Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
What is your approach in counseling a patient with delusions of parasitosis?
Delusions of parasitosis (DOP) or delusions of infestation (DOI) are among the most challenging conditions we treat as dermatologists. I am not sure there is one approach to treating these patients and it can often feel very frustrating and unsatisfying. Nonetheless, we all will encounter these pati...
How do you select your first line therapy in patients with CSU?
My basic first-line strategy does not change with severity; what changes is the speed with which I optimize and escalate therapy. For example, with a patient in whom I am confident the diagnosis is CSU, I begin with a second-generation H1 antihistamine at the standard approved dose, taken regularly-...
Would you consider adding dupilumab to adalimumab (or other monoclonal antibodies) in a patient who has RA and refractory atopic dermatitis and already is on MTX 25 mg weekly?
No. Unless the problem has been chronic since childhood, I would first run through the diagnostic checklist for adult-onset generalized dermatitis to be sure this is not a mimic of AD. If no other diagnosis is established after a thorough investigation, I would stop adalimumab and change to upadacit...
How do you manage patients with scleroderma who present with finger ulcerations without other signs of soft tissue infection and MRI demonstrates potential concern for osteomyelitis?
I think this is a tricky situation. Sometimes there is bone damage from acro-osteolysis from the ischemic injury of the scleroderma itself, which can sometimes be difficult to distinguish from osteomyelitis. I would consider watching closely for other signs of deeper infection. You could also consid...
Between the MERLIN and CASTLE tests for melanoma, which do you prefer and why?
I prefer DecisionDx-Melanoma, without question. It’s the only test that prospectively met its primary endpoint, with SLN positivity below 5% in the low-risk group. Merlin’s CP-GEP did not meet that threshold in MERLIN_001. DecisionDx also goes beyond the SLNB decision by independently predicting rec...
How would you approach management of a patient with longstanding history of SLE, but having active psoriasis?
In addition to above, I would consider deucravicitinib. It has PASI75 scores that are in the 60s, and is in trials for SLE. Its phase 2 trials seemed promising. Other PO JAK inhibitors should be efficacious but may carry worse side effect profile. I have also employed PDE4 inhibitors such as po apre...
How do you optimize retinopathy screening schedules for patients on hydroxychloroquine while also prioritizing cost-effectiveness?
I'll approach this from the cost-effectiveness standpoint as I agree with Drs. @Dr. First Last and @Dr. First Last on their excellent points.Patients with SLE have remarkably high costs when you add up copays, medications, imaging studies, travel, missing work, etc. Anything we can do to help reduce...
How do you prefer to repair skin cancer excisions done on lower extremities?
The approach to repairing on the lower legs after Mohs surgery often depends on the size and depth of the surgical defect, as well as patient-specific factors such as vascular status and mobility. I typically discuss the available options with the patient, outlining the pros and cons of each. On the...
How do you choose amongst first line advanced systemic therapies in a patient with antihistamine refractory CSU?
This has become one of the most interesting questions in CSU because the therapeutic landscape has changed substantially.For a typical antihistamine-refractory adult in 2026, I think about three licensed targeted approaches (Also alluded to in my initial responses re: CSU) anti-IgE → omalizumab (mor...
How does trimethoprim-sulfamethoxazole's efficacy against S. pyogenes influence your empirical treatment of skin infections in regions with high resistance rates?
Recommendations against using trimethoprim-sulfamethoxazole (TMP/SMX) for group A strep (GAS) skin and soft tissue infections (SSTIs) likely stemmed from a misconception that GAS is inherently resistant to the drug. Older studies reporting resistance used media containing a high thymidine concentrat...