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.

Acne Myth

A lot of people still consider acne outbreaks a hygiene issue. Despite stepping up their cleansing routine and frequent change of cleanser, their acne still persists! Little did they realize that excessive and too vigorous washing can sometimes make acne worse!

Acne Marks- cleared with subsequent skin & laser treatments

In a straightforward case, washing one’s face with a gentle cleanser and water 2-3 times a day will suffice. The main use of facial cleansing is to remove dirt, sweat, grimes, cosmetic and dead skin cells and it has very little impact on the control of the acne.

Many of the acne patients like to pick and squeeze their acne because a successful pop is always very satisfying! If you’ve given into the temptation before, you know the ugly aftermath: a red or brown mark that stuck around for months as a result of skin trauma.

Not that squeezing or extracting acne is absolutely bad, but one should only limit to blackheads! The hands should always be clean and the squeeze clinical and precise! Inappropriately squeezing the inflammatory lesions is likely to cause worsening inflammation, expansion of the lesion, and leads to even worse scarring!

Many patients were also talked into believing that acne is due to the accumulation of toxins and that they need detoxification treatment. Amazingly, some even believe that when their acne gets worse while on detox treatment is good as the treatment purges out the toxin from their face!

Many other myths about acne care are widely accepted and practiced and unfortunately, they contribute to the delay in seeking proper treatment. Sadly, this leads to acne scarring. Hence, early consultation and treatment by a skin specialist are all the more important if one is to minimize acne scarring during their youthful and acne phase of their life!

Adult Acne: Facts or Fictions

“Doc, I am not a teenager anymore! Why do I still have such an outbreak?” This is a recurring question that I get from irate patients with adult acne.”

I have to inform them that around 20-40% of adults over the age of 25 still suffer from acne, in one form or another. Women have a higher rate of being affected by adult acne.

In my contact with patients & media articles, I gathered some of the common beliefs on Adult Acne:

  • Acne in adulthood differs from the one during puberty.
  • Adult acne occurs specifically around the jawline and chin area.
  • Adult acne is associated with hormonal imbalances.
  • Adult acne has fewer but bigger and more inflamed acne spots.

However, a large-scale international study on adult acne was published in October 2014. This study involved 374 adult females over the age of 25 from many countries including Singapore, Malaysia and Thailand, and it revealed some interesting findings:

  • The data shows that 90% of facial acne distribution among the study subjects is similar to that of adolescent acne. This debunks the belief that adult acne is thought to occur only on specific locations of the face e.g. the jawline and chin area.
  • It reveals that most of the women experienced an extension of the acne problem from the adolescent period, rather than an adult outbreak with no prior acne history at all.
  • Most of the women involved in this study were not suffering from any hormonal disturbance. However, it did show that high-stress levels contributed to the severity of the acne condition. It is also interesting to note that no observations were made in regards to acne and dietary intake.
  • Another interesting finding derived was that acne scarring (59.4%) and pigmentation (50.4%) were common in women aged 25-30 with a decrease in frequency in the older group i.e. 30 years and above.

Overall, this study has shed new and important insights into the problem of adult acne especially amongst women above 25 years old & above. Many unfounded myths were debunked!

1. Large-scale international study enhances understanding of an emerging acne population: acne females. B. Dreno D. Thiboutot, A.M Layton. et al. JEADV 2014

Aesthetic Medicine, the Evidence behind it

I was the invited speaker on the topic ‘Aesthetic Medicine, the evidence behind it‘ during the Primary Care Forum 2015 held on the 3rd Oct 2015.  This is a forum jointly organized by Primary Care Academy and Singapore Health Biomedical Congress for family physicians. Below is the summary of my speech:

Aesthetic Medicine (AM) is an enigma. It is practiced by many doctors, loved by the media, and welcomed by patients. Yet doubts remain on whether it is really evidence based.

What exactly is Aesthetic Medicine? The truth is there is currently NO internationally accepted definition of aesthetic medicine. In the U.K, it is defined as “operations and other procedures that revise or change the appearance, color, texture, structure, or position of bodily features, which most would consider otherwise to be within the broad range of ‘normal’ for that person”.

AM is a form of aspirational medicine, where medical professionals help to fulfill their patients’ aspirations, or striving towards a better aesthetic ideal. In the past 20 years, there has been a tremendous growth in this field, with people starting to openly embrace AM. In their visits to clinics, people are requesting for cosmetic improvements to look good, feel better, and to combat the visible changes of aging.

In 2015, according to the market data published by the American Society of Aesthetic Plastic Surgery, around 10 million people underwent aesthetic procedures. The data showed these people were mainly women, with men showing increasing numbers. Treatment-wise, botulinum toxin and dermal fillers were the most popular.

