Yen Loo Lim

The role of intravenous immunoglobulin in toxic epidermal necrolysis: a retrospective analysis of 64 patients managed in a specialized centre

Toxic epidermal necrolysis (TEN) is a severe cutaneous adverse drug reaction with a mortality of 40%. Intravenous immunoglobulin (IVIg) is widely used as a specific treatment for this reaction, although evidence of its benefit is conflicting.

Mortality of bullous pemphigoid in Singapore: risk factors and causes of death in 359 patients seen at the National Skin Centre.

Bullous pemphigoid (BP) is the most common autoimmune‐mediated subepidermal blistering skin disease and is associated with significant morbidity and mortality.

Occupational skin diseases in Singapore 2003-2004: an epidemiologic update.

In this 2‐year retrospective epidemiologic study of occupational skin disease in Singapore, there were 125 patients with occupational contact dermatitis. The mean age of patients was 33.8 years, with a male to female ratio of 5.3:1. Irritant contact dermatitis made up 62.4% of all cases, whereas allergic contact dermatitis constituted 37.6%. Wet work/detergents, oil/grease and solvents remained the 3 commonest irritants. There was also a significant increase in representation of workers from the food/catering industry in our study.

Association of Bullous Pemphigoid and Malignant Neoplasms.

Methods | Our study cohort comprised all newly diagnosed patients with BP who were seen at the National Skin Centre in Singapore from April 1, 2004, to December 31, 2009. A diagnosis of BP was based on the presence of at least 3 of 4 criteria: (1) clinical findings consistent with BP; (2) histopathological findings of subepidermal blister; (3) a direct immunofluorescence finding of IgG and/or complement proteins along the dermo-epidermal junction; and (4) indirect immunofluorescence findings of a roof or roof-and-floor pattern or positive anti–BP180-NC16A IgG antibodies.2 Patients with BP were matched with persons in the Singapore Cancer Registry and Death Registry to identify those who had cancer and/or had died. Person-years were accrued from BP diagnosis until death, cancer diagnosis, or December 31, 2011, whichever was earliest. The expected number of cancer cases was calculated as the exposure multiplied by the incidence within each ageand sex-specific category and then summed across all categories for the period 2004-2008 in Singapore. The standardized incidence ratio was calculated as the ratio of observed to expected cancers, and 95% CIs were calculated for the standard incidence ratio based on Poisson distribution. The study was approved by the ethics committee of the National Healthcare Group, Singapore. Patient consent was waived.

An update of fixed drug eruptions in Singapore

Fixed drug eruptions (FDE) are most commonly caused by antibiotics and non‐steroidal anti‐inflammatory drugs (NSAIDs). The list of causative drugs changes with time and prescribing patterns but there has been no recent data on FDE seen in an outpatient setting in Singapore.

Retrospective Study on Autoimmune Blistering Disease in Paediatric Patients

Autoimmune blistering diseases (AIBDs) are rare in children and their prevalence in Singapore is unclear. We aimed to investigate the clinical and immunopathologic characteristics of children diagnosed with AIBDs in Singapore.

Tailoring of recommendations to reduce serious cutaneous adverse drug reactions: a pharmacogenomics approach

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

A polymorphous rash of an uncommon blistering disease

An 88-year-old Chinese man was admitted to an acute hospital for 10 days for treatment of pneumonia. He had received one dose of piperacillin–tazobactam and vancomycin on admission, before being switched to an 8-day course of co-amoxiclav. He then developed new-onset fever, maximum 39.7 °C, which was associated with blistering itchy erythematous patches and plaques over his neck, axillae and groin folds. Once the fever developed, piperacillin–tazobactam and vancomycin were re-initiated to replace co-amoxiclav under the assumption of possible new sepsis. The aforementioned exanthem occurred within 1 day of rechallenge with piperacillin–-tazobactam and vancomycin. No other systemic complaints were present. The patient’s comorbidities included dementia, diabetes mellitus, hypertension and hyperlipidaemia. He had previously received three courses of co-amoxiclav with no adverse reactions. Physical examination revealed confluent nontender erythematous patches and plaques with tense bullae at the flexures with atypical targetoid plaques on his back and buttocks (Fig. 1 a–d). There was no skin sloughing or duskiness. There was no mucosal involvement. Laboratory investigations showed normal liver function test, creatinine and full blood count with no peripheral eosinophilia.

Pemphigus herpetiformis with autoantibodies to desmocollins 1, 2 and 3

A 66-year-old man presented with a 1-month history of a generalized, pruritic, blistering eruption. His medical history included hypertension, iron-deficiency anaemia and poorly controlled diabetes mellitus. He had been prescribed subcutaneous insulin, hydrochlorothiazide and losartan 3 years prior to the onset of the rash. Physical examination revealed generalized eczematous patches with crusted erosions scattered over the patient’s scalp, face, trunk and limbs, while herpetiform vesicles and pustules were distributed over his arms, legs and abdomen (Fig. 1a,b). The mucous membranes were unaffected. Histological examination of a skin biopsy taken from an erosion on the chest revealed spongiosis with eosinophilic exocytosis and a superficial perivascular infiltrate of eosinophils. A repeat skin biopsy from of a vesicle on the right flank showed an intraepidermal blister with adjacent spongiosis and eosinophilic exocytosis (Fig. 2a). There were no features of acantholysis seen at either the granular layer or the basal epidermis. Direct immunofluorescence (DIF) revealed intraepithelial and intercellular deposition of IgG and C3. Serum indirect immunofluorescence (IIF) to human skin revealed IgG antikeratinocyte cell surface antibodies with titres of > 1 : 160 (Fig. 2b). ELISA for desmoglein (Dsg)1, Dsg3, bullous pemphigoid (BP)180 and BP230 were negative. ELISA using eukaryotic recombinant proteins to desmocollin (Dsc)1, Dsc2 and Dsc3 were positive at

A restrospective review of fixed drug eruptions presenting at a tertiary dermatology centre in Singapore between 2008 and 2012

Fixed drug eruption (FDE) is a well-recognised localized cutaneous adverse drug reaction, characterized by its recurrence in the same sites upon re-exposure to the causative drug. We aimed to better understand the epidemiology, clinical features as well as the causative drugs of fixed drug eruptions in Singapore.