Dermatology
Clinical insights on skin conditions, dermatologic procedures, and treatment approaches from practicing dermatologists.
Recent Discussions
Should the use of avacopan be limited to those patients at increased risk of steroid toxicity given the anticipated high cost of this medication?
Once Avacopan is available for clinical use in the treatment of patients with AAV, providers will need to carefully weigh risks and benefits of the medication while considering other factors including cost.The ADVOCATE trial used a novel glucocorticoid toxicity index that captures common GC-related ...
Does the presence of psoriatic arthritis affect your decision to use an anti-IL-17 or IL-23 drug in your psoriasis patients?
I tend to prefer IL-17s in patients with PsA as an indirect assessment of clinical trials suggests they are more effective than IL-23s (which fits my clinical experience) for PsA. IL-17s are also more effective for axial disease (IL-23s are not very effective in axial disease). If there is a history...
For patients with refractory Hidradenitis Suppurativa on biologic therapy, which specific agent, semaglutide, tirzepatide, or another GLP-1, has yielded the best clinical outcomes in your practice?
I haven't seen enough patients on different medications to form an opinion. I have seen some tough HS cases where we were struggling to gain control improve notably after starting a GLP-1. I just haven't seen enough to draw comparisons yet.
Which sclerotherapy agents do you prefer and why?
Hypertonic saline has no risk of allergic reaction/anaphylaxis, and if you dilute it a bit, it doesn't sting yet works well. We dilute a little for large vessels and cut the strength in half for small/tiny vessels. Key is to get into the vessels without extravasation and only inject enough to blanch...
Would you consider anti-IL-5 therapy (mepolizumab or benralizumab) to either prevent or treat the more severe manifestations of eosinophilic granulomatosis with polyangiitis, such as "infiltrative" (e.g., cardiomyopathy, pulmonary infiltrates, or gastroenteritis) or "vasculitic" (e.g., neuropathy, palpable purpura, or glomerulonephritis)?
Yes, I would consider early starting biologics for infiltrative EGPA.
How do you approach selection of systemic treatment in a patient with atopic dermatitis with severe itch?
The good news is we have 6 approved options here, 4 biologics and 2 small molecules, and all of these therapies have excellent itch data. Selecting a systemic therapy needs to take other comorbid conditions, medications, delivery preference (pill or injection), lifestyle, and other patient attribute...
Do you counsel isotretinoin patients to use supplements (fish oil, OTC antihistamines, or Omega 3s) to decrease purging and mucocutaneous dryness?
Agreed with the above on omega-3 fatty acids.I always recommend 2nd gen antihistamines as well (Pandey & Agrawal, PMID 31734672). Harmless addition that seems to not only help some of the symptoms associated with isotretinoin, but also seems to improve efficacy.Finally, if omega-3s don't help with j...
What criteria do you use to identify patients who can attempt biologic withdrawal after a year of complete clearance in recent-onset moderate-to-severe plaque psoriasis?
If the psoriasis was at the horrific end of moderate-to-severe before treatment, I'd be less excited about attempting withdrawal. If the patient had failed numerous treatments in the past, I would not want to play with the dose of the drug that is working, for fear that it may stop working.
What is your treatment algorithm for dissecting cellulitis of scalp?
I view dissecting cellulitis as a variant of HS (and we know it's a component of the follicular tetrad along with acne conglobata and pilonidal cysts). Anti-TNFa inhibitors and isotretinoin are preferred therapies for this condition with a high level of efficacy.
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 ...