Acneiform Disorders

Acneiform eruptions are a group of disorders, which are characterised by papules and pustules resembling Acne Vulgaris. It has an acute onset and can affect any age group. The characteristic lesion may be a papule, pustule, nodule or a cyst.

ACNE VULGARIS

Acne vulgaris is a common chronic skin disease involving blockage and/or inflammation of pilosebaceous units (hair follicles and their accompanying sebaceous gland). Acne can present as non-inflammatory lesions, inflammatory lesions, or a mixture of both, affecting mostly the face but also the back and chest.

Acne most often affects the face, but it may spread to involve the neck, chest and back, and sometimes even more extensively across the body. Individual lesions are centred on the pilosebaceous unit, i.e. the hair follicle and its associated oil gland. Several types of acne spots occur, often at the same time. They may be inflamed papules, pustules and nodules; or non-inflamed comedones.

Causes of Acne:

• The skin of an acne-prone person reacts to an increase in male hormone levels during puberty to produce excess sebum, leading to oil glands being blocked and formation of comedones – blackheads/whiteheads.
• Acne may stay largely comedonal in some patients, while in others progress to include inflammatory lesions such as papules, pustules, nodules and cysts.
• The release of chemicals by bacteria in the deeper part of hair follicles and beneath sebum blockage releases other chemicals leading to an inflammatory cascade that causes skin around hair follicles to become red and inflamed.
• In severe cases, large painful swellings called nodules and cysts may occur, leading to significant acne scarring.

ROSACEA

Rosacea is a chronic and relapsing inflammatory disorder principally affecting the central face (i.e. forehead, cheeks, nose and chin). It may be transient, or recurrent and persistent, and is typically characterised by its red colour.

Rosacea results in papules and sometimes pustules which are dome-shaped rather than pointed. Unlike acne, there are no blackheads, whiteheads, or nodules.

It is most commonly seen in adults over 30 years of age with female preponderance. However males are more likely to develop rhinophyma. Several hypotheses include vascular abnormalities, innate system dysfunction, microorganisms e.g. demodex follliculorum and environmental factors.

Rosacea may even involve other areas such as the eyes (Ocular Rosacea) in 50% of the cases.

ALLERGIES

An allergy is an abnormal response of the body to a foreign body, known as an “antigen”. This involves the immune system recognising this antigen and mounting one of a few types of response.

Most allergic reactions are mild to moderate, and do not cause major problems. However, some people may experience a severe allergic reaction called anaphylaxis which requires immediate lifesaving medication. Allergens which may cause anaphylaxis include foods, insects and medications.

Some of the most common skin problems that can be triggered by allergy include atopic dermatitis (eczema) and urticaria (hives). A few of the common types of allergies that dermatologists commonly see are discussed below:

Allergic contact dermatitis (contact allergy)

Allergic contact dermatitis is a form of eczema that is caused by an allergic reaction to a material which comes into contact with the skin. The allergen is usually harmless to people who are not allergic to it.

Allergic contact dermatitis usually arises hours after contact with the responsible material. It settles down over the course of a few days providing the skin is no longer in contact with the allergen.

Allergic contact dermatitis is also generally confined to the site of contact with the allergen, but may extend outside the contact area or become generalised.

Common examples of this include:

• Metals (eg nickel) found in some jewellery items and watches
• Fragrances in perfumes and cosmetic products
• Rosin found in adhesive plasters causing “plaster allergy”
• Paraphenylene diamine in permanent hair dye leading to rashes over the face and neck

Food allergy

Foods that commonly cause allergy include peanuts, dairy products, eggs and seafood. As infants are given formula milk, cow’s milk allergy may develop and this can cause eczema, asthma, and stomach upset.

Food allergy is due to an immunological reaction to a food protein that can be either immediate (occurring seconds to minutes after eating or touching the food item), or delayed (occurring hours or days later).

Food allergy is most common in young babies (4%), who most often outgrow their allergies. About 2% of adults also suffer from an allergy to one or more foods. The tendency to food allergy runs in families.

BENIGN SKIN GROWTHS

Many people suffer from lumps or bumps on the surface of their skin or deeper in the skin layers. Whilst many of these growths may be benign, some of them may occasionally be malignant. When it comes to your skin, it is always better to be safe than sorry. It is therefore advisable to first consult your trained, board-certified dermatologist for an accurate diagnosis before deciding on the most suitable management for both medical and cosmetic reasons.

Some common benign skin growths such as moles, skin tags, seborrhoeic keratosis, sebaceous hyperplasia, syringomas, lipomas, and epidermal cysts are discussed below.

Skin tags

Skin tags are harmless skin-coloured or brown growths, which commonly occur on the neck, underarm, groins and eyelids. They vary in size from less than 1 mm to pedunculated ones that can be as large as 1cm. They are usually asymptomatic and often occur as multiple lesions.

