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P E R S A T U A N

D E R M A T O L O G I newswww.dermatology.org.myIssue 9 September 2013

Persatuan Dermatologi Malaysia (PDM)

The Persatuan Dermatologi Malaysia mid term meeting took place on 13th -14th April 2013 in Kuala Lumpur at the JW Marriott Hotel, Kuala Lumpur. This meeting was organised primarily by the Persatuan Dermatologi Malaysia and the Faculty of Dermatology, Academy of Medicine Malaysia.

The aim is to provide PDM members, young dermatologists and trainees with continuing medical education and updates within the field of dermatology especially on psoriasis. The meeting was attended by local and overseas faculty members and more than 100 participants from various states, providing an excellent

opportunity for fruitful discussion of scientific and clinical matters. The faculty membeers consist of the following: Prof Alan Menter, Baylor University, Dallas, USA, Dr Suganthi Thevarajah, Kuala Lumpur Hospital, Dr Choon Siew Eng, Hospital Sultanah Aminah, Johor Bahru, Dr Koh Chuan Keng, Koh Skin Specialist Clinic, Petaling Jaya, Dr Anthony Downs, Royal Devon & Exeter Hospital, London and Dr Azura Mohd Affandi, Hospital Kuala Lumpur. Case Sharing was done by Dr Tang Jyh Jong, Hospital Raja Permaisuri Bainun, Ipoh, Dr Adawiyah Jamil, UKM, and Dr Lee Hock Leng, Penang GH.

1 Persatuan Dermatologi Malaysia (PDM) Mid-Term Meeting 20132 President’s Message2 Editorial3 New Guidelines on the Management of Psoriasis in Adults is Now Available to Improve Care of Patients Living with Psoriasis

4 Congratulatory Messages5 The Malaysian Psoriasis Registry Updates6 Advanced Master of Dermatology, Universiti Kebangsaan Malaysia (UKM). Some Good News7 My Fellowship Experience in Berne8 News from the North

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Mid-Term Meeting 2013

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Dr Henry Foong Boon Bee • Consultant Dermatologist, Foong Skin Specialsit Clinic

president’smessage

It gives me great pleasure to pen my message for the 9th issue of the PDM Newsletter as it has a special place in my heart and mind.

It has been a very hectic 12 months with the executive committee being involved in various CME activities.

The PDM and Faculty of Dermatology, Academy of Medicine Malaysia in collaboration with AADV and St. John’s Institute of Dermatology, UK organized the WXYZ Dermatopathology 2012 from 14th - 16th December 2012. It was an Advanced Course in Dermatopathology conducted by several foreign speakers such as Dr. Alistair Robson & Dr. Catherine Stefanato from UK, Dr. Nopadon Nopakkun from Thailand, Dr. Tetsu Kimura from Japan and Dr Yu--Hung from Taiwan while our local faculty included Dr. Noor Zalmy & Dr. Dawn Ambrose.

We hope to organize regular courses of Dermatopathology as well as start a Dermatosurgery course in the near future and will keep members informed of the various CME activities planned.

The executive committee of PDM and the Faculty of Dermatology also organized the PDM Mid-Term Meeting from 13th - 14th April 2013 which was a huge success. We were privileged that world renowned dermatologist, Professor Allan Menter was able to take time out from his busy schedule to be the leading speaker for the meeting. Several topics on psoriasis were discussed with overwhelming response and interaction from our members.

The 2nd Clinical Practice Guidelines (CPG) for Dermatology which is on the management of Psoriasis has been completed and is planned to be launched most probably in October. We hope to extend an invitation to our Health Minister, Dato Seri Dr. S. Subramaniam to be the chief guest for the official launching.

Finally wishing all fellow Muslims a very Selamat Hari Raya Puasa and maaf zahir & batin to everyone. I would like to extend my deepest appreciation to my fellow executive committee for their wonderful support in planning & preparing for the various activities the past 12months.

Happy reading and may all of us continue to strive towards excellence both professionally as well as personally.

