Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What treatment modalities have you had success in treating perioral or periorbital dermatitis when they have failed Topical calcineurin inhibitor and oral antibiotics?
The first line is typically metronidazole and/or clindamycin. Topical ivermectin is also a very reasonable approach, and sulfacetamide can help as well. I typically use these before topical calcineurin inhibitors. Rarely TCIs can worsen demodex as has been reported. Which oral antibiotics? Doxycycli...
What's your treatment algorithm for notalgia paresthetica?
Topical steroids + dermeleve (otc anti-pruritic) cream ILK versus other OTC topicals (capsaicin, Sarna, pramoxine) versus compounded gabapentin, amitriptyline, lidocaine (my main go-to second line) Oral - gabapentin vs doxepin vs desipramine Recalcitrant cases I’ve added dupilumab or phototherapy w...
Are there any instances when you use vitamin B6 to prevent kidney stones in patients with recurrent calcium oxalate nephrolithiasis who do not have primary hyperoxaluria?
I occasionally try empirical vitamin B6 in patients with hyperoxaluria that does not respond to usual dietary oxalate restriction plus low fat and higher calcium. I have not done it systematically and have only a handful of cases where it may have helped. Thus, I would not recommend routinely adding...
When do you refer a patient with MODY3 to GI/Hepatology for monitoring/management of hepatic adenomas?
As you know, maturity-onset diabetes of the young type 3 (MODY 3) is a consequence of heterozygous germ-line mutations in HNF1A. In addition, hepatocellular adenoma (HCA) may be caused by somatic HNF1A mutations. There are approximately a dozen cases reported of individuals with MODY 3 and HCA (1). ...
How would you approach rheumatoid arthritis treatment for widespread large rheumatoid nodules but no active synovitis or subjective joint pain?
One needs also to consider drug-induced accelerated nodulosis. I used to see it more often in the 1990s from methotrexate, but since then, it has also been described with other drugs like TNF inhibitors and leflunomide (Patatanian & Thompson, PMID 12222551, Ahmed et al., PMID 11470988, Akiyama et al...
What is your approach to managing patients with recurrent nephrolithiasis who have 24 hour urine chemistry results that demonstrate low risk for stone formation but continue to experience stone events?
My first question is what constitutes a "kidney stone event"? If it is a stone passage, l know of no treatment that will "glue" pre-existing stones in place. Uric acid and cystine stones can be dissolved, however. If the event is the formation of new stones or the growth of preexisting stones with n...
Would you recommend switching a diabetic CKD patient on oral semaglutide to the subcutaneous form since the benefits in CKD have primarily been reported in studies using subcutaneous GLP-1 receptor agonists?
Personally, I would not do so today. Obviously, the patient was prescribed oral semaglutide (SEMA) as opposed to injected SEMA for some reason. Assuming that the reason persists (e.g., preference for oral, greater availability) and the response with respect to A1c and weight has been reasonable, I w...
Does norethindrone suppress FSH, LH completely?
I don't think progesterone alone would suppress LH and FSH completely so other pituitary hormones should be checked and if low, check MRI of sella. Also check for other exogenous hormone use/OTC supplements.
Do you consider skin involvement associated with tattoos to be a marker of disease activity and an indication to start treatment in a patient with sarcoidosis?
Some patients give a clear history of swelling/pain/itch of tattoos coincident with extra-cutaneous symptoms. Others report no relationship. The variability may be related to the age, number, and size of the tattoos and the pigments they contain. Tattoos that cause symptoms should certainly be treat...
How do you counsel patients on migraine "triggers"?
What often triggers headaches or migraines is not just one factor acting alone, but rather a combination of triggers compounding together. Consequently, it's generally more effective and less demanding to prevent triggers from compounding, rather than avoiding them altogether. However, the first ste...