Skin tags can be easily removed after the application of topical anaesthesia by snip excision with electrocautery or CO2 laser. This can be done on the same day at our clinic with on-site surgical facilities. After the procedure, there will be small scabs which heal in 1-2 weeks.

Seborrhoeic keratosis (age spots)

These lesions are superficial skin overgrowths which appear in increasing numbers with age. They are typically brown and slightly raised in the early stages but may become fairly large, darkly pigmented and more raised over time. They are commonly located on the face, scalp, trunk and limbs.

Cosmetic removal of seborrhoeic keratoses can be performed in a variety of ways. Early flat seborrhoeic keratoses can be treated with pigment laser, or liquid nitrogen. Raised seborrhoeic keratoses are best treated with electrocautery or CO2 laser.

Sebaceous hyperplasia

Sebaceous hyperplasias are yellowish lesions often seen on the face starting in middle-age. They have a characteristic central dimpling and are due to a proliferation of oil glands just below the surface of the skin.

Sebaceous hyperplasia may be treated with electrocautery or CO2 laser. These treatments will flatten the lesions but there may be a gradual recurrence of the lesions over time.

Syringoma

Syringomas are benign tumours due to the abnormal proliferation of sweat ducts in the skin. They are flesh coloured papules, often located just below or around the eyes. A family history may be present.

Syringomas may be treated with CO2 laser or electrocautery. The treatment will flatten the lesions but there is a risk of recurrence of the lesions over time.

Lipomas

Lipomas are benign fat tumours that are often located in the subcutaneous tissues of the head, neck, shoulders, trunk and limbs. They are slow-growing and usually present as non-tender, round, mobile masses with a soft doughy feel.

Lipomas can be left alone but can be surgically removed with an excision done under local anaesthesia at our on-site surgical facilities. Lipomas are usually removed through a small incision made in the skin that is overlying. The incisions are usually smaller than the underlying tumor, and the lipoma is dissected and delivered through the incision made. The incision is then stitched up with fine sutures which can be removed between 7-14 days depending on the location of the surgery.

Epidermal cysts (sebaceous cysts)

Epidermal cysts are smooth, dome shaped bumps that occur beneath the skin, and are often seen on the face, scalp or trunk. A strong-smelling cheesy material can sometimes be expressed. These will not disappear without treatment and typically grow in size over time. They occasionally also become inflamed or infected. It is thus best to remove these cysts before symptoms occur or worsen. Epidermal cyst removal is a very safe procedure that can be done on the same day at our clinic with on-site surgical facilities.

Prior to any treatment, Dr Yong who is a dual fellowship-trained dermatological surgeon will first assess your condition and thoroughly discuss your options before you make any decision on surgery.

Epidermal cysts are usually removed via a minimal excision technique. Following local anaesthetic injection to the treatment area, Dr Yong usually makes as small a cut that is feasible on the surface of the skin which will allow for the entire cyst with its cyst wall and contents to be teased out gently. The resulting scar is usually small and cosmetically pleasing. Instead of simply squeezing out or draining the contents of the cyst, this excision method results in a very low rate of recurrence.

Should your epidermal cyst be infected, and swollen, Dr Yong usually recommends first treating with antibiotics, or drainage. She recommends treating the inflammed cyst first so that scarring is reduced during the surgery. This will also allow her to remove most of the cyst wall once the inflammation resolves, and will lower the risk of recurrence.

In summary, some of the procedures we commonly use to remove lumps and bumps at our clinic with on-site surgical facilities include:

• Cryotherapy
• Electrocautery
• Co₂ laser
• Surgery

This can all be done on the same day as your appointment to ensure the utmost convenience for you.

Dr Angeline Yong is a consultant dermatologist and dermatological surgeon whose subspecialty interests includes dermatological and laser surgery, and Mohs Micrographic Surgery. As a UK and USA dual fellowship-trained dermatological surgeon, you can be rest assured that you are in good hands. Dr Yong is well-skilled to deliver comprehensive, wholistic and tailored care when it comes to the management of various benign skin growths.

CONGENITAL BIRTHMARKS

There are varying types of birthmarks, but they typically fall into one of two categories, and can be classified as a pigmented or vascular birthmark. Pigmented birthmarks occur when there’s an overabundance of pigment cells in one area. Pigment cells are what give your skin its natural colour.

One of the most common forms is the congenital nevi (mole). This is formed by a proliferation of benign melanocytes present at birth or developing shortly after birth, and is also known as a brown birthmark. It is caused by localised genetic abnormalities resulting in the proliferation of melanocytes, which are the cells in the skin responsible for normal skin colour.

This proliferation usually occurs between the 5^th and 24^th weeks of gestation. If proliferation appears early in development, giant and medium-sized congenital melanocytic naevi are formed. Smaller congenital melanocytic naevi are formed later during development after the melanoblasts (immature melanocytes) migrate from the neural crest to the skin.