Warmest Regards

DR. NAJEEB AHMAD MOHD. SAFDAR • President, PDM

ExecutiveCommittee2012-2013

President Dr. Najeeb Ahmad Mohd Safdar

Vice President Dr. Henry Foong Boon Bee

Hon. Secretary Dr. Agnes Heng Yoke Hui

Hon. Treasurer Dr. Noor Zalmy Azizan

Committee MembersDr. Chan Lee ChinDr. Mohd Noh bin IdrisDr. Khaw Guat EeDr. Rohna Ridzwan

Immediate Past President Dr. Koh Chuan Keng

Hon. Auditor Dr Gan Ain Tian

editorialWelcome back! This has been an exciting year for the Persatuan Dermatologi Malaysia. We started our year with the WXYZ Dermatopathology 2012 , an advanced course in dermatopathology which was held in conjunction with the first Fellowship Asian Academy of Dermatology And Venerology (Dermatopathology) examination held at the Medical Academies of Malaysia, Kuala Lumpur on 13th December 2012. It was co-organised with the Asian Academy of Dermatology and venereology in collaboration with St John’s Institute of Dermatology.

The next major educational event was our mid-term meeting which was held at the JW Marriott Hotel, Kuala Lumpur on 13th and 14th April 2013. We were privileged to have Professor Alan Mentar from UT Southwestern Medical School, Dallas, Texas, USA with us and we had

a in-depth learning on what’s new on various aspectds of the management of psoriasis. The meeting was well attended by members of the PDM as well as our dermatology trainees.

In this issue of the PDM newsletter, you will see an array of news, articles, announcements and relevant information about recent activities of the Persatuan.

Education remains an important goal and objective of the Persatuan. The President, Dr Najeeb Ahmad Safdar and his organising committee have prepared a well balanced scientific program for our annual meeting this year in Kuantan and we look forward to an exciting coming year with useful educational programs for our members.

Enjoy your reading!

DR HENRY FOONGFRCP (Edin)EditorSkin Specialist Clinic

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Psoriasis affects 1-3% of the general population worldwide. Plaque psoriasis, the most common form, is seen in 85% of the 4,445 patients registered in our Malaysian Psoriasis Registry till year 2009. Psoriatic arthritis occurs in 16% of our patients with psoriasis. There are wide variations in clinical practice for the treatment of psoriasis across the whole spectrum of primary and specialty care in Malaysia. Hence, our MOH gathered a team of dermatologists, rheumatologists, pharmacists, dieticians and primary care physicians to develop evidence-based guidelines for the management of plaque psoriasis in adults. The development team identified 25 clinically important questions, searched and reviewed available literatures to develop recommendations and treatment algorithms based on the severity of psoriasis. These guidelines provide clear advice for all healthcare professionals (HCP) on the assessment and management of psoriasis in order to improve care and minimise the effects of living with psoriasis.

Psoriasis can be mentally and physically disabling. Patients not only have to deal with their highly visible skin disease, they also endure physical discomfort such as tightness, pain, bleeding and itch. Much like other chronic diseases such as diabetes and heart

diseases, psoriasis contribute to low self-esteem, anxiety, embarrassment and depression. However, these consequences may be overlooked by healthcare professionals if psoriasis is dismissed as a mere skin affliction. Studies showed that psoriasis patients are only better than patients with congestive heart failure in terms of physical disability and they only fare better than patients with depression and chronic lung disease in mental dysfunction when tested with SF36, a quality of life measure. Hence, it is essential that all HCP recognise not just the physical but also the psychological sufferings of their patients and routinely assess the impact that psoriasis exerts on their patients’ daily lives. Our first evidence-based National Clinical Practice Guidelines for the management of chronic plaque psoriasis in adults advise all HCP to assess the impact of psoriasis on the physical, psychological and social well being of their patients. This should be done when they first see their patients, before they refer them to dermatologists and when they monitor their treatments. Percentage of body surface area (BSA) involved is accepted as an adequate measure of physical severity and DLQI, a patient’s own assessment of quality of life, is the recommended measure of psychosocial disability.

