Thursday, 5 October 2017

Dark Eye Circles

Why are dark eye "circles" rather than semicircles? 

Probably because it can affect the upper eyelids in some people, not only the under eyes area.

Medical terms used for dark eye circles include periorbital melanosis, periorbital pigmentation, periocular hyperpigmentation, periorbital darkening etc.
Eye drops for glaucoma may cause temporary dark eye circles too. This is usually reversible once the medications are no longer needed.

Can you help me with my dark eye circles? 

As with any other medical concenrn, we have to first see the cause before discussing on treatment. And in many instances, it is more than just what some eye cream can solve.

There are many types and many ways of classifying dark eye circles. But generally dark eye circles can be cause be actual pigmentation (usually brown in colour), prominent vessels (usually bluish or purplish) and structural (skin colored), and frequently a combination of a few factors.

Aging and skin thinning, excessive sun exposure, fatigue and eye strain are among the most common cause of dark eye circles.

While patients are usually more concerned over the tired look, doctors should always look out for
đź’‰Systemic causes (presence of other more severe medical illness)
đź’‰Atopic diseases (often related with frequent rubbing)
đź’‰Chronic sinusitis
đź’‰Skin diseases
đź’‰Nutritional deficiencies
đź’‰Sleep disturbances
đź’‰Use of hormonal supplements / products

Certain medications such as glaucoma eye drops may cause dark eye circles too.

Treatment usually involve not a single visit. All contributing factors should be identified and if possible get treated. 

Cosmetic manufacturers often overly optimistic with their promises in dark eye circle treatment. Treatment with over-the-counter eye creams are unfortunately rarely successful. Apart from medical grade topical creams (often include a sunscreen and a bleaching agent, or chemical peels), botulinum toxins, fillers, lasers and even surgeries may be required. 

Thursday, 28 September 2017

Reducing that bruise

I want to go for filler injections. My doctor told me one of the potential side effects is that I could have bruises under my eyes. I know this should be temporary but I'm very worried as I usually bruise quite badly and easily with minor fall. Is there any way to reduce the chance of me bruising?

From a simple needle prick to procedures like filler, or even major surgery, every procedure that manipulate your skin potentially causes bleeding and bruising.

Here's how you can do to reduce the chance or the severity of bleeding and bruises.
✅ Avoid aspirin, NSAIDS (a type of painkillers), vitamin C & E, fish oil a week before
✅ Stop alcohol and garlic 2 days before
✅ Avoid excessive exercise immediately before and 2 days after
✅ Avoid flight 1-2 days if possible (change of cabin pressure)
❓Pineapples contains bromelain and may help to reduce bruising

Thursday, 14 September 2017

Acne in mature skin

I am in my late 40's. And I still get acne. Why?

Contrary to popular belief, acne isn't just a problem of the teenagers. Young babies can get acne (known as infantile acne, often temporary). Most people do not get severe acne after menopause but yes, you may still get acne at a mature age.

The reason you get acne is probably not much of a difference to that of the teenagers. But there may be other things that you would want to consider if you have never had acne and suddenly suffering from severe breakout at this point of time.

  1. Did you recently change your skin care products? Some people changed their skin care products to those "designed for mature skin" which are usually more greasy and may block the pores.
  2.  Did you recently change your skin care routine? Did you just started on a face scrubs? Or tried a new facial treatment?
  3. Did you recently go travelling?
  4. A recent change of job?
  5. Could it be something else rather than a true acne? Some skin diseases may mimick acne, and these include acne rosacea, sebaceous hyperplasia, milia and bacteria folliculitis.

Consult a dermatologist if you are not sure.

Tuesday, 12 September 2017

Healing Eczema Without Steroids

Recently, one of my patient with very severe eczema on methotrexate asked: "Can I heal my eczema without any steroids?"

Yes, you can.

Just like how your chickenpox can heal without antiviral, your runny nose can heal without any antihistamines, your sore throats can heal without any antibiotics, some women can even deliver at home, your eczema can heal without any steroids.

"Steroids is not a cure for eczema, they said," she told me. She was invited to join a support group for "healing eczema without steroids". And she has came across many natural healing advocates who strongly urge everyone to avoid steroids.

And I do not beg to differ.

What I want you to know is that "dermatologists readily dish out steroids" to help you getting over the most difficult time, and we have absolutely no intention not to harm you. In case some may have forgotten, our oath says "First do no harm" and our motto is "To cure sometimes, to relieve often, to comfort always".

I am not against natural path. But if you want to go absolutely steroids free, these are what I would suggest,
  1. Avoid all irritants and your known allergens
  2. Keep your bathing brief (<5 minutes) and not too frequent, using slight lukewarm water
  3. Use gentle cleanser instead of soap (no natural handmade soap please and no bubble bath)
  4. Always keep your skin moist, frequent re-application of moisturiser is the key
  5. Seal in the moisture with occlusives (parrafin, vaseline ointment, dimethicone if you hate that greasy feeling)
  6. If you feel really itchy, replace that scratch with applying cold pack or cold cream (no need to buy any particular brand of cold cream, just keep your hypoallergic moisturiser in the fridge)
  7. Use immunomodulators such as topical tacrolimus, pimecrolimus
  8. Ask your doctor about phototherapy (controlled light treatment) to see if you are a good candidate
  9. If you are going for alternative medicine, please go for facilities with proper registration and certification (although I have no idea how to check that these are in place), and do ask them if their treatments may have any potential short term or long term side effects (Perhaps they might not actively discuss with you if you don't ask? Well, the reason I said this is because I have a teenage boy with eczema who came to me after 2 years of herbal remedies which was initially very effective and now he is suffering from stunted growth and a few other problems)

Whatever your choice is, take good care of your skin and get better soon!

