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Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Antibiotic Resistance Pattern of Neisseria gonorrhoeae in
Hospital Kuala Lumpur, Malaysia (2001-2005)

Azura Mohd Affandi, MBBS, MRCP, HB Gangaram, MBBS, FRCP and Suraiya H Hussein, MBBS, FRCP
Department of Dermatology, Hospital Kuala LumpurKuala Lumpur Correspondence
Azura Mohd Affandi, MBBS, MRCP
Genito-urinary (GUM) Medicine Clinic
Department of Dermatology, Hospital Kuala Lumpur
50580 Kuala Lumpur
Email : affandi_azura@yahoo.co.uk
Keywords Gonorrhoea, Antibiotic Resistance Pattern
Background Gonorrhoea is the third most common sexually
transmitted infection (after syphilis and non-gonococcal urethritis) Gonorrhoea is amongst the most common sexually seen in patients attending the Genitourinary Medicine (GUM) Clinic transmitted infections in the world and is caused by gram in Hospital Kuala Lumpur (HKL). Its association with poor negative bacterium Neisseria gonorrhoeae. It usually infects reproductive health outcomes and the increasing prevalence of the mucosal surfaces, causing sexually transmitted urethritis antimicrobial resistance has made it a major public health concern.
in men and endocervicitis in women. It can also causeanorectal and pharyngeal infections and in neonates, Objective To determine the antibiotic resistance pattern of Neisseria
ophthalmic infection is acquired during passage through the Gonorrhoeae in patients attending the GUM Clinic in HKL and its birth canal. Complications particularly affect women, and comparison with other countries.
include salpingitis, pelvic inflammatory disease, first Method A retrospective study of all patients with gonorrhoea (new and
trimester abortion and decreased fertility. In men, extension recurrent) between 2001-2005. Antimicrobial susceptibility testing by of mucosal infection to contiguous areas may give rise to standard disc diffusion method was performed to detect sensitivity to epididymo-orchitis and thus reduced fertility. In a small penicillin, tetracycline, kanamycin, ciprofloxacin, spectinomycin, proportion of patients, gonococcaemia may occur and result ceftriaxone and cefuroxime.
in septic arthritis, endocarditis and meningitis. It is wellrecognized that gonorrhea, together with genital ulcer Results A total of 416 positive culture isolates of N.gonorrhoeae from
disease, are potent amplifiers of the spread of HIV1. Rates 2001-2005 were reviewed. Highest level of resistance was detected to of HIV transmission in those with gonorrhoea may be as tetracycline (86.8% of 296 isolates). Resistance to penicillin was noted much as 5 times more than in persons without gonorrhoea1.
in 64.4% of all isolates. Penicillinase Producing N.gonorrhoeae (PPNG) Those with gonorrhoea are also more susceptible to accounted for 62% of cases. Both penicillin and tetracycline showed an acquisition of HIV infection2.
increasing resistance trend from 2001-2005. The third commonestantibiotic resistance was to kanamycin (38.3%), followed byciprofloxacin (10.4%). The resistance to spectinomycin was 1.7%. No Gonorrhoea remains a major global disease with an resistance was detected to ceftriaxone and cefuroxime. All gonorrhea estimated 60 million cases per year globally, making it a patients in GUM Clinic, HKL were treated with ceftriaxone, and major public health concern3. About half of these cases subsequent cultures on follow-up were negative. We compared our occur in the Western Pacific and South East Asia regions5.
results with the data obtained from the Gonococcal Resistance to In GUM Clinic, HKL, gonorrhoea accounts for the third Antimicrobials Surveillance Programme (GRASP)6 and the WHO most common sexually transmitted infection (after syphilis Western Pacific Gonococcal Antimicrobial Surveillance Programme and non-gonococcal urethritis). In the recent years, incidence of gonorrhoea has also increased in otherdeveloped countries, with the highest rates in the socially Conclusion Penicillin and tetracycline resistance remain high in
and economically deprived subpopulations, and in Malaysia and other Western Pacific countries. Resistance to homosexual men4.
ciprofloxacin was however lower in Malaysia compared to othercountries. There was no resistance to ceftriaxone and cefuroxime. Thecurrent first line antibiotic for treating gonorrhoea in GUM Clinic,HKL is ceftriaxone.
Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Attempts to treat and control gonorrhoea are compromised Table 1. Positive culture isolates of N.gonorrhoeae
by the emergence and spread of antibiotic resistant Neisseria Number of isolates
gonorrhoeae. There are many surveillance programmes onantibiotic resistance pattern of N.gonorrhoeae such as GRASP (Gonococcal Resistance to Antimicrobial Surveilance Programme), which is based in London, UK and WHO WPR GASP (World Health OrganizationWestern Pacific Region Gonococcal Antimicrobial Surveilance Programme)5, 6. Tetracycline resistance is encountered in many countries. Since penicillin resistance emerged in the late 1970's, it has spread to most parts of theworld7. This is either due to Penicillinase Producing Neisseria gonorrhoeae (PPNG) or chromosomally mediated Majority of the patients (51.7%) were between the ages of resistance (CMRNG). South East Asian countries are 21-30 years old (Figure 1). 96.6% were males and 3.4% noted to have high PPNG rates7. Resistance to quinolones females. The majority of the patients were Malays (63.7%), was first observed in the South East Asia and the Western followed by Indian (23.6%), Chinese (8.9%) and others(3.8%). (Racial distribution of patients attending the GUM Pacific regions in the 1990's, and have now spread widely Clinic, HKL from 2001-2005 : Malay-44.7%, Indian-25.3% within and beyond the Western Pacific Regions8. There Chinese-18.6% and Others-11.4%).
were also reported cases of altered susceptibility to thirdgeneration cephalosporin in the Western Pacific Region9, 10and recently these strains have also appeared in centresoutside the region. Antibiotic resistance pattern vary Materials and methods
between different geographical areas. Therefore, it is This is a retrospective study of all patients with gonorrhoea important to know the local antibiotic resistance pattern, so (new and recurrent), attending the GUM Clinic, HKL that appropriate treatment can be instituted. In HKL, between 2001-2005. Antimicrobial susceptibility testing by kanamycin was used during the early 1970's and 80's, which standard disc diffusion method was performed to detect was subsequently changed to spectinomycin, followed by resistance to penicillin, ceftriaxone since the early 1990's.
ciprofloxacin, spectinomycin, ceftriaxone and cefuroxime.
All information was obtained from patients' case notes.
Objectives
To determine the antibiotic resistance pattern of
N.gonorrhoeae in patients attending the GUM Clinic, HKL A total of 416 positive culture isolates of Neisseria and to compare it with other countries.
gonorrhoeae from 2001-2005 were reviewed. The number
of isolates for each year is shown in Table 1.
Figure 1. Age of patients with gonorrhoea (n=416)
Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Table 2. Summary of antibiotic resistance pattern of N.gonorrhoeae (2001-2005)
Year / Antibiotics
Figure 2. Antibiotic resistance pattern of N.gonorrhoeae (2001-2005)



Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Figure 3. Overall antibiotic resistance pattern of N.gonorrhoeae (2001-2005)
Figure 4. Resistance of N.gonorrhoeae to Penicillin
Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Table 3. Comparison of N.gonorrhoeae antibiotic resistance pattern in Hospital Kuala Lumpur (HKL)
with other countries
Country / Centre
% Penicillin Resistant
England and Wales6 7The WHO Western Pacific Gonococcal Antimicrobial Surveilance Programme (GASP) 20046The Gonococcal Resistance to Antimicrobials Surveilance Programme (GRASP) 2004 Antibiotic resistance pattern of
Ciprofloxacin is not the first line treatment for gonorrhoeain our clinic. However, it is used by the primary care doctors for treating gonorrhoea due to its accessibility and ease of Tetracycline has never been used for treating gonorrhoea in administration. Susceptibility testing to ciprofloxacin was HKL as the resistance is very high. Nevertheless, the done since 2002. There was a gradual increase from 8.7% in resistance pattern is continuously monitored for 2002 to 12.5% in 2005 (Table 2 and Figure 2). The overall
epidemiological purposes. In 2002, 57.4% of the isolates resistance rate from 2001-2005 is 10.4% (Figure 3).
were resistant to tetracycline and the levels have continued
to rise, reaching 100% in 2004 (Table 2 and Figure 2). The
overall tetracycline resistance from 2001-2005 is 86.8% Spectinomycin showed a low resistance rate of 1.2% in 2001 (Figure 3).
and 2.3% in 2002 (Table 2 and Figure 2). The susceptibility
testing was discontinued in 2003. The overall resistance to
spectinomycin from 2001-2005 is 1.7% (Figure 3).
Resistance to penicillin also showed an increasing trend
from 54.3% in 2001 to 85.2% in 2005 (Table 2 and Figure
6. Cephalosporins - Cefuroxime and Ceftriaxone
2). The overall resistance rate from 2001 to 2005 is 64.4%
Susceptibilty of N.gonorrhoeae to cefuroxime was tested in (Figure 3). This can be due to Penicillinase Producing
2001 and 2002. None of the isolates were found to be N.gonorrhoeae (PPNG) or Chromosomal Mediated resistant to cefuroxime. Similarly, since 2001 to 2005, none Resistance N.gonorrhoeae (CMRNG) (Figure 4). Of the
of the N.gonorrhoeae isolates were found to be resistant to isolates resistant to penicillin, 62% were PPNG and 6.7% ceftriaxone (Table 2, Figure 2 and Figure 3). All patients in
our clinic were treated with ceftriaxone and subsequentcultures on follow-up were negative.
