Frequently Asked Questions on Some Common Skin Disorders
 
1. Acne Vulgaris
2. Botulinum Toxin Injection for Wrinkles
3. Contact Allergy and Patch Testing
4. Eczema and Atopic Dermatitis
5. Fungal Infections
6. Hairfall
7. Hands Eczema
8. Laser Treatment
       8a. What is Laser Surgery ?
       8b. Skin/Laser Surgery
       8c. Carbon Dioxide Laser Post-operative Instructions
       8d. Q-Switch Nd:YAG Laser (Pigment Laser) Treatment
       8e. Tattoos and Pigmented Birthmarks Removal
       8f.  Laser Treatment for Vascular Birthmarks
       8g. Laser Skin Re-surfacing for Scars and Wrinkles
9. Nail Disorders
10. Nickel Allergy
11. Phototherapy
12. Psoriasis
13. Scabies
14. Sclerotherapy
15. Shingles
16. Skin Day Treatment Services in NSC
17. Urticaria (Hives)
18. Viral Warts
19. Vitiligo
 
 

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1.  ACNE VULGARIS

What causes acne?
    Acne is a condition which develops in and around the hair follicles and their oil-producing glands called the sebaceous glands. Although we have these glands all over the surface of our bodies, it is only on the face, chest and back that acne develops. The oil produced by sebaceous glands is called sebum and it begins to appear soon after puberty. Acne usually starts during the teenage years but it may also begin in the twenties or thirties.

    The exact cause of acne is unknown. One theory is that when hormone levels increase during puberty, the skin of the acne prone person reacts to the hormone to produce excess sebum. No one knows why some people’s oil glands produce more sebum than others, but when this happens, the oil glands become blocked. One result is the familiar blackheads or if the blockages are deeper, whiteheads. In some people, the acne may not progress beyond this stage, but usually it does.

    Bacteria in the deeper part of the hair follicle, beneath the sebum blockage release chemicals which act upon the sebum and break it down to release other chemicals. These chemicals make the skin around the follicle red and inflammed resulting in a spot or papule. In bad cases, pus develops and the spot is called a pustule. Large, painful swellings called nodules and cysts may develop and could result in scarring – sunken pits or hard swelling – after the condition has eventually settled.

 What should I do when I have acne?
Consult your doctor early. Waiting to “outgrow” acne can be a serious mistake, since medical treatment can improve your appearance and prevent development of severe scars.

How is acne treated?
a. Treatment applied to the skin
Patients with mild acne usually respond well to such treatment. It includes sulphur and resorcinol preparations (eg acne cream and lotion), benzoyl peroxide containing preparations, antibiotics lotion  (erythromycin and clindamycin lotions) and Vitamin A derived cream or gel (known as tretinoin). Some lotions or creams may make the skin red or flaky but this effect is usually temporary. Consult your doctor if the lotions or creams cause excessive redness or irritation.

b. Oral Treatment
If your acne becomes worse and you have a lot of tender spots, then treatment alone will not be enough . Your doctor will probably prescribe antibiotic tablets. Tetracycline is the most common one prescribed. It has been used for many years and found to be very safe. Alternative antibiotics include erythromycin, minocycline and doxycycline. Tetracycline needs to be taken on an empty stomach to ensure that it is fully absorbed.

Whichever antibiotic you are prescribed, you will probably have to take it for at least a few months.

c. For severe acne
For very serious cases who do not respond to the above treatment or severe cystic acne, a tablet called isotretinoin may be given. This medication may give rise to side effects, the most serious being damage to the unborn baby if taken during pregnancy.

Does diet cause or aggravate acne?
There is no firm scientific evidence that diet in any way influences acne. In the majority of cases, no dietary restrictions are required.

How should I wash my face?
Remove surface oil from the face by washing with soap and water or with medicated cleansers. There is no need to use special soaps. Ordinary toilet soaps will do. Remember, you can’t wash acne away.

Does squeezing the spots affect the outcome?
It is advisable usually not to squeeze the spots, especially if they are deep. Superficial yellow spots may be gently squeezed to remove the pussy contents. If excessive pressure is required to remove the contents, the spot should not be squeezed, otherwise the irritant material will be squeezed further into the surrounding skin and produce a spot which will be bigger, last longer and may result in scarring.

Can I use cosmetics when I have acne?
It is possible that very greasy make-up might worsen acne. Use water-based oil-free cosmetics to contents
 
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2. BOTULINUM TOXIN INJECTIONS FOR WRINKLES

How does it work in wrinkles?
    It is a toxin produced by the bacteria Clostridium botulinum. When injected in large quantity, the toxin causes paralysis of muscles. When injected in very small amount into a particular muscle it causes paralysis of that muscle only. Therefore if it is injected into small groups of muscles which cause frowning and wrinkling, the frown lines and wrinkle lines will disappear.

The toxin (available to your dermatologists) has been purified through various stages.

What is Botulinum Toxin used for?
-Frown lines ( mid forehead)
-Crow’s feet  (side of eyes / cheeks)
-Forehead wrinkles
-Neck folds

How is Botulinum Toxin given?
The toxin is injected serially into a group of muscles which controls frowning and wrinkling, with a very fine needle attached to a small syringe.

When treating frown lines the toxin is injected into a group of muscles just above the eyebrows. The toxin is also injected into a muscle at the bridge of the nose.

When treating crow’s feet the toxin is injected serially at several points into the muscles causing the wrinkles at the sides of the eye.

How long will the treatment take? Is it a painful procedure ?
It takes only a few minutes to inject botulinum toxin.  It is a relatively painless procedure. The patient will experience pain from the needle pricks only.

What must I do after the injection?
    After the treatment you should remain upright for 3 to 4 hours. During this period you must try to move the muscles that have been injected as much as possible to activate the effect of the toxin on the muscle. Do not rub the skin or muscles on or around the injected site.

How long will the anti-wrinkling effect of Botulinum Toxin lasts?
    The antiwrinkling effect sets in within three to four days after the injection. By the second week full paralysis of the wrinkling muscle will take place. The antiwrinkling effect of Botulinum Toxin lasts for three to four months only. There is individual variation. Gradually the wrinkling muscle function returns and wrinkles reappear. When this happens a repeat treatment is necessary to maintain the desired results.

Are there any side-effects?
Botulinum Toxin injection is a relatively safe procedure. Side-effects are uncommon. They are usually related to the injection procedure itself. There may be slight discomfort from the needle prick and a small chance of a bruise developing around the injection site. Slight drooping of the eyelids may occur but this is uncommon and transient and usually not noticeable. Transient headaches may occur. No permanent side-effects from Botulinum toxin injection have been reported so far.

Is the antiwrinkling effect of Botulinum Toxin permanent?
No. Most patients will need to have repeated injections at 4-6 monthly interval.

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3.  CONTACT ALLERGY

What is contact allergy?
Contact  allergy is a sensitivity reaction of the skin which some people develop on contact with substances usually harmless to others. These substances, or allergens as they are called, can enter the skin and cause the skin to react in a rash.

What are the most common contact allergens?
The most common allergens are nickel, (in costume jewellery), cosmetics, dyes, perfumes, metals, industrial chemicals, rubber products, medicaments. People can be allergic to almost anything including foods.

Is there a cure for contact allergy?
In many cases, removing the cause of the allergy – ie the allergen can relieve the patient’s symptoms. With understanding and knowledge of their problems, most sufferers from allergic conditions can lead normal lives. Contact allergy, once developed is usually life-long. The care of allergic condition is not, however, solely a medical responsibility. Success depends on early diagnosis and co-operation between doctor and patient. Medication helps to relieve symptoms.

How does an allergen cause trouble?
When an allergen comes into contact with the skin, the tiny cells in the skin react by producing active chemicals. These active chemicals in the skin produce irritation resulting in itching rashes. This sensitivity may not appear suddenly or immediately, but only after repeated exposure to the offending allergen.

How is contact allergy confirmed?
When a patient or a doctor suspects an allergy, a case history will be taken which will include information on home and work, living habits and time of year when the symptoms occur. The doctor will decide from this what tests are necessary. He will then carry out skin tests (patch test and / or prick test) to different materials, and the results of these tests, together with the case history, will help him decide what treatment is needed.

PATCH TEST PROCEDURE
The patch test procedure: For detection of contact allergy

You may be allergic to a substance that you come into contact with.

A patch test is a procedure that helps us to identify the substance you are allergic to. During the test, pieces of tapes will be plastered on either your back, thigh or shoulders.

Your co-operation is needed to ensure the successful outcome of the test. Please observe the following points:

1. Leave the patches in place until they are removed in the doctor’s office.

2. In order to prevent false results, you should not wash your back or other test areas, and avoid exposure of the test areas to sunlight or ultraviolet light. You may shower the other parts of your body though.

3. Avoid strenuous exercise that will cause excessive perspiration, as well as movements that could cause the patch test plasters to fall off.

4. If the patch test plasters become loose, please fasten them with an additional adhesive tape in exactly the same place (and inform the physician). The tapes will be removed during the second visit (after 2 days).

5. If you should feel some itch, (this sometimes occur when the test is positive) please do not scratch.

6. Please visit your doctor’s office at the appointed date for the reading of your test results, on the 3rd day and on the 5th day.

7. After the patches are removed on the 3rd day, please remember that you should not wash or sunbathe the tested skin areas until after the final visit.

Should you be allergic to one or more of the substances tested, the corresponding test site will develop redness or itch. This redness or itchy rash usually disappears after a few days.

Important :
a) If you must use medication, even if just applied locally (ointment, creams, drops, etc) please report this to your doctor.

b) If you experience severe reaction after application of the patch test material, remove the patches and report to your doctor immediately.

c) Should a reddening of the skin or any other changes occur at the test site within a 3 week period after the final reading, please report this to your doctor immediately.

To help us with this test, please bring along all the substances you have come into contact with for testing including:-
- all self purchased and prescribed medications cosmetics and toiletries
- cleansers used at home and at work
- food substances that you handle
- substances handled at work
- any other substances that could have caused your rash.

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 4.  ECZEMA AND ATOPIC DERMATITIS

What are eczema and dermatitis?
Eczema and dermatitis are now generally used to describe the same skin condition.

Eczema is one of the commonest reasons for dry, sensitive skin, taking its name from the Greek word ECZEMA, meaning to boil. This is an apt description of the inflamed rash, which is often accompanied by an intense itching, which makes scratching almost inevitable.

One person in ten has eczema at some time in their life, and it affects all age groups.

Is there just one type of eczema?
No, there are many, but everyone with eczema experiences similar, unpleasant symptoms. These are some of the main types of eczema:

Atopic Dermatitis
It is possible to develop atopic eczema at any age but it is most commonly found in babies and young children. Atopic eczema is thought to run in families and it is part of a group of atopic conditions, which include eczema, asthma and hay fever.

Seborrhoeic Eczema
There are two types of this condition: one is most commonly seen in babies;  the second is fairly common in younger adults. Areas affected tend to be the oily parts of the body, such as the scalp, face, groin and chest. Seborrhoeic eczema is not normally itchy.

Discoid Eczema
This condition is usually confined to the arms and legs and consists of scaly, itchy, coin-shaped patches that can blister and weep.

Varicose Eczema
This is a condition of the legs, commonly found in the elderly and people with varicose veins.