New Guidelines onthe Management ofPsoriasis in Adultsis Now Available toImprove Care of Patients Living with Psoriasis

Siew Eng Choon, FRCP • Senior Consultant Dermatologist, Hospital Sultanah Aminah, Johor Bahru

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Persatuan Dermatologi Malaysia (PDM) Mid Term Meeting 2013Persatuan Dermatologi Malaysia (PDM) Mid Term Meeting 2013

The first session was focused on lectures that communicated basic and advanced knowledge in psoriasis including erythrodermic psoriasis, updates on psoriatic arthritis, generalised pustular psoriasis, and management of psoriasis in the biologics era.

The second half was devoted to sessions on genotyping psoriasis for individualised care and spectrum of comorbidities in psoriasis. There were sessions on hedgehog pathways in BCC and introducing topical therapeutic options in psoriasis. The session ended with

a case based learning and a talk on Malaysan psoriasis regisry. All posters and presentations were of very high quality.

Participants as well as speakers enjoyed the meeting in a conducive learning environment. The meeting ended with a photography session with all the past Presidents of the Persatuan. The meeting was a great success due to the hardwork of the President, the organising committee and the active interaction of the speakers and the participants. We thank Abbvie for their secretariat work and educational grant during the meeting.

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Psoriatic arthritis affects 6 to 42% of patients with psoriasis. Skin lesions precede arthritis in about 75% of cases. Hence, HCP who take care of psoriasis patients are very well-placed to identify onset of arthritis in their patients. Early diagnosis is important because psoriatic arthritis is aggressive and associated with progressive joint damage in up to 47% of patients. Effective treatments are available and so patients should receive these as soon as possible to prevent deformity. Our guidelines advise HCP to perform regular assessments for associated arthritis in their psoriasis patients by eliciting a history of significant morning stiffness, joint pain and/or swelling to facilitate timely referrals to rheumatologists so that patients can receive the treatments they need.

We now know that psoriasis, like other diseases associated with chronic systemic inflammation such as rheumatoid arthritis and systemic lupus erythematosus, carries a higher risk of cardiovascular morbidity and mortality. Our guidelines recommend screening all psoriasis patients for metabolic syndrome and other classic risk factors of atherosclerosis-related diseases. The risk of developing important co-morbidities such as myocardial infarction (MI) appears to correlate with the severity of skin lesions. Young adults with severe psoriasis have a 3-fold increased risk of developing MI and a reduction of 3 - 4 years in life expectancy. This association elicited a deliberation on whether effective control of cutaneous and joint disease would indeed reduce systemic inflammation and cardiovascular morbidity/mortality or is this just a pharmaceutical

marketing ploy to get us to treat our patients more aggressively. A cardio-protective effect has been shown in rheumatoid arthritis patients treated with TNF inhibitors and methotrexate in the CORRONA study but whether psoriasis patients will benefit similarly is still unclear.

Although there is no cure for psoriasis, skin clearance can occur with appropriate treatment. Unfortunately, surveys showed that patients frequently receive suboptimal care or were on ineffective treatment for longer than necessary. Effective treatments are available and include topical therapies, phototherapy and systemic medications which are generally prescribed based on the severity and extent of the disease. However, treatment expectation of patients with similar disease severity may vary greatly and discrepancies can exist between treatment expectation of patients and the healthcare professionals’ aspiration regarding disease control. Hence, treatment goals and the choice of treatment should be individualised based on disease severity, patients’ preferences and comorbidities. Treatment goals are important to enable treatment modification if goals are not met. Implementing and regular monitoring of treatment goals based on disease severity and patients’ preferences are necessary to ensure appropriate and adequate long-term effective treatment of patients living with psoriasis. Proposed treatment goals and time for evaluation of treatment outcome are clearly stated in the new guidelines. Let’s implement these guidelines to improve the care of patients living with psoriasis.

