What is a dermoscope?

"What is that? A magnifier?"

 

So this morning, I met a paediatrician colleague in the hospital and he curiously pointed to the "black colored tool" that I was holding.

We all know the cardiologists use stethoscopes. Yes, the thing that hang on the doctor's shoulder in typical "comic doctor" illustration. And the gastroenterologists use endoscopes. And yes, we dermatologists do have our "scopes" to play with. Many people including our fellow doctor colleagues have not came across it though.

Dermoscope is a bit more than a magnifier. Apart from a good quality magnification lens,  it comes with strong light and polorised filter, which is why it is much more expensive than a magnifying glass. How much? I spent 4 digits on this one more than 4 years ago, when our ringgit exchange rate was better than now.

What does it do? Essentially it is a form of skin surface microscopy. So your dermatologists can use it to look at the colours and the structures of the skin, nails and hair. This can help diagnosing skin conditions, in particular pigmented problems without or prior to cutting your skin and examined it under a microscope. So dermoscopy can cut down unnecessary skin biopsy. Of course, dermoscopy examination are not meant to replace skin biopsy. A lot of time, skin biopsy is still necessary for ultimate confirmation of a diagnosis, especially that of a suspicious skin cancers.

Oh, and we can connect this to a camera or a phone to take a clear picture of the skin too. :)

Bathing in Eczema

I have eczema and I'm confused if bathing is good for me. Some say bathing will make my skin worse. But I do sweat pretty easily. I usually shower three times a day because I feel itchy if I don't. Should I cut-down on my bathing?

Shower or Bath?

We don't know for sure which one is better. But we do know that spending too long with the water is not good for your eczema. Spending too long in the water might dry your skin up by washing away all your natural moisturising factor. Particularly if you use hot water to shower. Avoid scrubbing. Avoid antibacterial soap. Avoid harsh alkaline soap. Or better still, use a non-soap cleanser. Gently pat your skin dry. And always moisturise your skin as soon as you get out of baths (within 3 minutes).

How long should I spend in bathing?

Those who spend no more than 5 minutes bathing has significantly less severe eczema.

How frequent should I take a bath?

Bathing daily and twice a week does not make any difference in a study carried out in temperate country. In Malaysia, I believe you should bathe at least once a day, or maybe even more whenever you are all sweaty and dirty. Remember, sweat is an irritant that will worsen eczema as well. Just don't spend too long in the shower or bathtub.

My doctor(s) can't seem to help me. What should I do?

I have a serious skin problem. I have a red swelling on my cheek which started as a "pimple" but gradually getting larger. I had taken a few courses of antibiotics in the past one year, including a 6 months course of erythromycin from my family doctor. He took a small skin sample from my cheek prior to the long course of antibiotics but the report wasn't conclusive. Then I was given oral steroids which seems to get the swelling slightly smaller but it never goes away. I trusted my family doctor as my family has been under his care for years. But he can't seem to solve my problem. What should I do?

Here's what I think you should consider.

1. What is the diagnosis? Sounds like no definite diagnosis has been made so far. Effective treatments often comes from an accurate diagnosis. (Yes, I say "often", some people treat by hunches, and it works, sometimes. But the basic of medicine should be diagnosis first before treatment.)

2. How was the skin sample taken? Was it taken at the right place? Was it deep enough? Is the cut big enough for the laboratory to examine? What laboratory tests have been done? A histopathological examination? Any extra stain needed? What about culture for fungus and bacteria and other not so common bacteria?

3. Perhaps you might want to politely ask your family doctor if he thinks any other doctors or nearby dermatologists may help you with your problem? Most if not all good doctors do not mind writing you a letter, giving out your previous investigation and biopsy records. If a particular doctor is very defensive about you going for a second opinion, it may be, well, a warning sign perhaps.

4. Consider going to dermatologists in bigger or more well known medical centres because they may be more experienced in managing not-so-common skin problems.

Choosing The Best Sunscreen - Beyond UVR protection

Here's my take on what is the best sunscreen.

Choose a broad spectrum sunscreen

By broad spectrum, it should have

1. UVA protection, also marked by Protection of UVA (PA) value that ranged from + to +++. If the PA value isn't stated, look for ecamsule, avobenzone, oxybenzone, titanium dioxide, sulisobenzone, or zinc oxide in the ingredient. 
2. UVB protection, also marked by Sun Protection Factor (SPF) value. The higher the SPF, the higher the protection. However, the higher the SPF, the smaller the difference it offers. 

