne score
Almost clear 8 (17%) 10 (21.3%) 18 (38.3%)
Mild 10 (21.3%) 8 (17.0%) 18 (38.3%)
MATERIALS AND METHODS Moderate 5 (10.6%) 6 (12.8%) 11 (23.4%)
• This study was conducted using cross-sectional method, on
Table 2. Distribution of acne vulgaris severity with QoL]
subjects from Communication Science students in Universitas
Quality of life
Islam Indonesia, aged 17 – 22 years old. PGA acne
Normal Moderate Poor
• Acne severity were assessed using Physician’s Global Assessment score
n % n % n %
Total
(PGA) [10] method from three sides facial photographs. PGA Almost clear 11 61.1 7 38.9 0 0 18
category are clear, almost clear, mild, moderate and severe. Mild 12 66.7 6 33.3 0 0 18
• QoL were assessed using Cardiff Acne Disability Index (CADI). CADI Moderate 3 27.3 6 54.5 2 18. 11
score on each option has a value of 0-3 are then summed to 2
produce the total score. Maximum score is 15 and minimum score Total 26 55.3 19 40.4 2 4.3 47
is 0. Higher CADI score indicates more disruption of one's quality of
life [11]. Table 3. Post hoc analysis result
• Data were analyzed using Spearman dan Kruskal-Wallis statistic
Group P value
tests.
Almost clear vs mild 0.847
Almost clear vs moderate 0.023

DISCUSSION & CONCLUSIONS Mild vs moderate 0.013

• The correlation test result showed that there was no significant Figure 1. Distribution of CADI score
correlation between the severity of acne vulgaris with QoL. This Normal
result was in corcondance with the results from other studies[12, 13]. Moderate
• However, in comparative analysis using the Kruskal-Wallis test, this 4% Poor

study found significant differences of CADI scores among groups of

different acne severity (p=0.029). Post hoc analysis showed that
significant difference was seen in almost clear and mild group
versus moderate group as showed in Table 4. This result was
similar with the study by Ismail and Mohammed Ali in Erbil, which 41%
found that there was significant difference in proportion of high 55%
and low CADI score in different groups of acne severity. The study
also showed that the greater the grade of acne severity, the
greater proportion of subjects with poor QoL(14).
• As the conclusion, this study showed that there was no correlation
between acne vulgaris severity degrees with quality of life
categories in young adult students of Universitas Islam Indonesia.

REFERENCES
1. White, G.M. Recent findings in the epidemiologic evidence, classification, and subtypes of acne vulgaris. Journal of
the American Academy of Dermatology, 39(2 III), pp.S34–S37. 1998.
2. Tyekyan. Kejadian dan Faktor Resiko Akne Vulgaris. Jurnal Media Medika Indonesiana, 43(1), pp.6–12. 2008
3. Kelompok Studi Dermatologi Kosmetik Indonesia. Pedoman Tata Laksana Akne di Indonesia: Resume Hasil
Indonesian Acne Expert Meeting 2015 2nd ed. S. M. Wasitaatmadja et al., eds., Jakarta: Perpustakaan Naional RI:
KDT. 2016.
4. Zaenglein and Thiboutot. Acne Vulgaris. In Dermatology. China: Elsevier Ltd, pp. 545–559. 2012.
5. Ferry. Ferri’s Clinical Advisor, Philadelphia: Elsevier. 2015.
6. Afriyanti. Akne Vulgaris Pada Remaja. Medical Faculty of Lampung University, 4(6), pp.102–109. 2015
7. Habif. Clinical dermatology: a color guide to diagnosis and therapy. Elsevier, 13(978-0-7234-3541–9), p.904p. 2010
8. Duman, H., Topal I.O., Kocaturk E., Duman M.A. Evaluation of anxiety, depression, and quality of life in patients with
acne vulgaris, and quality of life in their families. Dermatologica Sinica, vol. 34(1), pp.6–9. 2016.
9. WHOQOL Group. Measuring Quality of Life : The World Health Organization Quality of Life Instruments. World Health
Organization, WHO/MSA/MN. 1997.
10. Pascoe, V.L., Enamandram M., Corey K.C., Cheng C.E., Javorsky E.J., Sung S.M., et al. Using the Physician Global
Assessment in a Clinical Setting to Measure and Track Patient Outcomes. JAMA Dermatology, 151(4), p.375. 2015.
11. Moetley, R.J. and Finlay, A.Y. Practical use of a disability index in the routine management of acne. Clinical and
Experimental Dermatology, vol. 17, no.1, pp.1–3. 1992.
12. Kokandi, A. Evaluation of acne quality of life and clinical severity in acne female adults. Dermatology Research and
Practice, vol. 2010, Article ID 410809, 3 pages, 2010.
13. Law M.P.M., Chuh A.A.T., Lee A., Molinari N. Acne prevalence and beyond: acne dissability and its predictive factors
among Chinese late adolescent in Hong Kong. Clinical and Experimental Dermatology. vol. 35, no.1, pp. 16-21. 2010.
14. Ismail, K.H., Mohammed Ali, K.B. Quality of life in patients with acne in Erbil city. Health and Quality of Life Outcomes,
vol. 10(1), p.60. 2012.
 Abstract ID: DSS48
Track: Acne and Acneiform Disorders

Contact Author: Smita Joshi

Country: Nepal

Organization: Others

Poster View Here

Efficacy and safety of oral azithromycin plus 30% salicylic acid peel in grade II – III facial
acne

Background: Acne vulgaris is a common, chronic inflammatory disorder affecting

pilosebaceous units. Oral tetracyclines and macrolides are commonly used oral antimicrobials
for acne, among which oral azithromycin has been used successfully in varying doses and
frequency. Salicylic acid peel, a β-hydroxic acid, is the peeling agent of choice in active acne
due to its comedolytic property and anti-inflammatory effect, thus decreasing post-inflammatory
hyperpigmentation and scarring due to acne.

Aims: To determine the efficacy, tolerability and safety of oral azitrhomycin and 30% salicylic
acid peel in grade II – III facial acne.

Materials and Methods: Twenty patients with grade II-III facial acne who fulfilled the inclusion
criteria were included in the study. Baseline grading of acne was done with Global Acne
Grading System (GAGS). Patients were treated with oral azithromycin 500 mg once daily for 3
consecutive days per week along with 30% Salicylic acid peel fortnightly for a total of 12 weeks.
GAGS was recorded every 4 weeks and serial photographs were taken for comparision.
Patients were advised for earlier follow up in case of any adverse events. Tolerablility of salicylic
acid peel and side effects of treatment were recorded.

Results: Among 20 patients, 16 were female and 4 were male. Mean age of patients was
23.05±4.84 years (16 – 35 years). Mean GAGS at baseline was 18.60±3.34, at week 4 was
14.20±3.81, at week 8 was 12.00±3.49, and at week 12 was 9.85±5.06. GAGS at week 4 ,
week 8 and week 12 showed statistically significant reduction when compared with baseline.
Mild adverse events were noted during treatment which did not require withdrawal from the
study. All patients reported moderate to good improvement of their facial acne at the end of 12
weeks.

Conclusion: Combination of oral azithromycin and 30% salicylic acid peel is effective in
treatment of grade II-III facial acne with mild and tolerable side effects.
Poster: DSS48
 Abstract ID: DSS61

Track: Acne and Acneiform Disorders

Contact Author: Wen Yang Benjamin Ho

Country: Singapore

Organization: Tan Tock Seng Hospital

Poster View here

Acne fulminans associated with neutrophilic dermatoses: case report

BACKGROUND
Acne fulminans is a severe variant of inflammatory acne and its pathogenesis is unclear.
Neutrophilic dermatoses are considered a form of autoinflammatory disease characterised by
dense cutaneous infiltration of neutrophils. We describe a patient presenting with acne
fulminans associated with lower limb rashes histologically consistent with neutrophilic
dermatosis. He was treated with prednisolone and isotretinoin with rapid resolution of both skin
conditions.

CASE
A 36-year-old male with a history of acne vulgaris presented with painful rashes on his face
and lower limbs for 1 week and left ankle pain. There were no prior contactants or drugs.
Physical examination revealed crusted haemopurulent papulopustules coalescing into plaques
on his chin, acneiform papules on his cheeks and papulopustules scattered over both lower
limbs.
Cefazolin was commenced for chin impetigo and lower limb folliculitis. However, his lesions
worsened , with lower limb rashes became increasingly purpuric. Ceftriazone and Azithromycin
were initiated for disseminated gonococcal infection in view of history of multiple sexual
partners, but he failed to improve.
Repeated microbiology cultures were negative for herpes zoster, bacterial, fungal pathogens.
Infective screen (HIV, Hepatitis B/C, Syphillis, Chlamydia, Gonorrhea) and autoimmune screen
(ANCA, ANA, Rheumatoid factor, complement levels) were unremarkable.
Histology of chin rashes showed psoriasiform dermatitis with mild folliculitis and perifollicular
inflammation. Histology of right shin lesions was consistent with neutrophilic dermatosis.
In view of severe acneiform lesions with systemic symptoms, lack of antibiotic response and
negative infective cultures, diagnosis was revised to acne fulminans associated with
neutrophilic dermatosis. High dose prednisolone and isotretinoin were commenced with rapid
improvement.

DISCUSSION
The pathophysiology of acne fulminans is postulated to involve autoinflammation and
alterations in immunity. As neutrophilic dermatoses are considered a form of autoinflammatory
disease, its co-occurrence with acne fulminans supports that the latter involves
autoinflammation. It is important to consider acne fulminans as a differential of impetigo if
patients don’t respond to antibiotics, especially if there is a history of acne vulgaris.
Poster:DSS61

Case Report: Acne Fulminans Associated with a

Neutrophilic Dermatosis
Wen Yang Benjamin HO1, Yan Ling KONG1,
Siyun Lucinda TAN1, Hazel H. OON1, Hong Liang TEY1,2
1. National Skin Centre, National Health Group, Singapore
2. Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore

Introduction

Acne fulminans is a severe variant of inflammatory acne with an unclear pathogenesis 1,2,5. Neutrophilic dermatoses are a spectrum of disorders
characterised by dense infiltration of neutrophils in the skin, and are considered a form of autoinflammatory disease 3. We describe a patient with a
history of acne vulgaris who presented with facial rashes possibly from acne fulminans, associated with lower limb rashes which were histologically
consistent with a neutrophilic dermatosis. He was treated with prednisolone and isotretinoin with rapid resolution of both skin conditions.
Case Report
A 36 year-old male with a history of mild to moderate acne vulgaris treated with topicals, presented with an abrupt onset of painful rashes on his face and
lower limbs for 1 week associated with left ankle pain and generalised myalgia. He did not have fever. There were no contactants, history of drug usage or
infective symptoms prior to the onset of these rashes. There was no precipitating trauma for his left ankle pain and swelling.

Figure 1 shows his physical examination findings on admission and describes his clinical progress with treatment. He was initially commenced on
intravenous (IV) cefazolin 1 gram 8 hourly but his condition worsened. Despite escalation of antibiotics to cover for disseminated gonococcal infection in
view of his history of multiple sexual partners, he failed to improve.

Work up for infectious and autoimmune etiologies were unremarkable. Histology of the chin rashes revealed non specific changes of psoriasiform
dermatitis. Histology of the right shin lesions was consistent with a neutrophilic dermatosis. Figure 2 shows the histopathology from his chin plaque and
left lower limb lesion. A summary of his investigations are described in Table 1.

Whilst an infective aetiology cannot be excluded, in view of his severe acneiform lesions associated with systemic symptoms, raised inflammatory
markers , the lack of response to antibiotics and negative results on repeated microbiology cultures, the clinical picture was consistent with probable
acne fulminans associated with neutrophilic dermatosis. He was started on high dose prednisolone at 40mg/day (~ 0.5 mg/kg/day ) and isotretinoin
20mg/day on Day 8 of admission and rapid improvements of both his chin and lower limb rashes was observed thereafter.
Figure 1: Clinical Progress with treatment
Day 1 Day 4 Day 10

A. Chin: crusted hemopurulent

papulopustules coalescing into plaques with A: Chin: worsening papulopustules A and B : Chin and Lower limb rashes improving
acneiform papules on cheeks B. Lower limbs: papulopustules after commencement of isotretinoin and
B. Lower limbs: papulopustules scattered increasingly purpuric prednisolone
over both lower limbs

Day 1 : Initiation of IV cefazolin 1 Day 4 : Antibiotics escalated to IV ceftriazone 1 gram Day 8 : Started on prednisolone Day 10 : Clinical
gram 12 hourly 8 hourly and once dose Azithromycin 1 gram 40mg/day and isotretinoin 20mg/day improvement observed

Table 1 : Summary of Investigation Results

Infective Screen 1. Human immunodeficiency virus : Non Reactive

and Microbiology 2. Hepatitis B and C serologies : non reactive
3. Varicella zoster DNA (PCR) : not detected
4. Chlamydia and gonorrhea DNA : not detected
5. Lower limb wound gram stain and culture : no organisms
6. Lower limb wound fungal culture : no fungal pathogen

Autoimmune screen 1. Anti double stranded DNA : not detected

2. Anti nuclear antibody titre : < 80 (Normal Titre < 80)
3. Anti neutrophilic cytoplasmic antibody : negative
4. Complement 3 : 1.78g/L (RI: 0.70-1.80)
5. Complement 4 : 0.83g/L (RI: 0.17-0.48) FIGURE2: Histopathology_______________________________________________
A.Histology of chin plaque: Psoriasiform hyperplasia. Follicular
Inflammatory Markers 1.Total White cell count : 10.8 X 10^9/L (RI: 3.6-9.3 X 10^9/L) plugging, perifollicular and interfollicular dermal infiltrate of
2.C Reactive Protein: 79.8mg/L (RI:0.0-5.0 mg/L) lymphocytes, plasma cells and rare eosinophils (H&E x 40).
3.Erythrocyte Sediment Rate (ESR) : 90mm/hr (RI:1-10mm/hr) B. Histology of left lower limb purpuric papule: Subcorneal pustule
filled with neutrophils. The papillary dermis contains neutrophilic
microabscesses and abundant fine nuclear dust (H&E x 100).

Discussion

The pathophysiology of acne fulminans is postulated to involve autoinflammation and alterations in both innate and adaptive immunity1,2,3,4,5. Whilst
an infective aetiology for this man’s chin rashes cannot be completely ruled out, the clinical presentation and progress, as well as rapid response to
prednisolone and isotretinoin makes acne fulminans a likely differential. As neutrophilic dermatoses are considered a form of autoinflammatory
disease, its co-occurrence with acne fulminans in this patient lends support that the latter involves an autoinflammatory process.
References
1. Greywal T, Zaenglein AL, Baldwin HE, Bhatia N, Chernoff KA. Del Rosso JQ, Eichenfield LF, Levin MH, Leyden JJ, Thiboutot DM, Webster GF, Friedlander SF. Evidence-based recommendations for the management of acne fulminans and its variants. J Am Acad Dermatol. 2017
Jul;77(1):109-117
2. Alakeel A, Ferneiny M, Auggret N, Bodemer C. Acne Fulminans: Case Series and Review of the Literature. Pediatr Dermatol. 2016 Nov;33(6):e388-e392
3. Wakabayashi M, Fujimoto N, Uenishi T, Danno K, Tanaka T. A case of acne fulminans in a patient with ulcerative colitis successfully treated with prednisolone and diaminodiphenylsulfone: a literature review of acne fulminans, rosacea fulminans and neutrophilic dermatoses occurring in the
setting of inflammatory bowel disease. Dermatology. 2011;222(3):231-5
4. Karvonen SL. Acne fulminans: report of clinical findings and treatment of twenty-four patients. J Am Acad Dermatol.1993 Apr;28(4):572-9
5. António F. Massa.Lena Burmeister.Dirk Bass.Christos C.Zouboulis.Acne Fulminans: Treatment Experience from 26 Patients.Dermatology 2017;233:136–140.

The authors have no conflict of interest to declare

 Abstract ID: DSS17
Urticaria and Other Dermal Hypersensitivity
Track:
Disorders
Contact Author: Min Moon Tang

Country: Malaysia

Organisation: Others

Poster View Here

Obstructive Sleep Apnea in Recalcitrant Chronic Spontaneous Urticaria: a report of 4

Adults in Hospital Kuala Lumpur

Background
Obstructive sleep apnea (OSA) has been reported to be associated with several dermatological
disorders such as psoriasis, atopic dermatitis in adults, acne vulgaris, acanthosis nigricans,
cicatricial pemphigoid, diabetic foot ulcers, malignant melanoma, mycosis fungoides, vibratory
urticaria, hereditary angioedema and chronic urticaria. In a case series of 28 patients with
chronic spontaneous urticaria (CSU), 7% was identified to have OSA. Here we aim to describe
4 adults with recalcitrant CSU who were diagnosed to have obstructive sleep apnea.

