Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
Are there any special considerations for treatment of metastatic acral melanoma?
In general, acral melanoma is a higher-risk disease. There are higher rates of acquired and primary resistance. Given this, I favor ipi-nivo since the overall risk is higher and response rates to single-agent PD-1 or nivo-rela tend to be lower. Emerging data suggest TIL therapy can work reasonably w...
With the increasing availability of biosimilars and their adoption onto payer formularies, how do you approach selection among available biosimilars in clinical practice?
Insurance payers consider FDA‑approved biosimilars to be clinically equivalent. In my experience, selection is ultimately driven by the insurance payer formulary - what you can get for the patient on the time. This can be fleeting and quickly changing at times. Cases can be made for patient experien...
How do you approach management of a patient with coexisting psoriasis and systemic sclerosis, particularly when both active psoriasis and skin tightening are present?
It depends if both diseases are considered significant and active. If so, a JAK-inhibitor would kill two birds with one stone. JAK's are already approved for psoriatic arthritis, and there is decent data for skin psoriasis as well, on par with some of our currently FDA-approved therapies. There is s...
If a BRAF-mutated melanoma patient developed metastatic disease progression on adjuvant anti-PD-1 monotherapy, do you recommend switching to BRAF/MEK targeted therapy or combination immunotherapy?
The developing pre-clinical and clinical data is clear on this and I believe it becomes even more clear with time. While the DREAMseq study did not enroll patients following adjuvant therapy as the patient in the case, the overall evidence clearly shows that BRAF/MEK inhibitor resistant melanomas ar...
In what situation would you recommend ipilimumab + nivolumab over relatlimab + nivolumab in the treatment of metastatic melanoma?
There is no clinical trial to provide a direct comparison between the two regimens, hence the answer to this question is usually driven by personal interpretation of the data and patient preference. The data for both regimens show a statistically significant PFS benefit and a superior response rate ...
Would you utilize rituximab or dupilumab for treatment resistant bullous pemphigoid?
Dupilumab is a phenomenal drug for BP in most patients and is inarguably safer. Updated to add that coverage is much easier with the new FDA approval! As an aside, tralokinumab has a better patient assistance program than dupilumab, and so far has worked just as well in my clinic as dupilumab. If a ...
Are there subgroups of patients with pemphigus in whom you prioritize lower-dose rituximab regimens?
No, I do not recommend ultra-low-dose rituximab for my patients. In general, even for patients with comorbidities, the overall complication rate with rituximab infusions is low, with infusion reaction being the most common, and this rarely has any long-term consequences for the patient. In Dr. Werth...
If methotrexate is contraindicated or not tolerated, what systemic treatments do you use for generalized morphea?
I typically reach for mycophenolate as a second-line agent if methotrexate failed or is contraindicated. If the generalized morphea is actively progressing, I will add a steroid taper as a bridge until the DMARD has time to take effect. Whole body UVA1 is also a helpful adjunctive treatment to a DMA...
How do you screen for colon cancer in patients with Behcet syndrome with colonic involvement?
Behcet syndrome, unlike some other rheumatologic conditions, for the most part, has not been shown to increase risk of malignancies in patients. This may in part be due to the fact that the disease tends to get milder/less severe with time and treatment. As such, colon cancer screening should follow...
How do you optimize retinopathy screening schedules for patients on hydroxychloroquine while also prioritizing cost-effectiveness?
I'll approach this from the cost-effectiveness standpoint as I agree with Drs. @Dr. First Last and @Dr. First Last on their excellent points.Patients with SLE have remarkably high costs when you add up copays, medications, imaging studies, travel, missing work, etc. Anything we can do to help reduce...