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Introduction: The human papillomavirus (HPV) vaccine has been reported to lead to clinical clearance of lesions when used as an off-label treatment for recalcitrant extragenital warts. The aim of the study is to evaluate the therapeutic and adverse effects of HPV vaccine as an adjunctive therapy for treatment-resistant acral warts. Methods: Patients with persistent warts despite first and second line therapies, and subsequently receiving the quadrivalent HPV vaccine between July 2013 and June 2016 as an adjunctive treatment for recalcitrant warts at the National Skin Centre, were included. Results: Twenty-six patients with a median age of 34 years (range 8 to 77 years) were treated with the HPV vaccine. Nineteen (73.1%) patients completed 3 doses of the vaccine, of whom 5 (26%) achieved complete clearance, 8 (42%) had partial clearance and 6 (32%) did not respond to the vaccine. Among the 4 patients who received 2 doses of the vaccine, 3 (75%) had complete clearance whereas 1 (25%) had partial improvement of their warts. None of the patients reported adverse reactions. Conclusion: Our study suggests a potential adjunctive role of the HPV vaccine in the treatment of acral warts recalcitrant to conventional therapy. Keywords: Acral warts, HPV vaccine, quadrivalent vaccine, recalcitrant warts

Higher risk of rapid progression in alopecia or male pattern baldness was observed in men who had family history. This could result from accumulation of DHT in hair follicles. Hair follicles on frontal region are more vulnerable to DHT. With development of minimal invasive hair transplantation surgery, hair follicles transplantation could be performed from frontal or occipital region to frontal region. However, limited hair follicles remained a problem. With development of technology of vitrification, we suggested extracting hair follicles from frontal region without affecting the appearance and preserving them with vitrification when the patient was young. When alopecia progressively developed, these extracted hair follicles would increase the donor number of hair follicles used for transplantation, which could extend longer dense hair appearance.

Background/Objectives Incidence of herpes zoster (HZ) increases with age. The vaccine to prevent HZ is available for those who are 50 and older. This study aims to investigate the cost-effectiveness of HZ vaccine on population older than 50 years old from a societal perspective in Singapore. Methods The established decision analytic (Markov) model was utilized to simulate the results of vaccination for adults who were older than 50 years of age, compared to those without vaccination. The total number of HZ cases, postherpetic neuralgia (PHN) cases, total direct cost of treatment and indirect cost due to productivity loss were estimated based on the characteristics of population, and treatment costs were collected from a local institute in Singapore. The public health consensus for the ICER benchmark in Singapore was S$65,000. Results One million individuals were simulated in this health economics analysis. Vaccination would reduce 48% of HZ cases and 33% of PHN cases over their life time. When a vaccination strategy for adults who are 50 years old and older was compared to a strategy with no vaccination, incremental cost-effectiveness ratio (ICER) was S$49,023 per quality adjusted life years (QALY) gained from the societal perspective. Conclusion The herpes zoster vaccination is likely to be cost-effective in societal perspective for adult over 50 years of age in Singapore.

Traditional treatments for onychomycosis, a fungal disease primarily affecting the toenails, are associated with poor tolerability or inadequate efficacy. Moreover, because many patients find onychomycosis embarrassing, achieving rapid cosmetic improvements is desirable. Kerasal NailTM is a marketed topical treatment containing propylene glycol, urea and lactic acid. The ability of Kerasal Nail to improve the appearance of an affected nail was investigated in a 4-week open-label study. Patients aged ≥21 years and with 25% to 75% of a big toenail or thumbnail (the “target” nail) affected by clinically suspected onychomycosis (n = 65) were instructed to apply Kerasal Nail to all their affected nails once daily for 4 weeks. After 1, 2 and 4 weeks of treatment, they assessed the appearance of the target nail on a 4-point scale, with a score of ≥2 indicating a minimum of some improvement. They also assessed the nail for improvements in thickening, discoloration, brittleness and softness. Adverse events (AEs) occurring between administration of the first dose of Kerasal Nail and the end of the 4-week treatment period were recorded. 85% of patients (95% confidence interval [CI] 74 to 92) achieved some improvement in the target nail at 4 weeks. Improvement of the target nail was reported by 65% of patients (95% CI 52 to 76) after 1 week of treatment and by 82% of patients (95% CI 70 to 90) after 2 weeks. 55% of patients achieved some improvement in discoloration in the first week of treatment. After 4 weeks of treatment, discoloration, thickening, brittleness and softness were each improved in more than half of patients. Treatment-related AEs were limited to two cases of administration site pain. Overall treatment compliance was 99%. In summary, Kerasal Nail produced very rapid improvements in nail appearance in patients with onychomycosis and was well tolerated.