3. Kanamycin
Kanamycin was used for treating gonorrhoea in HKL in the
early 1970's and 80's. However, because of increasing 44.3% of the N.gonorrhoeae isolates were found to be resistance since the early 1990's, it is not used anymore.
resistant to both penicillin and tetracycline. 5.1% of the Resistance of N.gonorrhoeae to kanamycin was done in 2001 isolates were resistant to all 3 antibiotics-penicillin, and 2002 only. There was a marked increase in the tetracycline and ciprofloxacin.
resistance pattern from 13.6% in 2001 to 89.7% in 2002
(Table 2 and Figure 2). The overall resistance to kanamycin
from 2001 to 2005 is 38.3% (Figure 3).
Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia The summary of N.gonorrhoeae antibiotic resistance pattern Surveillance of antibiotic resistance in Neisseria gonorrhoeae from 2001 to 2005 is illustrated in Table 2 and Figure 2.
in the WHO Western Pacific Region, 1998. Commun Dis Intell The overall (average) antibiotic resistance pattern from Tapsall JW. Antibiotic Reistance in Neisseria gonorrhoeae. Clin 2001-2005 is shown in Figure 3.
Infect Dis 2005;41:S263-268.
GRASP Steering Group. The Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) Year 2004 Attempts to treat and control gonorrhoea are compromised report. London: Health Protection Agency 2005.
by the emergence and spread of antibiotic-resistant N. The WHO Western Pacific Gonococcal Antimicrobial Surveillance Programme. Surveillance of antibiotic resistance in gonorrhoeae. WHO expert committee has recommended Neisseria gonorrhoeae in the WHO Western Pacific Region, that treatment regimens be altered once resistance to a 2004. Commun Dis Intell 2006;30:129–132.
particular antibiotic reaches 5 percent.11 Penicillin and WHO Western Pacific Region Gonococcal Antimicrobial tetracycline resistant N.gonorrhoeae remain high in Malaysia Surveillance Programme. Surveillance of antibiotic susceptibility of Neisseria gonorrhoeae in the WHO Western and other Western Pacific countries and the resistance rate Pacific Region 1992–4. Genitourin Med 1997;73:355–361. continue to increase. Resistance to ciprofloxacin was The WHO Western Pacific Gonococcal Antimicrobial however lower in Malaysia compared to other countries.
Surveillance Programme. Surveillance of antibiotic resistance in However, the level is gradually increasing and has to be Neisseria gonorrhoeae in the WHO Western Pacific Region, monitored closely. Current first line antibiotic for treating 2001. Commun Dis Intell 2002;26:541–545. The WHO Western Pacific Gonococcal Antimicrobial gonorrhoea in GUM Clinic, HKL is ceftriaxone, which has Surveillance Programme. Surveillance of antibiotic resistance in no documented resistance so far.
Neisseria gonorrhoeae in the WHO Western Pacific Region, 2000. Commun Dis Intell 2001;25:274-276. Guidelines for the management of sexually transmitted We would like to convey our special gratitude to Dr Akbal infections WHO/HIV-AIDS. Geneva: World Health Organization; 2001. Report No.WHO/RHR/01.10. Available online. Kaur, Encik Othman Thani and other staff from the Genitourinary Medicine Clinic, HKL for data collection.
/who_hiv_aids_2001.01/ Ito M, Deguchi T, Mizutani KS, Yasuda M, Yokoi S, Ito S et al. Emergence and spread of Neisseria gonorrhoeae clinical isolates harbouring mossaic-like structure of penicillin-binding protein 2 in Japan. Antimicrob Agent Chemother 2005;49:137- Cohen MS. Sexually transmitted diseases enhance HIV transmission: no longer a hypothesis. Lancet 1998;351 Tapsall JW. Annual Report of the Australian Gonococcal (Suppl III):5-7.
Surveilance Programme, 2004. Commun Dis Intell 2005;29:136- Cohen MS, Hoffman IF, Royce RA et al. Reduction of concentration of HIV-1 in semen after treatment of urethritis: Wang SA, Lee MV, O'Connor N, Iverson CJ, Ohye RG, Whiticar implications for prevention of transmission of HIV-1. Lancet PM et al. Multidrug-resistant Neisseria gonorrhoeae with decreased susceptibility to cefixime - Hawaii, 2001. Clin Infect Gerbase AC, Rowley JT, Heyman DHL, Berkley SFB, Piot P. Global prevalence and incidence estimates of selected curable STDs. Sex Transm Inf 1998;74 (suppl 1):S12-S16.
Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia A 10-year Retrospective Study on Changing Pattern
of Sexually Transmitted Infections in
Hospital Kuala Lumpur, Malaysia

Penny Lim, MBBS, MRCP, HB Gangaram, MBBS, FRCP and Suraiya H Hussein, MBBS, FRCP
Genito-Urinary Medicine (GUM) ClinicDepartment of Dermatology, Hospital Kuala Lumpur 50580 Kuala Lumpur Correspondence
Dr Penny Lim Poh Lu, MBBS, MRCP
Department of Dermatology, Hospital Kuala Lumpur
50580 Kuala Lumpur
Email : teoleetam@yahoo.com
which remained unchanged in both the study periods. Based onethnicity, there was an increase in the percentage of Malays being Background Sexually transmitted infections (STIs), and HIV
infected in STIs in the later study period. Syphilis was the commonest especially, are a major health problem in Malaysia. The emergence of STI seen in both the study periods. The second commonest STI seen HIV infection has increased the importance of early and effective in 1995-1999 was gonorrhoea and non-gonococcal urethritis (NGU).
treatment of STIs as any delay may lead to enhance transmission or In 2005, there were 184 patients with syphilis; 64% were heterosexuals; acquisition of HIV infection. A proper understanding of the patterns 39.6% homosexuals and 1.6% bisexuals. Majority (82%) were of STIs is necessary for effective planning and control strategies. The asymptomatic (latent syphilis with positive syphilis serology at present study is designed to determine the changing pattern of STIs in presentation. Symptomatic patients with early infectious syphilis the Genito-urinary Medicine Clinic (GUM), Hospital Kuala Lumpur constituted 15% (Primary 8%; Secondary 7%). Screening for HIV was positive in 31 (16.8%) patients. HIV infection was noted to be thecommonest STI associated with syphilis.
Objective To study the sociodemographic characteristics of patients
with STIs attending the GUM Clinic in HKL and to analyze any
Conclusion was an overall decline in the number of patients with
changes in the pattern of STIs seen between the 2 study periods of STIs attending the GUM clinic, HKL. The decline was more evident 1995-1999 and 2001-2005.
with bacterial STIs; viral STIs however showed an increasing trend.
Syphilis was still the commonest STI seen in the two study periods Method A retrospective review of case notes of new patients with
although the percentage has declined. Non specific urethritis has STIs attending the GUM clinic, HKL was done during two study superseded gonorrhoea as the second commonest STI. HIV was found periods of 1995-1999 (Poster presentation on "Pattern of STDs" at to be the commonest STI seen in association with syphilis.
14th RCD, Asia-Australasia, 26-30 July 2000, KL, Malaysia by HBGangaram et al) and 2001-2005.
Keywords Changing pattern, Sexually transmitted infections, STI
Results In 1995-1999, a total of 3150 STI patients were studied.
Among them, 2016 (64%) were males and 1134 (36%) were females. In Nearly one million new people are infected with sexually 2001-2005, a total of 2909 STI patients were examined, of which 1862 transmitted infections (STIs) every day nationwide. World (64%) were males and 1047 (36%) were female. There was a decrease Health Organization (WHO) estimated that approximately of 8.3% in the total number of cases seen in 2001-2005 as compared to 340 million new cases of the four main curable STIs 1995-1999. The decline was more evident with bacterial STIs which gonorrhoea, NGU, syphilis and trichomoniasis occur every included syphilis, gonorrhoea, NGU and chancroid. Viral STIs which year2,13. STIs are responsible for an enormous burden on consisted of herpes genitalis, genital warts and HIV showed an morbidity and mortality in many developing countries increasing trend.
because of their effects on reproductive and child health and A younger age group (20-39 years old) appeared to be infected with STIs in 2001-2005. Males outnumbered females in the ratio of 1.8:1, Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia their role in facilitating the transmission of HIV infection.
The emergence of HIV infection has increased the This study included a total of 2909 patients in 2001-2005 importance of measures aimed at control of STIs. A proper as compared to 3150 patients in 1995-1999 (Table 1).
understanding of the patterns of STIs prevailing in different There was a decrease of 8.3% in the total number of cases geographic regions of a country is necessary for proper seen in 2001-2005.
planning and implementation of STI control strategies4. Itis with this aim that the present study was undertaken.
Majority of the patients (51.7%) were between the ages of30-49 years old in 1995-1999. In the present study, a younger age group between 20-39 years old appear to be To study the sociodemographic characteristics of patients infected with STIs1,2,3,4,9,10 as shown in Figure 2. 64% were
with STIs attending the Genitourinary Medicine Clinic males and 34% females in both the study periods. In 1995- (GUM), Hospital Kuala Lumpur and to analyze any 1999, Malay comprised the majority of the patients (38%), changes in the pattern of STIs seen between the 2 study followed by Indian (22%), Chinese (17%), foreigners (18%) periods of 1995-1999 and 2001-2005.
and others (5%). In 2001-2005, there is was increase in thepercentage of Malays (47.8%) being infected with STIs, Materials and Methods
followed by Indian (21.4%), Chinese(18.9%), foreigners This is a retrospective review of case notes of new patients (8.0%) and others (3.9%) (refer Figure 2). (Ethnic
with STIs attending the GUM Clinic, HKL during two Distribution of Patients Attending the GUM Clinic, HKL from study periods of 1995-1999 and 2001-2005. The National 2001-2005 : Malay-44.7%, Indian-25.3% Chinese-18.6% Statistics figures were obtained from the Department of Public Health, Malaysia.