• SPF 15 sunscreens filter out about 93% (of UVB rays)
• SPF 30 sunscreens filter out about 97%
• SPF 50 sunscreens filter out about 98%
• SPF 100 sunscreens filter out about 99%

However, SPF value are based on application of 2mg/cm2, and who on the earth would apply sunscreen such thick!? Trust me, in reality, that extra small additional value of SPF does matter.

3. Infrared protection - probably less harmful than UV rays, but accounts for more than 50% of the sun energy that reach our skin, and also contributes to aging and skin cancer.
4. High energy visible light or near-UV protection - again, not as strong as UV rays but it could be another silent harmful agent from computer monitors, phones, lights etc. leafing to dry and sensitive skin apart from aging.

Read the product label

• Make sure that there isn't any ingredient that you are allergic to.
• Pick a non-comedogenic one if you are prone to acne.

Other things that you may want to consider

• Tinted sunscreen, so that you don't look all white out like Geisha!
• Sunscreen with antioxidants to counteracts reactive oxygen species production, not new but yay!
• Pleasant scent or a brand that you like -- you will not use it if you don't like it!
• Sunscreen for sensitive skin, go for physical agent such as titanium oxide and zinc oxide, rather than chemicals like oxybenzone. Avoid fragrance and alcohol too.
• If you are choosing a sunscreen for your children, try to get physical agents too.

More expensive sunscreen isn't necessarily better. Don't forget to look at the expiry date and use it correctly. Oh, and in case you don't know yet,  there are oral sunscreen too (the efficacy of which is doubtful, so don't use it alone without applying topical sunscreen).

Last but not least, using sunscreen isn't enough. There's a study that showed that people who uses sunscreen actually gets more sunburn as they tend not staying in shades. So, please don't forget your sunglasses and hats! After all, these can be part of fashion too, so all the beauty and handsome, why not?

Acne Myths

Eating oily food causes acne?

Food and acne is always a hot topic. More than 10 reviews have been done in the last ten years on fatty food, sugary food etc. Rather than oily food, sugary food is more likely to be responsible for your acne.

Kitavan Islanders of Papua New Guinea and Ache hunter-gatherers of Paraguay ate minimally processed plants and animals without typical carbohydrates and they have almost no acne!

Have you ever heard of the term Glycemic Index? Glycemic index described how much your blood sugar increases with a portion of carbohydrate. The higher the glycemic index of a food, the higher your blood sugar goes after eating it, and your sebaceous glands will produce more skin surface triglycerides and the more likely it is for acne to erupt.

What about milk and diary products?

Many observational studies suggested that the more milk you drink, the more likely it is for you to get acne in the same manner as taking high glycemic index food. Observational studies, however, are not strong studies with good design. We can only conclude that until better studies are carried out in the future, the evidences are not enough to ask all acne patients not to drink milk or take diary products.

Bad facial hygiene gives you acne?

Contrary to popular beliefs, washing your face too hard, particularly with scrub, gives you more acne (and we called it acne mechanica).

When you wash your face too much, you might remove all the protective oil on your face leading to dry skin. I usually tell my patients not to wash their face more than twice a day, and use a gentle face wash instead of strong ones that leaves your skin feeling tight and dry after using.

Make-up can cause acne?

Wearing thick make-up that clogs the pores and failure to remove make-up completely can cause acne (and we called it acne cosmetica). Look for the label "non-comedogenic" if you are worried. Also nowadays, many manufacturers actually added anti-acne medications such as benzyol peroxide and salicylic acid into the products. Tinted benzyol peroxide concealers might help to treat your acne while concealing it at the same time.

Stress causes acne?

No and yes. No becaurse there isn't enough scientific evidence yet. Yes because theoretically stress affects your hormones (more cortisol that activates the sebaceous glands) and can be the cause of your acne. In reality many patients do report their acne worsens when they are preparing for major exams. Perhaps exactly the same reason why some girls have acne every month before having their menses.

Sex causes acne?

Well, I have no idea where this myth starts from. To prevent teenagers from having sex perhaps?

Acne is a teenage issue?

False. Although more common among teenagers, acne can affect people in their middle age too.

Acne should not be squeezed or popped?

Squeezing an immature acne can gives you scar. Squeezing an acne incompletely or without hygienic measures may get it infected or spread it to surrounding skin too. However, squeezing a mature acne can actually reduces pain, infection and initiate healing earlier. Proper method of squeezing without picking on the skin should have low risk of leaving you a scar.

Apply toothpaste onto acne helps to heal it faster?

Toothpaste does not contain any ingredient to heal acne, and sodium lauryl sulphate in the toothpaste may not do any good to your skin. Perhaps it helps to dry up existing acne? I'm not too sure about that.

