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.
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.
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.
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
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
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
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.
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
elegant. It is found to be an effective and safe