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Interim analysis of the National Skin Centre Singapore Psoriasis Biologics Registry (SINGPSOR) from August 2017 to May 2021, in which 58 patients were analysed, showing that those receiving biologic treatment had significantly more severe psoriasis based on PASI (Psoriasis Area and Severity Index), BSA (body surface area) and PGA (Physician Global Assessment) measures at baseline, demonstrated a statistically non‐significant trend towards greater improvement with treatment, and had a lower percentage of adverse events compared to those receiving conventional systemic therapy. Future analyses of SINGPSOR, with larger sample size and longer follow‐up, will be invaluable to further characterize these patients and their treatment outcomes. [ABSTRACT FROM AUTHOR]

Background: Public trust in immunization is an increasingly important global health issue. Losses in confidence in vaccines and immunization programmes can lead to vaccine reluctance and refusal, risking disease outbreaks and challenging immunization goals in high- and low-income settings. National and international immunization stakeholders have called for better monitoring of vaccine confidence to identify emerging concerns before they evolve into vaccine confidence crises. Methods: We perform a large-scale, data-driven study on worldwide attitudes to immunizations. This survey – which we believe represents the largest survey on confidence in immunization to date – examines perceptions of vaccine importance, safety, effectiveness, and religious compatibility among 65,819 individuals across 67 countries. Hierarchical models are employed to probe relationships between individual- and country-level socio-economic factors and vaccine attitudes obtained through the four-question, Likert-scale survey. Findings: Overall sentiment towards vaccinations is positive across all 67 countries, however there is wide variability between countries and across world regions. Vaccine-safety related sentiment is particularly negative in the European region, which has seven of the ten least confident countries, with 41% of respondents in France and 36% of respondents in Bosnia & Herzegovina reporting that they disagree that vaccines are safe (compared to a global average of 13%). The oldest age group (65+) and Roman Catholics (amongst all faiths surveyed) are associated with positive views on vaccine sentiment, while the Western Pacific region reported the highest level of religious incompatibility with vaccines. Countries with high levels of schooling and good access to health services are associated with lower rates of positive sentiment, pointing to an emerging inverse relationship between vaccine sentiments and socio-economic status. Conclusions: Regular monitoring of vaccine attitudes – coupled with monitoring of local immunization rates – at the national and sub-national levels can identify populations with declining confidence and acceptance. These populations should be prioritized to further investigate the drivers of negative sentiment and to inform appropriate interventions to prevent adverse public health outcomes.

Background: Atopic dermatitis (AD) is one of the most prevalent chronic inflammatory skin conditions. We aimed to describe the clinical features of adult‐onset and childhood‐onset AD in a multi‐ethnic Asian population. Methods: A retrospective study was performed of 188 patients with AD managed at a tertiary skin institution in Singapore. Patient demographics, clinical features and disease scores were analysed. Results: Clinical features related to pigmentary changes, such as orbital darkening and Dennie–Morgan folds were more prevalent among childhood‐onset AD patients than in adult‐onset AD patients. Similarly, features related to prolonged scratching or friction, such as anterior neck folds, perifollicular accentuation and infra‐auricular/infranasal fissuring were also more prevalent in childhood‐onset AD patients. Disease scores such as SCORAD and EASI were not different between patients with childhood versus adult‐onset disease. Conclusion: There were significant differences in clinical features between childhood‐onset and adult‐onset AD. Certain features are related to pigmentary changes and might be more accentuated in patients with skin of colour. Further studies are needed to understand how the different features might be clinically significant and related to the various AD endotypes and disease trajectories. [ABSTRACT FROM AUTHOR]

Background: Previous studies regarding the risk of skin malignancy with NBUVB have been performed in Caucasian patients, but few studies have been conducted in Asians. Aim: The aim of the study was to determine the risk of skin cancer in Asian patients with psoriasis and vitiligo receiving NBUVB phototherapy. Methods: We performed a 9‐year retrospective study including all patients with psoriasis and vitiligo receiving NBUVB (either 311 nm wavelength through cabin phototherapy or 308 nm through excimer lamp phototherapy) at the National Skin Centre. We matched the identification numbers of patients to the National Registry of Diseases Office database and collected data on all skin cancers diagnosed. Results: A total of 3730 patients were included. During the course of the study, 12 cases of skin cancer were diagnosed, of which 10 were basal cell carcinomas, and 2 were squamous cell carcinomas. No cases of melanoma were detected in the study. The age‐standardized incidence of skin cancer in psoriasis and vitiligo patients who received phototherapy was 47.5 and 26.5, respectively, which is higher than the incidence of skin cancers in the general population. Risk of skin malignancy was positively correlated with the cumulative (p =.008) and maximum dose of phototherapy (p =.011) as well as previous systemic treatments (p =.006). Limitations: Limitations include a relatively short follow‐up period as well as the lack of quantification of solar exposure. Conclusions: NBUVB phototherapy in Asian skin increases the risk of skin malignancy. The risk of skin malignancy is higher with psoriasis patients, greater cumulative and maximal dose of phototherapy as well as the use of systemic therapy. Despite the increased risk, the absolute number of skin malignancies remains low, especially for vitiligo patients, with no cases of melanoma diagnosed—a reassuring finding that phototherapy remains a safe alternative in the treatment of psoriasis and vitiligo. [ABSTRACT FROM AUTHOR]