Saturday, 9 September 2017

Sunburn remedy

I came home from an outing with friends and found myself sunburnt despite using sunscreen! What should I do now?
No sunscreen offer 100% protection, which is why they are now known as sunscreen rather than sunblock.

Sunburn should be treated as soon as possible. Here's what you should do:
  1. Seek shade immediately, if you are still outdoor.
  2. Cool down with a shower or baths.
  3. Apply a generous layer of moisturiser over the sunburnt area.
  4. Apply mild topical corticosteroids to reduce the redness and swelling.
  5. Drink a lot of water to prevent dehydration.
If you have a blister at the sunburnt area, do not de-roof it. De-roofing and leaving raw skin exposed poses a risk of secondary bacterial infection and slows down healing.

If there is a large area of blisters, or you are starting to feel feverish or chills, you should seek medical consultation immediately.

Practise strict sun protection until the burned area completely heal.

Friday, 8 September 2017

Preparing your own saline solution

What it is for?

To wash the raw wound / blistering area, or you can even use it to bathe if there is any condition causing extensive skin loss.

Why using a saline solution?

It is isotonic. That means it will not draw water in or out of your raw wound hence there will be less pain.

It cleans and wound and reduces the risk of secondary bacterial infection.

How to prepare it?

Simply add 9g of salt to a litre of water. Viola!

If you have just a small wound, buy those bottled sterile saline bottle that are readily available in most pharmacies. Yes, those that are used to wash contact lenses one will do.

Expired sunscreen

I just noticed my sunscreen has expired 6 months ago. It wasn't cheap and I don't feel like wasting it. Can I still use it?

While a sunscreen may not necessary go bad immediately after the expiry date, the expiry date stated is actually the duration that the product remained effective and safe based on the manufacturer's test.

Physical agents such as zinc oxide and titanium dioxide usually lasts longer than chemical agents.

If it doesn't "smell bad", it could very well still be safe to be used despite a reduced effect of protection. A reduced effect means even if you are applying adequate amount, it may not reached the labelled SPF. Most sunscreen in the market comes in a bottle of 30-50ml. If you apply it generously on all the exposed part of the body, you would have finished the bottle in no time. ;P

Since there is no way to be sure of the efficacy and safety after the expiry date and if you ask for my advice, I would have to tell you to throw it out.

Monday, 4 September 2017

Stitch Removal

Someone asks,
"Can I remove my stitches myself at home?"
"What if I can't make it on the appointment date given for stitch removal?"

I personally would advice against attempting to remove the stitches at home if you are not a trained healthcare personnel.


There's a few things that your doctor need to assess when he or she removes your stitches. For one, he or she needs to check if your wound has healed nicely and it's ready for the stitches to be removed. If the stitches are removed too early, you may risk having the wound gaps and you may need re-suturing. If the stitches are removed too late, more often than not the suture materials maybe buried under the skin making it difficult to remove and at higher risk of scarring.

Also, he or she needs to check if there is any sign of infection. If there is any early sign of infection, it should be treated early.

When should a stitch be removed?

When a stitch needs to be removed depends on a few factors.

First, the location of the wound, generally the wound of the face heals faster and will be removed soonest compare to other parts of the body, for example legs.

Second, the types of sutures used. Some sutures are absorbable and does not require opening of stitches.

Third, the tension of the stitches on the skin.

Other factors include age, smoking, underlying skin disease, previously irradiated skin, general health, infection etc.

Generally the doctor who stitched it will be the best person to advice you when is the best time to remove it.

Can't make it for the appointment to remove the stitch?

If possible, always tell your doctor before he or she make that stitch so that he or she can plan something else for you. Intradermal or subcuticular stitching with absorbable sutures will be fine to leave in.

Is there any nearby healthcare facility, a family doctor clinic for example, to help you removing it?

If you are confident enough and really want to remove it yourself, ask your doctor if he or she could provide you with the material and teach you how. ;)

Wednesday, 30 August 2017

Quick Fix for Acne

I've picked a pimple and it became red and swollen. I have an event coming up in 3 days. How do I speed up the healing process?

Are there quick fix for acne? 

The answer is yes. But we will need to assess the condition of the "red and swollen" acne to see if which fix is for you.

If the acne was "properly picked", the picking itself should have shortened this particular acne's "lifespan". You can hasten the recovery further by applying a non-comedogenic moisturiser.

By "properly picked", I mean it should be picked hygienically and completely without any residue or pus being left behind.

If the acne was not "properly picked", and has "swollen" and might even appear to be forming up a cyst, then you might need intralesional steroids (which means injecting low concentration of steroids directly to the cyst itself) to reduce the redness and the swelling quickly.

If the acne was not ready to be picked, light and laser treatment could be helpful to hasten its maturity so that it can heal faster.

If in doubt, it is always good to pay a visit to your nearest dermatology facility. If that is not possible before your event, a professional concealer could do the trick! ;P

Monday, 28 August 2017

Hair Thinning? Could it be androgenetic alopecia?

Losing hair and it seems to run in the family? It could be androgenetic alopecia.

What is this?

This is a type of hair loss that is genetically determined.

The basic

Hair are produced from the hair follicles. And it has a few phases.
Anagen: growth phase
Catagen: involution phase
Telogen: resting phase

What happens in androgenetic alopecia is that there is
1. Increased hair shedding
2. Miniaturisation of hair (thick large pigmented terminal hair --> thinner and shorter indeterminate hairs --> short and non-pigmented vellus hair)

Generally people with this condition tends to have gradual hair loss.
For men,  it usually start with recession of frontal hair lone and gradual thinning at the sides.
For women, it usually start over the crown. Luckily usually there isn't an area of marked baldness.

