Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
Do you routinely perform de-fatting for full thickness skin grafts?
I de-fat full thickness skin graft skin simply because I am concerned about optimal graft take. I do realize, however, that leaving some fat behind may in some circumstances not interfere with graft take. Some feel that leaving fat behind, such on scalp grafts, may promote better contour fill of the...
What is your approach to diagnosis and treatment to intermittent cheilitis that does not respond to anti fungal therapy?
Clinical features matter. The differential is broad: granulomatous cheilitis, contact dermatitis, irritant dermatitis, lichen planus, and I have even seen SCLE present with cheilitis. Biopsy during a flare can be helpful even if only to rule out some possibilities, and a 3mm punch typically heals qu...
How would you treat disseminated flat warts in an immunosuppressed patient with skin of color?
Hard to imagine Imiquimod working in a dry wart. Thinking back to the genital studies... only the occluded (moist) warts responded. I generally try to curette them over several visits. Compounded cidofovir (off-label, etc.) might be the best bet.
Where do oral and topical JAK inhibitors fit into your treatment algorithm and approach to atopic dermatitis?
When considering systemic treatment for dermatitis, I perform extended patch testing based upon patient's history of cutaneous contactants. This identifies patients with dermatitis that can often be cured by avoiding cutaneous and systemic (i.e. ingestion) exposure to identified allergens. Patients ...
How do you counsel patients who inquire about microplastics in their cosmetics or physician-dispensed products given emerging associations with conditions such as psoriasis, eczema, lupus, and hormonal disruption?
That’s a really good question. It is absolutely true that patients are increasingly aware of environmental exposures, and microplastics in personal care products. When I address it with my patients, I tell them that there is ongoing research on microplastics in cosmetics and personal care products. ...
When would you pursue genetic testing for severe recalcitrant atopic dermatitis?
Not an easy question to answer, but severe and treatment-refractory AD, especially if early onset, is concerning for immune dysregulation and should warrant immune evaluation early. By treatment-refractory, I do not just mean topical therapies, but attempts to control the Th2 pathway that fail repea...
If you’re transitioning laterally between biologic classes due to adverse effects, do you repeat the loading dose?
I do usually repeat the loading dose when starting a new biologic, even if in the same class. If there is data on whether or not you should do this, I am not aware of it.
How do you approach the workup and initial treatment of systemic AL amyloidosis?
1: Ensure that this is light chain. Mass spectroscopy of the tissue to identify/confirm is very important. Even if a patient has positive serum monoclonal protein or light chain, it does not indicate that this is light chain amyloidosis. I have had patients with MGUS and smoldering myeloma with ATTR...
Do you recommend work up for POEMS and/or amyloidosis for IgM monoclonal gammopathies associated with neuropathy?
While IgM monoclonal disorders, amyloidosis, and POEMS syndrome may all be associated with peripheral neuropathy, they are not often confused with one another. A patient with a peripheral neuropathy can be diagnosed most simply by a serum protein electrophoresis. The presence of a monoclonal IgM spi...
How extensive of a workup do you do for systemic AL amyloidosis for a patient with a resected amyloidoma, localized AL amyloid deposition in their airway or lungs, who has no other symptoms?
It's common to over-test in these patients. We in hematology/oncology, often order bone marrow biopsies, PET/CTs, and cardiac MRIs without realizing that each test costs around $10,000 and can potentially harm the patient.Here are two points to assist with the work-up for these patients: Understand...