Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
How would you approach diagnosis of a patient with recurrent episodes of abdominal pain, severe myalgias, low grade fevers and urticaria?
Without the mEFV variant, from a rheumatologist viewpoint, the differential includes IBD, a periodic fever syndrome such as FMF or FCAS, and MCAS. Therefore, I would consider that workup with genetic testing (anyone can send!), fecal calprotectin, and MCAS eval with A/I. I don't think of urticarial ...
Do you reduce the dose of hydroxychloroquine in patients with skin graying if they are not particularly bothered by this side effect?
I wouldn't if they're not bothered, but I would think to look into their HCQ blood levels... we know that certain doses of HCQ are more effective in controlling disease activity than others, and that of course, higher levels may be associated with adverse effects, not just in the skin.
What is your late or no-show policy for patients?
I'm really interested in reading answers by those of you who have punitive policies for these patients. I wrestle with these problems several times per week, as I have Mohs surgery patients either no-show or cancel/reschedule with less than 24 hours' notice. On the one hand, I find that most patient...
What treatment options are there for uremic pruritus in an elderly patient with risk of sundowning?
Uremic pruritus is increasingly recognized as a multifactorial condition involving peripheral neuropathy and immune dysregulation, particularly upregulation of type 2 cytokine pathways. Dysregulated opioid signaling further contributes to itch amplification. Accordingly, κ-opioid receptor agonists, ...
How do you educate patients about the risks of actinic keratosis progressing to skin cancer?
I use verbiage from Dr. Kirby’s excellent study to describe risk appropriate to the patient’s history. Except in immunocompromised or patients with a history of SCC, I avoid characterizing AKs as “pre-cancer” so that they can make a value-informed choice regarding observation vs treatment.Berry et a...
What is your preferred method of wound closure after wide excision for hidradenitis suppurativa?
My favorite is always secondary intention healing. It has the best outcomes and the least risk of recurrence, plus it's the easiest since you don't have to do anything. It is important to counsel patients ahead of time, and I find it helpful to show them some photos. When they see the open wound, it...
What clinical scenarios warrant the use of a skin substitute?
Chronic wounds like diabetic and venous leg ulcers are the most common clinical indication, especially when healing fails to progress after standard wound care. Extensive full-thickness burns are also a primary indication, particularly when there is insufficient donor skin available for autografts o...
What psychiatric medications do you feel comfortable prescribing as a dermatologist?
What is the most appropriate next step in management for a patient with dermatomyositis who is maintained on methotrexate 25 mg weekly but develops disease flare when prednisone is tapered below 10 mg daily and is unable to receive IVIG?
The fact that the patient cannot taper prednisone below 10 mg indicates that methotrexate alone, while has some effect, is not sufficient to control the disease. There are several options, depending on the severity of each organ involvement. Since the joints are affected, I would favor an agent that...
What topical regimens do you recommend for redness related to rosacea in patients who defer laser treatments?
Naturally, laser is the most ideal and best solution. Green-tinted makeup is also a great adjunct. Aside from the usual routine counseling (avoidance of sun, food triggers, etc.), one product that I have found remarkable results with is the compounded SkinMedicinals ET-Rosacea Cream, which contains ...