Telemedicine - The Yay and Nay

Telemedicine is not new.

My very first telemedicine experience started in 2013 when I was still practising in government hospital. The service was mainly for medical officers from remote part of Malaysia who has no access to specialist advice. So the medical officers will upload patient photos together with their clinical findings and specific questions so that we can give advice on further management of their patients. It wasn't directly link to the actual patient.

Then I started offering free telemedicine advice on TELEME platform (link at the right side of this site) in 2018, which was often abused by some, until I have decided to put a stop to access from new patients and only using it to advice my existing patients only. (Also wrote a frustrated blog post here. Haha.)

Then came COVID pandemic and Movement Restriction Control in Malaysia, during which our hospital and clinic actually work as usual but many patients could not attend their appointments for various reason. Some suffered severe flare-up of their chronic eczema, psoriasis, blistering diseases etc for running out of medicine supply. And then I started offering telemedicine service again via my hospital's Telehealth Plus platform.

Unfortunately not all consultations can be conducted effectively via virtual / video call. It remains a challenge to see new patient (which I do not do) or existing patient but with a new complaint. It is not easy to get a complete impression of their skin condition and the assessment of mental burden to one is not easy as well.

There are a lot of things that we cannot do virtually, blood taking and laser procedure etc is impossible for sure. It is easier to explain things face-to-face because we can use tools such as flip chart, drawings etc. Not to mention technical issue such as camera quality and network connection.

Having said that, sometimes we have no choice, and sometimes telemedicine is convenient and probably good for follow up of people with well controlled conditions, or review and continuation of an ongoing satisfactory treatment.

If you are my existing patient, to see me for virtual consult, click here. ;)

Epidermolysis Bullosa

Oct 25 - 31st is epidermolysis bullosa awareness week.

Have you ever heard of epidermolysis bullosa?

Epidermolysis bullosa is a group of rare genetic disease where the skin and mucosa (mouth, stomach linings) are torn and develop blister with minimal friction. The mild ones only start to show up when the children learn to crawl or walk. The severe ones can be life threatening.

Children born with epidermolysis bullosa are also known as butterfly children because their skin is as fragile as butterfly skin. And they are often in pain from the raw wound.

The list of possible problems is long and include,
🩸 bleeding from the wound
🩸 constipation, avoiding bowel movement due to pain
🩸 painful and sensitive eyes, that may even leads to blindness
🩸 scarring on scalp, muscle, tendons that leads to hair loss, contracture and deformity affecting ability to walk and move
🩸 blisters in mouth that leads to difficulty in eating and malnutrition
🩸 infection
🩸 skin cancer

And not to mention poor quality of life with social isolation, school and work absentee. This is why they need our support.

You can reach out for EB community in Malaysia here.

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.

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

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?

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".

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!
 
⛔️painkillers
⛔️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
⛔️alcohol
⛔️caffeine
⛔️⛔️smoking

And don’t forget to start taking folic acid!