Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
What is your approach to diagnosis and treatment to intermittent cheilitis that does not respond to anti fungal therapy?
Clinical features matter. The differential is broad: granulomatous cheilitis, contact dermatitis, irritant dermatitis, lichen planus, and I have even seen SCLE present with cheilitis. Biopsy during a flare can be helpful even if only to rule out some possibilities, and a 3mm punch typically heals qu...
How would you treat disseminated flat warts in an immunosuppressed patient with skin of color?
Hard to imagine Imiquimod working in a dry wart. Thinking back to the genital studies... only the occluded (moist) warts responded. I generally try to curette them over several visits. Compounded cidofovir (off-label, etc.) might be the best bet.
Where do oral and topical JAK inhibitors fit into your treatment algorithm and approach to atopic dermatitis?
When considering systemic treatment for dermatitis, I perform extended patch testing based upon patient's history of cutaneous contactants. This identifies patients with dermatitis that can often be cured by avoiding cutaneous and systemic (i.e. ingestion) exposure to identified allergens. Patients ...
When would you pursue genetic testing for severe recalcitrant atopic dermatitis?
Not an easy question to answer, but severe and treatment-refractory AD, especially if early onset, is concerning for immune dysregulation and should warrant immune evaluation early. By treatment-refractory, I do not just mean topical therapies, but attempts to control the Th2 pathway that fail repea...
If you’re transitioning laterally between biologic classes due to adverse effects, do you repeat the loading dose?
I do usually repeat the loading dose when starting a new biologic, even if in the same class. If there is data on whether or not you should do this, I am not aware of it.
How do you approach the workup and initial treatment of systemic AL amyloidosis?
1: Ensure that this is light chain. Mass spectroscopy of the tissue to identify/confirm is very important. Even if a patient has positive serum monoclonal protein or light chain, it does not indicate that this is light chain amyloidosis. I have had patients with MGUS and smoldering myeloma with ATTR...
How extensive of a workup do you do for systemic AL amyloidosis for a patient with a resected amyloidoma, localized AL amyloid deposition in their airway or lungs, who has no other symptoms?
It's common to over-test in these patients. We in hematology/oncology, often order bone marrow biopsies, PET/CTs, and cardiac MRIs without realizing that each test costs around $10,000 and can potentially harm the patient.Here are two points to assist with the work-up for these patients: Understand...
What additional workup do you pursue in a patient in whom you suspect Yellow Nail Syndrome?
Mandatory pulmonology (and/or ENT for sinusitis) for comorbit workup or monitoring. Detailed ROS for eval of any underlying disease and workup as indicated. Age-appropriate cancer screenings.
How do you approach melanoma patients with a positive sentinel node with extra-nodal extension for definitive surgical management?
This is a multidisciplinary question so I reached out to our surgical oncologist (Dr. @Dr. First Last) at the Ohio State University Comprehensive Cancer Center for his thoughts as well. This is a grey area as the patients with extra-nodal extension (ENE) were not specifically studied in the landmark...
How should one manage a non-healing wound with tunneling at the site of a cyst excision on the back, now two months postoperatively, with negative wound cultures and in the context of a self-pay patient?
"Non-healing wound" suggests persistent granulation tissue or similar exam findings, which in the context of tunnel formation at the site of follicular cyst raises my concern for hidradenitis suppurativa (if only a diathesis toward follicular occlusion in a patient without a history of HS). If there...