Thursday, 17 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.

Summary

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

Tuesday, 15 August 2017

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

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.

Others

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



Monday, 14 August 2017

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%. :)

Saturday, 12 August 2017

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


Friday, 11 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.

Why?

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!


Friday, 4 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.

Thursday, 3 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.

Wednesday, 2 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.

Tuesday, 1 August 2017

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

Do's
  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.
Don'ts
  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.

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. :)

Sunday, 30 July 2017

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.

Saturday, 29 July 2017

My doctor(s) can't seem to help me. What should I do?

I have a serious skin problem. I have a red swelling on my cheek which started as a "pimple" but gradually getting larger. I had taken a few courses of antibiotics in the past one year, including a 6 months course of erythromycin from my family doctor. He took a small skin sample from my cheek prior to the long course of antibiotics but the report wasn't conclusive. Then I was given oral steroids which seems to get the swelling slightly smaller but it never goes away. I trusted my family doctor as my family has been under his care for years. But he can't seem to solve my problem. What should I do?

Here's what I think you should consider.

1. What is the diagnosis? Sounds like no definite diagnosis has been made so far. Effective treatments often comes from an accurate diagnosis. (Yes, I say "often", some people treat by hunches, and it works, sometimes. But the basic of medicine should be diagnosis first before treatment.)

2. How was the skin sample taken? Was it taken at the right place? Was it deep enough? Is the cut big enough for the laboratory to examine? What laboratory tests have been done? A histopathological examination? Any extra stain needed? What about culture for fungus and bacteria and other not so common bacteria?

3. Perhaps you might want to politely ask your family doctor if he thinks any other doctors or nearby dermatologists may help you with your problem? Most if not all good doctors do not mind writing you a letter, giving out your previous investigation and biopsy records. If a particular doctor is very defensive about you going for a second opinion, it may be, well, a warning sign perhaps.

4. Consider going to dermatologists in bigger or more well known medical centres because they may be more experienced in managing not-so-common skin problems.

Friday, 28 July 2017

Choosing The Best Sunscreen - Beyond UVR protection




Here's my take on what is the best sunscreen.

Choose a broad spectrum sunscreen

By broad spectrum, it should have
  1. UVA protection, also marked by Protection of UVA (PA) value that ranged from + to +++. If the PA value isn't stated, look for ecamsule, avobenzone, oxybenzone, titanium dioxide, sulisobenzone, or zinc oxide in the ingredient. 
  2. UVB protection, also marked by Sun Protection Factor (SPF) value. The higher the SPF, the higher the protection. However, the higher the SPF, the smaller the difference it offers. 
  • SPF 15 sunscreens filter out about 93% (of UVB rays)
  • SPF 30 sunscreens filter out about 97%
  • SPF 50 sunscreens filter out about 98%
  • SPF 100 sunscreens filter out about 99%
However, SPF value are based on application of 2mg/cm2, and who on the earth would apply sunscreen such thick!? Trust me, in reality, that extra small additional value of SPF does matter.
  1. Infrared protection - probably less harmful than UV rays, but accounts for more than 50% of the sun energy that reach our skin, and also contributes to aging and skin cancer.
  2. High energy visible light or near-UV protection - again, not as strong as UV rays but it could be another silent harmful agent from computer monitors, phones, lights etc. leafing to dry and sensitive skin apart from aging.

Read the product label
  • Make sure that there isn't any ingredient that you are allergic to.
  • Pick a non-comedogenic one if you are prone to acne.

Other things that you may want to consider
  • Tinted sunscreen, so that you don't look all white out like Geisha!
  • Sunscreen with antioxidants to counteracts reactive oxygen species production, not new but yay!
  • Pleasant scent or a brand that you like -- you will not use it if you don't like it!
  • Sunscreen for sensitive skin, go for physical agent such as titanium oxide and zinc oxide, rather than chemicals like oxybenzone. Avoid fragrance and alcohol too.
  • If you are choosing a sunscreen for your children, try to get physical agents too.
More expensive sunscreen isn't necessarily better. Don't forget to look at the expiry date and use it correctly. Oh, and in case you don't know yet,  there are oral sunscreen too (the efficacy of which is doubtful, so don't use it alone without applying topical sunscreen).

