CUHK Dermatology Symposium 2006

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					                                       Reports on Scientific Meetings                                    213



CUHK Dermatology Symposium 2006

Reported by AYK Chan              , GJ Chan             , TS Cheng




                                                          chest or become generalised, and may become
   Date:        29 October, 2006                          rapidly progressive with high mortality. Prompt
   Venue:       Postgraduate Education Centre,            treatment with intravenous acyclovir is essential.
                Prince of Wales Hospital, Shatin
                                                          Consideration of stopping topical steroids and
   Organiser:   Dermatology Research Centre,
                The Chinese University of Hong Kong       topical calcineurin inhibitors should be given.
                                                          Scabies can also be associated with eczema and
                                                          the pathognomonic scabetic nodules may often
                                                          be seen over the genitalia in children.
Update on paediatric skin
infections                                                Herpes simplex virus may present as herpes
Speaker: Dr. David Luk                                    gingivostomatitis, herpetic whitlow, herpes
Department of Paediatrics, United Christian Hospital,     simplex, and disseminated herpes. Herpes in the
Kwun Tong, Hong Kong                                      genital area should raise the suspicion of sexual
                                                          abuse. Varicella may be very itchy in children with
Bacterial, viral and fungal infections are common         atopic eczema, while for herpes zoster, prodromal
in children but seldom life threatening.                  pain and post-herpetic neuralgia is uncommon
                                                          in children. Ramsay-Hunt syndrome and
Molluscum contagiosum has a tendency to infect            ophthalmic herpes will require immediate therapy
atopic patients, may aggravate eczema, and may            with acyclovir. Other common viral infections
be complicated by secondary bacterial infection.          encountered in children were discussed. Roseola
Treatment is often preferred to prevent the child         infantum may be associated with a high risk of
being left out from social activities and may include     febrile convulsion. Slapped cheek syndrome from
short contact potassium hydroxide or by                   parvovirus B can rarely result in aplastic anaemia.
cryotherapy. Special ways of handling children            Coxsackie virus infection may have a risk of
may be required for struggling children. Viral warts      encephalitis. Measles may present as non-specific
are also commonly seen in children and may be             maculopapular eruption but examination of the
treated with cryotherapy. Careful history and             oral cavity will show the pathognomonic Koplik's
communication with the family and patient is              spots. Gianotti Costi syndrome is a self-limiting
essential to identify potential sexual abuse but          condition presenting with fever and papular
warts may also be caused by contact spread.               lesions over the limbs.
Cryotherapy and podophyllin may be used for
perianal warts.                                           Staphylococcal infections of the skin have always
                                                          been the most common bacterial skin infection
Children with eczema have altered skin immunity           and have an important role in causing eczema
which predisposes them to more severe viral               flares. Occasionally Staphylococcus aureus may
infection. Eczema herpeticum is an important              result in staphylococcal scalded skin syndrome and
infection to recognise in atopic patients and may         staphylococcal toxic shock syndrome. Therefore
present as a flare up of eczema with oozing               the importance of good wound management
vesicles. It may be localised to the face and upper       cannot be underestimated. Meningococcaemia
214                                      Reports on Scientific Meetings



