Inews WHAT S NEW? contents. Advanced Master of Dermatology- So what is new?

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1 Inews P E R S A T U A N D E R M A T O L O G Issue 10 September Advanced Master of Dermatology- WHAT S NEW? Datuk Dr Roshidah Baba Chief Coordinator, Advanced Master of Dermatology & Head of Dermatology Service, Ministry of Health, Malaysia The Advanced Master of Dermatology (AMD), since its inception in the year 2001, has seen the successful graduation of 25 trainees. Over the years, the programme has also evolved with some positive changes in the enrolment policy, the structure of training as well as the curriculum. The formation of the Conjoint Board of the AMD in the year 2012 was a significant milestone in the development of this programme. Members of the Conjoint Board are Ministry of Health (MOH), Academy of Medicine, Universiti Putra Malaysia (UPM), University Malaya Medical Centre (UMMC), Universiti Teknologi Mara (UiTM) and Universiti Sains Malaysia (USM). So what is new? i. Enrolment policy Previously, the AMD was open only to trainees from Ministry of Health (MOH) and public universities. However, since July 2014 the AMD is also giving opportunities to trainees from private medical schools. The basis of this new policy is to facilitate private medical schools in training their resident dermatologists. Currently many medical schools are not offering dermatology postings in their undergraduate curriculum due to shortage of dermatologists in the country. With this new policy, it is hoped that all medical schools will be able to introduce 2 weeks of dermatology in their curriculum in due course. The enrolment of a full time trainee from the International Medical University (IMU) in July 2014 is an encouraging start. ii. Structure of training In the past, the AMD stipulated general dermatology training in accredited state hospitals for the first 18 months followed by subspecialty training in Kuala Lumpur Hospital for the second 18 months. With the availability of trainers who are also subspecialists and to enhance training, rotational postings of two months outside Kuala Lumpur Hospital have been introduced in the following hospitals. Selayang Hospital for Contact Dermatitis Institute of Pediatrics for Pediatric Dermatology Sultanah Rahimah Hospital for Phototherapy Ampang Hospital for Dermatopathology Serdang Hospital for Dermatopathology continue on pg3 Front row (from left) : Dr. Tarita Taib, Dr. Henry Foong, Prof. Dr. Pablo Fernandez Pernas, Datuk Dr. Roshidah Baba, Dr. Adawiyah Jamil Second row (from left) : Dr. Ch ng Chin Chwen, Dr. Norli Marwyne, Dr. Wan Noor Hasbee, Dr. Voo Sook Yee, Dr. Nazatul Shima contents 1 Advanced Masters of Dermatology 2 President s Message 3 Editorial 4 Launching of CPG on the Management of Psoriasis Vulgaris 5. Highlights and Current Recommendations on the Management of Acne Vulgaris 6 National Eczema Awareness Month 2014 (NEZAM) 7 Aesthetic Dermatology Workshop 8 Northern Dermatology Summit

2 PRESIDENT S MESSAGE It gives me great pleasure in extending a warm invitation to members, family physicians, trainees and General Practitioners to the 39th Annual Dermatology Conference organized by the Persatuan Dermatologi Malaysia to be held from 15th September to 18th September 2014 at G Hotel Penang. The theme for this year s conference is Challenges in Skin, Hair and Nail diseases and we are really privileged and honoured to have Professor Jerry Shapiro as our key speaker. He is a world renowned authority on diseases of hair and he would be presenting an update on management of Alopecia Areata, Hair loss in women, Cicatricial Alopecia and Frontal fibrosing Alopecia: a new epidemic in women. The committee have also planned an Aesthetic workshop as well as an Interactive Hair and Nail Grand Rounds in addition to presentations on challenges in common skin diseases such as Atopic Dermatitis, Acne, Psoriasis and Onychomycosis. We have chosen Penang as the venue for this year s meeting due to its beautiful sandy beaches, cool breezy weather and without doubt it is the food capital of Malaysia and possibly of the world. Thus together with enhancing our knowledge on skin diseases and catching up with acquaintances we would be overwhelmed by the vast varieties of gastronomic delights available for us to enjoy. EXECUTIVE COMMITTEE President Dr. Najeeb Ahmad Mohd Safdar Vice President Dr. Henry Foong Boon Bee Hon. Secretary Dr. Agnes Heng Yoke Hui Hon. Treasurer Dr. Noor Zalmy Azizan Committee Members Dr. Chan Lee Chin Dr. Mohd Noh bin Idris Dr. Khaw Guat Ee Dr. Rohna Ridzwan Immediate Past President Dr. Koh Chuan Keng Hon. Auditor Dr Gan Ain Tian So mark your calender now and hope to meet up with everyone at fabulous Penang. DR. NAJEEB AHMAD MOHD. SAFDAR President Persatuan Dermatologi Malaysia 2

