Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
When do you consider adding steroids alongside intravenous antibiotics for patients with orbital cellulitis?
If the orbital cellulitis is infectious, I never add steroids. There is no literature or proof that they do anything, and decreasing immunity, in my opinion, is simply a bad idea. If it is inflammatory, then absolutely. Most infectious orbital cellulitis is from the sinuses and is more common in chi...
Why/How do patients report seeing flashes of light when receiving Pulsed Dye Light (PDL) treatments on the face?
Patients commonly report seeing flashes of light during pulsed dye laser treatments, especially on the face, although it happens even with proper eye protection. I typically will place an eye pad under the laser goggles for those patients more sensitive to the flashes. We understand the mechanism of...
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...
Under what circumstances would brachytherapy be preferred over electron therapy for treating skin cancers?
For small (<2 cm) nonmelanoma skin cancers, I would say that brachytherapy is preferred for these reasons: Better cosmesis - 90-95% report excellent, which is better than electron series, particularly at the edge. Better for curved surfaces like the nose b/c applicator is flush on the skin with no ...
How do you choose between Grenz ray in a short course (e.g., ~5–7 fractions) versus longer-course superficial/megavoltage external beam regimens for large, ill-defined lentigo maligna on the cheek when surgery is not feasible?
The practical answer to this question is based on resource availability. There is a significant body of literature from Europe demonstrating the efficacy of Grenz ray therapy (albeit in retrospective, observational studies, with all of the usual caveats). To my knowledge, Grenz ray therapy is not wi...
In what circumstances would you recommend adjuvant radiation for a keratocanthoma with SCC after resection?
KA by itself (in the absence of SCC) is at the interface of benign and malignant. In a pure KA, if margins are negative, no further RT is needed. If there is SCC mixed, as can happen even with BCCs, the adjuvant RT indication rules pertaining to SCC prevail.
How is your approach to a patient referred for radiotherapy for keloids with a history of Beals syndrome?
Although of theoretical concern, I am not aware of any contraindication to RT (treatment philosophy similar to Ehlers-Danlos syndrome).
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...
How do you decide when to biopsy a patient with overlapping signs of female-pattern hair loss and possible early central centrifugal cicatricial alopecia?
Biopsy is indicated when the diagnosis is uncertain, particularly when distinguishing between female-pattern hair loss (FPHL) and central centrifugal cicatricial alopecia (CCCA), as these conditions can have overlapping clinical presentations. Our T-shirt should also represent fibrosing alopecia and...
What is your approach to managing moderate to severe atopic dermatitis in pregnancy?
Gentle skin care practices, dilute bleach baths, diligent use of topical steroids, and phototherapy will cover most moderate to severe cases. If patients have any persistent lichenified areas, intralesional steroids can help temporize until after delivery/lactation. If a biologic is needed, work wit...