Dermatology
Questions discussed in this category
Have you encountered this scenario?
How frequently can you repeat the oral course?
Patient with chronic urticaria and rheumatoid arthritis. What would be the safest biologic option for RA?
The patient was diagnosed on the basis of ANA 1:1,280, strongly positive Smith, Sm-RNP, dsDNA, pericarditis, inflammatory arthritis, and discoid lupus...
Wataya-Kaneda et al., PMID 27837201
What about for Effexor, specifically?
Do you typically just perform with patient closing their eyes or do you feel the benefit of eye shields outweighs the risk of corneal injuries?
For example, in patients with many swollen/tender joints, enthesitis, nail involvement do you expect particularly good response? Are there patients in...
Are you less likely to prescribe it for patients with dyslipidemia or autoimmune disease?
How do you balance concern for causing skin hypopigmentation with many of the traditional treatment modalities we have?
Is isotretinoin the only effective option?
Given that Accutane can affect calcium homeostasis, would you recommend continuing Accutane or are additional steps or workups warranted?
The disease is responsive to ablative lasers however laser treatments are not an option.
Do you reserve biologics for more systemic involvement? When do you initiate biologics such as secukinumab?
Naturally, this is subject a number of factors and is likely patient-dependent. We also recognize that the way clinical trials have been designed lead...
Healthy kid <5 years old with hemangioma measuring 6 cm. No prior therapy was trialed. Lesions not growing or involuting.
What would you do next?
Any particular concentration?
Hayashi et al., PMID 22272655
Ekstein et al., PMID 32905614
What changes do you make to your treatment approach to adapt to this altered disease state?
Are you aware of any data regarding relative risk of molluscum contagiosum infection in reference to DMARDs/biologics?
What has been your experience with it in this condition?
Randolph & Tosti, PMID 32622136
SLE manifestations include arthralgias and cytopenias which are stable. Previously did well on methotrexate, but developed GI side effects. HCQ is on ...
Would you view this as a sign that disease is not adequately controlled despite labs and imaging suggesting no active vasculitis?
VA patient. Not responding to usual TCS, barrier pastes, acitretin, etc. Considering IL-17/-23 inhibitors.
What specific settings and devices do you prefer to use?
Do you have a preference for biologics or phosphodiesterase inhibitors?
Baeza-Hernández & Cañueto, PMID 38201585
Stratigos et al., PMID 37708630
Zargham & Strasswimmer, PMID 35872877
Patient has had previous failure of methotrexate. Would you switch to alternative (TNFi or Rituximab) or continue abatacept with regular dermatology...
Pedersen et al., PMID 36430669
Farberg et al., PMID 38896403
Ip & McKerrow, PMID 34160825
The patient has ongoing inflammatory arthritis despite methotrexate, apremilast, and jak inhibitor trials.
Are there other settings where MRI is used for nerve assessment and radiation planning such as for certain definitive RT cases?
For example, a 1 year old healthy female twin in whom a lesion appeared 6 mos ago and has been stable in size.
On exam, left upper back 1.3cm x 1cm s...
Specifically when surgery is not practical and the patient cannot tolerate SHH inhibitors. If using SHH inhibitors, how long do you keep patients on t...
Would you be comfortable combining a TNFi with Rituxan in this patient?
Vaienti et al., PMID 37615838
Fan et al., PMID 26730231
Wolf et al., PMID 15837872
Would you hypofractionate or be more conservative at 2 Gy per fraction? Would your management be affected knowing the patient is on hydroxyurea?
What treatment regimen have you found most effective?
Do you recommend any lifestyle changes or prescribe oral azoles?
Any experience with topical r...
Do you start/trial them on another biologic or just rely on topical therapies?
Do you taper one DMARD as you uptitrate another versus do you stop the first DMARD and quickly uptitrate another one?
Female in her early 40s with chronic spontaneous urticaria occurring consistently only at night for the past 4 years. Lesions develop only at night wh...
What treatment do you initiate before you have a clear diagnosis?
Drug elimination is often helpful, but some triggers are not easy to identify because they are found in food items.
I have a patient with recently diagnosed primary biliary cholangitis/cirrhosis (PBC) with SSc. Her laboratory values are within normal limits, but end...
Do you favor PDL vs IPL? Do you prefer hydroquinone-based therapies?
