Professor Malcolm Rustin was an invited speaker on the Dowling Club visit to the Institute of Dermatology in Bangkok, Thailand in January 2015. The Dowling club is a postgraduate educational dermatology group established in 1947 by Dr Geoffrey Dowling, a Consultant Dermatologist at St Thomas's Hospital.
There are monthly meetings at which journals are discussed, clinical meetings at which patients with unusual skin conditions are presented, possible diagnoses are proposed and the best treatment strategy suggested. There are also annual international visits to other dermatology units at which lectures are given by invited speakers and these are complemented by lectures from the host department and presentation of patients having skin diseases that are common in that part of the world.
Professor Rustin discussed the internal treatment of eczema. He indicated the criteria for commencing internal treatment which involves excluding uncommon genetic causes and any underlying cause such as a dietary trigger or an allergen being applied to the skin. Most importantly it was stressed that patients or their carers must have applied appropriate quantities of treatments to the affected skin long enough to ensure that the skin disease was indeed resistant to topical treatments before there was a real need for systemic therapy. In addition if the eczema was having a significant effect on the patient's quality of life and in children if their growth was being affected by the lack of sleep, there clearly was a need for stronger medication.
There is the exciting possibility of preventing the development of atopic eczema by giving pregnant mothers who are intending to breast feed, probiotics during the last two months of their pregnancy and for the first two months of the baby's life. This strategy would be particularly useful in those mothers who have a high risk of producing atopic children; those who have had eczema, asthma or hay fever in the past or who have had close family members with these diseases. This preventative treatment reduces the chances of a baby developing eczema by 50%.
Professor Rustin then discussed the different immunosuppressive agents that can be prescribed and these include azathioprine, methotrexate, mycophenolate, and in order to gain rapid control of severe disease, ciclosporin or a short course of steroids may be given. He described the screening investigations that must be undertaken before such treatments can be started and the common and less common side effects that may be encountered with these drugs. He then talked about the new class of drugs known as biologicals which are being trialled in patients with moderate to severe atopic eczema that has failed to respond to the standard immunosuppressive drugs.
These include high dose intravenous immunoglobulin, and a number of monoclonal antibody treatments - dupilumab an antagonist to the IL-4/13 receptor, ustekinumab, abatacept and an antibody to IgE omalizumab. There is hope that these treatments may offer the same benefit as seen in patients with severe psoriasis who already have a number of licensed biologicals available.
The dermatologists from the Institute of Dermatology then presented a number of patients. Unlike in the UK where the most common skin disorders are skin cancer, inflammatory dermatoses and infections, the most common skin disease in Thailand is infections. The reason for this is that a large proportion of the workforce is employed in agriculture and these workers are labouring in the fields which are wet and often footwear is not worn. Thus superficial and deep fungal infections can easily enter the skin after minor trauma. About 1% of the Thai population are infected with HIV and in these patients the fungal infections can become more aggressive.
In addition leprosy occurs in 4 per 100,000 of the population and several patients with varying stages of the disease kindly allowed themselves to be examined. It was a privilege to have seen skin conditions which are rarely encountered in London and then in contrast we had presentations by our Thai hosts on the use of skin lasers and the use of fillers to improve patients' cosmetic appearance. Indeed a patient volunteered for us to observe her having injections of fillers into her face.
Although this is a relatively simple procedure there are potential risks with the development of allergic and granulomatous reactions in which hard lumpy and often unsightly swellings appear at the sites of injections. In addition because the injections can accidentally enter veins on the face it is possible that clotting of the blood vessels supplying the eye can occur resulting in blindness. Unfortunately as there is no register of adverse events following fillers nobody knows how common these side effects are, but a straw poll of the dermatologists present identified several who had encountered such devastating side effects.
Our group then flew up to Chiang Mai in northern Thailand. We had been invited to visit a leprosy hospital which was established by Dr James McKean in 1908. The Director of Leprosy control in Thailand presented a number of patients having various stages of the disease and he demonstrated the different clinical signs. This tutorial was quite exceptional as the manifestations of the skin lesions depends on the patients' immunity to mycobacterium leprae and we saw all the types and the reactions that develop once treatment has been commenced.
Overall this was an amazing and privileged experience observing dermatology in a Far Eastern country.