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?

Keloids

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

Hair care tips for swimmers

I’m a professional swimmer and have very dry skin. I suspect it’s all those chlorine in the pool that has damaged my skin (and hair). I don’t want to quit swimming. What can I do?

1. Stay hydrated and drink regularly before, during and after your swim.
2. Wear silicone swim cap to protect your hair.
3. Apply occlusive moisturiser to seal your skin off chlorinated pool water before a dip.
4. Apply double layer of sunscreen and reapply every hour if you are swimming under direct sunlight.
5. Take a lukewarm shower after the swim and use a gentle cleanser. Don’t forget to use conditioner for your hair after shampooing.
6. Moisturise your skin immediately and generously after the shower.

How to keep your skin hydrated?

Malaysia is a humid country, yet we keep on seeing people, with underlying skin problem or without, coming with dry and even cracked skin.

Here's a few tips on how to keep your skin hydrated.

1. Drink water, whenever you feel thirsty. Sounds dumb but how many of us forget to listen to our body cues when er are too engrossed in our work? We lose water in our sweats, urine, bowel movements and even while we breathe. A standard recommendation is to drink 6-8 glasses a day but really there is no "standard" for everyone because we are all different. Exactly how much water one needs depends on many factors from how much you exercise to your metabolic rate to how dry the environment is. Drinking too much water to the extent of water toxicity can lead to confusion and even coma and death. (But who on the earth in their right minds would drink so much water!?)
2. Talk short cold or lukewarm water shower rather than long hot baths (if you have eczema, keep the shower shorter than 5 minutes).
3. Use gentle cleanser instead of soap bar or antiseptic shower gel.
4. Apply generous amount of moisturiser immediately after baths (well not exactly immediate, within 3 minutes or when your skin is still damp).
5. Use paper mask. Paper mask is a great and yet economical invention of facial skin care. If not properly use, it may over hydrate the skin around the eyes making you look puffy though.
6. Use fabric gloves and socks after putting on moisturiser if you have dry hands or feet. This is a form of occlusion which will help your skin absorbs the moisturiser better, keep the moisture longer besides keeping your bed sheet and blanket clean.
7. Avoid direct sunlight, smoking, sauna.

What is Epidermolysis Bullosa?

The Star has recently published an interview of a mother with her butterfly child. And Dr. Sabeera talking about what is Epidermolysis Bullosa, a group of rare genetic skin disease which is likely underdiagnosed in this part of the world as the awareness of its presence isn't high, not only among layperson but also among healthcare providers.

DEBRA Malaysia has "hunt down" about 100 families in Malaysia suffering from this condition since its establishment in 2013. I thought this video from DEBRA UK is a very nice illustration of what EB is all about, click play if you are interested to know. :)

Vitamin C for fairer skin?

Lemon lemon on the tree, who's the fairest of them all? Fair skin has long been considered beautiful by many. Can vitamin C lightens the skin?

Vitamin C inhibits tyrosinase enzymes to reduce conversion of tyrosine into melanin which is responsible for skin pigmentation. Vitamin C also boosts the level of glutathione and vitamin E in the blood besides being an antioxidant itself.

However it is difficult to obtain very high dose vitamin C from food alone. And even if you supplements, our body cannot retain the extra vitamin C level beyond a certain point and you will start urinating it out. The amount of vitamin C that can ever reach the skin is likely quite minimal.
 
The solution? Use topical vitamin C! And when you use topical vitamin C, choosing the right concentration (around 15-20%), the right stable form and the right packaging (easily oxidised away) matter!

Videos for Eczema Children

Acne in mature skin

I am in my late 40's. And I still get acne. Why?

Contrary to popular belief, acne isn't just a problem of the teenagers. Young babies can get acne (known as infantile acne, often temporary). Most people do not get severe acne after menopause but yes, you may still get acne at a mature age.

The reason you get acne is probably not much of a difference to that of the teenagers. But there may be other things that you would want to consider if you have never had acne and suddenly suffering from severe breakout at this point of time.

1. Did you recently change your skin care products? Some people changed their skin care products to those "designed for mature skin" which are usually more greasy and may block the pores.
2.  Did you recently change your skin care routine? Did you just started on a face scrubs? Or tried a new facial treatment?
3. Did you recently go travelling?
4. A recent change of job?
5. Could it be something else rather than a true acne? Some skin diseases may mimick acne, and these include acne rosacea, sebaceous hyperplasia, milia and bacteria folliculitis.

