Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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.
What is your approach to treating patients with lichen planopilaris who do not respond to hydroxychloroquine?
I have a few patients with progressive disease who have not responded to oral hydroxychloroquine or oral Doxy. For these, CellCept, either as monotherapy or as an add-on to Plaquenil is an option.There are many studies showing the efficacy of CellCept as monotherapy but I know my colleagues in acade...
How do you manage patients with alopecia totalis who are not candidates for JAK inhibitors?
Severe forms of alopecia areata are very difficult for the patient and provider. The first step in management is to assess where the patient is emotional. How are they managing? What support systems are in place? Once this is addressed, I discuss my treatment ladder. Initial options include class I ...
What is your approach to starting and monitoring methotrexate in elderly patients?
For the elderly, I start 10 mg weekly and get CBC/CMP at 2 weeks followed by monthly x3 then q3 months indefinitely.
How do you approach treating patients with acne keloidalis nuchae who do not respond to a potent topical steroid or retinoid?
For mild disease, topical steroids and topical clindamycin solution alone or in combination with benzoyl peroxide wash or gel are recommended. It is also important to counsel patients to reduce friction to the area (usually the occipital scalp) and avoid cutting hair close to the skin. For moderate ...
How do you manage patients with chronic flushing that do not respond to beta-blockers?
Firstly, I like to make sure the cause of flushing isn't something systemic like carcinoid, mastocytosis, or paraneoplastic. If the patient does have rosacea, I like to get the inflammatory part of rosacea under control with topicals like azelaic acid, a topical TCI (like Elidel), or topical iverme...
How do you manage patients with chronic telogen effluvium?
Chronic telogen effluvium is distressing to patients and a challenge to manage. First, I do a thorough lab evaluation looking for any underlying condition that may be contributing such as anemia, liver/kidney disease, thyroid disease, hormonal abnormalities, and nutritional deficiencies (iron, zinc...
When tapering moderate to high doses of long term steroids do you routinely monitor for adrenal insufficiency?
This is always a good question on which to reflect. In general, moderate dosing of steroids (> or = 20 mg prednisone equivalents) for 5 days or less do not need a taper and pose low risk of adrenal suppression, and by extension chronic adrenal insufficiency. Up to date suggests that up to 3 weeks is...
How do you treat celiac disease associated inflammatory arthritis refractory to gluten free diet?
There is no good evidence based answer to this great question. In general, if celiac patients have persistent symptoms and exam findings of inflammatory arthritis or enthesitis, I offer non-biologic DMARDs depending on the severity of symptoms. If very mild, we can use hydroxychloroquine and escalat...
Is there any adjunct therapy to help with tamoxifen-induced leg cramps?
When a patient is complaining of leg cramps, it is important to make sure that the patient is not complaining of signs or symptoms of a deep vein thrombosis. If this is not a concern, one may consider checking electrolytes to make sure no other potential explanation. Otherwise, tonic water can be he...