Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
How do you counsel patients on safety and toxicity of delgocitinib?
I request all eligible patients to complete the vaccines for herpes zoster prior to starting. Delgocitinib has been reported to cause neutropenia, suggesting there is systemic absorption, so I do not recommend it for patients with a history of VTE. I rarely see highly immunosuppressed patients with ...
Does the presence of psoriatic arthritis affect your decision to use an anti-IL-17 or IL-23 drug in your psoriasis patients?
I tend to prefer IL-17s in patients with PsA as an indirect assessment of clinical trials suggests they are more effective than IL-23s (which fits my clinical experience) for PsA. IL-17s are also more effective for axial disease (IL-23s are not very effective in axial disease). If there is a history...
Where in the current treatment algorithm for CHE do you feel delgocitinib best fits?
I see delgocitinib fitting in early in the algorithm after emollients, barrier repair, and avoidance strategies; particularly for patients who either fail a brief potent steroid course or who are not good candidates for ongoing steroid use, whether it be preference or previous experience. It can als...
What recommendations or protocol do you have in reducing pain when using levulan with blue light for field therapy to treat AKs?
Applying the blue light directly after the application of Levulan without an incubation period practically eliminates all of the discomfort associated with this type of field therapy for actinic keratoses. You may choose to double the usual exposure time to 34 minutes, but this is not necessary.
Is there a role for monitoring serum ANCAs to assess ANCA associated vasculitis disease activity?
This is (and remains) a somewhat controversial question. ANCA titers do appear to rise in anticipation of disease flares and patients with persistent titers appear to have more flares. This is especially true for PR3 ANCAs. However, the proximity of flares to rising ANCA titers is not terribly close...
Should nivolumab be discontinued in a patient who develops bullous pemphigoid but is otherwise responding well to therapy, if BP is being managed with dupilumab?
Nivolumab should be discontinued in a patient with grade 3-4 bullous pemphigoid, but may be held rather than permanently discontinued for grade 2 disease, even when the bullous pemphigoid is being managed with dupilumab. The National Comprehensive Cancer Network guidelines specify that discontinuati...
What lab monitoring and frequency do you recommend in an otherwise healthy young patient on biologics for psoriasis?
Yearly QuantGold testing in low risk patients has been shown to be unnecessary and actually carries a significantly higher risk of false positive than true positive. Unfortunately, many insurers still require yearly testing. I don't know of any data to support any other yearly lab testing for the dr...
How do you approach patients who identify so strongly with being sick or with a particular diagnostic label that it makes up a significant portion of their identity?
In many cases, the point at which this question is being asked is one at which the train has already left the station, and sickness as a way of life/career has set in. Unfortunately, with functional somatic syndromes, there is data suggesting that self-rated quality of life and functioning are lower...
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.
What are your preferred treatment options for recalcitrant pemphigus vulgaris?
Rituximab, typically combined with short-term corticosteroids, is the preferred treatment for recalcitrant pemphigus vulgaris, demonstrating superior efficacy compared to conventional immunosuppressants. In patients with moderate-to-severe disease, rituximab achieved sustained complete remission in ...