In this new installment of Tea with Dr D, host James Q. Del Rosso, DO, is joined by Karan Lal, DO, to examine 3 complex cases where clinical reasoning required moving beyond conventional pathways. This episode features visually impactful case images that bring the discussion to life.

The first case centers on an elderly patient on PD-L1 immunotherapy who developed erosive plaques on the head and neck. Dr Lal reviews the diagnostic challenges of atypical presentations, the limitations of standard treatments, and his decision to carefully introduce a JAK inhibitor with oncology support, illustrating the importance of balancing risks and benefits in drug-induced BP.

Next, they consider a young adult male with diffuse hair loss. A biopsy confirmed androgenetic alopecia without inflammation, prompting Dr Lal to initiate low-dose oral minoxidil with finasteride. He details why combination therapy can be advantageous in younger patients, the need for counseling about shedding phases and time to response, and how to interpret prostate screening in those taking finasteride.

The final case highlights a dramatic case of rhinophyma presenting as fibrotic nodules without classic inflammatory features of rosacea. Dr Lal explains his staged management of surgical debulking followed by laser resurfacing, along with the role of isotretinoin for long-term maintenance. For patients unable to pursue surgical options, he shares alternative approaches such as combining isotretinoin with neuromodulators to shrink tissue and improve appearance.

Tune in to the full episode to see striking clinical images, learn how expert dermatologists navigate diagnostic uncertainty, and gain insight into creative, patient-centered strategies for challenging presentations.