Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
If adjuvant radiation is offered to an elderly patient with H&N SCC s/p Mohs surgery who is planned for multi-stage reconstruction of the defect with plastic surgery, when should adjuvant radiation be started?
Tumor control comes first. If the surgical defect is such that reconstruction is required, it is even more imperative to focus on the above principle, as a recurrence would almost certainly risk ruining the entire collective effort. Vascular flaps could be safely performed post-RT in most cases by s...
When managing acute vascular compromise secondary to hyaluronic acid filler, what initial hyaluronidase dosing protocol do you employ, and do you find clinical value in traditional adjuncts like aspirin, nitroglycerin paste, or hyperbaric oxygen?
Whether it is acute vascular compromise due to cannulating the vessel, it is now believed best to flood the area with hyaluronidase. I have 6 vials of Hylenex and 2 vials of Vitrase in my fridge at all times in case of emergency. Usually, if you are performing hyaluronic fillers, going slow and obse...
What do you tell patients about swimming in the ocean or in lakes after biopsy or surgical procedure?
Bandages, no matter how waterproof, can leak due to patients' motion underneath the bandage. Consequently, I recommend that patients avoid soaking in water until after any sutures are out. It takes about two days following suture removal for the holes left by the sutures to seal up. I am not aware o...
How do you manage worsening cutaneous dermatomyositis when muscle disease appears controlled?
The fact that the patient still has an active pruritic rash while tapering steroids suggests that the current regimen isn't fully controlling the disease, and it can affect quality of life. I would consider adjusting immunosuppression, either adding another agent or switching therapies. The specific...
In patients with progressive, isolated nail lichen planus refractory to intralesional corticosteroid injections, which oral systemic agents have demonstrated the greatest clinical efficacy in your practice?
Oral JAK inhibitors have good efficacy, including tofacitinib, baricitinib, and upadacitinib, if you're able to get any of these covered. Otherwise, oral low-dose naltrexone (3 mg daily) can also be efficacious in patients.
What is your baseline protocol for total-body skin exams in patients with systemic sclerosis on immunosuppression: routine annual/biannual screening or interval follow-up tailored strictly to personal skin cancer history?
I don't know of much evidence around this but it does seem clear that attempting to stratify risk based solely on immunomodulatory medication doesn't make good clinical sense; it does seem that the patient's baseline risk is still highly relevant and likely the primary driver of overall risk. In mos...
What recommendations do you provide patients regarding immunization or boosters prior to initiating rituximab?
To my knowledge, there is no unified recommendation, although the majority of us recommend all age-appropriate immunizations plus strong consideration of younger-than-standard-age immunization for diseases such as pneumococcus and VZV prior to initiation of rituximab when medically feasible. Timing ...
What factors do you weigh most heavily in the selection of radiotherapy versus topical treatments for lentigo maligna in a patient who is not a surgical candidate?
The ability of a patient to travel to multiple sessions of radiotherapy would play a major role in making this decision. If the patient is frail and has someone who could reliably to topical therapy, it might make me lean towards topical therapy.
During staged excision ("slow Mohs") for MMIS, at what point do you stop due to patient morbidity and consider alternative or adjuvant treatments?
This can be a challenging decision to make. I think it varies by the patient's age and comorbidities, as well as the size and location of the MIS. The possible comorbidities of continuing surgery always need to be considered, especially if there may be significant functional impairment or aesthetic ...
What is your treatment algorithm for dissecting cellulitis of scalp?
I view dissecting cellulitis as a variant of HS (and we know it's a component of the follicular tetrad along with acne conglobata and pilonidal cysts). Anti-TNFa inhibitors and isotretinoin are preferred therapies for this condition with a high level of efficacy.