Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
Under what circumstances would brachytherapy be preferred over electron therapy for treating skin cancers?
For small (<2 cm) nonmelanoma skin cancers, I would say that brachytherapy is preferred for these reasons: Better cosmesis - 90-95% report excellent, which is better than electron series, particularly at the edge. Better for curved surfaces like the nose b/c applicator is flush on the skin with no ...
Have you used itraconazole as a primary or adjunct therapy for individuals with numerous BCCs?
Yes. I use itraconazole 100 mg daily with sonidegib 200 mg (daily or less frequently, depending on tolerance, but no less than twice a week) in every patient who shows a resistant SMO mutation on an NGS panel. I test all patients at baseline and at recurrence to determine what treatment to offer.
For patients on medications that are known to cause photosensitivity, would you counsel them to avoid laser hair removal or laser therapies?
"Known to cause photosensitivity" is almost every drug, but actually isn't all that common. I Rx doxycycline all summer and maybe see a possible reaction every few years. Variables are the dose of the drug and the amount and wavelength of light, but mostly studies are lacking. A test spot might giv...
What is your escalation strategy for chronic GvHD?
There are now several available options for steroid resistant cGVHD. The old standbys - ECP and rituxan are useful in about 30% of patients. Ibrutinib was the first new drug to get FDA approval. Unfortunately, I don't think the real-world experience is anywhere near as good as the trial (Chin et al....
How would you treat pattern hair loss in a woman on aromatase inhibitors for breast cancer?
I treat with topical or oral minoxidil. Spironolactone is considered safe. I avoid 5alpha reductase inhibitors, both topical and oral, in patients with a history of estrogen receptor-positive breast cancer. Topical 5α reductase inhibitors must be absorbed systemically for any benefit. Other tools fo...
In elderly patients with advanced melanoma and idiopathic pulmonary fibrosis receiving active antifibrotic therapy, would neoadjuvant or adjuvant immune checkpoint inhibition be preferred?
I'd be very careful with the use of immunotherapy in an elderly patient with any sort of autoimmune disease, especially when receiving disease-modifying therapy. Having said that, there is no such contraindication to giving immunotherapy in such patients. Neoadjuvant setting: It is always preferred ...
How do you reconcile the differing results of the C-POST and KEYNOTE-630 trials when discussing treatment options with high-risk CSCC patients?
I explain that the two trials enrolled different risk populations, which likely accounts for the apparent discrepancy in outcomes — but when you look closely, they actually lead to the same clinical conclusion. C-POST deliberately enriched for very-high-risk patients (using well-established adverse ...
What is your treatment algorithm for dissecting cellulitis of scalp?
I view dissecting cellulitis as a variant of HS (and we know it's a component of the follicular tetrad along with acne conglobata and pilonidal cysts). Anti-TNFa inhibitors and isotretinoin are preferred therapies for this condition with a high level of efficacy.
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 ...
Do you prefer Cantharidin Plus or Y-canth for management of pediatric molluscum?
I don't like cantharadin plus over Y-canth because I don't like the plus. I still prefer plain cantharadin by a large margin over both.