Drs. Brittany Criaglow and Brett King discuss difficult dermatology cases on Friday, November 10, 2023, at the 4th Annual Elevate-Derm PA/NP Dermatology Conference in Coachella Valley, CA.

In this video

Craiglow and King start with a piece of advice she gives every resident: in the exam room, "if you don't know, it's okay to say you don't know." Rather than eroding trust, telling patients you need to go back to the literature and then following up within a promised window makes them feel seen and grateful. King frames the mystery cases as "part of the fun" of the work — the satisfaction of digging deeper or asking a colleague to figure out what someone has or how to make them better.

Much of the conversation turns to hair loss, where they note the standard tools "almost never" work completely and describe borrowing from other disciplines — including the long, overlooked history of oral minoxidil, tracing back to a 1987 paper on alopecia areata. King also flags a practical blind spot: compounded JAK inhibitors and other drugs may underperform because the compounding pharmacy isn't accredited or rule-following, so clinicians should ask a few key questions before assuming the treatment failed. Craiglow adds that when a patient isn't improving on appropriate therapy, the diagnosis itself may be wrong — re-biopsy, pull old records, and get another opinion rather than keeping your "blinders on."

  • It's okay to tell a patient you don't know — commit to researching it and follow up within the timeframe you promise.
  • When standard treatments for alopecia fall short, consider tools borrowed from other disciplines, such as oral minoxidil, which has a long but overlooked history in medicine.
  • Vet your compounding pharmacies: confirm they're accredited and have a track record of following rules, since a poorly compounded drug may explain unexpectedly poor results.
  • If a patient isn't improving on what you believe is appropriate treatment, question the diagnosis — re-biopsy, gather records, or get a second opinion.
  • Stay fluid in your thinking and gather more data; don't fixate on a preexisting diagnosis just because a previous provider made it.