New guidelines on the management of psoriasis in adultsis now available to improve care of patients living with psoriasis • continued from pg3

Congratulatory MessagesMembers of PDM would like to offer our warmest congratulations toDato’ Seri Dr. S. Subramaniam for being appointed as the Health Minister of Malaysia in May 2013. It is truly a historical moment to have a member of PDM to be appointed as one of the Cabinet Ministers of Malaysia. Congratulations and we wish you every success in bringing our healthcare to the next level.

Congratulations toDato’ Dr Andrew Chua Sak Eng for being conferred Darjah Indera Mahkota Pahang (DIMP) on 25th May 2013.

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The Malaysian Psoriasis Registry Updates

The Malaysian Psoriasis Registry (MPR) is a prospective, ongoing, systematic collection of data on patients with psoriasis in Malaysia. The main reason for setting up a psoriasis registry is to have a more accurate data on the various aspects of psoriasis in Malaysia. Having a psoriasis registry would also help in research work and more importantly in improving the overall management of the patients.

Preliminary work on the MPR started in 1998 by a group of dermatologists. A case report form was developed and data collection started as a pilot project in 2000. A preliminary report of the registry was published in the Malaysian Journal of Dermatology in August 2005.

In 2007, under the guidance of Clinical Research Centre, Malaysia, and with the financial support from the Ministry of Health, Malaysia, MPR was extensively revised. A new case report form was introduced and a new centralized electronic database with web application was established to facilitate multi-centre data collection. To date, a total of 19 centres in Malaysia (15 government, 2 universities and 2 private centres) contribute data to the MPR. Preliminary report of the newly revised MPR was published in the Medical Journal of Malaysia in September 2008. The First Annual Report of MPR (2007-2008) was published the following year. All the annual reports, including the latest MPR annual report (2007-2010) are available to be downloaded from our website. Apart from the annual reports, we have also published our findings in the Malaysian Journal of Dermatology, Malaysian Medical Journal and the Australian Journal of Dermatology. We have also presented our data, either via oral or poster presentations at various meetings and conferences, locally and internationally. It is hoped that our young trainees and dermatologists would utilize our vast data for their presentation and publication.

In 2011, protocol for Biologic Treatment in Psoriasis was introduced to assist dermatologists in managing patients on biologics in Malaysia. In line with that, we have also introduced the Biologic Registry, which is aimed at evaluating the efficacy and safety of biologics, and also to assess the clinician’s adherence to guidelines. As for now, the rate of reporting of patients on biologics is still low, and we hope to get more involvement from all dermatologists.

In April 2011, the Malaysian Psoriasis Registry joined the Psoriasis International Network (PIN). PIN is an international network, representing dermatologists from all over the world. It promotes exchanges at international level and facilitates collaborations in the field of psoriasis. In July 2013, we had the privilege to participate in the Psor2013 Conference, held in Paris, France. Datuk Dr Roshidah Baba was invited to chair the Registry Workshop. She also presented a study on the ‘Clinical Characteristics of Patients with Facial Psoriasis in Malaysia’, which garnered positive remarks from the audience.

From January 2007–June 2013, a total of 8664 patients were notified to the MPR (Fig. 1). This number is probably under-represented, since the notification is voluntary, and only 19 centres in Malaysia participated. We hope to get more participation from other dermatology centres in Malaysia, so our data can represent the statistics of patients with psoriasis in Malaysia more accurately.

On behalf on the Malaysian Psoriasis Registry, I would like to thank all the participating centres involved, without which, we would have not existed. We are also grateful for the support from the Malaysian Society of Dermatology, Clinical Research Centre, Malaysia and the pharmaceutical companies in ensuring the existence of the registry. Further information on the Malaysian Psoriasis Registry is available online at http://www.acrm.org.my/dermreg/

Thank you.

Dr Azura Mohd Affandi • Consultant Dermatologist, Hospital Kuala Lumpur • Chairperson, The Malaysian Psoriasis Registry (MPR)

Fig. 1 Number of Psoriasis Patients Notified to the Malaysian Psoriasis Registry from January 2007 - June 2013

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Advanced Master of Dermatology,Universiti Kebangsaan Malaysia (UKM)

Some Good NewsWe are happy to report on some encouraging and positive developments with the Advanced Master of Dermatology (AMoD) in the past one year.