Background: Although the traditional understanding is that contact sensitization is less frequent in patients with atopic dermatitis (AD), recent studies have shown similar or higher rates of positive patch‐test results in AD patients. Objectives: We sought to characterise the pattern of contact sensitization in patients with and without AD and evaluate the association between AD and contact sensitization. Method: This was a single‐center, 10‐year retrospective review of patients who underwent patch testing between 2007 and 2017. Results: There were 4903 patients (male‐to‐female ratio = 1:1.4; mean age 40.1 years) included. About half (2499, 51.0%) of all patients developed at least one positive reaction. The top five frequent reactions were to nickel sulfate (45.4%), potassium dichromate (16.0%), p‐phenylenediamine (13.4%), Myroxylon pereirae (11.8%), and fragrance mix I (11.2%). The overall prevalence of contact sensitization was not significantly different between patients with or without AD. Patients with AD were less likely to develop contact allergies to budesonide and thiuram mix, and more likely to develop contact allergies to potassium dichromate. Conclusions: Contact sensitization was detected in 50% of patients who were patch tested. Nickel sulfate was the most frequently sensitizing allergen. The prevalence of contact allergies in atopic patients is comparable to that in non‐atopic patients. [ABSTRACT FROM AUTHOR]

Background: Pediatric allergic contact dermatitis (ACD) is increasingly prevalent. Patch testing is the gold‐standard diagnostic investigation. The aims of our study were to describe the clinical profile of pediatric patients with ACD in a multi‐ethnic Asian population and identify the common contact allergens. Methods: This was a retrospective study involving children and adolescents aged 16 years or younger with clinically suspected ACD who underwent patch testing between January 2007 and March 2020 at two institutions in Singapore. Information pertaining to their demographics, atopy history, clinical presentation, and patch test results was analyzed. Results: A total of 252 patients were included. The mean age was 10.9 years (1.0–16.7 years). The majority were Chinese (79.8%) and girls (57.5%). Many (66.3%) had atopic dermatitis (AD), which was mild. The most common presentation was an acral eczematous rash. The sensitization rate was 50.0%. The most frequent reactions were to nickel sulfate (49.2%) and fragrance mix (19.1%). The overall rate of relevant positive patch tests was 72.5%. Patients with AD were less likely to have a reaction to fragrance mix (p =.019) and more likely to have a reaction to disperse blue (p =.041). Compared to younger children, adolescents were less likely to have a positive patch test (p =.008). Indians were also less likely to have a positive reaction (p =.004). Conclusion: Metals and fragrances were the most common allergens causing childhood ACD in Singapore. Patients with AD were less likely to be sensitized to fragrances and more likely to be sensitized to disperse blue dye. [ABSTRACT FROM AUTHOR]

Introduction: Mildly symptomatic cases of Covid-19 in previously-well individuals form the majority of infections and also serve as potent vectors of transmission. The factors affecting the duration of SARS-CoV-2 RNA viral shedding (DVS) in these patients remain largely unknown. Objectives: To perform a systematic analysis of the clinical, radiologic, laboratory investigations in patients with few comorbidities infected with mild Covid-19 to identify factors associated with the DVS. Methods: In this retrospective cohort study, patients with mild or asymptomatic Covid-19 were included. Baseline characteristics including age, nationality, comorbidities, concomitant medications, and type of isolation arrangement in the facility (single or in pairs) were collected. Clinical features and radiologic/haematologic findings were also collected. Taking day 28 as the cut-off, 187 patients who had a negative swab result up to day 28 (no prolonged DVS) were compared to 126 patients with a persistently positive result on or after day 28 (prolonged DVS). Results: Of 964 consecutive patients included, 851 (88.3%) patients were symptomatic. 266 patients had a documented negative RT-PCR assay with a median DVS of 25 days (range: 13 to 96 days; interquartile range (IQR): 22 to 33 days). Patients isolated in pairs were associated with prolonged DVS (OR: 2.7; 95% CI: 1.7 to 4.5; p<0.0001) compared to those isolated individually. Among vital signs, only tachycardia was associated with prolonged DVS (OR: 2.6; 95% CI: 1.0 to 7.1; p = 0.03). Amongst investigations, only a raised CRP was associated with prolonged DVS (OR: 2.7; 95% CI: 1.1 to 6.8; p = 0.02). Conclusions: In young, mildly symptomatic Covid-19 patients, prolonged DVS was associated with being isolated in pairs compared to individually. In situations where a negative RT-PCR test result is required, retesting in patients who were not isolated individually, or who had baseline tachycardia or a raised CRP, may be delayed to increase the yield of a negative result. [ABSTRACT FROM AUTHOR]

