Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
What patient factors do you feel are most important when considering reduced dosing regimens of IL17a inhibitors such as secukinumab and ixekizumab for psoriasis?
If the psoriasis is completely clear, the patient may wonder if they need to continue treatment. If they want to spread out the doses to see how little they need, I usually have no objection.
When managing severe, treatment-refractory Hidradenitis Suppurativa exhibiting incomplete response to single biologic agents, what safety parameters, diagnostic biomarkers, and/or monitoring protocols govern your decision to utilize off-label dual targeted therapy (e.g., combining a JAK inhibitor with an IL-17 or TNF inhibitor)?
Two different MOAs and, to my knowledge, no additive risk of AEs. A JAK inhibitor, of course, requires initial blood work and "periodic" lab monitoring after a 12-week assessment. To date, "periodic" is left to the prescriber's discretion. Another three months seems reasonable, and then again in 6 m...
How do you approach treating patients who develop psoriasis while on Dupixent?
Stop the Dupixent. These patients likely had a non-Th2 driven type of dermatitis e.g. Malassezia yeast hypersensitivity, which is Th17 driven, or stasis dermatitis with autoeczematization, or eczematous drug reaction. Revisit the Diagnostic Checklist for Generalized Dermatitis.
For microneedling to treat boxcar scars, how should the needle be oriented?
Boxcar facial scars are difficult to treat because the dermis is fibrous, the sides are fixed, and they can range in size from several millimeters. The purpose of microneedling is to improve the underlying dermis, so it would make the most sense to aim the needle directly under the deepest part of t...
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.
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...
What is your treatment algorithm for dissecting cellulitis of scalp?
I view dissecting cellulitis as a variant of HS (and we know it's a component of the follicular tetrad along with acne conglobata and pilonidal cysts). Anti-TNFa inhibitors and isotretinoin are preferred therapies for this condition with a high level of efficacy.
In patients with delusions of parasitosis, given recent literature, would you attempt to trial biologic dupilumab therapy over, or in conjunction with, standard atypical anti-psychotics if they have prominent peripheral eosinophilia or severe secondary excoriative dermatitis?
Based on the available literature, I would not recommend dupilumab instead of atypical antipsychotic therapy for primary delusional parasitosis. I would consider dupilumab only as adjunctive therapy in selected patients with marked secondary inflammatory skin disease or refractory pruritus, recogniz...
How do you manage severe chronic scalp pruritus in older women when biopsies and exams show no primary skin disease and standard therapies fail?
I use gabaergic drugs like Pregabalin and Gabapentin in high doses up to 300 mg and 3600 mg, slowly tapering up as many of these cases are neuropathic. I use compounded topical KAL cream 10% ketamine, lidocaine 5, and amitriptyline 5, or foam formulation or pramoxine lotion bid or topical compounded...
What is your approach to prescribing off-label oral JAK inhibitors (ritlecitinib) for children under 12 years of age with severe alopecia areata, and how do you manage clinical monitoring?
In general, I have a similar approach to prescribing oral JAK inhibitors in children under 12 years of age as in adolescents 12 and older: I discuss risks and benefits, acknowledging that the impact of severe alopecia areata on patients can be tremendously negative, and children have some unique cha...