Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
How do you screen dermatomyositis patients for malignancy if they have a high risk antibody profile (NXP-2/TIF1gamma positive) and their initial screen is negative?
If an initial screen is negative, including age-appropriate malignancy screening, the need for additional testing in an NXP2 or TIF1 gamma patient would be driven by the clinical presentation and risk factors. An older patient with severe disease (including dysphagia, ulcerations, vasculitis), refr...
What is your approach to elective radiation of the neck with primary cutaneous squamous cell carcinoma?
The ASTRO Clinical Practice Guidelines for treatment of BCC and cSCC (Likhacheva et al., PMID 31831330) provides specific guidelines for elective treatment of draining lymphatics. A thorough review of the literature revealed that the most important predictive factor for occult lymphatic spread is tu...
How do you assess transaminitis in a patient with sarcoidosis with known liver involvement being treated with methotrexate?
This can be fairly tough, as you cannot assess for hepatoxicity from methotrexate in a patient who already has a transaminitis. Hepatic sarcoidosis occurs in 11-80% cases and is often asymptomatic. Some patients may have a transaminitis, elevated alk phos, or liver lesions noted on imaging. Serious ...
What agents can you use for treatment induction besides rituximab in cryoglobulinemic vasculitis (without hepatitis)?
The choice of induction/immunosuppression depends on the severity and is very similar to small vessel vasculitis like ANCA-associated vasculitis. So in addition to rituximab, cyclophosphamide is a very good induction agent for severe forms. This is one condition where plasma exchange is highly recom...
How does your treatment algorithm differ for drug-induced ANCA vasculitis compared to non drug-induced ANCA vasculitis in cases with severe/organ-threatening manifestations?
When end-organ manifestations are present, my initial treatment approach is similar for drug-induced and non-drug induced AAV and typically consists of glucocorticoids and rituximab, including pulse glucocorticoids with severe end-organ involvement. Common drug culprits such as PTU, hydralazine, min...
Would you recommend post-op RT for an ulcerated Clark's level IV melanoma of the zygomatic/preauricular region following a WLE with diffuse melanoma in-situ at the margins?
Yes.
Is it ever appropriate to use hydroxychloroquine temporarily in higher doses (more than 5mg/kg) to control lupus activity such as skin manifestations?
The risk of retinal toxicity with long-term use of doses higher than 5mg/kg was shown by Melles and Marmor; PMID 25275721. There are reports of developing retinal toxicity even with short-term use of HCQ mostly coming from oncology literature (e.g. Navajas et al., PMID 26651304).There is some publis...
Which immunosuppressed patients with SLE would benefit from antibiotic prophylaxis to prevent pneumocystis pneumonia?
Starting PCP prophylaxis in patients with lupus is controversial. We typically start lupus patients on PCP prophylaxis if they have underlying ILD and are on doses of steroids of 20 mg or higher. I also consider starting PCP prophylaxis in lupus patients while they are receiving cyclophosphamide and...
Should venous thrombosis in a patient with Behcet syndrome be treated with both immunosuppression and anticoagulation?
They should be treated with immunosuppressive medications, however, the additional benefit of anticoagulation is much debated. Various studies and metaanalysis have shown that anticoagulation, on average, does not add any benefit. There may be exceptions to this in the early part of treatment for so...
How would you manage a small recurrent melanoma of the lower eyelid in a patient deemed inoperable?
RT. 70Gy/35 fractions or its equivalent with orthovoltage, which I would prefer.