Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
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 ...
What topical or oral treatments do you recommend for patients with recurrent MRSA infections?
In my experience, the best way to evaluate recurrent MRSA infections is to check the nasal cultures of the patient and caregivers. Sometimes cutaneous carriage of the organism also needs to be checked and treated. Good hygiene with regular hand washing or alcohol sanitizers is essential. Treatment w...
How would you approach a patient with malignant spindle cell neoplasm of the scalp excised with a focally positive deep margin?
Although I agree that a re-excision would be helpful for margin clearance, it is probably unlikely that more tissue (which may be negative for Ca) would help delineate the pathology. An immunosuppressed transplant patient most likely has a cutaneous SCCa (with spindle cell features) and our surgeons...
How do you manage Desmoplastic Trichilemmoma?
I usually recommend treating these with Mohs surgery. Not every patient wants to have surgery for a benign tumor but these do tend to be in cosmetically sensitive areas and to slowly grow over time.
Do you avoid the use of hydroxychloroquine in patients with psoriasis and/or psoriatic arthritis?
There are many effective medications for PsA out there now that don't have the risk of making their skin disease worse as is the case with HCQ. Patients are also less compliant with daily pills. To me, 1 in 10 is an unacceptably high number to flare their skin.When viewing through a historical lens,...