AM is strongly supported by good scientific evidence. For example: The use of the Triluma cream in the treatment of skin pigmentation is well established, as well as the use of retinoid in reducing wrinkles. Many device-based treatments are backed by strong scientific evidence, while injectable toxin and fillers are well supported by medical publications. The man who revolutionized the world of lasers is Dr. Rox Anderson, a dermatologist from Wellman Laboratory in Boston. He and his colleague published “the theory of selective photothermolysis” that forms the basis of laser treatment for many of the devices that we use today.

AM is driven by a combination of the consumer, industry and the media. In the past, the laser companies put a lot of effort and money into good studies to prove that the clinical results of their new machine are evidence based. The doctors reviewed the publications and made the decision based on the merit and strength of the machine and the publications. These days, a lot of effort is put into driving up the consumer’s interest through social media. This exerts market pressure on the practitioners to buy the machine so as to offer the service. The limitations and downsides of such treatments are often omitted.

Many doctors have been attracted to join in the practice of AM and not all are well trained. The public at large also needs to be protected from many unproven and unsafe treatments, often provided at significant cost to patients. Hence Aesthetic Practice Oversight Committee (APOC) was set up in 2008 by the Ministry of Health in Singapore. The committee has come out with the “ Singapore Medical Council guidelines on Aesthetic practice for doctors” based on currently available evidence. The guidelines have helped to maintain some standard and rein in cowboy practice to minimize complications for patients. Still, we have had 2 deaths from liposuction and some recent reports of blindness due to filler injection. These are the more high profile cases. Many of the less serious complications suffered by patients have gone under the radar.

In summary, AM is booming in Singapore and more and more medical professionals are offering AM in their practice. The practice of AM can be evidence-based and doctors should abide by the time honored Hippocratic Oaths and preserve the finest traditions of our calling. In doing so, we will experience the joy of healing those who seek our help and the esteemed position bestowed to us by society.


American Survey on Top Facial Concerns & Treatment Preferences for Women

Men and women today are turning to doctors not just for medical help, many are seeking doctor’s help to groom themselves to feel good and look the best. These types of aesthetic treatments are so popular that in the US, there is a research survey on women’s preferences for Facial Aesthetic Treatment.

This survey titled “Facial treatment preferences in Aesthetically Aware Women” was published in the Journal of Dermatologic Surgery in April 2015. It showed for the very first time what female American patients are most interested in “fixing first “ to improve their facial appearance. A total of 603 aesthetically oriented American women, age 30-65 years, were included in this online research survey.

The study focused on the following main objectives:

  1. To rank the 14 facial areas (see Fig 1 for details) that women most likely to have aesthetic treatment.
  2. To understand the relationship between the most bothersome facial area and the area first planned for treatment.
  3. To see if there were differences in treatment preference between younger and older women.

The survey results showed that:

A. Women of All Age Group

Have the most concern on the following Facial Area: (Please see Fig 1 for reference)

  1. Crow’s feet lines: area (D)
  2. Oral commissures (down turning of the angle of the mouth): area (K)
  3. Tear trough (hollow area below the eye): area (E)

B. Women 50 years old and above

Have more concern on their Lower Face Area:

  1. Smile lines / nasolabial folds, Area (G)
  2. Wrinkles around the mouth/Marionette lines, Area (H)
  3. Sagging jowl, Area (L)

C. Women 45 years old and below

Have more concern on their Upper Face Area:

  1. Crow’s feet lines, Area (D)
  2. Tear trough, Area (E)
  3. Frown lines, Area (B)
  4. Forehead lines, Area (A)

D. The Most Preferred Areas of Treatment for All Women are :

  1. Crow’s feet lines: 82% indicated this area as their most preferred area for treatment
  2. Oral commissures: 74%
  3. Tear trough: 72%
  4. Forehead Lines: 66%
  5. Glabellar Lines: 65%

These findings concur with my practice of aesthetic dermatology in the clinic. Young women in Singapore have similar concerns about facial areas where lines and wrinkles appear and stay. For example, the crow’s feet lines, tear trough, frown lines and forehead lines. They mainly wanted to get rid of these lines to maintain their youthfulness or to improve their facial harmony.

Older women (over 50 years old) in Singapore are also more concerned about the ageing signs of their lower face. As women age, they are less concerned about upper facial lines because these lines have become consistent with their self-image and that of their peers. What bothers them the most is the sagging skin changes of the lower face. For example, the smile lines, Marionette lines and sagging jowl.

In both upper & lower facial areas, the skillful use of botulinum toxin and fillers injections at the right place has continuously delivered wonders. Many women have taken up these aesthetic injections to pamper themselves and went home happy. There are also more and more men coming to seek help for their facial aesthetic concern.

In summary, younger women seek aesthetic treatments to retain a youthful appearance, whereas older women seek treatment with the aim of softening the sagging and wrinkled appearance. That is why the first line treatment for doctors to treat these aesthetic concerns is still botulinum toxin & dermal fillers injections because they directly address these concerns safely and effectively.