Case Presentation
The mean age of the 4 patients was 45.7 years. Three were female. The mean body mass
index was 39.2kg/m2(range 25.5 to 45). The average duration of chronic spontaneous urticaria
was 3.1 years (range 1-7). There was one patient with hypertension and another with allergic
rhinitis. Three patients had urticaria which developed after the consumption of non-steroidal
anti-inflammatory drugs. All of them developed symptoms suggestive of OSA between 6
months and 10 years which included snoring and daytime somnolence. Polysomnography
performed in these patients showed mild to severe obstructive sleep apnea with apnea-
hypopnea index (AHI) scored between 9.7-66.8/hour. All patients required double high dose of
antihistamines (4x above recommended dose) with montelukast and cyclosporine to control the
CSU. One of them received a dose of omalizumab. At the point of last review, the CSU
symptoms were well controlled but they continued to have symptoms of OSA. They were
advised to use continuous positive airway pressure (CPAP) during sleep.

Discussion
The association of OSA among patients with CSU may be due to the common morbidities such
as obesity, upper airway obstruction due to soft tissue swelling from the urticaria or angioedema
and the heightened pro-inflammatory state in both conditions. Clinicians who are managing
recalcitrant CSU should have high index of suspicion on the presence of OSA in this group of
patients. Future studies are advocated to study the incidence of OSA among patients with CSU.
Poster: DSS17

Obstructive Sleep Apnea in Recalcitrant Chronic Spontaneous Urticaria:

a report of 4 Adults in Hospital Kuala Lumpur
Min Moon Tang, AdvMDerm(UKM), Suganthi Thevarajah, MMed(UKM)
Department of Dermatology, Hospital Kuala Lumpur, Malaysia
Dermatology HKL

Background
Obstructive sleep apnea (OSA) has been reported to be associated with several dermatological disorders such as psoriasis,
atopic dermatitis in adults, acne vulgaris, acanthosis nigricans, cicatricial pemphigoid, diabetic foot ulcers, malignant melanoma,
1
mycosis fungoides, vibratory urticaria, hereditary angioedema and chronic urticaria.
2
In a case series of 28 patients with chronic spontaneous urticaria (CSU), 7% was identified to have OSA.
Here we aim to describe 4 adults with recalcitrant CSU who were diagnosed to have obstructive sleep apnea.

Presentation of cases
Table 1. The characteristics of patients with recalcitrant CSU who were diagnosed to have OSA
No Age Duration BMI Duration Other co- AHI Severity Antihistamines Duration of Use of Baseline Latest
(years)/ of CSU 2
(kg/m ) of Sx of morbidities (/hours) of OSA used in high Cyclosporin Anti UAS7 UAS7
Gender (years) OSA dose use IgE*
(years) (months)
1 51/M 7.0 45.0 2.0 Hypertension 66.8 Severe Levoceterizine 13 N 42 6
Loratadine
2 40/F 1.5 43.0 10.0 Nil 7.7 Mild Levoceterizine, 1 Y 42 14
Bilaxten
3 47/F 3.0 25.5 0.5 Allergic 9.7 Mild Levoceterizine, 7 N 42 0
rhinitis desloratadine
4 45/F 1.0 43.4 1.0 Nil 32.2 Severe Levoceterizine, 6 N 42 2
Loratadine
CSU- chronic spontaneous urticaria; Sx - symptoms; OSA – obstructive sleep apnea, AHI- Apnea Hypopnea Index; Anti IgE* - omalizumab; UAS7- Urticaria activity score for 7 consecutive days;
M- male; F – female; Y – yes; N - no

The characteristics of 4 patients with recalcitrant CSU who Polysomnography performed in these patients showed
were diagnosed to have OSA are shown in Table 1. mild to severe obstructive sleep apnea with apnea-
The mean age of the 4 patients was 45.7 years. Three were hypopnea index (AHI) scored between 7.7-66.8/hour.
female. All patients required double high dose of antihistamines
2
The mean body mass index was 39.2kg/m (range 25.5 to 45). (4x above recommended dose) and cyclosporine to
The average duration of chronic spontaneous urticaria was 3.1 control the CSU. All had tried montelukast with no
years (range 1-7). additional benefit. One of them received omalizumab.
Three patients had urticaria worsened after the consumption At the point of last review, the CSU symptoms were quite
of non-steroidal anti-inflammatory drugs. controlled but they continued to have symptoms of OSA.
All of them developed symptoms suggestive of OSA between 6 They were advised to use continuous positive airway
months and 10 years which included snoring, daytime pressure (CPAP) during sleep.
somnolence and headache.

Discussion & Conclusion

It is well known that skin diseases may disrupt sleep. Some skin diseases are associated with specific sleep disorders like
OSA.3
The association of OSA among patients with CSU may be due to the common morbidities such as obesity, upper airway
obstruction due to soft tissue swelling from the urticaria or angioedema, and the heightened pro-inflammatory state in
both conditions.1
At this stage, it is unclear if aggressive treatment of OSA will benefit the control of the recalcitrant CSU.
Clinicians who are managing recalcitrant CSU should have high index of suspicion that OSA may co-exist in these patients.
In conclusion, we describe an interesting observation of OSA that occurred in 4 cases of recalcitrant CSU. Future studies
are advocated to study the incidence and the causal relationship between OSA and CSU.

References
1. Gupta MA et al. Clin Dermatol 2017;35:319-27 2. Perkowska J et al. Postepy Dermatol Alergol 3. Thorburn et al. Sleep Med Rev 2010;14:351-8
2016;33:63-7
 Abstract ID: DSS35
Connective Tissue Disorders and Autoimmune
Track:
Bullous Disorders
Contact Author: Panicker Vanitha

Country: India

Organisation: Others

Poster View Here

HENOCH SCHONLEIN PURPURA-A 5 YR STUDY FROM A TERTIARY CARE CENTRE

Introduction and Objectives -

Henoch Schonlein Purpura has a wide range of manifestations ranging from palpable purpura
with abdominal pain and arthritis to more severe manifestations like renal involvement. Though
the diagnosis of HSP is often clinical, the importance of skin biopsy cannot be understated.
We aimed to study the clinical manifestations of HSP and to corelate with histopathological and
immunofluorescence findings .
Methodology
A retrospective study of all patients diagnosed with HSP in Dermatology department of our
hospital between April 2012 to March 2017. They were analyzed with regard to age, sex,
cutaneous and systemic findings, histopathological and immunoflourescence findings.

Results-
A total of 84 patients were diagnosed with HSP. The youngest was 3 yrs and oldest 80 yrs .
The male to female ratio was 1.1 : 1 . Among cutaneous manifestations ,the most common
presentation was palpable purpura (100%). Other features were ulcers( 0.5 %),nodules
,bullae.The distribution of lesions was in lower limbs in majority (100 % ), some had lesions on
the upper limbs (35%) and trunk (25%).The most common systemic manifestation seen were
arthritis (64 %),abdominal pain (61%),renal involvement (35%).Severe renal involvement with
renal biopsy showing mesangioproliferative glomerulo nephritis was seen in 8 % with one
patient progressing to end stage renal disease. Among skin biopsy findings 96% showed
features of leukocytoclastic vasculitis ,dominant IgA deposits was seen in 73 % ,associated
C3 deposits was seen in 15 % cases. 2 cases showed lupus band ,who on detailed evaluation
were proved to be SLE.

Conclusion-
HSP is seen in both adults and children , in our series majority were adults. The frequency of
systemic involvement especially renal highlights the importance of detailed systemic
evaluation in all cases presenting with palpable purpura .The importance of skin biopsy with
immunofluorescence is reflected in the ability to effectively treat and follow up these patients.
The presence of lupus band in 2 of our cases also indicates the need of biopsy with
immunofluorescence as some of these cases clinically labelled as HSP could ultimately
become SLE.
Poster: DSS35
 Abstract ID: DSS08

Track: Drug Reactions

Contact Author: Damayanti-

Country: Indonesia

Organisation: Others

Poster View Here

Clinicoepidemiological Profile of Severe Cutaneous Adverse Drug Reaction at

dr. Soetomo Hospital Surabaya Indonesia: a Retrospective Study

Introduction and objectives: Drug eruption were frequently found and varied from mild to severe
reaction with high mortality rate. Few studies have assessed the severe reaction. The
clinicoepidemiological study was needed to show profile of severe cutaneous adverse drug
reaction (SCADR), especially in the setting of general hospital. The aim of this study is to
evaluate clinicoepidemiological profile of SCADR at Dermatology and Venereology Ward Dr.
Soetomo Hospital Surabaya Indonesia.

Materials and methods: All SCADR patients at Dr. Soetomo Hospital Surabaya Indonesia in
the period of January 2016 – June 2017 was evaluated. Stevens-Johnson syndrome (SJS),
toxic epidermal necrolysis (TEN), acute generalized exanthematous pustulosis (AGEP), drug
reaction with eosinophilia and systemic syndrome (DRESS) and exfoliative dermatitis cases
were included in the study. The drug reaction patterns and the common offending drugs were
identified.

Results: There were 24 patients in this study, consist of 11 SJS cases, 1 TEN case, 2 SJS/TEN-
overlap cases, 10 exfoliative dermatitis cases, no AGEP or DRESS cases. The highest
frequency of age group was 25-29 years old (58.3%). Man to woman ratio was 1:2.4. The mean
of latent period between drug intake and onset of symptoms was 15.8 days. The most common
offending drug was mefenamic acid (20.9%), followed by cefadroxil and phenytoin (each
16.7%). Antibiotics was the highest frequent offending drug-groups (62.5%), followed by non
steroid anti inflammatory drugs/NSAIDs. Prompt withdrawal of the offending drugs were done
to all patients and they were treated with systemic corticosteroid and supported therapy. These
management gave good results in 21/24 patients (87.5%).
Conclusions: In this study, antibiotics was the commonest offending drug-groups, and the
mortality rate was 12.5%. SCADR might give high mortality rate. Early diagnosis, prompt
withdrawal of the suspected drugs, closed monitoring to evaluate complications can improve
the prognosis of SCADR.
Poster: DSS08
 Abstract ID: DSS16

Track: Drug Reactions

Contact Author: Chong En Linus Chan

Country: Singapore

Organisation: Singapore General Hospital

Poster View Here

Drug reaction with eosinophilia and systemic symptoms (DRESS) in Singapore: Clinical
features, treatment and outcomes of 109 patients managed in an Academic Medical
Centre

Introduction and Objectives

Drug reaction with eosinophilia and systemic symptoms (DRESS), also termed drug-induced
hypersensitivity syndrome, is a life-threatening and rare severe cutaneous adverse drug
reaction. Its clinical course is variable, ranging from benign and self-resolving, to severe and
life-threatening with multi-organ failures and even death. This study aimed to evaluate the
clinical characteristics, course, response to therapy, and outcomes of DRESS.

Methods
Patients admitted to the Department of Dermatology, Singapore General Hospital, from
January 2009 to November 2017 were retrospectively screened for a discharge diagnosis of
DRESS. Using the criteria of the European Registry of Severe Cutaneous Adverse Reactions
(RegiSCAR), the patients were scored and validated. Clinical features, demographic data,
treatment choices and outcomes were retrieved from medical records.

Results
Of the 109 patients, 49 were men (45.0%) and 60 were women (55.0%) with an age range of
17–86 years (mean, 57 ± 17.77 years). The most commonly implicated drugs were allopurinol
(39.5%), sulfonamides (22.9%), and anti-epileptic drugs (11.0%). Facial edema (86%),
maculopapular exanthema (67.9%), and confluent erythema (67.9%) were the most common
dermatologic features. Other associated clinical features include atypical lymphocytes (85.3%),
eosinophilia (78.0%), hepatic involvement (67.9%), and renal involvement (40.4%). For
management, 54 (49.5%) patients and 55 (50.5%) patients were treated with topical and
systemic steroids respectively. ICU stay was 16.5% (n=18), and mortality during admission was
16.5% (n=18).

Conclusion
Our study validates the findings that the majority of DRESS is related to a small number of
medications. Liver, renal and blood involvement were the most common associated findings.
There appears to be a higher mortality rate in our cohort compared to prevailing studies and
this may be in part explained by the referral bias in an academic centre.
Poster:DSS16

INTRODUCTION Culprit Drugs

• Drug reaction with eosinophilia and systemic symptoms (DRESS), NSAIDs Anti-TB
also termed drug-induced hypersensitivity syndrome (DIHS), is a Other Antibiotics 2% 2%
life-threatening and rare severe cutaneous adverse drug reaction1. 4%
• Its clinical course is variable, ranging from benign and self- Vancomycin
resolving, to severe and life-threatening with multi-organ failures 5%
and even death2,3.
• This study aimed to evaluate the demographic and clinical Omeprazole
characteristics, treatment, and outcomes of DRESS. 7% Allopurinol
40%
Others
METHODS 8%
• Patients admitted to the Department of Dermatology, Singapore
General Hospital, from January 2009 to December 2017 were
retrospectively screened for a discharge diagnosis of DRESS.
Sulfasalazine
• Using the criteria of the European Registry of Severe Cutaneous
10%
Adverse Reactions (RegiSCAR), the patients were scored and
validated4. Clinical features, demographic data, treatment choices Anti-
and outcomes were retrieved from medical records. Epileptics Bactrim
• A total of 109 patients were screened. Six patients who had a 9% 13%
RegiSCAR score of 3 or less were excluded. This study included
the remaining 100 definite and probable cases for analysis. Dermatological Findings
Total DRESS patients Value, n (%)
109 Facial Edema 90 90
Limb/truncal Edema 59 59
No Case Possible Probable Definite Macules/Papules 72 72
(Score < 2) (Score 2-3) (Score 4-5) (Score > 5) Confluent Erythema 73 73
3 6 38 62
Atypical Targets 16 16
For evaluation: n = 100 Purpura 39 39
Pustules 13 13
RESULTS Scaling 45 45

• Of the 100 patients, 41 were men (41%) and 59 were women (59%) Treatment
with an age range of 17–86 years (mean, 57 ± 18 years).
Value, n (%)
• The most commonly implicated drugs were allopurinol (40%),
Topical Steroids 43 43
sulfonamides (23%), and anti-epileptic drugs (9%).
Systemic Steroids 54 54
• Facial edema (90%), confluent erythema (73%), and
maculopapular exanthema (72%) were the most common None 3 3
dermatologic features.
Outcomes
• Associated systemic features included eosinophilia (88%),
atypical lymphocytes (87%), hepatic involvement (73%), and renal Value, n (%)
involvement (42%). ICU 16 16
• For management, 43 patients (43%) and 54 patients (54%) were Intubation 10 10
treated with topical and systemic steroids respectively. Dialysis 15 15
• Sixteen (16%) of patients required ICU management, and the in- MARS 1 1
hospital mortality was 15% (n=15). Amongst survivors, 26% (n=26) Transplant 0 0
had flares requiring clinic visits or hospitalisations. Death during inpatient admission 15 15
Demographic Characteristics Death in 1 year 18 18
Flares in 1 year 26 26
Value, n (%) Readmissions due to DRESS 14 14
Gender (Male: Female) 41:59 -
Mean Age (years) 57 ± 18 -
Ethinicity CONCLUSION
Chinese 67 67
• Our study validates the findings that the majority of DRESS is
Malay 17 17 related to a small number of medications.
Indian 10 10
• Liver, renal and blood involvement were the most common
Others 6 6
associated findings.
Mean hospital stay (days) 21 ± 33 -
• There appears to be a higher mortality rate in our cohort
Community cases 91 91
compared to prevailing studies and this may be in part explained
Previous drug allergy 10 10 by the referral bias in an academic centre.
Clinical Characteristics • In addition to mortality, a significant proportion of cases had
flares and required readmissions for DRESS.
Value, n (%)
Fever > 38.5
Eosinophilia
66
88
66
88
REFERENCES
Atypical Lymphocytes 87 87 1. Bocquet, H., M. Bagot, and J.C. Roujeau. Drug-induced pseudolymphoma and drug
hypersensitivity syndrome (Drug Rash with Eosinophilia and Systemic Symptoms: DRESS). in
Liver Involvement 73 73 Seminars in cutaneous medicine and surgery. 1996. WB Saunders.
Kidney Involvement 42 42 2. Roujeau, J.C. and R.S. Stern, Severe adverse cutaneous reactions to drugs. New England Journal
of Medicine, 1994. 331(19): p. 1272-1285.
Lung Involvement 12 12 3. Criado, P.R., et al., Drug reaction with eosinophilia and systemic symptoms (DRESS)/drug-induced
Heart/Muscle Involvement 18 18 hypersensitivity syndrome (DIHS): a review of current concepts. Anais brasileiros de dermatologia,
2012. 87(3): p. 435-449.
Pancreas Involvement 6 6
4. Kardaun, S., et al., Drug reaction with eosinophilia and systemic symptoms (DRESS): an original
Gastrointestinal Involvement 14 14 multisystem adverse drug reaction. Results from the prospective RegiSCAR study. British Journal
Others (eg. Thyroid) 31 31 of Dermatology, 2013. 169(5): p. 1071-1080.
 Abstract ID: DSS21

Track: Drug Reactions

Contact Author: Laura Hui

Country: Singapore

Organisation: Singapore General Hospital

Lamotrigine-induced Severe Cutaneous Adverse Drug Reactions in a Singapore Population: A

Case Series and HLA genotyping

With advancements in pharmacogenetics, potential genetic associations with severe cutaneous

adverse drug reactions (SCARs) have been proposed. This is the first case series on lamotrigine-
induced SCAR in Asia.
We retrospectively looked at patients with lamotrigine-induced SCAR from 2 tertiary hospitals in
Singapore over an 8 year period from 2009 to 2017. Our findings supported existing data on proposed
risk factors, specifically being of the female gender (n=4, 67%) and concurrent valproate intake (n=3,
50%). However, there was differing evidence with regards to dosage, as all the 6 patients developed
SCAR despite being on low doses of lamotrigine with an average of 25mg/day. Low dose initiation and
slow drug escalation has similarly been highlighted as a risk factor in Allopurinol-induced SCAR and
should be further studied. HLA genotyping was performed for all and found carriage of HLA-A*33:03
(n=2), HLA-A*24:02 (n=2), HLA-DRB1*12:02 (n=3, 50%). No single HLA-related genetic risk factor was
demonstrated for lamotrigine-induced SCAR in patients from Singapore. Further studies are required
with larger sample sizes and with comparison with drug-tolerant controls
 Abstract ID: DSS63

Track: Drug Reaction

Contact Author: B.S.D.P. Keragala

Country: Sri Lanka

Organisation: National Hospital of Sri Lanka

Ocular complications related to high dose intravenous steroid therapy

Introduction and objectives

Ocular complications are well recognized following long-term steroid therapy. Unfortunately, many
dermatological diseases especially inflammatory types, need long term treatment with steroids and
sometimes even warrant high dose intravenous administrations.

