Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
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.
If a cSCC requires multiple Mohs stages and the final defect exceeds 2 cm, does this warrant additional staging workup such as imaging or referral for radiation?
It could, depending on other factors. Size greater than 2 cm, depth of invasion beyond the subcutaneous (subq) fat, poor differentiation, perineural invasion greater than 0.1 mm, and lymphovascular invasion are additional risk factors. I usually refer for adjuvant external beam radiation therapy (XR...
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 ...
Do you recommend checking anti-drug antibodies for patients on TNF inhibitors?
This is a very good question with direct clinical practice implications. I do not check or follow anti-drug antibodies when using TNF inhibitors for the treatment of rheumatoid arthritis or psoriatic arthritis. There are reports that suggest, on a group level, that these antibodies, if present, impa...
How do you manage atopic dermatitis in patients who have failed dupilumab?
The therapeutic landscape for atopic dermatitis is being updated every year, meaning that this question will have different answers in the next few years. In fact, new guidelines are being updated more frequently to capture new drug approvals. As always, medication selection should weigh risks and b...
Should the use of avacopan be limited to those patients at increased risk of steroid toxicity given the anticipated high cost of this medication?
Once Avacopan is available for clinical use in the treatment of patients with AAV, providers will need to carefully weigh risks and benefits of the medication while considering other factors including cost.The ADVOCATE trial used a novel glucocorticoid toxicity index that captures common GC-related ...
Do you offer adjuvant radiation therapy for a breast cancer patient with dermatomyositis?
This is an exceptionally important question for clinicians. I'm a little biased as I run an autoimmune Myositis Clinic, but here are my two cents: Paraneoplastic dermatomyositis (DM) is a fairly common occurrence (roughly about 15% of all DM cases, but up to 30-40% in some subtypes, such as adult pa...
In elderly patients with advanced melanoma and idiopathic pulmonary fibrosis receiving active antifibrotic therapy, would neoadjuvant or adjuvant immune checkpoint inhibition be preferred?
Given this scenario, it is most important to have a goal-of-care discussion. That would help sort out the optimal treatment for such patients. Always treat to relieve pain as needed.
How should the results of the ADVOCATE trial be applied in AAV patients who receive rituximab induction and maintenance therapy?
The following answer was jointly drafted by Dr. Peter Merkel and Dr. David Jayne:The data from ADVOCATE indicate that patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) treated with avacopan 30 mg twice daily and prednisone placebo were able to achieve remission w...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...