Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
What is the most appropriate next step in management for a patient with dermatomyositis who is maintained on methotrexate 25 mg weekly but develops disease flare when prednisone is tapered below 10 mg daily and is unable to receive IVIG?
The fact that the patient cannot taper prednisone below 10 mg indicates that methotrexate alone, while has some effect, is not sufficient to control the disease. There are several options, depending on the severity of each organ involvement. Since the joints are affected, I would favor an agent that...
When managing acute vascular compromise secondary to hyaluronic acid filler, what initial hyaluronidase dosing protocol do you employ, and do you find clinical value in traditional adjuncts like aspirin, nitroglycerin paste, or hyperbaric oxygen?
Whether it is acute vascular compromise due to cannulating the vessel, it is now believed best to flood the area with hyaluronidase. I have 6 vials of Hylenex and 2 vials of Vitrase in my fridge at all times in case of emergency. Usually, if you are performing hyaluronic fillers, going slow and obse...
Would you recommend against use of dupilumab for severe atopic dermatitis in a patient with a history of neonatal HSV meningitis but no history with recurrent outbreaks?
No, dupilumab may be used if the patient's atopic dermatitis remains moderate to severe with standard topical treatments. I am assuming this child has history of HSV meningitis, likely in the context of eczema herpeticum. Dupilumab lowers the risk of recurrent skin infections, including HSV.
How should the results of the ADVOCATE trial be applied in AAV patients who receive rituximab induction and maintenance therapy?
The following answer was jointly drafted by Dr. Peter Merkel and Dr. David Jayne:The data from ADVOCATE indicate that patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) treated with avacopan 30 mg twice daily and prednisone placebo were able to achieve remission w...
How do you manage worsening cutaneous dermatomyositis when muscle disease appears controlled?
The fact that the patient still has an active pruritic rash while tapering steroids suggests that the current regimen isn't fully controlling the disease, and it can affect quality of life. I would consider adjusting immunosuppression, either adding another agent or switching therapies. The specific...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
What do you tell patients about swimming in the ocean or in lakes after biopsy or surgical procedure?
Bandages, no matter how waterproof, can leak due to patients' motion underneath the bandage. Consequently, I recommend that patients avoid soaking in water until after any sutures are out. It takes about two days following suture removal for the holes left by the sutures to seal up. I am not aware o...
If adjuvant radiation is offered to an elderly patient with H&N SCC s/p Mohs surgery who is planned for multi-stage reconstruction of the defect with plastic surgery, when should adjuvant radiation be started?
Tumor control comes first. If the surgical defect is such that reconstruction is required, it is even more imperative to focus on the above principle, as a recurrence would almost certainly risk ruining the entire collective effort. Vascular flaps could be safely performed post-RT in most cases by s...
In patients with progressive, isolated nail lichen planus refractory to intralesional corticosteroid injections, which oral systemic agents have demonstrated the greatest clinical efficacy in your practice?
Oral JAK inhibitors have good efficacy, including tofacitinib, baricitinib, and upadacitinib, if you're able to get any of these covered. Otherwise, oral low-dose naltrexone (3 mg daily) can also be efficacious in patients.
What is your baseline protocol for total-body skin exams in patients with systemic sclerosis on immunosuppression: routine annual/biannual screening or interval follow-up tailored strictly to personal skin cancer history?
I don't know of much evidence around this but it does seem clear that attempting to stratify risk based solely on immunomodulatory medication doesn't make good clinical sense; it does seem that the patient's baseline risk is still highly relevant and likely the primary driver of overall risk. In mos...