Introduction: This study aimed to assess the frequency of anxiety and depression in a cohort of adult patients with atopic dermatitis (AD) in a tertiary dermatological centre, using the Hospital Anxiety and Depression Scale (HADS). We looked for any correlation between anxiety and depression with skin disease severity. Materials and Methods: Patients with AD were recruited from the National Skin Centre, Singapore, from 2008 to 2009 for a prospective cross-sectional study. The scoring atopic dermatitis (SCORAD) grade was determined and the HADS was administered via interviews. Results: A total of 100 patients (78 males, 22 females) were enrolled (92% Chinese, 4% Malays and 4% Indians). Their average age was 25.7 years. Sixty-five percent used topical steroids, 14% had previously taken oral prednisolone for the control of disease flares, and 20% were on concurrent systemic therapy. The mean SCORAD was 55.0, with 99% of patients having moderate or severe AD. The mean HADS anxiety score was 7.2 and the mean depression score was 5.0. The level of anxiety correlated well with that of depression (Spearman’s rank correlation coefficient, ρ = 0.59, P

Cell division cycle 42 (CDC42), a small Rho GTPase, plays a critical role in many cellular processes, including cell proliferation and survival. CDC42 interacts with the CRIB (Cdc42- and Rac-interactive binding) domain of CDC42SE1, a small effector protein of 9 kDa. We found that the expression of CDC42SE1 was reduced in human skin cancer samples relative to matched perilesional control. Exogenous expression of CDC42SE1 but not CDC42SE1H38A (mutation within CRIB domain) in A431 cells (A431SE1, A431SE1-H38A) reduced cell proliferation. Antibody microarray analysis of A431Ctrl and A431SE1 lysate suggested that reduced A431SE1 cells proliferation was due to inhibition of Akt pathway, which was confirmed by the reduced P-Akt and P-mTOR levels in A431SE1 cells compared to A431Ctrl cells. This suggests that CDC42SE1 modulates the CDC42-mediated Akt pathway by competing with other effector proteins to bind CDC42. A431SE1 cells formed smaller colonies in soft agar compared to A431Ctrl and A431SE1-H38A cells. These findings correlate with nude mice xenograft assays, where A431SE1 cells formed tumors with significantly-reduced volume compared to the tumors formed by A431Ctrl cells. Our results suggest that CDC42SE1 is downregulated in skin cancer to promote tumorigenesis, and thus CDC42SE1 might be an important marker of skin cancer progression.

Genital warts in immunocompromised patients can be extensive and recalcitrant to treatment. We report a case of recalcitrant genital warts in a female patient with systemic lupus erythematosus (SLE), who achieved complete remission with a combination approach of surgical debulking and oral isotretinoin at an initial dose of 20 mg/day with a gradual taper of dose over 8 months. She had previously been treated with a combination of topical imiquimod cream and regular fortnightly liquid nitrogen. Although there was partial response, there was no complete clearance. Her condition worsened after topical imiquimod cream was stopped because of her pregnancy. She underwent a combination approach of surgical debulking and oral isotretinoin after her delivery and achieved full clearance for more than 2 years duration. Oral isotretinoin, especially in the treatment of recalcitrant genital warts, is a valuable and feasible option when other more conventional treatment methods have failed or are not possible. It can be used alone or in combination with other local or physical treatment methods.