Why should you see a doctor?

There are many other causes of hair loss. Some people have temporary hair thinning due to stress, drugs or nutritional deficiency. Diffuse alopecia areata may look like androgenetic alopecia too.

Again, I must stress that effective treatment comes after an accurate diagnosis. What works for others who stand out to be the testimonials of certain products may not be what works for you. An accurate diagnosis to begin with will save you a lot of unnecessary money spent.

Investigations and treatment of androgenetic alopecia is not that cheap, but how many times we have encounter patients who have spent up to 5 figures buying packages of hair growth treatment at "hair specialist" saloon or spa trying to "treat Demodex infection that eats up the hair" or "clear the clogged hair follicles" etc.?

While majority of people with this condition can be otherwise quite normal, some people may have abnormal thyroid function, sex hormone etc. Others can have hair thinning as part of polycyctic ovarian syndrome where they might have acne, irregular menses, excessive body hair or even difficulty to get pregnant.

What are the treatments for me?

The treatment for androgenetic alopecia needs to be individualised. But before we talk about treatment, you must understand that the main aim of treatment is to slow or stop the progression of hair loss. While some people can get their hair regrowth, some may not. And it is difficult to predict who may response and who may not.

Main treatments available includes:
1. Topical solutions e.g. minoxidil
2. Oral tablets e.g. finasteride (for men only), spironolactone etc.
3. Low level laser therapy
4. Platelet rich plasma
5. Hair filler
6. Hair transplant

The list above is definitely not exhaustive. And don't forget cosmetic dermatology with hair thickening, hair camouflage, hair prosthesis and wigs.

At the moment,  hair implants are NOT recommended because these synthetic fiber implants are not only expensive, they are also dangerous and leading to a whole lots of complications.

Thursday, 24 August 2017

Eczema and Career

I have eczema since young. Will it affect my career choice?

Unfortunately yes.

Certain jobs can be problematic for people with more than just mild eczema, especially if you will be in contact with irritants that may make your eczema flare-up more frequent. These include nursing, cleaning, catering, hairdressing etc.

But if you really love a job, think about measures that you can take to protect your skin. Proper use of personal protective gear may help.

Tuesday, 22 August 2017

Sunscreen for Indoor

My melasma is getting worse although I hardly go outdoor. Should I use sunscreen indoor?

Yes you should!


Ultraviolet rays can get to you even if you just stay indoor.

Do not underestimate the amount of ultraviolet rays that pass through the windows or glass door. clear glass allows 75% of UVA rays through. Even if there is tinting, up to 50% of the UVA rays may still pass through.

Traveling in a car? The  ultraviolet rays may pass through the car windows. 

Indoor lighting particularly fluorescent lighting, especially if the distance from the skin is close. This means desk lamps, bed lamps and overhead lamps are not a good idea for those with melasma and photosensitivity.

Other sources include TV monitors, computer monitors, tablets etc. Luckily nowadays, most traditional monitors have been replaced by LCD display which do not emit UV rays. They still do emit high energy visible lights though.

What you can do?

Add acrylic or plastic diffusers to indoor lights.
Choose incandescent bulbs or LEDs rather than fluorescent lights .
Choose a broad spectrum sunscreen and use it even indoor.

You might be interested to read:
Choosing The Best Sunscreen - Beyond UVR protection 
How much sunscreen is 2mg/cm2
Sunscreen and Moisturiser

Monday, 21 August 2017

"Dress code" for eczema

I have severe eczema and I tend to scratch a lot. I find it embarassing to go out to meet people with all the rashes and scratch marks on my skin, in particularly on my legs. What should I wear?

Many people with eczema has similar struggle. While we do not want you to fight with your wardrobe and to limit your style of fashion, but choosing the right clothing can help you feel comfortable and make peace with your skin.

The softer the cloth, the gentler it is to your skin.

Cotton clothes is usually gentle and comfortable to the skin.

As a general rule, avoid wool, synthetic fabrics and lace especially if it is irritating to your skin.

Functional textiles

There are some studies on the use of functional textiles. These include the use of silk, antimicrobial silk and silver impregnated fabrics. The support is weak but at least there is no hazard to try (no hazard to your skin, but may be hazardous to your wallet, haha).

Sunday, 20 August 2017

Sunscreen and Moisturiser

Should I apply moisturiser before or after the sunscreen?

One of the frequently asked questions!

Save those bucks on day time moisturiser for a better sunscreen because you don't need another moisturiser to go with the sunscreen.

Using an extra moisturiser may reduce the actual amount of sunscreen applied on the face. And that means you are even farther away from the magical 2mg/cm2 figure to reach the labelled SPF value on the sunscreen bottle.

  1. If you feel your skin is too dry and need extra moisture, choose a thicker cream base sunscreen. If you feel your skin is often greasy and oily, choose a gel, fluid or lotion base sunscreen. Better still, choose one with diamethicone, so that it is occlusive with that extra protection effect, yet not leaving the greasy feeling.
  2. Apply sunscreen half hour before leaving the house and reapply every 2 hours particularly if you go under the sun.
  3. Don't leave out the back of the neck! Other commonly miss area include the ears and the toes.

Enjoy slapping your sunscreen away!

You might be interested in:

Friday, 18 August 2017

Bed bugs

I'm traveling soon. During my last trip to Italy, I came back with very itchy bumps which I was told could be due to bed bugs. What can I do to avoid getting bed bugs again?

Bed bugs is on the rise. More and more local and international travelers came back with bed bugs. Bed bugs usually gives rise to itchy red bumps on exposed part of the body. They do not transmit serious illness but can be a great nuisance.

Why is bed bugs on the rise? 

