What you need to know about mole removal!

Recently, a young lady with many moles came to me for a second opinion.  She has had her mole checked as well as laser mole removal done by another doctor. However, her mole specimens which were sent for laboratory analysis were reported to be too tiny, charred and inadequate for proper evaluation for the exclusion of skin cancer. Understandably, she was anxious!

After clinical consultation and examination, I concluded that her risk for skin cancer was low and all her remaining moles were normal looking. All her moles could have been removed without the need to send specimens for laboratory analysis. I then assured her that it was likely that the moles removed earlier were also normal too. With that assurance, she left the clinic happy and in peace.

Moles are common and generally not attractive. Most people would like to have them removed. In Singapore, this treatment is performed by a myriad of people, accredited skin specialist, beauticians in beauty salons and even some uncles at the night bazaar stall. Very often, people expect mole removal to be risk-free and they do not consider it necessary to have it examined or removed by a skin specialist. They assume that the skin will heal perfectly.

Many people are not aware that scars, indentations and colour changes may occur after mole removal procedures. The moles can also recur when there is incomplete removal. The worst-case scenario is when a cancerous mole was removed unknowingly and incompletely. That would have been disastrous and that was why the patient above was anxious!

When a patient comes for mole removal. I will evaluate their risk factors: skin type, past histories of skin cancer in the patient and family, history of occupational and recreational sun exposure and etc. If they are assessed to be of low risk, then I will remove their normal looking moles upon request. There is no need for any laboratory analysis. But if they are assessed to be of moderate or high risk, I will surgically remove the suspicious moles and send them for laboratory testing. It is important to be prudent and careful even with simple procedures like mole removal.

History and Progress of Modern Dermatology

I started my dermatology career 28 years ago in the Department of Medicine, National University of Singapore, under the mentorship of the late Professor Chan Heng Leong. It was the good old apprenticeship system. You follow the master, observe, discuss, learn and read up on your own. The emphasis then was still largely medical dermatology.

However, the ensuing 20 years turned out to be a rather exciting time. This was the time when laser surgery entered the field of dermatology. Firstly, CO2 laser, the workhorse laser. Thereafter, other lasers followed it e.g. Pulse dye laser and Q- switched YAG pigment removal laser. Soon after that, Botox came into the fold and with Hyaluronic acid fillers gradually replacing the cow collagen fillers, cosmetic dermatology began to make major inroads into modern dermatological practice.

This was also the time when large scale randomized control trials were the norm and dermatology was no different. Any new drug that was introduced needs to have solid trial evidence to show that it was both effective and safe e.g. Telfast in urticaria, Cyclosporin A in psoriasis, and topical Protopic in atopic dermatitis.

Historically, the first evidence of dermatological disease was discovered in the Egyptian mummies 5000 years ago. The ancient Egyptian medical text Ebers Papyrus included a formula to remove wrinkles and blemishes. The old testament of the Bible, written 2700 years ago, also recorded for us the details of dermatological diseases and their treatments. However, modern dermatology only began about 200 years ago in Europe and the past 20-30 years saw the emergence of molecular dermatology.

Modern research has helped us to unravel the many complex issues of inflammatory dermatosis, such as atopic dermatitis and psoriasis. Innovative treatment targeting the critical pathways of such problems will hopefully replace the now commonly used shot-gun steroid treatment, making treatments more effective with less side effects. New target-specific drugs are also now available for us to treat psoriasis e.g. Humira, Stelara and Tremfya heralding the new era of biologic treatment. Same goes for chronic idiopathic urticaria with Xolaire and atopic dermatitis with Dupixent.

There are many lasers or devices for dermatologists to choose from these days depending on what we are treating. Some are real gems while many are a waste of time! Continued advances in the field of laser medicine will see the introduction of many more new devices for we are forever seeking better and more effective technologies. We have moved away from ablative laser to non-ablative laser and now back to fractional ablative laser for the treatment of acne scars and aging skin. Constant change is the norm but one thing has emerged constant is that patients prefer the latest outpatient treatments that have minimal down time.