Background and Aim: The impact of chronic constipation on health‐related quality of life (HRQoL), work productivity, and healthcare resource use in Japan is not well understood. This study aimed to evaluate and compare the humanistic burden of respondents with chronic constipation to respondents without chronic constipation and to respondents with type 2 diabetes mellitus (T2DM), irritable bowel syndrome (IBS), and gastroesophageal reflux disease (GERD), respectively. Methods: This cross‐sectional study collected demographic and general health data and HRQoL data as measured by the Short Form 12‐Item (Version 2) Health Survey and EuroQol 5‐dimension health surveys. Health impacts on employment‐related activities and indirect costs were measured using the Work Productivity and Activity Impairment questionnaire. Propensity score matching was used to identify a control group without chronic constipation. Multivariate generalized linear models were used to identify potential factors that may impact the outcomes of respondents. Results: A total of 30 001 individuals responded to the Japan National Health and Wellness Survey 2017, whereof 3373 (11.2%) reported having chronic constipation; 963 were physician diagnosed. Compared with matched controls, patients with physician‐diagnosed chronic constipation had lower mean HRQoL scores and higher mean absenteeism, presenteeism, total Work Productivity and Activity Impairment, and indirect costs. Physician‐diagnosed chronic constipation was associated with a higher health burden than T2DM, IBS, and GERD. Conclusions: Chronic constipation is associated with a considerable health burden, which is higher compared with T2DM, IBS, and GERD. These results suggest an urgent need for effective treatment of Japanese patients with chronic constipation to improve their quality of life. [ABSTRACT FROM AUTHOR]

This retrospective study aims to identify the frequency, distribution, and temporal trends of contact allergens in the standard series at our tertiary referral centre over a 6-year period from 2014 to 2019. A multicentre study conducted in Central Europe found a slight increase in chromate allergy from 3.3% to 4.5% between 2015 and 2018.3 Once the relevance of these results is considered, our 1.4% is closer to the 1.1% observed in the American population.4 Nevertheless, we should monitor whether chromate sensitization continues to decline after peaking in 2015, which coincides with the European Union legislation on limiting hexavalent chromium content in leather. (iii) Exposed: the allergen had been encountered by the patient previously, but the patient did not develop dermatitis then. [Extracted from the article]

We examined the prevalence and impact of hair loss, treatment-seeking behaviour and expectations of treatment in patients with self-reported hair loss. This study highlights the health-seeking behaviours in hair loss, expectations of treatment, and factors associated with impaired QoL and willingness to pay. [Extracted from the article]

Dear Editors, Scleroderma is the most common form of fibrotic disease involving the skin, and the subtype that only affects the skin is known as morphea. Optical coherence tomography has been shown to be useful in fibrotic skin disorders, in obtaining in vivo cross-sectional visualization.1-3 The high-definition optical coherence tomography (HD-OCT) (Skintell®) developed more recently allows imaging with an enhanced resolution of 3µm in both axial and lateral planes and has an imaging depth of 570 µm.4 We developed a software platform that performs automated 3D skin layer segmentation in HD-OCT skin images5 and subsequent quantitative measurement of epidermal thickness and dermal heterogeneity across the entire skin layers in 3D. Virtual skin biopsy by optical coherence tomography: the first quantitative imaging biomarker for scleroderma. [Extracted from the article]

