Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
For large infantile hemangiomas treated with timolol, do you have any concerns about systemic absorption?
For a large infantile hemangioma, I would opt to treat with oral propranolol instead of topical timolol, as it has better and more consistent efficacy. Additionally, oral propranolol is a weight-based medication with well-established dosing, while topical timolol applied to large hemangiomas may hav...
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...
What criteria are used to select patients who have locally advanced BCC patients for treatment with sonidegib?
Patients with locally advanced BCC are candidates for sonidegib when 1) the BCC is not manageable with curative surgery or radiation, 2) there’s recurrence after prior surgery or radiation, or 3) when treatment would cause significant morbidity for the patient. It can also be used as a neoadjuvant o...
Is there a general consensus on margins to use when treating SCCIS or BCC with ED&C?
ED and C is a procedure that is done largely by 'feel'. Tumor is generally softer and more friable than normal skin, and is therefore more susceptible to removal with moderate pressure from a semi-sharpened curette. Generally speaking, I don't obsess over margins when ED and C'ing a low-risk skin ca...
Would you consider proceeding with a sentinel lymph node biopsy after wide excision revealed 1.2 mm residual non-ulcerated T2a melanoma on the upper back?
Any melanoma with Breslow’s depth of more than 0.8 mm (more than T1a) needs a sentinel lymph node biopsy for complete staging, due to higher chance of lymph node metastasis. Ideally, it should be done at the time of wide local excision, as doing the sentinel lymph node biopsy afterwards may be more ...
How should medical oncologists and dermatologists communicate about patients with at least Stage IIB/III cutaneous melanoma regarding neoadjuvant immunotherapy?
Only melanoma patients with stage III or resectable stage IV disease should be treated with standard-of-care neoadjuvant immunotherapy. These patients should see a medical oncologist first (and no longer last, as is the current process). I would recommend that the schedulers at your institution be e...
When would you offer neoadjuvant immunotherapy prior to Mohs surgery in a locally advanced squamous cell carcinoma for which clearance may require enucleation?
I would flip this question around and answer that radiotherapy is often a terrific option around the eyes, and it should always be considered in this area, especially when a radical surgical procedure is being entertained. Between en face therapy with a shield (superficial, electrons) and IMRT/VMAT,...
What’s your immediate post-procedure protocol for fractionated laser resurfacing (i.e., Sciton Pro-fractional Laser)?
My immediate post procedure protocol for fractionated laser resurfacing is to decrease stinging with the Zimmer chiller (approximately 10-30 minutes followed by the application of Vaseline. I have not seen significant pinpoint bleeding while treating acne scarring (Lumenis Encore laser) but have see...
In what situation would you recommend ipilimumab + nivolumab over relatlimab + nivolumab in the treatment of metastatic melanoma?
There is no clinical trial to provide a direct comparison between the two regimens, hence the answer to this question is usually driven by personal interpretation of the data and patient preference. The data for both regimens show a statistically significant PFS benefit and a superior response rate ...
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.