presenting as purpura fulminans must be treated          Atopy, commonly defined as the presence of
promptly by antibiotics even before the child is         allergen-specific IgE by skin prick testing or
transported to hospital due to rapid progression         detection of such antibodies in peripheral blood,
and associated high mortality.                           is closely linked to allergic diseases. These complex
                                                         diseases are caused by an intricate interplay
Uncommonly, erythema nodosum may be                      between genetic predisposition and environmental
encountered as tender nodules over the shins or          influences. The elucidation of candidate genes for
erythema induratum as nodules that may ulcerate          allergy and atopy is crucial in understanding their
over the posterior calves. Underlying tuberculosis       pathogenesis and also in predicting the risk of an
should be searched for and the BCG scar should           individual having these conditions later.
be examined.
                                                         Traditionally, genetic predisposition to allergic
Common fungal infections encountered in                  diseases may be assessed by either genome-wide
children include dermatophyte infections of the          linkage analysis or the candidate gene approach.
trunk, feet and nails. Tinea pedis may present as        The target population can either be a cluster of
a blistering eruption. Tinea capitis is less common      families with affected children, in which the genetic
nowadays as a result of improved hygiene and             association may be tested by transmission
living conditions. Axillary scaling may be a result      disequilibrium, or in unrelated case-control
of eythrasma. Pityriasis versicolor is also common       cohorts, in which we can evaluate the selective
and may be treated with a course of oral                 over- or under-representation of candidate gene
itraconazole for 5 days.                                 alleles among patients and non-allergic controls.
                                                         This latter approach has the merit of detecting a
                                                         smaller genetic effect, but it usually requires a
                                                         much larger sample size.
      Learning points:
      Skin infections are common in the paediatric       Over the past 7 years, our group has been
      age group but rarely they can be life              studying intensively on allergy genetics in Chinese
      threatening. It is important to have a high        children using mainly the case-control genetic
      index of suspicion in identifying infections       association approach. The genes which we
      which may have serious consequences and            genotyped include cytokines (IL13, IL1B, IL1RN,
      be aware of clues that may suggest sexual          IL4RA, STAT6), chemokines and mediators of
      abuse.                                             airway inflammation (FCERIB, TBXA2R, NOS1,
                                                         NOS2, NOS3, CTLA4) and bronchial smooth
                                                         muscle tone (ADRB2). A number of these
                                                         candidate genes showed significant association
Allergy genetics in Chinese                              with total and allergen-specific IgE in peripheral
children                                                 blood (IL13, TARC, CD14, DEFB1, NOS1, CTLA4,
Speaker: Professor Leung Ting-Fan                        TBXA2R and ADRB2) and, to a lesser extent,
Associate Professor, Department of Paediatrics, The      asthma (DEFB1, TARC, TBXA2R and MBL2), lung
Chinese University of Hong Kong, Hong Kong               function (RANTES, TBXA2R, STAT6 and IL1B) and
                                                         peripheral eosinophilia (TARC and DEFB1) in local
Allergy is the commonest chronic disease                 children. Some of these associations were not
worldwide and consists of a classical triad of           found in other ethnic groups. Our group also
asthma, allergic rhinitis and atopic dermatitis.         found significant interethnic variations in the minor
Many susceptible patients with allergies undergo         allele frequencies of many of these candidate
an 'atopy march' in which they first develop food        genes for allergy and atopy in Chinese children
allergy and atopic dermatitis during infancy, which      as compared to Caucasians and other Asians.
are followed by the occurrence of asthma and             Recently, our group published significant gene-
allergic rhinitis 2-3 years later.                       gene interactions for conferring risks to asthma
                                          Reports on Scientific Meetings                                      215