When do you switch to steroid-sparing medications? What steroid-sparing therapies do you prefer?
Do you empirically treat itchy patients -with a non specific rash- for scabies without obvious clinical findings for scabies?
Given the lack of efficacy of most treatment options, do you generally try to treat calcinosis cutis that is not bothering the patient even if it is q...
Back and chest who deferred systemic antibiotic.
Have you had experience continuing low dose Accutane past the goal dosage recommendation?
Do you use combination therapies such as betamethasone and calcipotriene foam?
If so, how long?
Would your management change given that this recurrent lesion is over 10 cm and the patient previously achieved complete response on immunotherapy 5 y...
Given the side effect profile and risk of relapse off oral TXA therapy, do you prefer pulse dosing (i.e. 3 months on, 3 months off) or continuous ther...
Do you first try adding topicals or UV? At what point do you decide to switch biologics and at that point do you try to class switch to a different MO...
And what workup do you pursue?
In which situations or patient populations do you find this useful? How is it sterilized?
The patient is a young African American female of reproductive age with positive Fibrillarin antibody and nucleolar antibody. No ILD.
And what factors push you towards the selection of a specific treatment modality?
Dutasteride versus Finasteride
What topical therapies have you found most effective? Have you found laser therapy to be effective?
What side effects do you highlight in conversation with them? How do you approach toxicity monitoring?
Relatively newly diagnosed RNA Pol 3+ dcSSc with rapidly progressive skin involvement now on methotrexate 20mg/week and tocilizumab for concurrent inf...
Are there patients that you find respond best to these therapies?
Mother's insurance plan has a high deductible and phototherapy is inconvenient (family lives 50 minutes away).
For instance - any tips regarding coordination of care/transportation, associated lymphedema management, wound care, and pain control would be welcome...
Would you combine antibiotics with isotretinoin?
I have an elderly patient with a history of biopsy-proven psoriasis on IL-17 biologic therapy. She has developed an intense itch without a primary ras...
With no high-risk exposure do you repeat quant gold?
Do you order blood work to evaluate for underlying dyslipidemia or other metabolic diseases?
Do you favor one treatment over the other?
Do you find one treatment more effective than the other?
(preschool-aged patients)
Have you had success with deroofing or surgical excision? Is ILK the best option?
If so, what dose-fractionation do you utilize? What other factors do you take into consideration?
Is a BM biopsy a must when there is skin involvement?
If tryptase level is mildly elevated but less than 20 would you recommend a BM biopsy?
Size: 3 cm, cN0
Do you frequently order liver biopsies for these patients?This question is part of a collaboration with RheumMadness and is specifically in reference ...
Have you recommended supplementing less common supplements such as zinc or selenium?
Would you treat the primary site alone, include the hand and arm lymphatics to the epitrochlear nodes (one continious treatment volume from hand to el...
Have you found dose adjustments to be effective?
Will you still favor starting with steroids and traditional immunosuppressive agents, move IVIG earlier in your treatment strategy, or start with IVIG...
Do your recommendations differ depending on the fragrance category (i.e fragrance mix I, II or balsam of Peru)?
How do you navigate insurance coverage?
Should we switch to a new TKI?
Is T4 disease a contraindication?
Do you utilize a standardized script or questionnaire and if so, what types of questions are you including? Would you use JAK inhibitors in patients w...
For example - keeping a baby under 1 year on tacrolimus ointment for 3 months BID
Are there any skin care products you would avoid in this population?
How has this impacted your counseling and management?
Do you recommend a six-month wait period? Have you had patients that developed poor outcomes due to pursuing cosmetic procedures too early after compl...
And if so how soon after do you start?
What treatment modalities have you tried for "dermal hypersensitivity reaction"?
Is completing nodal dissection warranted for surgical management?
What’s your preferred NSAIDs and next steps?
How do you compare safety to other oral immunosuppressants such as Methotrexate, CellCept, or Azathioprine?
What is your experience with ritlecitinib and how does it compare to baricitinib?
What special considerations or couseling do you provide for pediatric patients that are different from adult patients?
This question is part of a collaboration with RheumMadness and is in reference to Pathogenic ANCA (RAVE Trial).
How should IVIG and either biologic injections or infusions be spaced?
The SWOG 1801 trial showed improved event-free survival (EFS) in patients receiving neoadjuvant pembrolizumab followed by 15 cycles of adjuvant pembro...
