Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
Would you start glycopyrrolate in elderly population and how do you counsel the patient?
The short answer is no, I would not start systemic glycopyrrolate in the elderly population. Of course, more information is needed to thoroughly answer this question. For simplicity, I will assume glycopyrrolate is being considered for excessive sweating. A complete history and physical exam are nec...
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...
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 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