Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
Which patient factors drive you to pursue patch testing in the workup of chronic hand eczema?
Seasonal hand eczema occurring only during the cold season is usually irritant and best addressed by minimizing hand washing and using cotton under occlusive gloves with frequents changes for wet work. Careful examination for signs of psoriasis and anti-synthetase syndrome is important. Next step is...
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...
What treatments have you found most effective in removing syringomas?
Most often the syringomas I have treated have been multiple small lesions around the eyes. Because it is readily available, safe, of minimal cost, and easy, I like to use pinpoint electrodesiccation. I use a Hyfrecator 2000 electrosurgical unit on the low setting with 2-3 watts. Because electrodesic...
What is your preferred method of wound closure after wide excision for hidradenitis suppurativa?
My favorite is always secondary intention healing. It has the best outcomes and the least risk of recurrence, plus it's the easiest since you don't have to do anything. It is important to counsel patients ahead of time, and I find it helpful to show them some photos. When they see the open wound, it...
How would you palliate a large, symptomatic vaginal melanoma recurrence with limited small pelvic lymph node metastases?
Palliation. Treat problems that are symptomatic. No expensive systemic work up. Pall RT to the pelvis if it’s symptomatic. 30 Gy/10 fractions, 25 Gy/5 fractions, or 20 Gy/2 fractions with a 1 week inter-fraction interval. Apologize for the lengthy response.
Where in the current treatment algorithm for CHE do you feel delgocitinib best fits?
Given the cost of delgocitinib, I have difficulty justifying it unless there has been an inadequate response to high-potency topical steroids and calcineurin inhibitors. I expect there to be significant improvement with these, and consider an inadequate response to be the inability to decrease to a ...
How would you treat pattern hair loss in a woman on aromatase inhibitors for breast cancer?
I treat with topical or oral minoxidil. Spironolactone is considered safe. I avoid 5alpha reductase inhibitors, both topical and oral, in patients with a history of estrogen receptor-positive breast cancer. Topical 5α reductase inhibitors must be absorbed systemically for any benefit. Other tools fo...
What is your approach to management of patients with recurrent orolabial herpes?
Recurrent orolabial herpes is fundamentally a disease of viral latency with episodic reactivation, so my approach focuses less on “treating infection” and more on reducing recurrence burden, shortening symptom duration, and improving quality of life. First, I make sure we are actually dealing with H...
What treatment strategies are effective for senile gluteal dermatosis when patients do not improve with standard lifestyle modifications and emollients?
Senile gluteal dermatosis is very difficult to treat, as you know. What I have tried to do is methodically go through each lifestyle modification, such as sitting position and having the patient move frequently - be as sure as you can - that they are able to achieve these modifications to some degre...
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...