In some cases, there is also overgrowth of hair-forming cells and epidermis, forming an organoid naevus.

PORTWINE STAINS

A discoloration of the human skin caused by a vascular anomaly (a capillary malformation in the skin), a portwine stain is a vascular malformation that is typically present at birth. It does not regress and lesions may become darker and thicker over time. It typically also has a unilateral or segmental distribution respecting the midline. It may be associated with underlying syndromes.

Early treatment with pulsed dye laser yields better clearance than delayed treatment.

CUTANEOUS INFECTIONS

Cutaneous fungal infections are non-invasive infections of the skin, hair and nails causing pathologic changes in the host. The fungi can be yeast-like, causing infections such as Candidiasis, or mould-like, causing Tinea infections. It is common and generally mild. However, in extreme cases or otherwise immune suppressed patients, fungi can cause severe disease.

ATHLETE’S FOOT

Also known as Tinea Pedis, it is one of the most common fungal infections of the skin. Typically affecting the skin over the toe webs and foot soles, the infection tends to become scaly and peels, causing itchy skin with occasional appearance of small blisters. It may also concurrently affect the toenails.

HERPES ZOSTER

Herpes zoster (commonly known as shingles), is a localised, blistering and painful rash caused by reactivation of varicella-zoster virus (VZV). It is characterised by Dermatomal distribution – blisters confined to the cutaneous distribution of one or two adjacent sensory nerves.

Typically unilateral, with a sharp cut-off at the anterior and posterior midlines, patients previously affected by varicella (chicken pox) may subsequently develop zoster.

Commonly affecting adults, particularly older people, Zoster can sometimes also occur in children. It usually affects people with a weak immune system, especially cancer patients. It also occurs in individuals under high-stress or patients undergoing treatments suppressing the immune system.

Common symptoms:

• Pain or tingling sensation
• Extreme sensitivity in the affected area of the skin
• Blister formation on a red base lasting for up to 2-3 weeks

Ingestion of antiviral drugs helps reduce risk of post-herpetic neuralgia. Shingles is less contagious than chicken pox, however patients with blisters can spread it via contact with a susceptible person.

MOLLUSCUM CONTAGIOSUM

A common viral skin infection affecting children, Molluscum Contagiosum causes localised clusters of pearly spherical papules called mollusca. Typically presents as single or multiple painless, spherical, pearly white papules that classically has a central dimple. Crops of Molluscum may appear intermittently for several months and sizes may vary from tiny 1mm papules to larger nodules over 1cm in diameter.

Usually painless, it tends to disappear on its own and rarely leaves any visible scars when left untreated. The length of time varies for each person, but the bumps can remain on the skin from two months to four years.

Typically spread by direct contact with an infected patient, auto-inoculation into another site by scratching or shaving, or by touching an object contaminated with the virus, such as a towel or piece of clothing.

Diagnosis is clinical and treatment options include expectant management, ablative treatment with prick and expression, liquid nitrogen or topical treatment.

RINGWORM

A common term for superficial fungal infection of the skin, Ringworm appears as a scaly, red, round patch with a tendency to form rings. It is known as Tinea Corporis when it affects the body and Tinea Cruris when it affects the groin. Ringworm also affects the scalp (mainly in children) and is called Tinea Capitis.

VIRAL WART

A very common growth of the skin caused by infection with human papillomavirus (HPV). A wart is also called a verruca. It can grow on any part of the body, including the face, the forearms or the finger and toes. Warts usually create a rough surface on which tiny, dark dots appear. Pressure areas such as the palms or the soles appear flat. Warts on the sole (called plantar warts) grow inward from the pressure of standing and walking and are often extremely painful.

Warts are particularly common in:

• Growing children, but it tends to occur at all ages.
• Individuals suffering from eczema, due to a defective skin barrier.
• Individuals with a suppressed immune system due to medications such as Azathioprine or Ciclosporin, or with human immunodeficiency virus (HIV) infection. In these patients, warts may never disappear — despite treatment.

WHITE SPOTS

A common superficial fungal infection of the skin known as Tinea Versicolor, it usually appears as an itchy scaly rash that can variably be white, pink or brown. It has a predilection for the back, neck, chest and upper limbs. Excessive sweating usually aggravates it.

ECZEMA & ECZEMATOUS DISORDERS

Eczema is a condition where patches of skin are inflamed, itchy, red, cracked, and rough. The term “eczema” is used interchangeably with the word “dermatitis” and refers to an inflammation of the skin.

ATOPIC DERMATITIS

Atopic dermatitis is a chronic, itchy skin condition very commonly seen in children but affects people of all ages. Atopic dermatitis usually affects people having an ‘atopic tendency’. People having this tendency may develop any or all three closely linked conditions; Atopic dermatitis, Asthma and hay fever (Allergic Rhinitis). A family history of asthma, eczema or hay fever is particularly useful in diagnosis of Atopic dermatitis in infants.

