Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
How do you approach management of patients with psoriatic arthritis who have significant improvement in skin disease, but ongoing inflammatory arthritis despite multiple DMARDs and/or biologics?
Psoriatic arthritis is a heterogeneous disease and often the severity of MSK involvement and psoriasis are not well correlated. This is also true regarding treatment response. The approach to management in these cases depends on several factors:Psoriasis type and severity: If the patient has mild ps...
How would you counsel a patient with systemic sclerosis who wants to consider microneedling on the face or other skin which is not clearly involved with scleroderma?
Microneedling is a cosmetic procedure that utilizes multiple small needles to create tiny holes in the skin that stimulate the skin’s own "healing process", which, entails the production of collagen and elastin. While regardless of the specific device used, it is considered a relatively safe procedu...
How would you treat a basal cell carcinoma on the temporal skin and zygomatic area s/p excision with PNI and significant flaps for closure?
This case is a challenge as it is not clear what the indication for PORT is. Margin status is important, so discuss with the surgeon, and if positive, can a repeat resection occur, likely not given the presence of the flaps, however. The guidelines from 2019 are a neat and logical review that establ...
What treatment options would you recommend for a patient with severe generalized pustular psoriasis who has a history of colon cancer (s/p chemotherapy) and well-controlled HIV?
I'd feel comfortable doing an IL17 or IL23. Bimekizumab would be my first choice with it's higher efficacy with almost all types of psoriasis. There's also a small dataset showing it worked quite well for GPP in a subset of japanese patients. IL36 is my favorite drug for GPP but I'm not aware of an...
How would you manage active psoriasis and psoriatic arthritis in patient on Rituximab and prednisone for MPO positive vasculitis?
The answer is it depends on several factors, the most important being how severe the psoriasis is and if the patient has axial involvement. Since the patient has failed or not responded to methotrexate or apremilast, adding these would not be an option here.While we do not have much data on combinat...
What is your treatment approach for hidradenitis suppurativa?
In HS, we talk about a "window of opportunity." It's the idea that since HS causes tissue damage, scarring, and tunneling, treatment becomes more difficult as the disease progresses. A delay of 10 years between symptom onset and starting adalimumab was associated with a 1.92x higher odds that the pa...
What methods do you use to prophylactically reduce radiation dermatitis for head and neck irradiation?
My approach has been: Start Remedy (less greasy but less effective) and/or Aquaphor (more greasy but more effective) 3-4x daily at beginning of RT. Try to use Aquaphor at least at night when the greasiness is less bothersome. If patients have some other alcohol-free/non-anti-oxidant product they re...
When is mechlorethamine better than more common treatments like light therapy and topical steroids for mycosis fungoides?
Topical mechlorethamine and light therapy are both treatment options for mycosis fungoides, but they have different advantages and disadvantages depending on the patient's individual history and circumstances. Topical steroids are rarely used alone as their long-term use results in skin damage (skin...
How has the recently FDA-approved topical cantharidin altered your molluscum treatment algorithm?
I recommend the use of topical cantharidin on a limited number of lesions, since the blistering can be painful especially in young children. Moreover, by treating a few lesions you may trigger an immunologic reaction that results in spontaneous resolution of untreated lesions as well. Moreover, we p...
How would you sequence lifileucel (TIL therapy) in a patient with metastatic melanoma who is BRAF wild-type (BRAF WT) and progressed on adjuvant Nivolumab?
The FDA-approved label for Amtagvi is for BRAF wild-type metastatic melanoma patients who progressed following anti-PD-1 containing immune checkpoint therapy. Thus, progression following ipi/nivo would certainly meet the indication for TIL therapy. What you will have to assess though is whether the ...