Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
What additional workup do you pursue in a patient in whom you suspect Yellow Nail Syndrome?
Mandatory pulmonology (and/or ENT for sinusitis) for comorbit workup or monitoring. Detailed ROS for eval of any underlying disease and workup as indicated. Age-appropriate cancer screenings.
Do you obtain MRI for cutaneous SCC with microscopic PNI to assess for gross perineural tumor spread?
I would recommend both an MRI as well as consulting the pathologist regarding the exact nature of the PNI. We had an experience with more than 100 patients (Sapir et al., PMID 27475277). Those with gross PNI (evidenced by MRI, with or without cranial nerve deficit) and microscopic extensive PNI (>2 ...
How do you approach melanoma patients with a positive sentinel node with extra-nodal extension for definitive surgical management?
This is a multidisciplinary question so I reached out to our surgical oncologist (Dr. @Dr. First Last) at the Ohio State University Comprehensive Cancer Center for his thoughts as well. This is a grey area as the patients with extra-nodal extension (ENE) were not specifically studied in the landmark...
How should one manage a non-healing wound with tunneling at the site of a cyst excision on the back, now two months postoperatively, with negative wound cultures and in the context of a self-pay patient?
"Non-healing wound" suggests persistent granulation tissue or similar exam findings, which in the context of tunnel formation at the site of follicular cyst raises my concern for hidradenitis suppurativa (if only a diathesis toward follicular occlusion in a patient without a history of HS). If there...
What is your approach for workup and management of prurigo nodularis?
For work up of prurigo nodularis, I generally order a CBC/diff, CMP, and TSH to assess for underlying causes of pruritus.For management, I emphasize the importance of avoiding manipulation and suggest covering lesions with band-aids to minimize scratching. I start with topical and intralesional ster...
Do you anticipate trying nemolizumab in patients with other difficult to treat pruritic conditions?
I have already used this drug in a multitude of off-label indications, including but not limited to lichen simplex chronicus, acne keloidalis nuchae, keloids secondary to acne fulminans, delusions of parasitosis, itch of unknown origin, nostalgia parasitic, scrotal pruritus, and occipital neuralgia.
What are your recommendations for managing perivascular dermatitis with eosinophils unresponsive to high-dose antihistamines, a prednisone taper, and topical steroids?
I would check and treat for scabies.
What is your treatment algorithm for excoriation disorder?
Neurotic excoriation, also known as skin-picking disorder or excoriation disorder, is part of the obsessive–compulsive spectrum. There is no FDA-approved pharmacological treatment. The gold standard, evidence-based therapy is Habit Reversal Therapy (HRT), a form of cognitive behavioral therapy that ...
How would you approach treatment of an elderly patient with recurrent atypical fibroxanthoma (malignant spindle cell neoplasm) after Mohs surgery?
We published our experience of 8 cases of scalp atypical fibroxanthoma treated with XOFT 50 KeV photons as primary therapy. At 24 months, there was one failure which occurred in the only patient who was not debulked prior to radiation therapy.Treating with low energy photons or electrons after the r...
What is your preferred stain for melanocytic lesions?
Our lab uses all the listed stains. Which one(s) depends on context + question. Results will inevitably vary between labs. Currently, PRAME and SOX-10 are our two most popular. Nevus vs melanoma. PRAME, as an ancillary diagnostic test. Definitive confirmation of melanocytes (vs non-melanocytes) bey...