Index of Suspicion is the Friend of the Clinician: Great Cases from the Northeast

In this episode of Derms and Conditions, host James Q. Del Rosso, DO, welcomes Erik Domingues, MD, a dermatologist in Fall River, MA, to review 3 cases where cutaneous presentations led to unexpected findings or required creative treatment approaches.

The first case involves a 74-year-old man with diffuse granuloma annulare (GA). Although biopsy confirmed GA, the widespread involvement raised concern for an underlying condition. When standard therapy failed, Dr Domingues noted a cervical mass that proved to be an aggressive parotid carcinoma, detected earlier than it might have been without the skin eruption. The case highlights the need for thorough physical exams and clinical judgment when faced with atypical presentations.

They next consider a 34-year-old woman presenting with severe alopecia areata (AA). While her main concern was hair loss, Dr Domingues also observed long-standing facial vitiligo. She was started on ritlecitinib, approved for AA and under study for vitiligo, leading to complete scalp regrowth and substantial repigmentation of her vitiligo. The case highlights how treatment can address both immediate concerns and chronic disease burden, while also reminding clinicians that many patients remain unaware of newer therapeutic options.

The episode closes with a personal case: Dr Domingues’s 5-year-old son, who experienced a severe atopic dermatitis flare that stopped responding to crisaborole. Roflumilast 0.3% cream, approved for atopic dermatitis in patients 6 years and older at a lower concentration, was trialed off-label, producing rapid clearance and ongoing control with seasonal use. This case demonstrates how careful clinical judgment can guide effective off-label treatment.

Tune in to the full episode for practical pearls and real-world examples of clinical reasoning, autoimmune overlap, and innovative strategies for chronic skin disease.