Last but not least, using sunscreen isn't enough. There's a study that showed that people who uses sunscreen actually gets more sunburn as they tend not staying in shades. So, please don't forget your sunglasses and hats! After all, these can be part of fashion too, so all the beauty and handsome, why not?

Thursday, 27 July 2017

Acne Myths

Eating oily food causes acne?

Food and acne is always a hot topic. More than 10 reviews have been done in the last ten years on fatty food, sugary food etc. Rather than oily food, sugary food is more likely to be responsible for your acne.

Kitavan Islanders of Papua New Guinea and Ache hunter-gatherers of Paraguay ate minimally processed plants and animals without typical carbohydrates and they have almost no acne!

Have you ever heard of the term Glycemic Index? Glycemic index described how much your blood sugar increases with a portion of carbohydrate. The higher the glycemic index of a food, the higher your blood sugar goes after eating it, and your sebaceous glands will produce more skin surface triglycerides and the more likely it is for acne to erupt.

What about milk and diary products?

Many observational studies suggested that the more milk you drink, the more likely it is for you to get acne in the same manner as taking high glycemic index food. Observational studies, however, are not strong studies with good design. We can only conclude that until better studies are carried out in the future, the evidences are not enough to ask all acne patients not to drink milk or take diary products.

Bad facial hygiene gives you acne?

Contrary to popular beliefs, washing your face too hard, particularly with scrub, gives you more acne (and we called it acne mechanica).

When you wash your face too much, you might remove all the protective oil on your face leading to dry skin. I usually tell my patients not to wash their face more than twice a day, and use a gentle face wash instead of strong ones that leaves your skin feeling tight and dry after using.

Make-up can cause acne?

Wearing thick make-up that clogs the pores and failure to remove make-up completely can cause acne (and we called it acne cosmetica). Look for the label "non-comedogenic" if you are worried. Also nowadays, many manufacturers actually added anti-acne medications such as benzyol peroxide and salicylic acid into the products. Tinted benzyol peroxide concealers might help to treat your acne while concealing it at the same time.

Stress causes acne?

No and yes. No becaurse there isn't enough scientific evidence yet. Yes because theoretically stress affects your hormones (more cortisol that activates the sebaceous glands) and can be the cause of your acne. In reality many patients do report their acne worsens when they are preparing for major exams. Perhaps exactly the same reason why some girls have acne every month before having their menses.

Sex causes acne?

Well, I have no idea where this myth starts from. To prevent teenagers from having sex perhaps?

Acne is a teenage issue?

False. Although more common among teenagers, acne can affect people in their middle age too.

Acne should not be squeezed or popped?

Squeezing an immature acne can gives you scar. Squeezing an acne incompletely or without hygienic measures may get it infected or spread it to surrounding skin too. However, squeezing a mature acne can actually reduces pain, infection and initiate healing earlier. Proper method of squeezing without picking on the skin should have low risk of leaving you a scar.

Apply toothpaste onto acne helps to heal it faster?

Toothpaste does not contain any ingredient to heal acne, and sodium lauryl sulphate in the toothpaste may not do any good to your skin. Perhaps it helps to dry up existing acne? I'm not too sure about that.

Sun tanning helps to heal acne?

False. Many skin conditions get worse under the sun and acne is just one of them. Apart from that it puts you at risk of skin cancer too. Use a good sunscreen that is non-comedogenic especially under the hot sun of Malaysian weather.

Probably this is why dermatologists always talk about sun protection, sun protection and SUN PROTECTION! Upcoming next post will be on choosing the best sunscreen. I hope my take on choosing the best sunscreen offers a little extra information than what you can easily google from most skin care sites out there. :)

Wednesday, 26 July 2017

Food and Eczema

.... are you on a see-food diet or no-food diet?


"I don't eat meat, I don't eat seafood, I don't take processed food but I still get the rashes! Why?"

There is something about Asian and food. We love food. But we blame most if not everything to the food that we ate.

Dark ugly scar? Perhaps the soy sauce?
Good grades at school? Maybe the blackbean soup that the mother took years ago during pregnancy.

More so with skin conditions.