Background: Few studies have evaluated the relative cross-protection conferred by infection with different groups of viruses through studies of sequential infections in humans. We investigated the presence of short-lived relative cross-protection conferred by specific prior viral infections against subsequent febrile respiratory illness (FRI).Methods: Men enlisted in basic military training between December 2009 and December 2014 were recruited, with the first FRI as the study entry point. ResPlex II assays and real-time polymerase chain reaction assays were used to detect viral pathogens in nasal wash samples, and survival analyses were performed to determine whether infection with particular viruses conferred short-lived relative cross-protection against FRI.Results: Prior infection with adenovirus (hazard ratio [HR], 0.24; 95% confidence interval [CI], .14-.44) or influenza virus (HR, 0.52; 95% CI, .38-.73) conferred relative protection against subsequent FRI episode. Results were statistically significant even after adjustment for the interval between enlistment and FRI (P < .001). Adenovirus-positive participants with FRI episodes tended to be protected against subsequent infection with adenovirus, coronavirus, enterovirus/rhinovirus, and influenza virus (P = .062-.093), while men with influenza virus-positive FRI episodes tended be protected against subsequent infection with adenovirus (P = .044) and influenza virus (P = .081).Conclusion: Prior adenovirus or influenza virus infection conferred cross-protection against subsequent FRI episodes relative to prior infection due to other circulating viruses. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to determine if disposable filtering facepiece respirators (FFRs) that come with an exhalation valve (EV) and a novel active venting system (AVS) provided greater perceived comfort and exertion when compared to standard N95 FFRs without these features among male military personnel performing prolonged essential outdoor duties.Methods: We used a randomised open-label controlled crossover study design to compare three FFR options: (a) standard FFR; (b) FFR with EV; and (c) FFR with EV+AVS. Male military personnel aged between 18 and 20 years completed a questionnaire at the start of outdoor duty (baseline), after two hours of standardised non-strenuous outdoor duty and after 12 hours of duty divided into two-hour work-rest cycles. Participants rated the degree of discomfort, exertion and symptoms using a five-point Likert scale. The association between outcomes and types of FFR was assessed using a multivariate ordered probit mixed-effects model.Results: For a majority of the symptoms, study participants gave FFR with EV and FFR EV+AVS significantly better scores than standard FFR. Both FFR with EV and FFR with EV+AVS had significantly less discomfort (FFR with EV+AVS: 91.1%; FFR with EV: 57.6%) and exertion (FFR with EV+AVS: 83.5%; FFR with EV: 34.4%) than standard FFR. FFR with EV+AVS also had significantly better scores for exertion (53.4%) and comfort (39.4%) when compared to FFR with EV.Conclusion: Usage of FFR with EV+AVS resulted in significantly reduced symptoms, discomfort and exertion when compared to FFR with EV and standard FFR. [ABSTRACT FROM AUTHOR]

Introduction: For pathogens such as influenza that cause many subclinical cases, serologic data can be used to estimate attack rates and the severity of an epidemic in near real time. Current methods for analysing serologic data tend to rely on use of a simple threshold or comparison of titres between pre-and post-epidemic, which may not accurately reflect actual infection rates. Methods: We propose a method for quantifying infection rates using paired sera and bivariate probit models to evaluate the accuracy of thresholds currently used for influenza epidemics with low and high existing herd immunity levels, and a subsequent non-influenza period. Pre-and post-epidemic sera were taken from a cohort of adults in Singapore (n=838). Bivariate probit models with latent titre levels were fit to the joint distribution of haemagglutination-inhibition assay-determined antibody titres using Markov chain Monte Carlo simulation. Results: Estimated attack rates were 15% (95% credible interval: 12%-19%) for the first H1N1 pandemic wave. For a large outbreak due to a new strain, a threshold of 1:20 and a twofold rise (if pared sera is available) would result in a more accurate estimate of incidence. Conclusion: The approach presented here offers the basis for a reconsideration of methods used to assess diagnostic tests by both reconsidering the thresholds used and by analysing serological data with a novel statistical model. [ABSTRACT FROM AUTHOR]

Background: Correlations between hemagglutination-inhibition titers (hereafter "titers") and protection against infection have been identified in historical studies. However, limited information is available about the dynamics of how titer influences protection.Methods: Titers were measured in randomized, placebo-controlled vaccine trials in Hong Kong among pediatrics during September 2009-December 2010 and the United States among adults during Oct 2007-April 2008. Intermediate unobserved titers were imputed using three interpolation methods. As participants were recruited at different times leading to varying exposure to infection relative to entry, a modified proportional hazards model was developed to account for staggered entry into the studies and to quantify the correlation of titers with protection against influenza infections, adjusting for waning in titers. The model was fitted using Markov chain Monte Carlo and importance sampling.Results: A titer of 1:40 was associated with a reduced infection risk of 40%-70% relative to a titer of 1:10, depending on the circulating strain; the corresponding protection associated with a titer of 1:80 was 54%-84%. Results were robust across interpolation methods. The trivalent-inactivated vaccine reduced cumulative incidence of influenza B and influenza A(H3N2) infections by six percentage points (pp; 95% credible interval = 2 pp, 10 pp) and 1 pp (95% credible interval = 0.3 pp, 2 pp) respectively, but not for influenza A(H1N1)pdm09. The live-attenuated vaccine showed little efficacy against influenza A(H3N2) infections.Conclusions: Titers are correlated with protection against influenza infections. The trivalent inactivated vaccine can reduce the risk of influenza A(H3N2) and influenza B infections in the community. [ABSTRACT FROM AUTHOR]