Material and methods

A descriptive cross sectional study was conducted among all patients followed up in the dermatology
unit of National Hospital of Sri Lanka over a period of 1year, who were on monthly intravenous steroid,
equivalent to or more than intravenous dexamethasone 300mg per month or methylprednisolone 1.5g
per month. Data was collected using a pre-tested, interviewer administered questionnaire and were
screened for eye complications following ophthalmological assessment. Already diagnosed patients
with eye diseases were excluded from the study. Data analyzed with SPSS 17th version.

Results
Majority (60.9%) of patients were found to be suffering from eye complications (mean= 45 years
(SD=16); range= 19-77 years). Out of them most were treated for autoimmune blistering diseases
(pemphigus vulgaris 11, bullous pemphigoid 2) and was on Pasricha regime. Others had connective
tissue diseases (SLE, Diffuse Systemic sclerosis, Dermatomyositis) vasculitis and Bechet disease.
Some had co morbidities other than above mentioned diseases like diabetes mellitus, hypertension or
combination of both and thyroid diseases. Mean duration of treatment was 12.6 months (SD= 9.4);
range= 1-36months.
Out of 23 patients 7 had cataracts,3 had glaucoma, 1 had central serous retinopathy,2 had both cataract
and glaucoma and 1 had both glaucoma and central serous retinopathy. Duration of treatment >12
months and presence of comorbidities were significantly associated with eye complications(P<0.002
and P< 0.008 respectively).

Conclusions
Cataract, ocular hypertension, glaucoma and central serous retinopathy are the commonest ocular
adverse effects associated with high dose steroid therapy. The degree of involvement depends on the
duration of treatment and the presence of co morbidities. It is crucial to minimize the duration of steroid
therapy at least for less 1year to minimize irreversible ocular complications. And patients with
comorbidities needs proactive monitoring during steroid therapy for early identification of complications.
 Abstract ID: DSS32

Track: Hair, nail and mucous membrane disorders

Contact Author: Kyung-Hwa Kang

Country: South Korea

Organisation: Others

Poster View Here

Rumex japonicus Houttuyn and Arctium lappa Linné promotes hair regrowth in alopecia
models

Introduction and objectives: This study was conducted to evaluate the hair growth-promoting effects
by Rumex japonicus Houttuyn plus Arctium lappa Linné 25% ethanol extract (RAEE) in C57BL/6N
mice and human keratinocytes (HaCaT).
Materials and methods: The hair growth effect was examined by topical application of RAEE on the
shaved dorsal skin of C57BL/6 mice. Six-week old mice were separated in 4 groups; CON (vehicle),
MXD (2% Minoxidil), and RAEE (2% and 4% RAEE). The treatments were applied daily for 17 days.
The hair growth was determined photographically and the hair density, thickness and length were
identified by Folliscope. In dorsal skin tissue, the morphology was analyzed by H&E stain and the
expression of hair growth-related protein was analyzed by Western blotting. In HaCaT cells, the cell
proliferation and the protection against H2O2-induced cell damage by RAEE were analyzed.
Results: We observed that RAEE promoted the hair growth and the density, thickness and length of
hair compared to CON. In dorsal skin tissue, RAEE promoted the development of hair follicles,
activated the Wnt/β-catenin signaling and induced the expression of cell survival-related proteins,
such as pERK/ERK and Bcl-2/Bax. In HaCaT, RAEE also accelerated the cell proliferation and
protected the H2O2-induced cell damage in HaCaT cells.
Conclusions: These results suggest that RAEE promotes hair growth by regulating the activation of
Wnt/β-catenin signaling and cell survival signaling and protects oxidative stress-induced hair damage.
Therefore, RAEE has a hair growth activity and can be useful for the treatment of alopecia. (This work
(Grants No. C0510429) was supported by Business for Cooperative R&D between Industry,
Academy, and Research Institute funded Korea Small and Medium Business Administration in 2017.)
 Poster:

Rumex japonicus Houttuyn and Arctium lappa Linné

promotes hair regrowth in alopecia models
Kyung-Hwa Kang
Department of Physiology, College of Korean Medicine and Research Institute of Oriental Medicine, Dong-Eui University, Busan
47227, Republic of Korea

Abstract
Introduction and objectives: This study was conducted to evaluate the hair growth-promoting effects by Rumex japonicus Houttuyn plus Arctium lappa Linné 25% ethanol
extract (RAEE) in C57BL/6N mice and human keratinocytes (HaCaT).
Materials and methods: The hair growth effect was examined by topical application of RAEE on the shaved dorsal skin of C57BL/6 mice. Six-week old mice were separated
in 4 groups; CON (vehicle), MXD (2% Minoxidil), and RAEE (2% and 4% RAEE). The treatments were applied daily for 17 days. The hair growth was determined photographi
cally and the hair density, thickness and length were identified by Folliscope. In dorsal skin tissue, the morphology was analyzed by H&E stain and the expression of hair gro
wth-related protein was analyzed by Western blotting. In HaCaT cells, the cell proliferation and the protection against H2O2-induced cell damage by RAEE were analyzed.
Results: We observed that RAEE promoted the hair growth and the density, thickness and length of hair compared to CON. In dorsal skin tissue, RAEE promoted the develo
pment of hair follicles, activated the Wnt/β-catenin signaling and induced the expression of cell survival-related proteins, such as pERK/ERK and Bcl-2/Bax. In HaCaT, RAEE
also accelerated the cell proliferation and protected the H2O2-induced cell damage in HaCaT cells.
Conclusions: These results suggest that RAEE promotes hair growth by regulating the activation of Wnt/β-catenin signaling and cell survival signaling and protects oxidative
stress-induced hair damage. Therefore, RAEE has a hair growth activity and can be useful for the treatment of alopecia. (This work (Grants No. C0510429) was supported by
Business for Cooperative R&D between Industry, Academy, and Research Institute funded Korea Small and Medium Business Administration in 2017.)
Key words: Rumex japonicus Houttuyn, Arctium lappa Linné, alopecia, C57BL/6N, human keratinocytes (HaCaT).

Materials and Methods Keratinocyte proliferation & protection (HaCaT)

Hair Growth (C57BL/6N)
Topical treatment (200 µl, daily)
• Vehicle
• 2% and 4% RAEE
• 2% minoxidil
0 1 3 7 10 13 17 Day

Depilation BW BW BW BW BW H2O2
of dorsal hair matrix
→ 6 weeks Telogen Macroscopic observation → hair growth Basal
keratinocytes
Rumex japonicus Houttuyn keratinocytes
Folliscopic observation → hair density, thickness, length +Arctium lappa Linné
Collection of dorsal skin → H&E stain/WB 25% ethanol extract
(RAEE)
Fig. 1. Scheme of this experimental process Epidermis Hair follicle

Results
CON RAEE2% RAEE4% MXD CON RAEE2% RAEE4% MXD CON RAEE2% RAEE4% MXD
CON
D01 26 D07 D07
CON
RAEE2%
Body weight (g)

24
RAEE4%
MXD
D10 D10
22
D07
RAEE2%
20

D13 D13
18
D10 0 3 7 10 13 17
Days

RAEE4%
D13 100 *** 5000 2.5
CON CON CON CON
***
Thickness of hair (mm)
Number of hair (cm2)

*** 0.06
Length of hair (mm)
Hair growth rate (%)

RAEE2% ** 4000 RAEE2% *** RAEE2%

80 ** RAEE2% 2.0
RAEE4% *** RAEE4% *** ***
RAEE4% RAEE4% ***
MXD *** 3000
*
60 ** MXD 0.04 MXD 1.5 MXD
D17 *** **
40 *** 2000 *** 1.0
* ** **
** MXD
0.02
20 * 1000 * 0.5

0 0 0.00 0.0
1 7 10 13 17 7 10 13 7 10 13 7 10 13
Days Days Days Days

Fig. 2 Macroscopic observation of hair regrowth and changes of body Fig. 3. Folliscopic observation of hair density, hair thickness and hair length of C57BL/6N mice Fig. 4. Effect of RAEE on the histological cha
weight in C57BL/6N mice. Dorsal skins of mice were photographed by folliscope at the 7, 10, and 13 days after depilation. RAEE nges in C57BL/6N mice.
(a) The dorsal skins of mice were shaved and applied hair removal cream or MXD group had increased hair density, hair thickness and hair length compared to CON group. The Sections of dorsal skin tissues were stained at 7
externally, and the test treatments were applied daily for 17 days. (b) Parts data shown are the mean ± SE of 8 mice per group. **p<0.01, ***p<0.001 vs. CON group. days by H&E staining. X50. Histological findings
of the depilated and the hair growth area measured using the ImageJ soft of the hair follicles of depilated C57BL/6 mice.
ware. (c) Changes of body weight. The data shown are the mean ± SE (n=
8). Significant difference from CON group, ∗p <0.05, **p<0.01, ***p<0.001

200 ***
ERK 120
250
(% of untreatment)
Cell proliferation

150 ***
(% of untreatment)

p-ERK
DCF fluorescence

90 200
Cell viability

(% of control)

100 Wnt3α Bax ## ##

# ## 150
60
p-GSK3β(Ser9) Bcl-xL ***
50 100
β-catenin Bcl-2 30
50
0
0 0.1 0.2 0.4 0 0.1 0.2 0.4 β-actin β-actin 0
0 0 0.1 0.2 0.4 MXD 0
RAEE RAEE (mg/ml) CON 2% 4% MXD CON 2% 4% MXD 0 0 0.1 0.2 0.4 M
X
D
RAEE RAEE RAEE (mg/ml)
RAEE (mg/ml)
MXD (0.01 µM)
H2O2 (250 µM) H2O2 (250 µM)

Fig. 5. RAEE promotes the proliferation of HaCaT cells. Fig. 6. RAEE upregulate the expression of proteins involve Fig. 7. RAEE alleviates H2O2-induced oxidative toxicity and suppresses reac
HaCaT cells were plated in 96 well plates at a density of 1.5x105 ce d Wnt/β-catenin signaling and cell survival in HaCaT cells. tive oxygen species (ROS) generation in HaCaT cells.
lls/ml and then treated with the indicated doses of MXD and RAEE Western blot method was used to determine the expression of HaCaT cells were plated in 96 well plates at a density of 5ⅹ 104 cells/ml. After ove
for 5 d. Values are shown as percentages of controls. ∗∗∗ p<0.001 Wnt3α, p-GSK3β, β-catenin, p-ERK, Bax, Bcl-xl, and Bcl-2 expr rnight, the cells were treated with the indicated doses of RAEE for 24 h and then t
vs. vehicle control. essions at the translational level. reated with H2O2 for 30 min. Values are shown as percentages of controls. ∗∗∗ p<
0.001 vs. vehicle control. # p<.05, ##p<0.01 vs. H2O2 alone

Conclusion
In this study, we obtained the following results for RAEE: (1) RAEE showed acceleration of hair growth and the proliferation of hair follicles in mouse model; (2) RAEE
promotes the proliferation of HaCaT cells and inhibits H2O2-induced toxicity and ROS generation in HaCaT cells. (3) RAEE activated the expression of Wnt/β-catenin and the
phosphorylation of GSK-3β and ERK and the expression of Bcl-2 in HaCaT cells. From these results, it was considered that RAEE have the potential effect to promote the
hair growth and delay the start of stage of catagen. Therefore, it is suggested that RAEE might be a good candidate for helping hair growth promotion.
 Abstract ID: DSS09

Track: Skin Tumours (Benign / Malignant)

Contact Author: ZI TENGCHAI

Country: SINGAPORE

Organisation: Singapore General Hospital

Poster Veiw here

SPECTRUM OF SKIN CONDITION SEEN IN A DEDICATED TRANSPLANT CLINIC IN A TERTIARY

CENTRE

SPECTRUM OF SKIN CONDITION SEEN IN A DEDICATED TRANSPLANT CLINIC IN A TERTIARY

CENTRE

ZT CHAI1, CC OH2

1 DEPARTMENT OF INTERNAL MEDICINE, SINGAPORE GENERAL HOSPITAL

2 DEPARTMENT OF DERMATOLOGY, SINGAPORE GENERAL HOSPITAL

Introduction and objective : Skin malignancy is the most common malignancy in patients who have
received solid organ transplant. This study looks at the spectrum of skin conditions seen by
dermatologists in a dedicated transplant clinic in a tertiary hospital.

Material and method : We included all patients who were seen in Transplant Clinic by dermatologists
from Feb 2014 to April 2017. Age, gender, race, transplant type, regime of immunosuppressive therapy,
and all skin manifestations and investigations done were recorded for these 135 patients.

Results : Among 135 patients, there were 104 (77%) kidney transplant recipients, and 31 (23%) liver
transplant recipients. We detected 21 patients with squamous cell carcinoma (SCC) and 6 patients with
basal cell carcinoma (BCC). Mean time of transplant to development of skin malignancy is 18 ± 8.72
years. Most of the skin malignancy developed over head and neck (SCC 42.9%, BCC 50%), and trunk
(SCC 33.3%, BCC 50%). Azathioprine is identified to be significant in development of SCC (RR 12.03,
p <0.001). Other common conditions detected include viral warts (44%), skin inflammation (11.7%) and
seborrhoeic keratoses (11.7%).

Conclusion : Our study demonstrated that regular skin screening by a dermatologist among solid organ
transplant recipients increases detection of skin malignancy1, and this allows early treatment. Being
able to identify risk factors associated with development of skin malignancy, clinicians may consider
more frequent or prolonged follow up in the high risk groups, and switch of medication class of
immunosuppressive therapy.

