Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
How do you choose between oral and IV cyclophosphamide for the treatment of ANCA-associated vasculitis?
When considering cyclophosphamide for induction in severe AAV, both oral and IV regimens are reasonable routes of administration. In the CYCLOPS trial (DeGroot, Ann Int Med, 2009), oral cyclophosphamide 2mg/kg/d was compared with IV CYC 15mg/kg q 2 weeks for the first three pulses, then every 3 week...
How do you approach patients with ANCA vasculitis who had partial response, but continue to have disease activity on q 6 month maintenance rituximab and remain on steroids?
This question raises some fundamental issues about the management of patients with ANCA-associated vasculitis (as well as other vasculitides or chronic inflammatory disorders), including i) the need to consider the potential contribution of comorbidities to clinical signs or symptoms suggestive of v...
How do you approach breast conserving therapy in a woman who has formed bothersome keloids after prior surgeries?
I have only seen a few patients who developed keloids following breast surgery, whether or not they received radiation therapy. That also is true of individuals who have had keloids on other parts of their body. Hence, this fortunately seems to be a rare event, and I do not think prophylactic steroi...
Is it ever reasonable to switch to a different TNFi as opposed to switching to an agent in a different class in a case of TNFi induced lupus or psoriasis?
This is a very interesting question where the answer continues to evolve. I would also like to answer the question separately. Both Psoriatic skin lesions and lupus or lupus-like conditions can be induced by anti-TNF-alpha therapy. The pathogenesis may involve changes in cytokine balance.Regarding P...
How would you manage a nodal recurrence of cutaneous SCC if the patient is unable to receive surgery for 6-8 weeks?
I’d first consider referring the patient to a center that could perform the operation, as it is standard of care for a patient with resectable cSCC with nodal metastases. At some centers, there may be a clinical trial of neoadjuvant immunotherapy that could be considered. If those options were not...
Would you irradiate elective lymph nodes for a T1 Merkel cell carcinoma of the head and neck with a negative sentinel lymph node?
In general, I would not irradiate due to the negative sentinel lymph node biopsy (SLNBx). Either one trusts the prognostication of a SNLBx and obtains one, or not. If one does not trust the process of SLNBx, then you should not obtain one and electively treat. I do not see the utility in obtaining a...
What is the role for angiography in the workup of digital ischemia?
Digital ischemia is an especially serious complication in patients with rheumatic disease, particularly scleroderma but can also be a feature of lupus, vasculitis (ANCA associated, PAN), antiphospholipid syndrome, and rheumatoid vasculitis, among others.The presence of digital pain with permanent/pe...
Do you measure drug levels (particularly hydroxychloroquine or mycophenolate) in your lupus patients?
Hydroxychloroquine levels: I absolutely measure hydroxychloroquine (HCQ) drug levels in my patients regularly. As I have mentioned in other answers here and in The Rheumatologist, measuring drug levels has transformed my clinic into a clinic where most of my SLE patients are in remission or have low...
How often do you order imaging to assess for possible degenerative joint disease in the spine in patients with neuropathic itch?
Only if the itch is localized, mainly unilateral like in notalgia paresthetica of the back or the forearm.
What are your preferred treatment options for patients with cholestatic pruritus who do not respond to light therapy?
Great question as in my experience phototherapy does not have high success rate for this. Agree that rifampicin can help quite a bit! Here is an algorithm you might find useful: Initially treat with a bile acid sequestrant such as cholestyramine (total daily dose of 4 to 16 grams) If this does no...