Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
What factors do you weigh most heavily when deciding on the duration of treatment with dupilumab in a patient with atopic dermatitis who is responding well and tolerating therapy?
If the atopic dermatitis was severe and longstanding, I would continue dupilumab indefinitely. If the patient wanted to cut back, they could try gradually spreading out the doses until the disease recurred.
What is your preferred oral regime with duration for treatment of onychomycosis?
My new favorite regimen is: terbinafine 500 mg once daily for one week, then take 3 weeks off. Repeat for 4, once weekly cycles. Sprenger et al., PMID 31487828
Do you prefer switching to a biologic with a different mechanism of action such as an IL-17 inhibitor over cycling to another TNF inhibitor in a patient with moderate-to-severe HS who has experienced secondary failure to adalimumab after an initial good response?
I agree with @Dr. First Last's excellent suggestions. One other idea is adding methotrexate 10 mg weekly to adalimumab to see if neutralizing antibodies are the problem. I tend to do this if a patient has a good response but loses it down the road. I don't do this as much as I used to, now that we h...
Do you routinely recommend transition to dual PO antibiotic coverage for strep species and MRSA, for patients with purulent cellulitis and in the absence of culture data?
I use mostly Linezolid because: It’s now much cheaper. Even if on serotonin drugs, I can half the serotonin dose while they are on it. Covers pretty much all Strep and Staph, including MRSA. Protein synthesis inhibition may reduce toxins (like clinda in Strep fasciitis). There is no renal dose adju...
Do certain subtypes of BCC respond better to hedgehog pathway inhibitors?
I have found that the larger the BCC, the more dramatic the response (unfortunately, not all tumors respond). These are invariably of the nodular/infiltrative subtypes for which hedgehog inhibitors are indicated.
What is your strategy for managing radiation dermatitis in breast cancer in the prophylactic, erythema/dry desquamation, and moist desquamation stages?
Good question. Everyone seems to have a favorite home remedy with very little good supporting data. I am unaware of any good prophylaxis rx. The best thing is good treatment planning to minimize inhomogeneity. There are phase III data demonstrating the efficacy of soap and water cleansing for rx of ...
How do you approach selection of systemic treatment in a patient with atopic dermatitis with severe itch?
The good news is we have 6 approved options here, 4 biologics and 2 small molecules, and all of these therapies have excellent itch data. Selecting a systemic therapy needs to take other comorbid conditions, medications, delivery preference (pill or injection), lifestyle, and other patient attribute...
How do you approach managing perioperative anxiety in Mohs patients?
Great question. Music, stress balls, having your team engage in conversations with the patient, and other distraction techniques are helpful. Some patients may need medications such as Halcion to help with anxiety but this should be given after the patient signs consent and has a verified driver aft...
How do you decide when to recommend non-surgical management of Bowen's disease in light of long-term data showing very low risk of invasive cSCC after treatment with 5-FU as compared to surgical excision?
Generally, this is a low-risk lesion that can be treated effectively by a variety of modalities or, in some cases, not treated. However, one should always bear in mind that a biopsy may not truly represent the full extent of the lesion. One of the worst invasive SCCs I’ve observed was initially read...
Do you generally utilize calcium channel blockers on an as needed basis for patients with Raynaud's phenomenon?
Can certainly help when patients have conditions that trigger Raynaud's. If otherwise healthy, I discuss keeping the extremities protected from excessive cooling.