Reference :
1. Oh CC, Lee HY, Pang SM, et al. Dermatological Conditions Seen in Renal Transplant Recipients in
a Singapore Tertiary Hospital. Singapore Med J
Poster: DSS09

Spectrum Of Skin Condition Seen In A Dedicated Transplant Clinic In A Tertiary

Centre
ZT Chai1, CC Oh2
1 DepartmentOf Internal Medicine, Singapore General Hospital
2 Department Of Dermatology, Singapore General Hospital

INTRODUCTION Table 1
Organ transplant recipients (OTR) are at higher risk of SKIN CONDITION NO. OF PATIENTS
skin malignancy and skin infection. This study looks at Infectious diseases
the spectrum of skin conditions seen by dermatologists Viral warts 46
in a dedicated transplant clinic in a tertiary hospital. Cutaneous fungal infections 4
(dermatophyte/ candida/ pityriasis)
MATERIAL AND METHOD Herpes zoster 1
We included all patients who were seen in Transplant Herpes simplex 1
Clinic by dermatologists from Feb 2014 to April 2017. Total 52
Age, gender, race, transplant type, regime of Skin cancers
immunosuppressive therapy, and all skin Basal cell carcinoma 6
manifestations and investigations done were recorded Bowens disease 1
for these 135 patients. Extra mammary Paget’s disease 3
RESULT Squamous cell carcinoma 18
Total 28
Among 135 patients, there were 104 (77%) kidney
Drug induced
transplant recipients, and 31 (23%) liver transplant
Acne 2
recipients. The most common skin condition detected
is viral warts (34%), and other common conditions Sebaceous hyperplasia 4
include skin inflammation (10.3%) and seborrhoeic Total 6
keratoses (11.7%).S Of note, there were 28 patients Others
(20.7%) with skin malignancy detected; nineteen had Eczema 14
SCC, six had BCC, and 3 had extra-mammary Paget’s Seborrhoeic keratosis 16
disease. Most of the skin malignancy developed over Epidermal cyst 6
head and neck (SCC 42.9%, BCC 50%), and trunk (SCC Benign naevus/lentigenes/melasma 5
33.3%, BCC 50%). Azathioprine is identified to be Ichthyosis 3
significant in development of SCC (RR 12.03, p <0.001). IGH 6
Folliculitis 2
CONCLUSION
Pilomatrichoma 1
Our study demonstrated that skin infection is most Lichen aureus 1
common in OTR. SCC is the most common skin cancer Macular amyloidosis 1
detected, with Azathioprine as a significant risk factor.
Chronic urticaria 4
Regular skin screening by a dermatologist among solid
Chondrodermatitis nodularis helicis 1
organ transplant recipients increases detection of skin
Venous lake of lip 1
malignancy1, and this allows early treatment. Being
Keloid 1
able to identify risk factors associated with
Skin tags 1
development of skin malignancy, clinicians may
consider more frequent or prolonged follow up in the Total 64
high risk groups, and switch of medication class of Table 2
immunosuppressive therapy.
SCC (n=21)
REFERENCE Characteristics
n (%) RR [95% CI] P-value
1. Oh CC, Lee HY, Pang SM, et al. Dermatological Drug types
Conditions Seen in Renal Transplant Recipients in a Azathioprine 19 (90.5%) 12.03 (2.92, 49.64) < 0.001
Singapore Tertiary Hospital. Singapore Med
Ciclosporin 16 (76.2%) 2.17 (0.85, 5.58) 0.091
Mycophenolate Mofetil 7 (33.3%) 0.29 (0.13, 0.67) 0.002
MTOR 9 (42.9%) 0.73 (0.33, 1.61) 0.432
 Abstract ID: DSS14

Track: Skin Tumours (Benign / Malignant)

Contact Author: Pei MingYeo

Country: Singapore

Organisation: Singapore General Hospital

Poster View Here

Radiotherapy for Cutaneous Squamous Cell Carcinoma in Solid Organ Transplant Recipients, a
Systematic Review

Introduction and objectives

Solid organ transplant recipients (SOTR) are at higher risk than the normal population of developing
cutaneous malignancies, in particular squamous cell carcinoma. Radiotherapy is a good adjunct
treatment modality in this cohort of patients, especially in advanced or anatomically challenging
tumours.

Our objective is to assess the efficacy of radiation therapy either alone, or in conjunction with other
treatment modalities for cutaneous squamous cell carcinoma (cSCC) arising in SOTR.

Materials and methods

In August 2017, we searched for relevant trials in The Cochrane Central Register of Controlled Trials
(CENTRAL), CDSR, HTA, NHS EED and DARE); PubMed, Embase, CINAHL, and the ongoing trials
registries, WHO-ICTRP.

We included case series, retrospective cohort studies, case-control studies and randomised controlled
trials (RCTs) of radiotherapy for primary cSCC in SOTR. The primary outcome measure was local
remission. Secondary outcome measures were the rate of local recurrence. If data was missing, we
attempted to obtain it by contacting the authors.

Results
Only 7 studies were found to be suitable, out of which only 3 studies had quantitative measures of
primary and secondary outcomes. One retrospective cohort study (Amoils, 2017) showed an increase
in the 3-year survival rate for SOTR with cSCC who received surgery with adjuvant radiation therapy.
One case series (Veness, 1998) which studied the outcomes of cSCC in cardiothoracic transplant
patients, showed that patients who received both surgery and adjuvant radiation therapy had a longer
median time to relapse and better overall survival rates compared to patients who only received surgery.
In the third study (Rabinovics, 2015), all 21 patients received radiation therapy. This paper provided
only an overview of treatment received by all patients, and thus, we could not conclude from this study
the difference in primary and secondary outcomes in patients receiving radiation therapy compared to
patients who did not receive radiation therapy.

Conclusion
There is paucity of data regarding efficacy of radiotherapy used for cSCC in SOTR. There are no RCTs
that demonstrate the efficacy of radiotherapy. Future studies with RCT will be useful to address this
clinical gap in dermatology.
 Poster: DSS14
Radiotherapy for Cutaneous Squamous Cell Carcinoma in
Solid Organ Transplant Recipients,
a Systematic Review
Yeo Pei Ming 1, Nurun Nisa De Souza2, Rehena Sultana2, Oh Choon Chiat 1
1. Singapore General Hospital, Department of Dermatology
2. Duke-NUS Medical School

Introduction Outcomes of interest

• Our primary outcome of interest were local, regional
• Cutaneous squamous cell carcinoma (cSCC) is the most and distant recurrence, and death. Our secondary
common post-transplant neoplasm in solid organ outcome of interest were adverse events by the end of
transplant recipients (SOTR) and are considered high-risk. treatment.

• Complete surgical clearance is the standard of care and Results

adjuvant radiotherapy is advocated for cSCC showing
extensive perineural or large-nerve involvement, large and • Out of 2314 papers, 152 papers were reviewed in their
poorly differentiated tumours, or if tissue margins are entirety and we found only 21 eligible papers, out of
positive1. which only 2 papers were included in the qualitative
synthesis (fig. 1).
• We aimed to summarise the role of radiotherapy in cSCC
occurring in SOTR from existing literature. • There were no randomised controlled trials. The 2
eligible papers were observational studies2,3 resulting in a
M ethods total of 40 patients (41 cases).
Data sources
• For the 19 papers which were excluded after a review of
• We performed a systematic review following the Preferred
their full text, 4/ 21 papers did not specify the number of
Reporting Items for Systematic Reviews and Meta-
SOTR included in their study, 3/ 21 papers only had 1
Analysis (PRISMA).
SOTR included in their study, 3/ 21 papers did not
perform subgroup analysis for SOTR, 2/ 21 papers were
Inclusion and exclusion criteria
topic reviews, 2/ 21 looked at anal carcinoma or non-
• Studies involving more than 1 SOTR with cSCC and
SOTR, 2/ 21 did not specify choice of treatment modality,
treatment using surgery and adjuvant radiotherapy
2/ 21 full articles were unavailable and their authors
alone, or surgery and adjuvant chemoradiotherapy
uncontactable and 1/ 21 was a poll on radiotherapists.
were included.
Primary and secondary outcomes
• SCC of the mucous membranes and those of the skin of
• 32/ 41 cases (78%) had locoregional recurrence and
penis and anus were excluded since these sites require
7/ 41 cases (17%) had distant recurrence. 20/ 41 cases
special interventions and a different approach.
(49%) died, of which 11 cases died from their disease, 2
from other causes and it was unclear the cause of death
• Information on at least one outcome of interest was
in 7 cases.
required for inclusion. Studies were excluded if subgroup
analysis of the outcomes in SOTR were unclear or
• There was lack of uniformity in the definitions used to
unavailable.
determine end points of recurrence, metastasis and
disease-specific death. In addition, the time-to-death
Screening, data extraction and risk of bias assessment
duration was not specified in the paper by Rabinovics3.
• Two independent reviewers (YPM and OCC) screened the
titles, abstracts and full text articles independently. Any
• Only 1 study3 reported adverse events and only 1 patient
disagreement was resolved by discussion between the 2
who had surgery, radiation therapy, Cisplatinum, 5-
investigators. If outcome data were missing, we made up
fluorouracil and cetuximab died of mucositis.
to a maximum number of 3 attempts to obtain it via email
contact with the authors. Conclusion
• Assessment of study quality was performed by the 2 • Outcomes of cSCC in immunosuppressed patients are
reviewers (YPM and OCC) using the Newcastle-Ottawa known to be worse than in immunocompetent patients.
scale. Data was extracted by YPM and reviewed by NNDS Nevertheless, from our systematic review, we found a
and RS. profound paucity of high-quality research studying
the utility of adjuvant radiotherapy in primary cSCC in
SOTR.

• Barring randomised controlled trials which may be

deemed unethical, perhaps the most ideal studies to
understand optimal treatment modality for these patients
may be from extrapolation of data from observational
studies. A standardised list of tumour factors and
outcome measures will make studies easier to
compare.

• Until further data is available to guide clinicians, adjuvant

radiotherapy may be offered in SOTR, considering the
high-risk nature of cSCC in this population and the
minimal adverse effects conferred by radiotherapy.

References
1. National Comprehensive Cancer Network. Squamous Cell Skin Cancer (Version 1.2018). Accessed
on 18 February 2018.
2. Veness MJ, Quinn DI, Ong CS, Keogh AM, Macdonald PS, Cooper SG, Morgan GW. Aggressive cutaneous
malignancies following cardiothoracic transplantation: the Australian experience. Cancer. 1999 Apr
15;85(8):1758-64.
3. Rabinovics N, Hadar T, Mizrachi A, Bachar G, Purim O, Popovtzer A. Adjuvant treatment for head and neck
cancer in solid organ transplant recipients. Oral Oncol. 2015 ay;51(5):323-5.
Fig 1 PRISMA flowchart
 Abstract ID: DSS41
Track: Skin Tumours (Benign / Malignant)
Contact Author: Cathy Zhao
Country: Singapore
Organization: National Skin Centre
Poster View here

The incidence of basal cell carcinoma appears reduced in patients on anti-Programmed cell
death-1 therapy for metastatic melanoma

Introduction and objectives: Systemic melanoma therapies have the potential to affect basal cell
carcinoma (BCC) and cutaneous SCC (cuSCC) development. We aim to compare the incidence of BCC
and cuSCC in patients with metastatic melanoma treated with anti-programmed cell death 1 (anti-PD1),
BRAF inhibitor monotherapy (BRAFi) or dabrafenib and trametinib combination therapy (CombiDT) with
a group of control patients.

Methods: We reviewed the records of melanoma patients on anti-PD1, BRAFi or CombiDT, and patients
from the High Risk Melanoma Clinic, Westmead Hospital, Australia.

Results: Altogether 340 patients were included; 82 on anti-PD1, 134 on BRAFi, 69 on CombiDT and 55
controls. BRAFi had the highest incidence of BCC (12.7%), followed by CombiDT (10.1%) and anti-
PD1 (2.4%). The incidence of BCC was significantly lower in patients on anti-PD1 (2.4% versus 19.4%,
p<0.001) compared to controls. Controls were 8.54 times more likely to develop BCC than anti-PD1
patients (hazard ratio [HR] 0.117 [95%CI 0.026-0.526], p=0.005). BRAFi and CombiDT showed no
significant differences in BCC incidence compared to controls. BRAFi had the highest cuSCC incidence
(23.9%), followed by anti-PD1 (7.3%) and CombiDT (2.9%). The incidence of cuSCC was significantly
higher in patients on BRAFi (23.9% versus 3.5%, p<0.001) compared to controls, but anti-PD1 and
CombiDT showed no differences in cuSCC incidence compared to controls.

Conclusions: Our study suggests that anti-PD1 therapy decreases the incidence of BCC, as a result of
the PD1/PDL1 blockade. Future studies investigating the role of anti-PD1 in suppressing or treating
BCC may be warranted.
Poster: DSS41

The incidence of basal cell carcinoma is reduced in patients on anti-

Programmed cell death-1 therapy for metastatic melanoma
Cathy Yunjia Zhao1,3, Shelley Hwang1,3, Rachael Anforth1, Giuliana Carlos1, Matteo Carlino1,2 Pablo Fernández-Peñas1,3
1. Department of Dermatology, Westmead Hospital, Sydney 2. Department of Oncology, Westmead Hospital, Sydney 3. Medical School, University of Sydney, Sydney

1. INTRODUCTION 5. RESULTS (cont.)

In the last decade, BRAF-kinase inhibitors (BRAFi), BRAFi and
MEK inhibitors combination therapy (CombiDT), and anti-
Programmed cell death-1 therapy (anti-PD1) have revolutionised
the treatment of metastatic melanoma. However, these therapies
are accompanied by various skin side effects. The potential effect
of these therapies esp. immunotherapies in the development of
non-melanoma skin cancers (NMSC) is an area worth exploring.
Additional BCC immunohistochemistry study: Analysis of
10 BCC from under anti-PD1 therapy and 8 BCC from controls
patients showed that while all BCC had negative PDL1 staining,
the percentage of PD1 staining in anti-PD1 group is significantly
lower than that of the control group (Independent T-test, 8%
versus 26%, p<0.001).

SCC: BRAFi had the highest incidence of cuSCC (23.9%)

2. AIM
To compare the incidence of cutaneous squamous cell
carcinomas (cuSCC) and basal cell carcinomas (BCC) observed
in patients with metastatic melanoma treated with BRAFi,
CombiDT or anti-PD1, with a control group of high risk patients
with similar sporadic NMSC risks.
followed by anti-PD1 (7.3%), controls (3.5%) and CombiDT
(2.9%). Compared to controls, only BRAFi group had
significantly higher cuSCC incidence (p<0.001). Patients on
BRAFi were 10.71 times more likely to develop cuSCC (HR
10.71 [95%CI 2.550-44.970], p=0.001). Histological examination
of the SCC differentiation did not show any differences between
the groups.

Figure: Kaplan-Meier graph of the cumulative incidence of cuSCCs.

3. METHODS
All patients on systemic anti-
melanoma therapy seen at
Westmead Hospital between
2009-2013 (n=285), followed
3monthly.
Controls were included from our
High Risk Melanoma Clinic. They
were on no therapy and has a
history of at least one melanoma
(n=57), followed 3-6monthly.

4. RESULTS
Anti-PD1 BRAFi CombiDT Control
Number of patients 82 134 69 57
Median age in years 61 60 54 58
Sex - % of males 62 71 59 60
Median observed time
39.2 29.4 35.9 54.0
(weeks)

BCC: Controls had a the highest incidence of BCCs (19.4%),

followed by BRAFi (12.7%), CombiDT (10.1%), and anti-PD1
(2.4%). Compared to controls, only anti-PD1 therapy showed
significantly lower BCC incidence (p<0.001). Patients on anti-PD1
were 8.33 times less likely (HR 0.120 [95%CI 0.027-0.539],
p=0.006) than controls to develop BCC. Histological examination
of the BCC types amongst the groups did not show any
significant differences.
Figure: Kaplan-Meier graph of the cumulative incidence of BCCs.
6. DISCUSSION
Our most significant finding was the lower incidence of BCC in anti-
PD1 treated patients. We postulate that BCC development may
have been prevented with anti-PD1 induced T-cell immunogenicity,
as a recent study have shown a high intensity of PD1L staining in
BCCs.1 This landmark finding from our study may warrant future
RCTs to assess the efficacy of anti-PD1 for treating BCCs.

Surprisingly, the incidence of cuSCC was not lower in anti-PD1

group, despite the efficacy of anti-PD1 for head and neck SCCs.2

7. TAKEHOME MESSAGE
1. Anti-PD1 may reduce the incidence of BCC.
2. Anti-PD1 may not reduce the incidence of cuSCC.
3. BRAFi increases the incidence of cuSCC, which is
ameliorated by the addition of a MEK inhibitor.

8. REFERENCES/ACKNOWLEDGEMENT
1. Chang J et al. Association Between PDL1 Expression in Patients With Basal Cell Carcinomas and the
Number of Treatment Modalities. JAMA dermatology 2017;153:285-90.
2. Chow LQ et al. Antitumor Activity of Pembrolizumab in Metastatic Head and Neck Squamous Cell Carcinoma:
Results From the Phase Ib KEYNOTE-012 Expansion Cohort. J Clin Oncol 2016.
3. Carroll RP et al. Incidence and prediction of NMSC post-renal transplantation: a prospective study in
Queensland, Australia. Am J Kidney Dis 2003;41:676-83.