Atopic dermatitis arises because of a complex interaction of genetic and environmental factors. This includes defects in skin barrier function making the skin more susceptible to irritation by soap and other contact irritants, the weather, temperature and non-specific triggers. There is quite a variation in the appearance of Atopic dermatitis between individuals. Over time, most people have acute flares with inflamed, red, sometimes blistered and weepy patches. In between flares, the skin may appear normal or suffer from chronic eczema with dry, thickened and itchy areas.

At present, there is no permanent cure for Atopic eczema but the skin condition can be improved and controlled with appropriate skin care and the use of medications. Atopic eczema may also improve, as children get older, but may still occur sometimes during adulthood.

CONTACT DERMATITIS

Contact dermatitis (also called contact eczema) refers to a group of skin disorders in which the skin reacts due to direct contact with an exogenous causative agent. It can be acute (a single episode) or chronic (persistent).

The two main types of contact dermatitis are:

• Irritant contact dermatitis
• Allergic contact dermatitis

Irritant contact dermatitis is typically caused by exposure to substances such as detergents, bleach and engine oils. However, an excessive exposure to water alone can cause irritant contact dermatitis, with one of the main causes being frequent hand washing.

Allergic contact dermatitis is caused by a specific hyper-sensitivity to substances such as hair dye, fragrance and metals like nickel. A patch test is usually done to identify any suspected allergen.

Contact dermatitis is often mixed in origin, particularly when it results in hand dermatitis. Contact dermatitis is the most common cause of occupational skin disease, particularly in cleaners, healthcare workers, food handlers, caterers and hairdressers. Avoiding the irritant or allergen should lead to improvement.

DISCOID ECZEMA

Discoid Eczema occurs typically with distinctive scaly, coin-shaped patches that are very itchy and may even be weepy. Often mistaken as a fungal rash, it usually occurs on the limbs of young adults.

SEBORRHOEIC DERMATITIS

Most commonly seen in babies (Usually clears up by 2 months of age), Seborrhoeic dermatitis also affects adults with a more chronic/relapsing form of eczema/dermatitis that mainly occurs in the sebaceous, gland-rich regions of the scalp, face, and trunk. Dandruff is a non-inflammatory, milder version of Seborrhoeic dermatitis.

Causes of Seborrhoeic Dermatitis:

• Proliferation of various species of the skin commensal Malassezia, in its yeast (non-pathogenic form).
• In infants, the condition is related to developing oil glands.
• In adults, the condition occurs due to an inflammatory reaction to overgrowth of Malassezia yeasts.

Infantile Seborrhoeic dermatitis causes cradle cap (diffuse, greasy scaling on scalp), and the rash may also affect armpit and groin folds. Typically there are salmon-pink patches that may flake or peel, and these are not particularly itchy, so babies often seem undisturbed by the rash, even when generalised.

HYPERPIGMENTARY DISORDERS

FRECKLES

Freckles are small light brown flat spots on your skin, often in areas that are affected by sun exposure such as the cheeks and nose. It is usually present when young and develops with ageing and sun exposure. In most cases, freckles are harmless. It appears as a result of overproduction of melanin, which is responsible for skin and hair colour (pigmentation). Overall, freckles come from ultraviolet (UV) radiation stimulation.

HORI’S NAEVUS

A pigmentary disorder typically affecting Asian women between the ages of 30s-50s, it appears as discrete brown to grey spots across the upper cheeks. As the pigmentation is relatively deep within the skin, treatment with creams is less effective. Hori’s naevus however can be effectively treated with pigment lasers although multiple sessions are required.

MELASMA

A common skin problem that causing brown to grey-brown ill-defined patches, usually on the face. Melasma is a predominant issue amongst Asians, with women being more commonly affected than men.

Typically appearing on cheeks, forehead, chin, and above the upper lip, it can also be found on other parts of the body that get lots of sun, such as the forearms and neck.

Melasma results from the complex interplay of genetic, hormonal and UV factors; hence deterioration is often reported after sun exposure, during pregnancy (known as the mask of pregnancy), and the use of oral contraceptives.

It is difficult to treat, as recurrence and relapse rates are high. Adequate sun protection along with a combination of various modalities which includes topical lightening creams, chemical peels, intense pulsed light, low-fluence pigment lasers and oral medications can be used for treatment.

SOLAR LENTIGINES

Lentigines are brown flat lesions with a clearly defined edge. The most common type, solar lentigines, occurs during middle age as a result of sun damage. Most often found on face and hands, it is larger and more defined than freckles. Some lesions may slightly thicken over time.

Solar lentigines are caused by exposure to ultraviolet radiation from the sun. It is common in people over the age of 40, but younger people are also susceptible. It happens when UV radiation causes pigmented cells called melanocytes in the skin to multiply. Solar lentigines are harmless and do not turn malignant. It can be left untreated or can be removed for aesthetic reasons.

