June 2015 June 2015

PHOTO QUIZ VOL 41(2) PHOTO QUIZ VOL 41(2)

Photo Quiz
1. What is the diagnosis? vicinity of lesion leads to erosion
Contributed by Dr. Soh Soon Beng, MCFP(S), Editorial Board Member
or pressure on the bulla leads to NOTICE
Fixed Drug Eruption (FDE) lateral extension of the blister).
A 50-year-old Chinese woman had presented with rashes over the face, lips and
7. Bulbous pemphigoid
right upper arm. She had been seen previously by another doctor for persistent The close temporal relationship between We would like to request for the
the ingestion of the drug and the rashes Typically occurring in older
low backache and was prescribed Arcoxia (etoricoxib). This had provided some
patient (>60 years), presenting
following past publications to
relief from pain but then she had started to notice the rashes. The rashes suggested a possible link. Typically the
rash starts as a well-defined erythematous with erythematous urticarial be contributed to our archives:
started as well defined itchy red patches which gradually became plaque like.
macule which becomes oedematous, type lesion that precede bulla
The one on the upper arm had also developed a blister. She had also noticed
forming a plaque. Bulla can develop which formation by months. Bullae tend
that the rashes tend to occur on the same sites and nowhere else and had left
may then erode (as in this patient). The to be large and tense, arising from
behind ugly discolouration.
erythema became dusky with time and surrounding normal or

1. What is the diagnosis?

after healing leaves behind a dark brown
discolouration. The lesion can be solitary
2. What are the possible differentials?
or multiple and may even be generalised.
3. What is the management plan?
The genitalia and oral mucosal can be
involved independently or together with
the skin lesions. Rashes appeared from 30
minutes to 8 hours after ingestion of the
offending agents. Re-exposure to the same
offending drugs result in the occurrence
of the rash in the same previously affected
sites (and hence appears ‘fixed’). The rash
would resolve in days to weeks after
discontinuation of the drug. However the
post inflammatory hyperpigmentation may
persist for months or years and does not
(continued on the next page) generally respond to bleaching creams like
hydroquinone.
2. What are the differentials?
FAMILY MEDICINE CLINIC AT THE UPCOMING TAMPINES TOWN HUB
These depends whether it is a solitary
Eastern Health Alliance will be launching its 2nd Family Medicine Clinic (FMC), to be located at Tampines Town Hub, operational lesion, multiple or generalised. Possible
in the second half of 2016. It aims to provide quality collaborative primary care services to residents in the East. differentials include but not limited to the
following:
1. Herpes simplex
We invite proposals from GPs to partner with us to All interested parties must attend the following briefing: (oral and genital region)
provide:
2. Bite reaction especially for
• Continuing care of chronic diseases Date : 25 July 2015 (Saturday) solitary lesion.
3. Paronychia when rash is over the
• Relevant supporting services and tests to
Time : 3.30pm nail bed region.
improve patient’s care experience
4. Erythema multiforme (look out for
Venue : Lecture Room, Training Centre
the characteristics target lesion).
• Coordination of patient’s care with CGH, other Level 1, Changi General Hospital
5. Urticaria which is an extremely
healthcare institutions and community care 2 Simei Street 3, Singapore 529889 itchy blanchable wheals of acute
providers
onset which resolve without
• Management of acute illnesses residual discolouration.
To register please e-mail your name and MCR
6. Pemphigus vulgaris which
number to Rozanna.Mustaffa@easternhealth.sg.
• Training for Family Physicians is a mucocutaneous disorder
Upon registration you will receive an information
package and application form. Closing date for characterised by the presence
of painful flaccid blister or erosion
applications is 14 August 2015.
Key Requirement on surrounding normal skin with
or without an erythematous base.
At least one doctor in the FMC should be registered as
Nikolsky’s sign is positive
a Family Physician at the point of application.
(dislodging of the epidermis by
MMed and FCFP(S) certification would be lateral finger pressure in the
advantageous.
erythematous skin. The Singapore Family
8. Steven-Johnson syndrome/ Physician (SFP)
Toxic Epidermal Necrolysis
SFP Vol 23(2)
Syndrome
This is by far the most important
April - June 1997
differential to consider •
especially when there is SFP Vol 24(4)
generalised involvement as it is October - December 1998
potentially fatal. Lesions starts as •
morbilliform or diffuse erythema. SFP Vol 26(3)
Discrete lesions coalesced July - September 2000
and enlarge as blisters begin to •
form. Sheets of the epidermis are SFP Vol 26(4)
subsequently shed. October - December 2000
•
3. What is the management SFP Vol 34(4)
plan? October - December 2008
•
The key to management is to identify and SFP Vol 35(1) Supplement
remove any offending agents causing the January - March 2009
eruptions. Patch testing is of limited use.
The diagnosis is clinical and confirmed College Mirror
by the appearance of the rashes at the
Early issues of the newsletter
previously affected sites as reported in
since January 1994
this patient. Management of the rash is
symptomatic with topical steroid and
antihistamines being commonly used.
References
To contribute,
1. Fixed drug eruption,Colour atlas and
synopsis of clinical dermatology, Thomas
please contact the
B Fitzpatrick,Richard Allen Johnson,Klauss College Secretariat at
6223 0606 or email to
Wolff,Machiel K. Polano,Dick Suurmond,
3rd edition, P586-589. information@cfps.org.sg.
2. Fixed Drug Eruptions: A Case Report
We will proceed to make
and Review of the Literature
further arrangements on the
Sarah B. Gendernalik, DO; Kenneth J.
collection details.
Galeckas, MD, Cutis 2009;84,215-219.
All kind contributions are
CM
greatly appreciated.

THE THE
♦ 10 College Mirror College Mirror 11♦