(IL13 and IL4RA) and increased plasma total IgE           pulses with very large spot size ad multiple cut
concentration (IL13 and TARC) when a panel of             off filters for various pigmented and vascular
12 single nucleotide polymorphisms from eight             lesions, as well as photorejuvenation.
candidate genes were analyzed by multifactor
dimensionality reduction. In conclusion, the              New concepts in the treatment of specific
genetics of allergic diseases in Chinese children         diseases have appeared in recent years. Daily
is complex and cannot be extrapolated directly            Q-switched laser therapy for melasma and cafe-
from the results published in other populations.          au-lait macules (CALM) is based on additive
                                                          sublethal damage to melanocytes. The plasma
                                                          kinetic skin resurfacing concept provides the
                                                          basis of fractional resurfacing for wrinkle
     Learning points:                                     reduction. The aim of newer systems is to
     Atopy and the closely linked allergic diseases       improve clinical efficacy and safety for targeted
     involve an intricate interplay between genetic       skin problems, with reduced downtime and cost.
     predisposition and environmental
     influences. Local studies of allergy genetics
                                                          Other newly developed laser systems include
     in Chinese children using the case-control
     genetic association approach have been
                                                          ablative fractional resurfacing lasers for skin
     useful in genotyping relevant cytokines,             tightening, fractional infrared lasers for
     chemokines and various mediators,                    rejuvenation and combination systems (e.g.
     identifying interethnic variations of                radiofrequency device plus infrared laser).
     candidate genes and significant gene-gene            Lasers for cellulite therapy are still in the
     interactions conferring risks to asthma and          experimental stage.
     IgE.
                                                          Combination therapy using different laser
                                                          systems, or lasers with other non-laser modalities
                                                          (e.g. IPL systems, microdermabrasion, botulinum
Advances of laser in treating skin                        toxin injection, fillers, light emitting diode (LED)
diseases                                                  devices etc.) has been found to achieve better
Speaker: Dr. William KK Fung                              clinical results for certain skin problems, such
Specialist in Dermatology, Private Practice, Hong Kong    as acne scars and wrinkles, compared with
                                                          cases using single laser systems.
Laser systems have been developed for
treatment of skin diseases and beautification for         The future trend in laser advancement is the
over a decade. In recent years, new concepts              appearance of small sized home devices for skin
of laser technology continue to evolve, driving           rejuvenation, acne therapy and hair removal.
the manufacture of new laser systems at a very            Low energy LED devices for photorejuvenation
speedy pace.                                              have been developed for sale in the market for
                                                          home use.
The refinement of existing laser systems in terms
of energy output, wave form, pulse width
adjustment, operation speed, etc. has rendered
the operation safer, faster and more cost                       Learning points:
effective while producing better clinical efficacy             Continuing evolution and refinement of laser
and outcome. Examples of these include larger                  technologies and new concepts in the
                                                               treatment of skin diseases have provided
spot size and faster operation speeds of new
                                                               much improved safety and clinical efficacy
systems for hair removal, new non-laser intense                in treating various skin problems.
pulsed light (IPL) systems emitting square wave
216                                     Reports on Scientific Meetings



Update on the management of                              from secondary cutaneous ulceration and
cutaneous manifestations of                              infection. However, there is relatively little risk of
rheumatological diseases                                 association with SLE.
Speaker: Dr. Tam Lai-Shan
Associate Professor, Department of Medicine and          Lupus tumidus refers to photosensitive urticarial
Therapeutics, The Chinese University of Hong Kong,       plaques over the face, neck, upper trunk, and
Prince of Wales Hospital, Hong Kong                      proximal upper extremities. It involves deeper level
                                                         and is more nodular with little scaling. Chilbain
Cutaneous lupus erythematosus (CLE) can be               LE is cold-induced violaceous plaque affecting
divided into lupus specific and lupus non-specific       acral aspect of extremities and persists beyond
type, as defined by the presence of 'characteristic'     the cold season.
histology of LE. Lesions that are histologically
specific for lupus erythematosus are divided into        The treatment options are divided into local and
acute, subacute and chronic CLE.                         systemic measures. Sunscreen is advisable to block
                                                         both the UVA & UVB. Local therapies include
Malar rash is a photosensitive erythematous              topical or intralesional steroid, and topical
confluent rash involving both malar eminences            tacrolimus. Single-agent or combined
and crosses the nose bridge, being often referred        aminoquinoline anti-malarial therapy e.g.
to as butterfly rash. It is a form of acute CLE. It is   hydroxychloroquine, hydroxychloroquine and
associated with active systemic disease and will         quinacrine or chloroquine and quinacrine, is the
subside without any scars once the disease is under      initial systemic treatment of choice. Other options
control with steroid or immunosuppressant.               include thalidomide, retinoids, dapsone, gold,
                                                         clofazimine, prednisone, methotrexate,
Subacute cutaneous lupus erythematosus (SCLE)            azathioprine, cyclosporin, and mycophenolate.
accounts for 10-50% of CLE. It is a non-scarring,        Among these, thalidomide is the most efficacious
non-atrophy-producing photosensitive dermatosis          drug for anti-malarial-refractory cutaneous LE, but
and may occur in SLE, Sjogren syndrome, C2               its clinical utility is limited by its adverse effects.
deficiency and drug-induced case. It is more
common in whites. Fifty percent fulfill the diagnosis    The cutaneous manifestations of dermatomyositis
of SLE and serologic abnormalities are common.           (DM) include gottron's papule, heliotrope rash,
The male-to-female ratio in SCLE is 1:4. The             mechanics hands, shawl sign and V-sign. For the
morphology can be papulosquamous or annular.             relationship between cutaneous and systemic
                                                         manifestations of DM, 60% skin and muscle
Discoid lupus erythematosus (DLE) is a chronic,          changes appear together, 30% skin lesion precede
scarring, atrophic, photosensitive dermatosis. DLE       muscle weakness by weeks or months, and 10-
may occur in patients with systemic lupus                20% skin lesion occurs as isolated clinical findings
erythematosus (SLE), and less than 5% will               for more than 6 months beforehand, being called
progress to systemic disease. DLE is responsible         amyopathic dermatomyositis (ADM). ADM is
for 50-85% of CLE. DLE is slightly more common           defined by typical cutaneous disease and no
in African Americans than in whites or Asians. The       evidence of muscle weakness, with normal serum
male-to-female ratio in DLE is 1:2. DLE may occur        muscle enzyme levels repeated for more than 6
at any age but most often in persons aged 20 to          months in the absence of disease-modifying
40 years. The mean age is approximately 38               therapies and abnormal findings on sonogram,
years.                                                   MRI, or muscle biopsy.