Prevention is possible through regular usage of a broad-spectrum sunscreen and sun protection. It can be treated with lightening creams, intense pulsed light therapy or pigment lasers.

HYPERHIDROSIS

Hyperhidrosis is the name given to excessive and uncontrollable sweating. Sweat is produced by the eccrine sweat glands which are distributed over the entire body but are most numerous on the palms and soles.

Primary hyperhidrosis is reported to affect 1–3% of the population and nearly always starts during childhood or adolescence. The tendency may be inherited, whereas secondary hyperhidrosis which is due to endocrine or neurological conditions is less common and can present at any age.

Hyperhidrosis can also be classified as localised or generalised. Localised hyperhidrosis can affect the armpits, palms, soles, face or other sites; and generalised hyperhidrosis affects most or all of the body.

Axillary hyperhidrosis

• Clothing becomes damp and must be changed several times a day
• Wet skin folds are prone to irritation and infection

Palmar hyperhidrosis

• Slippery hands lead to avoidance of handshaking
• Difficulty in writing
• Difficulty in using certain equipment such as keypads and playing instruments like the piano
• Prone to a blistering type of hand eczema

Plantar hyperhidrosis

• Affects soles of the feet
• Leads to an unpleasant smell
• Prone to a blistering type of foot eczema
• Prone to secondary infection like fungal and bacterial infection

Treatment options

There are various treatment options available, and this includes:

• Topical antiperspirants
• Iontophoresis
• Oral medications
• Botulinum toxin injections which can be injected freehand, or done needle-free using the EnerJet delivery system. The EnerJet system at AYD delivers therapeutic substances such as botulinum toxin into the dermis via a high-pressure liquid jet which is almost pain-free unlike more traditional needle injections.

All the above treatments are available at AYD. Dr Angeline Yong will first evaluate your condition and lifestyle needs, and together with you, formulate a treatment plan which is most suitable for your needs.

HYPO & DE-PIGMENTARY DISORDERS

IMMUNODERMATOLOGY

KELOIDS & HYPERTROPHIC SCARS

KELOIDS

A type of raised scar representing an excessive tissue response to dermal injury characterised by local fibroblast proliferation and overproduction of collagen, these scars occur where skin has healed after injury and can grow to be much larger than the original injury that caused the scar.

Burn marks, cuts, or severe acne can also develop into a keloid. However, it has been observed that keloids usually occur due to a combination of genetic predisposition coupled with skin injury.

Other risk factors include skin tension and they also have a higher rate of forming over sites of predilection such as the upper chest, shoulders and jawline. A keloid scar is a firm, smooth, hard growth due to spontaneous scar formation. It can appear soon after an injury, or develop months later. Keloids may be uncomfortable or itchy and extend well beyond the original wound.

HYPERTROPHIC SCARS

Appearing clinically similar to keloids, these types of scars remain confined within the wound area. As wounds appear to heal, scar tissue forms, which at first is often red and prominent. Over months, the scar usually tends to flatten and pale. However, in case of severe tension on the healing wound, the area becomes thicker, causing a hypertrophic scar.

Both keloids and hypertrophic scars can be treated with varying modalities such as topical silicone gels and sheets, intralesional steroid injections, pulsed dye laser, CO2 laser and in very select cases excision. Surgery to remove keloid scars is not commonly recommended as there is a risk of recurrence and the scar may aggravate over time. It is best to consult a doctor regarding the options before deciding on the best approach.

MOLES & HYPERTROPHIC SCARS

MOLES & HYPERTROPHIC SCARS

A type of raised scar representing an excessive tissue response to dermal injury characterised by local fibroblast proliferation and overproduction of collagen, these scars occur where skin has healed after injury and can grow to be much larger than the original injury that caused the scar.

Burn marks, cuts, or severe acne can also develop into a keloid. However, it has been observed that keloids usually occur due to a combination of genetic predisposition coupled with skin injury.

PEDIATRIC DERMATOLOGY

ATOPIC DERMATITIS

Atopic dermatitis is a chronic, itchy skin condition very commonly seen in children but affects people of all ages. Atopic dermatitis usually affects people having an ‘atopic tendency’. People having this tendency may develop any or all three closely linked conditions; Atopic dermatitis, Asthma and hay fever (Allergic Rhinitis). A family history of asthma, eczema or hay fever is particularly useful in diagnosis of Atopic dermatitis in infants.

Atopic dermatitis arises because of a complex interaction of genetic and environmental factors. This includes defects in skin barrier function making the skin more susceptible to irritation by soap and other contact irritants, the weather, temperature and non-specific triggers. There is quite a variation in the appearance of Atopic dermatitis between individuals. Over time, most people have acute flares with inflamed, red, sometimes blistered and weepy patches. In between flares, the skin may appear normal or suffer from chronic eczema with dry, thickened and itchy areas.