3 from the EDITOR It gives me great interest to talk about passion for dermatology. It brings back my memory when I attended one of Dermanities meeting during the American Academy of Dermatology annual meeting in San Francisco several years ago where I first met Professor Walter Shelley. He was a great teacher and orator. He spoke about the subject and inspired me enormously. The love of medicine is important if we are to enjoy what we are doing. We all remember our excitement when we were medical students using our stethoscopes. We were so proud of hanging our stethoscope around the neck during our ward rounds. Walter Shelley says The soul of passion comes from curiosity. To be curious about your patients and about the diseases. Don t look merely at lesions as they are static and boring. What is there? What is not there? Look at the lesions in different ways with attention at the overlooked areas. Invert the lesions; transpose the lesions. Curiosity also applies to doing skin biopsies. We think we know about the lesions but when we biopsy the lesions we may not find what we thought of initially. Do it with bubbling curiosity. How do we maintain curiosity? Reading is important as it gives you lots of ideas. Of course the internet is an excellent source of information. Attending meetings help you to recharge your ideas. Meeting colleagues at the hallway can be a source of information too. Walter Shelley MD told this story when he spoke at the meeting in San Francisco. A physician in California who was making rounds with her students and she came in and they were all downcast, apathetic, passionless and bored. She asked What is the matter? And they replied we don t have any interesting patients to show you. They are all just dull patients and there is nothing interesting. Then she said, I want you to show me the LEAST interesting patient you have on the ward. So they took her to this old lady. The physician came up and said to the woman. Have you ever been in hospital before? The woman said, Yeah. Why were you in the hospital? I had a broken arm. And the physician said Well, how did you break your arm? The woman said, I fell out of a berth. The physician asked You fell out of a berth? Ya, the boat hit something and I was tossed down on the floor. Well, it was the TITANIC! This most uninteresting patient was then in a sense was the most interesting story of the day. And the physician was just using that to point out that if you are curious, things will become interesting. This story is important. When you do your rounds in the ward, you will find that your rounds become very interesting when you are curious about your patients. Don t let your practice drag you down with fatigue, tiredness and boredom. Enjoy your practice! You will be in the clinic and see new things, find new treatment, experience warmth and satisfaction of patients and have a wonderful day. And when you do that you will be passionate about your practice, you will enjoy it and as a result you will go home flying with happiness. Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words heard in the lecture room or read from the book. See, and then reason and compare and control. But see first. Sir William Osler M.D. Education remains an important goal and objective of the Society. The President, Dr Najeeb Ahmad Safdar and his organising committee has prepared a well balanced scientific program for our annual meeting this year in Penang and we look forward to an exciting coming year with useful educational programs for our members and trainees. Enjoy your reading! DR. HENRY FOONG FRCP (Edin) Advanced Master of Dermatology - WHAT S NEW? continued from pg1 iii. Curriculum In 3 successive years, the programme has engaged external dermatopathologists, Prof. Dr. Nopadon (Thailand) and Dr. Ghaznawie (Indonesia) in yearly dermatopathology workshops. In October 2014, Prof. Dr. Tetsu Kimura of Kimura Dermatopathology School (Sapporo, Japan) will be conducting a 2 week course on the basics of dermatopathology to enhance training in dermatopathology for all trainees, dermatologists and pathologists in Malaysia. Attention to soft skills and communication skills is also considered necessary for a wholesome training and trainees have been encouraged to attend these workshops. In May this year, four trainees passed the final examinations of the AMD. Prof. Dr. Pablo from University of Sydney and Dr. Henry Foong were their examiners. To update members, the proposal to introduce AMD in the 4th year of Master of Internal Medicine (MMed) was approved by the Conjoint Board of MMed in September The implementation of this proposal will require the final approval by the Director General of Health special committee. The success of this programme would not have been possible without the relentless support and commitment of all trainers. We would like to record our sincere appreciation to all trainers, Ministry of Health and Persatuan Dermatologi Malaysia for their continuous support in making this programme a successful and viable one. 3

