Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
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...
How do you manage patients with suspected chronic contact dermatitis and negative patch testing?
The management is the same as for any other eczematous dermatitis. Topical steroids, methotrexate or dupilumab for severe cases. The real question is do you have the correct diagnosis and if so, are you missing a rare allergen?
How do you approach treating cutaneous PAN?
I've had personal experience with treating at least a dozen patients with cutaneous polyarteritis nodosa. The diagnosis was made by the clinical appearance of the lesions usually erythematous nodules that spontaneously may disappear leaving behind a livedo pattern. A biopsy of the lesion verified th...
How do you approach treating patients with erythema nodosum recalcitrant to NSAIDs?
Work up for the cause of ENodosum to determine if there is a trigger:TB, sarcoidosis, cocci/crypto/histo/blasto, Hodgkin's. ASO, dental abscess, Crohn's, ulcerative colitis, OCPs to name a few. SPEP possibly and or quant IGA with free light chains, just to name a few. Assuming all this is, you can d...
Would you offer palliative radiation for painful bone metastases in a patient with scleroderma?
Yes, I have treated a breast cancer patient before who had scleroderma and she really wanted to avoid mastectomy. Maybe I was just lucky, but no major skin reaction. Maybe less than average even. Her disease was not active at the time. For bone met palliation, I would use higher energy like 15X for ...
How would you treat localized cutaneous PAN recalcitrant to high-dose steroids?
There was a recent JAAD article on treatment: colchicine is the best first line if no neuropathy followed by steroid bridge to azathioprine (0.5-2.5 mg/kg/day) which was better than methotrexate. Here’s the article for reference: Bettuzzi et al., PMID 34224771.
How do you counsel patients regarding the cardiovascular and cancer risks associated with tofacitinib?
In my experience, trying to discuss incidence rates and hazard ratios with patients is usually met with a response such as, “So what does this mean for me?” Translating the incidence rates into the number needed to harm (NNH) provides objective numbers which are easier for them to understand. Treati...
How would you manage a patient with essential thrombocythemia and persistent pruritus despite adequate control of CBC with hydroxyurea and aspirin?
First, I'd make sure to exonerate any other causes of itching. Second, would make sure that supportive treatments like good skin care, anti-histamines, anti-depressants have been tried. I'd then consider if this patient truly has ET, as itching is more common in PV. Ruxolitinib is approved for patie...
How do you manage patients with chemotherapy-induced paronychia?
I manage patients with chemotherapy-induced paronychia with a few tricks: First, ensure that there is no infection (active drainage, especially purulent) is more indicative of infection, as well as appropriate hygiene. Topical steroids and soothing soaks (such as Domeboro or diluted distilled white ...
How do you manage patients with cicatricial pemphigoid refractory to doxycycline and dapsone?
In general, I’m rather aggressive about treating cicatricial pemphigoid given its ability to cause long-lasting sequela if left untreated and active. Pre-pandemic, rituximab was a common agent given its ability to put patients into a remission for extended periods of time. Now, given the data about ...