Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
How do you manage patients with twenty nail dystrophy of unclear etiology?
My approach is to perform a longitudinal wedge biopsy from the hyponychium to the proximal matrix at a lateral aspect of a fingernail for histology. This can help point you in a direction to aid in treatment (spongiotic, psoriasiform, lichenoid, other rarer conditions such as amyloid or LCH).
How do you manage patients with yellow nail syndrome?
My experience is with PO vitamin E 1200 daily + weekly fluconazole or itraconazole pulse therapy for 6 months. However, it's also important to get chest imaging (CT > XR) on these patients and refer to Pulmonology.
What is your approach to managing patients with central centrifugal cicatricial alopecia (CCCA) who do not respond to ILK or doxycycline?
ILK + doxy of course is the mainstay but when going beyond that these are my typical thoughts: HCQ can help if there is some lichenoid inflammation on path Spiro+finasteride helps older women who likely also have some component of AGA 10% metformin in a lipoderm cream base has been used for CCC...
What is your approach to treating patients with lichen planopilaris who do not respond to hydroxychloroquine?
I have a few patients with progressive disease who have not responded to oral hydroxychloroquine or oral Doxy. For these, CellCept, either as monotherapy or as an add-on to Plaquenil is an option.There are many studies showing the efficacy of CellCept as monotherapy but I know my colleagues in acade...
How do you manage patients with alopecia totalis who are not candidates for JAK inhibitors?
Severe forms of alopecia areata are very difficult for the patient and provider. The first step in management is to assess where the patient is emotional. How are they managing? What support systems are in place? Once this is addressed, I discuss my treatment ladder. Initial options include class I ...
What is your approach to starting and monitoring methotrexate in elderly patients?
For the elderly, I start 10 mg weekly and get CBC/CMP at 2 weeks followed by monthly x3 then q3 months indefinitely.
How do you approach treating patients with acne keloidalis nuchae who do not respond to a potent topical steroid or retinoid?
For mild disease, topical steroids and topical clindamycin solution alone or in combination with benzoyl peroxide wash or gel are recommended. It is also important to counsel patients to reduce friction to the area (usually the occipital scalp) and avoid cutting hair close to the skin. For moderate ...
How do you manage patients with chronic flushing that do not respond to beta-blockers?
Firstly, I like to make sure the cause of flushing isn't something systemic like carcinoid, mastocytosis, or paraneoplastic. If the patient does have rosacea, I like to get the inflammatory part of rosacea under control with topicals like azelaic acid, a topical TCI (like Elidel), or topical iverme...
How do you manage patients with chronic telogen effluvium?
Chronic telogen effluvium is distressing to patients and a challenge to manage. First, I do a thorough lab evaluation looking for any underlying condition that may be contributing such as anemia, liver/kidney disease, thyroid disease, hormonal abnormalities, and nutritional deficiencies (iron, zinc...
How do you manage eruptive squamous atypia that does not respond to intralesional 5-fluorouracil or intralesional methotrexate?
We have tried to do unna boot wraps with 5FU for a couple of weeks and then rebiopsy any clinical lesions that do not resolve. Then consider surgery for ones that persist.