4 Launching of CPG on the Management of Psoriasis Vulgaris Choon Siew Eng, FRCP, Mohd Aminuddin MY on behalf of the Guideline Development group, Malaysia Health Technology Assessment Section, Medical Development Division, Ministry of Health Malaysia Presentation of the CPG to the audience & media Press conference after launching ceremony Psoriasis is a systemic chronic inflammatory disease that affects 1-3 % of the general population worldwide. In the Malaysian Psoriasis Registry 2013, plaque psoriasis is the commonest form (85%) while psoriatic arthritis occurs in 16% of the the patients. Patients with psoriasis do not only have to deal with their highly visible skin disease but also endure psychological problems such as low self-esteem, rejection and depression.. Due to the disease burden and wide variations of clinical practice on the treatment of psoriasis, an evidence-based CPG on the condition has been developed. Recommendations in the CPG include assessment of the physical severity of psoriasis and its impact on patients quality of life, regular assessments for associated arthritis for timely referrals to the rheumatologists and screening of metabolic syndrome and other classic risk factors of cardiovascular diseases. Although there is no cure for psoriasis, skin clearance can occur with appropriate treatments which include topical therapies, phototherapy and systemic medications. Treatment goals and the choice of treatment should be individualised based on disease severity, patients preferences and co-morbidities. Treatment goals should be monitored regularly to ensure adequate, long-term effective treatment. The newly-approved CPG entitled Management of Psoriasis Vulgaris was officially launched by YB. Datuk Dr. S. Subramaniam, Minister of Health Malaysia, on 13 October 2013 at Istana Hotel, Kuala Lumpur. The event was jointly conducted by MaHTAS and Dermatological Society of Malaysia. It was attended by about 100 participants who were mainly dermatologists, family medicine specialists and other healthcare providers involved in the management of psoriasis from both public and private sectors. The launching ceremony was preceded by a continuous medical education (CME) on selected CPG topics which was delivered by members of the CPG development group. The aim of the launching was to create awareness of the CPG existence which will help to increase its utilisation. In his launching speech, the minister stressed on optimising the treatment of psoriasis by not just reducing skin-related morbidity but also preventing co-morbidities. The minister also presented CPG packages consisting of the CPG and a concise Quick Reference to representatives from the state health department, medical faculty and professional society. This is a symbolic mandate for them to implement the CPG at their respective institutions. A press conference was held after that. 4

5 Highlights and Current Recommendations on the Management of Acne Vulgaris Treatment of acne vulgaris is directed toward the four main pathophysiologic processes involved in acne formation namely; excess sebum, follicular hyperproliferation, Propionibacterium acnes infection, and inflammation. The choice of treatment modality is influence by the grade and severity of the acne, the degree of scaring and also the degree of negative psychosocial impact experience by the patient. The following are some of the highlights and recommendations for the management of acne 1. Benzoyl peroxide is generally safe and effective as monotherapy or when used in combination with other topical agent(s). It has bactericidal effects by generating reactive oxygen species within the follicle. Benzoyl peroxide has anti-inflammatory properties and can prevent the development of antibiotic resistance. Irritation is the main side effect and it may bleach clothing, bedding and hair. All retinoids except adapalene are unstable with benzoyl peroxide and thus they should be used separately 2. Topical retinoids are now the mainstay of treatment. It may be used either as monotherapy or in combination with other therapeutic agents for acne of all types and severities, except when oral retinoids are used. Retinoids is also recommended for maintenance therapy due to their abilities to prevent the development of microcomedones. 3. Topical antibiotics (clindamycin, erythromycin) are used for mild to moderate acne especially when inflammatory lesions are present. Of concern is development of antibiotic resistance. Patterns of P acnes resistance correspond to trends in antibiotic use. This is not the only concern; may also cause development of Staphylococcus and Streptococcus resistance. Therefore, it is recommended to avoid antibiotic monotherapy and maintenance therapy but to use combined regimens and limit duration of topical antibiotics to 12 weeks when possible. Topical antibiotics should always be used with retinoids and possibly benzoyl peroxide. Combined topical and oral antibiotics should be avoided. 