Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
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...
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 do you approach use of Doxy PEP in a patient taking isotretinoin, as both drugs are (rarely) associated with pseudotumor cerebri, which is very uncommon in clinical practice?
Pseudotumor cerebri (IIH) is a devastating problem. I have seen a number of cases, usually neurosurgical shunt infections, over the years. These patients often have persistent headaches and may require VP shunting over and over again. Since doxy is sometime implicated in IIH (and has other side effe...
In which type of patient do you recommend a JAK inhibitor as first-line systemic therapy (biologic-naive) with moderate-to-severe atopic dermatitis?
A JAKi is almost never my first-line systemic therapy for AD. I generally reach for biologics targeting IL4/13 first and move to JAKi if those are ineffective or not tolerated. The main scenario where I would choose a JAKi first would be someone who had needle phobia or refused biologics.
How do you reassure families that no allergy testing is needed for urticaria?
I explain to them that it is an immunologic phenomenon (inside job) and not allergic (outside job).
Do you always pursue biopsy confirmation before diagnosing IgA vasculitis?
Technically, yes (by definition), but practically, not necessarily: Biopsy for direct immunofluorescence (DIF) testing would be required to confirm the status of IgA in cutaneous vasculitis. However, the presence of lesional IgA correlates positively with the clinical presentation (e.g., Henoch Schö...
When a pathology report shows SCC not connected to the epidermis, how often is this truly metastatic versus a sampling artifact, and do you routinely pursue full metastatic workup or referral in these cases?
Primary SCCs typically do have a connection to the epidermis. This is customarily found upon microscopic evaluation of an entire specimen of the SCC. However, partial biopsies, such as a punch biopsy, may show an area where the SCC is undermining the epidermis without a connection. In such a situati...
With emerging therapies, what is your general treatment ladder for chronic spontaneous urticaria (CSU)?
Antihistamines remain the first-line therapy for chronic spontaneous urticaria (CSU), and doses should be optimized before turning to other therapies. If patients fail a trial of adequately dosed first- and second-generation antihistamines, montelukast is a reasonable adjunct. For patients with high...
In a patient with high-risk cutaneous squamous cell carcinoma of the face with extracapsular extension after ipsilateral neck dissection and rapid contralateral cervical nodal recurrence, what is the optimal management?
In various published series, around half of patients fail to achieve a complete response to cemiplimab. From the clinical details, the current active area of disease appears to be the contralateral neck with no distant disease. Curative treatment is preferred. C-POST trial established surgery + adju...