Have you had success with topical lovastatin or PDT?
(Refractory to mycophenolate, azathioprine, and methotrexate. UpToDate suggests thalidomide or IVIG with mixed efficacy, while there are some case rep...
I have seen some patients who may undergo large complex closures (sometimes as a separate procedure) for smaller lesions with resulting scars that sig...
How does the timeframe affect your management? Is there always a concern for infection?
Very-low-risk stage IIIA disease includes non-ulcerated lesions, primary ≤2 mm thickness, SLN metastasis <1 mm. Per NCCN the toxicity of adjuvan...
https://www.jaad.org/action/showPdf?pii=S0190-9622%2824%2903329-2
How would you approach a recurrent, cutaneous SCC of the face with high-risk features s/p resection?
Definitive radiation therapy > 5 years ago. Positive margins, PNI of 0.1 mm. What volume would you cover? Dose/fractionation?
How would you treat the primary tumor (located in the chest)? Would you treat the regional lymph nodes?
Do anti-inflammatory topicals such as niacinamide or sulfur-based products help with this type of rosacea?
And if so, what is your approach to the diagnosis?
Do you recommend any dietary changes or supplements? Do you modify your recommendations if the patient is breast feeding?
If there were negative margins, what other factors would you consider to add adjuvant RT? Size of the tumor or depth of invasion?
Have any patients reported side effects?
Have you tried any of the newer biologics?
Porcine xenografts are no longer available and I am wondering what alternative dressings are other surgeons using.
Do you typically order a systemic workup? And, after topical corticosteroids, what other treatment options do you prefer?
Might a prior SJ incident pre-dispose to SJ reaction to radiation?
Would you be more or less apt to treat with RT for grade 2 DCIS with refusal of pr...
What agents have you found helpful? What agents have been proven to be effective/non-effective?
Do you do blood work? Or do you rely on review of systems?
D-TORCH compared topical diclofenac to placebo
Especially in cases where the MIS portion is obvious but the dermal component may not be.
Are dilute bleach baths enough? Should they use any topical therapies? Is there a need for Staph decolonization with something like mupirocin?
In this scenario do we use the actual tumor size for "T staging".
In patients with no apparent skin involvement but lymph-node showing basal cell carcinoma with extracapsular extension. Would this warrant radiation o...
Do you typically start the patient on hydroxychloroquine?
What work-up do you perform?
How often do you order labs?
I worry about introducing skip lesions and there is fairly limited data.
Majority of patients on the seminal trial (Gross et al., PMID 36094839) had tumors isolated to head & neck, what was the rationale for this?
Do you base your decision on extent of residual disease?
Does the use of (neo)adjuvant immunotherapy have an impact on surgical site size or he...
Is a placebo-controlled trial anticipated?
In what cases do you discontinue the medication?
Do you attempt to taper fully or maintain at a low dose?
Are there ways to overcome barriers in insurance coverage of this combination of treatments?
If, yes, what dose and fraction size did you use?
Do you use it for excisions to determine if margins are clear?
Do you use it for all melanocytic biopsies?
How do you balance using PRAME with the...
If the patient had no nodal sampling, would this influence your decision?
Any evidence behind this practice?
Do you prescribe JAK inhibitors as first-line treatments?
Do you perform any lab monitoring?
What dose and margins would you use? The patient is s/p a liver transplant on immunosuppression.
Do you have an age cutoff?
I see 16-18 years olds on occasion who are already developing androgenetic alopecia. I'm curious to know if other dermatol...
Reference: TROG 05.01 Trial
Several speakers at ACR 2021 commented on the important role of drug levels in the management of these patients and cautioned against adding medicatio...
Have you tried hyaluronidase?
What labs do you order? How often do you order labs?
Have you ever needed to discontinue isotretinoin due to lab abnormalities?
Do you find absorbable sutures more inflammatory?
What factors (cost, erythema, long-term appearance) contribute to your epidermal suture selection?
4 cutaneous biopsies with no evidence of vasculitis. Sjogren’s diagnosis based prominent sicca symptoms and a significantly elevated SSA.
For example, in the setting of cirrhosis incidentally found on imaging.
Groomed facial hair is an increasingly common style for men. Accordingly, there are patients who require treatment of the head and neck who become ups...