4. Oral antibiotics may be used for moderate-to-severe inflammatory acne for any age. It has antimicrobial and anti-inflammatory properties. Doxycycline. minocycline, tetracycline and erythromycin are most commonly used. Antibiotic selection is influence by side effect profiles and pattern of P acnes resistance. Local data by Tang JJ et al found that clindamycin resistance was the most common (15.1%) followed by erythromycin (7.5%), doxycycline (5.7%) and tetracycline (1.9%). Tetracycline is contraindicated in pregnant women and children (< 8 years old) as it causes tooth discoloration. Doxycycline causes photosensitivity. Minocycline may cause skin hyperpigmentation and drug induced systemic lupus erythematosus. Avoid prolonged antibiotic courses and antibiotic monotherapy because of the risk of bacterial resistance. Always use in conjunction with benzoyl peroxide or topical retinoid. When possible, limit antibiotic courses to 12 weeks duration. 5. Hormonal therapy with combination oral contraceptives may be used as second-line therapy in pubertal females with moderate-to-severe acne. Anecdotal reports found it particularly helpful in women with lesions confined to the lower half of the face and jaw. 6. Oral Isotretinoin is recommended for severe, scarring, and/ or refractory acne. 7. Do not underestimate the impact of acne on the patient s quality of life and mental health. Many studies have shown an association between acne and depression and anxiety, independent of disease severity. 8. Do not forget to assess treatment adherence, which may be limited by irritation or regiment complexity. 5

6 National Eczema Awareness Month 2014 (NEZAM) Dr Sabeera Begum Senior Pediatric Dermatologist, Institut Pediatrik, Hospital Kuala Lumpur In a bid to empower eczema suffers and caregivers on the proper management techniques of this condition, the Dermatological Society of Malaysia initiated a partnership with the Malaysian Paediatric Association, to commemorate, National Eczema Awareness Month ( NEZAM ), which ran through the month of April As part of NEZAM s 2014 educational initiative, the 30-day My Eczema Journey Challenge was launched on 2 April Themed Together in Eczema in 2014, this nationwide public education initiative is designed to put medical professionals back into the driver s seat in the treatment of eczema whilst empowering caregivers and patients on the importance of proper and proactive management of eczema. This 30-day Challenge sees eczema sufferers, recruited nationwide via a network of specialists, receive fully-sponsored fortnightly medical consultations together with medication (related to atopic eczema treatment) and complimentary supply of AtopiclairTM. Participants were required to document their My Eczema Journey by submitting weekly photographs of the affected skin, together with a short description of their current progress. 50 participants registered for the challenge and delightfully, 70% of them managed to improve their eczematous condition based on the photos they submitted. Besides sending their photos to update their progress, participants also gave their testimonies explaining their experiences, hopes and feelings throughout the challenge. At the end of the My eczema Journey 30-day Challenge winners were selected by experts panel based on the three categories: - The most remarkable improvement in eczema based on pre and post photos, - The most complaint or diligent participant - The most compelling story on battling eczema from the child/patient s perspective The closing ceremony and prize presentation to the winners was held on 28th May 2014 at KidZania, Kuala Lumpur. The grand prize winner was a four month old baby who had 95% improvement of her eczema during the My Eczema Journey programme. Indeed the My Eczema Journey 30 day Challenge had successfully helped a lot of the participants improve their eczema. Through determination and resolution, from the patients, supporting family members and medical personnel can get together to make a difference. We thank A. Menarini (manufacturer of Atopiclair TM ) for supporting My Eczema Journey and NEZAM 2014 via an unconditional educational grant. The National Eczema Awareness Month 2014 Expert Committee posing with the 30-Day Challenge winners: (from R-L) Mr Cheah Chor Eng, General Manager of A. Menarini, 2nd prize winner, Madam Gokilavani A/P Cilwarajan with her son, Dr Najeeb Safdar, Datuk Dr Zulkifli Ismail together with Grand Prize Winner, Mrs Ilda Halina Bt Ilyas and her baby, Mya posing for a group photo Grand Prize winner, Mrs Ilda Halina Bt Ilyas sharing her testimony from a parent s perspective on her baby s eczema journey. 6