Background: Few studies have comprehensively described tropical respiratory disease surveillance in military populations. There is also a lack of studies comparing clinical characteristics of the non-influenza pathogens with influenza and amongst themselves.Methods: From May 2009 through October 2012, 7733 consenting cases of febrile respiratory illness (FRI) (temperature [greater than or equal to]37.5 degrees C with cough or sorethroat) and controls in the Singapore military had clinical data and nasal washes collected prospectively. Nasal washes underwent multiplex PCR, and the analysis was limited to viral mono-infections.Results: 49% of cases tested positive for at least one virus, of whom 10% had multiple infections. 53% of the FRI cases fulfilled the definition of influenza-like illness (ILI), of whom 52% were positive for at least one virus. The most frequent etiologies for mono-infections among FRI cases were Influenza A(H1N1)pdm09 (13%), Influenza B (13%) and coxsackevirus (9%). The sensitivity, specificity, positive predictive value and negative predictive value of ILI for influenza among FRI cases were 72%, 48%, 40% and 69% respectively. On logistic regression, there were marked differences in the prevalence of different symptoms and signs between viruses with fever more prevalent amongst influenza and adenovirus infections than other viruses.Conclusion: There are multiple viral etiologies for FRI and ILI with differing clinical symptoms in the Singapore military. Influenza and coxsackevirus were the most common etiology for FRI, while influenza and adenoviruses displayed the most febrile symptoms. Further studies should explore these differences and possible interventions. [ABSTRACT FROM AUTHOR]

Recap of atopic eczema (RECAP) is a self-reported 7-item questionnaire recommended by the Harmonising Outcome Measures in Eczema initiative to measure eczema control. As RECAP has not been validated in a real-world clinical population in Asia, RECAP was investigated as a measure of eczema control in Singapore. Patients with atopic eczema at the National Skin Centre from July 2019 to January 2020 were included for analysis. Both patient- and physician-reported outcome measures were available for correlation analyses. Correlation analysis was also performed to investigate construct validity, and floor or ceiling effects of RECAP. A total of 260 atopic eczema patients aged between 15 and 87 years were recruited. There were minimal floor and ceiling effects for RECAP scores. There were strong, significant correlations of RECAP with POEM (r = 0.84, p < 0.001) and DLQI (r = 0.81, p < 0.001). Correlation with SCORAD was moderate (r = 0.60, p < 0.001). Correlations remained similar after age, gender, and ethnicity adjustments. Discriminative validity was demonstrated by a significant linear trend of increasing RECAP scores with increasing eczema severity. RECAP demonstrates good discriminative and construct validity evidenced by strong correlations with symptoms and quality of life and moderate correlations with eczema signs. RECAP is useful to measure eczema control in Singapore.

Introduction: Dupilumab, a biologic approved for treatment of moderate-to-severe atopic dermatitis (AD), has been reported to be largely effective with minimal adverse effects. However, being a targeted therapy, its effectiveness and side effects are expected to be varied in a heterogeneous ethnic population. Currently, the majority of studies on dupilumab are based on Western populations., Methods: A retrospective cohort of 51 patients with moderate-to-severe AD treated with dupilumab at a tertiary skin institute from January 2018 to February 2020 was included. Outcome measures such as Scoring Atopic Dermatitis (SCORAD), Eczema Area and Severity Index (EASI) and Dermatology Quality of Life Index (DLQI) were analysed at baseline and after 16 weeks of treatment. Laboratory tests at the respective time points were also measured., Results: Patients treated with dupilumab showed consistent reduction in body surface area (BSA) involved, SCORAD, EASI and DLQI scores. Concurrently, serum immunoglobulin E (IgE) and absolute eosinophil count showed a downward trend at 4 months of treatment. There was a transient increase in mean serum IgE at 1 month of dupilumab treatment. Also, 42.0% and 35.3% of patients developed eye symptoms, and head and neck dermatitis, respectively, but there were no major adverse events reported. Childhood-onset AD was more likely to have improved BSA scores compared to adult-onset AD., Conclusions: Our study confirms the efficacy of dupilumab with real-world data in an adult Asian population. Higher proportions of eye symptoms, and head and neck dermatitis were observed in our cohort compared to other Asian clinical cohort studies. Further studies are needed to evaluate these differences., (Copyright © 2024 Copyright: © 2024 Singapore Medical Journal.)