Sun tanning helps to heal acne?

False. Many skin conditions get worse under the sun and acne is just one of them. Apart from that it puts you at risk of skin cancer too. Use a good sunscreen that is non-comedogenic especially under the hot sun of Malaysian weather.

Probably this is why dermatologists always talk about sun protection, sun protection and SUN PROTECTION! Upcoming next post will be on choosing the best sunscreen. I hope my take on choosing the best sunscreen offers a little extra information than what you can easily google from most skin care sites out there. :)

Food and Eczema

.... are you on a see-food diet or no-food diet?


"I don't eat meat, I don't eat seafood, I don't take processed food but I still get the rashes! Why?"

There is something about Asian and food. We love food. But we blame most if not everything to the food that we ate.

Dark ugly scar? Perhaps the soy sauce?
Good grades at school? Maybe the blackbean soup that the mother took years ago during pregnancy.

More so with skin conditions.

Itch? Maybe it's from the silverfish that I took this morning.
Rashes? Could it be the prawn that I took last night? Or the gluten in the bread?

So here's a summary of what science says about your diet and eczema. (7 Cochrane Reviews)

Supplements and eczema

Fish oil, zinc sulphate, selenium, vitamin E, vitamin D, pytidoxine, sea buckthorn seed oil, hempseed oil, sunflower oil, docosahexaenoic acid -- too little evidence to say it is beneficial.

Why too little evidence?  Give for example vitamin D supplements, in one randomised controlled trial with 1600IU a day for 2 months says it improved, but another randomised controlled trial using 4000 IU daily for 2 months says no difference.

Primrose and borage oils

Yes, it is anti-inflammatory, theoretically it could be helpful. Unfortunately there were 27 studies with 1596 people involved took it and it makes no difference.

Prebiotics and probiotics

Now there are postulation that your eczema maybe related to food sensitisation and those bacteria in your gut may play a role. In case you are not sure, probiotics are supposed to be  "good bacteria" for your gut and prebiotics are the "fertiliser" for the probiotics to grow.

There are a lot of studies into these and looks like taking probiotics during pregnancy and after may help. For prebiotics, it is probably only helpful after delivery for children of up to 7 years old.

Diet restriction

Many patients say that when they take certain food, their eczema flares up. 6 studies asked the patients not to take egg and milk, another 1 asked to restrict their food to a few simple diet, and another 2 studies on elemental diet. Looks like there is significant benefit. One study that asked patient with positive egg-specific IgE to avoid eggs in their diet does see an improvement in their eczema severity. So what does this tells us?

Diet restriction is only good for those with food allergy. And therefore it is not necessary at all for everyone with eczema (but without food allergy) to practise diet restriction. Furthermore limiting yourself or your children's diet may pose a risk of nutritional deficiency, not to mention reducing our happiness because we all love food!

How to know if you have food allergy?

These are the things that your doctor may use

• Food diary
• Skin prick test
• Serum IgE testing
• Oral food challenges

Ask if you are not sure.

The mother's food

Many pregnant mothers and breastfeeding mothers are worried their food may affect their babies. 5 studies of 952 people in total says that avoiding certain food during pregnancy, breastfeeding or even both does not prevent eczema in babies up to 18 months old. And they notice that mother who practise diet restriction has an average lower weight gain during pregnancy and lower birth weight of the babies. Also there is actually increased rate of preterm birth!

In other words, there is a strong evidence that mothers should not restrict their diet during pregnancy or breastfeeding. Such practise brings more harm than good!

Breastfeeding and eczema

What about breastfeeding? Isn't it known to help eczema? The evidence from 18 studies say breastfeeding exclusively for 4 months if not using hydrolyzed formula (rather than formula milk) helps those babies at high risk. These are the babies with family members of atopy. However, for those people without family members with atopy, breastfeeding or formula milk doesn't matter really.

Confused over what food to take or not to take when you have eczema? Hope what I've put up here helps!

Weathering of Hair

A young beautiful Israel girl came complaining that her hair has changed. She came to Malaysia 2 years ago. And for the last one year, she found her hair turning more yellow and brittle. She reported her hair condition to be much better when she returned to her country for a month early this year.

The basic:

Hair is a dead structure consist of proteins, lipids, water, malanin and trace elements. When I said it is dead, it doesn't hurt when it is cut or damaged.

Our hair shaft consists of cuticle, cortex and medulla (from outside in).

• Cuticle is the protective layer of keratinized scales. 
• Cortex is the cysteine-rich keratin filaments that made up the bulk of hair and contributes to the color of hair.
• Medulla is the central core of the hair.

