Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
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...
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 ...
What are your favorite topicals when treating scarring alopecia?
Fortunately, topicals can often be effective for scarring alopecia. In general, I tend to use high-potency topical steroids in combination with non-steroidal topicals, including topical JAK inhibitors (e.g., ruxolitinib, delgocintib, or compounded tofacitinib). Because the inflammatory process is re...
How do you manage pemphigus patients who have persistent disease and circulating autoantibodies despite two full courses of rituximab?
I currently manage two recalcitrant pemphigus patients, both of whom have undergone various courses of typical systemic immunosuppression (e.g., CellCept, MTX, steroids) but continued to flare. Combinations of these traditional therapies, along with topicals, were not particularly helpful. While dis...
Do you prescribe silvadene cream for patients with a sulfa allergy?
No. I will consider hydrogel wound dressings in those situations
What is your approach to deciding when to stop therapy for cutaneous Mycobacterium chelonae infections?
I have an ongoing case of M abscessus cutaneous infection, possibly acquired from a pedicure. This is a similar bug to M chelonea, but even harder to treat. Our approach was to gather the opinion of several experts through email communication. The conclusion was to treat for 6-12 months, and follow ...