Aust. J. Derm. (1976), 17, 121
DERMATOLOGY IN PENANG, MALAYSIA* DALJIT S. NAGREHf
Penang, Malaysia SUMMARY
Dermatology in Malaysia and Penang is briefly otttlined as are the dermatological services provided from the Penang General Hospital. The skin diseases commonly seen are mentioned and tabulated. These include : eczema, photodermatitis, viral infections, contact dermatitis, bacterial and fungal infections, psoriasis, acne, disorders of pigmentation, alopecia and drug eruptions. Less common diseases referred to include : lichen amyloidosis, an interesting form of chronic folliculitis, and cutaneous tuberctdosis. This paper is based 07i patients seen during 1975. The island of Penang lies just off the northGENERAL BACKGROUND Malaysia, a federation of thirteen states, western coast of the Malay Peninsula. The occupies the greater part of the Malay Peninsula, State of Penang consists of the island and a certain off-shore islands, including Penang, and narrow stretch of land on the adjacent mainland. The State covers some 1,036 square kilometres part of Borneo. (400 square miles) and has a population of about West Malaysia, previously Malaya, contains 800,000. eleven states within the Peninsula between Often known as the ' Pearl of the Orient ', the Thailand and Singapore. East Malaysia, island of Penang has serene beauty with its comprising the two states of Sarawak and hilly terrain, tropical vegetation and attractive Sabah, is located in the north and west of beaches. Georgetown, the capital, has many Borneo. The land areas of Malaysia lie between places of interest and is a pleasant city for both the equator and seven degrees North latitude. residents and visitors. The climate is similar to The climate is equatorial with fairly high that in the rest of Malaysia with temperatures temperatures, rainfall and humidity. The which vary between SIX (70°F) and 32°C (90°F) seasons are marked more by changes in rainfall and fairly high humidity. than by variations in temperature. The population of Malaysia, approximately CLINICAL ARRANGEMENTS 12 million, is multi-racial and multi-lingual. The Penang General Hospital, situated in The three main racial groups are Malays (45%), Georgetown on the island of Penang, is one of Chinese (35%), Indians (10%), Indigenes and the largest hospitals in Malaysia. It has some others (10%). The proportions of the different 1,050 beds, out-patient services, and provides racial groups vary from state to state. Malay specialist facilities in almost every branch of is the national language. English is still widely medicine. used as are the various languages and dialects of The Department of Dermatology at the the Chinese, Indians, and other ethnic groups Penang General Hospital has existed for many throughout the country. years and provides services for the people in the State of Penang. In addition, this Department * Presented at the Annual Meeting of the Australasian provides a service for the neighbouring states, College of Dermatologists, Adelaide, May 1976. in the north-west of the Malay Peninsula, which t Department of Dermatology, Penang General Hospital, Penang, Malaysia. have a population of more than one million.
122
DAL JIT S. NAGREH
Dermatological clinics are also held at the hospitals in the State capitals of Kedah and Perlis, Alor Star and Kangar respectively. These hospitals are visited at regular intervals by the dermatologist attached to the Penang General Hospital. The patients seen in the skin clinics at the Penang General Hospital are referred from its various out-patient clinics, from district hospitals in the State of Penang and the neighbouring areas. Patients with leprosy are seen and diagnosed in the skin clinic. Afterwards they are registered and cared for at a clinic for patients with this condition. This clinic, which is attached to the Penang General Hospital, is under the control of the dermatologist. There is a separate clinic, with a venereologist in charge, for patients with venereal diseases. In 1975, 3,020 diseases were diagnosed in 2,817 patients seen in the skin clinic at the Penang General Hospital. In addition, there were 8,350 follow-up visits.
contributes to the production of keratotic and fissured lesions on the dorsal and plantar surfaces of the feet, especially as a result of repeated trauma and exposure to irritants. Eczema of the hands and feet is common and largely constitutional but often exacerbated hy the application of irritants. Secondary bacterial
MOST COMMON CONDITIONS
infection is a frequent feature of almost all types of eczema, especially when it affects the hands, feet and legs. Atopic, seborrhoeic and discoid eczema are by no means uncommon and their manifestations are much the same as in Western countries. Pityriasis alba is often more apparent in people with pigmented skins and, as with other conditions producing a loss of skin colour, can: cause great concern over the resulting
The most common skin diseases diagnosed are listed in Table 1. TABLE 1
The Common Diseases Condition Eczema . . Photodermatitis Viral infections . . Contact dermatitis Fungal infections Bacterial infections Psoriasis . . Acne Pigmentary disorders Alopecia . . Drug eruptions . .