There have been reports suggesting that patients with CTCL may be at increased risk for other malignancies.
Assume a mild but diffuse case of lichens sclerosis with involvement of the ipsilateral breast. If node negative disease, would you recommend she unde...
Are there cases where food or environmental allergies significantly worsen eczema in children?
Does your treatment management differs for oral erosive lichen planus?
How would you approach patients with active malignancy on chemo and radiation?
If so, where can patients find it? And besides topical clindamycin, what other topicals do you find helpful for individual lesions?
I have heard of long-term pentoxifylline and Vitamin E daily combination that can prevent and even reverse radiation fibrosis (Delanian et al., PMID 1...
The symptoms can be really miserable.I try to control it with antihistamines (don't find these helpful in most cases) and topical steroids, but that d...
Isotretinoin provides a permanent benefit to acne because it atrophies sebaceous glands. My assumption is that it leaves the skin and eyes permanently...
Is long-term oral ivermectin ok? What topical therapies other than topical ivermectin do you recommend/prescribe?
Do you refer them to Ophthalmology? Have you had to switch patients off of Dupixent due to their ocular side effects?
Has topical dapsone worked?
Should one restart lamotrigine or look for an alternative? If no other alternative available, is slow titration vs regular titration preferred?
There have been reports of pembrolizumab leading to lichen planus (my understanding is lichen planus pathophysiology unclear, but potentially autoimmu...
The lesion is still ulcerative despite wound care for two months. Would you treat immediately or wait for healing? Would hyperbaric oxygen to heal ful...
Are there particular indications you use for RT? i.e. multiply recurrent, refractory to other therapies, near critical structures, unresectable (or re...
When tumors come close to chest wall, how do you define skin contour?
Is a positive thimerosal test always a false positive?
What surgical and non-surgical techniques have you used in the past?
Is 6 months too early? Is anesthesia the only concern? Should they be followed by a Neurologist?
Is there any evidence to support the theory that this may cause worse skin reaction?
This is an elderly patient with a BCC/SCC over the shin who is not eligible for Mohs due to concern for wound-healing issues. Orthovoltage/superficial...
I prefer dutasteride for its safety and efficacy compared with minoxidil which can interact with different drugs and food.
Also, minoxidil is a hyper...
Do you favor topical treatments or surgical management?
Are there any medications that surgeons like discontinued before their procedure?
Does topical 5FU cause eruptive keratoacanthomas or have any other concerning side effects?
Have you had success with therapies such as L- carnitine and other remedies?
If so, how long before/after radiation?
Do you recommend any changes to their personal hygiene practices? or changes to their environment?
Especially after surgical procedures
Any success with hydroxychloroquine?
What recommendations do you provide if there is concern that the patient is beginning to flare? Have you prescribed any of the new JAK inhibitors?
When would you de-escalate therapy?
Any indications for triple therapy in the patients with subclinical ILD associated with MDA-5 dermatomyositis?
Would a history of immunosuppression impact your decision?
What are your preferred treatment methods other than topical Vitamin E and azole antifungals?
If you perform MART-1 staining, what protocol do you follow?
Does your evaluation hinge on nonresolution with warming? How extensive is your workup?
If not, what tumor characteristics prompt you to collect debulking specimens for paraffin or frozen section staining?
Does morphology guide your workup?
Would starting spironolactone be a good option?
In your experience, do specific patient features predict a better response?
Especially in the setting of these being more narrow acting than tofacitinib, should we consider them safer than our old drugs?
For kids experiencing moderate to severe urticaria that improve with single-dose antihistamine, do you scale up the manufacturer packaging dosages up ...
Have you prescribed Rituximab and IVIG simultaneously for patients?
Mycosis fungoides and Sezary syndrome are thought to be distinct genotypically and phenotypically. It is my understanding that Sezary syndrome typical...
Other than inflammatory markers and following symptoms/exam, do you need any other specific monitoring for progression to systemic disease?
ET is JAK2+
Do you prefer restarting the biologic with the loading or maintenance dosing?
Would you switch to itraconazole or perform fungal cultures?
When would you consider repeating the course of treatment?
Do you have a preferred sequence of therapies for diffuse skin limited MF?
Are there specific cases where you would or would not consider early flap division?
Assuming it has previously been treated with excision and steroid injections? Is it reasonable to treat a bothersome keloid in a pediatric patient aft...