The authors would like to thank Dr Marina Ali, Dr Rupalben Patel,

Dr Ali Azimi and the oncology team at Westmead Hospital.
 Abstract ID: DSS56

Track: Skin Tumours (Benign / Malignant)

Contact Author: Jazlyn Read

Country: Australia

Organization: Others

Poster View Here

Non-melanoma skin cancer in Africans with oculocutaneous albinism: 3 cases and review of
factors impacting management

Background
Compared with a prevalence of 2% in the African population, non-melanoma skin cancer (NMSC) is
virtually ubiquitous in Africans with oculocutaneous albinism (OCA). While OCA affects people of all
ethnic backgrounds, the clinical picture of NMSC in sub-Saharan Africa is influenced by a combination
of intense ultraviolet radiation, barriers to care, and cultural factors. We present 3 cases of NMSC in
Africans with OCA, comprising BCC and 2 cases of basosquamous carcinoma.

Case Presentation
A 20-year-old male presented with an erythematous scaly plaque to his right lateral eyebrow and upper
eyelid, clinically suspicious for SCC. He had very fair skin and blonde hair, with light tan macules
scattered over photoexposed areas, but no other lesions of concern. The lesion was widely excised,
and the defect reconstructed with a full thickness skin graft (FTSG). Microscopic examination
demonstrated infiltrative nests and islands of basosquamous carcinoma, with a morpheic growth pattern
at the deep aspect.
A 34-year-old female with a history of NMSC presented with an ulcerated lesion in the conchal bowl of
her right ear, on a background of moderate actinic keratoses across all photoexposed areas. The lesion
was excised and reconstructed with a FTSG. Histopathology showed an ulcerated invasive BCC.
A 59-year-old female with extensive actinic keratoses presented with a new scaly lesion to her upper
lip. The lesion was biopsied as a squamoproliferative lesion favouring well differentiated SCC, and
excised as a full thickness wedge. Microscopic assessment of the entire lesion revealed a
basosquamous carcinoma.

Discussion
A lack of protective eumelanin in OCA and exposure to ultraviolet radiation predisposes to NMSC, often
with an early age of onset. Skin protection measures are vital in this population, including protective
clothing, sunscreen, and minimising time outdoors. In sub-Saharan Africa, poverty and social
discrimination are recognised barriers to care, leading to delays in presentation and poor treatment
concordance. Superstition underpins the cultural stigma of albinism in many rural communities, such
as the belief that albino body parts have magical properties for use in traditional medicine. Ostracism
and persecution derived from cultural views further impede management."
Poster: DSS56

Non-melanoma skin cancer in Africans with oculocutaneous albinism:

3 cases and review of factors impacting management
Jazlyn Read
Groote Schuur Hospital, Cape Town, South Africa

Background

Compared with a prevalence of 2% in the African population, non-melanoma skin cancer (NMSC) is virtually ubiquitous in Africans with oculocutaneous
albinism (OCA). While OCA affects people of all ethnic backgrounds, the clinical picture of NMSC in sub-Saharan Africa is influenced by a combination of
intense ultraviolet radiation, barriers to care, and cultural factors.1,2,3

We present 3 cases of NMSC in Africans with OCA, comprising BCC and 2 cases of basosquamous carcinoma.

Case 1

A 20-year-old male presented with an erythematous scaly plaque to his

right lateral eyebrow and upper eyelid, clinically suspicious for SCC. He
had very fair skin and blonde hair, with light tan macules scattered over
photoexposed areas, but no other lesions of concern.

The lesion was widely excised with a 7mm margin, and the defect
reconstructed with a full thickness skin graft (FTSG) taken from non-sun
exposed supraclavicular skin. Microscopic examination demonstrated
infiltrative nests and islands of basosquamous carcinoma, with a
morpheic growth pattern at the deep aspect.

Case 2

A 34-year-old female with a history of NMSC presented with an

ulcerated lesion in the conchal bowl of her right ear, on a background of
moderate actinic keratoses across all photoexposed areas.

The lesion was excised and reconstructed with a FTSG. Histopathology

showed an ulcerated invasive BCC. The background dermis showed
severe solar elastosis, and marked lymphoplasmacytic inflammation
around infiltrating nests of BCC. The cartilage was not involved.
The defect was reconstructed with a trap door flap.

Case 3

A 59-year-old female with extensive actinic keratoses and history of

multiple NMSC presented with a new scaly lesion to her upper lip.

The lesion was biopsied as a squamoproliferative lesion favouring well

differentiated SCC, with a differential diagnosis of keratoacantoma. The
lesion was excised as a full thickness wedge and closed directly.

Microscopic assessment of the entire lesion revealed a basosquamous

carcinoma, with associated stromal desmoplasia and solar elastosis.

Discussion References

A lack of protective eumelanin in OCA and exposure to ultraviolet
radiation predisposes to NMSC, often with an early age of onset. Skin
protection measures are vital in this population, including protective
clothing, sunscreen, and minimising time outdoors. 1,2,3
In sub-Saharan Africa, poverty and social discrimination are recognised
barriers to care, leading to delays in presentation and poor treatment
concordance. Superstition underpins the cultural stigma of albinism in
many rural communities, such as the belief that albino body parts have
magical properties for use in traditional medicine.4 Other myths include
that people with OCA are ghosts or possessed by evil spirits.4
Ostracism and persecution derived from cultural views further impede
management.
1. Lekalakala PT, Khammissa RAG, Kramer B, Ayo-Yusuf OA, Lemmer J, Feller L.
Oculocutaneous Albinism and Squamous Cell Carcinoma of the Skin of the Head and
Neck in Sub-Saharan Africa. J Skin Cancer. 2015;2015:167847.
2. Kiprono SK, Chaula BM, Beltraminelli H. Histological review of skin cancers in African
Albinos: a 10-year retrospective review. BMC Cancer. 2014;14:157.
3. Mabula JB, Chalya PL, Mchembe MD, et al. Skin cancers among Albinos at a University
teaching hospital in Northwestern Tanzania: a retrospective review of 64 cases. BMC
Dermatology. 2012;12:5.
4. Cruz-Inigo AE, Ladizinski B, Sethi A. Albinism in Africa: stigma, slaughter and awareness
campaigns. Dermatol Clin. 2011 Jan;29(1):79-87.
Contact
Dr Jazlyn Read
Email: uqjread4@uq.edu.au
 Abstract ID: DSS62

Track: Basic Science

Contact Author: Byeong-Churl Jang

Country: Republic of Korea

Organization: Keimyung University

Poster View Here

Up-regulation of the expressions of involucrin, filaggrin and TGM1 in UVB-irradiated HaCaT cells
by fermented Schisandra chinensis extract

Abstract

Introduction and objectives: Reduced skin barrier function is associated with many inflammatory skin
diseases, such as atopic dermatitis. Reduced skin barrier function is attributable to no or low expression
levels of skin barrier-related proteins on epidermis. Schisandra chinensis extract is known for skin
protective and improving activities. Little is known about the relation between Schisandra chinensis
extract and gene expression of skin barrier-related proteins. The aim of this study was to evaluate the
effect of Lactobacillus paracasei fermented Schisandra chinensis extract (LPSC-E) on expression of
involucrin, filaggrin and transglutamidase 1 (TGM1), known skin barrier-related proteins, in ultraviolet B
(UVB)-irradiated HaCaT keratinocytes.

Materials and methods: Cell viability and survival of control or UVB (300 mJ/cm 2)-irradiated HaCaT
cells treated without or with LPSC-E were analyzed by MTS and cell count assay, respectively. Protein
and mRNA expression levels of involucrin, filaggrin and TGM1 in control or UVB (300 mJ/cm2)-irradiated
HaCaT cells treated without or with LPSC-E were measured by Western blotting and RT-PCR,
respectively.

Results: UVB at 300 mJ/cm 2 slightly reduced viability and survival of HaCaT cells. UVB at 300 mJ/cm 2
largely reduced protein and mRNA expression levels of involucrin, filaggrin and TGM1 in HaCaT cells,
suggesting UVB-induced transcriptional down-regulation of involucrin, filaggrin and TGM1. Notably,
LPSC-E concentration-dependently inhibited not only reduction of cell viability and survival but also
decrease in protein and mRNA expression levels of involucrin, filaggrin and TGM1 in UVB-irradiated
HaCaT cells. Furthermore, LPSC-E increased the cell viability and survival as well as the protein and
mRNA expression levels of involucrin, filaggrin and TGM1 in control HaCaT cells. In addition, LPSC-E
partially blocked UVB-induced decrease in the phosphorylation and/or expression levels of ERK-1/2
and c-fos in HaCaT cells. LPSC-E had no effects on UVB-induced decrease in the phosphorylation
and/or expression levels of p-38 MAPK, JNK-1/2 and c-Jun ERK-1/2 in HaCaT cells

Conclusions: These findings demonstrate firstly that LPSC-E has stimulatory effects on expressions
of involucrin, filaggrin and TGM1 in UVB-irradiated HaCaT cells and the effects are in part mediated
through ERK-1/2 activation and c-fos up-regulation. This study shows that LPSC-E can be used as a
novel anti-skin barrier material.

Key words: Schisandra chinensis extract; UVB; Skin barrier proteins; HaCaT
 Poster:DSS62

UP-REGULATION OF THE EXPRESSIONS OF INVOLUCRIN, FILAGGRIN AND TGM1 IN

UVB-IRRADIATED HACAT CELLS BY FERMENTED SCHISANDRA CHINENSIS EXTRACT

Kyoung Ran Shin1, Yu-Kyoung Park1, Byung Hee Park2, and Byeong-Churl Jang1,*
1Department of Molecular Medicine, Keimyung University School of Medicine
2Raphagen Co., Republic of Korea

INTRODUCTUIN-
Reduced skin barrier function is associated with many inflammatory skin diseases, including atopic dermatitis. Reduced skin barrier function is largely attributable
to no or low expression levels of skin barrier-related proteins on epidermis. Schisandra chinensis extract is known for skin protective and improving activities.
Little is known about the relation between Lactobaccilus fermented chisandra chinensis extract and gene expression of skin barrier-related proteins.

AIM-
The aim of this study was to evaluate the effect of Lactobacillus paracasei fermented Schisandra chinensis extract (LPSC-E) on expression of involucrin, filaggrin
and transglutamidase 1 (TGM1), known skin barrier-related proteins, in ultraviolet B (UVB)-irradiated HaCaT keratinocytes.

MATERALS AND METHODS-

Sample preparation: Schisandra chinensis was fermented with Lactobacillus paracasei at 30℃ for 48 h and the fermented products were fractionated using 30%
ethanol. The resultant sample was named as LPSC-E (Lactobacillus paracasei fermented Schisandra chinensis extract).
Cell culture: The human keratinocyte cell line HaCaT was cultured in DMEM F12 supplemented with 10% fetal bovine serum and 100 U/ml of
penicillin/streptomycin at 37˚C in cell culture incubator at 5% CO2.
Cell count assay: The numbers survived in control or UVB (300 mJ/cm2)-irradiated HaCaT cells treated without or with LPSC-E were counted by trypan blue
exclusion method and expressed as percentage control.
Western blotting: An aliquots of cellular proteins extracted from control or UVB (300 mJ/cm2)-irradiated HaCaT cells treated without or with LPSC-E were
analyzed by Western blotting using specific antibody for measurement of the protein expression levels of involucrin, filaggrin and TGM1 .
RT-PCR: Total RNA extracted from control or UVB (300 mJ/cm2)-irradiated HaCaT cells treated without or with LPSC-E was reverse transcribed and subjected to
PCR using specific primer for measurement of the mRNA expression levels of involucrin, filaggrin and TGM1.

RESULTS-

Figure 1. The effects of UVB irradiation on growth and protein
and mRNA expressions in HaCaT cells. (A) HaCaT cells were
exposed to UVB at the indicated doses for 5 h. Cells survived
were analyzed by the trypan blue dye. The cell count assay was
done in triplicates. (B, C) Whole cell lysates or total RNA from
HaCaT cells exposed to UVB at the indicated doses for 5 h were
extracted and analyzed by Western blot (B) and RT-PCR (C)
analysis, respectively. (D, E) Whole cell lysates from HaCaT cells
exposed to UVB (300 mJ/cm2) at the indicated times were
extracted and analyzed by Western blot (B) and RT-PCR (C)
analysis, respectively.
Figure 2. The effects of LPSC-E (#5-18) treatment
at different concentrations on growth and protein
and mRNA expressions of involucrin, filaggrin,
and TGM1 in control- or UVB (300 mJ/cm2)-
irradiated HaCaT cells. (A) HaCaT cells were
exposed to UVB (300 mJ/cm2) at the indicated
times in the absence or presence of LPSC-E at
the indicated concetraions for 5 h. Cells survived
were analyzed by the trypan blue dye in
triplicates. (B, C) Whole cell lysates or total RNA
from the (A) experimental conditions were
extracted and analyzed by Western blot (B) and
RT-PCR (C) analysis, respectively.
Figure 3. The effects of UVB irradiation and/or LPSC-E (#5-18)
treatment on growth and protein and mRNA expressions of
intracellular transcription factors and signaling proteins, which
are involved in involucrin, filaggrin, and TGM1 gene
expressions, in HaCaT cells. (A,B) HaCaT cells were exposed
to UVB (300 mJ/cm2) at the indicated times. Whole cell lysates
or total RNA from the conditioned cells were extracted and
analyzed by Western blot (B) and RT-PCR (C) analysis,
respectively. (C,D) HaCaT cells were exposed to UVB (300
mJ/cm2) in the absence or presence of LPSC-E (100 g/ml) for
5 h. Whole cell lysates or total RNA from the conditioned cells
were extracted and analyzed by Western blot (B) and RT-PCR
(C) analysis, respectively.

DISCUSSION-
Skin barrier function is impaired in many skin diseases, such as atomic dermatitis and eczema. Defective barrier function enables the enhanced penetration of
environmental allergens into the skin and initiates immunological reactions and inflammation, leading to the development of suck skin diseases. Barrier
dysfunction is therefore crucially involved in the pathogenesis of many skin diseases. Defective barrier function is largely due to UV-induced reduction of
expression levels of skin barrier-related proteins and factors on epidermis. Thus, any natural substance that can interfere with the UV-induced reduction of skin
barrier-related proteins and factors on epidermis will be used as potential anti-skin barrier material and/or cosmetic constituent.
In this study, UVB exposure largely reduced protein and mRNA expression levels of several skin barrier-related proteins, involucrin, filaggrin, and TGM1, in
HaCaT cells, suggesting UVB-induced skin barrier dysfunction. Strikingly, LPSC-E largely abolished the ability of UVB to down-regulate protein and mRNA
expressions of involucrin, filaggrin and TGM1 in HaCaT cells. Of further note, LPSC-E specifically increased the phosphorylation and expression levels of ERK-1/2
and c-Fos in HaCaT cells. The concentrations of LPSC-E used herein was not cytotoxic to HaCaT cells.

CONCLUSION-
Our findings demonstrate firstly that LPSC-E has stimulatory effects on expressions of involucrin, filaggrin and TGM1 in UVB-irradiated HaCaT cells and the
effects are in part mediated through ERK-1/2 activation and c-fos up-regulation. This study shows that LPSC-E can be used as a novel anti-skin barrier material.
 Abstract ID: DSS58

Track: Dermatological Treatment

Contact Author: Jazlyn Read

Country: Australia

Organization: Others

Poster View Here

Residual melanoma in situ following surgical excision – a role for topical imiquimod?

Introduction and objectives

Melanoma in situ (MIS) is a precursor lesion to malignant melanoma, and surgical excision with a 5-
10mm margin is the standard of care. However, MIS may be indistinct clinically, with radial extension
of subclinical disease extending beyond surgical margins. In situations where patient preference or
surgical site factors preclude further wide excision, topical imiquimod may be a viable option in second
line management of involved margins. We assessed clinical and histological clearance rates, rate of
recurrence, and rate of progression to invasive disease for MIS excised with involved margins and
subsequently treated with imiquimod.

Materials and methods

We performed a pooled analysis of published data for surgically excised MIS without an invasive
melanoma component, treated with adjuvant imiquimod monotherapy for involved margins. We pooled
data on clinical and histological clearance, treatment factors, and recurrence for the 14 patients who fit
the criteria.

Results
After a single imiquimod treatment course of 6–17 weeks (mean 11.4), 12 of 14 patients (86%)
demonstrated complete clinical clearance, 1 patient had partial clearance (7%), and 1 patient did not
respond to imiquimod (7%). Eleven of 14 patients (78.5%) demonstrated histological clearance and 3
patients (21.5%) had residual MIS on post-treatment surveillance biopsies. Two patients with clinical
response but residual MIS after a single course were treated with a further 12-week course of
imiquimod. After 2 courses, histological clearance rate was 93% (N=13). No recurrences were reported
at treatment sites, and no invasive melanoma was sampled on post-treatment mapping biopsies.