Table 1. Classification of Syphilis in GUM Clinic 2005 (n=184)
Figure 1. Total number of new patients with STI in GUM
Figure 2. Age distribution of new patients with STI
Age group (Age)


Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Figure 3. Sex distribution of new patients with STI
Figure 4. Ethnic distribution of new patients with STI
Syphilis was the commonest STI seen in both the study commonest STI seen in 1995-1999 was gonorrhoea and periods although there was a decline from 982 (31.2%) to non-gonococcal urethritis (NGU) in the present study 702 (24.1%) (Figure 5). In 2005, there were 184 patients.
(Figure 5). Generally, there was an overall decrease in
118 (64.1%) were heterosexual, 73 (39.6%) homosexuals bacterial STI (syphilis, gonorrhoea, NGU and chancroid) and 3 (1.6%) and 3 (1.6%) bisexuals (Figure 7). Majority
with an increase in viral STI (genital warts, genital herpes (82%) were asymptomatic (latent syphilis with positive and HIV)1,4,8,9 Figure 6.
syphilis serology at presentation (Table 1). The second
Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Figure 5. Types of STIs between 1995-1999 and 2001-2005
ypes of STIs
T

Figure 6. Comparison between Bacterial STI and Viral STI


Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Figure 7. Syphilis in GUM Clinic, HKL 2005 (n=184)
HIV seropositivity was 5.3% of all clinic attendes during 2001-2005. Of these 78 % were males and 22% females. 68 %were homosexuals, 24% heterosexuals and 8% bisexuals in HIV male patients. Chinese comprised the majority of patients(65%) followed by Malays (18%), Indian (15%) and others (2%). Majority of patients were in the age group 21-40 yearsold which is also the most sexually active age group.
Figure 8. HIV patients in GUM Clinic, HKL 2001-2005 (n=154)
Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia This study demonstrated an overall decline in the total There was an overall decline in the total number of patients number of STI cases1,4,8.9. The total number of patients with with STIs attending the GUM Clinic, HKL. The decline bacterial STIs such as syphilis, chancroid and gonorrhoea was more evident with bacterial STIs; viral STIs however also showed a declining trend. However there was an showed an increasing trend. Syphilis was still the increase in viral STIs like HIV, herpes genitalis and genital commonest STI seen in the two study periods although the warts. This is similar to the findings in other studies. This percentage has declined. NGU has superseded gonorrhoea decline in the number of patients with STIs attending the as the second commonest STI. HIV was found to be the GUM clinic could be attributed to either a true decline in most common STI seen in association with syphilis.
STIs with the onset of HIV more commonly patientsseeking treatment at private general practitioner (GP) clinic, expecting more confidentiality in dealing with these We would like to convey our special gratitude to Dr Akbal diseases. Awareness and fear of contracting HIV have Kaur, Encik Abdul Manaf B. Yusoff and other staff from influenced the risk-taking behaviour of people, thereby Genitourinary Medicine Clinic, HKL for data collection.
reducing the likelihood of being infected with STIs.
In the present study, males outnumbered females by 1.8:1.
This pattern of male preponderance is also seen in other Krishna Ray et al; Changing trends in sexually transmitted studies1,4,8,9. Of particular interest, the age group with the infections at a Regional STD Centre in north India; Indian J Med highest number of cases has shifted to a younger age11,14 (20- 39 years old ). This is not surprising as the average age for WHO Europe; Trends in sexually transmitted infections and HIV sexual debut nowadays occurs earlier. Factors that could in the European Region, 1980-2005; technical briefing document contribute to this include increasing exposure to sex 01B/06, Copenhagen, 12 September 2006.
Sevgi O. Aral et al; Sexually Transmitted Infections and HIV in periodicals, advertisements, the theater, radio, television and the Southern United States: An Overview; Sexually Transmitted the internet. This group are at a high risk of being Diseases; July (suppl) 2006;33(7):1-5.
behaviourally more vulnerable to STI acquisition, as they Narayanan B; A retrospective study of the pattern of sexually generally have a higher number of sexual partners and more transmitted diseases during a ten-year period; IJDVL 2005;71(5):333-7.
concurrent partnerships and change partners more often Kevin A. Fenton et al; Reported Sexually Transmitted Disease than older age groups. Being the economically productive Clinic Attendance and Sexually Transmitted Infections in Britain: group, there is great loss of workforce due to STI morbidity, Prevalence, Risk factors and Proportionate Population Burden; measured as disability adjusted life years (DALYS)1 lost.
The Journal of Infectious Diseases 2005;191(Suppl 1):127-38.
Although the teenagers were not spared, the percentage of Christopher J. Smith; Social geography of sexually transmitted diseases in China; Asia Pacific Viewpoint; April 2005;46(1):65-80. STI cases was not high. Nevertheless the young adults and E.N. Nnoruka and A.C.J.Ezeoke; Evaluation of syphilis in patients adolescents should constitute the priority target group in with HIV infection in Nigeria; Tropical Medicine and STI control programme.
International Health; Jan 2005;10:58-64.
Abdul Wahab Al-Fouzan and Nawaf Al- Mutairi; Overview of The disporportionate attendance of Chinese patients could Incidence of Sexually Transmitted Diseases in Kuwait; Clinics in Dermatology; 2004; 22:509-512.
be their preference for seeking treatment from GP clinics as Sharma VK, Khandpur S.; Changing patterns of sexually compared to government hospitals/ clinics.
transmitted infections in India, Natl Medical Journal India;2004;17(6):310-319.
Syphilis is the commonest STI seen in both the study Jaswal AK et al; Changing trends in Sexually transmitted diseases in North Eastern India; IJDVL2002;68(2):65-66.
periods although there is a decline. Of the different types, Hiok-Hee Tan, Roy Chan; Sexually transmitted infections in latent syphilis was the most common. The second Singapore Youths; National Skin Centre, Singapore 2005.
commonest STI seen in 1995-1999 was gonorrhoea whilst William K.Bosu; Syndromic management of sexually transmitted in the present study it was non-gonococcal urethritis diseases; Tropical Medicine and International Health ; February (NGU). This pattern change was also seen in most WHO, Office of Information; Sexually transmitted infections countries. HIV was the commonest STI seen in association increasing- 250 million new infections annually,1990;(152):1-6. with syphilis. Syphilis increases the risk of both Donald WH; The changing pattern of sexually transmitted transmitting and getting infected with HIV and can be diseases in adolescents; Practitioner;1979; 222(1329):383-5.
harder to cure and may progress more quickly and severely Raval RC et al; A study of a changing patterns of sexually transmitted diseases and HIV prevalence during intervals of in people infected with HIV2. However, further studies are different years; International Conference AIDS July 7-12, required to confirm this association.
2002;14: Abstract No. C10895 Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Allergic Contact Dermatitis in a private practice
Dermatology Clinic in Ipoh: A Seven-Year Retrospective
Study

Henry BB Foong, MBBS, FRCP1, Elizabeth M Taylor, MBBS1 and N Ibrahim2
1Foong Skin Specialist Clinic33A Persiaran Pearl, Fair Park, Ipoh 31400, Malaysia2Medical Student (Phase 3A), Universiti Kuala Lumpur RoyalCollege of Medicine Perak, Ipoh, Malaysia Correspondence
HBB Foong, FRCP,
Foong Skin Specialist Clinic
33A Persiaran Pearl, Fair Park, Ipoh 31400, Malaysia
Email : bbfoong@pc.jaring.my
recorded. All were patch tested to the NSC standard battery Patch testing has been accepted as the most important investigative (Chemotechnique) and additional allergens where technique of assessing allergic contact dermatitis (ACD) and indicated. The test allergens were mounted on Scanpore identifying the contact allergens. The epidemiology of ACD differs in tape. The allergens were removed at 48 hours and reaction different geographic region as the environmental allergens vary in recorded 15 minutes after removal. The reactions were different populations. In this study 59.8% of the patients had a positive recorded again at 96 hours.
patch test reaction to one or more allergens. The prevalence of ACDwas 64.7% in women and 51.4% in men. The commonest causes of Reactions were recorded according to the standard scoring ACD were nickel (30.4%), fragrance mix (18.16%) and balsam of Peru system recommended by International Contact Dermatitis Research Group. NR = nonreactive; +/- = erythema; + =erythema with papules; ++ = palpable erythema, papules and Keywords contact dermatitis, prevalence, patch tests
vesicles; +++ = palpable erythema, vesicles, bullae; IR =irritant reactions. Reactions of + and greater were considered positive. The prevalence of ACD (patients with Patch testing has been accepted as the most important one or more positive reactions) was evaluated.
investigative technique of assessing allergic contactdermatitis (ACD) and identifying the contact allergens1 The epidemiology of ACD differs in different geographic During the study period, 317 women and 173 men were region as the environmental allergens vary in different patch tested. The age ranged from 6-86 years with a mean populations. A study done in Hospital Kuala Lumpur using of 37.5 years. The prevalence of contact dermatitis was the European standard allergens for the period 1994-1996 64.7% (205/317) in women and 51.4% (89/173) in men.
showed the top three allergens to be nickel (36%), rubberchemicals (19%) and fragrance mix (17%) while in Table 1 shows the prevalence of positive reaction according
Singapore nickel (13.9%), fragrance mix (8.4%), flavine to age and sex. Most were in the 20-29 years age group.
(6.3%) and potassium dichromate (6.3%)2,3. The prevalence The rate appeared to increase with age. For those less than of ACD in 2471 patients patch tested in Singapore was 40 years old it was 58.2% (174/299) and more than 40 years 49.2% in women and 49.8% in men3. The epidemiology of 62.8% (120/191).
ACD in a private practice dermatology clinic has not beenwell documented. This is an epidemiologic study of ACD of Table 2 shows the prevalence of contact dermatitis
patients attending a private practice dermatology specialist according to the ethnic group. The rate was not significantly clinic in Ipoh. It also aims to identify the most common different from the major ethnic groups but was highest in contact allergens in this population.
the Chinese followed by Malays and Indians.