Contact Dermatitis
There are two types – irritant and allergic. Irritant is caused by exposure to substances such as soaps, detergents, engine oils, hair dyes and bleaches. Allergy is caused by specific sensitivity to a material such as nickel, chrome or rubber.

What is Atopic Dermatitis?
Atopic Dermatitis or eczema is an itchy, dry hypersensitive skin disorder affecting many people. It is common in children but can occur at any age. It is not infectious or contagious.

The exact cause of atopic eczema is unknown. It may be hereditary. The patient or some family members may have other hypersensitive conditions like asthma or hay fever.

The rash may appear red, wet and weepy or dry, thickened and scaly. When the disease starts during infancy, it is sometimes called infantile eczema. This is an itchy, crusted rash that tends to be localized principally on the face and scalp, but can appear at the other sites. Scratching often aggravates the rash. The skin thickens and becomes darker. It is a chronic condition. It can affect any part of the body, particularly the elbow bends, back of the knees and the neck.
 
What are emollients?
Emollients are basically simple moisturisers used to combat the dryness of eczema and to protect the skin from further water loss. There is a wide range of products of this kind and it may take you some time to find the one that is suitable for your skin.

Questions and Answers:
Q. Since atopic dermatitis is sometimes associated with food allergies, can the elimination of certain foods be of help?
A. Yes, but is not common. Although certain foods will sometimes provoke attacks, especially in infants and young children, elimination of foods rarely brings about a lasting improvement or cure.

Nevertheless, when all else fails, avoidance of common offending foods such as cow’s milk and eggs may be tried for a few weeks.

Q. Are the inhaled and contacted substances in the environment important causes, and should they be eliminated?
A. Yes. Dust and dust-forming objects  (for example, feather pillows and comforters, kapok pillows and mattresses, dust-forming carpet, drapes, toys and certain rough garments such as wool, coarse silk) worsen the rash. Try to wet mop or vacuum floors, rather than sweep. Reduce contact with animal furs.

Q. Are skin tests, as done in patients with hay fever or asthma of value in finding the offending substances?
A. Yes, at times. However, results can be misleading particularly when the tests are carried out by persons inexperienced with such tests.

Q We have had a cat for five years but our youngest child has developed atopic eczema and we have been advised to get rid of the pet. We are very worried about the effect this will have on the whole family. Is there anything else we can do to minimise the effects of the cats?
A. The problem with furry pets comes mainly from the shed skin or “dander” in the coat. Saliva and urine can also cause problems. However, when a pet has been in the family for a long time its sudden removal may not be feasible.

Restricting the cat’s movements within the house can be difficult but it is very important that the animal is not allowed to go into the child’s bedroom. It is also important to realise that people may transfer hair and dander via their clothing.

It has been suggested that weekly bathing of cats can help to reduce their allergenic effects. However, anyone with a cat can anticipate the type of problems this may cause! A wipe down with a damp cloth may not have quite the same effect but is used by some families to reduce the problem.

Q My first child has severe eczema. What is the likelihood of our next child developing the condition?
A It is thought that people inherit the potential to develop an atopic condition such as eczema, asthma or hay fever. It will take a trigger of some kind to bring out the condition. There is no straightforward pattern of inheritance but it seems that if one of your children already has the condition then your next child has a one-in-four possibility of developing eczema. However, it is important to bear in mind that in the majority of cases, eczema is a fairly mild condition and another child may not necessarily be affected to the same extent as the first.

Q. What should be done to treat atopic dermatitis?
A. See your dermatologist. Try to relieve itching by eliminating these aggravating factors:
-Rapid changes of temperatures, strenuous exercise and hot weather.
-Rough, scratchy, tight & woollen clothings.
-Frequent use of soaps, bubble bath, hot water and other cleansing procedures that tend to remove natural oil from skin. Use mild detergents for your clothes and rinse the clothes thoroughly during washing.
-Emotional upsets.

Wear light, smooth, soft, non-binding clothing. Do not increase the skin’s dryness by prolonged or frequent hot baths, or showers and soap. Use mild soaps or ‘soap-free” soaps or emulsifying ointment. Bathe or shower with luke warm  (not hot) water. When necessary sponge gently under the arms, in the groins and in other areas where cleansing is imperative. At other times, cleanse the entire skin with non-greasy lotion. Avoid sudden changes of temperature for instance, coming to air-conditioned rooms from the hot outdoors. Try not to rub or scratch. When the itching is severe, try to relieve it by dabbing or applying cloths soaked in iced water.

    It is important to comply with treatment. Your dermatologist can usually help you by prescribing external remedies (corticosteroid creams are most effective). Use sparingly. Apply a thin layer of cream on the rash with your fingers. Rub onto the skin till it disappears. Apply at least twice a day, preferably after showering. Do not use strong steroid creams for long periods as over-use will harm the skin. Use weak steroid creams when your eczema is mild. Oral medication (sedatives, antihistamines and sometimes, antibiotics by mouth) to control the itching and baths with diluted potassium permanganate are helpful.

Corticosteroids taken by mouth or given by injections should be avoided if possible. However, when all other measures have failed, your physician may prescribe systemic corticosteroids for short periods.

Generally 90% of children out-grow the condition by early teens, although some continue to have problems even as adults.

Q. Would a change in environment be helpful?
A. For reasons that are not yet known, a radical change of environment, like a cool environment, sometimes is the “best” cure for atopic dermatitis. Many patients get better rapidly in the hospital.

Q. Are there any other problems?
A. Bacterial infection (pus) and viral infection (eg. Herpes simplex) can occur. Antibiotics and antiviral treatment are needed.
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 5.  FUNGAL INFECTIONS

What is “ White Spot? ”
“White spot” or panau is a superficial fungal infection of the skin which is common in children and adults. It may be itchy.

It is made up of fine scaly white patches on brown skin, on your face, neck, shoulders, arms, trunks or legs. These sports are active fungi infecting your skin. The medical name is Pityriasis versicolor.

What is Ringworm?
Ringworm appears as scaly reddish ring-shaped patches with the tendency to form rings with raised borders. This is called tinea corporis (body), or tinea cruris ( groin).

What is Athlete’s (Singapore’s) Foot?
Athlete’s foot is present when the skin between your toes becomes very scaly and peels. You will also experience itchiness of the feet. The fungus, a ringworm infection may also spread to your soles and toenails and become scaly. This is called tinea pedis.

What is Moniliasis / Candidiasis?
This fungus is common on the lip area genitalia in persons with diabetes on oral steroids and long term antibotics. It is itchy and the rash is red. Females may have a genital discharge and itch.
 
How to prevent superficial fungal infection
1. Fungus grows when the skin is warm and sweaty. The space between your toes, the skin folds in the groin area and the armpits must be kept completely dry to prevent such fungal infection.

2. Do not walk barefoot in areas where the floor is wet – bathroom, lavatory, and the common swimming pool as the fungus is present. Wear slippers.

3. Avoid borrowing personal napkins, towels, combs and hair brushes as they may be infected. Make sure you use your own personal items because these fungal infections are easily transferable. Any item that comes into contact with the affected areas must be sterilised before use.

4. Nylon socks and covered shoes make your feet sweat. Wear cotton socks to absorb the sweat, or open-toe sandals if your feet sweat profusely.

5. Keep a healthy life-style with a balanced diet, exercise and time for rest, to increase your body resistance. You will catch fungal infections easily if you are weak.
 
How to treat superficial fungal infection:
1. Apply anti-fungal cream on the affected areas 2-3 times a day for 3 weeks. Such creams are nystatin, tolnaftate, imidazole or naftidine creams.

2. Do not stop using the medicine even when the rash has cleared. Continue using it for at least 7 days the infection appears  to be cleared. In the case of white spots, the white colour remains even after the infection has been successfully treated. However, this will gradually fade as the skin recovers its normal colouring.

3. Oral anti-fungal tablets are needed for fungal infections affecting large areas. Your doctor may prescribe them.

4. For prevention of white spots, use an anti-fungal shampoo once a month, on your scalp and body, leaving it on for 15 to 30 minutes before washing it off. In the event of an infection, use this nightly for 7 days consecutively.
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6.  HAIR FALL

How does hair grow?
Normal hair grows in cycles and goes through 3 stages:
- A growing phase
- A resting phase
- A falling phase

At any time, it may be normal for a person to lose as many as 50 hairs a day and these usually show up on a comb or brush or at the bottom of the bathtub, especially after washing your hair. Hair grows at a rate of 1 to 2 cm a month.

When does hair loss become abnormal?
Your hair loss may be abnormal if you are losing more than 100 hairs a day. This may result in a general thinning of hair or a patchy loss of hair over the scalp and other hair bearing areas such as the beard or eyebrows.

What are the different kinds of hair loss?
Androgenetic - this is the commonest cause of hair loss in both men and women. It is
commonly known as male pattern baldness. It is caused by a combination of 3 factors – testosterone ( the male hormone – also present in females), age (after 20 years of age) and heredity. It usually affects women later in life than men.

Alopecia areata - this usually results in a patchy loss of hair. It maybe associated with diseases like diabetes mellitus and thyroid disease.

Telogen Effluvium - diffuse loss of hair which may occur 2 to 4 months following childbirth or  high fever, acute illness, physical and emotional stress and crash dieting.

Chronic Illness - iron and other dietary deficiencies, thyroid diseases, syphilis and
Illness  connective tissue diseases are examples of chronic illness which may cause hair loss.

Scalp Diseases - fungal and bacterial infections, and other local scalp diseases.

Excessive traction - for example tight curlers and hair styles (corn-braiding, the pony-tails).

Drug Induced - anti-cancer drugs and anti coagulants are some of the drugs which may cause hair loss.

Certain kinds of hair loss like telogen effluvium are reversible.

What shall I do when I have abnormal hair loss?
If you feel your hair loss is excessive, you should consult your doctor.  He will try to find the cause of your hair loss and may be able to treat any underlying medical conditions.

-Scalp massage and over-the counter preparations are not proven to be of any therapeutic value.
-Use a wide-tooth comb and avoid brushes.
-Avoid curlers and excessive traction. It is advisable to keep your hairstyle short and avoid perm for a while.

Be wary of what others may offer you in terms of hair treatment and cure. When in doubt, seek the advice of a doctor.

Hair weaving is a procedure whereby colour and texture matched to human hair is woven, braided or knotted onto the natural hair – to conceal thinning or alter the normal hairstyle.

Hair transplantation is a complex procedure and requires a skilled surgeon to perform.
 
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 7.  HAND ECZEMA
What is eczema?
It is an inflammation or reaction to several factors like sensitive skin, irritants or allergic substance.

Your hand eczema may be caused by:
1. Constitutional factors, that is, an inherited sensitive skin.
2. Irritation from too much wetwork, detergents, solvents, acids, etc.
3. Allergy to a specific substance (eg, cement,perfume etc).
4. A combination of all the above factors.

Your doctor will:
- Help you uncover any allergy and / or irritant that is causing or aggravating your hand eczema.
- Prescribe wet dressing, medicated creams, ointments or tablets to suppress the eczema.

You on your part should:
- Assist your doctor by telling him the substances you come into contact with in your home or work environment and in your hobby.
- You must inform your doctor of the medication or skin care products you have applied. You should also protect yourself from irritants.