Conclusions
In this small pooled analysis, imiquimod offers a 93% histological clearance rate for residual MIS after
surgical excision. For patients with persistently margin positive MIS after appropriate surgical excision
where invasive melanoma has been excluded, re-excision may not be possible due to patient refusal
or site-specific factors. We suggest that watchful waiting of residual MIS is unacceptable, owing to risk
of recurrence and also progression to invasive melanoma, and propose topical imiquimod as a second
line surgical adjunct. Limitations include a small number of cases and variable follow-up, and further
studies are needed.
Poster: DSS58

Residual melanoma in situ following surgical excision

– a role for topical imiquimod?
Jazlyn Read
Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia

Introduction and objectives Results

Melanoma in situ (MIS) is a precursor lesion to malignant melanoma,
and surgical excision with a 5-10mm margin is the standard of care.
However, MIS may be indistinct clinically, with radial extension of
subclinical disease extending beyond surgical margins. In situations
where patient preference or surgical site factors preclude further wide
excision, topical imiquimod may be a viable option in second line
management of involved margins.
We assessed clinical and histological clearance rates, rate of
recurrence, and rate of progression to invasive disease for MIS excised
with involved margins and subsequently treated with imiquimod.
Materials and methods
We performed a pooled analysis of published data for surgically excised
MIS without an invasive melanoma component, treated with adjuvant
imiquimod monotherapy for involved margins. We pooled data on
clinical and histological clearance, treatment factors, and recurrence for
the 14 patients who fit the criteria.
A total of 14 patients (7 male, 7 female, mean age 69.9, range 56-83)
with 14 MIS lesions that had been surgically excised with involved
margins were included. Lesions were located on the head and neck in
12 patients (85.7%), and on the extremities in 2 patients (14.2%).
After a single imiquimod treatment course of 6 – 17 weeks (mean 11.4
weeks), 12 of 14 patients (86%) demonstrated complete clinical
clearance, 1 patient had partial clearance (7%), and 1 patient did not
respond to imiquimod (7%).
Eleven of 14 patients (78.5%) demonstrated histological clearance and
3 patients (21.5%) had residual MIS on post treatment surveillance
biopsies.
Two patients with clinical response but residual MIS after a single
course were treated with a further 12-week course of imiquimod.
After 2 courses, histological clearance rate was 93% (N=13). No
recurrences were reported at treatment sites, and no invasive
melanoma was sampled on post treatment mapping biopsies.

Authors Patient Site Application frequency Duration Inflammation Clinical Histological Follow up Recurrence
(days/week) (weeks) clearance clearance (months)
Elia et al 2016 78 M R lower eyelid 7 8 Present, NOS Complete No MIS 6 No
(1)
Ellis et al 2012 82 M R cheek 7 12 Present, NOS Complete No MIS 6 No
(2)
Pandit et al 52 F R frontal hairline 5 17 Severe Complete No MIS 52 No
2015 (3)
62 F R lateral eyelid, R nose 5 6 Severe Complete No MIS 46 No

49 M R cheek 2-5 12 Severe Complete No MIS 46 No

80 F L forehead 2-5 22 (10+12) Severe Partial No MIS 23 No

75 M L great toe 3-5 12 Moderate Complete No MIS 6 No

82 F L ear 3 24 (12+12) Moderate Complete No MIS 8 No

63 M R upper cheek 0.5 - 5 13 Moderate Complete No MIS 53 No

75 M Dorsum of nose 3 10 Severe Complete No MIS 12 No

59 M R neck 3 12 Severe Complete No MIS 6 No

83 F R index finger 5 7 None Failure Persistent MIS 10 Non-clearance

82 F L upper lip 3-7 12 Severe Complete No MIS 15 No

56 F R nasal ala 3-5 16 Severe Complete No MIS 7 No

Initially residual MIS on mapping biopsies after 1 course of imiquimod, no residual MIS on mapping biopsies after a 2nd treatment course
On further excision – persistent MIS at margins. Clinically no evidence of recurrence.

Conclusions References

In this small pooled analysis, imiquimod offers a 93% histological
clearance rate for residual MIS after surgical excision. For patients with
persistently margin positive MIS after appropriate surgical excision
where invasive melanoma has been excluded, re-excision may not be
possible due to patient refusal or site-specific factors.
We suggest that watchful waiting of residual MIS is unacceptable, owing
to risk of recurrence and also progression to invasive melanoma, and
propose topical imiquimod as a second line surgical adjunct.
Limitations include a small number of cases and variable follow-up, and
further studies are needed.
1. Elia MD, Lally SE, Hanlon AM, Choi JN, Servat JJ, Shields JA, Shields CL,
Levin F. Periocular Melanoma In Situ Treated With Imiquimod. Ophthal Plast
Reconstr Surg. 2016 Sep-Oct;32(5):371-3.
2. Ellis LZ, Cohen JL, High W, Stewart L. Melanoma In Situ Treated
Successfully Using Imiquimod After Nonclearance with Surgery: Review of
the Literature. Dermatol Surg. 2012 Jun;38(6):937-46.
3. Pandit AS, Geiger EJ, Ariyan S, Narayan D, Choi JN. Using
topical imiquimod for the management of positive in situ margins after
melanoma resection. Cancer Med. 2015 Apr;4(4):507-12.
Contact
Dr Jazlyn Read
Email: uqjread4@uq.edu.au
 Abstract ID: DSS39

Track: Dermatopathology

Contact Author: Priya Bishnoi

Country: Singapore

Organization: KK Women's and Children's Hospital

Poster View here

Sub-type of Epidermolysis Bullosa – clues hidden in histopathology

Background - Epidermolysis Bullosa (EB) is a genetic condition characterized by development of

blisters and erosions after subtle trauma to skin or mucous membranes. Diagnostic modalities include
Immunofluorescence antigen mapping (IFM), transmission electron microscopy (TEM) and genetic
analysis. Although TEM and genetics are considered as confirmatory tests but IFM is a simple modality
which can precisely locate the level of cleavage in most of the cases. Histological features of EB have
not been studied so far as they have not been of much help in EB diagnosis.

Objectives – To study the histological features and find clues which could help us in predicting the level
of cleavage based on simple H&E staining of EB biopsies.
Methods – This was a retrospective review of histology sections of EB biopsies primarily analyzed and
confirmed by IFM.

Results – We had a total of 40 confirmed cases of EB based on IFM and out of which 12 were simplex,
9 - Junctional, 17 - Dystrophic and 2 were Kindlers syndrome. On reviewing the histopathology of these
cases intra-epidermal cleft was seen in 7 out of 12 cases of simplex and sub-epidermal blistering was
seen in 4 of the junctional and 10 of dystrophic EB cases. Of all the simplex cases 5 showed linear
basal clefting, 2 cases showed focal areas of basal and supra-basal clefting with slight disintegration of
epidermis, 2 of them showed complete detachment of epidermis from the dermis and in the remaining
3 no blister was found. In all cases of simplex rete pegs were preserved and few keratinocytes were
always found on the floor of the cleft. In Junctional EB cases 2 kind of blisters were noticed, one was
the usual sub-epidermal (4) type and second was blistering along the basement membrane zone (m/l
foci of small clefts all along the basement membrane) which was seen in 6 cases. Clean linear sub-
epidermal cleft (10) or a complete detachment (6) was the most common pattern seen in dystrophic
cases with epidermal atrophy noticed in 5 cases.
Conclusion – Routine light microscopy cannot replace IFM as a diagnostic modality, but many clues in
microscopy can point towards a certain sub-type.
Poster: DSS39

Sub-type of Epidermolysis Bullosa – clues hidden in histopathology

Priya Bishnoi1, Mark Koh1, Yi Zhen Ng2, John Common2, Lukas Lacina2, Declan Lunny2, Madeline Ho3, Yoke Chin Giam3, Kin Fon
Leong4, Hoey Hoey Oh5, E. Birgitte Lane2
1KK Women's and Children's Hospital, Singapore; 2Institute of Medical Biology, A*STAR, Singapore; 3National Skin Centre, Singapore; 4Institut

Pediatrik, Hospital Kuala Lumpur, Malaysia; 5Penang General Hospital, Malaysia

Introduction and Objectives Methods

Epidermolysis Bullosa (EB) is a genetic condition characterized
by development of blisters and erosions after subtle trauma to
skin or mucous membranes. Diagnostic modalities include
Immunofluorescence (IMF), transmission electron microscopy
(TEM) and genetic analysis. IMF is a simple modality which can
precisely locate the level of cleavage in most of the cases.
Histological features of EB have not been studied so far as they
have not been of much help in EB diagnosis. Aim of this study is
to find clues in histology which could help us in predicting the
level of cleavage based on simple hematoxylin and eosin (H&E)
staining.
H&E staining and antigen mapping was performed for all tissue
samples received between 2013 – 2017 with a suspected
diagnosis of EB at Institute of Medical Biology, A*STAR. IFM was
done using a standard panel of antibodies against keratin 5&14,
plectin, integrin α6 & β4, collagen XVII, laminin 332, collagen IV
and collagen VII. H&E sections for all cases with a confirmed
diagnosis of EB on immunofluorescence were reviewed
retrospectively to look out for patterns that could be suggestive of
any particular subtype. Review was done based on level of cleft,
type of clefts seen and unique patterns if any.

Results

Antigen mapping confirmed a diagnosis Subtype of EB by Level of cleft (n / %) Complete Pattern observed
of EB in 40 cases which were further IMF detachment of
divided as simplex (12), Junctional (9), epidermis from
dermis
dystrophic (17) and kindlers syndrome Simplex (12) Intra-epidermal (7/58%) 2 (17%) Keratinocytes nuclei hanging
(2) (Table 1). EBS and DEB with a basal Linear, basal – 5 from the roof of the blister
intra-epidermal and sub-epidermal Basal & supra basal – 2 (5/42%)
No blister (3/25%) Few nuclei found lining the floor
blister respectively. Multiple small clefts of the blister– (5/42%)
were noticed along the basement Junctional (9) Sub-epidermal (4/44%) 0 Finger like projections seen
membrane in cases of JEB (67%) as Along the basement membrane lining the roof of the blister
compared to the usual sub-epidermal (6/67%) (6/67%)
Multiple focal
blistering. In eight samples there was Dystrophic (17) Sub-epidermal (10/59%) 6 (35%) Epidermal atrophy (5/30%)
complete detachment of epidermis from Clean, linear sub epidermal (8)
the dermis and six of these were Few focal (2)
No blister (1/5%)
recessive for DEB on IMF. Epidermal Kindlers syndrome Along the basement membrane 0 -
atrophy was seen in 30% of the cases (2) (2/100%)
with DEB.
Table 1

Conclusion A C E

H&E can never replace IMF as a

diagnostic modality due to its own
limitations. But certain features if
looked for can help us in predicting the
sub-type on H&E. Complete
detachment of epidermis from dermis
with presence of epidermal atrophy is a B D F
strong predictor of RDEB. Clefts along
the basement membrane were quite
unique to JEB and can help us identify
this subtype. We would also like to add
in a different level of cleavage in
subtypes of EB which is very unique to
JEB
Limitations (A&B) EB Simplex - blistering at the basal layer of epidermis with keratinocyte nuclei seen along the roof and the floor
(C) Junctional EB – m/l small clefts seen along the basement membrane
Small sample size and review done by (D) Junctional EB – finger like projections seen along the roof of the blister
single reviewer are few limitations of (E&F) Dystrophic EB – linear sub-epidermal blister with significant epidermal atrophy
this study.
 Abstract ID: DSS05

Connective Tissue Disorders and Autoimmune

Track:
Bullous Disorders

Contact Author: Li Cheng Heng

Country: Singapore
Organisation: Singapore General Hospital
Poster View here

Pemphigoid and Pemphigus: Comparative Analysis of clinical epidemiology, course

and outcome in an Academic Centre

Introduction and Objectives

The differences in epidemiology and clinical outcome of Bullous pemphigoid and Pemphigus
are not well described in the Asian population. The aim of this study is to compare the
differences in epidemiology, comorbidities, treatment and outcomes in patients with Bullous
Pemphigoid and Pemphigus in Singapore.

Materials and Methods

This study compared 34 Pemphigus and 141 Bullous Pemphigoid patients diagnosed in an
Academic Centre between January 2005 to June 2016. Information regarding patients’ co-
morbidities, treatment and outcome was collected retrospectively. The data was analysed via
Cross Tabulation with Chi Square testing, and Mann-Whitney U tests using IBM SPSS v 23.

Results
Compared to Pemphigus patients, Pemphigoid patients were less likely to be of Indian ethnicity
(p=0.047). Pemphigoid patients had a higher age-adjusted Charlson Comorbidity Index Score
(5.87) than Pemphigus (2.65 )(p<0.001) and were more likely to have hypertension(p<0.001),
Ischemic heart disease(p=0.015), Stroke(p<0.001), Dementia(p<0.001), Parkinson’s Disease
(p=0.039) and Chronic Renal disease(p=0.03). Pemphigoid patients had greater functional
impairment with 55.3% who were Non-Ambulant vs 5.9% in Pemphigus patients (p<0.001) and
a higher proportion requiring nasogastric tubes for feeding (p=0.012). In both conditions,
prednisolone was the most common treatment modality, however fewer patients with
Pemphigoid required treatment with MMF/Azathioprine/Cyclophosphamide, IVIG and
Rituximab compared to Pemphigus (p<0.001). Whilst inpatient mortality at initial diagnosis was
lower in Pemphigoid (1.4%) compared to Pemphigus (8.8%)(p=0.020 ), a greater proportion of
patients with Pemphigoid required re-hospitalization within the first year compared to
Pemphigus patients(p<0.001).

Conclusion
Prognosis for patients with Pemphigoid who survive past their diagnostic admission may be
poorer than that for Pemphigus patients. This is likely due to their older age, comorbidity burden
and poorer functional status at baseline. This study confirms the need for a difference in
approach to prognosticating and management of patients with these two conditions due to the
differences in their epidemiology and disease course. With increasing usage of new treatment
modalities, mortality in Pemphigus may decrease further.
Poster: DSS05

Pemphigoid and Pemphigus: Comparative Analysis of clinical

epidemiology, course and outcome in an Academic Centre
Heng LC1,2, Phoon YW, Pang SM, Lee HY1
1Department of Dermatology, Singapore General Hospital , 2Yong Loo Lin School of Medicine, National University Hospital

Background
• Bullous Pemphigoid and Pemphigus Vulgaris are
the most common autoimmune blistering diseases
• Comparative disease associations, clinical course
and outcomes are largely unknown.
Objectives
• To compare and contrast the differences in patient
characteristics and clinical outcomes
Methods
• 141 newly diagnosed BP patients and 34
Pemphigus patients between the study period of
2005 to 2016 were analysed
• Associations and outcomes were compared
Results
• Compared to BP, pemphigus patients were
younger, and had less comorbidities.
• Pemphigus patients were also more independent
and a greater percentage were cognitively normal
• There was no significant difference between the 1
year mortality of pemphigus and pemphigoid
patients
• Pemphigus patients were more likely to die during
the initial hospitalization compared to BP
patients.
• The incidence of hospitalization within the 1st
year of diagnosis was also lower in Pemphigus
compared to BP

Conclusion
• Contemporary mortality in pemphigus and pemphigoid is similar despite variation in comorbid burden
• However long term prognosis for patients with Pemphigoid who survive past their diagnostic admission may
be poorer than that for Pemphigus patients

Table 1: Associations
Frequency(%) Pemphigus BP P
N=34 N=141
Age N=34 N=141 0.000
Mean(s.d) 59.24(13.4) 77.16 (10.7)
Age adjusted CCIS N=34 N=141 0.000
Mean(s.d) 2.44 (2.50) 5.87 (2.36)
Mobility Independent :31(91.2) Independent: 63(44.7) 0.000
Dependent:2(5.9 ) Dependent: 78(55.3)

Mental Status Cognitively Normal: Cognitively Normal: 0.000

32(97.0) 85(60.3)
Cognitively impaired: Cognitively impaired:
1(3.0) 56(39.7)
Feeding Independent: Independent: 0.012
31(93.9) 104(73.8)
Assisted(NG/ PEG): Assisted(NG/ PEG):
2(6.1) 37(26.2)
Table 2: Outcome
Frequency(%) Pemphigus BP P
N=34 N=141
1st Year Mortality Passed Away: 8(23.5) Passed Away: 44(31.2) 0.379
In-hospital mortality Passed away: 3(8.8) Passed Away: 2(1.4) 0.020
Sepsis within 1 year 9(26.5) 50(35.5) 0.320
Hospitalisation 1st year 11(33.3) 87(62.6) 0.002
 Abstract ID: DSS25

Track: Pigmentary Disorders

Contact Author: Joseph Toh

Country: Singapore

Organisation: National Skin Centre

Poster View here

Automated Scoring of Vitiligo Using Superpixel-Generated Computerised Digital Image

Analysis of Clinical Photographs: A Novel and Consistent Way to Score Vitiligo

Introduction/objectives
Objective outcome measures for vitiligo severity are essential for the evaluation of severity as
well as response to treatment. We aim to develop and validate a novel image analysis software
designed to automatically calculate the area of depigmentation in vitiligo from computer image
analysis of clinical photographs, thereby deriving an automated Vitiligo Area Scoring Index
(VASI) score.

