Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
How would you manage treatment of keloid that is so large it requests a graft?
16 Gy/4 fractions
For microneedling to treat boxcar scars, how should the needle be oriented?
Boxcar facial scars are difficult to treat because the dermis is fibrous, the sides are fixed and they can range to several millimeters in size. The purpose of microneedling is to improve the underlying dermis so it would make the most sense to aim the needle directly under the deepest part of the ...
Do you read contact patch tests on removal at 48 hours, and do those results matter if negative at 72 or 96 hours?
Great question, and one that comes up frequently in clinical practice. I remove patches at 48 hours, and at that point I do perform a quick read or, at a minimum, have the tested areas thoroughly photographed. While it is difficult to draw firm conclusions from a 48-hour read alone, it is genuinely ...
Would you consider adding dupilumab to adalimumab (or other monoclonal antibodies) in a patient who has RA and refractory atopic dermatitis and already is on MTX 25 mg weekly?
No. Unless the problem has been chronic since childhood, I would first run through the diagnostic checklist for adult-onset generalized dermatitis to be sure this is not a mimic of AD. If no other diagnosis is established after a thorough investigation, I would stop adalimumab and change to upadacit...
Are there any special considerations for treatment of metastatic acral melanoma?
In general, acral melanoma is a higher-risk disease. There are higher rates of acquired and primary resistance. Given this, I favor ipi-nivo since the overall risk is higher and response rates to single-agent PD-1 or nivo-rela tend to be lower. Emerging data suggest TIL therapy can work reasonably w...
What topical therapies and procedures do you recommend for patients with atrophic acne scarring?
If the patient has hyperpigmentation, then some sort of topical lightening approach (i.e., tretinoin/kojic acid/niacinamide/Vit C/tranexamic acid, etc) or chemical peels. For the actual scarring, assuming that the acne process has burned out, the most ideal procedure depends on the particular type o...
With the increasing availability of biosimilars and their adoption onto payer formularies, how do you approach selection among available biosimilars in clinical practice?
Insurance payers consider FDA‑approved biosimilars to be clinically equivalent. In my experience, selection is ultimately driven by the insurance payer formulary - what you can get for the patient on the time. This can be fleeting and quickly changing at times. Cases can be made for patient experien...
How do you educate patients about the risks of actinic keratosis progressing to skin cancer?
I use verbiage from Dr. Kirby’s excellent study to describe risk appropriate to the patient’s history. Except in immunocompromised or patients with a history of SCC, I avoid characterizing AKs as “pre-cancer” so that they can make a value-informed choice regarding observation vs treatment.Berry et a...
What incubation times do you use for PDT?
We have had good success with the zero incubation time + 2 back-to-back illumination cycles method described by Gandy et al. This method involves no pain and an overall shorter visit time compared to standard incubation protocols.Briefly, this method includes the following steps: Prep treatment area...
What recommendations do you provide to patients who develop ocular side effects with Dupixent?
I would start with over-the-counter artificial tears without preservative and then refer to an ophthalmologist, ideally a corneal specialist who is experienced in the nuances of treating this condition. I have also had success switching from Dupixent to Adbry, although JAK inhibitors are a better o...