Lupus profundus involves subcutaneous lobular            For treatment, UVB & UVA blocking sunscreen is
lymphocytic inflammation with or without overlying       advisable. Local therapies include emollients,
surface change of DLE. Subcutaneous calcification        topical or intralesional steroids and topical
may occur and can produce considerable disability        tacrolimus. Systemic therapies include
                                          Reports on Scientific Meetings                                     217



hydroxychloroquine, combination of                          to multiple drugs. Staphylococcal chromosomal
hydroxychloroquine and quinacrine or chloroquine            cassette mec (SCCmec) type IV, clonal type
and quinacrine. If these fail, other options include        ST30, panton-valentine leukocidin (PVL) gene
dapsone, prednisone, methotrexate, azathioprine,            are also present. The major differences between
cyclosporine, mycophenolate, and intravenous                HA- and CA- MRSA are summarised in the
immunoglobulins. It was found that elevated level           following table:
of TNF-α and its soluble receptors in muscle biopsy
might be directly toxic to myofibers, while
preventing muscle regeneration. TNF inhibitor and           HA-MRSA                  CA-MRSA
B cell depletion therapy might have its role in             Healthcare contact       No healthcare contact
future.                                                     >50 years old            <20 years old
                                                            Bacteraemia              Skin and soft tissue
                                                                                     infections, necrotizing
                                                                                     pneumonia
     Learning points:
     The multi-facet nature of rheumatological              Resistant to β-lactams   Resistant to β-lactams
     cutaneous lesions calls for vigilance and              Multidrug resistance     Usually only resistant to
     completeness in clinical examination as well           (MDR) to clindamycin,    erythromycin,
     as laboratory verification.                            gentamicin,              fluoroquinolones
                                                            fluoroquinolones
                                                            SCCmec I, II or III      SCCmec IV or V
Update on bacterial skin infections                         PVL rare (5%)            PVL positive (95%)
Speaker: Professor Margaret Yip                             Clones ST239, 5 etc.     Clonal type ST30
Department of Microbiology, The Chinese University
of Hong Kong, Hong Kong
                                                            The risk factors for CA-MRSA infections include
Staphylococcus aureus is a major cause of skin              history of previous MRSA infection or colonisation
and soft tissue infections including impetigo,              in patient or close contact, high prevalence in local
folliculitis, cellulitis, erysipelas, scalded skin          community, recurrent skin diseases, crowded living
syndrome and toxic shock syndrome. According                condition, frequent or recent antibiotic usage, and
to Reuters Health Information reported in 2006,             children under 2 years of age. In Hong Kong,
methicillin resistant strain of Staphylococcus aureus       there were 25 episodes (23 cases) of CA-MRSA
(MRSA) is the most common cause of skin and                 from January 2004 to December 2005. Twenty-
soft-tissue infections in major US cities. It can be        four episodes were skin and soft tissue infections
community acquired (CA) and hospital acquired               and 1 episode was meningitis. For those
(HA). Community-acquired MRSA (CA-MRSA) is                  presenting with skin and soft tissue infection,
defined as MRSA infection diagnosed in an                   majority presented as furuncles or carbuncles.
outpatient setting or by a positive culture of MRSA         Other presentations included perianal abscess,
within 48 hrs of hospital admission with the                deep seated thigh infection, infected sebaceous
exclusion of any medical history of MRSA infection          cyst and scalp abscess. The mean age was 28
or colonisation, past medical history including             years ranging from 13 months to 91 years. Three
hospitalisation, admission to a nursing home or             children had eczema, 1 patient was a hepatitis B
institution, dialysis, surgery, and no permanent            carrier and the rest had no underlying disease.
indwelling catheters or medical devices. MRSA               Most cases resolved with incision and drainage,
often affects healthy people and presents as skin           with or without antibiotics.
infections such as boil or abscess by skin contact.