..
No. of Cases
Percentage
999 243 230 181 184 181 131 114 99 65 45
33 1 8-0 7-7 6-0 6-1 6 0 4 3 3-8 3 3 2-2 1-5
Eczema, the commonest condition, was diagnosed in 33% of patients. The different types of eczema seen are shown in Table 2. A large proportion of the eczema seen is nonspecific and not classified. Eczematous lesions on the lower limbs are particularly common. The types of clothing and foot-wear used in the humid climate expose the legs and feet to a large variety of external factors, such as trauma, insect bites and irritants. These underlie eczematous changes on the lower limbs and similar changes on other parts of the body. The use of open foot-wear of the sandal type
TABLE 2
Types of Eczema No. of Cases Unclassified Infantile Atopic Hand, hand and feet Feet and lower limbs Seborrhoeic . . Discoid Lichen simplex Pityriasis alba Exfoliative Stasis
444 28 45 159 174 44 36 24 27 7 11 999
TABLE 3
Viral Infect ions and Pityriasis Rosea No. of Cases Warts . . Herpes sim.plex Herpes zoster MoUuscum cont igiosum Pityriasis rosea Exanthemata Vaccinia
135 5 32 24 26 6 2 230
appearance, or the likelihood of early leprosy,, particularly in places where this disease is endemic. Photodermatitis was diagnosed in 8% of the new cases seen. The incidence was comparable to that of 9% found in a study of this condition in another part of Malaysia.^ This condition
123
DERMATOLOGY IN PENANG, MALAYSIA
mainly results from the indiscriminate use of medicaments and soaps which contain photosensitizers. Viral infections of the skin were diagnosed in 230 patients (7-7%) and the different types are listed in Table 3. Viral warts are common in children. A special clinic, for treatment with liquid nitrogen, is held once a month. Contact dermatitis was seen in 181 patients (6-0%). Primary irritant dermatitis was seen in 141 patients where strong detergents, antiseptics, and irritant proprietary preparations, were largely responsible for the condition. Allergic contact sensitization was seen mainly after the topical use of sulphonamides, acriflavine and other medicaments. Bacterial and treponemal infections of the skin were diagnosed in 180 (6-0%) patients. An analysis is shown in Table 4. Leprosy was
concern to the individual. Chromoblastomycosis was diagnosed in two patients. Psoriasis was present in 4-3% of new cases. Pruritus is a more common complaint among psoriatic patients in Malaysia, than among patients in cooler climates. Pigmentary disorders were seen in 99 patients (3-3%). These produce effects considered by pigmented people to be cosmetically undesirable. Table 6 shows that a considerable proportion of these conditions resulted from inflammatory TABLE 5
Fungal and Yeast-like Infections No. of Cases Dermatophytoses Pityriasis versicolor . . Candidosis Chromoblastomycosis
136 41 5 2 184
TABLE 4
Bacterial, Treponemal and Other Infections No. of Cases Impetigo FoUiculitis Paronychia . . Furunculosis Cellulitis Abscess Pyoderma Toxic epidermal necrolysis . . Leprosy Yaws . . Syphilis (secondary) Chancroid Tuberculosis (skin) . .