When doing housework:
- When doing “wet” work like washing clothes and dishes, wear impervious (rubber or PVC) gloves.
- Do not wear the gloves for more than 30 minutes at a time. Do not wet the inside of the gloves.
- Avoid handling fruits, vegetables, shellfish and raw meat with bare hands. Use gloves when preparing these foods.
- Avoid handling dirty diapers with bare hands. Use gloves.
- Never squeeze floor mops with bare hands.
- Change the gloves if they are wet inside.

When working with water, solvents, coolants, oils, greases, etc:
- Try to protect your hands with gloves when it is safe to do so.
- Use rubber or plastic gloves.
- Cotton gloves are not recommended. They soak up the irritants and worsen the problem.
- Do not use strong or medicated soaps or detergent powder to wash your hands. Use a gentle soap instead.
- Do not wash your hands too often.
- Never use solvents to clean your hands.
- Once an allergy is detected, avoid the allergen completely.
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 8a.  What is LASER SURGERY?
    Laser stands for light Amplification by the Stimulated Emission of Radiation. Because they work by converting electrical energy into a parallel beam of intense bright light, lasers can cut, seal or vaporize tissue and blood vessels. The laser’s advantages come from its ability to produce a specific and powerful wavelength of light with a wide variety of intensities.

This pure beam of light is utilized by directing it at a tissue, which absorbs the light. For light energy to be absorbed, it is necessary to have some absorbing molecule in the tissue.

In the field of skin surgery, there are several types of laser systems currently available for important clinical applications. However, no single laser is capable of treating all skin conditions. Rather, the type of laser used determines the kind of light emitted from it, and the kind of light, in turn, determines what skin problems can be treated. Following is an overview of lasers most commonly used and their applications.
 
What are the Benefits of Laser Technology?

The use of laser can offer the following general benefits:
1. Reduces the risk of infection.
2. Makes surgery virtually “bloodless”
3. Enables precision therapy – fine, clean and delicate cuts.
4. Replaces surgery in many cases.
5. Minimizes scarring by not damaging surrounding tissue.
6. Permits outpatient, same day surgery for many procedures.
 
What are the Common Laser Systems?
The Carbon-Dioxide Laser
    A gas laser, the carbon-dioxide  (CO2), continuous wave laser emits light in the far infrared portion of the colour spectrum. The CO2 laser wave length is highly absorbed by water. Since all living tissue contains about 80 percent water, this laser system is currently the most frequently used surgical laser. In addition, because the CO2 laser beam can be used in two ways – focused and defocused, it can perform two distinct therapeutic functions.

    When the laser light is focused into a small powerful spot, the skin can be cut as if the light were a scalpel. This method of excision is often used to remove tumors or other growths and to treat precancerous conditions. The wound may then be sutured just as in traditional surgery.

    If the laser light is defocused, the spot of light is larger and less powerful. This enables the laser to vaporize shallow surface layers of the skin without cutting into deeper skin layers. This is particularly helpful for shallow tumors, actinic cheilitis (precancer of the lip), warts or other lesions that are typically superficial. The CO2 laser has the unique advantage of sealing blood vessels as it cuts, allowing for “bloodless surgery”. Its other benefits include minimal scarring, reduced risk of post-operative infection of complications and less pain.

The Argon Laser
This laser system is based on the principle of relatively selective destruction of haemoglobin, melanin and coagulation of the blood vessels of pigment-making cells.

    The argon laser is best used for the treatment of vascular (pertaining to blood vessels) lesions, especially those that are large, thick and overdeveloped. Argon laser therapy results in flattening and significant lightening of lesions with little scarring. It is helpful in adults for the treatment of port-wine stains, haemangiomas (overdevelopment and / or malformation of blood vessels under the skin) and facial telangiectasias (dilated or enlarged small blood vessels). Additional conditions for argon laser therapy include red-nose syndrome (as a result of acne rosacea or rhinoplasty) and dark, pigmented lesions due to the presence of melanin.

    Limiting factors of the argon laser include a superficial depth of penetration, scarring, loss of pigmentation, and the need for post-operative wound care.
 
The Dye Laser
The Dye Laser uses organic dyes that are capable of emitting yellow light in a range of wavelengths, depending on the chosen dye.

    The flashlamp-pumped dye laser is generally used at a rapid, high-energy pulse over a short period of time. One of its key applications is for treatment of “broken” or dilated small blood vessels below the skin. Also treated are port wine stains, spider veins, red noses and red facial spots such as small strawberry haemangiomas. A major advantage of the pulse dye laser is that infants and children can be treated exceptionally well with minimal risk of scar.

The argon-pumped dye laser emits continuous wave, tunable light at a lower energy power than the flashlamp-pumped laser. In addition to treatment of vascular lesions, the argon-pumped laser is being used in connection with photodynamic therapy (PDT) research. PDT involves the injection of photosensitizers that are absorbed in skin cancers, followed by laser irradiation.

The copper vapour laser produces a pulsed yellow light is regarded as a quasi-continuous wave device. A train of short pulses, rapidly repeated, makes it seem like a continuous beam. It is used to treat vascular disorders such as portwine stains and dilated veins. A disadvantage of the copper vapor laser is that it is not as selective in producing heat damage to its target as other yellow light lasers.
 
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8b.  Day Skin & Laser Surgery

What is Skin/Laser Surgery?
Skin/Laser Surgery refers to the treatment of certain skin disorders by surgical means.
It also includes the surgical treatment of certain conditions of the scalp and nails.
 
What are the methods used in Skin / Laser Surgery?
There are various methods employed in Skin/Laser Surgery. Besides removing skin lesions by cutting with a surgical knife. Other methods used include: cryosurgery,electrosurgery and laser surgery.

In cryosurgery, a cold substance (usually liquid nitrogen) is used to destroy the skin growth by a freezing process.
In electrosurgery, various forms of controlled electric currents are employed to destroy tissue.
In laser surgery, a precise and intense light beam is used to burn and destroy tissue.

All of the above methods are usually performed under local anaesthesia, in some cases, no anaesthesia is required at all. Usually such surgical procedure will take less than 30 minutes to perform.

The patient will usually be able to return home immediately after surgery and often, be able to resume work in a day or two.
 

What skin disorders can be treated by Skin / Laser Surgery?
Certain lesions on the skin or just beneath it can be treated by Skin/Laser Surgery. These include:

1 Growths of infectious origin, eg Viral Warts and molluscum contagiosum.
2 Birthmarks, eg: port-wine stains.
3 Growths associated with ageing, eg: seborrhoeic keratoses and skin tags. Seborrhoeic keratoses are rough spots, usually brownish, that look as if they are ‘stuck’ on the skin. They commonly occur on the face of people over 40 years of age. Skin tags are soft, fleshy growths most commonly seen around the neck and in the armpits.
4 Skin cancers which present itself either as sores (ulcers),growths (tumours) or pigmented patches.
5 Tattoos for removal.
6 Other benign growths on the skin.

Some of the above-mentioned lesions can be treated by one or a combination of the skin/laser surgery methods. Your doctor will select the treatment method most appropriate for the specific lesion that you have.

Besides the removal of skin growths, skin/ laser surgery is used to treat other conditions of the skin and some problems of the nails and hair. Please consult your dermatologist if you have concern in these areas.
 
How are patients referred for skin surgery
Patients for skin / laser surgery should be referred to the NSC general clinics (private and subsidized) in the usual way. After review in our general clinic, patients suitable for surgery will be referred to our skin / laser service for surgery.

The Day Surgery Procedure
You can have certain minor skin surgeries e.g. removal of skin growths, treatment of birthmarks, etc done and then recover, and go home all on the same day. This Day Skin & Laser Surgery service is provided at the National Skin Centre, at a reasonable cost.

Instructions before your surgery
- No need to fast
- As only local anaesthesia is used, you do not have to fast before the surgery
- When to come: You should arrive 15 minutes before surgery
- Where to go: Go to the Operating Theatre on the ground floor

Except for those who would normally require assistance by their family members, patients can come for the procedure by themselves and can return home by themselves as only local anaesthesia is used.

Girls less then 21 years old and men under 18 years old must be accompanied by one of their parents/guardians to provide consent for surgery.

Most day surgery patients are able to go home right after the surgery. But your doctor  may decide to keep you longer, depending on his satisfaction with your recovery.
 

After surgery
After your skin surgery your nurse will give you instructions on your medications and any activity restrictions to follow at home, as specified by your doctor. It is very important that you follow these instructions closely.

For your protection, don’t take alcoholic drinks within 24 hours after surgery and for as long as you are taking medications.

Here are some of the procedures that can be performed on a day surgery basis:
- Laser treatment of certain skin tumours and warts and birthmarks
- Surgery to remove skin, scalp and nail lesions and tumours
- Electrosurgical treatment of skin lesions and tumours
 
 
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8c. Carbon Dioxide Laser Post-Operative Instructions

What to expect after carbon dioxide laser treatment?
- The local anaesthetic and the laser treatment may cause swelling to treated area for several hours or even days.

- If the treated area is near your eyes or near your forehead, your eye lid may become swollen and you may develop a mild “black eye”.

- You may experience some discomfort after the CO2 laser treatment. For adults, take two tablets of paracetamol (eg. Panadol) every six hours when needed for pain ( if you are not allergic to it).

- During the first few weeks, the CO2 laser treated area may be wet but ultimately a dry scab will form. The edges of the wound may become reddened and you may see some yellowish crust in the wound. This is the normal appearance of a  healing wound. These are not the signs of infection.

- The wound will heal spontaneously.

- If bleeding occurs, apply continuous pressure directly to wound with your hand for 20 minutes. If the bleeding continues after 20 minutes of pressure, notify your doctor at the National Skin Centre. If he cannot be reached, go to the nearest general practitioner or hospital for advice.
 
Home Care Dressing for Carbon Dioxide Laser Treatment Wound
- Keep the treated area dry 24 hours following the CO2 Laser treatment.
- Remove the dressing after 24 hours.
- If the dressing is stuck to the wound, soak dressing in saline solution to loosen.
- Clean the wound either using cotton applicators (cotton bud) or cotton balls with prescribed cleansing solution,   applying gentle pressure and cleansing edges and inside the wound.
- After cleaning the wound, dry the wound.
- Apply antibiotic ointment with cotton applicators.
- Cover the wound with non-adherent dressing eg. Airstrip or Melolin (this will prevent the dressing from adhering to the wound) and secure the dressing with tape.
- Wound dressing may be changed daily or twice a day (morning and evening) depending on the cleanliness of the wound.
- Do not use any cosmetic or cover-up on Laser wound until the skin has totally healed.
 
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8d. Q – Switched Nd:YAG Laser

    The Q-Switched Nd: YAG Laser is a type of laser developed to remove blue, brown, black and possibly other colours of tattoo pigment and certain brown pigment growths and birthmarks from the skin. Although laser surgery is effective in most cases, no guarantee can be made that a specific patient will benefit from the treatment. Treatment of the tattoo or pigment will be done in stages. Initially a test dose may be done to determine the necessary energy settings of the laser. Once this dose is determined, the entire tattoo or pigmentation will be treated at the next visit. The tattoo or pigmentation will be re-examined and retreated if necessary at two months or longer intervals until either the entire pigment is removed or it is decided that the pigment will not be capable of being removed by the laser.

    The number of treatment with the Q-Switched Nd: YAG Laser will vary depending on the lesion, size, location, colour and age of the patient and age of the tattoo. Most likely a total of 3-7 visits / treatment or more will be necessary.

