Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
How long do you give systemic therapies or skin directed therapies to work before changing treatments in patients with diffuse skin limited mycoses fungoides?
It really depends on the patient, the side effects profile. Some systemic therapies are “skin directed” like bexarotene. Also, access to a dermatologist's office for nbUVB is an important factor in making such a decision. I generally don’t recommend topical agents when there is more than 10% eBSA sk...
In what scenario would you add systemic therapy with adjuvant radiation therapy in resected, locally-advanced, cutaneous squamous cell carcinoma?
This is an active area in clinical trials, here is a recently published reviewNewman et al., PMID 34096664 More to come in a future post, I will see what trials are currently available in the Chicago area!
Do you avoid dupilumab (IL-4 inhibition) for severe asthma in patients already taking a biologic agent for RA?
Dupixent (dupilumab) is a humanized monoclonal IgG4 antibody that works by blocking the signaling of interleukin-4 (IL-4) and interleukin-13 (IL-13). This is achieved by binding to the IL-4Rα subunit. When dupilumab occupies this subunit, it prevents IL-4 signaling via the Type I receptor and both I...
Do you recommend a deep shave biopsy or punch biopsy for sampling concerning melanocytic lesions?
Based on the available literature, either is an acceptable form of sampling concerning melanocytic lesions: Mills et al., PMID 23592167 Zager et al., PMID 21463767 I recommend scooping (deep shave) most melanocytic lesions to acquire the breadth and depth of the lesion as much as possible. Superfic...
Would you still consider durvalumab consolidation after definitive chemoradiation for patients with Stage III NSCLC who are on stable weekly methotrexate dosing for psoriasis/psoriatic arthritis?
I would. Given the (now) long-term follow up with the PACIFIC trial showing an approximately 10% improvement in 5-year survival from 33 to 43% (Spigel et al., ASCO 2021, abstract 8511), I believe the risk of psoriasis flare is acceptable. I would have a discussion ("shared decision") with the patien...
How do you manage patients with suspected chronic contact dermatitis and negative patch testing?
The management is the same as for any other eczematous dermatitis. Topical steroids, methotrexate or dupilumab for severe cases. The real question is do you have the correct diagnosis and if so, are you missing a rare allergen?
How do you approach treating cutaneous PAN?
I've had personal experience with treating at least a dozen patients with cutaneous polyarteritis nodosa. The diagnosis was made by the clinical appearance of the lesions usually erythematous nodules that spontaneously may disappear leaving behind a livedo pattern. A biopsy of the lesion verified th...
How do you approach treating patients with erythema nodosum recalcitrant to NSAIDs?
Work up for the cause of ENodosum to determine if there is a trigger:TB, sarcoidosis, cocci/crypto/histo/blasto, Hodgkin's. ASO, dental abscess, Crohn's, ulcerative colitis, OCPs to name a few. SPEP possibly and or quant IGA with free light chains, just to name a few. Assuming all this is, you can d...
Would you offer palliative radiation for painful bone metastases in a patient with scleroderma?
Yes, I have treated a breast cancer patient before who had scleroderma and she really wanted to avoid mastectomy. Maybe I was just lucky, but no major skin reaction. Maybe less than average even. Her disease was not active at the time. For bone met palliation, I would use higher energy like 15X for ...
How would you treat localized cutaneous PAN recalcitrant to high-dose steroids?
There was a recent JAAD article on treatment: colchicine is the best first line if no neuropathy followed by steroid bridge to azathioprine (0.5-2.5 mg/kg/day) which was better than methotrexate. Here’s the article for reference: Bettuzzi et al., PMID 34224771.