Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you consider use of an oral bisphosphonate (such as alendronate liquid) in a patient with eosinophilic esophagitis?
My general approach to patients with any form of esophagitis for whom bisphosphonate therapy is indicated is to treat with zoledronate. I am not aware of any data that has reviewed the use of a liquid form of a bisphosphonate for patients with esophageal disorders including eosinophilic esophagitis,...
How do you evaluate and treat patients with suspected POTS?
POTS is diagnosed based on increased heart rate of more than 30 beats per minute in adults and more than 40 beats per minute in adolescents with no major drop in blood pressure from supine to standing or after tilt table from supine to 70 degrees upright. Many patients have POTS as an isolated cond...
Is it ever appropriate to reduce urate lowering therapy dose due to very low urate levels?
In my opinion, there are no known adverse outcomes related to very low serum urate levels. Suspected, but not proven, associations of dementia with sustained hypouricemia, have been used to create an impression that there may be one benefit of avoiding hypouricemia. There are multiple reasons for no...
How long after completion of radiation therapy should patients continue fluoride treatment for dental health?
Indefinitely
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 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).