At present, there is no permanent cure for Atopic eczema but the skin condition can be improved and controlled with appropriate skin care and the use of medications. Atopic eczema may also improve, as children get older, but may still occur sometimes during adulthood.

CONGENITAL BIRTHMARKS

There are varying types of birthmarks, but they typically fall into one of two categories, and can be classified as a pigmented or vascular birthmark. Pigmented birthmarks occur when there’s an overabundance of pigment cells in one area. Pigment cells are what give your skin its natural color.

One of the most common forms is the congenital nevi (mole). This is formed by a proliferation of benign melanocytes present at birth or developing shortly after birth, and is also known as a brown birthmark. It is caused by localised genetic abnormalities resulting in the proliferation of melanocytes, which are the cells in the skin responsible for normal skin colour.

The proliferation usually occurs between the 5^th and 24^th weeks of gestation. If proliferation appears early in development, giant and medium-sized congenital melanocytic naevi are formed. Smaller congenital melanocytic naevi are formed later during development after the melanoblasts (immature melanocytes) migrate from the neural crest to the skin.

In some cases, there is also overgrowth of hair-forming cells and epidermis, forming an organoid naevus.

EPIDERMAL NEVUS

An epidermal nevus is an abnormal, noncancerous (benign) patch of skin caused by an overgrowth of cells in the outermost layer of skin (epidermis). Epidermal nevi are typically seen at birth or develop during early childhood. Affected individuals show signs of one or more nevi that vary in size. Lesions are present at birth or develop during childhood (mostly in the first year of life). The abnormality arises from a defect in the ectoderm (the outer layer of the embryo that gives rise to epidermis and neural tissue).

Epidermal naevi are distributed along the lines of Blashko. These lines are the tracks taken by groups of genetically identical cells in the developing embryo. Skin cells that have the active abnormal gene spread out to form the epidermal naevus, whereas the remaining skin cells form the other areas of apparently normal skin.

MOLLUSCUM CONTAGIOSUM

A common viral skin infection affecting children, Molluscum Contagiosum causes localised clusters of pearly spherical papules called mollusca. Typically presents as single or multiple painless, spherical, pearly white papules that classically have a central dimple. Crops of Molluscum may appear intermittently for several months, and sizes may vary from tiny 1mm papules to larger nodules over 1cm in diameter.

Usually painless, it tends to disappear on its own and rarely leaves any visible scars when left untreated. The length of time varies for each person, but the bumps can remain on the skin from two months to four years.

Typically spread by direct contact with an infected patient, auto-inoculation into another site by scratching or shaving, or by touching an object contaminated with the virus, such as a towel or piece of clothing.

Diagnosis is clinical and treatment options include expectant management, ablative treatment with prick and expression, liquid nitrogen or topical treatment.

SEBORRHOEIC DERMATITIS

Most commonly seen in babies (Usually clears up by 2 months of age), Seborrhoeic dermatitis also affects adults with a more chronic/relapsing form of eczema/dermatitis that mainly occurs in the sebaceous, gland-rich regions of the scalp, face, and trunk. Dandruff is a non-inflammatory, milder version of Seborrhoeic dermatitis.

Causes of Seborrhoeic Dermatitis:

• Proliferation of various species of the skin commensal Malassezia, in its yeast (non-pathogenic form).
• In infants, the condition is related to developing oil glands.
• In adults, the condition occurs due to inflammatory reaction to overgrowth of Malassezia yeasts.

Infantile Seborrhoeic dermatitis causes cradle cap (diffuse, greasy scaling on scalp), and the rash may also affect armpit and groin folds. Typically there are salmon-pink patches that may flake or peel, and these are not particularly itchy, so babies often seem undisturbed by the rash, even when generalised.

PRE-CANCEROUS GROWTHS

ACTINIC KERATOSIS

An actinic keratosis is a rough, scaly patch on the skin that develops from years of sun exposure. It is most commonly found over the face, ears, forearms and scalp.

An actinic keratosis enlarges slowly and usually causes no signs or symptoms other than a non-healing, persistent patch on your skin. These patches take years to develop, and reflect a history of sun exposure.

A small percentage of actinic keratosis lesions can eventually become skin cancer. Hence it is important to reduce your risk of actinic keratoses by minimizing your sun exposure and protecting your skin from ultraviolet rays.

Symptoms

The signs and symptoms of an actinic keratosis include:

• Rough, dry, scaly patch of skin
• Colour as varied as pink, red or brown
• In some cases, a hard, wart-like surface

When to see a doctor

It can be difficult to distinguish between noncancerous spots and cancerous ones. So it’s best to have new skin changes evaluated by a doctor — especially if a spot or lesion persists, grows or bleeds.