Background: Chronic pruritus of unknown origin (CPUO) is poorly understood and lacks effective treatment options., Objectives: We aimed to elucidate abnormalities in the sweat apparatus of patients with CPUO, and to assess efficacy and safety of treatment with systemic retinoids., Methods: An initial case-control study included 20 affected patients and five healthy controls, for whom heat and sweating were induced, either through a standardized exercise protocol or ingestion of hot water. In vivo high-definition optical coherence tomography, whole-body starch-iodine testing, and skin biopsy for immunofluorescence staining were done to evaluate for sweat duct obstruction. A subsequent retrospective cohort analysis included 56 patients with CPUO, seen at an Itch subspecialty clinic of a single tertiary referral centre, who failed conventional treatments and were treated with isotretinoin and/or acitretin from May 2014 to November 2020. Treatment response to retinoids was defined as a sustained reduction in itch score of ≥2/10. Safety was assessed by proportion stopping treatment due to side effects., Results: In vivo imaging in 19 (95%) patients revealed features of partial keratinaceous sweat duct obstruction with statistically significant luminal dilatation compared to controls. Immunofluorescence studies of three patients' paired lesional/non-lesional biopsies revealed dermcidin accumulation within sweat glands coupled with dermcidin leakage in itchy skin. Fifty-six patients (mean [SD] age 55.2 [17.5] years, 69.6% male) were treated with systemic retinoids. Mean (SD) duration of itch was 116.3 (140.4) months and mean (SD) itch score was 8.2 (1.8). Forty-one (73.2%) initially received isotretinoin, and 15 (26.8%) acitretin. At three months, mean itch score reduced by 2.38 (95% CI -3.2 to -1.6, p  < 0.0001). Thirty-eight (67.9%) had a sustained response. Eight (14.81%) achieved an itch score of 0 or 1, with four stopping treatment for a mean (SD) of 318.5 (291.2) days without relapse. Eight (14.3%) stopped or switched retinoid due to adverse effects, with similar incidences between both retinoids, the commonest being dryness., Conclusion: Based on novel findings from physiological imaging studies identifying partial keratinaceous sweat duct obstruction in CPUO, we instituted systemic retinoid treatment to address the underlying pathology. In patients who failed conventional therapies, the treatment appears effective and safe., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Lim, Tan, Zhang, Zhao, Ng and Tey.)

Introduction: Nail psoriasis treatment is challenging due to difficult drug delivery and systemic therapy toxicities. Self-dissolvable microneedle patches embedded with corticosteroids offers a potentially rapid, minimally invasive drug delivery platform with good efficacy and minimal adverse side effects., Methods: We conducted a 4-month prospective randomised controlled trial. Subjects with psoriatic nails were randomised to receive microneedle device delivered topical steroids on one hand and control treatment (topical Daivobet gel) on the other. Two independent dermatologists blinded to the treatment assignment scored their Nail Psoriasis Severity Index (NAPSI) during visits at baseline, 2 and 4 months. All treatment was discontinued after 2 months. Average NAPSI score on each hand was analysed., Results: A total of 25 participants were recruited, aged 22 to 73 years. Majority were Chinese (72%), followed by Indian and Malay. There was equal randomisation of treatment to the left and right nail. While there was a rapid significant improvement in average NAPSI score for the control arm at 2 months, the treatment arm had a greater, more sustained improvement of the NAPSI score at 4 months. The average NAPSI score improved for both treatment and control group at 4 months compared to baseline. However, only the NAPSI value improvement in the controls at 2 months compared to baseline was statistically significant ( P =0.0039). No severe adverse effects were reported., Conclusion: To the best of our knowledge, this is the first prospective randomised control trial comparing microneedle technology against conventional topical steroids in nail psoriasis treatment. Our findings demonstrate microneedle technology is as efficacious as topical therapy.

