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Lee H.Y.,Singapore General Hospital | Lim Y.L.,National Skin Center | Thirumoorthy T.,Singapore General Hospital | Pang S.M.,Singapore General Hospital
British Journal of Dermatology | Year: 2013

Background Toxic epidermal necrolysis (TEN) is a severe cutaneous adverse drug reaction with a mortality of 40%. Intravenous immunoglobulin (IVIg) is widely used as a specific treatment for this reaction, although evidence of its benefit is conflicting. Objectives We sought to evaluate whether the use of IVIg improved mortality in patients with Stevens-Johnson syndrome (SJS)/TEN overlap and TEN. Methods We retrospectively analysed data for 64 patients with SJS/TEN overlap and TEN who were treated with IVIg at a single referral centre. The primary outcome analysed was in-hospital mortality. Predicted mortality was calculated based on severity-of-illness score for TEN (SCORTEN) values. Secondary analyses of survival based on IVIg dosages and prior corticosteroid exposure were also performed. Results There were 28 cases of SJS/TEN overlap and 36 cases of TEN, with a mean SCORTEN value of 2·6. The mean dose of IVIg given was 2·4 g kg-1 and the mean delay from the onset of epidermal detachment to administration of IVIg was 3·2 days. There were 20 deaths (31%) in our cohort. The standardized mortality rate was 1·10 (95% confidence interval 0·62-1·58). Subgroup analysis comparing survivors and nonsurvivors showed a higher SCORTEN in nonsurvivors (3·4 vs. 2·2). There were no differences with regard to the dosage, delay and duration of IVIg administration. When stratified according to dosage, there was no mortality difference between patients who receive high-dose (≥ 3 g kg -1) vs. low-dose (< 3 g kg-1) IVIg. Conclusions This study shows that the use of IVIg does not yield survival benefits in SJS/TEN overlap and TEN, even when corrected for IVIg dosages. What's already known about this topic? The use of intravenous immunoglobulin (IVIg) in the treatment of toxic epidermal necrolysis (TEN) is controversial. What does this study add? This study shows that the use of IVIg in the treatment of Stevens-Johnson syndrome/TEN overlap and TEN does not yield survival benefits, even when corrected for IVIg dosages and prior exposure to corticosteroids. See also the Commentary by Creamer and Walsh © 2013 British Association of Dermatologists.


Chia K.Y.,Tan Tock Seng Hospital | Tey H.L.,National Skin Center
Journal of the European Academy of Dermatology and Venereology | Year: 2013

Hypohidrosis refers to diminished sweating in response to appropriate stimuli. This can cause hyperthermia, heat exhaustion and death. The aetiology of hypohidrosis can be divided into exogenous, dermatological and neurological causes. Exogenous causes act either by systemic neurohormonal inhibition of sweating or localised damage to the skin and sweat glands. Dermatological disorders can result from congenital disorders, wherein other ectodermal tissues may also be affected, or acquired disorders in which manifestations of the primary disease predominate. Neurological disorders should be classified based on an upper motor neuron or lower motor neuron pattern of disease. In the former, there is spasticity and hyperactive reflexes whereas in the latter, flaccidity and hypoactive reflexes predominate. Acquired idiopathic generalised anhidrois refers to isolated anhidrosis with no other detectable abnormalities. When approaching a patient with hypohidrois, exogenous causes should first be excluded. Physical examination, paying attention to mucocutaneous manifestations and neurological signs, will dichotomise if the lesion is dermatological or neurological. In the former, a skin biopsy is the investigation of choice. In the latter, one should consider magnetic resonance imaging of the brain and spinal cord for upper motor neuron lesions, nerve conduction tests for lower motor neuron lesions and autonomic nerve function tests for autonomic dysfunction. Finally, if a diagnosis of acquired idiopathic generalised anhidrosis is suspected, a quantitative sudomotor axon reflex test and serum immunoglobulin-E levels may be performed. Treatment involves addressing the underlying condition and avoidance of aggravating factors. Acquired idiopathic generalised anhidrosis responds well to high dose systemic corticosteroids. © 2012 European Academy of Dermatology and Venereology.