The biggest reason is probably because more and more people are traveling. These bugs are often found in hotels, hostels, apartments. They can hide in small crevices of luggage from one place to another. As they are small, they can conveniently hide on clothing, furniture and even on your pets. A lot of pesticides for example DDT has been banned for environmental issue. And the natural predators of bed bugs such as cockroaches are being hunted down. Other predators of bed bugs include spiders and ants.

How do I know it is bed bugs and not something else?

If there are new itchy bumps on the exposed part of the body, especially when you have slept on a used bed the night before, then most likely you are getting bed bugs.

You might want to look at the seams of the mattresses for blood stains, rusty spots of bed bug excrement, egg shells, or you might even find a bug or two, which is usually visible with naked eyes as they are about 5mm in size. Bed bugs give a musty odor. Do not forget to check the phone directories, carpets and your luggage too.

How to reduce the risk of bed bugs when travelling?
  • Avoid sleeping on used bed, especially if it has a musty odor
  • Keep the luggage zipped up even within hotel room
  • Store the luggage high
  • Store the luggage in the bathroom if possible (it is not easy for bed bugs to climb up the slippery porcelain)
  • Wash all your clothes upon getting home, even if you have not worn some of them
Click here for a slideshow on bed bugs.

You might be interested in
Skin and Traveling

Itchy Food (Pseudo-food allergy)

I have eczema. Every time I take seafood, my skin itches. What are the food that I should avoid?

I have wrote on Food and Eczema earlier. Diet restriction is only recommended for people with proven food allergy. But a lot of people with negative skin prick test and negative serum IgE to food allergen still complain of itch when they take certain food.

Yes, certain food does make you feel more itchy even though you do not really have food allergy! Why? 

These are food that contains high level of histamine. While most people are happily eating away, some people has lower enzymes (s.g. diamine oxidase) to degrade histamine content in food and may experience "pseudoallergy". Itch and hives are among the common symptom, others may experience facial flushing, angioedema (eye and lips swelling), eczema and even flare up of acne, rosacea and psoriasis. Some people may experience diarrhoea, headache, runny nose and asthma. Just to name a few.

Food with high histamine-releasing capacities include
  • Alcohol
  • Canned food
  • Shellfish
  • Smoked meat
  • Sausage 
  • Certain fishes such as tuna and mackerel
  • Beans
  • Nuts
  • Chocolates
  • Vinegar

Food that may not contain high histamine level but trigger the body to release histamines include
  • Citrus fruits
  • Strawberries
  • Tomatoes
  • Papaya
  • Wheat germ
  • Nuts
  • Chocolates
  • Liquorice
  • Certain fish 
  • Shellfish
  • Pork
  • Egg white
  • Certain additives and spices

Food that reduces diamine oxidase enzymes include alcohol, energy drink, black tea and green tea.

Should eczema patient takes low histamine diet?

Some patients with severe eczema find taking low histamine diet helpful, in particularly during flare ups. Generally diet restriction is not recommended for people living with eczema, unless there is real intolerance.

You may be interested to read:
Food and eczema

Wednesday, 16 August 2017

Choosing A Topical Steroids

Which topical steroids is the right one for me?

I have previously blogged about Steroid Fear and The do's and don't of using topical steroids in eczema. Before I start on how to choose the right topical steroids, I cannot stress enough that the success of using topical steroids starts from an accurate diagnosis, which means using it in the indicated and right situation.

Common conditions treatable with topical steroids include eczema, psoriasis and lichen planus.

There are many topical steroids in the market. They vary in potencies and preparations. Some even comes in combination with antifungals and antibiotics. Generally combinations of topical steroids and antifungals is not recommended as it may lead to persistent fungal infection.

Preparations (vehicles)

Steroids comes in various preparations, generally the ""heavier" the preparation, the "stronger" the strength of the same steroids it carries. One example is that 1% hydrocortisone ointment is stronger than 1% hydrocortisone cream.

Ointment provides occlusion and enhanced absorption of the steroid that it carries. However, some patients may not like the greasy feeling it leaves on the skin. You may want to avoid using it on skin folds and hairy areas. Best timing to use it will be right after a shower or bath.

Creams is good to hydrate the skin and patients love it because they get absorbed after a while. However, creams do not provide occlusives effect. They often contain preservatives and some people can have allergic contact dermatitis to creams.

Lotions are even less greasy than creams. Lotions contain alcohol. Lotions are good for hairy skin because they can penetrate through the hair easily and do not leave much residue on the hair.

Gels are jelly-like. They are good for acne-prone skin. Typically gels dry up very quickly so even if you apply it on hairy area, it does not give matting of hairs.

Other preparations of medications include foams, mousses, shampoos and powder.

Strength of steroids (potency)

In laboratory, the strength of steroids is assessed based on how much it causes blanching (due to constriction of blood vessels) in normal and healthy people. This does not always translate to how strong a particular steroids' anti-inflammatory effects on a patient. However, generally the strength of clobetasol propionate is higher than betamethasone dipropionate than betamethasone valerate than hydrocortisone.

Lower potency steroids are safer for using in large surface area, longer term, thinner skin area and in children.

Superpotent steroids should not be used on face and under occlusion, unless for a very short duration.

Superpotent steroids such as clobetasol propionate are typically not recommended for continuous use longer than 3 weeks, other steroids are typically not recommended for continuous use longer than 3 months.


