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Monday, 22 October 2018

Pimples at the wrong site or recurring bumps? You may have hidradenitis suppurativa

In the afternoon clinic today, two young men with recurring foul smelling pimples and bumps and even pus at their armpits for years came seeking  for help. One of them has complicated sinus tracts (tunnels under the skin), scars and keloids (painful or itchy overgrown scars).

Contrary to popular beliefs, this really has nothing to do with personal hygiene or food. This is hidradenitis suppurativa, some called it acne inversa, caused by abnormal skin near the hair follicles blocking the sweat and oil glands. A condition that is really not fun to have and they tends to go to skin folds such as the armpits, under breasts and groin.

Hidradenitis suppurativa usualy start after puberty and may worsen over time. For some it can be nothing more than "an occasional pimple at odd location", for others it can be painful, affecting daily activities, destroying one’s self esteem and social life. Very rarely, people with severe uncontrolled disease can develop skin cancer (squamous cell carcinoma) at the affected area.

Being overweight, having hormonal disorders, smoking, living in hot and humid environment are among key factors that can worsen hidradenitis suppurativa. Wearing tight fitting clothes of irritating materials and shaving can trigger a flare-up as well. Hidradenitis suppurativa often happen in the same family.

Seek medical help early if you have this condition. Early diagnosis and early treatment not only reduces bumps and pain but also keep complications such as sinus tracts and scarring at bay.

Common treatments (depending on severity and individual condition) include,
  • Antiseptics
  • Antibiotics
  • Steroid injection into a painful breakout
  • Hormone therapy
  • Immunosuppresantrs
  • Oral retinoids
  • Radiation therapy
  • Laser treatment to destroy hair follicles
  • Biologic (injections of genetically engineered proteins to block the inflammatory response)
Surgery may be required, such as
  • Incision and drainage of the most painful 1-2 lesions, mainly for short term relief, but often the symptom will return
  • Deroofing, turning a repeatedly return lesion into a scar
  • Excision, cutting out the affected area and closed by skin flap or skin graft
People with hidradenitis suppurativa may feel anxious or depressed. Patient support group is available in Malaysia. You can reach their Facebook page here.

Tuesday, 11 September 2018

100 Years of Illegal Beauty Products

Interesting video! How far would you go for beauty?

It was once illegal to makeup below 44 years old.

Oh, and thank goodness you don't have to take the risk of getting blind to remove some facial or upper lip hair. Easily and safely done with a quick 5 minutes laser.  ;P

Monday, 7 May 2018

100 Years of Acne Treatments

From 1910s to 2010s.

A lot are still in use and proven effective over time, such as topical retinoids from 1970s and oral retinoids in 1980s.

My favourite is 2000s' acne extraction and cortisone shots. What about you?

Sunday, 6 May 2018

Telemedicine, Blindmen and the Elephant

We all know face-to-face consultation in the clinic is the best. However sometimes it is not possible, due to distance etc. Consultation over phone calls, emails, social medias and even proper telemedicine platform such as TELEME has a lot of limitation especially when it comes to dermatology. Not just because I cannot see the skin clearly but also because I cannot examine it.

To be honest, a lot of times, I feel like a blind man. Asking many questions rather than answering. How accurate and relevant my guess and advice is depends very much on whether the person on the other end decided to let me know the tail, the horn or whichever part of the elephant. And as a doctor, we have to be responsible for the advice we dispense.

Despite the best reasonable effort, many times I still can't be sure that I am getting the full picture of what the patient's true problem is. The information are often distorted. Worse still is that some people are asking questions on behalf of someone else. And expecting me to offer one miracle cream that will solve their problems through a blur picture, not even revealing which body part that picture belong to.

As my ex-colleague and friend put it, blind man touching part of an elephant + wearing a thick gloves.

Anyway, I must say Telemedicine is not without it's benefit, probably best general enquiry for non-medical person, or for second opinion among healthcare personnels, hopefully and likely we will be speaking the same "language".