Introduction: Melanomas in Asians have different clinicopathological characteristics and prognosis from melanomas in Caucasians. This study reviewed the epidemiology and treatment outcomes of cutaneous melanoma diagnosed at a tertiary referral dermatology centre in Singapore, which has a multiracial population. The study also determined whether Asians had comparable relapse-free and overall survival periods to Caucasians in Singapore., Method: This is a retrospective review of cutaneous melanoma cases in our centre between 1996 and 2015., Results: Sixty-two cases of melanoma were diagnosed in 61 patients: 72.6% occurred in Chinese, 19.4% in Caucasians and 3.2% in Indians, with an over-representation of Caucasians. Superficial spreading melanoma, acral lentiginous melanoma and nodular melanoma comprised 37.1%, 35.5% and 22.6% of the cases, respectively. The median time interval to diagnosis was longer in Asians than Caucasians; median Breslow's thickness in Asians were significantly thicker than in Caucasians (2.6mm versus 0.9mm, P =0.018) and Asians tend to present at a later stage. The mortality rates for Asians and Caucasians were 52% and 0%, respectively., Conclusion: More physician and patient education on skin cancer awareness is needed in our Asian-predominant population for better outcomes.

Introduction: Pemphigus is a chronic, relapsing immunobullous disease. There is limited data on the clinical course and prognostic factors of pemphigus in Asian patients., Materials and Methods: We conducted a retrospective cohort study of all newly diagnosed pemphigus vulgaris (PV) and pemphigus foliaceus (PF) patients seen at the National Skin Centre from 1 January 2004 to 31 December 2009. Demographic and clinical data on comorbidities, treatment and remission were recorded. Mortality information was obtained from the National Registry of Diseases. Prognostic endpoint was overall remission at last visit., Results: Sixty- one patients (36 PV and 25 PF) were recruited. Among PV patients, higher initial prednisolone dose ( P = 0.017) and the use of azathioprine ( P = 0.028) were significantly associated with overall remission at last visit. However, higher desmoglein 1 antibody titres at diagnosis ( P = 0.024) and the use of dapsone ( P = 0.008) were negatively associated with overall remission at last visit. Among PF patients, only higher desmoglein 1 antibody titre at diagnosis ( P = 0.041) was found to be associated with lower overall remission at last visit. There was no mortality during the 3-year follow-up period in both PV and PF., Conclusion: Higher initial prednisolone dose and the use of azathioprine in PV desmoglein 1 antibody titre at diagnosis in PV and PF might be prognostic markers for achieving remission. Use of dapsone was associated with lower overall remission in PV, but this might be confounded because dapsone was used as an adjuvant therapy in recalcitrant cases. Owing to study methodology and limitations, further evaluation is needed for better prognostication of pemphigus.

BACKGROUND: Two extracts derived from the gastropod Cryptomphalus aspersa have been shown to have dermal regeneration properties: SCA® (secretion filtrate) with fibroblast growth factor-like activity and IFC®-CAF (cellular activating factor), a snail egg extract with skin stem cell activation activity. OBJECTIVE: The objectives of this study were to evaluate the synergic antiaging activity and tolerability of SCA and IFC-CAF in a combined regimen compared to vehicle as a placebo control. METHODS: A three-month, single-center, double-blinded, randomized, vehicle-controlled trial assessed the effects of a daily skincare routine divided into two treatment phases, as follows: intensive (1 month) and maintenance (2 months). Fifty women, aged 45-65 years, with signs of photoaging were randomized to receive either the active ingredients (n=30) or vehicle (n=20). Clinical evaluations included objective measurements of barrier function and skin hydration, elasticity, and color/brightness. Subjective assessments were conducted according to the Rao-Goldman and Glogau scales for wrinkles, the Patient Global Assessment (PGA) scale and Investigator Global Assessment (IGA) scale. RESULTS: Subjects in the active treatment group experienced reductions in transepidermal water loss and significant improvements in skin roughness, firmness, and elasticity. Both groups showed significant improvements in fine lines and wrinkles. PGA and IGA assessments indicated greater improvement in the active treatment group. CONCLUSION: The active snail extract treatment appears to be effective in improving signs of skin aging in women 45 to 65 years old. Larger randomized, controlled studies are needed to confirm our results., Competing Interests: FUNDING:This work was supported by grants from Cantabria Labs. DISCLOSURES:Dr. Goh is an advisory board member for Cantabria Labs. Dr. Vitale is an employee of Cantabria Labs. The other authors have no conflicts of interest relevant to the content of this article., (Copyright © 2020. Matrix Medical Communications. All rights reserved.)

