Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
How should the use of the DecisionDx-Melanoma test be integrated into clinical practice to potentially avoid sentinel lymph node biopsy?
At this time, DecisionDx should be used as an extra piece of molecular information, not for clinical decision-making. The study done on DecisionDx was mainly retrospective, not prospective, so it has limited value in guiding patient care at this time. I would base your decision on SLBx on the curren...
For large infantile hemangiomas treated with timolol, do you have any concerns about systemic absorption?
For a large infantile hemangioma, I would opt to treat with oral propranolol instead of topical timolol, as it has better and more consistent efficacy. Additionally, oral propranolol is a weight-based medication with well-established dosing, while topical timolol applied to large hemangiomas may hav...
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...
How do you choose between Grenz ray in a short course (e.g., ~5–7 fractions) versus longer-course superficial/megavoltage external beam regimens for large, ill-defined lentigo maligna on the cheek when surgery is not feasible?
The practical answer to this question is based on resource availability. There is a significant body of literature from Europe demonstrating the efficacy of Grenz ray therapy (albeit in retrospective, observational studies, with all of the usual caveats). To my knowledge, Grenz ray therapy is not wi...
What criteria are used to select patients who have locally advanced BCC patients for treatment with sonidegib?
Patients with locally advanced BCC are candidates for sonidegib when 1) the BCC is not manageable with curative surgery or radiation, 2) there’s recurrence after prior surgery or radiation, or 3) when treatment would cause significant morbidity for the patient. It can also be used as a neoadjuvant o...
Is there a general consensus on margins to use when treating SCCIS or BCC with ED&C?
ED and C is a procedure that is done largely by 'feel'. Tumor is generally softer and more friable than normal skin, and is therefore more susceptible to removal with moderate pressure from a semi-sharpened curette. Generally speaking, I don't obsess over margins when ED and C'ing a low-risk skin ca...
Do you typically excise Spitz nevus/nevi?
I excise Spitz nevi in patients 12 years of age or older.
Would you consider proceeding with a sentinel lymph node biopsy after wide excision revealed 1.2 mm residual non-ulcerated T2a melanoma on the upper back?
Any melanoma with Breslow’s depth of more than 0.8 mm (more than T1a) needs a sentinel lymph node biopsy for complete staging, due to higher chance of lymph node metastasis. Ideally, it should be done at the time of wide local excision, as doing the sentinel lymph node biopsy afterwards may be more ...
How should medical oncologists and dermatologists communicate about patients with at least Stage IIB/III cutaneous melanoma regarding neoadjuvant immunotherapy?
Only melanoma patients with stage III or resectable stage IV disease should be treated with standard-of-care neoadjuvant immunotherapy. These patients should see a medical oncologist first (and no longer last, as is the current process). I would recommend that the schedulers at your institution be e...
When would you offer neoadjuvant immunotherapy prior to Mohs surgery in a locally advanced squamous cell carcinoma for which clearance may require enucleation?
I would flip this question around and answer that radiotherapy is often a terrific option around the eyes, and it should always be considered in this area, especially when a radical surgical procedure is being entertained. Between en face therapy with a shield (superficial, electrons) and IMRT/VMAT,...