Dilemmas in dermatology practice


Dr Rajat Kandhari    21 October 2017

Many disorders presenting to the dermatologist are generally easily diagnosed and well managed, using widely accepted therapeutic regimens all around the world. Conversely, we are often presented with exceptions to this rule.There are times even after years in practice, when you find yourself in the situation when youre examining the patient and quietly thinking to yourself what exactly is this? Few of such dilemmas that I have been faced with include situations when a nodular scabies eventually turned out to be a borrelial lymphocytoma cutis (after much probing into the history and subsequent biopsy and immunohistochemistry) or a simple, long standing, eczematous lesion on the foot reveals atypical T cells on biopsy and IHC and is diagnosed as a pagetoid reticulosis and purpuric lesions on the palms demonstrate granular deposits of IgA on DIF at the tips of the dermal papillae demonstrating an unlikely dermatitis herpetiformis. YES, everyday is an adventure in our OPDs as dermatologists and would we have it any other way?Further at other times we are faced with difficulties with management of a particular disorder, where common diseases may prove refractory to widely accepted treatment regimens or difficult to control. Few of the common yet so notorious ones are recurrent furunculosis, chronic urticaria and pompholyx and more recently superficial dermatophytosis. Other not so common ones include Hidradenitits suppurativa, pemphigus vulgaris, vasculitic disorders and rosacea to name a few where at times we need to go one step further or think out of the box to make them more manageable. We have also seen dermatological treatment evolving at a rapid rate. We have a steady flow of newer drugs being introduced to us every day - omaluzimab seems to be quite the warrior against a recalcitrant chronic urticaria, a plethora of hair care range particularly Capixyl (Biochanin A and Acetyl tetrapeptide 3), which seems to be offering some help when we add it to our conventional regimen of topical minoxidil in cases unresponsive to minoxidil for reasons still not so clear. Then we have ammonium lactate reemerging as an adjuvant and steroid-sparing treatment in psoriatics and numerous non-steroidal and non-hydroquinone containing formulations for the distressing melasma. Dapsone has undergone a reinvention and presents itself in the topical form in the Indian market and oisturizers promising not only hydration but restoration, and repair of the epidermal barrier.

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