Whether it is medical or aesthetic skin concern, patients need doctor’s honest opinion as to which is the best treatment that they should undergo. There are many options and choices and dermatologists have to make a prudent recommendation and be the guardian of our patient’s interest. Despite all the advances in research and technologies, sound judgement and professionalism still remains the cornerstone of our profession.

The holy grail of anti-aging skin care – Sun Protection

Having lived and worked in London for 2 years, I could now understand and appreciate the beauty, the warmth, the colour and the life that the sun brings! Sun lovers tend to focus on the goodness of sun exposure and cite the need for vitamin D, which promises strong joints and bones. They never thought much about the bad effects of sun exposure.

Most sun damage is cumulative in our lifetime. Besides causing premature ageing, sun exposure may lead to diseases such as skin cancer and the deadly melanoma. Fortunately, it is never too late to be wise about sun protection. Just make sure you follow the right sun-protection routine to keep your skin youthful and glowing. Use sunscreen with an SPF ( Sun Protection Factor) of at least 25 for everyday use, and 50 for sports.

A truck driver with cumulative sun damage on the left side of his face after driving for 28 years

When it comes to ageing, sun damage tops the list. UV rays penetrate deep into the skin to cause skin ageing by damaging the collagen. It also generates a lot of free radicals to damage the gene, the proteins and the cells leading to the formation of wrinkles, photodamaged skin and even cancer.

Pigmentation caused by overexposure to the sun is another common complaint, especially among Asian women. Careful sun protection alone can diminish the appearance of pigmentation disorders like sunspots and freckles.

Comparing the skin of sun protected abdomen and sun exposed forearm

Most sunscreens contain both physical and chemical filters. Physical filters reflect the sun rays like a mirror while chemical filters absorb UV rays and prevent them from penetrating deeper into the skin. If you would like to have some extra protection while doing sports, you could take an oral suncare tablet like Heliocare oral capsules and choose swimwear / sportswear with UPF (Ultraviolet Protection Factor). But remember, there is still no substitute for applying appropriate sunscreen.

In general, moisturizers formulated with SPF tend to be weaker than dedicated sunscreens. Makeup with SPF contains some physical filters, but the protection is still weak overall. These products should be used together with proper sunscreens for maximum protection.

In my counseling with patients seeking the holy grail of anti-aging skincare, I always tell them to look at their own buttock. Almost 99.99% of the time, the skin there is baby-like and in pristine condition. I am certain that most have not bothered to apply any skin care or do any laser there. But I am also certain that the 2 cheeks there have much better skin than the 2 cheeks above our neck. Most left happy and convinced that I have given them a truthful answer – “Sun Protection is the key to the fountain of youth!”

Skin Brightening

Since time immemorial, women of light and fair skin have always been considered beautiful. Women around the world often go to great lengths to lighten their skin to look more attractive. In Asia, it is every woman’s dream to have light and fair skin. That is why skin lightening treatment and skin care products are so very popular in this part of the world. 4 in 10 women surveyed in Taiwan, Hong Kong, Malaysia, the Philippines and the Republic of Korea have been reported to use skin brightening products.

Skin Brightening

What is Skin Brightening? The term “Skin brightening” is used pretty loosely. Skin care companies may market the same products as “Brightening” in the West and as “ Lightening” or “Whitening” in Asia.

Actually, skin brightening is not about shade or color of skin, but about an overall glow. A brightened skin can be likened to that of a peeled, hard-boiled egg that exudes radiance and luminosity, regardless of color of skin.

How can one achieve the holy grail of even, glowing, and brightened skin?