Materials and methods
Table 3 shows the prevalence of contact dermatitis to
All patients seen at the Foong Skin Specialist Clinic standard allergens according to sex. Nickel (30.4%), between 1999 and 2006 who have had patch tests done were fragrance mix (18.16%), Balsam of Peru (6.73%), cobalt included in the study. The age and sex of the patient were (5.31%), potassium dichromate (3.47%), neomycin (3.27%),wool alcohol (3.27%) and parabens (3.27%). were thecommonest Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Table 1. Prevalence of Allergic Contact Dermatitis according to the age group and sex
Age Group
Table 2. Prevalence of Allergic Contact Dermatitis according to ethnic group and sex
Ethnic Group
Table 3. Prevalence of Allergic Contact Dermatitis according to standard battery
allergens and sex.
Female n+317
Male n=173
Total n=490
Potassium dichromate Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia commonest allergens. Nickel allergy was more common in dermatitis under the chin as a result of the pin worn by women. Female patients outnumbered the male patients in Muslim women. The use of costume jewellery and ear their allergens for the above except potassium dichromate piercing are among the common causes of sensitization to and parabens where the reverse is true.
Fragrance mix (18.16%) was the second commonest contact Allergic contact dermatitis (ACD) is an important allergen in this study. The rate appeared to be higher in dermatologic disease with considerable morbidity and women (21.14%) than in men (12.72%). Fragrance is economic impact. It represents delayed type hypersensitivity present in most perfumes, cosmetics, toiletries and many to small molecular weight chemicals which acts as haptens.
household products. They are important in our community It is caused when contact with a specific allergen elicits a because they are widely used. Balsam of Peru formed the specific immunologic inflammatory response in the allergic third commonest contact allergen. Balsam of Peru is a plant individual 24 to 72 hours after re-exposure. Diagnosis of product, a balsam derived from the trees of the genus ACD is frequently facilitated or confirmed through the use Myroxylan found in Central and South America. It of patch test procedure.
contains a mixture of fragrance constituents such ascinnamic acid, eugenol, benzyl benzoate, benzyl alcohol, The prevalence of contact dermatitis to various allergens vanillin, etc. As such it is a useful marker to detect fragrance differs in different population group. Therefore, it is allergy. Not surprising, it was higher in women (9.74%) important for dermatologists to be aware of the common than in men (1.73%).
allergens and to monitor them in their place of practice. Atour dermatology clinic in Ipoh, 59.8% of patients had a Other common contact allergens were cobalt (5.31%), positive patch test reaction to one or more allergens. The potassium dichromate (3.47%), neomycin (3.27%), wool prevalence was 49.5% in Singapore3, 55% in Scotland4 and alcohol (3.27%) and parabens (3.27%). In women, co- 60.5% in Spain5. In this study the prevalence of ACD and sensitivity of cobalt and nickel occur commonly due to the causative allergens are not much different from existing wearing of costume jewellery. In men, cobalt allergy is often published epidemiological studies.
associated with chromate allergy due to occupationalcement exposure.
It has been found that allergic contact dermatitis was morefrequent in women as compared to men6. Thepreponderance in women could be due to the high rate of sensitization to certain allergens such as nickel and Ang P, Ng SK. Chapter editor: "The Principles and Practice of fragrances. In our study the prevalence of allergic contact Contact and Occupational Dermatology in the Asia-Pacific dermatitis was 64.7% (205/317) in women and 51.4% Region." Edited by Ng SK and Goh CL. Investigative techniques (89/173) in men. The prevalence of ACD was significantly in Contact Dermatitis." World Scientific 2001.
higher in women than in men. (test of significance, p value Rohna R. Pattern of contact and photocontact dermatitis at <0.05) However, Goh in his study found that men and Hospital Kuala Lumpur - a two year study (1994-1996). Paper presented at the Update Contact Allergy Occup Dermatoses, women were equally susceptible to epicutaneous Kuala Lumpur, 6 April 1996.
sensitization. In his study the prevalence was 49.2% in Goh CL. Epidemiology of Contact Allergy in Singapore. Int J women and 49.8% in men3.
Husain SL. Contact Dermatitis in the west of Scotland. Contact Dermatitis 1977;3:327-332.
ACD in different ethnic groups has seldom been studied Romaguera, C, Grimalt F. Statistical and comparative study of before. The prevalence between black and white Americans 4600 patients tested in Barcelona (1973-1977). Contact appeared to be the same8. In our study, Chinese had the highest prevalence rate (63%), while Malays had a Rees JL et al. Sex differences in susceptibility to development prevalence rate of 55.4% and Indians 41.7%.
of contact hypersensitivity to dinitrochlorobenzene (DNCB) Br J Dermatol 1989; 120:371-374.
Hammershoy O. Standard patch test results in 3225 consecutive Nickel allergy (30.4%) was the commonest cause of ACD in Danish patients from 1973-1977. Contact Dermatitis 1980; 6:263- our study. It was more common in women (36.3%) than in men (19.3%). The unique ethnic lifestyle has brought about Leyden JJ, Kligman AM. Allergic contact dermatitis: sex peculiar presentation of nickel allergy as scarf button differences. Contact Dermatitis 1977; 3:332-336.
Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Prevalence of herpes simplex virus infection in patients
with genital herpes using the immunofluorescent
antibody test

HB Gangaram, MBBS, FRCP1, Akbal Kaur, MBBS1, S Mangalam, MBBS, FRCPath2 and Suraiya H Hussein, MBBS, FRCP1
1Genito-Urinary Medicine Clinic, Department of Dermatology, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia2Department of Pathology, Hospital Kuala LumpurKuala Lumpur, Malaysia Correspondence
Gangaram Hemandas, MBBS, FRCP
Department of Dermatology
Hospital Kuala Lumpur, 50586 Kuala Lumpur
Email : ghbelani@hotmail.com
Conclusions In our study, HSV-2 was still more common causing
57% of the cases seen,
HSV-1 29% and HSV-1 and HSV-2 Background Herpes genitalis (HG) is the commonest cause of
coinfection in 14%. An increased rate of HSV-1 seen could possibly be sexually transmitted ulcerative disease in the world, including due to a change in sexual behavior of the patients especially with Malaysia1. Herpes simplex virus (HSV) type 2 is more frequently regards to oro-genital sexual contact.
implicated than HSV type 1. This pattern has seen some changes inmany parts of the world, with increasing HSV type 1 rates2.
Keywords Genital herpes, Immunofluorescent antibody test, HSV
types
Objective The aim of this study was to determine the type of HSV
implicated in patients with herpes genitalis at the Genito-Urinary
Medicine Clinic, Department of Dermatology, Hospital Kuala Herpes genitalis (HG) is the commonest cause of sexually transmitted ulcerative disease in the world, includingMalaysia1. It is associated with not only physical but also Methods A retrospective study was undertaken on 242 patients with
important psychosocial and economic consequences.
a diagnosis of herpes genitalis at the Genito-Urinary Medicine Clinic Herpes simplex virus (HSV) type 2 is more frequently from January 2000 to December 2004. The study included all cases of implicated than type 1. This pattern has however seen some genital herpes in patients aged over 12 years. The typing was done by a changes in many parts of the world, with HSV type 1 immunofluorescent - labeled monoclonal antibody technique specific becoming more common than HSV type 2. This is evident for HSV antigens.
in most parts of the world including Australia, Europe andthe USA. Some of the reasons postulated included earlier Results Majority (76%) were between the ages of 20-49 years. Males
onset of sexual debut, change in sexual behavior especially outnumbered females by 1.6:1. Younger women (20-29 years old) tend with regards to oro-genital sexual contact and lower rates of to be more frequently affected than their male counterpart. One fourth (25.7%) of the patients reported having sex with sex workers and lessthan 1% (0.4%) were sex workers. A significant percentage (30.5%) of The aim of this study was to determine the type of HSV married men reported extramarital relationship with sex workers or had implicated in patients with herpes genitalis at the Genito- a casual or regular partner. Usage of condoms was low at 12%. Clinical Urinary Medicine Clinic, Department of Dermatology, diagnosis at presentation was primary herpes genitalis (56%) and Hospital Kuala Lumpur.
recurrent (44%). 162 (67%) out of a total of 242 patients had the herpesimmunofluorescent test done. 110 (68%) of those done were negative.
Materials and Methods
Only 34 (21%) of patients with herpes genitalis had a positive A retrospective study was undertaken on 242 patients with immunofluorescent antibody test. Of the 21%, herpes simplex virus a clinical diagnosis of herpes genitalis at the Genito- type 2 was found in 19 (12%) of patients with herpes genitalis, HSV Urinary Medicine Clinic from January 2000 to December type 1 in 10 (6%) and HSV types 1 & 2 coinfection in 5 (3%) patients.
2004. The study included all clinical cases of genital herpesin patients aged over 12 years. Specimens were collectedfrom


Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia from genital lesions with a cotton-tipped swab and smeared Kingdom3. This direct immunofluorescent antibody onto micro-wells of daflon-coated slides, air-dried, fixed technique (IFAT) read with a fluorescent microscope was with acetone and stained with ImagenTM HSV-1 or HSV- utilized for HSV detection as well as typing. This is the 2 using specific monoclonal antibodies conjugated to FITC routine, cost-effective and rapid detection method for in two individual wells, from Dalco Cytomation Co; United genital HSV in this hospital.
Table 1. Total number of new cases of
Table 2. Source of referral of herpes genitalis
herpes genitalis by year (n=242) A total of 242 case notes were reviewed Majority of the patients were self-referred or camefrom the outpatient department of the hospital Table 3. Occupation of patients with herpes genitalis
Table 4. Distribution of herpes genitalis by age & sex
Younger women (20-29 years old) tend to suffer more fromherpes genitalis than men. Majority were office-workers. Only 1% of the patientswere commercial sex workers.
