Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
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...
What is your approach to counseling patients on the safety and side-effect profile of a biosimilar compared to its reference biologic?
Relevant question as insurance companies may require a biosimilar over the reference biologic. According to the FDA, the spin-off (my term) must be "highly similar" to the original in both efficacy and safety. Approval is based on review of clinical trial data. As for my approach: until proven other...
Do you add encapsulated benzoyl peroxide before escalating to oral doxycycline in moderate to severe papulopustular rosacea?
I personally do not, as I'm a little concerned about further irritating their skin (though I understand encapsulation is meant to negate exactly that). Occasionally, I will consider starting this if they have overlapping acne (rather than rosacea alone).
When do you recommend HLA testing prior to prescribing lamotrigine, carbamazepine, or oxcarbazepine to patients of Asian descent?
This is one of the few actionable tests to avoid the more frequent occurrence of DRESS (Drug Rash with Eosinophilia Syndrome) or SJS (Stevens-Johnson Syndrome). Practically speaking, it is unusual for clinicians to have these HLA tests available in a fashion timely enough to match the usual need for...
How would you treat a patient with basal cell carcinoma of the medial canthus, with ultimately negative margins after Moh’s surgery, if tumor was “peeled off bone?”
I would treat this patient based on a conversation with the dermatologist, not the PA or other assistant. I'd tell the office that I need the dermatologist to give me 15 minutes and to have all the slides ready for review of what was actually removed, as the periosteum is a good barrier. I reckon th...
What clinical features do you value most when evaluating a patient in whom you suspect CSU?
For me, I think/ask myself: “Does the morphology and behavior of this eruption actually fit the diagnosis of CSU?” vs., sometimes our colleagues may be thinking first -- ?? Are these “hives”? “What laboratory tests and panels should I order?” CSU is defined by spontaneous recurrent wheals, angioedem...
Have you used itraconazole as a primary or adjunct therapy for individuals with numerous BCCs?
Yes. I use itraconazole 100 mg daily with sonidegib 200 mg (daily or less frequently, depending on tolerance, but no less than twice a week) in every patient who shows a resistant SMO mutation on an NGS panel. I test all patients at baseline and at recurrence to determine what treatment to offer.
How do you approach patients who identify so strongly with being sick or with a particular diagnostic label that it makes up a significant portion of their identity?
In many cases, the point at which this question is being asked is one at which the train has already left the station, and sickness as a way of life/career has set in. Unfortunately, with functional somatic syndromes, there is data suggesting that self-rated quality of life and functioning are lower...
How do you tailor rituximab dosing for mucosal-predominant vs mucocutaneous pemphigus?
In pemphigus specifically, my approach to dosing rituximab is not typically dictated by clinical phenotype. Interestingly, while anti-desmoglein 1 antibody level reductions following rituximab have been correlated with improved treatment response when compared with desmoglein 3 antibody level change...
What lab monitoring and frequency do you recommend in an otherwise healthy young patient on biologics for psoriasis?
Yearly QuantGold testing in low risk patients has been shown to be unnecessary and actually carries a significantly higher risk of false positive than true positive. Unfortunately, many insurers still require yearly testing. I don't know of any data to support any other yearly lab testing for the dr...