Things to consider when choosing the most suitable topical steroids of the right strength and right preparation include:

  1. The diagnosis
  2. Condition of the skin intended to apply (acne prone? very dry?)
  3. Site intended to apply (thin skin area? skin folds? hairy area?)
  4. Surface area intended to apply
  5. Duration intended to use
  6. Age (children? elderly?)
  7. Pregnancy
  8. Allergy (contact dermatitis to preservatives?)
  9. Personal preference

You might be interested to read about:
Steroid fear 
Do's and Don'ts of Using Topical Steroids
Bathing in Eczema
Food and Eczema
Color cosmetics and Eczema
Acne and Eczema

Facial Eczema

I have eczema since childhood. I believed I have my eczema inherited from my father. My eczema has been mild all these while until my pregnancy when it suddenly become very severe. I am now 5 months post delivery but my eczema is getting worse each day. It is all over my face and I feel very miserable and depressed.

I have visited numerous doctors and tried numerous creams, steroids and non-steroids, but each time, it came back after a few days. None of the medicine heals. I expressed my frustration on facebook, and after recommendations from another mother, I seek treatment at a traditional chinese medicine centre from Taipei. I was given a soap, a spray and some creams. It helps a bit but still comes back. I was told I can't take medicine because I am still breastfeeding.

I lose my temper easily and totally lost my confident to get out of the house. What can I do?

Hugs. You are not alone. Eczema can be very frustrating. Especially when it involves the face of a young mother.

The Basics

Eczema is a group of inflammatory problem involving skin that is usually itchy. There are many types of eczema.

The one that you seems to have from your description maybe:
  • Atopic eczema: typically starts young, with personal or family history of atopy, associated with defect in skin barrier and immune dysfunction
  • Contact dermatitis: typically persistent and relapsing, particularly if the culprit allergens or irritants is not identified, and appropriate skin care is not in place
A little detective work

Could this be the culprit?
  • Nickel and chromium, not necessarily from costume jewelleries, don't forget the mobile phones (Not common, but people can be allergic to silicone cover of the phone as well)
  • Preservatives and fragrance in cleansing agent including shampoo, cleanser, mouth wash.
  • Skin care products
  • Cosmetics 

Important points:

A product that has been used for several years may not necessarily be safe because:
  • We are not born with allergy, allergy develops over time.
  • The manufacturers can change their formulas to include different ingredient and may not states it clearly.
Don't forget indirect applications can come from the touch of your own hand.

How to get better? 

Management plan of eczema needs to be personalised. Things that need to take into considerations include the stage and severity of your condition.

If your skin is weeping and oozy, you may need temporary usage of astringents, baths or even draining of water blisters. Viral and bacterial infections, if present, must be treated.

Generally, steroids and non-steroidal products help to reduce inflammation, itch and all the suffering that you are having right now.

Moisturised your skin as often as you can. Choose a hypoallergenic moisturiser. Choose an occlussive moisturiser that coats and protects your skin, preventing transepidermal water loss. Choose a therapeutic moisturiser that will help to restore the defective skin barrier.

Avoiding the culprit should get you better within a week or two although it might take months to clear up completely. If you are really not sure which is the culprit, patch testing may help.

You might be interested to read about:
Food and Eczema
Color cosmetics and Eczema
Steroid fear 
Do's and Don'ts of Using Topical Steroids
Bathing in Eczema
Acne and Eczema

Tuesday, 15 August 2017

Skin and Traveling

I came back from a trip lately and had very bad skin eruption which has never happened to me before. I believe the drastic change of weather is the cause. Is that true that weather affects our skin?

Yes. It is true.

Dry weather

Skin is the most superficial organ and hence it is one organ that is most exposed to the external environment and most susceptible to the change in weather.

We, Malaysian are used to hot and humid weather. If you travel to temperate countries during winter, dry skin and cracked lips are among the most common skin problems. People with eczema may suffer a severe flare if they don't moisturise their skin diligently enough.

Heat trapping clothing?

Traveling in winter, most people will wear heat trapping clothes. Wearing tight fitting or heat trapping clothing can lead to folliculitis due to irritated hair follicles.

Soaking comfortably in hot water bath?

A contaminated bathtub, or even whirlpool, swimming pool and water slides can give one pseudomonas folliculitis. There is even reports of infection from contaminated diving suits.

Sun exposure

Many people gets sunburn while traveling. We hide in shades and in air-conditioned room back in our hometown. When we go traveling, we go outdoor much more frequently. During winter in particular, we love to stand under direct sunlight, not to forget that beautiful snow reflects ultraviolet rays to our faces that are often not covered by the winter coat. The results? The flare-ups of acne, rosacea, eczema, psoriasis, blistering diseases and lupus erythematosus (For people with all this conditions).

More exposure to ultraviolet rays also means higher skin cancer rate apart from lower the immunity and higher chance of cataracts.


Apart from the change of weather, don't forget that stress, diet etc. can affect our skin. Not all trips are nice and relaxing. If you are under stress, acne, rosacea and psoriasis can crop up. If you take a lot of comfort food with high glycemic index during the trip, acne can crop up; or spicy food, and rosacea can crop up.

Do you share blankets, pillow cases or even towels and clothing while traveling? Many skin infections can spread via contacts.

Last but not least, don't forget that bed mites, ticks and scabies can be rampant in certain accommodation with suboptimal hygiene.

I love good skin but I love traveling too. What can I do to avoid skin problem?
  • Sun protection - hats, scarfs, sunglasses, sunscreen, shades
  • Stay moisturised and hydrated
  • Stay warm
  • Keep to your usual skin care routine
  • Avoid sharing of personal items
  • Steer away from contaminated / parasites infested places as far as possible

Acne or Eczema

My face itch with many small red bumps. Is this acne or eczema?

Acne is not typically described to be itchy. In many textbooks, itch is not mentioned as a symptom of acne at all. Having said that, a few studies have shown that 50-70% of people with acne do complain of facial itchiness, in particularly when they sweat, or in heat, or under dry air or when they feel stressful.

