Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
Would you continue cemiplimab adjuvantly, following resection of initially unresectable cutaneous squamous cell carcinoma treated with downstaging immunotherapy?
This is a challenging question because, as you know, we have no randomized data to address it. I generally do not continue immune checkpoint therapy after resection of SCC skin. However, given the adjuvant data in melanoma and the high efficacy of anti-PD1 in skin SCC, I do think it is reasonable to...
Do you typically excise cellular dermatofibromas?
I don't see a reason to remove them beyond cosmetic reasons or patient preference.
How would you approach diagnosis of a patient with recurrent episodes of abdominal pain, severe myalgias, low grade fevers and urticaria?
Without the mEFV variant, from a rheumatologist viewpoint, the differential includes IBD, a periodic fever syndrome such as FMF or FCAS, and MCAS. Therefore, I would consider that workup with genetic testing (anyone can send!), fecal calprotectin, and MCAS eval with A/I. I don't think of urticarial ...
When managing acute vascular compromise secondary to hyaluronic acid filler, what initial hyaluronidase dosing protocol do you employ, and do you find clinical value in traditional adjuncts like aspirin, nitroglycerin paste, or hyperbaric oxygen?
Whether it is acute vascular compromise due to cannulating the vessel, it is now believed best to flood the area with hyaluronidase. I have 6 vials of Hylenex and 2 vials of Vitrase in my fridge at all times in case of emergency. Usually, if you are performing hyaluronic fillers, going slow and obse...
What is your approach for dosing regimen and threshold for initiating oral dutasteride or finasteride in patients with active lichen planopilaris, and what outcomes have you observed regarding disease stabilization?
0.5 mg daily of dutasteride>>2.5-5 mg daily of finasteride. It usually takes 6-9 months to see an effect, but I have seen reduction/slowing of hair loss and some reduction in erythema.
In overweight or obese patients with hidradenitis suppurativa receiving targeted biologics (e.g., TNF-α or IL-17 inhibitors), do you personally initiate GLP-1 receptor agonists for metabolic synergy, or do you defer prescribing to primary care?
I have seen quite a few HS patients improve after starting a GLP-1, and they were all under my care and on therapy for their HS. We were struggling to get control in some of them, then the GLP really helped as part of the treatment. Having said that, I tried writing some myself. My staff didn't love...
Should TNF inhibitors be held in patients undergoing radiation therapy?
We do not hold TNF inhibitors when needed for patients undergoing radiation therapy.
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.
What is your approach to a patient with undetectable MMR titers checked prior to or during immunosuppression and a history of MMR vaccination in childhood?
MMR titers are good correlates of protection. If any titer is undetectable it could be one of these situations: Primary failure. The components of the MMR have different efficacy. Two doses of appropriately given MMR will have 96+% against measles, but only 88% for mumps. Thus 1 in 10 appropriately...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...