Objective: When faced with an emergent epidemic with high mortality and morbidity potential, policy makers must decide what public health interventions to deploy at different stages of the outbreak. However, almost nothing is known about how the public view these interventions or how they trade off risks (of disease) with inconvenience (of interventions). In this paper, we aim to understand public perceptions on pandemic interventions, as well as to identify if there are any distinct respondent preference classes., Design: A discrete choice experiment., Setting: This study was fielded in Singapore between November 2012 and February 2013., Participants: A random sample of 500 Singapore residents aged 21 and over, including 271 women and 229 men, was analysed., Outcome Measures: Demographic information was collected from each participant. Participants were also shown a series of pairs of alternatives, each combining interventions and morbidity, mortality and cost outcomes and declared a preference for one combination. A random utility model was developed to determine the individual's preference for interventions and a hierarchical cluster analysis was performed to identify distinct respondent preference classes., Results: On average, participants preferred more intense interventions, and preferred scenarios with fewer deaths and lower tax. The number of infections did not significantly influence respondents' responses. We identified two broad classes of respondents: those who were mortality averse and those who were expenditure averse. Education was found to be a predictor of group membership., Conclusion: Overall, there was considerable support for government interventions to prevent or mitigate outbreaks of emerging infectious diseases, including those that greatly restricted individual liberties, as long as the restrictions showed a reasonable chance of reducing the adverse health effects of the outbreak., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: The distributions of incubation and relapse periods are key components of infectious disease models for the malaria parasite Plasmodium vivax; however, detailed distributions based upon experimental data are lacking., Methods: Using a range of historical, experimental mosquito-transmitted human infections, Bayesian estimation with non-informative priors was used to determine parametric distributions that can be readily implemented for the incubation period and time-to-first relapse in P. vivax infections, including global subregions by parasite source. These analyses were complemented with a pooled analysis of observational human infection data with infections that included malaria chemoprophylaxis and long-latencies. The epidemiological impact of these distributional assumptions was explored using stochastic epidemic simulations at a fixed reproductive number while varying the underlying distribution of incubation periods., Results: Using the Deviance Information Criteria to compare parameterizations, experimental incubation periods are most closely modeled with a shifted log-logistic distribution; a log-logistic mixture is the best fit for incubations in observational studies. The mixture Gompertz distribution was the best fit for experimental times-to-relapse among the tested parameterizations, with some variation by geographic subregions. Simulations suggest underlying distributional assumptions have critically important impacts on both the time-scale and total case counts within epidemics., Conclusions: These results suggest that the exponential and gamma distributions commonly used for modeling incubation periods and relapse times inadequately capture the complexity in the distributions of event times in P. vivax malaria infections. In future models, log-logistic and Gompertz distributions should be utilized for general incubation periods and relapse times respectively, and region-specific distributions should be considered to accurately model and predict the epidemiology of this important human pathogen.

Background: The rate of decline of antibody titers to influenza following infection can affect results of serological surveys, and may explain re-infection and recurrent epidemics by the same strain., Methods: We followed up a cohort who seroconverted on hemagglutination inhibition (HI) antibody titers (≥ 4-fold increase) to pandemic influenza A(H1N1)pdm09 during a seroincidence study in 2009. Along with the pre-epidemic sample, and the sample from 2009 with the highest HI titer between August and October 2009 (A), two additional blood samples obtained in April 2010 and September 2010 (B and C) were assayed for antibodies to A(H1N1)pdm09 by both HI and virus microneutralization (MN) assays. We analyzed pair-wise mean-fold change in titers and the proportion with HI titers ≥ 40 and MN ≥ 160 (which correlated with a HI titer of 40 in our assays) at the 3 time-points following seroconversion., Results: A total of 67 participants contributed 3 samples each. From the highest HI titer in 2009 to the last sample in 2010, 2 participants showed increase in titers (by HI and MN), while 63 (94%) and 49 (73%) had reduction in HI and MN titers, respectively. Titers by both assays decreased significantly; while 70.8% and 72.3% of subjects had titers of ≥ 40 and 160 by HI and MN in 2009, these percentages decreased to 13.9% and 36.9% by September 2010. In 6 participants aged 55 years and older, the decrease was significantly greater than in those aged below 55, so that none of the elderly had HI titers ≥ 40 nor MN titers ≥ 160 by the final sample. Due to this decline in titers, only 23 (35%) of the 65 participants who seroconverted on HI in sample A were found to seroconvert between the pre-epidemic sample and sample C, compared to 53 (90%) of the 59 who seroconverted on MN on Sample A., Conclusions: We observed marked reduction in titers 1 year after seroconversion by HI, and to a lesser extent by MN. Our findings have implications for re-infections, recurrent epidemics, vaccination strategies, and for cohort studies measuring infection rates by seroconversion.