What is the role for surgery vs RT?
Would you offer systemic therapy and/or radiation therapy to groin/pelvis?
If so, how long after phototherapy (eg. NB-UVB) is it safe to proceed with RT?
See: Systemic review of phototherapy for pruritic skin disorders
Do you obtain vascular imaging routinely in these cases, and if so, do you use cross-sectional or invasive angiography?
In a patient who would be otherwise fit for surgery +/- adjuvant RT, and the delay is caused by COVID-related OR staffing issues, what would be your a...
In other words, do we think of TNFi induced lupus and TNFi induced psoriasis as a drug effect or a class effect?
Is there any alteration in approach from the medical, surgical, or radiation oncology perspective that can mitigate the risk of forming keloids withou...
Would you change rituximab maintenance dose or schedule?
Specifically: starting dose, rapidity of up-titration, frequency of lab monitoring, frequency of office visits, and timing of assessment for treatment...
ADVOCATE trial
What is the role and sequence of surgery and/or RT?
Which nodal levels would you include in your RT field(s)?
Muscle disease is quiescent and no other manifestations such as ILD
In the ADVOCATE trial, patients were not re-dosed with rituximab.
E.g., MPO vs PR3, newly diagnosed vs relapsed, renal involvement. Acknowledge that the ADVOCATE study was not powered to detect these differences, but...
What if the patient has MGUS?
Do patients with type 1 cryoglobulins need a bone marrow biopsy as part of the work up?
Post-auricular cutaneous angiosarcoma, pT1 (19 mm) with negative margins. Unclear if there is any indication for systemic therapy, given early stage a...
What approaches (surgical vs non-surgical) offer the best cosmesis for keratoacanthoma (low grade squamous cell carcinoma) ?
Is there a role for radiation? Does your approach differ depending on site(s) of disease, and/or if the patient has Basal-Cell Nevus (Gorlin) sy...
If so, are there specific patient populations for which you would use this metric?
In general, how would you approach such a case with regards to creation of your treatment volumes and dose-fractionation?
Would you recommend radiation therapy or immunotherapy? If proceeding with radiation therapy, what dose-fractionation and technique would you utilize?
What dose-fractionation schedule would you utilize?
When do you electively treat the ipsilateral versus ipsi- and contralateral neck?
This particular case involves a patient with a frontal scalp low grade eccrine carcinoma status-post excision with positive margin complicated by...
If you use both, how do you decide which to use for a particular patient?
This question is part of a collaboration with RheumMadness and is specifically in reference to: ADIRA Diet
Would you recommend locoregional radiation therapy or systemic or immunotherapy alone? If you would consider radiation therapy, what would be your rec...
If this upstages the patient, do you modify treatment recommendations?
Given the location but no other high risk features would you offer RT?
If so, what dose and fields?
What pathologic features are most important when evaluating the possible need for adjuvant therapy?
Would you offer RT? If so, shat dose fractionation do you recommend?
*Negative margins, <1cm in size, no LVI, negative SLNB, not immunocompromised, no prior surgery (as well as a negative PET/CT scan).
e.g., subungual hemorrhage and onycholysis?
If so, what is your suggested dose/fractionation?
NCCN lists only substantial perineural invasion. What about other high-risk adverse features such as histologic subtype, multiple recurrences, d...
When elective nodal radiation is recommended, which nodes would you treat (i.e. facial, pre-auricular, peri-parotid, levels I-III, etc.)?
Patient underwent a shave biopsy of a 6x5x2mm preauricular lesion that showed moderatley differentiated sebaceous carcinoma with deep and lateral marg...
What dose/fractionation would yield the lowest risk of graft failure? Does your treatment management change based of location, ex the ear vs back?
If so, how large of a margin would you place on the primary lesion and would you incorporate any adjacent lymph node levels?
Following Mohs surgery and in the absence of other high risk features, do you offer RT for any PNI? A single nerve < 0.1 mm? A single ne...
What is the best management for recurrent basal cell carcinoma after prior radiation and vismodegib?
Would re-irradiation be an appropriate option? What dose/field would you incorporate? If treating with standard fractionation, would you take the enti...
If so, what is your treatment volume?
Is modern surgical/reconstruction treatment superior to radiation therapy?
If contact brachytherapy or superficial (orthovoltage) therapy isnt possib...
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