Instructions for skin care after Q-switched Nd:YAG Laser treatment
You have been treated with the Q-Switched Nd: YAG Laser. The treated area is very delicate and should be treated with care. Please read and follow instructions given.

Care of the treated area:
- Keep the treated area dry for 24 hours following the Q-Switched Nd:YAG Laser   treatment.
- Remove the dressing after 24 hours.
- If it is difficult to remove the dressing, soak it in saline solution (salt water) to loosen.
- Clean the wound with cotton balls with prescribed cleansing solution.
- Apply gentle pressure and clean the edges and the wound.
- Apply antibiotic ointment with cotton applicators.(Q tips)
- Cover the wound with non-stick dressing (eg. Melolin) to prevent the dressing from sticking to the wound.
- Apply antibiotic ointment to the treated area twice a day for 7 days or until the surface is totally healed.
- Showers are permitted but gently pat the area dry.
- Do not rub wound with a towel because the area is extremely delicate while any crusting is present.
- You may experience some discomfort after the laser treatment.
- For adults take two tablets of paracetamol (eg. Panadol) every six hours when needed for pain.
- If swelling occurs, an ice pack wrapped in a soft can be applied.
 
Precautions to take following your laser treatment
- Avoid direct exposure to the sun. Use a sunblock.
- Do not rub, scratch or pick at the treated area.
- A protective dressing should be applied if the area is irritated by clothing or jewellery.
- Do not apply make-up until the crust disappears.(Usually 2 to 4 days)
- Avoid swimming and contact sport while any crusts are present.
- If the treated area shows signs of infection (tenderness, redness, swelling or pus), notify your doctor  National Skin Centre or Operating Theatre Nurse-in-Charge.

What are the side effects and possible complications of laser surgery
Pain: You will feel some pain during treatment. The pain is mild and it is similar to snapping the skin with a rubber band. Some areas are more sensitive than others.

Healing wound: Laser surgery may cause a superficial burn on the surface of the skin which takes several days to heal. This may result in swelling, weeping and crusting of the treated area. This usually takes 4 to 10 days to heal.

Pigmentary changes: In most patients the treated area loses pigmentation (hypopigmentation) and becomes lighter in colour than the surrounding skin temporarily. This type of reaction tends to gradually fade away and return to normal over a period of 2-4 weeks. With repeated treatments the pigment loss may become more persistent and take time to heal, up to 6 to 8 months. There is some risk of permanent pigment loss in the area of treatment, leaving a white shape similar to the original tattoo or pigment lesion being treated, but this is rare and usually avoidable by allowing adequate healing time between treatment.

There is some risk of increased pigmentation (hyperpigmentation) as a healing reaction. However this type of change is very rare. If this should occur the increased pigment usually fades away over a 2-6 month period.

Scarring: Scarring is a very rare occurrence but it is a possibility. To minimize the chances of scarring, it is important that you follow the post-operation instructions carefully.

Persistence of tattoo or pigment:  Some tattoo ink or pigment is located too deep in the skin to be removed completely in spite of repeated treatments and may leave vague spots of colour remaining after treatment. There may be some ink colours that change colour prior to removal and others that simply will not respond to this laser. eg. Green tattoo). This means that it may not be possible to completely remove all tattoo and skin pigmentations with this laser. If this situation arises, there may be other treatment alternative available.
 
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8e.  Removal of Tattoos and Pigmented Birthmarks Q-switched Nd:  YAG Laser
    The Q-Switched ND:YAG Laser is a type of laser developed to remove blue, brown, black and possibly other colours of tattoo pigment and certain brown pigment growths and birthmarks from the skin. Although laser surgery is effective in most cases, no guarantee can be made that a specific  patient will benefit from the treatment. Treatment of the tattoo or pigment will be done in stages. Initially a test dose may be done to determine the necessary energy settings of the laser. Once this dose is determined, the entire tattoo or pigmentation will be treated at the next visit. The tattoo or pigmentation will be re-examined and re-treated if necessary at two months or longer intervals until either the entire pigment is removed or it is decided that the pigment will not be capable of being removed by the laser.

The number of treatment with the Q-Switched Nd: YAG Laser will vary depending on the lesions, size, location, colour and age of the patient and age of the tattoo. Most likely a total of 3-7 visits/treatment or more will be necessary.

Instructions for skin care after Q-switched Nd:YAG Laser treatment
You have been treated with the Q-Switched Nd: YAG Laser. The treated area is very delicate and should be treated with care. Please read and follow instructions given.

Care of the treated area:
- Keep the treated area dry for 24 hours following the Q-Switched Nd: YAG Laser treatment.
- Remove the dressing after 24 hours
- If it is difficult to remove the dressing, soak it in saline solution (salt water) to loosen
- Clean the wound with cotton balls with prescribed cleansing solution.
- Apply gentle pressure and clean the edges and the wound.
- Apply antibiotic ointment with cotton applicators (Q tips)
- Cover the wound with non-stick dressing (eg. Melolin) to prevent the dressing from sticking to the wound.
- Apply antibiotic ointment to the treated area twice a day for 7 days or until the surface is totally healed.
- Showers are permitted but gently pat the area dry.
- Do not rub with a towel because the area is extremely delicate while any crusting is present.
- You may experience some discomfort after the Q-Switched Nd. YAG Laser treatment.
- For adults take two tablets of paracetamol (eg. Panadol) every six hours when needed for pain.
- If swelling occurs, an ice pack wrapped in a soft cloth can be applied.
 
Precautions to take following your laser treatment
- Avoid direct exposure to the sun. Use a sunblock.
- Do not rub, scratch or pick at the treated area. A protective dressing should be applied if the area is irritated by clothing or jewellery.
- Do not apply make-up until the crust disappears. (Usually 2 to 4 days).
- Avoid swimming and contact sport while any crusts are present.
- If the treated area shows signs of infection (tenderness, redness, swelling or pus), notify your doctor at National Skin Centre or Operating Theatre Nurse-in-Charge.
 
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 8f.  Laser Treatment for Vascular Birthmarks
Certain birthmarks can now be removed using laser treatment:

Portwine stain
This is a blood vessel abnormality affecting up to 0.5% of the population. It looks like a pink patch at birth and will not go away.

Instead as one grows older the birthmark will steadily darken and becomes larger. By midlife, many of those afflicted with the condition may suffer cosmetic dis-figurement, which can occur on any part of the body. If the birthmark becomes too large or thick it may bleed.

Strawberry haemangiomas
These are overgrown or enlarged blood vessels which grow very rapidly after birth but often go away with time. The birthmark usually resolves by 5-6 years. Some, however, may occur near the mouth or eyes and interfere with eating or eyesight and should be treated early before problems set in. (Sometimes the birthmark may bleed or become infected).
 
Spider veins
Like strawberry haemangiomas, spider veins are overgrown or enlarged blood vessels. They contain central large blood vessels with tiny vessels radiating from the centre, hence the name. They usually do not cause problems except that they look unsightly.
 
Why should I have my birthmarks treated?

A.  Many people are uncomfortable with unsightly birthmarks. Young children or infants can be treated before they are subject to the psychological as well as physical blemishes that may be associated with the birthmarks. Sometimes birthmarks may bleed, become infected or interfere with vision, eating or other body activity.

Q How safe is the treatment?
A.   The flashlamp pulse dye laser is able to selectively treat the blood vessels of the birthmark without adversely affecting the surrounding tissues. Thus, it will eliminate many lesions while leaving the surrounding skin and skin pigment intact, thus reducing scarring. This treatment is safe to be used on infants as young as a few weeks old.

Q What does treatment by the flashlamp pulse dye laser machine consist of?
A. The treatment varies from patient to patient depending on the type of birthmark, size of the affected area, the color of the skin and the depth to which the abnormal vessels extend beneath the skin’s surface.

The steps involved are:
1. The doctor will test your skin reaction to the laser during your first visit to determine the most effective treatment.
2. Because the laser operates at a wavelength that is potentially harmful to the eye, you will be asked to wear some form of eye protection consisting of an opaque covering or goggles.
3. Treatment consists of placing a small handpiece or “wand” against the surface of the skin and activating the laser. The flashlamp pulse dye laser will strike the skin in an intermittent fashion. Each pulse feels, for a small fraction of a second, like the snapping of a small rubber band against your skin.
4. Small birthmarks, like spider veins, will require only a few pulses, while others like portwine stains, will require many more. Larger birthmarks will require re-treatment, necessitating multiple patient visits.

Q Is the treatment painful?
A. Most adults tolerate treatment without the need for anaesthesia, although treatment of larger lesions may be less comfortable. Children and particularly infants may have a lower pain threshold and may tolerate the procedure better with the use of sedatives or anaesthesia.

Q What happens after treatment?
A.  Immediately after treatment, the lasered area will turn dark-grey. This will remain for up to two weeks until the dead blood cells are absorbed by the cells in your skin. Occasionally, a very thin scab will form on the surface of the skin. This will fall off within two weeks.

 In the first several hours after treatment, the lasered area may feel hot, like a sunburn. You may relieve this by applying a cool cloth soaked in cold water, or you can use a cloth wrapped around ice cubes or an ice pack.

 For the next three to four days:
- avoid hot water for the face
- avoid hot conditions e.g. sauna, spa
- you can wash the face with tepid water but avoid soaps and rubbing or friction on the skin
- avoid or minimize sun exposure
- you may use moisturiser on the face if it is applied gently and not rubbed in

After the first four days, you may use a  sunscreen if you are going outside, It is very important that you avoid excessive sun exposure for the first 3 months, Otherwise, a brownish pigmentation may occur which would take a few months to fade.

Q What other concerns should I know about?
A.   Optimal results will be achieved with the flashlamp pulse dye laser only if you are not sun tanned. It is also recommended that you avoid exposing the treated area to the sun and to cover the area with a sun block that is approved by your doctor. Of course, this area may be exposed to the sun when your course of treatment is complete.

 Patients with tanned or darker skin types will achieve less satisfactory results from this form of treatment.

 The cost per treatment ranges from $200 to $2,500 depends on the size of the lesion treated. Most patients will require about three to six treatment sessions.
 
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8g. Laser Skin Re-surfacing for Scars and Wrinkles
What is Laser Skin Re-surfacing?
Using a special scanner attached to a carbon dioxide laser, your dermatologist can delicately exfoliate your skin accurately layer by layer.

The superficial layer of skin is removed and the deeper layer of skin is exposed. Here collagen is stimulated and a new layer of skin is formed over a period of time.

With this precise control over the interaction between the laser energy and the skin, bleeding is eliminated and scarring generally associated with other wrinkle treatments, is significantly reduced.

What are the indications for Laser Skin Re-surfacing ?
Fine lines and wrinkles around the eyes and mouth,
Deep laugh and frown creases,
Acne, traumatic,chicken-pox and surgical scars,
Photodamaged skin,
Miscellaneous lesions and conditions
 
Is Laser Skin Re-surfacing suitable for me?
Your dermatologist will take your medical history, age, skin type (including pigmentation) and desired results into consideration to determine whether you are a suitable patient for laser Skin Re-surfacing.

Be sure to mention any past or present viral infection, sun sensitivity, drugs (eg roaccutane) used within the past year, problems with wound healing or prior chemical peels or dermabrasion to your dermatologist.

How many times must I come for Skin Re-surfacing procedure?
This depends on the type and depth of the wrinkle or scar you have. One or more treatment sessions may be required.
 
