Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
When managing an adult patient with moderate-to-severe atopic dermatitis who achieves only a partial clinical response on dupilumab after 6 months, how do you primarily approach treatment escalation?
In patients who partially respond to dupilumab, next steps depend on the extent of the patient's response. For patients who improve at least 50% compared to baseline, it would be reasonable to either increase dupilumab dosing frequency or add methotrexate. If much less than 50% improvement, reasonab...
Do you screen for cardiac disease in patients with dermatomyositis in the absence of symptoms?
I don't typically evaluate for cardiac disease in patients with dermatomyositis who are not symptomatic. There are subtypes of myositis patients where cardiac involvement is more common (such as those with antimitochondrial antibodies and anti-SRP antibodies), and there it may make sense to keep a c...
Are there particular subsets of AAV patients in which avacopan is more effective?
The following answer was jointly drafted by Dr. Peter Merkel and Dr. David Jayne:Patients in the ADVOCATE trial were stratified at entry according to time of diagnosis (new/relapsing), diagnosis (GPA/MPA), ANCA serotype (PR3/MPO), and background immunosuppressive (cyclophosphamide/rituximab) with re...
What is the current role for genetic profile testing (e.g. DecisionDx-SCC) in the treatment paradigm for cutaneous malignancies?
This is a very cool test that has a lot of potential to help us make decisions in practice (full disclosure, I advise Castle and get research support from them, but am not directly compensated by them). The data published thus far shows that it is prognostic to predict nodal or distant mets. However...
How do you approach work up for underlying rheumatologic disease in patients referred for chronic urticaria?
Chronic urticaria (6 weeks or longer) is often a self-limited disorder seemingly idiopathic in etiology. There are certain autoimmune disease more prevalent in patients with chronic urticaria including systemic lupus erythematosus, Sjogren's syndrome, autoimmune thyroid disease, celiac sprue, and rh...
Would you consider neoadjuvant immunotherapy followed by radiation for a patient with locally advanced basal cell carcinoma?
This is a relatively data-free area, so there's no “right” answer.I think the first question to ask is whether this basal cell carcinoma (BCC) is amenable to curative intent radiotherapy (assuming surgery is not possible). If so, any adjunctive drug therapies are of secondary relevance.For locally a...
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 generally treat family members of patients with scabies?
Yes, if "family members" refers to those living in the same household or have had close contact with the affected individual within the past 3-4 weeks. Treating such contacts simultaneously is the best option to help eradicate the infestation.
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...
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...