Itch? Maybe it's from the silverfish that I took this morning.
Rashes? Could it be the prawn that I took last night? Or the gluten in the bread?

So here's a summary of what science says about your diet and eczema. (7 Cochrane Reviews)

Supplements and eczema

Fish oil, zinc sulphate, selenium, vitamin E, vitamin D, pytidoxine, sea buckthorn seed oil, hempseed oil, sunflower oil, docosahexaenoic acid -- too little evidence to say it is beneficial.

Why too little evidence?  Give for example vitamin D supplements, in one randomised controlled trial with 1600IU a day for 2 months says it improved, but another randomised controlled trial using 4000 IU daily for 2 months says no difference.

Primrose and borage oils

Yes, it is anti-inflammatory, theoretically it could be helpful. Unfortunately there were 27 studies with 1596 people involved took it and it makes no difference.

Prebiotics and probiotics

Now there are postulation that your eczema maybe related to food sensitisation and those bacteria in your gut may play a role. In case you are not sure, probiotics are supposed to be  "good bacteria" for your gut and prebiotics are the "fertiliser" for the probiotics to grow.

There are a lot of studies into these and looks like taking probiotics during pregnancy and after may help. For prebiotics, it is probably only helpful after delivery for children of up to 7 years old.

Diet restriction

Many patients say that when they take certain food, their eczema flares up. 6 studies asked the patients not to take egg and milk, another 1 asked to restrict their food to a few simple diet, and another 2 studies on elemental diet. Looks like there is significant benefit. One study that asked patient with positive egg-specific IgE to avoid eggs in their diet does see an improvement in their eczema severity. So what does this tells us?

Diet restriction is only good for those with food allergy. And therefore it is not necessary at all for everyone with eczema (but without food allergy) to practise diet restriction. Furthermore limiting yourself or your children's diet may pose a risk of nutritional deficiency, not to mention reducing our happiness because we all love food!

How to know if you have food allergy?

These are the things that your doctor may use
  • Food diary
  • Skin prick test
  • Serum IgE testing
  • Oral food challenges
Ask if you are not sure.

The mother's food

Many pregnant mothers and breastfeeding mothers are worried their food may affect their babies. 5 studies of 952 people in total says that avoiding certain food during pregnancy, breastfeeding or even both does not prevent eczema in babies up to 18 months old. And they notice that mother who practise diet restriction has an average lower weight gain during pregnancy and lower birth weight of the babies. Also there is actually increased rate of preterm birth!

In other words, there is a strong evidence that mothers should not restrict their diet during pregnancy or breastfeeding. Such practise brings more harm than good!

Breastfeeding and eczema

What about breastfeeding? Isn't it known to help eczema? The evidence from 18 studies say breastfeeding exclusively for 4 months if not using hydrolyzed formula (rather than formula milk) helps those babies at high risk. These are the babies with family members of atopy. However, for those people without family members with atopy, breastfeeding or formula milk doesn't matter really.

Confused over what food to take or not to take when you have eczema? Hope what I've put up here helps!

Tuesday, 25 July 2017

Weathering of Hair







A young beautiful Israel girl came complaining that her hair has changed. She came to Malaysia 2 years ago. And for the last one year, she found her hair turning more yellow and brittle. She reported her hair condition to be much better when she returned to her country for a month early this year.

The basic:

Hair is a dead structure consist of proteins, lipids, water, malanin and trace elements. When I said it is dead, it doesn't hurt when it is cut or damaged.

Our hair shaft consists of cuticle, cortex and medulla (from outside in).

  • Cuticle is the protective layer of keratinized scales. 
  • Cortex is the cysteine-rich keratin filaments that made up the bulk of hair and contributes to the color of hair.
  • Medulla is the central core of the hair.

The tip of the hair has more cuticle and less cortex.

What has happened?

Her hair is damaged, or some say has underwent "weathering". Hair weathering is structural damage to hair fibres. The defect in hair shaft can be progressive from loss of cuticular protection to reduction in the ability of the cortex of the hair to maintain moisture. When the hair is dry it is more frizzy and can create "flyaway" look. Ultimately the hair loss its elasticity, shine and strength and could easily be broken.

Is this common?