Firstly, the phenomenal increase in the intake of new trainees, a total of 17 trainees for December 2012 (9) and July 2013 (8) as compared to an average number of 4-6 trainees per year in the previous years . This pink performance is partly due to the revised policy of MOH in introducing biannual intake of trainees for postgraduate training. This change is benefitting the AMoD programme and the Dermatology fraternity. We would like to record our appreciation to the Director General of MOH for approving the largest enrollment of trainees thus far in the history of AMoD. We would like to believe that our negotiations with MOH are seeing some results. The biannual intake of trainees also means that as of 2016 the final examinations of AMoD will be conducted twice a year instead of once a year which is the current practice. To UKM this is a non issue as it will also give opportunity to unsuccessful candidates to resit in 6 months instead of a year. For dermatology service in MOH this is a welcome change as it will help overcome the shortage of dermatologists in the public sector. The compulsory scholarship stipulates a minimum of 3 years service upon completion of training.

Secondly, our proposal to introduce the AMoD in the 4th year of Master of Internal Medicine (MMeD) has received the approval of the Director General of Health last year. The Conjoint Board of Master of Internal Medicine has kindly given us the opportunity to present the proposal

in the upcoming “National Workshop for Revamping of the Masters of Internal Medicine Programme 2013” which will be held on 19th of September. What does this mean? Should this proposal be accepted by the Conjoint Board then we are only a step away from its final stage of approval by the Director General Special Committee.

Thirdly, we are proud to announce that in June this year, 4 trainees were successful in the final examinations of AMoD. The entire examination was conducted at Hospital UKM with Puan Sri Dr. Suraiya Tun Hussein and Professor Dr. Rokiah Ismail as the examiners. Both examiners were satisfied with the general performance of the candidates and book prizes were awarded to the following :

Best Clinical Performance : Dr Norazirah Md Noor Best Thesis : Dr Tan Wooi Chiang

Dr. Tan Wooi Chiang is now giving service in Hospital Sultanah Bahiyah, Alor Setar; Dr. Peter Ch’ng Wee Beng in Hospital Tengku Ampuan Afzan, Kuantan;Dr. Khor Yek Huan in Hospital Tuanku Fauziah, Perlis; and Dr Norazirah Md Noor in Hospital UKM.

The AMoD programme owes its success to the relentless support and commitment of all trainers in the accredited training centres. Our sincere appreciation to these trainers, the Ministry of Health, Persatuan Dermatologi Malaysia and to all those who have contributed directly or indirectly in making this programme viable and successful.

Front row (from left) : Prof. Dr. Rokiah Ismail, Prof. Datin Dr. Norlinah Mohd Ibrahim, Datuk Dr. Roshidah Baba, Puan Sri Dr. Suraiya Tun HusseinSecond row (from left) : Dr. Norazirah Mohd Noor, Dr. Tan Wooi Chiang, Dr. Peter Ch’ng Wee Beng, Dr. Khor Yek Huan

Datuk Dr Roshidah BabaChief Coordinator of Advanced Master of Dermatology &Head of Dermatology Service, Ministry of Health, Malaysia

My Fellowship Experience in Berne

My 6-month dermatology fellowship began with a colorful late autumn in October 2011, through the white icy winter and ended with the chilly spring in April 2012. This engraved a wonderful and memorable experience in my heart and soul. It was a great privilege for me to be given a chance to experience life in Switzerland, a European paradise best known for its cheese, chocolate, watches, Red Cross, snowy mountains, banking, army knife or Toblerone.