Table 5. Risk factors and marital status in patients with
herpes genitalis (n=282)
Table 6. Provisional diagnosis at first visit (n=242)
Provisional diagnosis at first visit was :Primary herpes genitalis 135 (56%) Recurrent herpes A significant percentage (30.5%) of married men reported genitalis 107 (44%) extramarital relationship with sex workers or had a casual orregular partner


Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Table 7. Correlation of clinical presentation and
immunoflourescent test (n=162)
In primary herpes genitalis, HSV type 2 accounted for 70.6% ofthe positive cases, HSV type 1, 17.6% and HSV types 1 and 2coinfection in 11.8%. In recurrent herpes genitalis, HSV types 1and 2 were found to be equally frequent (41.2%) and HSV types1 and 2 coinfection in 17.6%.
Figure 1. Age distribution of patients with herpes
genitalis (n=242)
Figure 2. Distribution of herpes genitalis by sex (n=242)
Majority (76%) of the patients were between the ages of Males outnumbered females by 1.6 :1 Figure 3. Racial distribution of patients with herpes genitalis
(n=242)
Malays accounted for 44%, Indians 28% and Chinese 25% of the totalpatients. This probably reflects the normal pattern of clinic attendance



Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Figure 4. Sexual orientation of patients with herpes
Figure 5. Marital status of patients with herpes genitalis
genitalis (n=242) Majority (97%) of the patients were heterosexually About two thirds (64.9%) of the patients were married Figure 6. Risk factors in patients with herpes genitalis (n=242)
About 1/4 (25.7%) of the patients reported sex with sex workers. Lessthan 1% (0.4%) of the patients were sex workers Figure 7. Use of condoms by patients with herpes genitalis (n=242)
Condom usage was low (12%) Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Figure 8. Herpes immunoflourescent test in patients with herpes genitalis
(n=162)
162 (67%) patients had the herpes immunofluorescent antibody test done.
110 (68%) of those done were negative. Only 34 (21%) patients with herpesgenitalis had a positive immunofluorescent antibody test. Of the 21%,herpes simplex virus type 2 was found in 19 (12%) patients with herpesgenitalis, HSV type 1 in 10 (6%) and HSV types 1 & 2 coinfection in 5 (3%)patients. Therefore, the most frequent type of HSV causing herpes genitalisin our study was found to be HSV type 2 (57%), HSV type 1 (29%) and HSVtype 1 & 2 coinfection (14%).
to new patients6, longer time between recurrences, and Genital herpes is a common lifelong virally transmitted lower clinical recurrence rates7. Once the primary or non- sexually transmitted disease which may cause not only primary attack has resolved, 88% of untreated patients with significant physical but also severe psychological and HSV-2 genital infection suffer episodes of recurrence at a emotional impact on the life of a patient. It almost certainly mean rate of 0.3 and 0.4 recurrences per month, compared facilitates HIV acquisition4 and can cause a life-threatening to 55% of people infected with HSV-1 with a mean encephalopathy if transmitted to an infant around birth5. It recurrence of 0.09 per month8.
is hence important that we make an accurate diagnosis. It isequally important to determine the infecting viral type in Recent studies suggest that HSV-1 is becoming more order to assess the natural history, prognosis and clinical frequent as a cause for genital herpes2. The table below management of a patient with genital herpes. The clinical compares the prevalence of HSV-1 and 2 in genital herpes presentation of genital primary HSV-1 and HSV-2 in various countries. A striking observation seen in both the infections is similar. However, their natural history is Bangkok and Sydney studies was the increase in rates of different. Genital HSV-1 infections are characterized by HSV-1 as a cause of genital herpes. Our HSV-1 rate is less asymptomatic shedding, a lower transmission frequency similar to the second study done in Sydney.
Prevalence of Herpes simplex virus using immunofluorescence antibody test type (IFAT) Bangkok, Thailand* Western Sydney, Australia2 ** *Used viral culture followed by IFAT **Used viral culture followed by IFAT Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia The sensitivity of the IFAT is about 75%. The specificity however, is higher at 85%. Viral culture, said to be the ‘goldstandard', is not routinely available in our hospital.
S Zainah, M Sinniah, Y M Cheong et al. A microbiological study Although the PCR assay is available in-house, we did not of genital ulcers in Kuala Lumpur. Med J Malaysia 1991;46:274- apply this technique for HSV diagnosis on genital lesions L J Haddow, B Dave, A Mindel et al. Increase in rates of herpes mainly because of the prohibitory cost. Moreover, the simplex virus type 1 as a cause of anogenital herpes in western genital lesion specimens are collected sporadically, not in Sydney, Australia, between 1979 and 2003. Sex Transm Infect batches. The IFAT can be applied to even one clinical sample at a time, is rapid giving results within an hour, if Patrick C.Y. Woo, Susan S Chiu, Wing-Wong Seto, Malik Peiris. Cost-effectiveness of rapid diagnosis of viral respiratory tract necessary. The benefits of Imagen IFAT technique over infections in pediatric patients. J Clin Mivrobiol 1997;35(6):1579- viral isolation for reduction of hospitalization and reduction of anti-bacterial use, are well established. The Freeman EE, Weiss HA, Glynn JR, et al. Herpes simplex virus 2 immunofluorescence positive rate for herpes simplex virus infection increases HIV acquisition in men and women: in our study was about 21%. Being a retrospective study, systematic review and meta-analysis of longitudinal studies. AIDS 2006;20:73-83.
some of the reasons for this would include the stage of the Whitley R. Neonatal herpes simplex virus infections. J Med Virol disease when the specimen was taken, possibility of inadequate specimen for antigen testing, pretreatment with Kinghorn GR. Limiting the spread of genital herpes. (Review) specific anti-viral agents, and the technique itself.
(39 refs). Scand Infect Dis (suppl.) 1996;100:20-5.
Mindel A, Weller IV, Faherty A, Sutherland S, Fiddian AP, Adler MW. Acyclovir in first attacks of genital herpes and prevention In conclusion, our study showed that HSV-2 was found in of recurrences. Genitouri Med 1986;62:28-32.
12% of patients with herpes genitalis, HSV-1 in 6% and Corey L. The current trend in genital herpes: progress in HSV-1 & 2 co-infection in 3%. Therefore, the most prevention. Sex Trans Dis 1994;21:S38-44.
common type of HSV causing herpes genitalis is HSV-2 Puthavathana P, Kanyok R, Horthongkham N, Roongpisuthipong A.Prevalence of herpes simplex virus infection in patients (57%), followed by HSV-1 (29%) and HSV-1 & 2 co- suspected of genital herpes; and virus typing by type specific infection (14%). The increased rate of HSV-1 is possibly fluorescent monoclonal antibodies. J Med Assoc Thai 1998 due to a change in sexual behavior of the patients especially with regards to oro-genital sexual contact.
Bhattarakosol P, Visaprom S, Sangdara A, Mungmee V. Increase of genital HSV-1 and mixed HSV-1 and HSV-2 infection inBangkok, Thailand. J Med Assoc Thai 2005 Sep;88 Suppl4:S300-4.
Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Autoimmune Bullous Diseases in Ipoh, Malaysia:
A 5-Year Retrospective Study

Tang MM, MD, MRCP, Chan LC, MD, MMed and Heng A, MBBS, MRCP
Department of Dermatology, Ipoh HospitalIpoh, Perak, Malaysia Correspondence
Agnes Heng, MRCP
Department of Dermatology
Ipoh Hospital, 30990 Ipoh, Malaysia
Email : agnesheng@gmail.com
Introduction
Autoimmune bullous diseases (ABD) represent a group of
Background Autoimmune bullous diseases (ABD) represent a group
chronic blistering dermatoses in which management is of chronic blistering dermatoses in which management is often often challenging. Broadly, it encompasses the pemphigus challenging. Epidemiologic data on these diseases in Malaysia has been group in which 2 major subtypes are recognized, namely, pemphigus vulgaris (PV) and pemphigus foliaceus (PF);and the subepidermal group which includes bullous Objectives Our purpose was to study the spectrum of the various
pemphigoid (BP), dermatitis herpetiformis (DH), linear ABD presented to the Department of Dermatology, Ipoh Hospital, IgA bullous dermatosis (LABD), and to determine the clinico-epidemiological pattern of the 2 main pemphigoides (LPP), epidermolysis bullosa aquisita (EBA), ABD, namely pemphigus and bullous pemphigoid.
cicatricial pemphigoid (CP), pemphigoid gestationis (PG)and bullous systemic lupus erythematosus (BSLE).
Methodology We performed a retrospective review of records for all
Epidemiologic data on these conditions in Malaysia has patients who were diagnosed with ABD confirmed by histopathology been limited. In 1992, a study carried out in a university- and direct immunofluorescence test in this centre between 2001 and based hospital in Malaysia on the epidemiology of ABD 2005. The data were analyzed with regard to age, sex, ethnicity, showed that pemphigus vulgaris was the commonest ABD subtypes of ABD, treatment provided and outcome.
encountered followed by bullous pemphigoid, with anincidence of 0.2/100,000/year and 0.12/100,000/year Results There were a total of 79 cases of ABD presented to us during
respectively1. The study also showed that Indians were this period. Bullous pemphigoid was observed to be the commonest more likely to develop ABD, especially BP, when compared (60.8%) followed by the pemphigus group (36.7%) with the mean to the other ethnic groups in Malaysia.
incidence of 0.45/100,000/year and 0.28/100,000/year respectively.
44% of patients were of ethnic Chinese origin. There was an overall We aim to study the spectrum of various ABD presented to female preponderance. The mean age of presentation was 65.5 years for the Dermatology Department, Ipoh Hospital, Malaysia and bullous pemphigoid and 55 years for pemphigus group. The mean to determine the clinico-epidemiological pattern of the 2 duration of disease before presentation was 1.6 months for bullous main ABD, namely pemphigus and bullous pemphigoid.
pemphigoid and 6.3 months for pemphigus. Various combinations ofimmunosuppressive agents were used to treat the patients. 48% of Materials and Methods
bullous pemphigoid cases were controlled with prednisolone alone The Department of Dermatology, Ipoh Hospital, is the while 67.9% of pemphigus group required at least 2 main referral centre for all dermatological diseases in the immunosuppressive agents to achieve disease control.
state of Perak, Malaysia, with a catchment area of about2.15 million populations. The ethnic mix of Perak's Conclusion In our study population, bullous pemphigoid was more
population between 2001 and 2005 comprised 53% Malay, frequently seen than pemphigus.
