In this episode of The Spot Check, host Jamie Restivo, MPAS, PA-C, welcomes Scott Dinehart, MD, board-certified dermatologist, Mohs surgeon, and founder of Arkansas Dermatology, for a frank and myth-busting discussion on hedgehog pathway inhibitors (HHIs) and their role in treating locally advanced basal cell carcinoma (BCC).

Dr Dinehart, one of the first fellowship-trained Mohs surgeons in Arkansas, shares his firsthand experience with vismodegib and sonidegib, emphasizing that PAs and NPs are ideal prescribers for these agents and should feel confident managing this patient population. He addresses common misconceptions about efficacy and tolerability head-on, noting that “These drugs work—and they work in more than 90% of patients.”

Together, they explore clinical indications for sonidegib and discuss expanding the mindset beyond large, neglected tumors. Dinehart urges clinicians to consider HHIs for older adults, nursing home residents, patients with multiple lesions, or those who simply prefer to avoid surgery or radiation. “Shrinkage”, he reminds listeners, is always a win—improving quality of life and often allowing for simpler, less invasive procedures down the line.

Dinehart outlines his proven approach, or “secret sauce” to prescribing these drugs; begin with daily dosing for one month, then reduce frequency to twice-weekly (Tuesdays and Fridays) to maintain efficacy with fewer adverse effects. He pairs this with L-carnitine supplementation (1,500 mg daily), started two weeks before therapy to mitigate muscle cramps—one of the most common and treatment-limiting reactions. He walks through the rationale, dosing, and patient-counseling details that make this strategy both practical and well-tolerated.

Other key pearls include monitoring for potential statin interactions, checking baseline creatine kinase (CK) and renal function, and using clinical judgment for follow-up labs. Dinehart stresses that most patients tolerate therapy well with adjusted dosing and that side effects such as muscle cramps or dysgeusia rarely necessitate discontinuation.

For clinicians hesitant about long-term therapy, he explains that many patients can remain on HHIs for six months or longer, and some, such as those with basal cell nevus syndrome, can stay on therapy safely for years. Resistance is uncommon, but when lesions recur or fail to respond, he advises a repeat biopsy to ensure accurate diagnosis prior to switching therapies or recommending surgical removal.  

They close with three take-home points: reduce dosing frequency, use L-carnitine, and don’t defer care—clinicians themselves can and should manage these cases. Dr Dinehart’s enthusiasm is infectious: “Your patients will love you for it, and you’ll get tremendous satisfaction from doing it.”

Supplemental Clinical Resources 

To support adoption of HHIs in everyday practice, Dr Dinehart has provided two references:

• Sonidegib Quick Reference Sheet: summarizes key prescribing information, laboratory guidance, drug-interaction tables, and L-carnitine dosing details for muscle-cramp prevention.
• HHI Dosing Calendar: a visual schedule illustrating his modified twice-weekly regimen to aid patient counseling and adherence tracking.

For clinicians who have additional questions or would like to discuss treatment approaches, Dr Dinehart welcomes inquiries at smdinehart@gmail.com.