Wang E.C.,National Skin Center
Dermatology online journal | Year: 2012

Extra-mammary Paget disease (EMPD) is a rare intra-epithelial carcinoma that is usually found on the apocrine-rich skin of the perineum. We report 2 cases in which EMPD was initially misdiagnosed on the initial punch biopsy as melanoma-in-situ and Bowen disease respectively. Reasons for the misdiagnoses included a rare pigmented axillary variant of EMPD in the first case and atypical bowenoid features on H&E in the second. The cases are described with a critical review of the histopathological findings, along with a review of the current literature. This highlights the necessity of a comprehensive immunohistochemical panel for the assessment of intra-epithelial pagetoid atypical cells.


Chan R.,National Skin Center
Annals of the Academy of Medicine Singapore | Year: 2012

Introduction: This article presents recent developments in biomedical interventions for prevention of sexual transmission of the human immunodeficiency virus (HIV) infection. Materials and Methods: A review of results from randomised clinical trials on the use of antiretroviral (ARV) medications and other biomedical methods to prevent the transmission and acquisition of HIV infection. Results: Pre-exposure prophylaxis (PrEP) refers to the provision of ARV medications to uninfected persons at high risk of HIV infection either in the form of topical agents, e.g. vaginal microbicide gels, or orally administered tablets. The Caprissa study demonstrated the efficacy of vaginal microbicides, the Vaginal and Oral Interventions to Control the Epidemic (VOICE) study however was not able to confirm these results. Oral PrEP was found to be efficacious in the iPrEx study on men who have sex with men (MSM), and among heterosexual couples in the Partners-PrEP and the TDF2 studies in Africa. The HPTN 052 trial demonstrated that the provision of early ARV treatment was able to prevent transmission of HIV by 92% compared with delayed treatment. This has led to enthusiasm to roll out treatment as prevention (TasP) programmes. Encouraging results from studies on male circumcision to prevent HIV acquisition have resulted in several implementation projects inAfrica.Another encouraging result has been the success, albeit modest, of the prime-boost combination RV144 vaccine trial in Thailand. Conclusion: New advances in prevention strategies are urgently needed to slow down the HIV pandemic. Recent developments particularly in the form of PrEP and TasP have given new hope that we will be able to achieve this goal.


Baral S.D.,Center for Public Health and Human Rights | Friedman M.R.,University of Pittsburgh | Geibel S.,Population Council | Rebe K.,Anova Health Institute | And 6 more authors.
The Lancet | Year: 2015

Male sex workers who sell or exchange sex for money or goods encompass a very diverse population across and within countries worldwide. Information characterising their practices, contexts where they live, and their needs is limited, because these individuals are generally included as a subset of larger studies focused on gay men and other men who have sex with men (MSM) or even female sex workers. Male sex workers, irrespective of their sexual orientation, mostly offer sex to men and rarely identify as sex workers, using local or international terms instead. Growing evidence indicates a sustained or increasing burden of HIV among some male sex workers within the context of the slowing global HIV pandemic. Several synergistic facilitators could be potentiating HIV acquisition and transmission among male sex workers, including biological, behavioural, and structural determinants. Criminalisation and intersectional stigmas of same-sex practices, commercial sex, and HIV all augment risk for HIV and sexually transmitted infections among male sex workers and reduce the likelihood of these people accessing essential services. These contexts, taken together with complex sexual networks among male sex workers, define this group as a key population underserved by current HIV prevention, treatment, and care services. Dedicated efforts are needed to make those services available for the sake of both public health and human rights. Evidence-based and human rights-affirming services dedicated specifically to male sex workers are needed to improve health outcomes for these men and the people within their sexual networks. © 2015 Elsevier Ltd.

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