When can I do my Laser Skin Re-surfacing?
Your dermatologist will usually schedule a test patch (about 3cm in diameter) for you before conducting the full laser skin re-surfacing.

The reason why a test patch is done is to ascertain the risks of hyperpigmentation and scarring you may have.
 
When can I do my full Laser Re-surfacing?
If all goes well  with the test patch (allowing 6 – 8 weeks postoperatively to look for adverse effects), and you remain committed to have the laser treatment, your dermatologist will schedule you for full laser re-surfacing.

The whole procedure usually takes less than 1 hour.
You can expect to go home immediately after treatment.
 
How long does it take for the laser wound to heal?
Following the laser re-surfacing procedure you may expect slight swelling and redness on the treated sites.

The initial redness fades in a few weeks to light pink, which can be easily camouflaged with cosmetics. The redness usually disappears completely in one to three months for most patients.

Generally patients enjoy a short recovery time after laser skin re-surfacing.
 
When can I return to work?
You can return to work as soon as you feel comfortable. Most patients prefer to wait until their laser treated areas can be covered with cosmetics (usually by day 7) before returning to work.
 
Are there special precautions to follow after the Laser Re-surfacing treatment?
It is important to avoid direct sun exposure for several months following the laser treatment.

Some patients may experience transient hyperpigmentation  (increased pigmentation) or hypopigmentation  (decreased pigmentation) on the laser resolve in several months.
 
What Type Of Anaesthesia Do I Need?
1. Local Anaesthesia
Usually you will need local anaesthesia for laser skin re-surfacing treatment.

2. Topical Anaesthesia
Some patients will need topical anaesthesia only.
Topical anaesthetic cream applied under occlusion 1 – 2 hours prior to the laser re-surfacing treatment may provide pain relief during the treatment (no injection is needed).

Instructions for skin care after Laser Skin Re-surfacing
You have been treated with carbon dioxide laser skin resurfacing. The treated skin is very delicate and should be treated with care.
 
Care of the Treated Skin
Keep the dressing on the treated skin dry for 24 hours following the laser skin re-surfacing treatment.
Remove the dressing 24 hours later:
- For test patch only: you can do your own cleansing and change the dressing at home.
- You may be asked to come back to the Clinic the next day to change your wound dressing.

If the wound dressing is stuck to the wound, soak the dressing in saline solution to loosen it. DO NOT forcibly tear away the dressing.

Clean the wound with cotton balls soaked with the prescribed cleansing solution. Apply gentle pressure and clean the laser wound and the edges of the laser wound thoroughly.

Remove all crusts and scabs by soaking them with the cleaning solution.
After cleansing the laser wound, dry the wound with sterile gauze.
Apply the antibiotic ointment prescribed to you with cotton applicators.
Cover the wound with non-adherent dressing provided. Secure the dressing with tape.
Apply antibiotic ointment to the treated area 1 or 2 more times (as instructed by your dermatologist) daily for 7 days or until the skin surface is completely healed.

You may experience some discomfort and pain immediately after the laser re-surfacing treatment. For adults take two tablets of paracetamol every six hours for pain  (make sure you are not allergic to it).

If swelling occurs on the treated skin apply an ice pack wrapped in a soft cloth over the wound dressing.
 
Precautions to take following your Laser Skin Re-surfacing treatment
- Avoid direct exposure to sunlight.
- DO NOT rub, scratch or pick at the treated skin.
- Avoid swimming and contact sport before the laser wound heal.
- If the laser treated skin shows sign of infection (e.g. presence of pain, redness, swelling or pus), notify your dermatologist.

What to expect after Laser Skin Re-surfacing treatment of my “Wrinkles”?
- Wrinkles are removed by destroying and removing the top layer of skin.
- When the skin laser wound heals, it becomes tightened and the wrinkle lines disappear or become less prominent.
 
What are the side effects and possible complications of Laser Skin Re-surfacing treatment?
Pain : You may feel mild pain during the laser skin re-surfacing procedure.

Laser Wound Healing:  Laser treatment cause a superficial burn on the surface of the skin which takes several days to heal. This is associated with some skin swelling, oozing and crusting on the treated skin.
It usually takes 4 – 10 days for the skin to heal.

Erythema (Redness):  Redness is usual and should not be regarded as a complication of laser treatment.
It typically lasts 2-3 months and can be camouflaged with cosmetics.

Hyperpigmentation ( Increased Pigmentation):  Hyperpigmentation following laser treatment is most often in patients with dark skin colour tones but it can occur in patients with light colour skin tone.
Pigmentation may be minimized by applying a bleaching cream prescribed by your dermatologist.

Milia and acne may occur, especially if occlusive ointments are used after laser treatment.

Herpes Simplex Infections:  Herpes simplex infections can occur in patients who had a past history of cold sores. You should report any sign of herpes simplex infections (presenting as blisters and erosions) to your dermatologist immediately.

Scarring:  The risk of scarring may be increased in patients who have recently been treated with oral retinoids (e.g roaccutane). It may occur in those who develop secondary bacterial infection after laser treatment.

Secondary bacterial infection may occur if the laser wound is not properly cleansed and dressed.
Consult your dermatologist immediately if there is any sign of scarring or bacterial infection.
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9.  COMMON DISESASES OF THE NAIL
 
Nail disorders can occur in a number of diseases; nail disorders may occur alone or associated with rashes. Common diseases of the nail include:

1 Nail infections by bacteria, fungus, yeast and virus.
2 Paronychia – an infection of the nail fold
3 Nail disorder due to skin diseases – e.g. psoriasis
4 Nail injury
 

1 Nail Plate Infection
The commonest nail infection is fungal nail infection.  Fungal nail infection can affect the finger and toe nails.
The infection reaches the nail plate from the free margin and sides of the nail.  The nail plate may become brittle, thickened or completely destroyed.

Fungal nail infection can be confirmed by laboratory microscopic examination of the clippings of the nail.

Oral antifungal tablets, or antifungal lotion may be prescribed by your doctor for treatment. Treatment may last from 2 to 12 months depending on the type of infection and the oral antifungal tablets prescribed.  However, the nail may take as long as a few months to return to near normal appearance even after the treatment has been stopped.

Another common nail disorder is caused by viral wart infection of the nail fold and nail bed.  The condition is called periungual viral warts.  This condition is best treated by laser surgery.
 
2 Paronychia
Paronychia is an inflammation of the nail folds.  Nail fold damage usually results from injury to the proximal nail fold.  Cause of injury include habit biting and constant wet work.  People whose hands are exposed to water most of the time, e.g . housewives, canteen operators, cooks are more prone to develop paronychia.

Secondary infection by bacteria or fungus will cause painful swelling of the nail fold.  If the infection had been there for a long time, the nail plate becomes deformed.

Treatment of paronychia include draining pus in the infected nail fold and oral and antibiotics.  Topical antifungal and antiseptic lotions may be used to treat paronychia.  Patients with paronychia must avoid prolonged wet-work and injury to the hands.   Wearing of impervious gloves during wet work helps to prevent paronychia.
 
3 Skin diseases affecting nails
Psoriasis: : Nail changes in psoriasis are very varied.  They may appear as pits on the nail plate.  The nail plate may be separated from the nail bed (onycholysis).  The nail may lose its normal lustre and appear discoloured.  Gross thickening of the nail is another feature of psoriasis. Typical psoriasis rash would often be present on the fingers, toes and elsewhere on the body.
 
4 Nail injury
The nail can be damaged by nail-biting, habit-tic e.g. scratching the nail folds, bad manicuring or industrial accident.  Damaged nails may appear ridged or cracked or broken.

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10.  NICKEL ALLERGY
Who gets nickel allergy?
Nickel sensitivity is common, especially in women. Anyone can become allergic to nickel, but most cases begin during teenage when girls in particular start to wear cheap metal jewellery. Ear piercing often starts up a nickel allergy which is why it’s more common in women than in men. As more men have their ears pierced, the number of men with nickel allergy is increasing rapidly.

It’s possible, but much less common to become allergic to nickel later on in life. People who have been in contact with nickel for many years can become allergic to it for no reason - this can cause problems if your work involves handling nickel. Babies and children are rarely allergic to nickel.

People with atopic eczema are no more likely to develop nickel allergy than others with normal skin. But if you have sore broken skin and you’re allergic to nickel, you are more likely to develop a rash whenever you touch anything made of it.
 
What causes nickel allergy?
We don’t know why some people become allergic to nickel when others don’t. But, those with certain jobs are more likely to become sensitive to nickel – these include hairdressing, nursing, catering, cash handling, and those handling metals.
 
What does nickel allergy look like?
Many people sometimes notice a red, itchy rash under a jean stud, zip or watch strap buckle which can be due to irritation and sweat. Often this rash, called “jewellery dermatitis”, is the first sign of nickel allergy.

Nickel allergy makes the skin red and itchy at first - later on tiny water blisters can appear, making the skin moist and oozy. The skin may then peel off. This rash can start in one place or in a number of places on the body at the same time. If the condition carries on for a long time the skin will dry out and become red, scaly and cracked. Any part of the body can develop an allergic rash to nickel – hands, wrists, ears, and stomach are most often affected.

Normally the rash appears wherever nickel is in close contact with the skin. But it is possible for the rash to spread so that later on even areas which haven’t come into contact with the metal become red and itchy, although the rash is usually worse where the skin is in contact with nickel. If you handle anything made of nickel, then traces of metal may remain on the fingertips and cause a rash elsewhere, such as on the eyelids or neck, if these are touched later.

Once you have developed an allergic rash due to nickel on a particular part of the body, it’s possible for the rash to spring up again on that site whenever you come into contact with nickel, even at a different place on your body. So, you could touch nickel with your fingers, and get a rash on your ear lobes as well!

Soon after becoming allergic to nickel, if you avoid any contact with it, the rash will clear and leave your skin looking just as before. But if the rash remains for a long time, because you didn’t realise it was due to nickel, it can become very difficult to clear up, even when you no longer are in contact with the metal.

If the hands become generally affected so that a rash covers them, this can be especially difficult to clear – this is a particular problem for those who do a lot of housework, and those whose jobs involve their hands being frequently wet. Once the hands have become affected it’s really important to protect them until the skin is properly healed,otherwise they will remain sore for a long time.

Most people realise they’re allergic to nickel because of where the rash is, for example under earrings. But if your rash is in an unusual place or really bad, the cause may not be clear. In this case your GP might refer you to a dermatologist who may carry out patch tests to see if you’re allergic to nickel.
 
Can an allergic rash become infected?
Yes – if the skin becomes moist then it can become infected with bacteria. The same is true if the skin becomes broken and raw, perhaps because of scratching – the hands are especially likely to become infected. If the skin becomes crusted and yellow, weeps, or smells odd, then it is probably infected, and you should see your doctor to get treatment – the rash will not improve until you do so.
 
What things contain nickel?
Almost anything made from metal contains nickel, especially if it’s silver coloured. Some every day items which contain nickel are: coins, jewellery, metal ornaments, scissors, pins, needles, thimble, press studs, zips, paperclips, metal wool scouring pads, cigarette lighters, filing cabinets, pens, metal typewriters, handles, taps, keys, keyrings, saucepans (stainless steel) kitchen utensils, cutlery.

As you can see it’s almost impossible to avoid nickel at home or work. But luckily, most nickel-sensitive people find a rash only comes up if they are in contact with nickel for a long time or when their skin is wet or sweaty.
 
