Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
Is it ever reasonable to switch to a different TNFi as opposed to switching to an agent in a different class in a case of TNFi induced lupus or psoriasis?
This is a very interesting question where the answer continues to evolve. I would also like to answer the question separately. Both Psoriatic skin lesions and lupus or lupus-like conditions can be induced by anti-TNF-alpha therapy. The pathogenesis may involve changes in cytokine balance.Regarding P...
How would you manage a nodal recurrence of cutaneous SCC if the patient is unable to receive surgery for 6-8 weeks?
I’d first consider referring the patient to a center that could perform the operation, as it is standard of care for a patient with resectable cSCC with nodal metastases. At some centers, there may be a clinical trial of neoadjuvant immunotherapy that could be considered. If those options were not...
Would you irradiate elective lymph nodes for a T1 Merkel cell carcinoma of the head and neck with a negative sentinel lymph node?
In general, I would not irradiate due to the negative sentinel lymph node biopsy (SLNBx). Either one trusts the prognostication of a SNLBx and obtains one, or not. If one does not trust the process of SLNBx, then you should not obtain one and electively treat. I do not see the utility in obtaining a...
What is the role for angiography in the workup of digital ischemia?
Digital ischemia is an especially serious complication in patients with rheumatic disease, particularly scleroderma but can also be a feature of lupus, vasculitis (ANCA associated, PAN), antiphospholipid syndrome, and rheumatoid vasculitis, among others.The presence of digital pain with permanent/pe...
Do you measure drug levels (particularly hydroxychloroquine or mycophenolate) in your lupus patients?
Hydroxychloroquine levels: I absolutely measure hydroxychloroquine (HCQ) drug levels in my patients regularly. As I have mentioned in other answers here and in The Rheumatologist, measuring drug levels has transformed my clinic into a clinic where most of my SLE patients are in remission or have low...
How often do you order imaging to assess for possible degenerative joint disease in the spine in patients with neuropathic itch?
Only if the itch is localized, mainly unilateral like in notalgia paresthetica of the back or the forearm.
What are your preferred treatment options for patients with cholestatic pruritus who do not respond to light therapy?
Great question as in my experience phototherapy does not have high success rate for this. Agree that rifampicin can help quite a bit! Here is an algorithm you might find useful: Initially treat with a bile acid sequestrant such as cholestyramine (total daily dose of 4 to 16 grams) If this does no...
What is your approach to treating patients with chronic pruritus of unclear etiology?
After a thorough workup (which includes some or all of the tests below) I typically follow a treatment algorithm for Chronic Pruritus of Unknown Origin or CPUO. This includes empiric ivermectin or permethrin to rule out atypical scabetic itch (this has fooled even the most astute clinicians), topica...
How do you approach restarting biologics for psoriasis patients who have discontinued therapy for 3-6 months?
For patients that have missed just a couple of months, I just restart the maintenance dose. If they have been off the medication for 6 months or more, I prefer to start with a loading dose again.
What therapies do you use in patients with cutaneous lupus recalcitrant to topical steroids?
I agree with Dr. @Dr. First Last. In addition, strict photoprotection is absolutely key to clearing up cutaneous lupus of any severity. I also typically consider (and find to be helpful) mycophenolate mofetil if the patient is not responsive to first-line treatment (hydroxychloroquine). While useful...