19 16 22 26 9 2 11 5 64 3 10 1 2 180
processes of the skin. Fortunately, in most of these patients, the skin colour returns to normal with time. Vitiligo is more obvious in pigmented people but, with the practical treatments presently available, the results of treatment are generally unrewarding. Alopecia, including alopecia areata, was seen in 2-7% of the cases. The male type of alopecia accounted for a considerable proportion of these cases and was a sizeable emotional problem for the younger adult males affected. TABLE 6
Pigmentary Disorders
diagnosed in 54 patients. The prevalence of leprosy is about 10/10,000 population. In Penang there were 993 cases of leprosy on the register in 1975. Ten patients seen in the skin clinic were found to have secondary syphilis. Yaws is endemic at Balik Pulau, on the western side of the island of Penang, and from this area about 60 cases are seen annually. Fungal infections of the skin were diagnosed in 184 patients (Table 5). Dermatophyte infections were common and a clinical diagnosis was supported by direct microscopic examination of wet preparations made from skin scrapings. Pitjniasis versicolor is much more common than the figure given in Table 5 indicates. It is seen in a considerable proportion of the rural population and often does not cause much
No. of Cases Post-inflammatory : tiyper- and h)rpo-pigmentation Vitiligo Melasma
42 40 17 99
Drug rashes were diagnosed in 45 patients (1-5%). This figure does not reflect the true occurrence, as a large number of patients with dermatitis medicamentosa were included in the classification of contact dermatitis and photodermatitis. Fixed drug eruptions, resulting from the use of tetracyclines, are commonly seen in Malaysia. A rash from ampiciUin, with characteristic presentation, is also common.
DALJIT S. NAGREH
124 LESS COMMON DISEASES
Primary cutaneous amyloidosis (lichen amyloidosis) was diagnosed in 26 patients. This condition is much more common in the East than in the West. It usually presents with hyperkeratotic papules on the legs, especially over the shins. The lesions are accompanied by rather intense pruritus. The disease is chronic and difficult to treat. It may spread progressively to affect the thighs, upper limbs, and sometimes the trunk. One clinical variant shows macular or fine papular lesions which are hyperpigmented and arranged in a rippled fashion. Chronic folliculitis of the leg was seen in twelve patients. This condition was most often seen in people of southern Indian origin. The patients gave a long history of foUicular pustules on the legs and shins. As the lesions healed, the skin became shiny and atrophic. Some hair follicles became scarred and atrophic, while others produced small, distorted wiry hairs. The disease slowly spread peripherally and was rather difficult to treat. The moiphology and clinical couise of this form of chronic folliculitis of the legs, fit the description of dermatitis cruris pustulosa et atrophicans (Nigerian shin disease) seen in West African Negroes.2- ^ Tuberculosis of the skin, in the warty form, was seen in two patients. The condition responded well to anti-tuberculous treatment. Sometimes erythema nodosum was seen in patients with active pulmonary tuberculosis. Pityriasis rosea was diagnosed in 26 patients. The condition was seen mainly in young adults and often presented with the typical clinical appearance. Lichen planus, seen in eleven patients, appeared with two rather distinct patterns. One showed hyperpigmented, keratotic, discoid lesions, especially on the lower limbs, and often little or no pruritus. The other showed the typical flat-topped, polygonal papules of lichen planus which were accompanied by pruritus. Carotenaemia, with yellow discolouration of the palms and soles, was seen in healthy young people, usually after they had eaten large quantities of fruits such as oranges, papayas, tomatoes, carrots and certain green leafy vegetables. In Malaysia, papayas are cheap and plentiful and are the commonest cause of this condition in young Chinese females who eat plenty of fruits hoping to improve their complexion. The condition is harmless and disappears when the intake of fruits and vegetables is reduced.