Which parts of the body are most often affected?
Any part of the body can develop a rash if something made from nickel comes into close contact with the skin. Common places to be affected are given below.
- scalp  hairgrips, metal  hairbrush, curlers
- face  curlers, hairpins, jewellery, coins
- eyelids  some eyeshadow, metal on fingertips, make-up  brushes, eyelash curlers
- nose  spectacle frames
- lips  pins held in mouth, metal lipstick cases, pens, pencil ends
- ears  earrings, spectacle frames, pens
- neck  necklaces, clasps, zips, perfume sprays
- chest  brooches, medallions, chains
- breasts  wire support in bras, necklaces
- back  clip & strap adjusters on bras, zips
- stomach press studs (especially jeans), clothes fastenings
- arms  bracelets
- wrists  watches (back, strap buckle), bracelets, metal scent bottles
- hands  coins, umbrellas, metal trim on handbags & purses, handles, pram frames, taps,
- cutlery
- fingers  rings, thimbles, scissors, pins & needles, coins, pens, typewriter keys
- thighs  coins in pockets, metal chairs, metal clasps on suspender belts
- feet  shoe buckles, metal studs
 
Will I always be allergic to nickel?
Once you become sensitive to nickel you are likely to remain so for life. But not everything containing nickel will necessarily bring out a rash every time. If your skin is raw or broken, nickel can easily pass through the surface, and you are more likely to get a rash – the same is true if your skin is damaged by being wet a lot. If you are sweaty and come into contact with nickel, you are more likely to get a rash – for example a red itchy patch may come up underneath your watch when you’re hot, but not when you’re cold.

If something containing nickel is pressed very close to your skin, or rub against it, you are also more likely to develop a rash – metal studs often found on the tops of jeans and canvas trousers are more likely to cause a reddened patch if the trousers are tight fitting!

Some  women find they are more sensitive to nickel on certain days of their menstrual cycle, but this is not always the case.
 
Can nickel allergy be treated?
1) There aren’t any medicines you can take to stop you being allergic to nickel.  The main way to prevent a rash starting once you’re sensitive to nickel is to avoid coming into prolonged contact with anything made of it.  This is very hard when so many things have nickel in them, but you must aim for this.

2) Look closely at everything at home and at work and decide whether it is likely to be made of nickel. Anything made of wood, plastic, glass, paper, or fabric is safe, but check there isn’t a metal trim on these things.

3) For anything made of metal, try to find out whether it contains nickel – if you can’t then assume it contains nickel, and avoid touching it.

4) If something made of nickel is coated with paint, nail polish, lacquer or varnish, this will prevent your skin coming into direct contact with the metal. Although everything can’t be painted in this way, it can sometimes be useful. For example a bra fastener or press stud can easily be painted to protect your skin. But remember, this only works as long as the coating is complete – if it chips or flakes off, nickel will touch your skin. Some metal objects can also be covered with masking tape.

5) Some metal items can be backed with material so that they can be worn. Some people wear a sweat band under their watch if it’s made of metal. Tucking a shirt into jeans so the metal stud doesn’t touch your skin is often sufficient, but if you find a rash appearing whenever you’re hot and sweaty then coat the stud with lacquer or cover it with material as well.

6) Keep money in a bag, purse or wallet, rather than loose in your trouser pocket.

7) Jewellery can be covered with clear nail varnish to protect your skin but this is difficult to do and may spoil it – plastic jewellery won’t cause you any problems! Watches made only from plastic, or with plastic material watch straps, are available, or else wear a fob watch instead.

8) Wear cotton gloves if you need to handle anything made of nickel at home or work and rubber or PVC gloves with cotton liners for any wet work.

9) If your skin becomes damaged after being in contact with nickel, look after it carefully until it is fully healed. Use a moisturiser frequently to stop the skin becoming dry and cracked, and watch out for signs of infection.

10) A mild steroid cream or ointment, such as 1% hydrocortisone cream, may be prescribed by your doctor to clear up the rash and reduce itching. But only use a steroid cream or ointment for a few days until the rash clears.

11) Remember – even when the rash goes away you are still allergic to nickel, so all contact with it still needs to be avoided.
 
I’m allergic to Nickel – can I wear gold jewellery?
If you are allergic to nickel you are unlikely to be allergic to gold too. But, pure gold is not used to make gold jewellery because it’s not hard enough, so other metals have to be mixed with gold to make it stronger and more easily worked. 18– and 24- carat gold doesn’t contain nickel, so you can safely wear jewellery made from either.   9– carat gold can contain nickel so this should be avoided. Unfortunately, most jewellery is made of 9-carat gold, so be careful!

Gold-plated jewellery and rolled gold should not be worn either. Gold plating is usually thin and wears off quickly, and nickel then comes to the surface. Foreign gold is made up of a different mixture of metals and so this type of gold should also be avoided. White gold can also contain nickel.

Sterling silver doesn’t contain nickel so jewellery made from these metals can be safely worn. Stainless steel does contain nickel, but if it’s good quality it can be worn as the nickel is tightly bound to other metals and won’t be released.
 
Can I stop my child becoming allergic to nickel?
There isn’t much you can do to stop anyone becoming allergic to nickel, because everyone comes into contact with it every day. But, ear piercing often starts off a nickel allergy, so if anyone decides to have their ears pierced, make sure the studs that are put in as the ears are pierced are either sterling silver, 18-carat gold or good quality stainless steel. When the holes have healed wear good quality gold earrings.

Can a special diet help my nickel allergy?
Studies abroad have found that some people with severe hand eczema, thought to be due to nickel allergy, have improved following a nickel-free diet. Nickel can be released into food if anything acidic  (rhubarb, apples, citrus fruit) is cooked in a stainless steel saucepan. Canned foods also contain nickel. Many foods, such as leafy green vegetables, naturally contain nickel, which makes this diet a difficult one to follow.

More research needs to be done on this subject before we can be sure whether hand eczema really is helped by this diet. If you are considering modifying your diet to try to improve your skin, always consult your doctor first.

Conclusions
Once you have become sensitive to nickel you are likely to stay like that for life. But, many people find that they are not so sensitive as time passes. If you can’t handle anything containing nickel now, even for a very short time, you may become more tolerant to the metal in future, when perhaps you will only need to avoid cheap metal jewellery.
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11.  WHAT IS PHOTOTHERAPY?

Phototherapy is the use of light in the treatment of a disease. It was noted in ancient times that psoriasis often improves with exposure to the sun. The sun’s ray consists mainly of visible light, ultraviolet “A” and ultraviolet “B” (UVA and UVB). In the treatment of psoriasis, two main types of phototherapy are used, UVB therapy and oral photochemotherapy called PUVA (Psoralen + UVA).

UVB, which has a shorter wavelength than UVA, is used more often than PUVA. It is used without the ingestion of drugs.

PUVA involves the ingestion of psoralen, a photoactive medication (furocoumarin) which makes the skin much more sensitive to UVA. Without psoralen, UVA is not active against psoriasis.
 

UVB Therapy
How does UVB therapy work?

Its mechanism of action is not clearly understood but is probably via the alteration of activity in the skin cells by electromagnetic energy. The effect on the body’s own defence system may also play a role.

Is ultraviolet B (UVB) therapy effective in psoriasis?
Yes, it is safe and effective treatment. UVB therapy helps most patients clear their psoriasis. About 20 to 30 treatments are required to achieve clearance when used with creams like tar or dithranol. More extensive psoriasis may require more prolonged treatment. Such clearance may last several months. Very severe psoriasis may not respond completely to UVB.
 
How do you receive UVB phototherapy?
The  treatment is prescribed by your doctor. Special light tubes emitting mainly UVB are used. UVB may be used with tar (called a modified Goekerman regimen), or with dithranol ( modified Ingram regimen) or with emollients ( an agent that moisturizes your skin).
 
-Phototherapy procedure:
A tar bath is recommended in the morning before the UVB therapy. This will hydrate the skin. Emollients are applied before receiving UVB.

Protection of the eyes during treatment is important as direct exposure to  the eyes can cause damage. The amount of UVB delivered to the body is gradually increased. Treatment may be given daily or a few days a week.
 
What are the side effects of UVB?
The immediate effect is sunburn. After many years of continuous UVB treatment, the possible side effects include skin cancers and ageing of the skin. Short term therapy does not increase the risk of skin cancers. Skin cancers can be easily removed in the early stages.
 
PUVA
What is PUVA and how does it work?
In PUVA, the medication, psoralen, makes the skin much more sensitive to long-wave ultraviolet light (UVA). The drug enables UVA to slow down cell division in the skin, helping to clear psoriasis.
 
Is PUVA therapy effective in psoriasis?
Certainly.  PUVA is usually recommended for patients who do not respond to UVB or to creams. About 70% to 90% of patients clear with PUVA. The number of treatments required is about 14 to 24, or more if the condition is extensive. This clearance with PUVA lasts from a few weeks to a year or more.
 
How do you use PUVA?
The patient takes psoralen by mouth and 2 hours later, receives UVA light. Treatment is given 3-4 times per week. Once the skin lesions are cleared, periodic treatment (once a week) may be continued to maintain clearance.

PUVA therapy must be carried out under medical supervision. A special cabinet is used to deliver the  UVA and the skin’s reaction to the light is monitored carefully. The amount of UVA exposure is gradually increased until clearance is achieved.
 
What are the side effects of PUVA?
Excessive PUVA may cause a deeper sunburn as UVA penetrates deeper into the skin than UVB. The patient must protect his skin from the sun on treatment days. Long term consequences of UVB include skin cancer and ageing of the skin. Skin cancers can be easily removed in the early stages.

PUVA gives a deep tan which is cosmetically pleasing. If you are unwell during the treatment period, inform your doctor.
 
What are combination treatments?
Both UVA and UVB may be used in combination with other medications like retinoid, eg. Etretinate (Tigason – a form of Vitamin A) or Methotrexate. Combination treatments increase effectiveness in clearing psoriasis.

Re-PUVA is the combination of retinoid and PUVA. This is very effective for the treatment of generalized and severe, plaque psoriasis. It is generally recommended for those who fail to respond to UVB and PUVA. Retinoid (Tigason) enhances the effect of PUVA. In Re-PUVA, the number of PUVA treatments and the total UVA dosage is reduced significantly. Tigason is usually given 7 to 14 days starting PUVA.
 

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 12.  PSORIASIS THE FACTS
How do you know if you have psoriasis?
Psoriasis usually presents with red scaly patches on the scalp, body and limbs.  The scaly patches on the scalp are usually thicker and more extensive than ordinary dandruff.  Common sites of the body affected are the elbows, the knees and the back.
 
What is psoriasis?
Psoriasis is an inflammatory skin disease characterized by an increased rate of skin cell turnover resulting in thick scales appearing on the skin. The affected skin becomes dry and unsightly.  Itching is often experienced in our hot and humid climate.

As part of our skin, nails also show changes like “pitting” of their surface in up to half of people with psoriasis.  Joint pains and swelling are associated in 5% to as much as 40% in more extensive psoriasis.
 
Why does psoriasis happen?
The cause of psoriasis is unknown.  Studies point to a genetic predisposition, although complex interaction with environmental factors is necessary to trigger off the appearance of psoriasis.  Once psoriasis starts, there will be periods or remission alternating with periods of active psoriasis.
 
