Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
Is a biopsy of either skin or muscle always indicated in the diagnosis of dermatomyositis?
A biopsy of either skin or muscle is not always necessary and the need for each depends on each patient's presentation. A typical history and physical exam, along with MRI or EMG findings, or more importantly, a positive myositis specific antibody can be adequate to make the diagnosis of dermatomyos...
What is your preferred infliximab dosing strategy for hidradenitis suppurativa?
I usually start at 5mg/kg every 4 weeks. If patients are doing well, you can try to extend to every 6 weeks. If not sufficiently controlled at 5mg/kg, you can increase to 7.5 or 10mg/kg every 6 or 8 weeks.Alikhan et al., PMID 30872149 Oskardmay et al., PMID 31095972Fernández-Vozmediano et al., PMID ...
What is your approach to treating dermatomyositis patients with pruritus recalcitrant to oral and topical steroids?
I find this issue of pruritus is best handled by getting better control of the cutaneous inflammatory disease. In this regard, typical DMARD agents (e.g. MTX, mycophenolate, etc) can be helpful in addition to IVIG or even JAK inhibitors. Obviously, all a risk/benefit assessment depends on how debili...
In the absence of lung disease, do you prefer methotrexate or mycophenolate mofetil in the initial treatment of cutaneous-only manifestations in systemic sclerosis?
I typically will use mycophenolate if I think the patient needs "skin only" treatment. This recommendation is based on my personal experience, retrospective and observational data, and data that can be gained from other clinical trials (SLS2 for example). If the patient has prominent joint disease, ...
Does irradiation of a patient with pyoderma gangrenosum carry risk of morbidity similar to necrosis caused by minor surgery?
I have treated a few patients with breast cancer with adjuvant RT with a history of pyoderma gangrenosum on active treatment on immunosuppressive therapy with no untoward acute effects.
How long do you give systemic therapies or skin directed therapies to work before changing treatments in patients with diffuse skin limited mycoses fungoides?
It really depends on the patient, the side effects profile. Some systemic therapies are “skin directed” like bexarotene. Also, access to a dermatologist's office for nbUVB is an important factor in making such a decision. I generally don’t recommend topical agents when there is more than 10% eBSA sk...
In what scenario would you add systemic therapy with adjuvant radiation therapy in resected, locally-advanced, cutaneous squamous cell carcinoma?
This is an active area in clinical trials, here is a recently published reviewNewman et al., PMID 34096664 More to come in a future post, I will see what trials are currently available in the Chicago area!
Do you avoid dupilumab (IL-4 inhibition) for severe asthma in patients already taking a biologic agent for RA?
Dupixent (dupilumab) is a humanized monoclonal IgG4 antibody that works by blocking the signaling of interleukin-4 (IL-4) and interleukin-13 (IL-13). This is achieved by binding to the IL-4Rα subunit. When dupilumab occupies this subunit, it prevents IL-4 signaling via the Type I receptor and both I...
Do you recommend a deep shave biopsy or punch biopsy for sampling concerning melanocytic lesions?
Based on the available literature, either is an acceptable form of sampling concerning melanocytic lesions: Mills et al., PMID 23592167 Zager et al., PMID 21463767 I recommend scooping (deep shave) most melanocytic lesions to acquire the breadth and depth of the lesion as much as possible. Superfic...
Would you still consider durvalumab consolidation after definitive chemoradiation for patients with Stage III NSCLC who are on stable weekly methotrexate dosing for psoriasis/psoriatic arthritis?
I would. Given the (now) long-term follow up with the PACIFIC trial showing an approximately 10% improvement in 5-year survival from 33 to 43% (Spigel et al., ASCO 2021, abstract 8511), I believe the risk of psoriasis flare is acceptable. I would have a discussion ("shared decision") with the patien...