Consult a dermatologist if you are not sure.

Healing Eczema Without Steroids

Recently, one of my patient with very severe eczema on methotrexate asked: "Can I heal my eczema without any steroids?"

Yes, you can.

Just like how your chickenpox can heal without antiviral, your runny nose can heal without any antihistamines, your sore throats can heal without any antibiotics, some women can even deliver at home, your eczema can heal without any steroids.

"Steroids is not a cure for eczema, they said," she told me. She was invited to join a support group for "healing eczema without steroids". And she has came across many natural healing advocates who strongly urge everyone to avoid steroids.

And I do not beg to differ.

What I want you to know is that "dermatologists readily dish out steroids" to help you getting over the most difficult time, and we have absolutely no intention not to harm you. In case some may have forgotten, our oath says "First do no harm" and our motto is "To cure sometimes, to relieve often, to comfort always".

I am not against natural path. But if you want to go absolutely steroids free, these are what I would suggest,

1. Avoid all irritants and your known allergens
2. Keep your bathing brief (<5 minutes) and not too frequent, using slight lukewarm water
3. Use gentle cleanser instead of soap (no natural handmade soap please and no bubble bath)
4. Always keep your skin moist, frequent re-application of moisturiser is the key
5. Seal in the moisture with occlusives (parrafin, vaseline ointment, dimethicone if you hate that greasy feeling)
6. If you feel really itchy, replace that scratch with applying cold pack or cold cream (no need to buy any particular brand of cold cream, just keep your hypoallergic moisturiser in the fridge)
7. Use immunomodulators such as topical tacrolimus, pimecrolimus
8. Ask your doctor about phototherapy (controlled light treatment) to see if you are a good candidate
9. If you are going for alternative medicine, please go for facilities with proper registration and certification (although I have no idea how to check that these are in place), and do ask them if their treatments may have any potential short term or long term side effects (Perhaps they might not actively discuss with you if you don't ask? Well, the reason I said this is because I have a teenage boy with eczema who came to me after 2 years of herbal remedies which was initially very effective and now he is suffering from stunted growth and a few other problems)

Whatever your choice is, take good care of your skin and get better soon!

Sunburn remedy

I came home from an outing with friends and found myself sunburnt despite using sunscreen! What should I do now?

No sunscreen offer 100% protection, which is why they are now known as sunscreen rather than sunblock.

Sunburn should be treated as soon as possible. Here's what you should do:

1. Seek shade immediately, if you are still outdoor.
2. Cool down with a shower or baths.
3. Apply a generous layer of moisturiser over the sunburnt area.
4. Apply mild topical corticosteroids to reduce the redness and swelling.
5. Drink a lot of water to prevent dehydration.

If you have a blister at the sunburnt area, do not de-roof it. De-roofing and leaving raw skin exposed poses a risk of secondary bacterial infection and slows down healing.

If there is a large area of blisters, or you are starting to feel feverish or chills, you should seek medical consultation immediately.

Practise strict sun protection until the burned area completely heal.

Preparing your own saline solution

What it is for?

To wash the raw wound / blistering area, or you can even use it to bathe if there is any condition causing extensive skin loss.

Why using a saline solution?

It is isotonic. That means it will not draw water in or out of your raw wound hence there will be less pain.

It cleans and wound and reduces the risk of secondary bacterial infection.

How to prepare it?

Simply add 9g of salt to a litre of water. Viola!

If you have just a small wound, buy those bottled sterile saline bottle that are readily available in most pharmacies. Yes, those that are used to wash contact lenses one will do.

Expired sunscreen

I just noticed my sunscreen has expired 6 months ago. It wasn't cheap and I don't feel like wasting it. Can I still use it?

While a sunscreen may not necessary go bad immediately after the expiry date, the expiry date stated is actually the duration that the product remained effective and safe based on the manufacturer's test.

Physical agents such as zinc oxide and titanium dioxide usually lasts longer than chemical agents.

If it doesn't "smell bad", it could very well still be safe to be used despite a reduced effect of protection. A reduced effect means even if you are applying adequate amount, it may not reached the labelled SPF. Most sunscreen in the market comes in a bottle of 30-50ml. If you apply it generously on all the exposed part of the body, you would have finished the bottle in no time. ;P

Since there is no way to be sure of the efficacy and safety after the expiry date and if you ask for my advice, I would have to tell you to throw it out.