Yes, this is the top 3 hair concern that comes to dermatologists, after hair loss and thinning.

How would the dermatologist diagnose hair weathering?

The diagnosis of hair weathering is made after detailed history of hair care practices and hair products used. He or she may collect your hair shaft samples to be examined.


What could be the cause?

The name of hair "weathering" suggests the cause is environmental. Ultraviolet (UV) radiation, wind, sea salt, polution, chlorinated water are among the culprits. Despite the name, the cause is not necessary limited to bad weather. Excessive combing, brushing, braiding, weaving, hair extensions, straightening, perming and dyeing could potentially damage the hair structure. In short, any sort of physical or chemical trauma can damage the hair.

I lived in Malaysia for years and have no problem with my hair. How can she attribute our environment to the possible cause of her hair problem? How is hair different among different ethnicity / race?

The proteins and the structure of hair fiber is similar among Asian, Caucasian or Africans.

The cross-section of Asian straight hair is usually round and larger in diameter and therefore usually stronger in tensile strength. The sebum coating, moisture, water swelling rate are the highest among typical Asian straight hair. For the same reason, black hair is most difficult to perm or dye. When they are subjected to chemical treatment, often, they are given higher concentration of chemicals and longer duration of exposure leading to hair damage.

Among the Caucasian, the cross-section of the hair shaft is round to oval and therefore often curls. Among the Africans, the  cross-section is elliptical or flattened. When they groom their hair, there is significantly increase friction and hence there is increasingly at risk of weathering as well.

Regardless of ethnicity, as we aged, our hair turns grey which are coarser, stiffer and dryer.

How can I prevent this?

  • Avoid prolonged direct exposure to UV radiation and extreme weathers.
  • Choose combs that are made of bendable plastic instead of hard metal or wood, particularly those with irregular teeth. Soft brush are better than hard ones. Round tips are better than sharp ones.
  • Avoid backcombing that raises the hair cuticle, expose the cortex and make the hair more vulnerable to damage.
  • Avoid excessive brushing particularly when the hair is wet. Wet hair produces more friction than dry hair and hence easier to be stretched until its breaking point. It is a good practice to dry the hair before combing.
  • Avoid braiding and weaving.
  • Straightening and waving by heat (temporary) or chemical (permanent) may damage the hair. Exposure to heat on wet hair results in greater damage than dry. Using a heat protector spray onto dry hair prior to the procedure may reduce the risk of hair breakage, bubble hair* and thermal burn on scalp skin.
  • Avoid hair styling or treatment by non-professionals as overperming, poor neutralisation after washing off perming solution can damage the hair.
  • Shampooing the night of or after the perming and cause formation of new incomplete bonds for the new shape of the hair. Hair breakage can happens close to the scalp. This usually happens a few days after perming.
  • Dyeing of hair may cause contact dermatitis to the skin. There are many different type of hair dyes. Permanent dyes usuallly use a highly alkalinised solution to make the cuticle swell so that the dye can penetrate into the cortex. Bleaching with hydrogen peroxide to oxidise the melanin in the cortex of the hair can destroys the keratin and cuticle making the hair more dull and brittle due to loss of water.

*bubble hair is the formation of holes that are filled with steam when the hair shafts are overheated.

My hair has weathered. What can I do?

  • Get a good quality haircut.
  • Minimise further damage, physically or chemically. (Avoid bad hair treatment from inexperience staffs!)
  • Frequent shampooing is good. Fluffy hair (rather than greasy ones) may give an illusion of thicker hair. Use a mild and gentle shampoo. Minimise massage and dry the hair (especially long hairs) from tip to root.
  • Use a conditioner to improve manageability and reduce static electricity.
  • Get a good, bendable, soft comb.
  • Detangle your hair from ends to root with your fingers when it is still wet.
  • Air dry your hair before combing.
  • If you use a blower or dryer, make sure the temperature in increase gradually rather than abruptly.
  • If you have itchy scalp condition, get it treated to avoid scratching.
And finally don't forget to put on a cap when you go under the sun!

One last happy note: Our hair grows continuously (unless you have damaged hair follicles), so hair shaft problem can be completely solved! Exercise good hair care and be patient to wait for your new healthy lustrous hair to grow out soon!


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