31.5% Chinese, 12.8% Indian and 2.7% others. In thisretrospective study, the case records of all patients diagnosed Keywords Autoimmune bullous diseases, bullous pemphigoid,
to have ABD in Ipoh Hospital between January 2001 and pemphigus vulgaris December 2005 were analyzed.
Patients with typical clinical and histopathological findingswere included. Diagnosis was further confirmed by directimmunofluorescence (DIF) test from perilesional skinbiopsy.
Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia biopsy. Various clinico-epidemiological characteristics achieve disease control was 3.8 months for BP and 13.6 including age, sex, ethnicity, duration of disease, treatment months for pemphigus.
provided and the outcome were analyzed for all cases.
Disease was considered controlled when the skin eruptions Among the 48 patients with BP, 11 (23%) died but none of were minimal while the patients were receiving treatment.
the deaths were directly related to their disease. The cause Remission was defined as no development of new lesions of death was due to other medical problems like and patients were able to taper down the cerebrovascular accidents, ischaemic heart disease, immunomodulators. The data findings were analyzed using complications of diabetes and malignancy. Of the 5 out of SPSS statistical analysis for Windows 10.
29 patients with pemphigus who died, 1 succumbed tosepsis while the others died of unrelated illnesses. None of the BP patients had active disease at the time of death and Over the 5 year period, 79 patients were diagnosed to have were on low dose corticosteroids.
ABD in which 48 (60.8%) had bullous pemphigoid (BP);29 (36.7%) pemphigus (pemphigus vulgaris (PV) -16, pemphigus foliaceus (PF) -11, pemphigus vegetans (PVG) Bullous pemphigoid was the commonest ABD seen at our -1 paraneoplastic pemphigus (PNP) -1); 1 (1.3%) linear centre, representing 60.8% of all cases. This is in contrast to IgA bullous dermatosis and 1 (1.3%) lichen planus the previous study done in Malaysia1 in which pemphigus pemphigoides. The racial distribution for all cases of ABD was more commonly encountered. The incidence rate of was as follows: 44% Chinese, 37% Malay and 16% Indian.
0.45/100,000/year and 0.28/100,000/year respectively for There was a female preponderance in both BP and BP and pemphigus is higher than previously thought.
pemphigus group with a male to female ratio of 1:1.53 and However, the true incidence of ABD in this region may be 1:1.8 respectively. The estimated incidence of BP in the higher than reported in this study as some cases may have state of Perak, Malaysia was 0.45/100,000/year whereas for been treated and followed up by dermatologists in private the pemphigus group was 0.28/100,000/year. The age of practice and hence, not captured in this study. Mild cases of patients at presentation ranged from 15 to 91 years; the BP with localized disease may have also been treated by mean age of presentation for BP and pemphigus was 65.5 primary care physicians and not reaching us. There may also years and 55 years respectively. Patients with BP appeared to be some referral bias; for example pemphigus confined to present earlier with the mean disease duration before first the oral mucosa may have been referred to the dentists and presentation of 1.6 months (range 0.3 – 12 months) for BP CP to the ophthalmologists. Furthermore, some cases could compared to 6.3 months (range 0.3 – 48 months) for the have been treated by traditional/complementary medicine pemphigus group (Table 1).
(TCM) practitioners instead as this is not an uncommonpractice among Malaysians. This could explain the lower Among the pemphigus cases, PV was the predominant incidence for both BP and pemphigus in this region as subtype seen in 16 patients followed by PF in 11 patients, compared to the incidence rate of other countries (Table 4).
pemphigus vegetans (PVG) in 1 patient and paraneoplasticpemphigus (PNP) in 1 patient. PV appeared to be more There was a predilection of ABD for ethnic Chinese which common among the Chinese (50%) while PF was more comprised 44% of all cases although they constitute only frequently seen among Malays (54.5%). The mean age of 31.5% of the Perak population during the study period. The presentation was 49.6 years for PV and 65.2 years for PF.
Malays, on the other hand, were less likely to develop ABD The mean duration of disease before presentation was 7.1 while the percentage of Indians affected corresponds to the months for PV and 6.7 months for PF (Table 2). One
ethnic distribution of this region. This, again, differed from patient presented with oral erosions for 4 years to various the result of an earlier study done in this country which doctors before the diagnosis of mucous membrane PV was showed a predilection of ABD for ethnic Indians1.
made while another patient with PF took 3 years before Although the incidence of ABD in the Malays was presenting to us. Our only patient with PNP was a 65 year relatively lower, it was observed that they were more old Malay female with non-Hodgkin's lymphoma stage 3B predisposed to develop PF where they made up of 54.5% of who succumbed to her disease even before treatment was all PF cases in this study (Table 2). The Singapore study
instituted. Majority of the PV patients had both oral noted an over-representation of PF in their Malay erosions and skin lesions while none of the PF patients had population, which constituted 25% of all PF cases studied when compared to their normal ethnic composition, ofwhich the Malays constitute 10%4.
Prednisolone was used alone or together with variouscombinations of immunomodulators to treat the ABD Although an equal sex predisposition has been reported in which included azathioprine, dapsone, cyclophosphamide, the previous Malaysian study1, we observed a female tetracycline and mycophenolate mofetil (Table 3). Majority
preponderance in both bullous pemphigoid (M:F = 1:1.53) of the pemphigus cases (67.9%) required at least 2 and pemphigus (M:F = 1:1.8). A similar observation was immunomodulators to treat while 47.9% of BP cases were also seen in Kuwait2,3. Singapore reported an equal sex controlled with prednisolone alone. The mean duration to Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Table 1. Comparison of characteristics between bullous pemphigoid and pemphigus
Bullous pemphigoid (n=48)
Incidence (per 100,000/year) Duration to diagnosis (months) Duration to disease control (months) No. of deaths over 5 years Table 2. Demographic data, treatment and course of disease in patients with pemphigus vulgaris and
pemphigus foliaceus
Duration of disease before diagnosis (months) Prednisolone alone Prednisolone + 1 adjuvant 6 (37.5%) 5 (45.5) Prednisolone + 2 adjuvants 5 (31.3%) 2 (18.2%) 1 (6.3%) 2 (18.2%) Course of disease Duration to disease control (months) No. of patients with disease controlled No. of patients in remission No. of patients with active disease No. of patients transferred to other centre No. of patients who died of disease/sepsis No. of patients who died of unrelated causes No. of patients lost to follow-up * lost to follow-up before treatment was instituted Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Table 3. Therapy for bullous pemphigoid and pemphigus
Combinations of Immunomodulators
(PV + PF+ PVG)
Prednisolone alone Prednisolone + Azathioprine Prednisolone + Tetracycline Prednisolone + Dapsone Prednisolone + Cyclophosphamide Prednisolone + Methotrexate Prednisolone + Azathioprine + Dapsone Prednisolone + Cyclophosphamide + Tetracycline Prednisolone + Azathioprine + Tetracycline Prednisolone + Mycophenolate +Tetracycline * 1 BP patient and 3 pemphigus patients defaulted follow-up before treatment was instituted. Table 4. Incidence of bullous pemphigoid and pemphigus in studies carried out in different regions of the
world
Incidence (per 100,000 per year)
Country and year of publication
Southern Saudi Arabia 200116 Current study (Perak, Malaysia) distribution in pemphigus4 but a striking female indirect immunofluorescence test at the time of the study preponderance (M:F = 1:2) in their BP patients5. Similar period and therefore some of the cases may have been female predominance was also observed in previous grouped together with BP since they share similar DIF pemphigus studies from Greece6 (M:F = 1:2.25 ), Turkey7 findings. We also did not have any cases of BSLE despite (M:F = 1:1.41) and Iran8 (M:F = 1:1.33). The factors SLE being a fairly common disease in this region. This responsible for this gender difference have yet to be could either be due to the incidence of BSLE being rare in this region or the cases were being treated byrheumatologists instead. We have had few cases of CP, PG While the Singapore study reported EBA to be their second and DH on our follow-up but no new cases during the 5 commonest subepidermal immunobullous disorder3, we had year study period. This finding is similar to the studies done none during our study period. This could be explained by in Singapore5 and China11 which reflects the rarity of these the fact that we did not have facilities for salt-split skin diseases in this region.
Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia The first line of treatment for all cases of ABD was with incidence rate is higher for both BP and pemphigus than oral prednisolone. Adjuvant therapy with various previously thought. Chinese are more predisposed to ABD, immunomodulators was added when prednisolone alone especially BP and PV, while PF is more common in Malays.
was not enough to achieve disease control. The choice for There is no evidence of a predilection for ethnic Indians as adjuvant therapy was azathioprine or dapsone as they are previously reported1. There is a female preponderance effective and relatively inexpensive. In the event of an among BP and pemphigus patients and a low occurrence of adverse drug reaction or poor response to these 2 other subepidermal blistering diseases like EBA, CP, DH, other drugs like methotrexate, PG and BSLE in our patients. These results provide a basis cyclophosphamide and mycophenolate mofetil were used on which future research activities in this region can be instead. Tetracycline was usually added as a third agent when 2 drugs were not adequate to control the disease. Wefound mycophenolate mofetil to be an effective adjuvant therapeutic agent in 2 of our pemphigus patients who hadfailed to respond the other conventional agents. In addition Adam BA. Bullous diseases in Malaysia: epidemiology and to systemic therapy, most of our patients also received natural history. Int J Dermatol 1992; 31: 42-45.
treatment with potent topical corticosteroids.
