Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
Do you recommend on-demand versus fixed-schedule dosing for rituximab maintenance in ANCA vasculitis?
This is a fairly hot question in the field, and one that reflects the success we have had with advancing therapy for ANCA-associated vasculitis; it’s nice to have choices! Although there are data for both approaches, there are more data (larger numbers, etc.), in my opinion, for fixed-dosing. The tr...
What clinical factors do you use to determine timing of on-demand dosing of rituximab in ANCA vasculitis maintenance therapy?
I tend to use scheduled dosing (q 6 months) with RTX for maintenance in my GPA/MPA patients, but will occasionally use "on-demand" dosing in those who are eager to minimize their RTX, do not tolerate the infusions well, or occasionally those who have lower risks of flare (mild disease, no history of...
How would you approach the treatment of a low grade adnexal carcinoma of the scalp in a patient with prior history of WBRT as a child?
Post-op RT and RT alone for the second one, if surgery is not an option. No hypofractionation.
Would the diagnosis of skin-only morphea (localized scleroderma) alter treatment recommendations for localized anal cancer?
There is enough data about the acute and late toxicity from radiation in these patients to be concerned. However, none of it rises to the level of the toxicity of APR. Therefore, my approach would be to involve the patient in the decision, document, and reduce the dose by 10%.
Would you continue TNFi for inflammatory arthritis if the patient develops a solid organ malignancy while on that therapy?
In nearly all cases, I would stop the TNF inhibitor (TNFi). Though there is no evidence that these drugs raise the risk for solid organ tumor, the clinician must tread cautiously. First, the patient may require other potentially immune-suppressive anti-cancer therapies (plus radiation in some cases)...
What is your approach to bladder cancer surveillance in patients who have received cyclophosphamide?
Risk of bladder cancer following cyclophosphamide treatment can be associated with oral therapy and likely also related to cumulative dose (1). Risk of bladder cancer with intermittent IV cyclophosphamide has been reported in some observational studies, but has not been consistently reproduced (2). ...
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...