Quick takes on patient management

Managing patients in the real world is seldom simple. A Friday symposium, “Common, Challenging, and Controversial Short Topics in Patient Management” (S011), offered fast takeaway wisdom from five clinical leaders.

Atopic dermatitis (AD)

  • Data on the effects of bathing on AD symptoms are inconclusive.
  • There is no good evidence that food allergies contribute to AD.
  • Dermatologists thinking of antihistamines should instead be thinking about more potent anti-inflammatory therapy.

– Eric Simpson, MD, MCR, professor of dermatology at Oregon Health and Sciences University

Skin cancers

  • Most melanoma is localized — 84% — but all patients should be evaluated for metastatic disease.
  • Imaging is not indicated for stage 0-II melanoma unless needed to evaluate specific signs and symptoms of metastases. CT, brain MRI, and PET-CT are appropriate for stage III-IV disease.
  • Recurrent nonmelanoma skin cancer is a chronic disease.

– Adam Sutton, MD, MBA, Micrographic Surgery and Cutaneous Oncology Fellow, Scripps Clinic

Minnelly Luu, MD

Pediatric melanoma

  • Pediatric nevi grow and regress more frequently than adult nevi and commonly appear atypical even though they exhibit benign biologic behavior.
  • Routine biopsy of childhood scalp nevi is not recommended.
  • Anogenital warts may be a sign of sexual abuse in children, but are not conclusive.

– Minnelly Luu, MD, director of pediatric dermatology, Children’s Hospital Los Angeles

Zakia Rahman, MD

Aesthetic dermatology

  • The three botulinum toxins approved for use in the United States are similar, but not interchangeable on a unit-per-unit basis.
  • Long pulse lasers for vascular lesions are less painful for patients, but recovery may take longer.
  • Patients are asking for vaginal rejuvenation using radiofrequency and thermal ablation devices, but nonfunctional treatments may not be appropriate for all patients.

– Zakia Rahman, MD

April W. Armstrong, MD, MPH


  • Dermatologists must be cautious when assessing long-term safety and efficacy data for biologics. The statistical method used to account for missing data makes a significant difference in perceived benefit. Non-responder imputation is the most conservative approach; multiple imputation is more positive. Last observation carried forward is optimistic and as-observed the most optimistic.
  • IL-17 inhibitors secukinumab, ixekizumab, and brodalumab should be used cautiously in patients who have or develop inflammatory bowel disease.

– April W. Armstrong, MD, MPH, vice chair and associate professor of dermatology, Keck School of Medicine, University of Southern California


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