Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
Would you recommend against use of dupilumab for severe atopic dermatitis in a patient with a history of neonatal HSV meningitis but no history with recurrent outbreaks?
No, dupilumab may be used if the patient's atopic dermatitis remains moderate to severe with standard topical treatments. I am assuming this child has history of HSV meningitis, likely in the context of eczema herpeticum. Dupilumab lowers the risk of recurrent skin infections, including HSV.
If adjuvant radiation is offered to an elderly patient with H&N SCC s/p Mohs surgery who is planned for multi-stage reconstruction of the defect with plastic surgery, when should adjuvant radiation be started?
Tumor control comes first. If the surgical defect is such that reconstruction is required, it is even more imperative to focus on the above principle, as a recurrence would almost certainly risk ruining the entire collective effort. Vascular flaps could be safely performed post-RT in most cases by s...
In patients with progressive, isolated nail lichen planus refractory to intralesional corticosteroid injections, which oral systemic agents have demonstrated the greatest clinical efficacy in your practice?
Oral JAK inhibitors have good efficacy, including tofacitinib, baricitinib, and upadacitinib, if you're able to get any of these covered. Otherwise, oral low-dose naltrexone (3 mg daily) can also be efficacious in patients.
What is your baseline protocol for total-body skin exams in patients with systemic sclerosis on immunosuppression: routine annual/biannual screening or interval follow-up tailored strictly to personal skin cancer history?
I don't know of much evidence around this but it does seem clear that attempting to stratify risk based solely on immunomodulatory medication doesn't make good clinical sense; it does seem that the patient's baseline risk is still highly relevant and likely the primary driver of overall risk. In mos...
What recommendations do you provide patients regarding immunization or boosters prior to initiating rituximab?
To my knowledge, there is no unified recommendation, although the majority of us recommend all age-appropriate immunizations plus strong consideration of younger-than-standard-age immunization for diseases such as pneumococcus and VZV prior to initiation of rituximab when medically feasible. Timing ...
What factors do you weigh most heavily in the selection of radiotherapy versus topical treatments for lentigo maligna in a patient who is not a surgical candidate?
The ability of a patient to travel to multiple sessions of radiotherapy would play a major role in making this decision. If the patient is frail and has someone who could reliably to topical therapy, it might make me lean towards topical therapy.
During staged excision ("slow Mohs") for MMIS, at what point do you stop due to patient morbidity and consider alternative or adjuvant treatments?
This can be a challenging decision to make. I think it varies by the patient's age and comorbidities, as well as the size and location of the MIS. The possible comorbidities of continuing surgery always need to be considered, especially if there may be significant functional impairment or aesthetic ...
How soon after excising a keloid do you inject kenalog?
I ran into this issue in clinic a few months ago when I started doing keloid excisions on patients' ears - there's some decent data in the following article for doing immediate kenalog injections without impairing wound healing.Burusapat et al., PMID 34367855
If a cSCC requires multiple Mohs stages and the final defect exceeds 2 cm, does this warrant additional staging workup such as imaging or referral for radiation?
It could, depending on other factors. Size greater than 2 cm, depth of invasion beyond the subcutaneous (subq) fat, poor differentiation, perineural invasion greater than 0.1 mm, and lymphovascular invasion are additional risk factors. I usually refer for adjuvant external beam radiation therapy (XR...
How often do you recommend ophthalmologic screening exams for patients with sarcoidosis?
The American Academy of Ophthalmology has guidelines for routine eye exams for an asymptomatic, healthy individual (not someone with sarcoidosis). These guidelines include a complete, dilated eye exam at age 40, interim exams at the discretion of the patient and one's ophthalmologist, and an exam ev...