Nanda A, Dvorak R, Al-Saeed K, Al-Sabah H, Alsaleh QA. Spectrum of autoimmune bullous diseases in Kuwait. Int J Dermatol 2004, 43: 876-881 As expected, BP was easier to control compared to Alsaleh QA, Nanda A, Al-Baghli NM, Dvorak R. Pemphigus in pemphigus. About half of the BP patients (47.9%) achieve Kuwait. Int J Dermatol 1999; 38:351-356 disease control with prednisolone alone compared to only Goon A, Tan SH. Comparative study of pemphigus vulgaris and 25% of pemphigus patients. The duration to disease control pemphigus foliaceus in Singapore. Australasian J Dermatol 2001;42:172-5 was also shorter in BP compared to pemphigus, with a mean Wong SN, Chua SH. Spectrum of subepidermal immunobullous duration of 3.8 months and 13.6 months respectively (Table
disorders seen at the National Skin Centre Singapore: a 2-year 1). Although the number of deaths was higher in the BP
review. Br J Dermatol 2002; 147: 476-480.
group, all deaths were due to unrelated causes as most of the Michailidou EZ, Belazi MA, Markopoulous AK, et al. BP patients were older and had concomitant illnesses. It is Epidemiologic survey of pemphigus vulgaris with oral manifestation in northern Greece: Retrospective study of 129 noteworthy that none of them had active disease at the time patients. Int J Dermatol 2007; 46: 356-361 of death. This result is in keeping with a previous study Uzun S, Durdu M, et al. Pemphigus in the Mediterranean region done in Scotland9 which reported the first year mortality of Turkey: A study of 148 cases. Int J Dermatol 2006, 45, 523-528 rate of 25%. Most deaths were related to old age and the Salmanpour R, Shahkar H, Namazi MR, Rahman-Shenas MR. general condition of the patient and rarely due to BP itself.
Epidemiology of pemphigus in South Western Iran: A 10-year retrospective study (1991-2000). Int J Dermatol 2006; 45,103-105.
Another study from Germany10 demonstrated the first year Gudi VS, White MI, Cruickshank N, et al. Annual incidence and mortality rate of 29% and they attributed low serum mortality of bullous pemphigoid in the Grampian Region of albumin, high dosage of corticosteroids and old age as risk North-east Scotland. Br J Dermatol 2005; 153: 424-427.
factors for lethal outcome in BP.
Rzany B, Partscht K, Jung M et al. Risk factors for lethal outcome in patients with bullous pemphigoid: low serum albumin level, high dosage of glucocorticosteroids, and old age. Between PV and PF, PV appeared to be more difficult to Arch Dermatol 2002; 138: 903-8. control with about one third of them requiring 2 adjuvant Jin P, Shao C, Ye G. Chronic bullous dermotoses in China. Int J agents to achieve disease control. The duration needed to Dermatol 1993; 32: 48-52 achieve control was also longer. It is interesting to note that Bernard P, Vaillant L, Labeille B, et al. Incidence and distribution of subepidermal autoimmune bullous skin diseases in three our PF patients present at an older age (mean 65.2 years) French regions. Arch Dermatol 1995; 131: 48-52.
when compared to neighbouring Singapore4 (57 years) and Zillikens D, Wever S, Roth A, et al. Incidence of autoimmune Turkey7 (52 years). The reason for this is unclear but it could subepidermal blistering dermatoses in a region of central explain the higher mortality encountered in these patients.
Germany. Arch Dermatol 1995; 131: 957-958.
Mahé A, Flageul B, Cissé I, et al. Pemphigus in Mali. A study of 30 cases. Br J Dermatol 1996; 134: 114-119.
Tsankov N, Vassileva S, Kamarashev J, et al. Epidemiology of The results of our retrospective study demonstrate that BP pemphigus in Sofia, Bulgaria. A 16-year retrospective study is almost twice as common as pemphigus. This is (1980-1995). Int J Dermatol 2000; 39: 104–108.
comparable to reports from Singapore where they found BP Tallab T, Joharji H, Bahamdan K, et al. The incidence of pemphigus in Southern region of Saudi Arabia. Int J Dermatol to be three times more common than pemphigus5. The 2001; 40: 570-572.
Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia The effect of explanation and demonstration of topical
therapy on the clinical response of atopic eczema

Tang MM, MD, MRCP, Chan LC, MD, MMed and Heng A, MBBS, MRCP
Department of Dermatology, Ipoh Hospital, Ipoh, Perak, Malaysia Correspondence
Tang Min Moon, MRCP (UK)
Department of Dermatology
Ipoh Hospital, 30990 Ipoh, Perak, Malaysia
Email : minmoon2005@yahoo.com
evidenced by a further reduction to 67% (p=0.001) by week 4. In groupB, a significant SASSAD score reduction (64.8%; p=0.002) was seen Background Atopic eczema is a common dermatological condition
only at week 4 after patient education and demonstration. The seen in our practice in which the mainstay of treatment is topical magnitude of improvement in patients' symptoms which included itch, medications. One of the main reasons for poor clinical response to sleep disturbance and irritability, measured by the patient using visual therapy in atopic eczema is the lack of understanding of topical analog score, were only significant for group A after 4 weeks.
preparation usage and thus poor adherence to treatment.
Conclusions This study reinforces the importance of explanation and
Objectives The aim of this study is to determine the effect of
demonstration on the proper usage of topical medications in achieving explanation and demonstration of topical medication on the clinical better clinical response. Failure to explain on the use of topical response of atopic eczema.
medications may lead to patient dissatisfaction, poor compliance andlack of treatment efficacy.
Methodology Twenty newly diagnosed patients with atopic eczema
who fulfilled the study criteria were recruited and randomized
consecutively into 2 groups - A & B. All patients were assessed on the The cause of failure of response to therapy in many severity of the eczema using the six area, six sign atopic dermatitis dermatological skin conditions including atopic eczema is severity score (SASSAD) and patients' assessment of itch, sleep poor adherence, rather than severity of disease. This can disturbance and irritability were recorded on 10-cm visual analogue arise from a number of reasons, the most important of scales. They were also assessed on their level of understanding on the which is a lack of understanding of topical applications.
proper usage of topical medications using a questionnaire. Group A Other reasons include failure to renew prescriptions, under- then received explanation and demonstration on how to apply the prescribing, lack of faith in the treatment, or insufficient topical medications while Group B was not educated on these. They time to apply the medication. About 80% of our patients are were followed up 2 weeks after treatment and were re-evaluated on prescribed more than one topical medication at any one their understanding and the severity of their skin condition. This was time. Confusion with treatment may arise when patients are followed by education by a dermatology nurse on the proper usage of not educated on the proper usage of the various topical topical medications for both groups. A third evaluation was done 2 medications. So far there is no published record of any weeks later.
studies carried out in Malaysia to support the fact thatimproving patients' knowledge of proper topical application Results At baseline, 70% of the patients did not understand the
by explanation and demonstration will improve the potency of topical corticosteroid and between 20-30% of them did not outcome of treatment. Atopic eczema is chosen for this know the correct sites, frequency, time and duration of each topical study because it is one of the commonest conditions seen at application prescribed. About two thirds of the patients claimed that our clinic; the modality of treatment is mainly by topical they did not receive any explanation or demonstration from either their medications and the availability of a standard scoring doctors or the pharmacy dispensers. After education on the proper system of severity of disease.
usage of topical medications, the level of understanding improved to100% for group A at visit 2 and group B at visit 3. A clinical In this study, we aim to determine the effect of explanation improvement as measured by SASSAD score reduction was seen in and demonstration of topical medications by a trained both groups. In group A, a significant SASSAD score reduction of dermatology nurse on the clinical response of atopic 49.5% (P=0.003) was seen after 2 weeks and it was sustainable, as Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Materials and Methods
New patients who were diagnosed with moderate to severe A total of 20 patients participated in the study. At baseline, atopic eczema using the Hanifin and Rajka Criteria1 at the 60% of the respondents recalled not receiving any Dermatology Clinic Ipoh Hospital between February to demonstration from the doctors on how to apply the topical August 2006 were recruited into the study. Patients who treatments and 55% claimed that the dispensers did not give have had any previous consultations with a dermatologist or any explanation to them. 70% of the respondents did not at any dermatology department were excluded. Those who understand the potency of the topical corticosteroid have a skin disorder other than atopic eczema in the area to prescribed and between 20-30% of them did not know the be treated were also excluded from this study.
correct sites, frequency, time and duration of each topicalapplication prescribed.
Once the patients were enrolled, they were randomizedconsecutively into 2 groups, Group A and Group B. The Only 14 patients were followed till the end of the study, 7 severity of atopic eczema was determined by a global each for group A and B. The 6 patients who did not physician assessment using the Six Area, Six Sign Atopic complete the study were excluded from further analysis.
Dermatitis (SASSAD) severity score2 (Appendix 1). The
Out of the 6, 2 defaulted scheduled follow-up, 3 were not patients' assessments of itch, sleep disturbances and willing to spend additional time at the clinic for further irritability were recorded on 10-cm visual analogue scales.
assessment and explanation, and therefore left aftercollecting their medications from the pharmacy and 1 felt After consultation, a prescription was given to the patients that the skin lesion had improved and did not want further to collect their medications from the out-patient pharmacy.
consultation. After education on the proper usage of topical They were instructed to return to the clinic after collecting medications, the level of understanding had improved to their medications to fill up a study questionnaire assessing 100% for group A at visit 2 and group B at visit 3.
their knowledge about the treatment given by their doctors.