Sutton's halo naevi, with depigmented macules surrounding pigmented epidermal naevi, were seen in two patients. Several of these naevi eventually disappeared leaving areas of leucoderma. Pityriasis lichenoides was seen in five patients. One of these patients presented with a severe onset of acute varioliform lesions after pregnancy. She responded to treatmei.t with steroids and has remained in complete remission. The chronic variety, with asymptomatic lesions, responded poorly to treatment. Bullous diseases were diagnosed in six patients. Three patients had pemphigus vulgaris, one had bullous pemphigoid, one had subcorneal pustular dermatosis, and one patient had dermatitis herpetiformis. The patient with subcorneal pustular dermatosis gave a 15 year history of superficial pustular lesions on her trunk especially in and around the flexures. The lesions appeared in groups and spread peripherally in a gyrate pattern. She responded well to treatment with dapsone. Lichen sclerosus et atrophicus was diagnosed in one patient who had earlier been treated by vulvectomy for severe vulval pruritus. She had hypopigmented, atrophic papular lesions on the sides of her neck and similar lesions on her vulva. Histological examination of a lesion from the neck showed hyalinization of the upper dermis and atrophy of the epidermis. Rosacea, perioral dermatitis and sarcoidosis are very rare in Malaysia. Chronic solar dermatitis and its sequels are great rarities. SOME CONCLUSIONS
Eczematous conditions, although common, were often non-specific and not readily classified. Eczematous lesions on the limbs were common and trauma, insect bites and irritants were commonly associated. Secondary infection is extremely common. Photodermatitis was common and mainly produced by use of medicaments and soaps containing potent photosensitizers. Many products of this kind are readily available. Some carry no labels. Skin infections due to viruses, bacteria and fungi, and cases of contact dermatitis were seen in roughly equal numbers of patients. Psoriasis is probably a common disease. Leprosj'-, yaws, and tuberculosis of the skin were seen, but are almost certainly less common than in some other tropical countries. Lichen amyloidosis is weU known in Malaysia.
DERMATOLOGY IN PENANG, MALAYSIA
Dermatitis cruris pustulosa et atrophicans is an interesting form of folliculitis of unknown cause and needs further study. Dermatological work in Penang offers great interest and is a rewarding challenge. lOE Green Lane, Georgetown, Penang, Malaysia.
125
REFERENCES 1 Nagreh, D. S. (1975) : " Photodermatitis—Study of the Condition in Kuantan, Malaysia ", Contact Dermatitis, 1, 27. =»Harman, R. R. M. (1972) " Dermatitis Cruris Pustulosa et Atrophicans , Essays on Tropical Dermatology, Vol. 2, Jan s Marshall, Excerpt a Medica, Amsterdam, 189. ^Harman, R. R. M. (1968) " Dermatitis Cruris -the Nigerian Shin Pustulosa et Atrophi e ", Brit. J. 1 i., 80, 97.
DERMATOLOGY IN PENANG, MALAYSIA* DALJIT S. NAGREHf
Penang, Malaysia SUMMARY
Dermatology in Malaysia and Penang is briefly otttlined as are the dermatological services provided from the Penang General Hospital. The skin diseases commonly seen are mentioned and tabulated. These include : eczema, photodermatitis, viral infections, contact dermatitis, bacterial and fungal infections, psoriasis, acne, disorders of pigmentation, alopecia and drug eruptions. Less common diseases referred to include : lichen amyloidosis, an interesting form of chronic folliculitis, and cutaneous tuberctdosis. This paper is based 07i patients seen during 1975. The island of Penang lies just off the northGENERAL BACKGROUND Malaysia, a federation of thirteen states, western coast of the Malay Peninsula. The occupies the greater part of the Malay Peninsula, State of Penang consists of the island and a certain off-shore islands, including Penang, and narrow stretch of land on the adjacent mainland. The State covers some 1,036 square kilometres part of Borneo. (400 square miles) and has a population of about West Malaysia, previously Malaya, contains 800,000. eleven states within the Peninsula between Often known as the ' Pearl of the Orient ', the Thailand and Singapore. East Malaysia, island of Penang has serene beauty with its comprising the two states of Sarawak and hilly terrain, tropical vegetation and attractive Sabah, is located in the north and west of beaches. Georgetown, the capital, has many Borneo. The land areas of Malaysia lie between places of interest and is a pleasant city for both the equator and seven degrees North latitude. residents and visitors. The climate is similar to The climate is equatorial with fairly high that in the rest of Malaysia with temperatures temperatures, rainfall and humidity. The which vary between SIX (70°F) and 32°C (90°F) seasons are marked more by changes in rainfall and fairly high humidity. than by variations in temperature. The population of Malaysia, approximately CLINICAL ARRANGEMENTS 12 million, is multi-racial and multi-lingual. The Penang General Hospital, situated in The three main racial groups are Malays (45%), Georgetown on the island of Penang, is one of Chinese (35%), Indians (10%), Indigenes and the largest hospitals in Malaysia. It has some others (10%). The proportions of the different 1,050 beds, out-patient services, and provides racial groups vary from state to state. Malay specialist facilities in almost every branch of is the national language. English is still widely medicine. used as are the various languages and dialects of The Department of Dermatology at the the Chinese, Indians, and other ethnic groups Penang General Hospital has existed for many throughout the country. years and provides services for the people in the State of Penang. In addition, this Department * Presented at the Annual Meeting of the Australasian provides a service for the neighbouring states, College of Dermatologists, Adelaide, May 1976. in the north-west of the Malay Peninsula, which t Department of Dermatology, Penang General Hospital, Penang, Malaysia. have a population of more than one million.