Background The successful treatment of onychomycosis depends on accurate diagnosis. Conventional diagnostic methods, including direct microscopy and fungal culture, are non-specific, insensitive and time-consuming. Recently, PCR has shown promise in improving the diagnosis of onychomycosis. We aimed to evaluate a commercially available PCR kit for the in vitro detection of dermatophytes and specifically Trichophyton rubrum in nail specimens with suspected onychomycosis, and to compare the detection rates of PCR with conventional diagnostic methods. Methods Nail specimens were prospectively collected from patients with clinically suspected onychomycosis. All nail specimens were positive on direct microscopic examination. PCR and fungal cultures were administered, and the detection rates of dermatophytes were compared. Results In all, 107 nail specimens were analysed. The fungal culture was positive in 57 (53%) specimens (38 dermatophytes and 19 non-dermatophytes). PCR was positive in 77 (72%) specimens (63 T. rubrum and 14 pan-dermatophyte). A total of 37 specimens (35%) were positive for both fungal culture and PCR. PCR detected dermatophytes in 39 specimens that were missed by the fungal culture, increasing the diagnosis of dermatophyte-positive specimens by 37%. Five dermatophyte–culture-positive specimens were negative for PCR. Conclusions This study demonstrates that PCR increases the sensitivity of detection of dermatophytes in nail specimens. Despite its limitations, the use of PCR can complement direct microscopic examination and fungal cultures to aid clinicians in the diagnosis of suspected dermatophytic onychomycosis.

Protothecosis is an uncommon condition resulting from infection by achlorophyllous algae of the Prototheca species. Immunocompromised individuals are generally most susceptible to protothecal infection and tend to develop severe and disseminated disease. However, the association between protothecosis and HIV-induced immunosuppression is not clear, with only a handful of cases having been described to date. Here we report a case of cutaneous protothecosis in a Chinese man with previously undiagnosed HIV infection that responded well to oral itraconazole.

We present a case of disseminated molluscum contagiosum (MC), occurring in an ornamental bird breeder with poorly-controlled atopic eczema. The molluscum poxvirus has been identified histologically in birds; and lesions in atopic dermatitis tend to be more extensive with a protracted clinical course. We review the literature regarding MC and reflect on its clinical aspects, risk for dissemination, management and interestingly its association with various bird species.

Non-tuberculous mycobacteria (NTM) are a group of environmental pathogens, which cause a broad spectrum of disease. The incidence of NTM infection is increasing, especially in immunocompromized patients. The past three decades also saw a rapid increase in the incidence of NTM infection involving otherwise healthy subjects. We report a case of cutaneous NTM infection in a 79-year-old Chinese woman, who was receiving methotrexate for psoriasis. Mycobacterial culture grew Mycobacterium abscessus, and the lesions cleared with a combination of oral clarithromycin, ciprofloxacin and doxycycline. Interestingly, she then developed a second episode of cutaneous NTM infection with Mycobacterium haemophilum over the same body region, five years after stoppage of methotrexate. Both episodes were separated in time and involved different species, indicating that they were independent from each other. We further discuss the risk factors for cutaneous NTM infection, treatment, and highlight the need for diagnostic vigilance.

Genital warts in immunocompromised patients can be extensive and recalcitrant to treatment. We report a case of recalcitrant genital warts in a female patient with systemic lupus erythematosus (SLE), who achieved complete remission with a combination approach of surgical debulking and oral isotretinoin at an initial dose of 20 mg/day with a gradual taper of dose over 8 months. She had previously been treated with a combination of topical imiquimod cream and regular fortnightly liquid nitrogen. Although there was partial response, there was no complete clearance. Her condition worsened after topical imiquimod cream was stopped because of her pregnancy. She underwent a combination approach of surgical debulking and oral isotretinoin after her delivery and achieved full clearance for more than 2 years duration. Oral isotretinoin, especially in the treatment of recalcitrant genital warts, is a valuable and feasible option when other more conventional treatment methods have failed or are not possible. It can be used alone or in combination with other local or physical treatment methods.