Materials and methods

The automated algorithm was developed in collaboration with image analysis experts. The
algorithm derives the score in 3 steps. Firstly, the algorithm identifies and segments away the
background and undergarments of each image using segmentation methods. Next, the image
is converted into superpixels using linear spectral clustering. These superpixels are then used
for feature extraction and further classification of vitiligo versus non vitiligo areas. Finally, the
segmented vitiligo area is expressed as a percentage of the total body surface area (BSA). This
is subsequently validated in a prospective clinical trial which involves 21 vitiligo patients
undergoing narrowband UVB (NBUVB) light therapy. VASI scores were obtained during the
clinical visits at baseline and post treatment.

For each patient, standardized photographs of the trunk were taken at baseline before
treatment initiation, 3 and 7 months. These were sent for digital image analysis to determine
percentage BSA involvement of trunk. Algorithm-derived percentage BSA were then compared
with both VASI(c) score done during clinical visits and VASI(p) score of clinical photographs by
dermatologists.

Results
Automated VASI (aVASI) scores from our computerized algorithm produced estimates of skin
depigmentation that were correlated significantly with both VASI(p) and VASI(c) with correlation
coefficients of above 0.7 and p-values less than 0.001. aVASI scores correlate better with
VASI(p) (r=0.97) than VASI(c) (r=0.71) as there is much more variability in VASI score done
during clinical visits.

Conclusions
This algorithm proposes a novel approach in consistent and reliable scoring of vitiligo using
digital image analysis. It holds great promise as a tool that would enable easy and standardized
vitiligo severity scoring and outcome measures and hence allowing different treatment options
to be compared accurately.
Poster:DSS25
Automated Scoring of Vitiligo Using
Superpixel-Generated Computerized Digital
Image Analysis of Clinical Photographs:
A Novel and Consistent Way to Score Vitiligo
Joseph Toh1, Suman Bhoi2, Virlynn Tan1, Sai Yee Chuah1, Anjali Jhingan1, Adams Kong2, Steven Thng1,3
1 National Skin Center, Singapore. 2 Nanyang Technological University, School of Computer Science and Engineering, Singapore.
3 Skin Research Institute of Singapore, Agency for Science, Technology and Research, Singapore.
Background
Objective outcome measures for vitiligo severity are essential for
the evaluation of severity as well as response to treatment. The
Vitiligo Area Scoring Index score (VASI) is a validated tool for
assessing severity of vitiligo. However, the estimation of area and
extent of depigmentation in VASI is often subject to much inter-
and intra-observer variability.
Objectives
We aim to develop and validate a novel image analysis software
designed to automatically calculate the area of depigmentation in
vitiligo from computer image analysis of clinical photographs,
thereby deriving an automated VASI score.
Methods
The automated algorithm was developed in collaboration with
image analysis experts. The algorithm derives the score in 3 steps.
Firstly, the algorithm identifies and segments away the background
and undergarments of each image using segmentation methods
(Figure 1). Next, the image is converted into superpixels using
linear spectral clustering (Figure 2).
Figure 1. An overview of the proposed vitiligo segmentation
architecture.
Figure 2. Steps involved in the proposed vitiligo segmentation and
superpixel creation.
These superpixels are then used for feature extraction and further
classification of vitiligo versus non vitiligo areas. Finally, the
segmented vitiligo area is expressed as a percentage of the total
body surface area (BSA). The percentage body surface area
involvement derived from the algorithm is subsequently validated
in a prospective clinical trial. In the validation, 21 vitiligo patients
undergoing narrowband UVB (NBUVB) light therapy treatment for
vitiligo were recruited. VASI scores were obtained during the
clinical visits at baseline and up to 7 months post treatment.
For each patient, standardized photographs were taken at baseline
before treatment initiation, 3 and 7 months. At each photography
session, a set of 10 standardized photographs were taken focusing
on trunk (front and back, left and right lateral), upper limbs (dorsum
and ventral), and lower limbs (front, back, left and right lateral). In
this study, only the trunk photos were used and sent for digital
image analysis to determine percentage BSA involvement of trunk.
Algorithm derived percentage BSA were then compared with both
VASI(c) score done during clinical visits and VASI(p) score of
clinical photographs by dermatologists.
Results
Automated VASI (aVASI) scores from our computerized algorithm
produced estimates of skin depigmentation that were correlated
significantly with both VASI(p) and VASI(c) with correlation
coefficients of above 0.7 and p-values less than 0.001. aVASI
scores correlate better with VASI(p) (r=0.97) (Figure 3) than
VASI(c) (r=0.71) (Figure 4) as there is much more variability in
VASI score done during clinical visits.
Figure 3. Correlation between computerised algorithm aVASI with
VASI(p).
Figure 4. Correlation between computerised algorithm VASI with
VASI(c).
Conclusions
This algorithm proposes a novel approach in scoring of vitiligo
using digital image analysis which is consistent and reliable. It
holds great promise as a tool that would enable clinicians around
the globe to standardize vitiligo severity scoring and outcome
measures in an easy and reproducible manner, enabling different
treatment options to be compared accurately.
 Abstract ID: DSS34

Track: Medical Dermatology

Contact Author: Yong Adeline

Country: Singapore

Organisation: National University Hospital

Poster View here

A DERMATOLOGY HEALTH SERVICES STUDY OF NURSING AND COMMUNITY

HOSPITALS IN SINGAPORE

Data is scant on the burden of skin conditions locally; especially among residents in step-down
care. We aim to assess the burden of skin conditions as well as medical and nursing
requirements for their care in nursing homes, community hospitals and chronic sick units in
Singapore.

Six nursing homes and one community hospital were selected under the “West catchment area”
of Singapore. 2 nursing homes participated.
We performed a two-fold retrospective cohort study. A questionnaire was sent to institution
heads to assess the epidemiology of residents and current nursing/doctor manpower profile.
Monthly reviews were then conducted to assess details on skin conditions, treatment and follow
up among patients in these facilities.

Results:
250 residents from 2 nursing homes were screened for skin conditions. Their average age was
81.5 years. The average number of nursing staff for each home was 44, with a patient-to-nurse
ratio of 2.8 : 1. Majority were nursing aids (77.3% of total nursing staff) with 0 advanced practice
nurses. There was only 1 nurse educator available throughout. The average number of in-
house doctors was 1. There were no volunteer doctors, although an average of 2 nearby
general practitioner (GP) clinics for each home were available for referrals.
There were 26 (10.4%) residents with skin conditions. 61.5% were females, 38.5% were males.
Majority (50.0%) were admitted with chronic medical illnesses; 45.8% for functional decline and
20.8% for recurrent falls. The mean age at admission was 84.8 years. The most prevalent skin
condition was eczema (48.6%), followed by tinea infections (29.7%), cellulitis (8.1%) and
scabies (5.5%). These residents were reviewed a total of 19 times. Of these reviews, 21.1%
were by a GP in-house or at a nearby polyclinic/private clinic. 73.7% were reviewed by
dermatologists at private/specialist dermatology centres. 5.3% were reviewed by
dermatologists/other physicians at acute hospitals. The average duration between onset of skin
issue to review was 2.65 months.

Conclusions:
There exists a burden of skin diseases in local nursing homes. There is a significant delay
between recognition of skin issues and definitive diagnosis and management. More
comprehensive training in dermatology for nursing home staff as well as doctors could
address this gap.
 Poster:DSS34

A DermatologyHealth ServicesStudyof
Nursingand CommunityHospitalsin Singapore
Adeline MY YONG1, AJ LEUNG2, HH WONG1, Nisha S CHANDRAN1
1. National University Hospital, Singapore
2. Yong Loo Lin School of Medicine, National University of Singapore

Introduction Subgroupdescriptive analysis

Data is scant on the burden of skin conditions locally; especially
among residents in step-down care. We aim to assess the burden
of skin conditions as well as medical and nursing requirements for
their care in nursing homes, community hospitals and chronic sick
units in Singapore.
We performed a descriptive analysis on patients from the nursing
home who had skin issues. There were 34 (6.95%) residents with
skin conditions. 55.9% were females, 44.1% were males. Their
characteristics are shown in Graphs 1-3. Only 24 patients were
reviewed; the average time lapse between a skin issue noted by
the nursing staff till a review by a doctor was 2.03 months.

Methodology 16 15
Graph 1: Admission diagnosis (n=34)
14 13
Six nursing homes and one community hospital were selected Admission diagnosis for patients with
dermatological conditions. Patients
under the “West catchment area” of Singapore. 3 nursing homes 12
10 were mainly admitted for chronic
participated. We performed a two-fold retrospective cohort study. 10 9 medical illnesses, dementia, falls and
A questionnaire was sent to institution heads to assess the functional decline.
8

epidemiology of residents and current nursing/doctor manpower

6
profile. Monthly reviews were then conducted to assess details on
skin conditions, treatment and follow up among patients in these 4 3
2
facilities. 2 1 1

0
Chronic medical Dementia Recurrent falls Functional decline Malignancies Congenital Dermatological Psychiatric
illness conditions condition disorder

30
Results Graph 2: Dermatological diagnosis (n=34)
24
25 Dermatological diagnosis of patients with
skin issues. A vast majority had eczema,
489 residents from 3 nursing homes were screened for skin followed by infections (tinea, cellulitis and
20
conditions. Their average age was 83 years. The average number of scabies). Few had bullous pemphigoid while
nursing staff for each home was 58.7, with a patient-to-nurse ratio even fewer had papulo-squamous
15
disorders.
of 2.8 : 1. Majority were nursing aids (63.6% of total nursing staff) 12

with 0 advanced practice nurses. There was only 1 nurse educator 10

available throughout. The average number of in-house doctors was 5

4
1. There were no volunteer doctors, although an average of 2.3 5
2
3
1 1 1 1 1
nearby general practitioner (GP) clinics for each home were
0
available for referrals.
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Summaryof nursing home data 20 19

18
Graph 3: Nature of Reviews (n=24)
No. of residents (%), n=489 No. of residents with skin conditions (%), n=37
16
A vast majority of reviews made during the 6-month
Gender
time period were by in-house GPs. An equal
Males 200 (40.9) 15 (44.1) 14 proportion of 20% were reviewed at private
Females 289 (59.1) 19 (55.9) 12
dermatologists/NSC or acute hospital
physicians/dermatologists
10
Ethnicity
8 7 7
Chinese 452 (92.4) 34 (100)
Malay 14 (2.9) 0 (0) 6

Indian 9 (1.8) 0 (0)

4
Caucasian 1 (0.2) 0 (0) 2
2
Others 13 (2.7) 0 (0)
0
In-house GP Polyclinic/private GP Dermatologist at private/specialist Dermatologists/other physicans at
Ave. age 81.25 83.4 dermatology centre acute hospitals

Admission diagnosis
Functional decline - 15 (44.1) Conclusion
Recurrent falls - 9 (26.5)
Dementia - 10 (29.4)
There exists a burden of skin diseases in local nursing homes.
Chronic medical illness - 13 (38.2)
There is a significant delay between recognition of skin issues and
Skin conditions - 2 (5.8)
definitive diagnosis and management. More comprehensive
Malignancies - 1 (2.9)
Congenital conditions - 3 (8.8)
training in dermatology for nursing home staff as well as doctors
Psychiatric diagnosis - 1 (2.9)
could address this gap.
 Abstract ID: DSS19

Track: Dermatological Treatment

Contact Author: Ellie Choi

Country: Singapore

Organisation: National University Hospital

Poster View here

Corticosteroid phobia – A Questionnaire study using TOPICOP© score

Introduction
Topical corticosteroids (TCS) are commonly used in dermatology for its anti-inflammatory use.
The recent development of the validated TOPICOP© score to assess steroid phobia in patients
with atopic dermatitis and their caregivers has made it easier for the quantification and
comparison of steroid phobia.

Methods
A cross sectional survey was designed to assess the degree of steroid phobia of patients seen
in the outpatient clinics of the Division of Dermatology, National University Hospital (Singapore)
regardless of steroid use. The TOPICOP© score was used in this survey, in addition to
questions assessing fear of ‘steroid addiction’ and use of traditional medications. The
TOPICOP© score assesses three domains of TCS phobia: knowledge and beliefs, fears and
behavior, with scores expressed as a percentage of the maximum. We also identified sources
of information from which patients obtain information regarding TCS from, and assessed the
level of trust in these different sources. Patient demographics, dermatological condition and
previous prescription of TCS were collected. Patients who had been prescribed topical steroids
were additionally asked to comment on whether they had benefitted from its use, and if they
had experienced side effects.

Results
186 surveys were analysed. The median domain TOPICOP subscores were 38.9% (IQR: 27.8-
50.0, SD 24.4) for knowledge and beliefs, 44.4% (IQR: 33.3-66.7, SD 24.4) for fears, and 55.6%
(IQR: 33.3-66.7, SD 27.2) for behavior. The median global TOPICOP score was 44.4% (IQR:
33.3-55.6, SD 17.6). Female gender was associated with a higher behavior, fear and global
TOPICOP score, while there was no difference in scores between disease condition, steroid
use, age or education. Dermatologists were the most common source of information on topical
steroids, and trust was highest in dermatologists. A proportion of participants reported side
effects from TCS use (21.6% agree, 5.2% strongly agree).

Conclusion
This study highlights that misconceptions of topical steroids are still present and prevalent.
Strategies to target steroid phobia should target these possible misconceptions, and ideally
should be done in the dermatology service where trust is the greatest.
 Poster:DSS19
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knowledge and beliefs, fears, and behavior. median global TOPICOP score was 44.4% (IQR: 33.3-55.6, SD 17.6).
ace digital photos Responses are graded with a 4-point Lickert
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select a Discussion and Conclusion Poste

on of 100% when In our study, with a global TOPICOP score of 44.4%, this would have placed our cohort approximately midway in terms of steroid phobia compared with
g your poster. This 15 other countries4. However, the fact that our cohort includes non atopic derma s pa ents limits the direct comparison. Once yo
ou a good idea of Greater steroid phobia in females has been shown also in other studies3-5. This gender difference may be a ributed to females more cau ous approach
ready, v
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quality,
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References
ed size. can del
1. Charman, C. & Williams, H. The use of cor costeroids and cor costeroid phobia in atopic derma s. Clin. Dermatol. 21, 193–200 (2003).
2. Moret, L. et al. TOPICOP©: a new scale evalua ng topical cor costeroid phobia among atopic derma s outpa ents and their parents. PloS One 8, e76493 (2013). next bu
e that graphics 3. Gonzales, F. et al. Monitoring of topical cor costeroid phobia in a popula on of parents with children with atopic derma s using the TOPICOP(®) scale: prevalence,
risk factors and the impact of therapeu c pa ent educa on. J. Eur. Acad. Dermatol. Venereol. JEADV 31, e172–e174 (2017). within t
ites (such as the 4. Kojima, R. et al. Factors associated with steroid phobia in caregivers of children with atopic derma s. Pediatr. Dermatol. 30, 29–35 (2013).
Canada
5. Müller, S. M. et al. Topical Cor costeroid Concerns in Dermatological Outpa ents: A Cross-Sec onal and Interven onal Study. Dermatol. Basel Switz. 232, 444–452
ur hospital's or (2016).
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 Abstract ID: DSS45
Track: Bacterial Infections
Contact Author: Anugandha Ghatge
Country: India
Organization: Datta Meghe Institute Of Medical Sciences Wardha

Poster View here

EFFICACY OF PLATELET RICH FIBRIN CLOT IN TREATMENT OF

TROPHIC ULCERS IN HANSEN’S DISEASE

Introduction: Trophic ulcers secondary to leprosy pose a great stigma to the patients and remain
a challenge to the treating dermatologists. The discovery of Platelet Rich Fibrin clot (PRF) with
its favourable role in wound healing is a boon for the patients. PRF introduces the growth factors
directly into the wound and aids in rapid healing. There has been less study performed for its
use in trophic ulcers in hansen’s disease so our study brings out the use PRF in treating non
healing ulcers in hansens disease.