For patients below 17 years of age, their parents or Both groups showed a reduction in SASSAD score (clinical guardians responded to the questionnaire. Patients who did improvement) at Visit 2 and Visit 3 (Figure 1). A
not know how to read or write were interviewed by the significant reduction of 49.5% (p=0.003) in the severity of study nurse. Following that, Group A received explanation eczema was noted after 2 weeks (Visit 2) in Group A and a regarding their disease followed by demonstration on how further reduction of 67% (p=0.001) was noted after 4 weeks to apply the topical treatments by a trained nurse from the (Visit 3). In Group B, a significant reduction of SASSAD dermatology clinic. All their topical treatments were labeled score (64.8%; p=0.002) was only noted at week 4 (Table 1).
with cartoon and multi-languages stickers. Patientinformation leaflets regarding the disease and the topical For the improvement of symptoms based on visual analogue treatments which were available in 3 languages (English, scores, there was a reduction of score at every visit for both Malay, and Mandarin), were handed out to the patients.
groups (Figure 2, 3, 4). At the end of the study, there was a
Group B, on the other hand, did not receive additional significant improvement for itch, sleep disturbance and explanation or demonstration from the nurse.
irritability for group A whereas in group B, only the scorefor sleep disturbance showed significant reduction at Visit 3 Both groups of patients were reviewed after 2 weeks (Visit (Table 2).
2). All patients were re-assessed on their knowledge of thecorrect usage of topical treatments. The disease severity was again assessed using SASSAD score and patients' Due to the busy clinics and heavy workload, most doctors assessments using visual analogue scale. They were given the do not spend enough time explaining the nature of a disease same prescription as the first visit and were instructed to and the proper use of medications prescribed to their return to the clinic after collecting their medications from patients. Moreover, doctors tend to depend very much on the pharmacy. This time, all patients from both Group A the pharmacists or dispensers to teach patients on the usage and Group B were educated on the methods of application or administration of medications prescribed by them. In of their medications. This was again reinforced using addition, patient educational materials are also insufficient written instructions. Medications were labeled and for patients' reference after each consultation. Educating the information leaflets on the disease were also given.
patients or parents helps them to take charge of themanagement of their illness. One trial had demonstrated Both groups were followed up 2 weeks later (Visit 3) and that education and demonstration of treatment for atopic were re-assessed on their knowledge of the correct usage of eczema improved parents' knowledge and the outcome of topical treatments. The disease severity was assessed using their child's eczema3. Our current study is the first study SASSAD score and patients' assessments using visual done in Malaysia to support this finding.
analogue scale. All results were analyzed and interpretedusing SPSS program version 10.0.
From the literature review, only 5-20% of parents hadreceived or recalled receiving any explanation of the causesof eczema or demonstration on how to apply topicaltreatments and the side effects of the topicalcorticosteroids4, 5, 6. Thirty to 60% of patients who werefgfgfg Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Table 1. The Magnitude of SASSAD score reduction for Group A and B
% of reduction at Visit 2 (p value) baseline (p value) 49.5* (0.003) 35.2 (0.054) 67.3* (<0.001) 34 (0.043) 46.6 (0.03) 64.8* (0.002) Table 2. The Magnitude of Symptom Improvement using Visual Analog Score
baseline (p value) 51.9* (0.007) 45.8* (0.007) 43.3* (0.009) 58.1* (0.007) * Significant (p<0.01) Figure 1. Global Physician Assessment on the severity of Atopic Eczema using
Six Area, Six Sign Atopic Dermatitis severity Score (SASSAD)
Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Figure 2. Comparison of Mean Reduction of Itch between Group A and B
Figure 3. Comparison of Mean Reduction of Sleep Disturbances between Group
A and B
Figure 4. Comparison of Mean Reduction of Irritability between Group A and B
Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia prescribed topical corticosteroid were not aware of the demonstration was given to them (Table 1). Besides
potency and resulted in either over or under usage of the improvement in the disease severity, we also found that topical application5,7. Following repeated education and there was improvement in the patients' symptoms of itch, demonstration of topical therapies by a specialist sleep disturbances and irritability.
dermatology nurse, there was a 65% reduction in theseverity of the eczema (SASSAD severity score) after 3 The main limitation of this study is the small sample size.
The disease severity of Group A appeared to be milder thanGroup B at baseline. We felt that this randomization bias We had excluded patients from entry into this study if they was due to the small number of subjects in the study. In have had any previous consultation with any dermatology addition, the magnitude of symptom improvement of itch centre, in order to provide a population who had not been and irritability in Group B after education and exposed to a dermatologist or specialist dermatology nurse demonstration were not statistically significant as compared in the past. At the first visit, which reflected the usual to Group A (Table 2). This, again, could be due to the small
dermatology clinic consultation, majority of patients sample size.
claimed they received neither explanation nordemonstration on how to apply topical medications from At the end of the study, we noted that the key to the the doctors or dispensers at the pharmacy. After successful management of atopic eczema is to spend time to questioning, not all of them understood completely the listen and to explain the nature of disease and how to use correct use of topical medications. It is not possible to topical therapies and dressings. In addition to explanation, determine whether the lack of knowledge was due to failure practical demonstrations on how to apply topical of the healthcare providers in educating the patients/parents medications and dressings should be given to the patients or or because they had forgotten what they had been told.
parents. Patients or parents should also be given written Either way, one can conclude that at the end of a instructions and information to reinforce the therapies consultation, appropriate medications were given to the which have been explained and demonstrated. The quality patients but the information on the disease and proper of topical medications' labels could also be improved with usage of medications were not delivered to the patients.
the cooperation of the pharmacy department.
Our intervention included recruitment of a trained dermatology nurse to explain regarding the disease and to We found a positive effect of explanation and demonstrate to the patients and/or parents on how to apply demonstration of topical therapy on the clinical response of the topical medications. The patients were taught on the atopic eczema as evidenced by a significant reduction of correct time, frequency, sites of applications, duration of use disease severity score (SASSAD) as well as improvement in and the potency of the topical corticosteroid prescribed.
itch, sleep disturbances and irritability. This study reinforcesthe importance of having a trained dermatology nurse to As reinforcement, all the topical medications were labeled explain and demonstrate on proper usage of topical with multi-languages cartoon labels and patient applications in the management of atopic eczema. We information leaflets on atopic eczema available in 3 suggest that all dermatology clinics utilize the services of languages were also given to the patients. We also spent these nurses especially in cases when the doctors themselves some time answering to any queries from patients/parents.
cannot afford to spend more time with the patients due totheir busy schedule. Failure to explain on how to use topical There was an improvement in the disease severity in Group applications may lead to patient dissatisfaction, poor A as evidenced by a significant reduction of SASSAD score compliance and lack of treatment efficacy.
when proper education and demonstration on how to applytopical treatments were given during the first visit as compared to Group B, where the consultation was done in We thank the QAP committee of Ipoh Hospital in the usual manner but without further education or supporting this study and all the staff of the Department of demonstration. This significant reduction was reproducible Dermatology, especially staff nurse Kong Siew Hong, for in Group B at the third visit when similar education and their cooperation and commitment.
Appendix 1. The Six Area, Six Sign Atopic Dermatitis (SASSAD) severity score
Six Signs: Erythema, Exudation, Excoriation, Dryness, Cracking, and Lichenification Six Sites: Arms; Hands; Legs; Feet; Head & neck; and trunk Grade of severity (Range of score: 0-108) The sign cannot be detected with certainty even after careful inspection The sign is certainly present but requires careful inspection to see it The sign is immediately apparent The sign is very prominent Malaysian Journal Of Dermatology Jurnal Dermatologi Malaysia Basak PY, Ozturk M, Baysal V. Assessment of information and education about topical corticosteroids in dermatology outpatient departments: experience from Turkey. J Eur Acad Hanifin JM, Rajka G. Diagnostic features of atopic dermatitis. Dermatol Venerol 2003;17: 652-658 Acta Derm Venereol (Stockh) 1980; Suppl 92: 44-47.
Beattie PE, Lewis-Jones MS Parental knowledge of topical Berth-Jones J. Six area, six sign atopic dermatitis (SASSAD) therapies in the treatment of childhood atopic dermatitis. Clin severity score: a simple system for monitoring disease activity Exp Dermatol 2003; 28: 549-553.
in atopic dermatitis. Br J Dermatol 1996; 135: 25-30.
Charman C.R., Morris A.D., Williams H.C. Topical corticosteroid Broberg A, Kalimo K, Lindblad B et al. Parental education in the phobia in patients with atopic eczema. Br J Dermatol 2000; 142: treatment of Childhood atopic eczema. Acta Derm Venereol (Stockh) 1990;70: 496-9.
Cork MJ, Britton J, Butler L et al. Comparison of parent knowledge, therapy utilization and severity of atopic eczema before and after explanation and demonstration of topical therapies by a specialist dermatology nurse. Br J Dermatol 2003;149: 582-589.

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Journal of Engineering and Technology DEVELOPMENT OF SIMVASTATIN PRODUCTION BY MONASCUS PURPUREUS IN SOLID-STATE FERMENTATION USING AGRICULTURAL PRODUCT Faculty of Chemical and Natural Resources Engineering, Universiti Malaysia Pahang, 25000, Kuantan, Pahang, Malaysia ABSTRACT Monascuspurpureus is a non-pathogenic fungus that can produce statin called simvastatin, which can lower blood cholesterol level. The objectives of this research were to explore the potential of agricultural product on simvastatin and identify the optimal condition of simvastatin production in solid-state fermentation by Monascuspurpureus FTC 5356. The local agricultural products used were banana, guava, pumpkin, coconut meat, corn and papaya. Initially, the local agricultural products were ground and the initial moisture content of the agricultural products was fixed at 50% and pH 6. The mixtures were then incubated at 30°C for 11 days. Later, variety conditions of initial moisture content and nitrogen supplementation were introduced and examined on the simvastatin. Further experimental work was carried out using Central Composite Design (CCD) of Response Surface Methodology (RSM), with two factors of initial moisture content and nitrogen source. The results suggested that, among the agricultural products tested; only corn powder was able to produce simvastatin. The optimal condition for simvastatin production on corn was at 50% initial moisture content with supplementation of 0.2% nitrogen source.