Clinical Tips: When a Patient Asks, “Do I Need Filler?"

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Be Honest

If a cosmetic patient asks whether they need filler on a particular visit, even though I have booked time to treat them, I am very honest with them and often say, “No” or “Likely in 4 months.” The patient appreciates the honesty, often tells their friends, and has greater trust in me in the future.

Benjamin Barankin, MD, FRCPC
Toronto, ON, Canada

Delusions of Parasitosis

A recent contributor, Dr Esther Balogh of Wake Forest, had excellent suggestions regarding the challenging patient with delusional parasitosis. Dr Balogh stressed the importance of initially gaining the patient’s confidence.

In addition to listening to the patient’s history and examining their skin, a great way to do this that has worked in my many years of practice is to have them submit a sample of the parasite from their skin and send it to parasitology for examination. Then show the patient the lab result indicating “hair” or “fibers from clothing.”

To avoid confronting the patient with the suggestion that their condition is not real, I will then say the bug may have been present to initiate the problem but appears to have gone. And I may even place them on topical permethrin lotion as per scabies “to make sure that the bug is completely gone.”

To get the patient on an antipsychotic or to see a psychiatrist, l do not say it is all in their head, but rather that the resulting itch and their concern is extremely stressful for them and requires further measures.

Harvey Shapero, MD, FRCPC
Toronto, ON, Canada

Drug-Induced Balanitis and Phimosis

I had a recent experience with a patient who has chronic balanitis and partial phimosis that responded well to ongoing usual topical treatments but with frequent relapses.

The patient was taking Forxiga (dapagliflozin), which belongs to a class of medications called sodium-glucose cotransporter 2 inhibitors. It removes excess sugar from the body through the urine. In so doing, it predisposes patients to genital yeast infections.

When this drug was discontinued, he had a rapid spontaneous improvement of his balanitis and phimosis. Something to be aware of with this class of medications.

Eric Eisenberg, MD, FRCPC
Mississauga, ON, Canada

Bimekizumab and Lab Testing

Want to start your first patient on bimekizumab-bkzx but wondering what to do about the prescribing information recommendation that says, “Test liver enzymes, alkaline phosphatase, and bilirubin at baseline” and then “according to routine patient management”? I would check at baseline and then annually together with the tuberculosis interferon-gamma release assay. If you are more conservative, then checking liver function tests every 3 to 6 months is reasonable but be prepared to deal with more false positives. What about bimekizumab’s warning about suicidal ideation and behavior (SIB)? There is no boxed warning with a monitoring system in place like with brodalumab. Patients with psoriasis are already at a higher risk for depression and SIB, and treating the psoriasis to clearance is likely to reduce depression and SIB. However, I would not use bimekizumab as a first-line treatment in patients with a history of depression and/or SIB for medicolegal purposes.

Jashin J. Wu, MD, FAAD
Irvine, CA