Gabriela Cobos, MD, discusses key points from her lecture "Going Beyond Prednisone," given on Friday, November 4, 2022, at the PA/NP Elevate-Derm Conference in Tucson, Arizona.

In this video

Dr. Cobos walks through therapies that give patients "their life back" when standard options fall short. For refractory Raynaud's — especially the severe, scarring digital disease seen in connective tissue disease — she calls Botox "one of the most effective treatments we have," injected at the base of each finger and lasting three to four months so patients can get through the cold winter months without adding another daily oral medication. For dermatomyositis that has failed antimalarials, methotrexate, mycophenolate, and even IVIG, she describes off-label tofacitinib, typically started at 5 mg twice daily and titrated up as needed, then tapered to the lowest effective dose once control is achieved.

She also highlights hyaluronidase for microstomia in systemic sclerosis — a debilitating problem that limits patients' ability to eat and undergo dental care. Her protocol starts with a 20-unit test dose, doubles to 50 units at the next visit, then moves to a full superficial perioral treatment of 200 units repeated roughly every two months, with patients "wowed by the ability to do normal things again." Throughout, she frames the shared goal as improving quality of life.

  • Botox is a highly effective option for refractory Raynaud's; inject at the base of each finger (diluted) with effect lasting three to four months, and growing published evidence is helping secure insurance coverage.
  • MLOT can numb fingers for an hour before Botox, though many patients tolerate it without and time treatments to the winter or repeat year-round every three to four months.
  • Off-label tofacitinib can control severe refractory dermatomyositis after antimalarials, methotrexate, mycophenolate, and IVIG have failed — start at 5 mg twice daily, titrate up as needed, then reduce to the lowest effective dose.
  • For scleroderma-related microstomia, use hyaluronidase with a stepwise approach: a 20-unit test dose, then 50 units, then a full 200-unit superficial perioral treatment repeated about every two months.
  • Hyaluronidase injections are well tolerated with low adverse events (mild bruising or swelling) and can meaningfully restore patients' quality of life.