Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
How do you counsel patients regarding the improvement they can expect when starting nemolizumab?
I tell patients that this medicine is a relatively newly approved medication in dermatology, although we have had significant experience with it in veterinary medicine for years. I state that the benefits of this drug go beyond just improving itch and skin clearance, but also have a role in impactin...
What is your preferred oral regime with duration for treatment of onychomycosis?
My new favorite regimen is: terbinafine 500 mg once daily for one week, then take 3 weeks off. Repeat for 4, once weekly cycles. Sprenger et al., PMID 31487828
Do you reduce the dose of hydroxychloroquine in patients with skin graying if they are not particularly bothered by this side effect?
1. I would check a trough whole blood HCQ level. Nathalie Costedoat-Chalumeau and her colleagues found higher levels in patients who developed skin pigmentation (Jallouli et al., PMID 23824340), but actual levels were not reported. Petri et al also showed that levels above 1200 ng/mL were associated...
What is the most appropriate next step in management for a patient with dermatomyositis who is maintained on methotrexate 25 mg weekly but develops disease flare when prednisone is tapered below 10 mg daily and is unable to receive IVIG?
The fact that the patient cannot taper prednisone below 10 mg indicates that methotrexate alone, while has some effect, is not sufficient to control the disease. There are several options, depending on the severity of each organ involvement. Since the joints are affected, I would favor an agent that...
During staged excision ("slow Mohs") for MMIS, at what point do you stop due to patient morbidity and consider alternative or adjuvant treatments?
This can be a challenging decision to make. I think it varies by the patient's age and comorbidities, as well as the size and location of the MIS. The possible comorbidities of continuing surgery always need to be considered, especially if there may be significant functional impairment or aesthetic ...
What would prompt you to obtain IGRA in a patient starting an IL-17 inhibitor for psoriasis who is also on concomitant immunosuppression despite the ‘no routine testing’ recommendations before initiating this class of biologic?
If the IGRA was indicated for the concomitant immunosuppressive drug, that would prompt me to obtain the IGRA. Also, more commonly, if the insurer required the IGRA, I would order it.
Do you typically recommend initial therapy with a JAK inhibitor or systemic corticosteroids in acute extensive alopecia areata?
I typically treat acute extensive alopecia areata with a JAK inhibitor (at the highest relevant dose) rather than systemic corticosteroids, as I have found that patients tend to respond well with this approach. The JAK inhibitors work very quickly to reduce the inflammatory processes underlying alop...
How often do you recommend ophthalmologic screening exams for patients with sarcoidosis?
The American Academy of Ophthalmology has guidelines for routine eye exams for an asymptomatic, healthy individual (not someone with sarcoidosis). These guidelines include a complete, dilated eye exam at age 40, interim exams at the discretion of the patient and one's ophthalmologist, and an exam ev...
Do you typically excise Spitz nevus/nevi?
I excise Spitz nevi in patients 12 years of age or older.
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...