Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
What is your approach to initiating JAK inhibitor therapy in patients for refractory inflammatory disease with a history of venous thromboembolism who are currently on anticoagulation?
A few questions: age of patient, nature of the "refractory" dermatitis, and prior therapies utilized in management...No matter what the response, I would use a JAK inhibitor in a patient with a history of venous thromboembolism with extreme caution, given the black box warning of an elevated risk of...
What are your favorite modalities for preventing hypergranulation tissue?
Although exuberant granulation tissue is not totally preventable nor predictable, persistent inflammatory impetus, such as from hairs embedded in a surgical closure, or spitting suture reactions, can stimulate excess granulation tissue. Careful avoidance of trapped hairs as well as burying absorbabl...
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...
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...
How have you incorporated gene expression profiling tests for melanoma or SCC into your practice and has it changed your approach to treatment and/or monitoring?
We routinely utilize GEP testing for our melanoma and high-risk SCC patients. For melanoma, it helps refine the care we offer. For T1a high-risk, T1b, and T2a melanomas, it helps rule in or rule out a Sentinel Lymph Node Biopsy (SLNB), or even guide imaging protocols. For node-negative patients, a h...
How do gene expression profiling results influence your recommendations for surveillance intensity in patients with early-stage melanoma?
Gene expression profiling (GEP) defines surveillance intensity for early-stage melanoma. Early-stage melanoma (i.e., stage I) would not typically be expected to metastasize or recur. Patients at high genomic risk of recurrence should be surveilled more closely, including self-skin exams in between r...
How do gene expression profiling results impact your decisions regarding adjuvant therapy in node-negative or borderline-risk melanoma patients?
Node-negative patients comprise a majority of bad outcomes from melanoma deaths. These are the patients that I worry about the most, and 90% or so of lymph node biopsies are negative. High-risk DecisionDx-Melanoma (DDx-M) scores allow for routine serial imaging despite a negative lymph node biopsy. ...
In light of recent measles outbreaks in the US, would you recommend an MMR booster for immunocompetent patients born before 1957?
I would not recommend a measles vaccine for a person born before 1957. This year has been chosen because people before born before 1957 have a very very high likelihood of having had measles because virtually all children got this highly contagious disease. On the other hand, there is no harm to get...
Is morphea, cutaneous scleroderma, with no organ involvement a contraindication for radiation in early stage breast cancer as part of breast conservation therapy?
I am not sure anyone can answer this question with a solid yes or no answer. The information we have about limited scleroderma and radiotherapy is for, lack of a better term, limited. We can draw from some experiences to guide the thought process. In one large series of patients from two scleroderm...
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 ...