Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
How do you go about switching from one DMARD to another In patients with dermatomyositis that remains active?
Typically, we are adding additional drugs in combination to get response. Once we get response then we try to taper down the first DMARD slow until off. If first DMARD, didn't work at all, then we would stop the first and quickly untitrate another one, but that scenarios is uncommon.
What prescription or over-the-counter therapies do you recommend for patients with side effects from vismodegib?
For muscle cramps, L-carnitine supplements most definitely, and sometimes a lower dose regimen of a calcium channel blocker like amlodipine if needed. The vismo dosing can be adjusted to allow for breaks as well. For nausea, Zofran can be helpful as well as medical cannabis (which can also help with...
How do you approach the workup of clinically diagnosed cutaneous vasculitis in healthy young individuals without systemic symptoms?
As with all of medicine this answer depends on the presentation. A thorough review of systems and exam is needed to stratify workup. If we are talking about classic LCV below the knee in an otherwise healthy person, with no other concerning s/sx (as sounds like you are asking), I do generally confir...
Do you always excise down to the fascia when treating invasive melanomas and does body site location influence the depth of excision?
This a great question.Recommendations for the width and depth of cutaneous melanoma excisions aim to prevent local and satellite/in-transit recurrence. Results of randomized controlled trials (RCT) currently guide the recommendations for the width of excision, however, RCTs that evaluate the ideal d...
What would be the main indications for opting for biosimilars over an original biologic, outside of insurance barriers?
A timely question, as we head to 2023! The only reason to use biosimilars is for the broad purpose of resource stewardship. There isn't a medical reason to prefer a biosimilar over a reference product (or vice versa), because if a product were found to have a significantly different therapeutic effe...
In patients with multiple basal cell carcinoma lesions on vismodegib, would you hold vismodegib while delivering radiation therapy to one locally advanced BCC lesion that was not amenable to surgery?
I agree. Based on the recently published paper in JCO (Barker et al., PMID 38630954), vismodegib can be safely administered with radiation therapy for locally advanced BCC. RT + vismodegib yielded high rates of control and progression free survival.
How would you manage a Merkel cell carcinoma that spontaneously regressed clinically in a patient medically high-risk for surgical resection/anesthesia?
Less than 5% of MCCs are T0. I’ve never seen spontaneous regression of a biopsy-proven MCC in over 45 years. That said, should lightning strike, RT to the primary site and elective RT to the regional nodes.
Do you give neoadjuvant intralesional 5FU/MTX prior to Mohs for CSCC purely to reduce scar size and improve cosmetic outcome?
No. With Mohs surgery, we know we can get high cure rates and good cosmetic outcomes.
How do you approach the management of basal cell carcinoma with single lymph node involvement?
If all the tumor has been resected, I would recommend adjuvant XRT on the nodal basin, depending on the age of the patient. For very old patients or patients with comorbidities, observation might be warranted. If there is remaining BCC visible on examination or scans, I would treat systemically with...
What is the best management for recurrent basal cell carcinoma after prior radiation and vismodegib?
Recurrent basal cell carcinoma can be challenging to manage. It is important recognize that vismodegib is FDA approved for basal cell carcinoma that is not treatable with surgery or radiation therapy. In this case, if you think radiotherapy could be given again, vismodegib should have never been us...