Eczema is usually itchy. One senior consultant dermatologist that I know loves to say, "If it ain't itchy, it is not eczema". Is there any new skin care, paper masks, makeup and any other items that you have recently use on your face prior to the onset of the problem? Or did you just have a facial treatment lately? Having said that, all that itch may not be eczema too.

Other possible "itchy red bumps" that may appear on face include rosacea, seborrheic eczema, bacterial folliculitis, pseudofolliculitis barbae, miliaria, perioral dermatitis etc.

Do me a favour. If you can't figure it out it's acne or eczema in the next one to two weeks, and if it's not going away, please consult your nearest dermatologist.

Sunday, 13 August 2017

Can a person with HIV get babies?

Ok, this is totally unrelated to skin, but guess I can put this under health. This morning as I was going out with my family to our favourite Bak Kut Teh place for breakfast, I received a call from my university friend who is an opthalmologist asking about this:"If a person with HIV on HAART (medicines for HIV) is getting married, can he gets babies?"

Obviously the best person to discuss his family plan would be his infectious disease physician with whom he is following up. I might not be up to date but I did a little search on BHIVA & CDC before getting the answer as follows.

If the male partner is HIV positive:
  • Wait till the viral load is less than 50 for at least 6 months
  • Make sure there are no other infections
  • Unprotected sexual intercourse only at the fertile time of the woman's cycle
  • Consider assisted conception with sperm washing or donor sperm if your risk of tramitting HIV is high (ask your ID physician) 
  • Consider pre-exposure prophylaxis treatment (ask your ID physician)
If the female partner is HIV positive:
  • Wait till the viral load is less than 50
  • Make sure there are no other infections
  • Take folic acid at least 3 months before planning for pregnancy, in particular if you are on antibiotics such as bactrim (co-trimoxazole)
  • Both natural delivery and Caesarean section are possible options if your viral load is less than 50
  • Intravenous infusion of HIV medicine may be given if your waters have broken or if your viral load is high
The baby will be given HIV medicine for at least 4 weeks and tested for HIV. Breastfeeding is not encouraged especially if in countries where formula milk is easily accessible.

Good to know: 
Take the HIV medications diligently, don't ever miss a dose, if the viral load is low, the risk of transmitting HIV from male partner to female partner is almost zero, and the risk of transmitting HIV from mother to newborn is less than 1%. :)

New Miracle Cream, should I try it?

My friend bought acne products online. There's a number of consumers' testimonials and looks very convincing. I'm tempted looking at the pre- and post-treatment results. Should I try it or should I not?

I can't advise you if the particular product is good or otherwise but maybe I can give you a few guides on choosing the products. There are a lot of online or over-the-counter or direct selling products with testimonials and claims from consumers. Some people practically swear by it, claiming the extreme effectiveness without the side effects of "standard treatment".

A few points to ponder:

I am sure you know that most skin diseases progress and change and heal with time. Be it acne or eczema or psoriasis, there are good times and bad times. Even if you do not treat it, it may gets better on its own. And of course, it may worsens too. The reason we are treating it is to make it recovers faster, lessens the itch and the pain, lessens the marks and the scars.

Plain vehicles aka. plain creams without active ingredients can heal. We know that skin conditions like acne and eczema do improve with moisturiser. Yes, it does. There are many therapeutic moisturisers, marketed in particularly for eczema, with proper well designed scientific studies such as randomised controlled trials to prove its efficacy. These are really awesome, especially for young babies and adults who are steroid phobic. If you noticed, most of the time if not all, they are comparing with 1% hydrocortisone (aka one of the weakest topical steroids). This means that the claims they can made is that they are effective, but the effects is not inferior but also not better than the weakest steroids.

There is something called placebo effect. A person's condition can improve because he or she is very confident and expecting the recovery. Likewise, he or she is more likely to experience side effects from the treatment if he or she is expecting it. (But unlike alternative or integrative medicine practitioners, we the doctors still need to tell you the possible side effects of every drugs prescribed, don't we?)

Before forking out your cash, some reality check: 
Is the active ingredients listed?
Is the potential side effects listed?

Remember that something with literally no side effect at all, is likely to be just a vehicle (aka. plain moisturiser, even that could have irritations sometimes).

If you are keen to try, perhaps you can do a little scientific study at home. Most skin conditions affect both side of your face / body with similar severity. You can do a split face trial. Use the new product on one side of the face and standard treatment on the other side and compare. Scientifically, a new medication should be compared to the standard treatment for its efficacy before it is launched.

Good luck!

You might be interested to read:
Moisturiser for acne
Steroid fear

Saturday, 12 August 2017

Moisturiser for oily skin? Yay or Nay?

I have oily skin with frequent acne breakout. Do I still need moisturiser?

Many people with acne reported that their facial skin is "oily", "greasy", "clogged up", "an additional layer on skin" because of the extra sebum production.

But the answer is yes. You still need moisturiser.


In acne, your skin barrier is actually impaired. The four main features in acne are
  • Increased sebum production (more "oil")
  • Follicular keratinisation (plugging of pores)
  • Propionibacterium acnes (a type of bacteria) proliferation
  • Inflammation
That extra sebum does not contribute much to skin barrier but can be used by the bacteria called Propionibacterium acnes to grow and break the balance of the many other natural organisms on the skin (more than 500 species live on our skin, if they live in harmony, they should not be causing any trouble) and leading to inflammation. An inflamed skin is a skin that is in a mess. Moisturising it helps to reduce inflammation, to restore the harmony and the balance of our skin.

Many medications that are used to treat acne, ranging from antimicrobials to retinoids, can cause dry skin. Moisturising the skin helps to reduce irritation and itch and makes you feel more comfortable.

