Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Is a bone marrow necessary in patient with splenomegaly and polycythemia vera?
Yes. Bone marrow is necessary in a patient with polycythemia vera and splenomegaly. There is a possibility of missing ET or associated primary or secondary myelofibrosis. The only way to distinguish between the three bcr-abl negative MPN namely MF, ET, and PV is by performing a bone marrow biopsy an...
How do you utilize JAK inhibitors in combination with other therapies to manage alopecia?
In general, JAK inhibitors can be considered a first-line treatment for many patients with severe alopecia areata, so they are often the primary treatment that I use for this condition. In almost all patients, however, I also add oral minoxidil to the treatment regimen (depending on the person, typi...
What are some measures to prevent flares of loin pain-hematuria syndrome?
Loin pain hematuria syndrome is a difficult problem because there are multiple potential causes that require individual solutions. For example, nutcracker syndrome requires decompression of the left renal vein. Recurrent kidney stones require the expertise of a urologist skilled in ureteroscopic or ...
What is your approach to the management of symptomatic Cystic Fibrosis carriers?
It depends on what symptomatic means. If they have symptoms of bronchiectasis, I treat them as bronchiectasis patients with airway clearance, antibiotics, hypertonic saline, etc. If they have one mutation, I will also make sure they get full gene sequence and also do sweat testing (if available nasa...
What is your approach to treating genital lichen sclerosus that is not responding to super-potent topical steroids?
Biopsy is the next step if it was never done to rule out SCC or another alternative process since clobetasol typically works in these cases. Traditionally, methotrexate has been a standard treatment. However, more recently, I've started using Rinvoq off-label with great efficacy.
Which medications do you recommend for lactating mothers with kidney disease and proteinuria that persists post-delivery?
I use ACE inhibitors, including enalapril and lisinopril, in the lactating mothers with proteinuria and hypertension. Captopril is also safe, but as it is dosed multiple times per day, I avoid this. There is no data on ARBs. If they are still recovering from an AKI or there is another issue, like hy...
Aside from lifestyle measures such as calcium intake, vitamin D repletion, and weight-bearing exercises and ruling out all secondary causes, what is the preferred approach to managing osteoporosis in young women with Z score of less than -2.5 and planning to get pregnant soon?
It is very helpful to have some knowledge as to the reason for the Z score of <2.5. Young women with low BMI can have a low Z score just due to the unloading of the skeleton. Increasing body weight can often improve BMD in these women. Presumably, she has a normal menstrual cycle. If not, the instit...
What treatment modalities have you had success in treating perioral or periorbital dermatitis when they have failed Topical calcineurin inhibitor and oral antibiotics?
The first line is typically metronidazole and/or clindamycin. Topical ivermectin is also a very reasonable approach, and sulfacetamide can help as well. I typically use these before topical calcineurin inhibitors. Rarely TCIs can worsen demodex as has been reported. Which oral antibiotics? Doxycycli...
What's your treatment algorithm for notalgia paresthetica?
Topical steroids + dermeleve (otc anti-pruritic) cream ILK versus other OTC topicals (capsaicin, Sarna, pramoxine) versus compounded gabapentin, amitriptyline, lidocaine (my main go-to second line) Oral - gabapentin vs doxepin vs desipramine Recalcitrant cases I’ve added dupilumab or phototherapy w...
Are there any instances when you use vitamin B6 to prevent kidney stones in patients with recurrent calcium oxalate nephrolithiasis who do not have primary hyperoxaluria?
I occasionally try empirical vitamin B6 in patients with hyperoxaluria that does not respond to usual dietary oxalate restriction plus low fat and higher calcium. I have not done it systematically and have only a handful of cases where it may have helped. Thus, I would not recommend routinely adding...