122
DAL JIT S. NAGREH
Dermatological clinics are also held at the hospitals in the State capitals of Kedah and Perlis, Alor Star and Kangar respectively. These hospitals are visited at regular intervals by the dermatologist attached to the Penang General Hospital. The patients seen in the skin clinics at the Penang General Hospital are referred from its various out-patient clinics, from district hospitals in the State of Penang and the neighbouring areas. Patients with leprosy are seen and diagnosed in the skin clinic. Afterwards they are registered and cared for at a clinic for patients with this condition. This clinic, which is attached to the Penang General Hospital, is under the control of the dermatologist. There is a separate clinic, with a venereologist in charge, for patients with venereal diseases. In 1975, 3,020 diseases were diagnosed in 2,817 patients seen in the skin clinic at the Penang General Hospital. In addition, there were 8,350 follow-up visits.
contributes to the production of keratotic and fissured lesions on the dorsal and plantar surfaces of the feet, especially as a result of repeated trauma and exposure to irritants. Eczema of the hands and feet is common and largely constitutional but often exacerbated hy the application of irritants. Secondary bacterial
MOST COMMON CONDITIONS
infection is a frequent feature of almost all types of eczema, especially when it affects the hands, feet and legs. Atopic, seborrhoeic and discoid eczema are by no means uncommon and their manifestations are much the same as in Western countries. Pityriasis alba is often more apparent in people with pigmented skins and, as with other conditions producing a loss of skin colour, can: cause great concern over the resulting
The most common skin diseases diagnosed are listed in Table 1. TABLE 1
The Common Diseases Condition Eczema . . Photodermatitis Viral infections . . Contact dermatitis Fungal infections Bacterial infections Psoriasis . . Acne Pigmentary disorders Alopecia . . Drug eruptions . .
..
No. of Cases
Percentage
999 243 230 181 184 181 131 114 99 65 45
33 1 8-0 7-7 6-0 6-1 6 0 4 3 3-8 3 3 2-2 1-5
Eczema, the commonest condition, was diagnosed in 33% of patients. The different types of eczema seen are shown in Table 2. A large proportion of the eczema seen is nonspecific and not classified. Eczematous lesions on the lower limbs are particularly common. The types of clothing and foot-wear used in the humid climate expose the legs and feet to a large variety of external factors, such as trauma, insect bites and irritants. These underlie eczematous changes on the lower limbs and similar changes on other parts of the body. The use of open foot-wear of the sandal type
TABLE 2
Types of Eczema No. of Cases Unclassified Infantile Atopic Hand, hand and feet Feet and lower limbs Seborrhoeic . . Discoid Lichen simplex Pityriasis alba Exfoliative Stasis
444 28 45 159 174 44 36 24 27 7 11 999
TABLE 3
Viral Infect ions and Pityriasis Rosea No. of Cases Warts . . Herpes sim.plex Herpes zoster MoUuscum cont igiosum Pityriasis rosea Exanthemata Vaccinia
135 5 32 24 26 6 2 230
appearance, or the likelihood of early leprosy,, particularly in places where this disease is endemic. Photodermatitis was diagnosed in 8% of the new cases seen. The incidence was comparable to that of 9% found in a study of this condition in another part of Malaysia.^ This condition
123
DERMATOLOGY IN PENANG, MALAYSIA