The Department of Dermatology, Inselspital, Bern University Hospital is headed by Prof Luca Borradori who is a renowned expert in connective tissue diseases and immune-bullous diseases. Prof Nikhil Yawalkar is highly respected in the areas of drug allergy and psoriasis while Prof Dagmar Simon is the head of the contact dermatitis unit, eczema and allergy. I was very fortunate to be trained by these 3 distinguished professors in Inselspital. In addition, I also had periodic attachments with Prof Eckart Haneke, the expert in nail diseases and surgery; Prof Albert-Adrien Ramelet, the angiologist; Dr Helmut Beltraminelli, the dermatopathologist; Prof Thomas Hunziker, an expert in connective tissue disease

and tissue engineering for wounds; Dr Robert Hunger, expert in skin cancer and acne inversa; and Dr Michael Horn, an expert in immunofluorescence microscopic study. All the professors, specialists and staff were very warm, approachable, and pleasant.

As a fellow, I underwent comprehensive training and hands-on sessions in epicutaneous tests such as skin prick test, scratch test, intradermal test, scratch-patch test and patch tests for various allergens including drugs and atopy patch test. I attended the in-house case discussion every Monday, Wednesday and Friday morning; and the grand ward round with Prof Luca Borradori every Tuesday morning. I was also attached with Prof Luca Borradori twice a week in his sub-specialized clinic on connective tissue diseases and immunobullous diseases. Apart from that, I never missed the general dermatology clinics with the other professors and specialists. Dermato-pathology teaching was conducted every Monday after 5pm. I have also observed duplex ultrasound and sclerotherapy in the phlebology clinic conducted every Wednesday afternoon.

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Figure a) The view of Inselspital from the dermatology building during the winter. b) Entrance of the Department of Dermatology, Inselspital. c) St. Nicholas celebration with the laboratory, research & clinic staff and Prof Dagmar Simon. d) Eat out with Prof Luca Borradori, Prof Nikhil Yawalkar and other fellows.

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Tang Min Moon, MRCP • Consultant Dermatologist, Hospital Kuala Lumpur

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I am very grateful that I was given the opportunity to get involved in research where I was exposed briefly to various types of immunohistochemistry stainings, immunofluorescence double staining procedures, manual and digital quantitative analysis of positively stained cells in cutaneous diseases such as acute generalized exanthematous pustulosis and generalized pustular psoriasis. To date, I have published 3 articles related to my work with this department in the international journals and there are 4 more on the way.

Contact and Occupational Dermatitis Conference for the northern region was held on the 7-8th May 2013 at the auditorium of Penang Hospital. It was organized by the Department of Dermatology, Penang Hospital in collaboration with the Penang Occupational and Environmental Health Unit. The main objective of the conference was to educate health care providers on the identification, management and prevention of the various contact and occupational dermatosis. The indication and safety of patch test and photo patch test in contact dermatitis were also emphasized. On the second day of the conference, an introduction on administrative and clinical governance was also given to all the dermatology staffs from the various states. The main speakers for the event were Dr Rohna Ridwan and her team (Dr Muhammad Yusof Sibert and Staff Nurse Kasmawati Taib) from Selayang Hospital and Dr Chan Lee Chin. A total of 146 specialist, medical officers and paramedics from Perlis, Kedah, Penang and Perak attended the conference.

The most recent event was the Northern Dermatology Summit 2013, held on 17-18th August 2013 at the Park Royal Resort Hotel. It was organized by the Department of Dermatology, Penang Hospital in collaboration with the Dermatological Society of Malaysia (PDM), Postgraduate Medical Education Society (Penang Hospital) and Malaysian Medical Association (Penang Branch). The theme for this year was “The Art and Science of Dermatology”. Topics on aesthetic dermatology, skin, hair and nails diseases were presented and discussed by various experienced dermatologists from oversea and local. The conference began with the pre-congress workshop where demonstration on botulinum toxins injection and chemical peels were given. A total of 160 participants (100 from government sector and the rest from the private sector) attended the conference.

In short, it was a fruitful and eye opening experience. Many thanks to Professor Puan Sri Datuk Dr Suraiya Hussein who recommended me to Prof Luca Borradori and made this fellowship possible. I was indeed blessed and I appreciate not only the knowledge I have gained but also the friendship. I have been enlightened to strive to become a better dermatologist and physician, and do my very best to provide excellent patient care at all times.

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News from the NorthDr Chan Lee Chin • Consultant Dermatologist, Penang Hospital