Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
How do you approach treating patients with acne keloidalis nuchae who do not respond to a potent topical steroid or retinoid?
For mild disease, topical steroids and topical clindamycin solution alone or in combination with benzoyl peroxide wash or gel are recommended. It is also important to counsel patients to reduce friction to the area (usually the occipital scalp) and avoid cutting hair close to the skin. For moderate ...
How do you manage patients with chronic flushing that do not respond to beta-blockers?
Firstly, I like to make sure the cause of flushing isn't something systemic like carcinoid, mastocytosis, or paraneoplastic. If the patient does have rosacea, I like to get the inflammatory part of rosacea under control with topicals like azelaic acid, a topical TCI (like Elidel), or topical iverme...
How do you manage patients with chronic telogen effluvium?
Chronic telogen effluvium is distressing to patients and a challenge to manage. First, I do a thorough lab evaluation looking for any underlying condition that may be contributing such as anemia, liver/kidney disease, thyroid disease, hormonal abnormalities, and nutritional deficiencies (iron, zinc...
How do you manage eruptive squamous atypia that does not respond to intralesional 5-fluorouracil or intralesional methotrexate?
We have tried to do unna boot wraps with 5FU for a couple of weeks and then rebiopsy any clinical lesions that do not resolve. Then consider surgery for ones that persist.
When tapering moderate to high doses of long term steroids do you routinely monitor for adrenal insufficiency?
This is always a good question on which to reflect. In general, moderate dosing of steroids (> or = 20 mg prednisone equivalents) for 5 days or less do not need a taper and pose low risk of adrenal suppression, and by extension chronic adrenal insufficiency. Up to date suggests that up to 3 weeks is...
Is a biopsy of either skin or muscle always indicated in the diagnosis of dermatomyositis?
A biopsy of either skin or muscle is not always necessary and the need for each depends on each patient's presentation. A typical history and physical exam, along with MRI or EMG findings, or more importantly, a positive myositis specific antibody can be adequate to make the diagnosis of dermatomyos...
What is your preferred infliximab dosing strategy for hidradenitis suppurativa?
I usually start at 5mg/kg every 4 weeks. If patients are doing well, you can try to extend to every 6 weeks. If not sufficiently controlled at 5mg/kg, you can increase to 7.5 or 10mg/kg every 6 or 8 weeks.Alikhan et al., PMID 30872149 Oskardmay et al., PMID 31095972Fernández-Vozmediano et al., PMID ...
What is your approach to treating dermatomyositis patients with pruritus recalcitrant to oral and topical steroids?
I find this issue of pruritus is best handled by getting better control of the cutaneous inflammatory disease. In this regard, typical DMARD agents (e.g. MTX, mycophenolate, etc) can be helpful in addition to IVIG or even JAK inhibitors. Obviously, all a risk/benefit assessment depends on how debili...
In the absence of lung disease, do you prefer methotrexate or mycophenolate mofetil in the initial treatment of cutaneous-only manifestations in systemic sclerosis?
I typically will use mycophenolate if I think the patient needs "skin only" treatment. This recommendation is based on my personal experience, retrospective and observational data, and data that can be gained from other clinical trials (SLS2 for example). If the patient has prominent joint disease, ...
Does irradiation of a patient with pyoderma gangrenosum carry risk of morbidity similar to necrosis caused by minor surgery?
I have treated a few patients with breast cancer with adjuvant RT with a history of pyoderma gangrenosum on active treatment on immunosuppressive therapy with no untoward acute effects.