Wednesday, 6 December 2017

Protect your baby even before you get pregnant

Retinoids is a wonderful medicine that helps to treat acne, rosacea, folliculitis, psoriasis and many skin conditions. It can even smoothen skin tone and stimulate collagen production. But do not use retinoids especially the oral form (e.g. Roaccutane) during pregnancy or breastfeeding. In fact, you must be more than 100% sure you are not pregnant before starting it, and if you are sexually active, use at least two forms of birth control e.g. birth control pill + condoms.

Being a parent is a serious responsibility. With oral retinoids, it is almost a sure thing that the innocent baby will end up with birth defects.

You are on oral retinoids and planning to get married? Afraid not. Just inform your dermatologist so that we can help with your family and skin care planning by changing your medications to other safer options. 

Different oral retinoids stay in the body for different duration. Usually you will be told to stop your isotretinoin for at least a month (or until next menstrual cycle), but with acitretin, it is probably best to plan for pregnancy after 3 years of stopping it! For this reason, we seldom start young ladies on childbearing age on acitretin unless we have no other option.

Some medications may even pass to the future baby from the father. One of the example is methotrexate. The whole process of spermatogenesis in human takes about 74 days, and if you count in the transport in the ductal system, it can take about 3 months. Hence, it is best to wait for at least 3 months after the father has stopped methotrexate before making baby!

For all future mothers, here’s other medicines and things you need to stop. This list is not complete and some medications can not be stopped just like that, your baby need healthy mother to take good care of him/her too, so please check with your doctor before planning for your family!
⛔️immunosuppresants and chemotherapies
⛔️some blood thinners e.g warfarin
⛔️cholesterol medicines
⛔️some seizure medicines
⛔️some antihypertensives
⛔️some antidepressants and mood stabiliser
⛔️some antifungals
⛔️some antibiotics

And don’t forget to start taking folic acid!

Friday, 10 November 2017


My friend has keloids on her chest. Cryotherapy, laser or plastic surgery?

Keloids happen when your skin doesn’t realise it has healed and continues to grow much larger than the original wound, often to the extent that it is painful. Once started, it can continue to grow for months and even years.

Cryotherapy may help small keloids. My first line treatment of choice is intralesional corticosteroid injections because it is cost effective in softens/ shrinks the scar and reduces the pain. Patient often feel much better after the very first injection. I usually encourage patient to use silicone sheets and do scar massages at home. If the location allows, wearing pressure garment is a great adjunct.

Ablative and non-ablative lasers can help to reduce the height and redness.

Surgical removal (especially on the chest) has nearly 100% recurrence rate and is only used in combination with other treatment modalities.

My scar did not heal well

My first surgical scar healed well but the second surgical scar doesn’t. Why?

Many factors could affect scar formation.
1. The site of less tension (less tightness) tends to heal better e.g. inner arm vs. shoulder
2. The site of better blood supply heals better, e.g. face vs. feet
3. The doctor’s skill
4. Patient factors, e.g smoking, diabetes, genetics
5. Timing of stitch removal, hygiene, absence of infection and good wound care etc.

How do minimise scar after surgery / injury?
1. Keep the area dry especially the first few days.
2. Keep the area clean.
3. Allow the wound to "breathe".
4. Consider silicone adhesive dressing.
5. Minimise movement of the area (avoid pulling or tugging on the wound)
6. If there is risk of infection, consider the use of antiseptics. Consult your doctor if there is a need for antibiotics if the wound is weepy, changing colour or foul smelling.
7. If it forms a scab, do not pick on it, allow the scab to fall off naturally.
8. Sun protection
9. Moisturiser --- but not on raw wound
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Pimples at the wrong site or recurring bumps? You may have hidradenitis suppurativa

In the afternoon clinic today, two young men with recurring foul smelling pimples and bumps and even pus at their armpits for years came ...