It can also occur in clusters such as athletes,             Concerning the management of CA-MRSA, the
military personnel, children, prisoners etc. Its            primary therapy is adequate incision & drainage
characteristic is resistance to oxacillin but sensitivity   of abscess, and to obtain material for culture if
218                                      Reports on Scientific Meetings



possible. The suitable choice of antibiotics can be       pregnancy, pruritic folliculitis of pregnancy and
either topical or systemic but the latter is preferred.   papular dermatitis of pregnancy.
For the systemic route, cotrimoxazole, clindamycin,
and minocycline are treatment options while               In polymorphic eruption of pregnancy (PEP)
macrolides and fluoroquinolones are not                   (Pruritic urticarial papules and plaques of
recommended because of the increased risk of              pregnancy, PUPPP), pruritic erythematous eruption
resistance. Topical 2% mupirocin can also be used.        occurs in the second half of pregnancy or
The patients should be advised to come back if            immediate post partum. It may be related to
there is no improvement within 48-72 hours. It            damage to connective tissue or elastic fibres within
can also occur as carrier status. The sites with          striae distensae, hormonal factors or fetal factor.
highest sensitivity for MRSA screening are nose,          The condition is self limiting and tends not to recur
throat and perineum (up to 98.3%). There are              in subsequent pregnancy. It does not affect the
various methods used to eradicate MRSA carriage:          fetal outcome and is not associated with changes
2% mupirocin applied over nasal mucosa 3 times            in fetal and birth weight. Management is
per day for 5 days, rifampicin with fusidic acid or       symptomatic with emollients, topical
ciprofloxacin for 5 days applied in throat in             corticosteroids and chlorpheniramine. Systemic
refractory cases or outbreak situation, 4%                steroid is rarely needed.
chlorhexidine bath for 5 days or shampooing hair
2 times weekly with antiseptic detergent. Finally,        Pemphigoid gestationis is associated with
contact precautions are also important such as            hydatidiform moles, choriocarcinomas, Graves'
handwashing, personal protective equipment, and           disease, HLA-DR3 (61-80%), HLA-DR4 (52%) or
environmental cleansing.                                  both (43-50%). The target antigen is BP 180 (BP
                                                          antigen 2, type XVII collagen) transmembrane
                                                          protein in hemidesmosome. The main epitopes
                                                          are restricted to the noncollagenous domain NC-
      Learning points:                                    16A found in placenta after second trimester. The
      Sound microbiological knowledge and                 onset is in 2nd or 3rd trimester, rarely in
      cautious infection control measures are the         postpartum. Spontaneous remission occurs in
      best armaments against the common but               weeks or months after delivery. The condition
      sometimes very noxious Staphylococcus               tends to recur in subsequent pregnancy. Flare with
      aureus skin infection.                              oral contraceptive pills was reported. The condition
                                                          starts in the umbilical region in 50% of the cases
                                                          while sparing the mucosa. It presents with pruritus
Pregnancy related dermatoses                              and urticated lesions initially. Progress to blisters
Speaker: Dr. Shirley W Chan                               is noted in days or weeks. Systemic corticosteroid
Department of Medicine and Therapeutics, The              is used to treat this condition. There is an increased
Chinese University of Hong Kong, Prince of Wales          risk of small for gestational age and premature
Hospital, Shatin, Hong Kong                               delivery. However, there is no increase in fetal
                                                          mortality. Transient blisters or urticated lesions are
Pregnancy related dermatoses included                     noted in up to 10% of the babies due to
1 ) polymorphic er upt ion of pr egn ancy ,               transplacental transmission of maternal
2) pemphigoid gestationis, 3) prurigo of                  antibodies. Indirect IMF with enzyme linked
pregnancy, 4) pruritic folliculitis of pregnancy,         immunosorbent assay (ELISA) detecting BP 180
5) impetigo gestationis, 6) cholestasis of                IgG antibodies to the extracellular domain (NC-
pregnancy, 7) eczema of pregnancy.                        16A) is a potential useful tool in the future.