Tips on choosing the right moisturiser.
  1. Pick one that says non-comedogenic
  2. Pick one that says hypoallergenic or for sensitive skin
  3. Pick therapeutic moisturiser that helps to restore skin barrier
  4. Look at the ingredient, I personally loves one that contains dimethicone because it is an occlusive that helps to retain moisture and yet doesn't give that greasy feeling while gives that little extra protection to the skin
  5. Try it on, it should feels soothing
Oily skin? Don't worry. Happy moisturising it away!

You might be interested in:
Acne myths 
Skin oils for acne skin

Tuesday, 8 August 2017

Why is my fungal infection keeps coming back to bug me?

My fungal infection keeps coming back despite treatment. What else can I do?

Tinea cruris is a superficial fungal infection known for its recurring nature. Moist skin is very prone to re-infection.

Here is what you can do:
  1. Keep the crural folds dry after bathing by using a separate towels
  2. Avoid tight fitting garments that will trap your sweats
  3. Bring extra garments out, especially if you know you may sweat soon
  4. Do not share personal garments and towels with others
  5. Lose weight to reduce apposition of skin folds
  6. If you nails, hands and feet or any part of the body has fungal infection, get them treated at the same time

Monday, 7 August 2017

Contact Dermatitis to Color Cosmetics

This morning, my 21-month-old daughter did this to my eye palette. (She loves to play with whatever on my vanity table.) I thought maybe it's time I should write something about cosmetics. Thanks for the reminder, little girl.

Not too long ago, a friend of mine told me his wife cannot put on purple color eye shadow.

"Anything to do with purplish hue will make her itch and red and swollen."

Yes, this is a form of allergy.

Color cosmetics can cause various skin reactions. These include:
  • Contact urticaria - wheals and hives, itchy or burning, often resolve within 24 hours
  • Contact dermatitis - dry, itchy and scaly rashes, may form blisters and become oozy and weepy, lasted for days
  • Photocontact dermatitis - similar to contact dermatitis, but form because the ingredient interacts with sunlight
  • Anaphylaxis - eye and lips swelling, difficulty to breathe, death has been reported in association with black dye
  • Others: acne, pigment and skin color changes
Common allergens found in eye shadow include:
  • Nickels (often found on eyelash curler, and some make up brushes as well)
  • Cobalts
  • Fragrance
  • Preservatives
  • Carmine (red, violet, margenta shades)
  • Dyes
  • Formaldehyde
  • Lanolin

No, I'm not saying you should not make up. I do regularly apply make up myself. But if you are atopy (having conditions such as eczema, asthma, allergic rhinitis) and are prone to skin reactions, be in the knows and this is what you may want to do:
  1. Read the list of ingredients before buying a product.
  2. Do a mini test, try the product on the inner aspect of your elbow or wrist a few times before buying it. (That is what testers are for!)
  3. Choose hypoallergic, fragrance free and non-comedogenic ones, even though it doesn't guarantee no skin reaction.
  4. Perhaps pick product with less complicated ingredient.
 Finally, enjoy your color cosmetics!

Saturday, 5 August 2017

How much sunscreen is 2mg/cm2?

How much sunscreen should I apply?

In previous article on Choosing The Best Sunscreen, we have mentioned that the SPF value stated on the sunscreen is actually based on the application as thick as 2mg/cm.

Ever wonder how much is 2mg/cm2?

I do. Let me measure my own face with a curve ruler. From forehead till chin 20cm, from ear to ear 26cm.

This is going to be a very rough figure. Although I'm a Virgo, I'm not very good at maths after leaving my mathematics class for years.

Surface area of a rectangle is Height x Width, then 20 x 26 = 520cm2.

If my face is a perfect oval, then the surface area will be 3.14 x 10 x 13 = 408.2cm2

I'm not good at maths, but the surface area of my face would be probably between 408 to 520cm given that he shape is between oval and rectangle?

To apply 2mg/cm2 to the face means I will need roughly 1040mg to cover the whole face = slightly more than 1g.

Say my 1 FTU = 0.4g, I need around 2.5 FTU of sunscreen to cover my whole face, not to mention neck and other areas.

To use this much of sunscreen, I probably have to apply layer by layer, let one layer dry and put on another layer. Else, I will look fairer than Geisha. Haha.

The other way of looking at whether I'm using enough sunscreen or not will be this: A 50g sunscreen will only be enough to be use for 50 times for me. Say that I apply twice a day, a 50g sunscreen will be used up in less than a month's time if I'm using according to the recommendation of 2cm/cm2!

This is exactly why we should buy the best sunscreen, the highest SPF, not just more than SPF35, because nobody use that much of sunscreen, and since we are under-applying, that little extra SPF protection, does make a difference.

Friday, 4 August 2017

How much steroids should I use?

I was instructed to apply the steroids "thinly" over the affected area of the skin. How thin is "thin"?

Why just a thin layer?
No, not because your doctor is fear of side effects of topical steroids, he or she should not be. A thin layer  is needed because a thicker layer does not equate an enhanced penetration or a better effect. (But not too thin as well, or there will be inadequate effect.)

How thin is thin? 
A thin layer is probably between 0.01 to 0.1mm. But it is impossible to measure that. So we usually use fingertip unit (FTU) as measurement instead.

If you squeeze the cream or ointment out from a tube with 5mm nozzle, and let it covers the tip until the first crease of on your index finger, that is 1 FTU.

1 FTU is roughly 0.5g for an average man, 0.4g for a woman, and even lesser for children.

And how much does 1 FTU covers?

One hand (front and back) or two palms.

Having said that, don't worry if you need to use slightly more or less. This is just a rough guide. As long as you keep the steroids on the affected / thick and rough skin area, you should be fine.

Thursday, 3 August 2017

Skin Oils for Acne Skin?