What makes Psoriasis worse?
Physical and emotional stress are well known to aggravate psoriasis.  Throat infections or the flu may trigger off aggravation of disease.  Some drugs, e.g. steroid hormones and certain antihypertensives may provoke the appearance of psoriasis.
 
What’s the natural history of Psoriasis?
Psoriasis usually starts in the 20’s but has been described at birth and in  old age.  Like diabetes and other chronic diseases, psoriasis has a delayed onset and seldom remits permanently.  However, unlike other chronic illnesses, it rarely shortens life expectancy.
 
What treatments are available for psoriasis?
Topical Creams / Ointments
Most people with psoriasis have mild disease and get considerable relief with moisturizing creams/ointments. Anti-psoriatic medicaments containing coal tar, anthralin and vitamin D3 are effective against psoriasis.  Mild steroid creams are usually used over the face, hairline and groins.

Phototherapy
Psoriasis responds to ultraviolet light treatment.  Ultraviolet light, either UVB or UVA have been found to be effective in clearing psoriasis if used in gradually increasing doses over a period of one to several months.  UVA is usually given with tablets called psoralens to enhance the effect of phototherapy (PUVA).

Oral Drugs
Your dermatologist may prescribe oral medications when psoriasis does not respond to topicals and phototherapy.  Examples of such drugs are methotrexate, etretinate and sulphasalazine.  Unfortunately, these drugs cause side-effects.  Patients who are taking such drugs will require regular blood tests to detect side-effects eg. liver damage, bone marrow damage, etc.

What can I do for myself if I have psoriasis?
1  Learn to cope with stress.  In this fast-paced world of ours, we must all know our limits and be pro-active in taking on only as much stress as we can handle.

2 Avoid falling ill with throat infections.  Simple measures like avoiding crowded places, adequate hydration and rest are commonsense measures you can take.

3 See your physician early when you fall ill with sore throats and the flu.  This may prevent a relapse.

4 Avoid situations which make psoriatic skin itch or become sore.  Simply putting on gloves when doing manual work or avoiding heat and a humid environment to pre-empt itching helps.

5 Take time to apply the medication given by your doctor.  Regular compliance with the treatment schedule will avoid expensive inpatient care.

6 Follow your doctor’s advice on oral medications and ultraviolet light treatment (phototherapy).
Look out for potential adverse reactions and complications of treatment.
 
FICTION
Is Psoriasis contagious?
No

 
Will I pass my psoriasis on to my children?
Not necessarily.  Psoriasis is a hereditary disorder but only about 10% of people with psoriasis have a family member affected by psoriasis.  The causation of psoriasis is multifactorial and inherited genes do not always express disease without the appropriate environmental triggers.
 
Is Psoriasis a rare skin disease? No, psoriasis is not an uncommon skin disease.  It is estimated that 1 – 2 % of the population have psoriasis.
 
Are there any foods to avoid, or supplements to help my psoriasis?
No.  But it is wise to consume a nutritious, balanced diet containing more green vegetables and less meats.  Alcohol abuse is best avoided because of its associated malnutrition and liver disease.

Is there a quick cure for Psoriasis?
No, but your doctor should be able to help you control your psoriasis. Oral steroid treatment is best avoided because it helps to clear psoriasis fast, it invariably results in a quick and severe rebound of psoriasis.  But remember, psoriasis can be controlled with appropriate treatment.
 
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13.  SCABIES
What is scabies?
Scabies is a very itchy skin problem, that commonly affects the hands, wrists and fingers. It can affect the elbows, armpits, nipples and buttocks. In males, the genitals are often affected. The itch is worse at night.

How do you get scabies?
This condition is caused by the scabies mite, which is a small parasite that burrows into the skin of infected patients. It is usually transmitted by close person-to-person contact, and by sharing the same bed or clothings, especially among children and people with poor hygiene. The whole family can be affected as scabies is quite infectious.

How is scabies treated?
The mite can be killed rapidly by the use of an effective medication eg. Benzyl benzoate emulsion or malathion or permethrin. Attention should be paid to the specific instruction on how the medication should be applied.

Why does it itch even after treatment?
You may still itch for some days to weeks,after correct treatment. This is because of the development of a hypersensitive reaction of your body to the dead mite. Your doctor would prescribe anti-histamine tablets and steroid creams to stop the itch. DO NOT APPLY the anti-scabies medication repeatedly, and excessively unless advised by your doctor, as you can develop a more severe dermatitis.

What are the medication to treat Scabies?
These include benzyl benzoate emulsion (for 3 days), malathion (Derbac) (1 day), crotamiton (Eurax) lotion or cream (5 days). For infants and young children, it is preferable to use crotamiton, or permethrin.

How should the medication agent be applied ?
First Evening :
Immediately after a shower, apply the lotion to the whole body from neck downwards, even to the unaffected areas. Do not forget the soles, armpits, genitals and other body folds. Do not apply on the face. Do not wash away the lotion until the next evening. Re-apply the lotion on the hands each time you wash them.

Second and Third Evenings:
Repeat the above treatment in the same manner. To eradicate any mites in the family, all warm clothings should be washed in hot water and then sunned. Bed linen, pillow case, pillows, mattresses should be dusted and sunned.

Is it necessary to treat family members?
Any family member with itch, or those with close body contact, or share the same bed or linen with the patient, whether affected or not, should have the same treatment at the same time. Your doctor would usually supply sufficient medicine for all of them.
 

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14.  SCLEROTHERAPY

What is Sclerotherapy for?
Sclerotherapy is for superficial leg veins which are dilated, small surface vessels, also called spider veins, telangiectasias, star burst blemishes. They are either pink, red or purple and can occur on ankles, lower legs or thighs as lines or clusters.
 
What is the cause of these vessels?
The cause is unknown but these vessels are more common in females. A familial predisposition, pregnancy, hormones, obesity, trauma, long periods of standing and sitting have been implicated. Hereditary tendency is probably one of the most significant factors.
 
What is Sclerotherapy?
Sclerotherapy is the injection of a chemical agent into the cavity of a blood vessel. These agents cause inflammation of the blood vessel walls resulting in the occlusion of the blood vessels.
 
Can spider veins be prevented?
Exercise, weight loss and support stockings may help limit the number of new vessels, but will not prevent a predisposed female from developing any at all.
 
What can I expect during injection?
A very fine needle is used during the injection. You may experience a mild pin prick sensation which feels like a small mosquito bite. 15-30 seconds of mild discomfort or burning at the site of injection may be experienced. Some patients will experience a local muscle cramp, lasting a few minutes.

The injected veins completely disappear for a few seconds as blood is pushed out by the solution, but when blood flow returns they reappear. Since many of the vessels interconnect, one injection may eradicate several dozens vessels at one time.
 
Are there any special instructions before the procedure?
Do not take aspirin for a one week prior to treatment. Be sure to eat before treatment to avoid becoming lightheaded during the procedure.
 
How soon will the vessels disappear?

The vessels will either lighten or completely disappear. The fading occurs over the first month but may take as long as 2-3 months for some vessels. The treatment does not prevent new vessels from appearing. It only treats vessels that have been injected.

Are there certain vessels which tend to recur more commonly?

Yes, the type of vessels which occur in a mat of very fine radiating vessels.
 
How often can I be treated?
The same area should not be injected for six to eight weeks to allow for complete healing. Different areas may be treated sooner.
 
How many times does it have to be done?
This varies with the number of areas that have to be injected as well as the response to each injection. It usually takes one to three injections to obliterate any vessels and 10-20 vessels may be treated in any one session.
 
What are the post treatment instructions?
Pressure bandages will be placed on the treated areas and should remain until the following morning. Contact sports and strenuous activities should be avoided for the first 48 hours.
 
What kind of side effects may occur?
There are no serious effects with the procedure, however, temporary side effects may occur.

1. Bruising and Swelling: Local swelling and bruising may occur at the site of needle penetration and along the vessel. Swelling resolves within 24 hours, bruising fades slowly within several weeks.

2. Tenderness:  Tenderness which may occur at injection site and along the vessel persists for 1-2 weeks.

3. Urticaria and itching:  Immediately following injection, a hive-like reaction with itching may develop at the site, usually subsiding within 30 minutes.

4. Ulceration:  A small ulcer may develop at the injection site which will crust and heal in 1 – 2 weeks.

5. Pigmentation Changes:  Spider veins often rupture during the treatment process leaving linear brown streaks or small brown spots which clear within 6 months.

6. Cramping:  Following injection of the ankle, cramping may occur. Moving the toes and massage will alleviate the discomfort.

7. Telangiectatic Mats:  A network of very small veins may develop near the injection site during the course of treatment and will clear spontaneously or after repeated treatment.
 
- Walk for 30 minutes immediately following the injections.
- If possible, do not drive home yourself. If you have to drive, do not keep the legs and feet  still.
- Maintain normal daytime activities.
- Walk at least an hour a day- the longer the better.
- No hot baths for two weeks.
- Avoid standing still. If you must stay in one place, move feet and toes frequently.
- If the legs become painful after the injection, walk.
- Do not remove the bandages (stockings) for ……….. days.
- Avoid strenuous, physical activity (aerobics) for the first 48-72 hours.
 

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 15.  SHINGLES

Herpes zoster, or shingles is caused by the same virus that causes chicken pox, called varicella zoster virus. The virus remains in a dormant state in certain nerve cells of the body from months to many years, and then reactivates, causing shingles.

This infection is due to a temporary decrease in the body’s resistance, allowing the virus to start multiplying and to move along nerve fibres towards the skin. It occurs often in elderly people because the immune response is believed to be weaker in older people. Trauma or possibly stress may also contribute to shingles attack.

Another immune depressed group includes some people with cancer, such as leukemia or lymphoma, or who have undergone chemotherapy or radiation therapy for cancer; people who have organ transplants and are taking drugs to ward off transplant rejection, and people with disease that affect the immunological system, such as AIDS.

What are the symptoms of shingles?
The first main symptom is a burning pain or tingling and extreme sensitivity in oral area of the skin. This maybe present for one to three days before a red rash occurs. A group of blisters appears on a red base which looks like chicken pox. The blisterslast for two to three weeks, during which time pus may appear and then crust over and begin to disappear. The pain may last longer. The blisters appear on one side of the body.

How severe is the pain?
The pain is severe enough for the doctor to prescribe pain killers. A long- lasting painful complication of shingles called post-herpetic neuralgia occurs in some older patients, and some doctors believe that aggressive use of pain relievers for the usual shingles pain may help prevent later development of this complication.

Where do shingles appear on the body?
Most commonly, blisters will appear on one side of body, the buttocks and genitalia, or the face because the nerves may be affected. If the blisters involve the eye region, permanent eye damage can result and your doctor will refer you immediately to an eye specialist. It occurs on one side of the body, and is not caused by a “snake”. It does not circle the body. Do not burn the skin as scars will form.

What are the complications of shingles?
Post-herpetic neuralgia, a condition in which either constant or episodic pain persists for a long time after the skin has healed.

Infection of the blisters by bacteria can also cause delayed healing of the skin. Antibiotic treatment is needed.

Another complication is high fever and spread of the disease all over the body, in ill persons.

How do I know I have shingles?
This is by the appearance of the blisters and pain on one side of the body. To be certain, your doctor may do a special test, Tzanck test, in which fluid from a blister is put on a slide, and examined under the microscope for “giant cells”.
 
