Sai Yee Chuah

Reflectance confocal microscopy is a useful non-invasive tool in the in vivo diagnosis of pigmented basal cell carcinoma in Asians

The clinical differentiation between pigmented basal cell carcinoma (BCC) and other benign pigmented skin lesions can be challenging even with an additional dermoscopic evaluation, especially if the lesion is small. In vivo reflectance confocal microscopy (RCM) is an emerging, non‐invasive imaging tool that allows near‐microscopic evaluation of skin lesions. The features of RCM for pigmented BCC and seborrhoeic keratosis have previously been described. However, the use of RCM to differentiate between these clinically and dermoscopically challenging pigmented skin lesions among Asians has not yet been demonstrated.

Double Blind Placebo Controlled Trial to Evaluate of the Effectiveness of aDietary Supplement Rich in Carotenoids as Adjunct to Topical LighteningCream for the Treatment of Melasma: A Pilot Study

Objectives: To evaluate the efficacy of an oral supplement containing carotenoids as an adjunct to a topical cosmetic lightening cream for the treatment of melasma. Methods: 44 subjects with melasma were recruited into a double-blinded, randomized, placebo controlled trial over 84 days at the Singapore National Skin Centre, to receive either an oral dietary supplement containing carotenoids or a placebo. All were prescribed a commercially available cream. Patients were assessed at onset, day 54 and day 84 by the Modified Melasma area and Severity Index (mMASI), photographic documentation, melanin and erythema indexes using a Mexameter®. Results: 44 patients completed the study. The median mMASI score fell significantly in both groups (both p<0.001). There was a greater decrease seen in those who received the oral supplement group (-2.1 vs -1.8, p <0.379). The erythema score showed significant improvements in both groups, with greater improvement in the group on the oral supplement, compared to placebo (median difference = -30, p =0.018, vs median difference = -20, p =0.020). Conclusion: Oral supplements containing carotenoids are potential adjuncts in melasma treatment. 1.5 Limitations: Small sample size and short study duration limit the observations noted in this study. Further larger-scale studies are required.

The role of in vivo reflectance confocal microscopy in assessing the stability of vitiligo vulgaris prior to cellular grafting

Noncultured cellular grafting (NCG) on stable vitiligo is an essential requirement for successful repigmentation.1 Vitiligo is considered stable, when there is no progression of old lesions or development of new lesions in the past 6 months. This is determined clinically, through vitiligo disease activity (VIDA) score and Wood’s lamp examination. However, this is very subjective. Although test punch grafting has been shown to aid in selecting appropriate patients for surgical intervention, it is not an absolute indication for successful surgical repigmentation. There have been instances of failed surgical attempts in patients with positive test grafting and vice versa. This suggests that the stability may be sitedependent.2 Recently, the noninvasive realtime in vivo reflectance confocal microscopy (RCM) imaging has been reported to be a useful tool to stage the activity of vitiligo.3,4 RCM allows noninvasive imaging of the epidermis and the upper dermis at a nearhistological resolution. This technique has been used for the evaluation of several inflammatory, neoplastic and melanocytic skin conditions and may constitute an excellent alternative to invasive biopsy collection in the diagnosis of several skin disorders. In this open observational study, we aim to evaluate the role of RCM in assessing the stability of vitiligo vulgaris prior to NCG and to correlate the observed RCM features with the success of NCG. A total of 28 patients with clinically stable vitiligo vulgaris (defined by no progression of old lesions or development of new lesions in the past 6 months) scheduled for test punch grafting or NCG were recruited. Vitiligo disease activity scoring and RCM were performed on the vitiligo lesion prior to the procedure (Table 1). The result of the procedure was assessed after 6 months. A successful grafting was defined as achievement of >75% repigmentation, and failure of grafting was defined as achievement of <75% repigmentation. RCM imaging was performed at the centre and the border of the vitiligo lesion. The assessment of RCM findings was done by two dermatologists using the scoring index proposed by Li et al4 to indicate the stage of vitiligo. This was the scoring index used: (a) Pigmentation status in the lesional skin: +1 score denoted the existence of remaining pigment and −1 score denoted complete loss of pigment; (b) Status of the border of vitiligo lesion: +1 score denoted indistinct border and −1 score denoted clear border; (c) Inflammatory cell infiltration: +1 score if inflammatory cell infiltration was detected at the edge of the lesion; and (d) Melanocyte regeneration: −1 score if dendritic melanocytes appeared in the vitiligo lesion. Total score <1 represented stable stage; ≥1 represented active stage; ≥2 represented rapid active stage (Figures 1 and 2). Five patients were lost to followup. Out of the 23 patients who had completed the study, 21 patients had NCG and two had test punch grafting. Nineteen patients had successful grafting. When comparing the success of grafting with the RCM score, 14 out of 19 patients had stable RCM staging (sensitivity: 73.7%; positive predictive value: 87.5%). Four patients had unsuccessful grafting. Two out of the four patients had an active RCM staging (specificity: 50%;

Treatment outcomes of vitiligo in Asian children

This retrospective study aimed to identify factors that predict treatment response in a cohort of Asian children with vitiligo. Shorter duration of vitiligo was associated with better repigmentation. Patients with focal vitiligo of short duration have a good chance of achieving repigmentation with topical agents alone.

A retrospective clinico-pathological study comparing lichen planus pigmentosus with ashy dermatosis

Controversy persists as to whether lichen planus pigmentosus and ashy dermatosis are separate clinical entities. This study was conducted to examine the clinicopathological features and treatment outcome of the two conditions.

