British Association of Dermatologists Elective Prize/Project Report

2018

Dermatology Elective at the National Skin Centre, Singapore, Summer 2018

DrNimaiVadgama

ImperialCollegeLondon

TheNationalSkinCentre,Singapore

Acknowledgements I am extremely honored and grateful to have received the British Association of Dermatologists (BAD) Winter elective prize in order to support my clinical elective, which would not have been possible otherwise. Furthermore, I would like to express my gratitude to all of the clinicians at the National Skin Centre (NSC), especially to my clinical supervisor Dr. Eugene Tan for his invaluable pedagogy and guidance during my elective (figure 5). Introduction My final year medical school elective consisted of a 5 weeks clinical placement at the National Skin Centre (NSC) in Singapore. During this time, I was able build upon my limited exposure of Dermatology that had been gained during my clinical rotation which I had enjoyed in the UK. My primary aim was to observe how Medicine is practiced abroad and to increase my exposure to Dermatology. The NSC is a tertiary hospital that is a centre of excellence in Dermatology, located in Novena, Singapore and was founded in 1988. It is a major teaching hospital and manages the burden of the country’s Dermatology caseload. Additionally, the centre has a twinned research centre in order to develop novel therapies to help further manage skin disease in a translational manner. Clinical Experience My elective was extremely varied and involved rotating in: minor surgery, outpatient specialist and general clinics and inpatient ward rounds. I was able to see a wide range of conditions in numerous clinics including: pigmentation, phototherapy, skin cancer, general, psoriasis, eczema, pigmentation and pediatric atopic dermatitis. I was also able to observe minor surgical procedures, in which I assisted, as well observed Mohs surgery. The atopic dermatitis clinic was particularly interesting and I learnt that atopic dermatitis has a significant prevalence in Singaporeans due to the increased incidence of filaggrin mutations in the ethnic Chinese population exacerbated by living in humid tropical climate which is thought to aggravate dermatitis (1,2). I was also able to assist in minor surgical procedures such as excisional biopsies of skin lesions as well as observe Mohs micrographic surgery in excising Basal Cell Carcinomas (BCC) and Squamous Cell Carcinomas (SCC). I witnessed how delicate this procedure is and appreciated the importance of using colored paints to provide orientation to the surgeon (figures 2 and 3), which is crucial during the histological examination under a microscope in order to assess whether the tumour margins are clear. The Mohs technique provides a 98% chance of a curative outcome as well as superior cosmetic result with minimal scarring (3). Dermatologists in Singapore are responsible to practice in genitourinary medicine, I was fortunate to spend a day at the DSC (Department of Sexually Transmitted Infections Control) Clinic which was very insightful, especially considering the taboo cultural perception of sexually transmitted infections in the country.

Figure2.MohsSCCCtissuesamplestobeanalysedbytheDermapathologytrainedsurgeontoseeifthetissueistumourfree

Figure1.PaintsusedinMohssurgeryinordertoidentifyskintumourborders

I was pleasantly surprised that the NSC had such a strong emphasis on teaching and mentorship. Every lunchtime there was some form of teaching including: case based discussions, lectures and discussing clinical guidelines. During my visit, I was fortunate that Professor Thomas Luger, Professor of Dermatology at the University of Münster, Germany and leading expert in the field, visited the NSC as a visiting expert. He delivered a series of lectures with a focus on novel immunotherapeutic drugs revolutionizing the treatment of pruritic conditions, immunobullous disorders, dermatitis and psoriasis (figure 3). Although these drugs have transformed the management of these conditions, he highlighted the large financial expense of these drugs as well as concerns regarding their long term safety. What I took from my experience is to always consider a wide range of dermatological differential diagnosis and perform a thorough history and examination in order to methodically follow clinically deduction in forming a correct diagnosis. This opportunity allowed me to see rare dermatological conditions including: dermatographic urticaria, idiopathic lipodermatosclerosis and cutaneous leprosy. I learnt how to perform a thorough skin examination as well as correct technique of using dermatoscopy. A key highlight of my experience was spending time assisting in the itch clinic with consultant; Dr Tey Hong Liang, who had formulated a product called Suu Balm containing menthol to alleviate the symptoms of pruritus. This product was developed by him with the help of the research scientists and is now available worldwide (figure 4). I found it particularly resourceful that the consultant had identified the issue that numerous antipruritic medications caused side effects and were ineffective in a subset of patients. He then devised a solution which was Suu Balm, a menthol-containing lotion to relieve the symptoms of pruritus. This was possible with the help of the linked research centre at the NSC and shows the power of translational research.

Figure3.ProfessorThomasLurgerdeliveringalectureonpruritus

Conclusion In conclusion, I received significant exposure to Dermatology in Singapore, specifically learning how to examine the skin thoroughly and generating appropriate differential diagnosis and managing skin diseases. This experience has further cemented my decision to pursue Dermatology as my career. References

1. Chen H, Common JE, Haines RL, Balakrishnan A, Brown SJ, Goh CS, Cordell HJ, Sandilands A, Campbell LE, Kroboth K, Irvine AD. Wide spectrum of filaggrin-null mutations in atopic dermatitis highlights differences between Singaporean Chinese and European populations. British Journal of Dermatology. 2011 Jul;165(1):106-14.

2. Chen H, Common JE, Haines RL, Balakrishnan A, Brown SJ, Goh CS, Cordell HJ, Sandilands A, Campbell LE, Kroboth K, Irvine AD. Wide spectrum of filaggrin-null mutations in atopic dermatitis highlights differences between Singaporean Chinese and European populations. British Journal of Dermatology. 2011 Jul;165(1):106-14.

3. Finley EM. The Principles of Mohs Micrographic Surgery for Cutaneous Neoplasia. The Ochsner Journal. 2003;5(2):22-33. Cheok S, Yee F, Song MJ, Leow R, Ho MS, Yew YW, Tay YK, Rebello SA, Luo N, Koh MJ. Prevalence and descriptive epidemiology of atopic dermatitis and its impact on quality of life in Singapore. The British journal of dermatology. 2018 Jan;178(1):276.

Figure4.SuubalmmenthollotiondevisedbyDrTeyHongLianginordertorelievepruritusafterobservingthelackofefficaciousagents

Figure5.DrEugeneTanandIinthegeneraloutpatientclinic