mainly results from the indiscriminate use of medicaments and soaps which contain photosensitizers. Viral infections of the skin were diagnosed in 230 patients (7-7%) and the different types are listed in Table 3. Viral warts are common in children. A special clinic, for treatment with liquid nitrogen, is held once a month. Contact dermatitis was seen in 181 patients (6-0%). Primary irritant dermatitis was seen in 141 patients where strong detergents, antiseptics, and irritant proprietary preparations, were largely responsible for the condition. Allergic contact sensitization was seen mainly after the topical use of sulphonamides, acriflavine and other medicaments. Bacterial and treponemal infections of the skin were diagnosed in 180 (6-0%) patients. An analysis is shown in Table 4. Leprosy was
concern to the individual. Chromoblastomycosis was diagnosed in two patients. Psoriasis was present in 4-3% of new cases. Pruritus is a more common complaint among psoriatic patients in Malaysia, than among patients in cooler climates. Pigmentary disorders were seen in 99 patients (3-3%). These produce effects considered by pigmented people to be cosmetically undesirable. Table 6 shows that a considerable proportion of these conditions resulted from inflammatory TABLE 5
Fungal and Yeast-like Infections No. of Cases Dermatophytoses Pityriasis versicolor . . Candidosis Chromoblastomycosis
136 41 5 2 184
TABLE 4
Bacterial, Treponemal and Other Infections No. of Cases Impetigo FoUiculitis Paronychia . . Furunculosis Cellulitis Abscess Pyoderma Toxic epidermal necrolysis . . Leprosy Yaws . . Syphilis (secondary) Chancroid Tuberculosis (skin) . .
19 16 22 26 9 2 11 5 64 3 10 1 2 180
processes of the skin. Fortunately, in most of these patients, the skin colour returns to normal with time. Vitiligo is more obvious in pigmented people but, with the practical treatments presently available, the results of treatment are generally unrewarding. Alopecia, including alopecia areata, was seen in 2-7% of the cases. The male type of alopecia accounted for a considerable proportion of these cases and was a sizeable emotional problem for the younger adult males affected. TABLE 6
Pigmentary Disorders
diagnosed in 54 patients. The prevalence of leprosy is about 10/10,000 population. In Penang there were 993 cases of leprosy on the register in 1975. Ten patients seen in the skin clinic were found to have secondary syphilis. Yaws is endemic at Balik Pulau, on the western side of the island of Penang, and from this area about 60 cases are seen annually. Fungal infections of the skin were diagnosed in 184 patients (Table 5). Dermatophyte infections were common and a clinical diagnosis was supported by direct microscopic examination of wet preparations made from skin scrapings. Pitjniasis versicolor is much more common than the figure given in Table 5 indicates. It is seen in a considerable proportion of the rural population and often does not cause much
No. of Cases Post-inflammatory : tiyper- and h)rpo-pigmentation Vitiligo Melasma
42 40 17 99
Drug rashes were diagnosed in 45 patients (1-5%). This figure does not reflect the true occurrence, as a large number of patients with dermatitis medicamentosa were included in the classification of contact dermatitis and photodermatitis. Fixed drug eruptions, resulting from the use of tetracyclines, are commonly seen in Malaysia. A rash from ampiciUin, with characteristic presentation, is also common.