I have acne. Can I use skin oils as my facial moisturisers?

We all know oily skin are acne-prone skin. Common sense tells us that people with acne prone skin should avoid oily greasy product that can clog your pores and make your acne worse.
But a lot of people say otherwise, so is skin oil really okay for acne-prone skin?

After some search, this is what I get:

1. People don't get oily skin everywhere. A lot of people has what we called "combination skin" where one part of the skin maybe oily and another part maybe dry. It is definitely okay to use it on your dry skin area.

2. Oils have many grades. Some experts* say certain cosmetic grade mineral oils may not clog the pores.

What's my take?

Avoid it if you are not sure.

Still very keen to give it a try? Try it on a small part of your skin instead of the whole face, and share with us what happens next.

*picture is for illustration purpose only.

Wednesday, 2 August 2017

Do's and Don'ts of Using Topical Steroids In Eczema

  1. Use steroids on affected area (Touch and feel your skin with your fingers if you are not sure, affected skin areas are rough, bumpy and thick with different texture compare to unaffected area.)
  2. Apply adequate amount of steroids.
  3. Apply steroids onto dry area.
  4. Use steroids once to twice a day or whenever necessary.
  5. Smooth the steroids in the direction of hair growth, especially if the area is hairy and you are using a greasy ointment.
  6. Leave 30 minutes in between applying another topical preparations onto the same area of the skin.
  1. Do not use steroids in ointment form onto wet and weepy area (more often than not, wet and weepy areas are infected).
  2. Do not use strong steroids on thin skin area such as genitals and face particularly around the eyes, unless instructed by your doctor. (ask your doctor how long you can use it on your face)
  3. Do not use strong steroids under occlusion (under dressings, tight clothing, folded skin area such as in the buttock folds), unless instructed by your doctor. (Occlusion increases absorption)
  4. Do not use steroids to raw skin area.
  5. Do not apply occlusive ointment (such as mineral oils, paraffin, petrolatum) prior to steroids.
  6. Do not use steroids (and any other medicines) after expiry date.
  7. Do not share steroids (and any other medicines) with your family or friends.

Tuesday, 1 August 2017

Steroid Fear

"Four out of five people are afraid of using corticosteroids in eczema..." --news from last week.

Definitely true in my practice.

Steroids generally have bad reputation. And perhaps western medicines have a bad reputation of dishing out steroids to patients so a lot of them turns to traditional medicines or alternative medicines, which are unfortunately sometimes being adulterated with steroids.There are reports of parents, in fear of using steroids for their children, turn to alternative medicines with potent steroids, click here for one of the report from Hong Kong.

Is Steroids Bad?

Yes and no. It depends on how it is being used.

If eczema is fire, then topical steroids (be it gel, lotion, cream or ointment) is water. Yes, and we are saying that 4 out of 5 people, in fear of drowning, many avoid water or use minimal amount of water to pour on the fire that is burning them down.

Common sense tells us that you can pour water onto the fire as long as it is still burning. Using the correct formulation and strength onto the appropriate area based on appropriate indications under proper supervision should keep you safe.

There are alternative of extinguishing fire without using water, and yes, there are alternative of non-steroidal preparation too. But I must say that most of the time, topical steroids are often powerful and yet cheaper.

Read about the Do's and Don't of Using Topical Steroids in Eczema here and how much steroids to use here.

Monday, 31 July 2017

What is a dermoscope?

"What is that? A magnifier?"

So this morning, I met a paediatrician colleague in the hospital and he curiously pointed to the "black colored tool" that I was holding.

We all know the cardiologists use stethoscopes. Yes, the thing that hang on the doctor's shoulder in typical "comic doctor" illustration. And the gastroenterologists use endoscopes. And yes, we dermatologists do have our "scopes" to play with. Many people including our fellow doctor colleagues have not came across it though.

Dermoscope is a bit more than a magnifier. Apart from a good quality magnification lens,  it comes with strong light and polorised filter, which is why it is much more expensive than a magnifying glass. How much? I spent 4 digits on this one more than 4 years ago, when our ringgit exchange rate was better than now.

What does it do? Essentially it is a form of skin surface microscopy. So your dermatologists can use it to look at the colours and the structures of the skin, nails and hair. This can help diagnosing skin conditions, in particular pigmented problems without or prior to cutting your skin and examined it under a microscope. So dermoscopy can cut down unnecessary skin biopsy. Of course, dermoscopy examination are not meant to replace skin biopsy. A lot of time, skin biopsy is still necessary for ultimate confirmation of a diagnosis, especially that of a suspicious skin cancers.

Oh, and we can connect this to a camera or a phone to take a clear picture of the skin too. :)

Bathing in Eczema

I have eczema and I'm confused if bathing is good for me. Some say bathing will make my skin worse. But I do sweat pretty easily. I usually shower three times a day because I feel itchy if I don't. Should I cut-down on my bathing?

Shower or Bath?

We don't know for sure which one is better. But we do know that spending too long with the water is not good for your eczema. Spending too long in the water might dry your skin up by washing away all your natural moisturising factor. Particularly if you use hot water to shower. Avoid scrubbing. Avoid antibacterial soap. Avoid harsh alkaline soap. Or better still, use a non-soap cleanser. Gently pat your skin dry. And always moisturise your skin as soon as you get out of baths (within 3 minutes).

How long should I spend in bathing?

Those who spend no more than 5 minutes bathing has significantly less severe eczema.

How frequent should I take a bath?

Bathing daily and twice a week does not make any difference in a study carried out in temperate country. In Malaysia, I believe you should bathe at least once a day, or maybe even more whenever you are all sweaty and dirty. Remember, sweat is an irritant that will worsen eczema as well. Just don't spend too long in the shower or bathtub.
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