Aim: To study the efficacy and safety of PRF in the healing of trophic ulcers secondary to
Hansen’s disease in a tertiary care centre in India.

Materials and Methods: Based on inclusion and exclusion criteria, 10 patients were enrolled in
the study. PRF gel clot was prepared by using single spin method without the use of
anticoagulant. After wound bed preparation, PRF gel clot was applied over the ulcer and
occlusive dressings were applied. Same procedure was repeated every week until complete
re-epithelisation or up to six sittings whichever occurred earlier.

Results: In our study, 5 patients (50%) showed complete healing, in 4 patients (40%) there was
marked reduction in wound size and 1 patient (10%) lost to follow up. Mean healing time of
ulcer is 5 weeks.

Conclusion: PRF therapy leads to faster rate of induction of granulation tissue with rapid
healing.
It is a simple, safe and cost effective opd procedure, albeit requiring an optimal set-up and
expertise. More sample size will be required for definitive results.
Poster: DSS45
 Abstract ID: DSS01
Track: Medical Dermatology
Contact Author: Jarische Frances Lao-Ang
Country: Philippines
Organisation: St Luke’s Medical Center

Poater View here

Wells' syndrome in an 18 year-old female

Introduction:

Wells’ syndrome, also known as eosinophilic cellulitis, is a rare inflammatory dermatosis that
mostly affects adults and manifests as recurrent erythematous papules and nodules. With
predilection sites that may vary and clinical presentation that may mimic other cutaneous
diseases, Wells’ syndrome disease can be misdiagnosed and eventually mismanaged. Hence,
it is important for dermatologists to warrant the need to investigate further when faced with a
recurrent dermatitis such as Wells’ syndrome.

Case Summary:

We are presented with an 18 year old Filipino female, with no known comorbidities, who
presented with a three year history of recurrent erythematous papules, vesicles and nodules
over her bilateral chin, initially managed with topical steroids and oral antibiotics but with
minimal improvement. Serology revealed elevated IgE level at 949.2 IU/mL. A skin punch
biopsy was done, and findings revealed diffuse eosinophilic infiltrates, exhibiting flame figures
admixed with few lymphocytes and neutrophils, consistent with Wells’ syndrome. Patient was
then given oral corticosteroid, with note of complete resolution of lesion.

Conclusion:

Wells’ syndrome is a rare skin disease but it may be misdiagnosed with other more common
cutaneous diseases. When confronted with a cutaneous lesion that is not responding to
treatment, a dermatology referral is warranted. Various treatment modalities for Wells’
syndrome exist, such as systemic corticosteroids, systemic immunomodulators and topical
application of steroid or tacrolimus. Among the aforementioned treatment options, systemic
corticosteroid is still considered the first-line therapy because it provides good therapeutic
response and complete clearance of skin lesions.
Poster:DSS01

Wells’ Syndrome in an 18 year old Female:

A Case Report
Lao-Ang, Jarische Frances S.,MD and Yap-Silva, Claudine, MD, FPDS
St. Luke’s Medical Center, Philippines

Introduction

Wells’ syndrome, also known as

eosinophilic cellulitis, is a rare
inflammatory dermatosis that
mostly affects adults and
manifests as recurrent
erythematous papules and
nodules. With predilection sites
that may vary and clinical
presentation that may mimic
other cutaneous diseases,
Wells’ syndrome disease can be
misdiagnosed and eventually
Figure 2. Skin biopsy. Flame figures
mismanaged. Hence, it is
noted at H&E.
important for dermatologists to
warrant the need to investigate
Figure 1. Initial Presentation. Conclusion
further when faced with a Erythematous vesicles and nodules on
recurrent dermatitis such as left chin Wells’ syndrome is a rare skin
Wells’ syndrome. disease but it may be
misdiagnosed with other more
Case Discussion Serology revealed elevated IgE common cutaneous diseases.
level at 949.2 IU/mL. A skin punch Various treatment modalities
biopsy was done, and findings for Wells’ syndrome exist,
This is a case of an 18 year old
revealed diffuse eosinophilic such as systemic
Filipino female, with no known
infiltrates, exhibiting flame figures corticosteroids, systemic
comorbidities, who presented
admixed with few lymphocytes and immunomodulators and
with a three year history of
neutrophils, consistent with Wells’ topical application of steroid or
recurrent erythematous
syndrome. tacrolimus. Among the
papules, vesicles and nodules
over her bilateral chin, initially Patient was then prescribed with aforementioned treatment
managed with topical steroids oral Prednisone at 0.5 mg/kg/day. options, systemic
and oral antibiotics but with Lesion completely resolved after 4 corticosteroid is still
minimal improvement. weeks of therapy. considered the first-line
therapy because it provides
good therapeutic response
and complete clearance of
skin lesions.

References:
Philippine Dermatologic Society Health Information System data.
Retrieved : August 2017.

Cormerais, M., Poizeau, F., Darrieux, L., Tisseau, L., & Safa, G. (2015).
Wells’ Syndrome Mimicking Facial Cellulitis: A Report of Two Cases. Case
Reports in Dermatology, 7(2), 117–122.

Heelan K, Ryan JF, Shear NH, Egan CA (2013) Wells syndrome

(eosinophilic cellulitis): proposed diagnostic criteria and a literature review
of the drug-induced variant. J Dermatol Case Rep 7: 113–120
 Abstract ID: DSS02

Track: Skin Tumours (Benign / Malignant)

Contact Author: Calvin Santosa

Country: Indonesia

PERDOSKI,Indonesian Association of
Organisation:
dermatovenereologist.

Poster View here

Angiolymphoid Hyperplasia with Eosinophilia with Clinical Pictures of

Keratoacanthoma: A Rare Case Report

Introduction: Angiolymphoid hyperplasia with eosinophilia (ALHE) is a benign vascular disorder

which clinically may mimic other diseases such as cylindroma, basalioma and
keratoacanthoma. Due to the clinical feature that may imitate other diseases, ALHE often
treated inappropriately which leads to high in recurrence of this disease.

Objective: To report the clinical picture of ALHE which may imitate other skin tumors like
keratoacanthoma.

Case Description: A 55-year old man presented with nodule on the nose since 7 months ago.
History of bleeding when the patient rub the lesion is mentioned. One year ago he was
diagnosed with keratoacanthoma and treated for the same lesion on the same area with
electrocauterization. On physical examination there was a solitary nodule with 0.5 cm in
diameter with solitary ulcer on top of it. Dermoscopic examination shows keratin mass with pink
background and ulcer on the central area. Vascular features such as dots and globular was
also seen. The dermoscopic features suitable for a keratoacanthoma. From the
histopathological examination shows a multiple mass with proliferation of capillary vessels,
lymphoid cells and eosinophils infiltration which consistent with the diagnosis of angiolymphoid
hyperplasia with eosinophilia. The patient was done an L-plasty and there is no sign of
recurrence up to this day.

Conclusion: The various clinical pictures of Angiolymphoid hyperplasia with eosinophilia can
be very confusing and challenging to diagnose. History of recurrence lesion in short time should
make us suspecting ALHE which can be diagnose thru histopathological examination. This
report illustrate ALHE with the clinical and dermoscopic pictures of keratoacanthoma.

Keywords: Angiolymphoid hyperplasia with eosinophilia, ALHE, keratoacanthoma rare

 Poster: DSS02

ANGIOLYMPHOID HYPERPLASIA WITH EOSINOPHILIA WITH

CLINICAL PICTURES OF KERATOACANTHOMA: A RARE CASE REPORT
Calvin Santosa1, Made Wardhana1, Herman Saputra2, Swastika Adiguna1
1Department of Dermatology and Venereology

2 Department of Pathology

Faculty of Medicine Udayana University/ Sanglah General Hospital Denpasar

Email: Calvinsantosa@hotmail.com

I NT ROD UCT I ON
Angiolymphoid hyperplasia with eosinophilia (ALHE) is a benign vascular disorder which clinically may mimic other diseases such
as cylindroma, basalioma and keratoacanthoma. Due to the clinical feature that may imitate other diseases, ALHE o en treated
inappropriately which leads to high in recurrence of this disease.

CASE
ü A 55-year old man presented with nodule on the nose since 7
months ago. History of bleeding when the pa ent rub the lesion
is men oned.
ü One year ago he was diagnosed with keratoacanthoma and
treated for the same lesion on the same area with
electrocauteriza on.
ü On physical examina on there was a solitary nodule with 0.5
cm in diameter with solitary ulcer on top of it.
ü Dermoscopic examina on shows kera n mass with pink
background and ulcer on the central area. Vascular features
such as dots and globular was also seen. The dermoscopic
features suitable for a keratoacanthoma. CLINICAL PICTURES ON NASAL AREA: A SOLITARY
ü Histopathological examina on shows a mul ple mass with ERYTHEM ATOUS NODULE W ITH ULCER ON THE CENTRE
prolifera on of capillary vessels, lymphoid cells and eosinophils
infiltra on which consistent with the diagnosis of
angiolymphoid hyperplasia with eosinophilia.
ü The pa ent was done an L-plasty and there is no sign of
recurrence up to this day.

HISTOPATHOLOGICAL PICTURES OF ALHE: W ELL-DEFINED M ARGIN M ASS CONSIST OF LYM PHOID

DERM OSCOPIC PICTURE OF THE LESION: KERATIN M ASS W ITH PINK BACKGROUND AND CENTRAL CELLS AND CAPPILARY ACCOM PANIED W ITH DISPERSE DISTRIBUTION OF EOSINOPHILS AROUND
ULCER W ITH DOTS AND GLOBULES VASCULAR PATTERN THE VESSELS

D I SCUSSI ON
Angiolymphoid H yperplasia with Eosinophilia (ALH E) is a vasoproliferative condition with unknown cause which clinically seen as a papules, plaques,
or nodules in head or neck area. T is condition clinically may mimic other diseases such as cylindroma, basalioma and keratoacanthoma. T e patient
usually complaining of pain or itch in the area of the lesion. T is entity is very similar to Kimura D isease which can be differentiated through clinical,
histopathological, and I gE level examination. D ermoscopic examination has helped with the diagnosis of ALH E and mainly to rule out basalioma as
diagnosis. H istopathological examination is still the goal standard in diagnosis of ALH E which can be further classif ed as the acute and chronic lesion.
Acute lesion tend to give more prominent vascular properties, where as chronic lesion more into prominent lymphocyte structure accompanied with small
mature blood vessels. T e treatment for ALH E depends on number, size and location of the lesion. Excisional surgery and M ohs micrographic surgery
commonly used, with I NF- α , cryotherapy, pulsed-dye laser and tacrolimus topical hasbeen reported asalternative modality.

References
1. Buder K, Ruppert S, Trautmann A, Brocker EB, Goebeler M, Kerstan A. Angiolymphoid hyperplasia with eosinophilia and Kimura’s disease – a clinical and histopathological comparison. JDD G. 2014; 12(3): 224-8.
2. Adler BL, Krausz AE, Minu A, Silverberg JI, Lev-Tov H. Epidemiology and treatment of angiolymphoid hyperplasia with eosinophilia (ALHE): a systema c review. J Am Acad Derm atol. 2016; 74: 506-12.
3. Ahmad SM, Wani GM, Khursheed B, Qayoom S. Angiolymphoid Hyperplasia with Eosinophilia Mimicking Mul ple Cylindromas: A Rare Case Report. Indian J Derm atol. 2014; 59(4): 423.
4. Leiferman KM, Peters MS. Eosinophils in Cutaneous Diseases. In: Goldsmith AL, Katz IS, Gilchrest AB. Fitzpatrick’s Derm atology in General M edicine 8 th ed. New York: McGraw Hill; 2012: p. 386-400.
5. Zaraa I, Mlika M, Chouk S. Angiolymphoid hyperplasia with eosinophilia: a study of 7 cases. Derm atol Online J. 2011;17(2):1.
6. Rodriguez-Lomba E, Aviles-Izquierdo JA, Molina-Lopez I, Parra-Blanco V, Lazaro-Ochaita P, Suarez-Fernandez R. Dermoscopic features in 2 cases of angiolymphoid hyperplasia with eosinophilia. J Am Acad Derm atol. 2016;75: e19-21.
7. Shenefelt PD, Rinker M, Caradonna S. A case of angiolymphoid hyperplasia with eosinophilia treated with intralesional interferon alfa-2a. A rch D erm atol. 2000;136(7): 837-839.
8. Wozniacka A, Omulecki A, Torzecka JD. Cryotherapy in the treatment of angiolymphoid hyperplasia with eosinophilia. M ed Sci M onit. 2003;9(1):CS1-CS4.
9. Abrahamson TG, Davis DA. Angiolymphoid hyperplasia with eosinophilia responsive to pulsed dye laser. J Am Acad Derm atol. 2003;49(2):S195-S196.
10. Mashiko M, Yokota K, Yamanaka Y, Furuya K. A case of angiolymphoid hyperplasia with eosinophilia successfully treated with tacrolimus ointment. Br J D erm atol. 2006;154(4): 803-804.
11. Baghestani S, Firooz A, Ghazisaidi MR. A refractory case of angiolymphoid hyperplasia with eosinophilia successfully treated by surgery. J Derm atolog Treat. 2011;22(1): 49-51.
 Abstract ID: DSS07
Track: Skin Tumours (Benign / Malignant)
Contact Author: Lynette Lee
Country: Singapore
Organisation: KK Women's and Children's Hospital

Epstein-Barr Virus-Positive Diffuse Large B-Cell Lymphoma Presenting with Vaginal

Sloughing and Ulcerated Skin Nodule

Diffuse large B-cell lymphoma (DLBCL) is an aggressive non-Hodgkin’s lymphoma (NHL) with
subtypes that can be distinguished on the basis of clinical, immunophenotypic, morphologic,
and molecular characteristics. The genital tract as a primary site for NHL is very rare. We report
a patient with Epstein Barr virus (EBV) -positive DLBCL presenting with vaginal discharge and
a groin nodule. This case adds to our limited knowledge on EBV-positive DLBCL presenting in
the vagina and skin, and highlights that NHL in the female genital tract should be considered in
patients with similar clinical presentations.
 Abstract ID: DSS26

Track: Drug Reactions

Contact Author: MeiQi May Liau

Country: Singapore

Organisation: National University Hospital

A case of Acute generalised exanthematous pustulosis (AGEP) with remarkable neutrophilic

leukocytosis

A 35-year-old Chinese male was admitted for a 5-day history of generalized rash preceded by fever,
sore throat and cough. He had taken Ibuprofen 1 day prior to development of the rash for 3 days.
Examination showed a generalized eruption of widespread non-follicular pinhead sized pustules on an
erythematous oedematous base, with sparing of his back and face (45% body surface area).

His white blood cell (WBC) count was 54.31 x 10^9/L (neutrophil 94.8%, 51.47x 10^9/L) on admission,
peaking at WBC 62.19 x 10^9/L (neutrophil 94.6%, 58.84 x 10^9/L) on the 2nd day (Day 6 of rash). Skin
biopsy revealed subcorneal pustules containing neutrophils, with a perivascular infiltrate of neutrophils,
lymphocytes and eosinophils. A diagnosis of AGEP secondary to Ibuprofen was made. His EuroSCAR
(AGEP) score was 11, constituting a definite diagnosis.

His significant leukocytosis, fever and transient episodes of hypotension raised concerns about
systemic infection by the medical team. He was transferred to the intensive care unit. A thorough
evaluation including blood and urine cultures and radiological investigations were all unremarkable.
Upon Dermatology review, he was commenced on wet wrap therapy with topical steroids and
moisturisers. His skin lesions improved and resolved completely within 2 weeks. There was overall
downtrending of his WBC count to 23.71 x 10^9/L (neutrophil 84.5%, 20.02 x 10^9/L) on the 6th day of
admission (day 10 rash).

A local retrospective study of 8 patients diagnosed with AGEP had a WBC range from 9.3 (neuts 84%)
to 39.2 (neuts 88%). Our patient had significant neutrophilia even on comparison with others with the
same diagnosis. This typically raises concerns of systemic infection or even haematological malignancy
such as chronic myeloid leukaemia (CML) and polycythaemia vera (PV). Importantly, our patient
remained systemically well despite extensive cutaneous manifestations, and WBC count declined
rapidly on instituting appropriate dermatological treatment.

We highlight a marked neutrophilic leukocytosis associated with AGEP. Appreciation of significant

neutrophilia coupled with timely dermatological management leads to optimal patient outcome.