Stitch Removal

Someone asks,
"Can I remove my stitches myself at home?"
"What if I can't make it on the appointment date given for stitch removal?"

I personally would advice against attempting to remove the stitches at home if you are not a trained healthcare personnel.

Why?

There's a few things that your doctor need to assess when he or she removes your stitches. For one, he or she needs to check if your wound has healed nicely and it's ready for the stitches to be removed. If the stitches are removed too early, you may risk having the wound gaps and you may need re-suturing. If the stitches are removed too late, more often than not the suture materials maybe buried under the skin making it difficult to remove and at higher risk of scarring.

Also, he or she needs to check if there is any sign of infection. If there is any early sign of infection, it should be treated early.

When should a stitch be removed?

When a stitch needs to be removed depends on a few factors.

First, the location of the wound, generally the wound of the face heals faster and will be removed soonest compare to other parts of the body, for example legs.

Second, the types of sutures used. Some sutures are absorbable and does not require opening of stitches.

Third, the tension of the stitches on the skin.

Other factors include age, smoking, underlying skin disease, previously irradiated skin, general health, infection etc.

Generally the doctor who stitched it will be the best person to advice you when is the best time to remove it.

Can't make it for the appointment to remove the stitch?

If possible, always tell your doctor before he or she make that stitch so that he or she can plan something else for you. Intradermal or subcuticular stitching with absorbable sutures will be fine to leave in.

Is there any nearby healthcare facility, a family doctor clinic for example, to help you removing it?

If you are confident enough and really want to remove it yourself, ask your doctor if he or she could provide you with the material and teach you how. ;)

Quick Fix for Acne

I've picked a pimple and it became red and swollen. I have an event coming up in 3 days. How do I speed up the healing process?

Are there quick fix for acne? 

The answer is yes. But we will need to assess the condition of the "red and swollen" acne to see if which fix is for you.

If the acne was "properly picked", the picking itself should have shortened this particular acne's "lifespan". You can hasten the recovery further by applying a non-comedogenic moisturiser.

By "properly picked", I mean it should be picked hygienically and completely without any residue or pus being left behind.

If the acne was not "properly picked", and has "swollen" and might even appear to be forming up a cyst, then you might need intralesional steroids (which means injecting low concentration of steroids directly to the cyst itself) to reduce the redness and the swelling quickly.

If the acne was not ready to be picked, light and laser treatment could be helpful to hasten its maturity so that it can heal faster.

If in doubt, it is always good to pay a visit to your nearest dermatology facility. If that is not possible before your event, a professional concealer could do the trick! ;P

Eczema and Career

I have eczema since young. Will it affect my career choice?

Unfortunately yes.

Certain jobs can be problematic for people with more than just mild eczema, especially if you will be in contact with irritants that may make your eczema flare-up more frequent. These include nursing, cleaning, catering, hairdressing etc.

But if you really love a job, think about measures that you can take to protect your skin. Proper use of personal protective gear may help.

Sunscreen for Indoor

My melasma is getting worse although I hardly go outdoor. Should I use sunscreen indoor?

Yes you should!

Why?

Ultraviolet rays can get to you even if you just stay indoors.

Do not underestimate the amount of ultraviolet rays that pass through the windows or glass door. clear glass allows 75% of UVA rays through. Even if there is tinting, up to 50% of the UVA rays may still pass through.

Travelling in a car? The  ultraviolet rays may pass through the car windows. 

Indoor lighting particularly fluorescent lighting, especially if the distance from the skin is close. This means desk lamps, bed lamps and overhead lamps are not a good idea for those with melasma and photosensitivity.

Other sources include TV monitors, computer monitors, tablets etc. Luckily nowadays, most traditional monitors have been replaced by LCD display which do not emit UV rays. They still do emit high energy visible lights though.


What you can do?

Add acrylic or plastic diffusers to indoor lights.
Choose incandescent bulbs or LEDs rather than fluorescent lights .
Choose a broad spectrum sunscreen and use it even indoor.


You might be interested to read:
Choosing The Best Sunscreen - Beyond UVR protection 
How much sunscreen is 2mg/cm2
Sunscreen and Moisturiser