Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
Would you offer definitive radiation therapy for a Merkel cell carcinoma in which surgical resection would be disfiguring or result in significant dysfunction?
I would, but after an appropriate discussion. First, I favor full staging of all Merkel cell patients with a PET/CT (though many would argue this is not mandatory for small tumor, node-negative patients). I would also recommend a sentinel node procedure because the risk of nodal disease is significa...
Are there particular concerns related to the use of B-cell depletion therapies such as rituximab for rheumatic disease during the COVID-19 pandemic?
The attendant depletion of CD20+ B cells associated with treatment with rituximab likely results in impaired development of host immunity to previously unrecognized microbial pathogens. This has, therefore, been of concern in the context of the Covid-19 pandemic due to potential greater adverse outc...
How would you counsel a patient with extragenital lichens sclerosis on the acute and long term risks of post-lumpectomy radiotherapy?
Lichen sclerosis (LS) is a rare entity, however, there are reports of successful treatment with radiation for various cancers associated with this condition. (Wang et al., PMID 33356763). There is also a suggestion of worse LC in women with vulvar cancer and preexisting LS (Fokdal et al., PMID 34392...
What is the biologic of choice in a patient with RA and history of non-melanoma skin cancer?
We have long known that patients treated with TNF inhibitors (TNFi) have a higher risk of developing non-melanoma skin cancers. For this reason, all patients prescribed these drugs should undergo annual full-body dermatology skin exams. If this recommendation is followed, there should be no contrain...
Are you recommending the mRNA COVID-19 vaccines to your patients with immune mediated inflammatory diseases?
This is THE question at the moment for providers of patients with immune mediated inflammatory diseases. For now, we are merely extrapolating as patients with active IMIDS were censored from trials (Pfizer & Moderna). Organizations like the American College of Rheumatology are moving quickly to clos...
Is there a role for measuring hydroxychloroquine blood levels in clinical practice?
This is being actively investigated by a number of groups around the world, with no final consensus, but the groups in France have studied this the longest, and published the most, to date. The major outcome has been that some (quite a few) patients had very low levels, who admitted on careful quest...
What type of surveillance would you recommend following resection of primary mucinous carcinoma of the skin?
A full skin examination every 6 to 12 months. Reminding the patient to call the clinic immediately for any symptoms that are unusual, or for a new skin lesion and perform a symptoms directed work-up.
What is considered an adequate treatment period to assess response of AAV induction therapy with rituximab or cyclophosphamide?
This is an issue of considerable interest both clinically and for research studies, and the approach to both settings is currently similar: are there any signs or symptoms of ongoing active disease? The key words being “ongoing” and “active”. The expectation once glucocorticoids are started and then...
Are there AAV patients for whom you would consider combination therapy with cyclophosphamide and rituximab?
The combination of RTX and CYC does not have a significant evidence base. The rationale for this regimen comes from the hypothesis that CYC acts quicker than RTX and can serve to quiet down the disease early and potentially spare steroids. However, there is no empirical support for this concept so f...
How would you approach an early inguinal recurrence after surgical resection of Merkel Cell carcinoma in the popliteal region?
I would make sure there is no distant metastases with a PET-CT. Would try to enroll this patient in a trial. Current approach if localized in surgery followed by radiation, but with availability of immunotherapy, I would recommend at least an adjuvant immunotherapy after surgery. No one knows if rad...