The tip of the hair has more cuticle and less cortex.

What has happened?

Her hair is damaged, or some say has underwent "weathering". Hair weathering is structural damage to hair fibres. The defect in hair shaft can be progressive from loss of cuticular protection to reduction in the ability of the cortex of the hair to maintain moisture. When the hair is dry it is more frizzy and can create "flyaway" look. Ultimately the hair loss its elasticity, shine and strength and could easily be broken.

Is this common?

Yes, this is the top 3 hair concern that comes to dermatologists, after hair loss and thinning.

How would the dermatologist diagnose hair weathering?

The diagnosis of hair weathering is made after detailed history of hair care practices and hair products used. He or she may collect your hair shaft samples to be examined.


What could be the cause?

The name of hair "weathering" suggests the cause is environmental. Ultraviolet (UV) radiation, wind, sea salt, polution, chlorinated water are among the culprits. Despite the name, the cause is not necessary limited to bad weather. Excessive combing, brushing, braiding, weaving, hair extensions, straightening, perming and dyeing could potentially damage the hair structure. In short, any sort of physical or chemical trauma can damage the hair.

I lived in Malaysia for years and have no problem with my hair. How can she attribute our environment to the possible cause of her hair problem? How is hair different among different ethnicity / race?

The proteins and the structure of hair fiber is similar among Asian, Caucasian or Africans.

The cross-section of Asian straight hair is usually round and larger in diameter and therefore usually stronger in tensile strength. The sebum coating, moisture, water swelling rate are the highest among typical Asian straight hair. For the same reason, black hair is most difficult to perm or dye. When they are subjected to chemical treatment, often, they are given higher concentration of chemicals and longer duration of exposure leading to hair damage.

Among the Caucasian, the cross-section of the hair shaft is round to oval and therefore often curls. Among the Africans, the  cross-section is elliptical or flattened. When they groom their hair, there is significantly increase friction and hence there is increasingly at risk of weathering as well.

Regardless of ethnicity, as we aged, our hair turns grey which are coarser, stiffer and dryer.

How can I prevent this?

• Avoid prolonged direct exposure to UV radiation and extreme weathers.
• Choose combs that are made of bendable plastic instead of hard metal or wood, particularly those with irregular teeth. Soft brush are better than hard ones. Round tips are better than sharp ones.
• Avoid backcombing that raises the hair cuticle, expose the cortex and make the hair more vulnerable to damage.
• Avoid excessive brushing particularly when the hair is wet. Wet hair produces more friction than dry hair and hence easier to be stretched until its breaking point. It is a good practice to dry the hair before combing.
• Avoid braiding and weaving.
• Straightening and waving by heat (temporary) or chemical (permanent) may damage the hair. Exposure to heat on wet hair results in greater damage than dry. Using a heat protector spray onto dry hair prior to the procedure may reduce the risk of hair breakage, bubble hair* and thermal burn on scalp skin.
• Avoid hair styling or treatment by non-professionals as overperming, poor neutralisation after washing off perming solution can damage the hair.
• Shampooing the night of or after the perming and cause formation of new incomplete bonds for the new shape of the hair. Hair breakage can happens close to the scalp. This usually happens a few days after perming.
• Dyeing of hair may cause contact dermatitis to the skin. There are many different type of hair dyes. Permanent dyes usuallly use a highly alkalinised solution to make the cuticle swell so that the dye can penetrate into the cortex. Bleaching with hydrogen peroxide to oxidise the melanin in the cortex of the hair can destroys the keratin and cuticle making the hair more dull and brittle due to loss of water.

*bubble hair is the formation of holes that are filled with steam when the hair shafts are overheated.

My hair has weathered. What can I do?

• Get a good quality haircut.
• Minimise further damage, physically or chemically. (Avoid bad hair treatment from inexperience staffs!)
• Frequent shampooing is good. Fluffy hair (rather than greasy ones) may give an illusion of thicker hair. Use a mild and gentle shampoo. Minimise massage and dry the hair (especially long hairs) from tip to root.
• Use a conditioner to improve manageability and reduce static electricity.
• Get a good, bendable, soft comb.
• Detangle your hair from ends to root with your fingers when it is still wet.
• Air dry your hair before combing.
• If you use a blower or dryer, make sure the temperature in increase gradually rather than abruptly.
• If you have itchy scalp condition, get it treated to avoid scratching.

And finally don't forget to put on a cap when you go under the sun!

One last happy note: Our hair grows continuously (unless you have damaged hair follicles), so hair shaft problem can be completely solved! Exercise good hair care and be patient to wait for your new healthy lustrous hair to grow out soon!