Through a Combination Approach of:

  1. Skin Lightening
  2. Exfoliating
  3. Stimulating
  4. Moisturizing
  5. Controlling Oil Production
  6. Sun Protection

To achieve a glowing and brighten skin, one needs to go beyond just skin lightening. In addition to lightening agents, Skin Brightening usually needs exfoliating agents to help peel away the superficial dead skin cells and the darker-stained uppermost layers of the skin, revealing a lighter, healthier and smoother skin underneath. A lighter and smoother skin can reflect light better, like that of a polished marble floor, giving the skin a glow and radiance.

Stimulating the skin with Retinoids to replenish the skin with healthier and more vibrant skin cells is important, especially for the more mature skin.

A good moisturizing regimen or treatment program that nourishes and moistens one’s skin will definitely make it more hydrated and more radiant.

Another observation I have made from my years of experience is oil control. A baby’s oil free skin is glowing all the time. Patients who are on an oil control regime also have bright and healthier looking skin!

Above all, it’s essential to employ sun protective measures because sun triggers the pigment production in the first place. That’s why it’s so important to wear sunscreen to make sure your effort in Skin lightening and Skin Brightening will not be in vain!


Viral warts – the illegal immigrants on our skin

Warts are common and they are a type of skin infection. Warts are caused by virus, Human papillomavirus (HPV) to be specific. One British Professor of Dermatology once quipped that dermatologists are kept gainfully employed because of warts!

Indeed, as a dermatologist, I see patients with wart weekly, sometimes even daily. Patients are concerned if the warty growths they have are cancerous? Why and how did they get them? Will it spread to their family members? Quite a few are conscious that they are carrying a skin infection!

Many have tried all kinds of self-remedy. Often, they have tried with limited success by the time they come to see me. Yet, many do not realize that their own immunity is a critical player in eradicating warts and dermatologists are just facilitating the healing process when they administer the treatments strategically.

For those who know me, I often use metaphors to explain the medical problems to my patients. Our immune system is like our security troopers. They patrol our body and keep it safe from intruders like viruses and bacteria. The existence of the wart indicates that the HPV have somehow managed to stay in the skin as “illegal immigrants” escaping the detection of our immune system. Administering treatments like topical lotions, freezing treatment and laser, I am trying to alert and jolt the immune system into action. The wart can be eradicated only when the immune system swings into action and kills the virus with antibodies.

A young Caucasian boy was traumatized by repeated freezing treatments because of its associated pain. When his father brought him to see me for a change, I explained to him the principle behind the treatment strategy and that I would dispense only topical treatment to spare his son the agony of pain. After 6 months of treatments, all the 30 or so warts that scattered on his face, neck, arms and fingers were all eradicated! I did the same approach to another young girl’s warts on her thumb and got rid of them after several weeks!

Although topical treatments are painless, they are quite tedious to follow when there are many warts. Not all patients who are on topical treatments end up with great success stories like those alluded to above. Freezing treatment is still the treatment of choice for many dermatologists, including myself.

I remember 2 Italian patients well. The first was an Italian male adult with 30 warts on both his soles for more than 10 years. The warts were a mixed collection of big and small lesions. I asked him to identify for me the “Godfathers “, the patriarch of the lot! I froze 5 of the patriarch lesions hard with freezing treatment. 2 months later, the patient came back smiling, reporting that all the warts have gone for good! “The warts just crumbled down like powders!”, said the patient.

Another Italian patient was a teenager, who was brought to see me by his mother. He had literally hundreds of warts on his lower abdomen and supra-pubic area. After identifying the “God father” of the lot, I treated 12 warts hard and behold, all the rest of the warts resolved gradually in the ensuing weeks! In these 2 examples, I merely initiated the process by treating the selected warts, the good results were the work of the patients’ own immune reactions.

Some patients’ responses are dramatic while others’ are a long drawn affair. Spending time explaining to patients, helping them to understand the treatment rationale are important as treatment of warts requires patience, from both patient and doctor. With patience, experience and a bit of luck, I set out to help all my patients to initiate the amazing healing process that our body is capable of achieving!

