Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
Do you routinely collect debulking specimens for paraffin-embedded or frozen section staining prior to taking a Mohs layer for all skin cancers?
There should rarely be a need to send debulked specimens for paraffin sections. Tumors that can be histologically challenging can be debulked and processed as positive controls when doing Mohs micrographic surgery. However, when a frozen section, whether a layer or a debulked specimen, is processed ...
How would you treat pemphigus foliaceous in an elderly patient intolerant to oral steroids?
It depends on the extent of the disease and the severity of symptoms. Home wet wraps, when they can be done, can be essentially as effective as oral steroids in many situations, but can be time intensive. I provide the patient with instructions and a pound jar of triamcinolone ointment. Be careful s...
What maintenance therapies do you most commonly recommend for patients with improving genital lichen sclerosis?
Betamethasone dipropionate with clotrimazole cream is my treatment of choice to provide a sufficiently potent corticosteroid while mitigating the risk of secondary Candida infections. Adjust the frequency of application from daily to once weekly to every other week for severe symptoms vs maintenance...
What treatments have you found to be most effective for granulomatous rosacea?
Isotretinoin 20mg/day
How do you approach balancing the potential risk of worsening actinic damage and maintaining CTCL clearance in patients treated with nb-UVB?
NB-UVB continues to be the most effective skin directed therapy for patch MF. I try to use it as much as possible as monotherapy, or commonly in combination with retinoids for treatment and maintenance of early-stage disease. In patients with severe solar damage, I may continue phototherapy adding l...
What biologics have you found to be most effective in treating hidradenitis suppurativa?
I'll answer the easy part of the question first. For insurance coverage, the HS Foundation website has wonderful prior auth letter templates for biologics, laser therapy, and other treatments. I have had a lot of successes in getting off-label biologics covered with them. It doesn't always work, but...
Are there certain subsets of ANCA vasculitis patients for whom you would consider life long maintenance therapy?
Overall the field is moving towards longer, and sometimes indefinite maintenance therapy. This is because multiple studies have demonstrated that relapse risk increases when maintenance therapy is stopped. I consider indefinite maintenance therapy for the following patients: 1. Frequent relapsers - ...
Have you found success in managing refractory hidradenitis suppurativa with ertapenem?
Ertapenem is the magic bullet for HS. It is the one therapy that you can count on to shut down the disease, even in the most severe cases. So, why isn't it our first-line therapy? It only works while the patient is on therapy, and it can't be continued indefinitely owing to the risks associated with...
What is your approach to using apremilast for psoriatic arthritis in patients with history of depression?
Depression is a common comorbidity of psoriasis and psoriatic arthritis (20% at least mild and 14% at least moderate in a recent meta analysis). Depression is a known but relatively infrequent side effect of apremilast (<1.8% in clinical trials). It is important to screen for depression in all patie...
How do you approach treating patients with delusions of parasitosis who can not tolerate an antipsychotic?
I continue to switch them until I find one they can tolerate. My typical approach is Abilify 2 mg daily and increase by 2 mg every other week until on 10 mg daily if tolerable. If they can’t tolerate that, then I switch to Risperdal and if they can’t tolerate that then I switch to pimozide. If they ...