Complications

If treated early, almost all actinic keratoses can be removed before they develop into skin cancer. If left untreated, some of these spots may occasionally progress to squamous cell carcinoma (SCC) — a type of cancer that usually isn’t life-threatening if detected and treated early. It is rare for a solitary actinic keratosis to evolve to SCC, but the risk of SCC occurring at some stage in a patient with more than 10 actinic keratoses is thought to be about 10 to 15%. A tender, thickened, ulcerated or enlarging actinic keratosis is suspicious of SCC.

Prevention

Prevention of actinic keratoses is important because the condition can precede cancer or be an early form of skin cancer. Sun safety is necessary to help prevent development and recurrence of actinic keratosis, and this can come in the form of limiting your time in the sun, wearing tightly woven clothing that covers your arms and legs, wearing a broad-brimmed hat to protect the scalp and face, and also regular re-application of a broad-spectrum sunscreen when outdoors. It is also important to check your skin regularly and report any changes to your doctor such as the development of new skin growths or changes in existing moles, pigmented lesions and birthmarks.

Treatment

Actinic keratosis can be treated in a variety of ways such as cryotherapy, topical creams, photodynamic therapy, curettage with electrosurgery, and ablative lasers. At Angeline Yong Dermatology, a range of options are available for the treatment of actinic keratosis, and Dr Yong will partner you to come up with a treatment plan that best suits the type of lesion and location involved, your skin phototype and also your personal and lifestyle preferences.

SQUAMOUS CELL CARCINOMA-IN-SITU (BOWEN’S DISEASE)

This is a very early form of skin cancer that is easily treatable (i.e. early form of SCC), where the malignant cells are only located within the upper layer (epidermis) of the skin and has not yet spread into the deeper ones. It typically presents as a scaly raised red plaque, which does not respond to treatment.

Treatment options depend on the location, size, patient preference and co-morbidities. Options include wide excision, cryotherapy, topical therapy, photodynamic therapy and radiotherapy.

PSORIASIS AND PSORIASIFORM DISORDERS

Psoriasis is a chronic inflammatory skin condition characterised by clearly defined, red and scaly plaques (thickened skin). It is classified into several subtypes. The immune system plays a key role in psoriasis. A certain subset of T lymphocytes (a type of white blood cell) abnormally triggers inflammation in the skin as well as other parts of the body. These T cells produce inflammatory chemicals that cause skin cells to multiply and produce changes in small skin blood vessels, resulting ultimately in the elevated scaling plaque of psoriasis.

Causes of Psoriasis:

• Psoriasis has a genetic basis, with some people carrying genes that make them more susceptible to it. About one-third of people with psoriasis have at least one family member affected by the disease. Certain factors trigger psoriasis to flare up in those carrying the genes.
• Environmental factors such as smoking, alcohol ingestion and streptococcal sore throat, may increase the frequency of flares.
• Injury to the skin has been known to trigger psoriasis.
• A number of medications have also been shown to aggravate psoriasis.

As part of our skin, nails can also show changes such as “pitting” and splitting at the ends (Onycholysis). Joint pains and swelling are also associated with more extensive psoriasis.

Treatment Options:

• Topicals such as Corticosteroids, non-steroidal vitamin D3 derivatives (e.g. Calcipotriol), and coal tar.
• Phototherapy and oral drugs (e.g. Methotrexate, Cyclosporin and Acitretin) can be used for extensive psoriasis.
• The advent of biologics has changed the landscape for patients suffering from extensive psoriasis. These biologics have to be administered via injection and work by balancing the immune system in the skin.

SKIN CANCERS (NON-MELANOMA)

NON-MELANOMA SKIN CANCERS (BCC, SCC AND SCC-IN-SITU)

There are many types of skin tumours/growths. Whilst some of them are harmless and need no treatment, some are cancerous and should be detected and removed early. Some of the most common malignant skin tumours are the non-melanoma skin cancers, which include Basal Cell Carcinoma and Squamous Cell Carcinoma.

BASAL CELL CARCINOMA (BCC)

This is the most common type of skin cancer, which develops gradually and is often painless in an earlier stage. Typically occurring as a longstanding ulcer with a pearly raised margin (known as a rodent’s ulcer), BCC often appears pigmented in Asians and non-pigmented in fairer skin types. They commonly develop over sun-exposed areas of the skin such as the face and upper limbs, and if left untreated, this locally invasive cancer can slowly erode into surrounding skin and underlying structures such as muscle and bone.

Chronic sun exposure is a predisposing factor, and increased risk has also been associated with chronic arsenic exposure. The tumour rarely metastasizes to regional lymph nodes or distant organs but causes morbidity by local tissue destruction and may lead to subsequent disfigurement or functional impairment.

SQUAMOUS CELL CARCINOMA-IN-SITU (BOWEN’S DISEASE)

This is a very early form of skin cancer that is easily treatable (i.e. early form of SCC), where the malignant cells are only located within the upper layer (epidermis) of the skin and has not yet spread into the deeper dermal layer. It typically presents as a scaly raised red plaque, which does not respond to treatment.