The term atopic eruption of pregnancy was                 Prurigo of pregnancy occurs more in patients with
proposed by Ambros-Rudolph and MM Black to                an atopic tendency. The onset is 25 to 30 weeks.
include eczema of pregnancy, prurigo of                   It does not recur in subsequent pregnancy.
                                       Reports on Scientific Meetings                                        219



Excoriated papules and nodules are found and            Eczema in pregnancy is probably the commonest
there is no specific laboratory or histopathological    pruritic condition in pregnancy. Pruritic eruption
finding in this condition.                              is found more over the flexural areas. It has a
                                                        variable or early onset. The patients may have a
In pruritic folliculitis of pregnancy, follicular       past or family history of atopy or raised IgE.
papules with sterile pustules are found clinically
and perifolliculitis is noted in the histopathology.
It occurs at 4 to 9 months gestation. It does not
recur in next pregnancy and there is no adverse              Learning points:
fetal outcome. Treatment needs only mild topical             Advances in molecular biology have
steroid and benzoyl peroxide.                                contributed to a better understanding of the
                                                             specific dermatoses of pregnancy and hence
Impetigo herpetiformis (IH) is a rare specific               a better therapeutic approach and
dermatosis of pregnancy. The onset is in 3rd                 prognostic predictability. However, the
trimester. It resolves soon after delivery and tends         aetiopathogenesis remains unclear in most
                                                             entities. It is important to recognise the
to recur in subsequent pregnancy or even with
                                                             diagnosis and initiate appropriate
menstruation or oral contraceptive pills. The
                                                             treatment. Potential fetal and maternal risks
condition may start in flexural regions and spread           must be identified. A team approach that
centrifugally, forming polycyclic plaques with               involves dermatologist, paediatrician, and
pustules over the periphery. It does not have flare          obstetrician is helpful.
after withdrawal of systemic steroid. The histology
is similar to generalised pustular psoriasis (GPP).
Most authorities believe that it is a specific
condition, though IH may develop in patients with       Recent advances in topical
a history of plaque psoriasis. The condition is         treatment of melasma
associated with electrolyte problems,                   Speaker: Dr. Cheong Wai Kwong
hypocalcaemia, hypoparathyroidism and sepsis.           Specialist Skin Clinic, Singapore
Placental insufficiency may also be found and is
associated with fetal abnormality, stillbirth and       Melasma may affect up to 4% of some populations
neonatal death. The management of this condition        in Southeast Asia. It is more commonly seen in
is supportive. Systemic corticosteroid and              patients of skin type III to VI. It is related to solar
cyclosporin may be needed.                              radiation and hormonal changes. About 90% of
                                                        cases are women.
In cholestasis of pregnancy (intrahepatic
cholestasis of pregnancy = obstetric cholestasis        Centrofacial melasma is the most common (64-
= prurigo gravidarum), secondary changes due            70%) type of melasma, affecting forehead, nose,
to itch, e.g. excoriations are found. The incidence     chin, central (flush) area of cheeks and upper lip
is 0.02-2.4% and it occurs more in twin pregnancy.      region. It is important to differentiate between the
Seventy percent recurs in next pregnancy.               epidermal and the dermal varieties as the
Increased total bile acids, alkaline phosphatase,       epidermal variety responds better to treatment.
bilirubin, cholesterol, lipids are found. It is         Pigmentation is intensified in the former but less
associated with increased incidence of stillbirth and   prominent in the latter variety under Wood's light
premature birth, postpartum haemorrhage and             examination.
fetal intracranial haemorrhage due to vitamin K
malabsorption. Treatment options include                Treatment strategies of melasma include
cholestyramine, ursodeoxycholic acid,                   protection from the sun, inhibition of tyrosinase
phenobarbitone and phototherapy to reduce itch.         activity, removal of melanin and blocking transfer
Anti-histamine is not effective.                        of melanosomes. Hydroquinone, tretinoin, topical
220                                    Reports on Scientific Meetings