Eczema FAQ

Why do I develop an allergy?

  • Immune tolerance is essential for our body to harmoniously handle and have peaceful coexistence with many food proteins and external antigens on a daily basis.
  • Allergic reaction develops e.g. allergic rhinitis, asthma, atopic dermatitis, food or drug allergy, when our body becomes intolerant to the external antigens.

Do I need to do any food allergy test? Is there any food that I need to avoid?

  • The vast majority of patients do not require a food allergy test. Dr Wong does not order any food allergy test routinely unless in special situation.
  • Keeping a food allergy journal is more useful. Discussing with your dermatologist over your observation of the association of eczema outbreak and certain food is more relevant than doing test blindly.

Why do doctors continue to use steroid cream as the first line of treatment for eczema despite so many known side effects?

  • Common side effects of steroid creams include skin thinning, stretch marks, easy bruising, enlarged blood vessels, and localised increase in hair.
  • Steroid cream is still used as first line treatment most of the time because it is effective and affordable.
  • When a patient wants to save the cost of a consultation and starts buying steroid cream on his / her own, that is when the problem starts.
  • Side effects occur when a patient self-medicates, often with the most potent steroid cream, or is not under the supervisory care of just one primary doctor.
  • Not all steroid creams are of the same potency. Some creams are a lot more potent than others.
  • Dermatologists are trained to supervise, manage and minimize the side effect impact of steroid treatments. They will advise the patients when to reduce the cream or switch to gentler steroid creams over the course of treatment.
  • Dermatologists will also administer holistic skin care to reduce the side effects of steroid cream e.g. anti-bacterial treatment, regular moisturization and steroid sparing cream or oral medicine.

In what circumstances are oral steroids or oral immuno-suppressants recommended?

  • Since there is immune over-activity in the skin of patients with eczema, oral steroids and immuno suppressant drugs are very useful and important in the treatment of eczema.
  • Oral steroids and immuno-suppressants are used when patients have very severe eczema that is not responding to topical treatments, when their sleep or quality of life is severely affected.
  • Common side effects of oral steroids include thinning of the bone, weight gain, increased chance of infection, increase in blood pressure and blood sugar, increased risk of developing glaucoma, cataract and stomach ulcers, muscle weakness and mood changes. Side effects of oral immunosuppressants include increased blood pressure, liver or kidney impairment.
  • For many patients, the benefits of these oral treatments usually outweigh the risk of the side effects. A short course of oral steroids e.g. 1-2 weeks usually cause no side effects.
  • Many patients have benefitted from such treatments as their inflamed skin is finally controlled. They can sleep better and live as normal a life as possible.

FDA-approved drugs such as Elidel cream and Protopic ointment claim to have no side effects apart from “Black Box” warning of increased risk of cancer. How concerned should I be?

  • Topical immunosuppressant drugs like Elidel and especially Protopic ointment are very useful because they reduce the use and reliance of steroid creams. Dermatologists all over the world are using them, especially in situations where there are concerns over the use of steroids.
  • It is especially useful on the face, around the eyes, neck and groin area.
  • We share with patients that the FDA “Black Box “ warning of increased skin cancer is only observed in the animals during the trials.
  • Dermatologists have been monitoring very carefully with regard to the occurrence of skin cancer and the use of Elidel and Protopic over many years and are not alarmed so far. The likelihood of cancers occurring in real life patients is very low.
  • Despite the controversy, most patients accept our recommendation.

When will you recommend the use of Dupixent, the latest drug in the fight of eczema?

  • When a patient has moderate to severe eczema that is not responding to topical treatments, when their sleep or quality of life is severely affected, I would consider offering Dupixent.
  • The cons with Dupixent are the high cost of treatment and the reluctance of insurance companies to reimburse the cost of treatment.
  • The pros of Dupixent are that it is free from serious organ side effects and the need for any frequent monitoring blood tests.