Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When should you discontinue narrow band UVB when a patient is in clinical remission from patch stage mycosis fungoides?
It depends on the patient, and whether they have a history of flaring after stopping phototherapy. In that setting, maintenance phototherapy (once weekly or sometimes every other week) may be helpful.
What recommendations do you have for a transgender female patient with history of prothrombin gene mutation who is interested in starting gender affirming hormone therapy?
A review of the literature suggests that the risk of VTE associated with hormone therapy in this setting is quite low, even in the presence of other risk factors for clotting (see, for example, Mullins et al., PMID 33753543). Furthermore, the presence of an asymptomatic prothrombotic genotype is rar...
Do you continue to routinely screen for renal involvement in a patient with established Sjogren's syndrome who otherwise has only sicca symptoms?
In an article published in Rheumatology and Therapy in December 2021 titled Renal Disease in Primary Sjogren's syndrome. The authors encouraged yearly screening for renal disease as it can occur at any time during the disease course.
How do you manage calcium and vitamin D replacement in scleroderma and myositis patients with dysphagia and malabsorption?
Dietary calcium is a good choice. I recommended that my patients with dysphasia caused by scleroderma drink 2-3 glasses of skim milk daily. 8 ounces contain 300 mg of calcium which is highly bioavailable. It also provides a good source of whey protein that contains all the essential amino acids. Ano...
Other than B12 repletion, is there any further treatment or work-up indicated in pernicious anemia with positive parietal cell antibodies?
Pernicious anemia is an autoimmune disorder that can occur as a componet of multiple endocrine adenopathies, so evaluating the patient for thyroid, parathyroid, adrenal, etc. disorders is indicated both short and long term. More controversial is how to monitor the increased risk of stomach cancer as...
What treatment options do you recommend to patients with microstomia secondary to scleroderma?
Perioral and masseter botox 8U upper lip and 4U lower lip. 16U per masseter.
What dressings do you recommend for patients with hidradenitis suppurativa to help prevent friction and collect drainage from open areas?
My favorite is a dressing/garment called Hidrawear. It’s clothing made specifically for HS with pockets to hold bandages for drainage. Patients can pay out of pocket, but it is also covered by some insurances. Order forms are available through the website: https://hidrawear.com/ Otherwise, the pati...
What diet modifications do you recommend for patients with acne to help prevent breakouts?
For those motivated to make dietary changes, I recommend avoiding high-glycemic index food, dairy (especially skim milk), and red meat. I do recommend a Mediterranean diet enriched in vegetables, legumes, fish, as well as vitamin D and zinc.References: Meixiong et al., PMID 35373155 Hasamoh et al.,...
What is your treatment approach for steroid-refractory necrobiosis lipoidica?
I have never had success treating NLD. I have seen rare spontaneous improvement over the course of several years however.
Do you offer anticoagulation to patients with prior antiphospholipid antibodies detected in pregnancy without a history of pregnancy loss or thrombosis?
I do not know what the risk of pregnancy loss is in a woman without a prior history of VTE or pregnancy loss. I am sure the risk is affected by whether the woman has an underlying rheumatological disease (SLE) and whether she has single positive vs. triple positive LAC. I recommend a baby aspirin on...