Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
What are your preferred alternative biologic agents for Blau Syndrome when anti-TNFα therapies are contraindicated?
As is true for most of us, I have limited direct clinical experience treating patients with Blau Syndrome. I have treated members of several families and am convinced that corticosteroids are effective and fraught with long-term toxicity. As the question implies, a TNF inhibitor (specifically a mono...
Can Dupixent (dupliumab) be safely used in patients who are taking other biologics for rheumatic disease?
This is a really broad question given how many biologics exist now, but the answer is likely yes, given its outstanding safety profile. I have used it concurrently with other biologics on many occasions without any issues so far. As concurrent use increases, we may find out more if there are any "tw...
How often do you draw screening ANAs for discoid lupus?
Because a positive ANA is associated with an increased risk of progression to SLE in patients with discoid lupus, I routinely check an ANA at the initial visit in virtually all patients. If negative, I repeat it only if new symptoms concerning systemic involvement arise (e.g., joint pain, cytopenias...
Do certain subtypes of BCC respond better to hedgehog pathway inhibitors?
I have found that the larger the BCC, the more dramatic the response (unfortunately, not all tumors respond). These are invariably of the nodular/infiltrative subtypes for which hedgehog inhibitors are indicated.
What topical therapies have you found most effective for managing scalp psoriasis?
For tough scalp psoriasis, I use an old regimen. 10% LCD 2% Sal acid in olive oil applied tiw x 1 hour under a shower cap. This is then washed out with a zinc-based shampoo followed by the application of a potent topical steroid. This is labor intensive but can be incredibly effective and sometimes ...
How do you counsel patients with dermatomyositis on sun protection?
We make sure patients know that sun exposure can trigger flares, so we strongly recommend staying out of direct sunlight between 10 AM and 4 PM, using broad spectrum, SPF30+ sunscreen daily even when indoors (as UVA can penetrate through windows), and wearing sun protective clothing (ideally UPF-rat...
How would you approach adjuvant RT for porocarcinoma of the face?
The reported outcomes after surgery in the published literature are all over the place. With some saying surgery alone is adequate and others reporting that these have a high incidence of local, in-transit, and regional recurrence. I tend to treat these with Merkel cell carcinoma volumes.
How would you palliate a large, symptomatic vaginal melanoma recurrence with limited small pelvic lymph node metastases?
Palliation. Treat problems that are symptomatic. No expensive systemic work up. Pall RT to the pelvis if it’s symptomatic. 30 Gy/10 fractions, 25 Gy/5 fractions, or 20 Gy/2 fractions with a 1 week inter-fraction interval. Apologize for the lengthy response.
What is your approach to managing Grover's Disease (Transient Acantholytic Dermatosis) that has failed topical steroids?
I'm a big fan of low-dose naltrexone for Grover's Disease (and Hailey-Hailey and Darier's Disease). It's a safe and effective treatment that I've seen work very well. The dose ranges between 1-5mg daily. It seems like 3mg is often the sweet spot. Patients sometimes report more trouble sleeping and/o...
What are the most effective treatments for flat warts on the face?
Facial flat warts are notoriously difficult to treat. I’ve had success using Tretinoin 0.025-0.05% cr HS MWF HS and iniquimod 5% cr sparingly on the lesions only HS T and Th. It is often slow but steady progress without scarring as long as the patient does not have significant actinic damage.