7 Aesthetic Dermatology Workshop for Dermatologist Dr Irene Lee Chew Kek MBBS, MRCP, Adv M Derm Associate Professor, Head of School of Anti-Aging, Aesthetics and Regenerative Medicine, Faculty of Medicine and Health Sciences, UCSI University, Kuala Lumpur Persatuan Dermatologi Malaysia organized the first Aesthetics Dermatology Workshop for Dermatologist in collaboration with School of Anti-aging, Aesthetics and Regenerative Medicine, UCSI University and Allergen Sdn Bhd on 5th and 6th October The workshop was opened to all members of Persatuan Dermatologi Malaysia and dermatology trainees currently in the Master of Dermatology course. It was held at the School of Anti-aging, Aesthetics and Regenerative Medicine, UCSI University, Kuala Lumpur and was attended by 17 participants. Speakers included Dr Lee Kim Siea, an experienced plastic surgeon from Carl Corrynton Medical Centre, Penang and Dr Irene Lee from UCSI University, Kuala Lumpur. The two-day workshop included a series of lectures, practices on mannequin, demonstrations as well as practical sessions on volunteers. At the end of the workshop, participants were armed with the theoretical knowledge and practical experience in both botulinum toxin and dermal filler. On top of that, continuous medical education (CME) points were awarded by Malaysian Medical Association and certificate of attendance were given to all participants. 7

8 Northern Dermatology Summit 2014 Report Dr Tan Wooi Chiang Consultant Dermatologist & Head, Department of Dermatology, Hospital Sultanah Bahiyah, Alor Setar. On 17th and 18th May 2014, the Department of Dermatology Hospital Sultanah Bahiyah in collaboration with the Department of Dermatology, Hospital Pulau Pinang organized the Northern Dermatology Summit This year s summit was held in Hospital Sultanah Bahiyah, Alor Setar, Kedah and was chaired by the Head of Department of Dermatology, Dr Tan Wooi Chiang. The theme for this two-day event was ABC in Dermatology. As the name suggested, the focus was on the basics of Dermatology in hopes of imparting dermatological knowledge to primary care physicians; as well as to attract young doctors to further into the field of Dermatology as their specialty. This event has attracted participants from and outside of Kedah, with total participants of 300 and was supported by MMA, Kedah Branch, PDM, PGMES Hospital Pulau Pinang and pharmaceutical counterpart. The event started off on 17th May with a Morning Focus session on New Insight of Atopic Eczema which was delivered by Dr Leong Kin Fon, consultant paediatric dermatologist Hospital Kuala Lumpur. The program then continued with Symposium 1, focusing on Common Skin Disorders and boasting a prestigious list of speakers such as Dr Ng Su Yuen, consultant paediatric dermatologist from Hospital Pulau Pinang (Lumps and Bumps on The Skin) and Dr Tang Jyh Jong, Consultant Dermatologist and Head, Hospital Raja Permaisuri Bainun Ipoh (Cutaneous Infection) Symposium 2 focused on How Do I Approach, with lectures presented by Dr Leong Kin Fon (Clinical Approach to Febrile Rash: The Urgencies and Emergencies), Dr Tang Jyh Jong (Clinical Approach to Itch), Dr Lo Kang Shang Chit, a Consultant Dermatologist from Island Hospital Penang (Clinical Approach to Urticaria), Dr Chong Yew Thong (Clinical Approach to Hair Loss), Dr Agnes Heng Yoke Hui, Consultant Dermatologist, Agnes Heng Dermatology Ipoh (Clinical Approach to Facial Hyperpigmentation, Clinical Approach to Blistering Skin Disorders), Dr Khor Yek Huan, Dermatologist and Head of Hospital Tuanku Fauziah, Kangar (Clinical Approach to Leg Ulcer), and Dr Henry Foong (Clinical Approach to Facial Hypopigmentation). Symposium 3, which focused on practical aspects of procedures in Dermatology & Dermatologic Therapeutics, were presented by Dr Leong Kin Fon (Skin Prick Test), Dr Ng Su Yuen (Wet Wrap), Dr Lo Kang (Topical Medications in Dermatology), Dr Chong (Kenacort Injection), Dr Chan Lee Chin, Consultant Dermatologist & Head of Hospital Pulau Pinang (Modern Dressing), Dr Ng Su Yuen (Epidermolysis Bullosa Wound Dressing), Dr Henry Foong Boon Bee, who is the Vice President of PDM, Consultant Dermatologist for Foong Skin Specialist Clinic, Ipoh, Perak (Dermatological Laser), Dr Peter Ch ng Wee Beng, Dermatologist and HOD of Hospital Tengku Ampuan Afzan (Cryotherapy and Skin Patch Test). Dr Yeoh Chin Aun presented the last lecture of the day entitled Specimen Sampling: Fungal Scraping, Tape Test and Tzanck Smear. We have also added the dermatological quiz sessions for the participants and prizes were given to the top three scorers for the quiz. Overall this Summit had been a huge success and participants were satisfied with the knowledge gained from their two-day participation. The Dermatology Department of Hospital Sultanah Bahiyah is hoping to organize more dermatology events in the near future. 8