DALJIT S. NAGREH
124 LESS COMMON DISEASES
Primary cutaneous amyloidosis (lichen amyloidosis) was diagnosed in 26 patients. This condition is much more common in the East than in the West. It usually presents with hyperkeratotic papules on the legs, especially over the shins. The lesions are accompanied by rather intense pruritus. The disease is chronic and difficult to treat. It may spread progressively to affect the thighs, upper limbs, and sometimes the trunk. One clinical variant shows macular or fine papular lesions which are hyperpigmented and arranged in a rippled fashion. Chronic folliculitis of the leg was seen in twelve patients. This condition was most often seen in people of southern Indian origin. The patients gave a long history of foUicular pustules on the legs and shins. As the lesions healed, the skin became shiny and atrophic. Some hair follicles became scarred and atrophic, while others produced small, distorted wiry hairs. The disease slowly spread peripherally and was rather difficult to treat. The moiphology and clinical couise of this form of chronic folliculitis of the legs, fit the description of dermatitis cruris pustulosa et atrophicans (Nigerian shin disease) seen in West African Negroes.2- ^ Tuberculosis of the skin, in the warty form, was seen in two patients. The condition responded well to anti-tuberculous treatment. Sometimes erythema nodosum was seen in patients with active pulmonary tuberculosis. Pityriasis rosea was diagnosed in 26 patients. The condition was seen mainly in young adults and often presented with the typical clinical appearance. Lichen planus, seen in eleven patients, appeared with two rather distinct patterns. One showed hyperpigmented, keratotic, discoid lesions, especially on the lower limbs, and often little or no pruritus. The other showed the typical flat-topped, polygonal papules of lichen planus which were accompanied by pruritus. Carotenaemia, with yellow discolouration of the palms and soles, was seen in healthy young people, usually after they had eaten large quantities of fruits such as oranges, papayas, tomatoes, carrots and certain green leafy vegetables. In Malaysia, papayas are cheap and plentiful and are the commonest cause of this condition in young Chinese females who eat plenty of fruits hoping to improve their complexion. The condition is harmless and disappears when the intake of fruits and vegetables is reduced.
Sutton's halo naevi, with depigmented macules surrounding pigmented epidermal naevi, were seen in two patients. Several of these naevi eventually disappeared leaving areas of leucoderma. Pityriasis lichenoides was seen in five patients. One of these patients presented with a severe onset of acute varioliform lesions after pregnancy. She responded to treatmei.t with steroids and has remained in complete remission. The chronic variety, with asymptomatic lesions, responded poorly to treatment. Bullous diseases were diagnosed in six patients. Three patients had pemphigus vulgaris, one had bullous pemphigoid, one had subcorneal pustular dermatosis, and one patient had dermatitis herpetiformis. The patient with subcorneal pustular dermatosis gave a 15 year history of superficial pustular lesions on her trunk especially in and around the flexures. The lesions appeared in groups and spread peripherally in a gyrate pattern. She responded well to treatment with dapsone. Lichen sclerosus et atrophicus was diagnosed in one patient who had earlier been treated by vulvectomy for severe vulval pruritus. She had hypopigmented, atrophic papular lesions on the sides of her neck and similar lesions on her vulva. Histological examination of a lesion from the neck showed hyalinization of the upper dermis and atrophy of the epidermis. Rosacea, perioral dermatitis and sarcoidosis are very rare in Malaysia. Chronic solar dermatitis and its sequels are great rarities. SOME CONCLUSIONS
Eczematous conditions, although common, were often non-specific and not readily classified. Eczematous lesions on the limbs were common and trauma, insect bites and irritants were commonly associated. Secondary infection is extremely common. Photodermatitis was common and mainly produced by use of medicaments and soaps containing potent photosensitizers. Many products of this kind are readily available. Some carry no labels. Skin infections due to viruses, bacteria and fungi, and cases of contact dermatitis were seen in roughly equal numbers of patients. Psoriasis is probably a common disease. Leprosj'-, yaws, and tuberculosis of the skin were seen, but are almost certainly less common than in some other tropical countries. Lichen amyloidosis is weU known in Malaysia.
DERMATOLOGY IN PENANG, MALAYSIA
Dermatitis cruris pustulosa et atrophicans is an interesting form of folliculitis of unknown cause and needs further study. Dermatological work in Penang offers great interest and is a rewarding challenge. lOE Green Lane, Georgetown, Penang, Malaysia.
125
REFERENCES 1 Nagreh, D. S. (1975) : " Photodermatitis—Study of the Condition in Kuantan, Malaysia ", Contact Dermatitis, 1, 27. =»Harman, R. R. M. (1972) " Dermatitis Cruris Pustulosa et Atrophicans , Essays on Tropical Dermatology, Vol. 2, Jan s Marshall, Excerpt a Medica, Amsterdam, 189. ^Harman, R. R. M. (1968) " Dermatitis Cruris -the Nigerian Shin Pustulosa et Atrophi e ", Brit. J. 1 i., 80, 97.