SQUAMOUS CELL CARCINOMA (SCC)

Squamous Cell Carcinomas are malignant skin tumours of the keratinizing cells of the epidermis or its appendages, and also that of mucous membranes with squamous epithelium. It is more aggressive than BCC and on top of local tissue destruction, and perineural and vascular involvement; SCC has a risk of spread to regional lymph nodes and distant metastasis.

Typically developing as an irregular fleshy growth over sun-exposed skin, SCC growths increase in size, giving rise to a lump, which may break down to form an ulcer in some cases. Chronic sun exposure is an important contributing factor as well as chronic arsenic exposure. Other risk factors include chronic immunosuppression (e.g. organ transplant patients and patients on immunosuppressive medications), in addition to chronic non-healing wounds and ulcers.

SUSPECTING SKIN CANCER? HERE’S WHAT YOU SHOULD DO:

A biopsy should be done to confirm the diagnosis and type of cancer. Treatment options depend on the histological subtype, location, size and patient preference as well as co-morbidities. Options include wide excision, Mohs micrographic surgery, cryotherapy, topical therapy, photodynamic therapy and radiotherapy.

URTICARIA

Urticaria is characterised by weals (hives) or angioedema (swelling around the eyes, lips, tongue).

A weal is a superficial skin-coloured skin swelling, that is usually surrounded by redness and can last from a few minutes to < 24 hours. It is usually very itchy, but may have a burning sensation. Angioedema is deeper swelling within the skin or mucous membranes and can be skin-coloured or red. It typically takes longer to resolve (within 72 hours). Angioedema may be itchy or painful.

It is important to understand the duration of symptoms as urticaria is usually classified as:

1. Acute urticaria: Attacks lasting < 6 weeks
2. Chronic urticaria: Attacks lasting > 6 weeks

The causes for acute urticaria and chronic urticaria are typically different, with causes for acute urticaria including acute viral infection or bacterial infection, drug or food allergy, and drug pseudoallergy like NSAID intolerance. Chronic urticaria on the other hand is mainly idiopathic (cause unknown), with other causes being chronic autoimmune diseases such as thyroid disease or systemic lupus erythematosus, or from chronic underlying infection such as H. pylori infection. Blood tests are therefore typically performed when the duration of symptoms exceed 6 weeks.

Urticaria may also be inducible by various physical triggers which includes:

• Cold urticaria
• Cholinergic urticaria
• Contact urticaria
• Solar urticaria
• Heat urticaria
• Aquagenic urticaria

Treatment often involves the avoidance of triggers once identified but the main treatment of all forms of urticaria in both adults and children is still that of an oral antihistamine. If non-sedating antihistamines are not effective, and the urticaria severe and extensive, a short course of oral prednisolone may be warranted. Other medications include montelukast and now omalizumab (Xolair) which is a new-class biologic for the control of urticaria. All these medications are available at Angeline Yong Dermatology.

VASCULAR CONDITIONS

CHERRY ANGIOMAS

Angioma or haemangioma describes a benign vascular skin lesion. An angioma is due to proliferating endothelial cells, which are cells that line the inside of a blood vessel. Whilst angiomas can occur early in life (infantile proliferative haemangioma) or later in life; the most common type of angioma is a cherry angioma.

A cherry angioma is a small papular angioma also known as a Campbell de Morgan spot. Whilst it is commonly referred to as a senile angioma, it can occur in young people too. Cherry angiomas are very common in males and females of any age or race. It significantly increases in number after the age of 40 and there may also be a family history of similar lesions.

Cherry angioma can develop on any part of the body but mostly appear on the scalp, face, lips and trunk. Cherry angiomas are harmless, and hence can be left alone. It can be treated with varying options such as electrosurgery, pulsed dye laser or cryotherapy.

PORTWINE STAINS

A discoloration of the human skin caused by a vascular anomaly (a capillary malformation in the skin), a portwine stain is a vascular malformation that is typically present at birth. It does not regress and lesions may become darker and thicker over time. It typically also has a unilateral or segmental distribution respecting the midline. It may be associated with underlying syndromes.

Early treatment with pulsed dye laser yields better clearance than delayed treatment.

TELANGIECTASIAS

Telangiectasia is a condition in which there are visible small linear red blood vessels (broken capillaries). These prominent blood vessels can be physiological or pathological. Across the face, it is a common sign of rosacea, but it can also be caused by certain medications such as long-term topical or systemic corticosteroids, intralesional steroid injections and even oral vasodilators such as calcium channel blockers.

Other causes include certain inheritable conditions such as ataxia-telangiectasia, as well as conditions such as liver disease and systemic sclerosis. Telangiectasias can also be acquired from sun-damage, and may follow scarring and radiation damage.

This condition can be treated with an intense pulsed light or pulsed dye laser.