Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
How do you approach patients with early stage resected melanoma (Stage IIA) for adjuvant treatment?
The current guidelines do not recommend adjuvant treatment for patients with stage I/IIA disease outside the setting of a clinical trial. Major trials including the KEYNOTE-054 and CheckMate 238 have excluded patients with early stage I/IIA disease. However, in patients with stage IIB/IIC disease ad...
How do you approach patients with a new primary melanoma, not an in-transit metastasis, while on adjuvant immunotherapy/treatment for a previous melanoma lesion?
This is tough because of the paucity of data to answer the question. In my practice, I recommend patients who develop a new primary melanoma undergo standard-of-care therapy for the new melanoma (e.g., WLE +/- SLNB).
How would you approach a recurrent, cutaneous SCC of the face with high-risk features s/p resection?
Likely previously treated with 6 MeV. Reirradiate the primary site and track nerves to skull base. Electively treat the regional nodes.
How do you approach patients with polypoid/nodular melanoma for adjuvant therapy when Breslow depth is not available on pathology?
If it is nodular, the depth of invasion (Breslow) starts from the outer edge of the lesion vertically down and perpendicular to the dermis, so most likely if polypoid, it will be at least 3 or 4 mm, thus T3 or T4. If ulcerated, T3b or T4b.
What histologic findings most commonly lead you to order additional staining for potential desmoplastic melanoma?
I am pretty liberal on ordering IHC stains to rule invasive melanoma in or out. If I see anything questionable like atypical or spindled cells in the dermis, I will order for sure. However, I often do SOX10 and PRAME on MIS biopsies to help with margins, so I usually have them done in most cases any...
How would you approach patients receiving neoadjuvant pembrolizumab (SWOG 1801) for melanoma with no response to systemic treatment?
There isn't a definitive answer to this question as patients without a pathologic response tend to have the worst outcomes in terms of relapse-free survival outcomes. There is no prospective data to support the change in treatment strategy from single agent to dual agent, especially in the absence o...
Would you hesitate to give breast radiation to a patient with prior near-fatal Stevens Johnson medication reaction?
Although this is an extremely rare occurrence when looking at the literature on this subject, limited to case reports/series, I think that I would hesitate to give breast RT in this case. This is based on the fact that in this case, it is DCIS that is being treated, and despite the DCIS being recurr...
How would you treat a periungual squamous cell carcinoma of the thumb?
Digit-sparing margin-negative excision if possible. If amputation is the only surgical option, then consider definitive RT, reserving surgery for salvage.
Are there special recommendations for the use of hydroxychloroquine and methotrexate together?
In my view, there are no considerations to make when combining these therapies. I’m not sure what the person asking the question was concerned about.
How would you interpret a positive single specific markers like SSA or SSB in setting of working up an connective tissue disease, especially when ANA is negative?
Ha! Good question. And this is an issue I literally just talked about with our residents during an autoimmune labs lecture that I give. If you have a negative ANA by IFA (immunofluorescence assay), the sensitivity of such a test is extremely high (99%) as hundreds of antinuclear antibodies are scree...