steroids and azelaic acid are established topical       treatment for melasma. Seventy-three percent
treatments for melasma. However, hydroquinone           cleared or nearly cleared at 1 month and the figure
or tretinoin monotherapy may lead to possible           rose to 81% at 12 months. There was no increase
post-inflammatory hyperpigmentation resulting           in severity of adverse events observed in long term
from irritant dermatitis which is more common in        use over 8 week controlled study. An excellent
dark skinned persons. Moreover, prolonged               safety profile was noted even after 12 months.
duration of treatment may be required for
meaningful results.                                     To effectively manage melasma, the following
                                                        points should be noted: (1) make the right
Hydroquinone has been used in combination with          diagnosis e.g. Hori's naevus might cause
other agents to improve efficacy and minimise           confusion, (2) assess the skin type and beware of
adverse effects. The original combination               sensitive skin type or aged skin, (3) good sun
treatment was developed by Kligman and Willis           protection: daily use of broad spectrum sunscreen
in 1975. Dermatologists worldwide have used             with SPF greater or equal to 30, (4) note details
compounded formulations. However, these                 of previous treatments, (5) optimise the use of
formulations are unstable, not standardised and         Tri-Luma by discontinuing all existing skin care
prone to oxidation. The proposed mechanism of           product if unsure of interaction and treating any
action include 1) tretinoin reduces atrophogenic        existing dermatitis before starting using Tri-Luma,
effect of steroid 2) tretinoin facilitates the          (6) go slow when treating sensitive skin, and (7)
epidermal penetration of hydroquinone 3) the            avoid topicals that dry the skin.
steroid helps reduce irritation caused by tretinoin.
The results were significantly less favourable if one
of the components were omitted.
                                                             Learning points:
Tri-Luma® cream (hydroquinone 4%, tretinoin                 A combination of hydroquinone, tretinoin
0.05%, fluocinolone acetonide 0.01%) is a stable            and steroid is useful in the treatment of
formulation of a recognised compounded                      melasma. Tri-Luma®, a stable formulation
formula. It has a longer shelf life than                    of a recognised compounded formula, is
                                                            found to be effective and safe in treating
compounded formulations and is cosmetically
                                                            melasma.
elegant. It is found to be an effective and safe

				
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