Protothecosis is an uncommon condition resulting from infection by achlorophyllous algae of the Prototheca species. Immunocompromised individuals are generally most susceptible to protothecal infection and tend to develop severe and disseminated disease. However, the association between protothecosis and HIV-induced immunosuppression is not clear, with only a handful of cases having been described to date. Here we report a case of cutaneous protothecosis in a Chinese man with previously undiagnosed HIV infection that responded well to oral itraconazole.

The successful treatment of onychomycosis depends on accurate diagnosis. Conventional diagnostic methods, including direct microscopy and fungal culture, are non-specific, insensitive and time-consuming. Recently, PCR has shown promise in improving the diagnosis of onychomycosis. We aimed to evaluate a commercially available PCR kit for the in vitro detection of dermatophytes and specifically Trichophyton rubrum in nail specimens with suspected onychomycosis, and to compare the detection rates of PCR with conventional diagnostic methods.Nail specimens were prospectively collected from patients with clinically suspected onychomycosis. All nail specimens were positive on direct microscopic examination. PCR and fungal cultures were administered, and the detection rates of dermatophytes were compared. In all, 107 nail specimens were analysed. The fungal culture was positive in 57 (53%) specimens (38 dermatophytes and 19 non-dermatophytes). PCR was positive in 77 (72%) specimens (63 T. rubrum and 14 pan-dermatophyte). A total of 37 specimens (35%) were positive for both fungal culture and PCR. PCR detected dermatophytes in 39 specimens that were missed by the fungal culture, increasing the diagnosis of dermatophyte-positive specimens by 37%. Five dermatophyte-culture-positive specimens were negative for PCR.This study demonstrates that PCR increases the sensitivity of detection of dermatophytes in nail specimens. Despite its limitations, the use of PCR can complement direct microscopic examination and fungal cultures to aid clinicians in the diagnosis of suspected dermatophytic onychomycosis.

Vitiligo is an acquired, progressive depigmenting disorder of the skin and mucous membranes in which melanocytes in affected skin are selectively destroyed. Theories regarding the mechanism of melanocyte destruction include autoimmune, cytotoxic, oxidative, and neural mechanisms. Vitiligo affects 0.5-2% of the world's population and the usual age of onset is in the third decade of life. Photochemotherapy, along with phototherapy and topical therapy, are the most commonly utilized and effective vitiligo treatment modalities. Photochemotherapy for the treatment of vitiligo was historically used in ancient India and Egypt, where Hindus and Egyptians applied psoralen-containing plant extracts to depigmented vitiligo lesions where were then exposed to sunlight. These plants were found to be Ammi majus and Psoralen corylefolia, which contain 8-methoxypsoralen (8-MOP) and 5-methoxypsoralen (5-MOP). Phototherapy has been shown in many studies to induce effective repigmentation in more than 70% of patients with early and/or localized disease. Narrow-band ultraviolet B radiation (NB-UVB) with an emission spectrum of 310-312 nanometers (nm) is a safe treatment modality that is often used two to three times weekly as monotherapy, or combined with topical steroids. The treatment is safe in children, pregnant women and lactating mothers, and has minimal adverse effects (xerosis, pruritus, skin aging, and tanning). The risk of skin cancer is minimal even with multiple treatments although there is a greater risk of phototoxicity with depigmented skin. NB-UVB has also been used in combination with antioxidants such as vitamin E. Photochemotherapy involves the usage of psoralens combined with natural sunlight or UV light, usually ultraviolet A radiation (PUVA). 8-MOP or 5-MOP can be applied topically or used orally, followed by light exposure. Psoralens may not be used in pregnancy and there is a need for photoprotection following their use; there is as well a higher risk of burns, eye injury, and cutaneous malignancy than NB-UVB that may limit their cumulative usage. A 10-year retrospective study showed that PUVA is only moderately effective in widespread vitiligo (Kwok et al, 2002). Another small study from India successfully combined PUVA with a keratinocyte-melanocyte graft technique for stable vitiligo (Kachhawa et al, 2008).

