Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
What is your approach to treating patients with melasma that does not respond to hydroquinone-based topical therapies?
This is my Melasma algorithm: Hydroquinone triple cream qhs x 6 months + azelaic acid in the AM + tinted sunscreen Consider PO TXA (half of 650 mg tab bid), polypodium leucotomos bid (heliocare) Maintenance: stop hydroquinone and switch to compounded TXA/kojic/tretinoin combo cream qhs + vitamin C/...
What topical and oral therapies do you prescribe for patients with recalcitrant melasma?
This is my Melasma algorithm: Hydroquinone triple cream qhs x 6 months + azelaic acid in the AM + tinted sunscreen Consider PO TXA (half of 650 mg tab bid), polypodium leucotomos bid (heliocare) Maintenance: stop hydroquinone and switch to compounded TXA/kojic/tretinoin combo cream qhs + vitamin C/...
How are you utilizing vibratory devices for reducing pain associated with injection or procedures?
Specifically for intra-articular/bursal/tenosynovial/carpal tunnel injections: Our office purchased the vibration distraction devices over a decade ago based upon the promising use from the pediatric literature. Our providers were underwhelmed with their use in our adult patients and we all stopped ...
What alternative therapies do you recommend for botox non-responders?
For non-responders, I recommend waiting longer between injection sessions, trying different brands especially those with less protein associated with them such as Xeomin which has the least amount of protein, and therefore, less likely to trigger the development of neutralizing antibodies. In some c...
What laser and topical therapies have you found to be most effective for post-inflammatory hyperpigmentation from acne?
While the most important issue is to mitigate and reduce the active acne, but once that has been performed, 1 can use a combination hydroquinone, retinoid cream, tend to avoid steroids with the acne. Also very gentle fractional 1927 nm lasers can be used as well as laser toning with a pico second or...
Are there situations in which you treat calcinosis cutis that is not symptomatic for the patient?
There is NO treatment for either the prevention of calcinosis or the dissolution of calcinosis. Every 5-10 years over the past 40 years there have been potential treatments but none have been confirmed. I do not use anything specific for the asymptomatic patient. I do rarely recommend surgery by an ...
How would you approach management of a patient with rapidly progressive systemic sclerosis with worsening skin disease, myositis, arthritis, dysphagia and failure to thrive developing within 6 months?
This is a unique subset of patients with very aggressive disease and high risk for poor outcomes with myopathy, poor GI dysmotility, at risk for early PH. We tend to treat them aggressively. I would consider rapid escalation of immunosuppression such as MMF and consider IVIG up front as well, especi...
How do you manage patients with bullous pemphigoid who have IgE autoantibodies to BP180?
40% of patients with BP can have IgE class autoantibodies directed against BP. Treatment does not have to differ from patients without IgE class autoantibodies: for mild or localized disease or in patients who cannot tolerate immunosuppression, doxycycline and high potency topical steroids can be us...
Any concern for lupus flare in patients undergoing laser hair removal?
Great question - no there is little concern for this because LHR wavelengths are not in the ultraviolet spectrum which is known to spark SLE flares. Even narrow-band UVB (phototherapy) has been used in SLE patients without much issue, however, this is controversial and some feel that depending on th...
What recommendations do you provide to patients with sensitive skin that can not tolerate retinoids more than a few times per week?
Our studies showed sensitive skin is mostly the result of a compromised stratum corneum. Microfissures provide channels allowing access to the underlying vulnerable epidermal epithelium. In the past, these patients were very difficult. Low doses of tretinoin partially encapsulated in microsponges we...