The Scoring Aid: MASI and Modified MASI

There are currently several ways to quantify severity of melasma in patients. Quantitative methods using the Mexameter and chromameter are useful for point measurements of degree of darkness, but these instrumentations suffer from the inability to quantify the extent of melasma. Scoring aids, like the melasma severity scale (MSS), the melasma area and severity index (MASI) and the modified melasma area and severity index (mMASI), were developed to take into account both the darkness and extent of melasma. While these scoring systems are better measures of melasma severity, they are nevertheless fraught with problems as it requires a doctor to estimate the area and degree of darkness and as such results in intra-observer and inter-observer variability. Without a good, reproducible, standardized way of scoring melasma severity and response to treatment accurately, treatment outcomes cannot be standardized and as such, efficacy of various treatment modalities cannot be compared in meta-analyses. Of late, there are several efforts underway to utilize computer image analysis to accurately score melasma, using the principles of the mMASI. These systems seem to offer much promise in standardizing and accurately scoring melasma, enabling treatment options to be compared.

Diagnosis of Melasma in Brown Skin: Wood’s Lamp, Dermoscopy, and Confocal Microscopy

The diagnosis of melasma is usually made clinically and is rather straightforward due to its characteristic appearance. There are several distinct patterns based upon its distribution which includes centrofacial, malar, and mandibular pattern. Melasma has also been subdivided based on the different depth of melanin pigment into epidermal, dermal, mixed, and indeterminate types. The use of additional tools such as Wood’s lamp, dermoscopy, and reflectance confocal microscopy (RCM) may help to identify the depth of the pigment. These classifications aid in prognosis and predicting the therapeutic outcome. RCM is a new innovative tool which can also help in monitoring response to therapy.

Retrospective study on the characteristics and treatment of late-onset vitiligo

Background: Late-onset vitiligo, defined as being aged 50 years and above at the point of clinical onset, remains poorly characterized till now. Aim: This study aims to describe the clinical characteristics and treatment response of patients with late-onset vitiligo. Methods: We retrospectively reviewed the case records of all patients diagnosed with late-onset vitiligo, from January 1, 2010 to December 31, 2014. Information obtained included patient demographics, characteristics of vitiligo and treatment responses. Results: Of the 3128 patients diagnosed with vitiligo over the 5-year period, 461 (14.7%) had late-onset disease. The study had more females (n = 260, 56.4%) than males, with an average onset age of 59.4 ± 7.4 years. Majority of patients were Chinese (n = 308, 66.8%) and 45 (9.8%) patients had an associated autoimmune disease. Focal vitiligo, defined as the localized presence of depigmented patches, was most common (n = 209, 45.3%). Treatment response was evaluated in 359 patients, of which 216 received monotherapy (topical creams: n = 210, 97.2%; phototherapy: n = 6, 2.8%) and 143 received both modalities. Fifty six (15.6%) patients received oral steroids. Patients who were treated with both topical creams and phototherapy yielded better clinical responses compared to those on monotherapy (P < 0.001) with 56.6% (n = 81) of them achieving good epidermal repigmentation, defined as >50% return of pigmentation compared to baseline (vs. n = 66, 30.6% in the monotherapy group). The choice of phototherapy (targeted, narrowband ultraviolet B or psoralen + ultraviolet A) did not significantly affect clinical response (P = 0.774). Limitations: This study is limited by its retrospective nature, the nonstandardized documentation resulting in the inability to determine disease progression and associated metabolic comorbidities and also by the gradual loss to follow-up of patients. Conclusion: Late-onset vitiligo is not uncommon and tends to be of the focal vitiligo subtype. Nonsegmented vitiligo is more prevalent than segmental vitiligo. Combination therapy with topical medications and phototherapy is superior to monotherapy.

Handheld reflectance confocal microscopy: A useful tool to aid diagnosis of acral pigmented lesions.

1 Muro Y, Sugiura K, Akiyama M. Cutaneous manifestations in dermatomyositis: key clinical and serological features-a comprehensive review. Clin Rev Allergy Immunol 2015; doi: 10.1007/s12016-0158496-5. 2 Hamaguchi Y, Fujimoto M, Matsushita T et al.Common and distinct clinical features in adult patients with anti-aminoacyl-tRNA synthetase antibodies: heterogeneity within the syndrome. PLoS One 2013; 8: e60442. 3 Matsushita T, Hasegawa M, Fujimoto M et al. Clinical evaluation of anti-aminoacyl tRNA synthetase antibodies in Japanese patients with dermatomyositis. J Rheumatol 2007; 34: 1012–1018. 4 Ikeda N, Takahashi K, Yamaguchi Y, Inasaka M, Kuwana M, Ikezawa Z. Analysis of dermatomyositis-specific autoantibodies and clinical characteristics in Japanese patients. J Dermatol 2011; 38: 973–979. 5 Nakashima R, Imura Y, Hosono Y et al. The multicenter study of a new assay for simultaneous detection of multiple anti-aminoacyltRNA synthetases in myositis and interstitial pneumonia. PLoS One 2014; 9: e85062.

A retrospective review of the therapeutic response with remission in patients with newly diagnosed bullous pemphigoid

We reviewed the clinical characteristics and therapeutic response in cases of newly diagnosed bullous pemphigoid at the National Skin Centre between June 2009 and December 2010. Most (76%, n = 68/90) achieved clinical remission within 6 months of commencement of therapy. Oral mucosal involvement was identified as a risk factor associated with a prolonged duration of treatment beyond 6 months.