Summary Cancer is a leading cause of death worldwide. Tumor cells exploit various signaling pathways to promote their growth and metastasis. To our knowledge, the role of angiopoietin-like 4 protein (ANGPTL4) in cancer remains undefined. Here, we found that elevated ANGPTL4 expression is widespread in tumors, and its suppression impairs tumor growth associated with enhanced apoptosis. Tumor-derived ANGPTL4 interacts with integrins to stimulate NADPH oxidase-dependent production of O 2 − . A high ratio of O 2 − :H 2 O 2 oxidizes/activates Src, triggering the PI3K/PKBα and ERK prosurvival pathways to confer anoikis resistance, thus promoting tumor growth. ANGPTL4 deficiency results in diminished O 2 − production and a reduced O 2 − :H 2 O 2 ratio, creating a cellular environment conducive to apoptosis. ANGPTL4 is an important redox player in cancer and a potential therapeutic target.

Eccrine syringofibroadenomatosis (ESFA) is a rare adnexal tumor with acrosyringeal differentiation. Clinically, it can be mistaken for granulomatous infections or malignancies such as squamous cell carcinoma. Despite the rarity of the condition, we recently encountered two cases of the reactive subtype, which occurred in patients with poorly controlled chronic psoriasis. Both patients presented with long-standing, thick verrucous lesions on the lower legs. The diagnosis was made after histological examination and exclusion of infectious and neoplastic disorders. As this is a reactive disorder, management is focused on treating the underlying condition. Unfortunately, psoriasis was difficult to manage in both our patients and they defaulted further treatment. It is important to recognize ESFA as it can be confused with infectious or malignant disorders.

Background Herpes zoster (HZ) is a prevalent viral disease that inflicts substantial morbidity and associated healthcare and socioeconomic burdens. Current treatments are not fully effective, especially among the most vulnerable patients. Although widely recommended, vaccination against HZ is not routine; barriers in Asia-Pacific include long-standing neglect of adult immunisation and sparse local data. To address knowledge gaps, raise awareness, and disseminate best practice, we reviewed recent data and guidelines on HZ from the Asia-Pacific region. Methods We searched PubMed, Scopus, and World Health Organization databases for articles about HZ published from 1994 to 2014 by authors from Australia, China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, New Zealand, the Philippines, Singapore, Taiwan, Thailand, and Vietnam. We selected articles about epidemiology, burden, complications, comorbidities, management, prevention, and recommendations/guidelines. Internet searches retrieved additional HZ immunisation guidelines. Results From 4007 retrieved articles, we screened-out 1501 duplicates and excluded 1264 extraneous articles, leaving 1242 unique articles. We found guidelines on adult immunisation from Australia, India, Indonesia, Malaysia, New Zealand, the Philippines, South Korea, and Thailand. HZ epidemiology in Asia-Pacific is similar to elsewhere; incidence rises with age and peaks at around 70 years – lifetime risk is approximately one-third. Average incidence of 3–10/1000 person-years is rising at around 5% per year. The principal risk factors are immunosenescence and immunosuppression. HZ almost always causes pain, and post-herpetic neuralgia is its most common complication. Half or more of hospitalised HZ patients have post-herpetic neuralgia, secondary infections, or inflammatory sequelae that are occasionally fatal. These disease burdens severely diminish patients’ quality of life and incur heavy healthcare utilisation. Conclusions Several countries have abundant data on HZ, but others, especially in South-East Asia, very few. However, Asia-Pacific countries generally lack data on HZ vaccine safety, efficacy and cost-effectiveness. Physicians treating HZ and its complications in Asia-Pacific face familiar challenges but, with a vast aged population, Asia bears a unique and growing burden of disease. Given the strong rationale for prevention, most adult immunisation guidelines include HZ vaccine, yet it remains underused. We urge all stakeholders to give higher priority to adult immunisation in general and HZ in particular. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2198-y) contains supplementary material, which is available to authorized users.