Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
What is the role for angiography in the workup of digital ischemia?
Digital ischemia is an especially serious complication in patients with rheumatic disease, particularly scleroderma but can also be a feature of lupus, vasculitis (ANCA associated, PAN), antiphospholipid syndrome, and rheumatoid vasculitis, among others.The presence of digital pain with permanent/pe...
Do you measure drug levels (particularly hydroxychloroquine or mycophenolate) in your lupus patients?
Hydroxychloroquine levels: I absolutely measure hydroxychloroquine (HCQ) drug levels in my patients regularly. As I have mentioned in other answers here and in The Rheumatologist, measuring drug levels has transformed my clinic into a clinic where most of my SLE patients are in remission or have low...
How often do you order imaging to assess for possible degenerative joint disease in the spine in patients with neuropathic itch?
Only if the itch is localized, mainly unilateral like in notalgia paresthetica of the back or the forearm.
What are your preferred treatment options for patients with cholestatic pruritus who do not respond to light therapy?
Great question as in my experience phototherapy does not have high success rate for this. Agree that rifampicin can help quite a bit! Here is an algorithm you might find useful: Initially treat with a bile acid sequestrant such as cholestyramine (total daily dose of 4 to 16 grams) If this does no...
What is your approach to treating patients with chronic pruritus of unclear etiology?
After a thorough workup (which includes some or all of the tests below) I typically follow a treatment algorithm for Chronic Pruritus of Unknown Origin or CPUO. This includes empiric ivermectin or permethrin to rule out atypical scabetic itch (this has fooled even the most astute clinicians), topica...
How do you approach restarting biologics for psoriasis patients who have discontinued therapy for 3-6 months?
For patients that have missed just a couple of months, I just restart the maintenance dose. If they have been off the medication for 6 months or more, I prefer to start with a loading dose again.
What therapies do you use in patients with cutaneous lupus recalcitrant to topical steroids?
I agree with Dr. @Dr. First Last. In addition, strict photoprotection is absolutely key to clearing up cutaneous lupus of any severity. I also typically consider (and find to be helpful) mycophenolate mofetil if the patient is not responsive to first-line treatment (hydroxychloroquine). While useful...
What are some of your preferred treatment options for managing facial papules that occur in the setting of lichen planopilaris?
Low-dose isotretinoin is fairly established to help with facial papules in LPP. I typically do 20 mg per day although higher doses can be used for quicker disease control. Other than this, I have also had success with compounded topical ruxolitinib or tofacitinib in the past which I like for anti-in...
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.