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.

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!

Reference
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