Is shingles contagious?
Shingles is much less contagious than chicken pox. People with shingles can spread the virus if blisters are broken and a susceptible person (someone who has never had chicken pox or who is already ill) is close by. The main people at risk are babies or those who already are ill, such as cancer or AIDS patients.

Is there much scarring?
Scarring occurs in those who have more severe infections, elderly people, those whose blisters become infected, those who used toxic home remedies, or those who have used chemicals to treat themselves.

How is shingles treated?
Shingles clears on its own in a few weeks and seldom recurs. Treatment consists of pain killers, as well as cool compresses to help in drying the blisters.

The antiviral drug, acyclovir, is usually given for severe cases of shingles, those with eye involvement or patients who are very ill.

Acyclovir may occasionally cause headache, some stomach upset and giddiness. The earlier it is taken after the disease begins, the better. Early cases of shingles thus can sometimes be stopped from progressing further. If it is taken after 3 days, it is less effective, but may lessen pain. The drug does not seem to prevent post-herpetic neuralgia, but it may prevent a widespread of the disease.

Post-herpetic neuralgia can be treated with high doses of tranquilizers at night and during the day by frequent use of pain killers. See your doctor early for shingles.
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16.  SKIN DAY TREATMENT SERVICE (SDTS)

The Skin Day Treatment Service (SDTS) at the National Skin Centre offers a range of treatments to assist patients with the practical outpatient management of their skin problems. Patients with extensive skin diseases who need instructive and specialized nursing care on cream / lotion applications, medicated baths and scalp treatment will benefit from attending our SDTS.

This service is provided for doctors who have little time or lack the facilities to instruct patients on skin treatment.
 

Skin treatment procedures available at our SDTS include:
1. Scalp treatment
This is particularly suitable for patients who have thick scales or lesions on their scalp and who need intensive treatment to remove the scales. It is also suitable for patients requiring application of lotions / ointments onto their scalp lesions. Patients with psoriasis, seborrhoeic dermatitis and atopic dermatitis with scalp involvement will benefit from this treatment.

2. Medicated baths
Skin disorders with generalized lesions that are inflammed or scaly will require medicated baths to relieve itch and irritation, reduce inflammation, and remove scales. Thick scales on the body cause discomfort and itch and also impair penetration of creams applied onto the skin. Some patients do not have a long bath at home, or do not know how to prepare the medicated baths properly. Such treatment at our SDTS will ensure that these patients receive the best medical care.

Our special baths include
- emulsifying ointment bath – this is particularly therapeutic for dry and scaly dermatoses e.g. eczemas and generalized exfoliative dermatitis.

- potassium permanganate bath – for weepy skin lesions eg acute eczema.

- oatmeal bath – for patients with extensive inflammed skin, to relieve itch and irritation, e.g erythrodermic psoriasis, or erythroderma from any eczema.

- Coal tar bath – this is therapeutic for psoriasis and occasionally for eczema.

Patients requiring medicated baths include those with:
- erythroderma
- extensive psoriasis
- extensive atopic dermatitis (especially in children).
- extensive seborrhoeic dermatitis
- congenital ichthyosiform erythroderma
 
3. Application of creams
After the appropriate baths, our nursing staff will help patients to apply creams / ointments properly as prescribed by their doctors. At the same time our nurses will instruct the patients or their parents on the correct procedures.
 
Charges* for our SDTS procedures are:
1. Treatment with: Creams/ointments/lotions : $31 / treatment
2. Medicated bath   : $15 / treatment
3. Shower    : $  5 / treatment
4. Scalp treatment   : $26 / treatment
5. Medicated bath + opical treatment  : $46 / treatment
6. Scalp treatment + medicated bath + topical treatment   : $67 / treatment

*    Charges exclude costs of medication
 
All treatments are done by our dedicated and experienced nurses. During treatment, our nurses will, at the same time, explain and instruct patients on the correct procedures in skin treatment, enabling them to learn to cope with their skin problems.
 
How to refer patients:
You can refer your patients to our SDTS by filling up the treatment form. Please tick the relevant services required. Appointments may be made by calling our clerk at 3508551.

Persons referred for treatment at SDTS shall remain the patients of the referring doctor. The referring doctor will be solely responsible for the treatment prescribed. Your patient will not be reviewed by any NSC doctor unless requested. Patients will be referred to their respective doctors in the event of problems arising from the treatment or worsening of their condition.

Please call 3508551 for more copies of the treatment form.
 

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17.  URTICARIA
What is urticaria (Hives)?
Urticaria or hives as it is commonly called is an itchy rash consisting of localized swellings of the skin that usually last for a few hours before fading away. When urticaria develops around loose tissues of the eyes or lips, the affected area may swell excessively. Although frightening in appearance, the swelling (called angio-oedema) goes away in 12 to 24 hours with treatment.

How is urticaria produced?
Urticaria results from some changes in the small blood vessels of the skin. Such changes are brought about by the release of some substances in the body, the commonest of which is histamine. Histamine is released from cells called mast cells by either an allergic or non allergic reaction.

What causes single attacks of urticaria?
Acute urticaria which can last from a few hours to as long as a week is usually caused by drugs, specific foods or a viral infection. Sometimes no cause can be detected.

What are the foods that can cause acute and repeated attacks of urticaria?
Foods that can cause urticaria include:
- Nuts
- Eggs
- Fresh fruits (especially citrus)
- Chocolates
- Fish and shellfish
- Tomatoes
- Milk and cheese
- Spices
- Yeasts

Food additives and preservatives such as tartrazine (yellow dye) may also be responsible. Hives may appear within minutes or several hours after ingestion of the food depending on its rate of absorption.

What are the drugs that can cause urticaria?
Drugs that commonly cause urticaria include:
- Pain killers eg Aspirin, Codeine, Indomethacin
- Antibiotics eg Penicillins & Sulphonamides

However, any drug should be suspected even if it has been taken for a long time without ill effects. Drugs commonly cause acute urticaria but they may also aggravate chronic urticaria.

What else can cause urticaria?
Recurring attacks of urticaria may be caused by physical agents such as sunlight, cold, pressure and sweat. Urticaria caused by such agents is called physical urticaria. The causative agent is usually recognized by the patient.
 

Chronic urticaria
This is urticaria occurring almost daily and lasting more than two months. In the majority of patients, no cause or significant aggravating factors can be found. Physical urticaria may be present as well in some patients. Food allergy is seldom a cause of chronic persistent urticaria even though some foods may aggravate it. Infections such as candidiasis (a kind of yeast infection) may be a cause although not common. Emotional stress is known to aggravate chronic urticaria in some. Fifty per cent of cases of chronic urticaria clear in about 6 months.

How is urticaria treated?
The best treatment for urticaria is to identify and avoid the cause and any aggravating factors. While investigating the cause, anti-histamines are prescribed for symptomatic relief. Anti-histamines when given orally take about 90 minutes to relieve an already formed hive. They work best if taken on a regular basis to prevent the formation of hives. To avoid side effects like drowsiness, non-sedative anti-histamines are available. Anti-histamine creams are ineffective.

Elimination diets are not helpful unless a particular food is suspected. Skin tests are generally of no use.
 

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 18.  VIRAL WARTS

Warts are harmless skin growths caused by a virus. Warts can grow on any part of the body like on the face, along the forearms or on the fingers. Warts have a rough surface on which tiny, dark dots can often be seen. On pressure areas like the palms or the soles, they appear flat. Warts on the sole (called plantar warts) grow inward from the pressure of standing and walking and are often painful.

Warts are common and can be a nuisance. They may bleed if injured. Common warts never turn cancerous. Warts are contagious, and may spread from one part of the body to another or to other children. We don’t know why some people get warts while others don’t. There is no way to prevent warts.

Warts may disappear by themselves, especially in young children. This spontaneous disappearance is less common in older children and adults.

Warts on the genitalia are usually sexually acquired.

Treatment
There is no perfect treatment for warts. Treatment consists of destroying the outer layer of skin where the wart grows on. This can be done by surgery (including laser), electrocautery (destroying with a weak electrical current), by freezing (with liquid nitrogen) or with chemicals like salicylic acid. The treatment to be used depends on the location and size of the warts and the judgement of the dermatologist.

Sometimes new warts will form while existing ones are being destroyed. All we can do is treat the new warts when they become large enough to be seen.

No matter what treatment is used, warts occasionally fail to disappear. Warts may return weeks or even months after an apparent cure. Don’t be concerned if a wart recurs; just consult your dermatologist for further therapy. The treatment may be repeated, or a different method may be used to get rid of the warts.

Liquid Nitrogen Treatment:  Liquid nitrogen treatment (cryotherapy) is the commonest treatment method for warts. Your wart and the surrounding skin can be treated with liquid nitrogen, a very cold substance. Liquid nitrogen, when applied to the skin, usually results in blister formation similar to a burn. The wart is lifted and it will fall off when the blister dries. You may experience some pain which can easily be controlled with simple pain killers.

There is no need to cover the treated areas if the blisters are intact. However, if these blisters are very large and tense, they may be pricked with a needle sterilized in a flame. A simple dry dressing may also be applied.

Do not apply any cream or ointment of any description unless prescribed by a doctor.

At least a week must lapse between treatments, even if a blister does not form.
 

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 19.  VITILIGO

What is vitiligo?
Vitiligo is a skin disorder which presents as white spots and patches on the skin. This is due to a progressive loss of the pigment, melanin, which gives us our skin colour. The loss of pigment occurs when pigments cells (melanocytes) are destroyed and melanin cannot be produced. Vitiligo is not contagious.

Common sites affected include:
Bony surfaces - back of hands and fingers, elbows and knees.
Around body - around the eyes, mouth and nose
Orifices
Body folds - armpits and groins
Other areas - legs, wrists, nipples and genitalia

Vitiligo may also develop over an area of injury such as cut or burn. Hair within the affected patch may be white too.

What causes vitiligo?
The cause of vitiligo remains unknown. However, persons with vitiligo have a higher incidence of :
- diabetes mellitus
- thyroid disease
- and other autoimmune diseases

Can vitiligo be treated?
Yes. Several forms of treatment are available but the response to treatment varies with each person and site affected.

How can vitiligo be treated?
1. Corticosteroid creams
Potent corticosteroid creams are effective in some patients. Regular monitoring by your doctor is necessary to prevent side effects.

2. Psoralen photochemotherapy (PUVA)
PUVA is a combination treatment involving the use of a drug called PSORALEN (P) and then exposing the skin to ultraviolet A (UVA) – hence the term PUVA. Psoralen makes the skin temporarily sensitive to UVA  which forms part of natural sunlight. Psoralen can either be used in the lotion form or as tablets. When the lotion is used with subsequent exposure to UVA, the treatment is known as topical PUVA . If the tablet form is used, it is called oral PUVA.
 
Generally, topical PUVA is used to treat vitiligo affecting limited skin areas. Patients treated with PUVA must be prepared to undergo therapy for a  year or longer for maximum results. Close medical supervision is necessary. Use of psoralen lotion followed by exposure to sunlight may be risky and unreliable as the amount of UVA in sunlight varies from day to day. Artificial sources of UVA used under proper supervision are preferred.

3. Camouflage cosmetics
Some cosmetics can provide very good colour match and camouflage and are particularly useful for white patches on the face and back of the hands.

4. Sunscreens
Areas affected by vitiligo are very prone to sunburn as they are devoid of protective pigments. It is advisable for patients to use broad spectrum high protection factor sunscreens on affected areas which may be exposed to sunlight.