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How should dermatologists determine when to escalate from topical to systemic acne treatments?

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How Should Dermatologists Determine When To Escalate From Topical To Systemic Acne Treatmen...

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How should dermatologists determine when to escalate from topical to systemic acne treatments?

Featuring:

CBChristopher Bunick, MD, PhDFaculty

Updated:May 7, 2025

1

What does topical treatment fatigue look like in your patients, and how often do you see it drive dissatisfaction or nonadherence?

1:25

What does topical treatment fatigue look like in your patients, and how often do you see it drive dissatisfaction or nonadherence?

2

What subtle cues, behavioral or clinical, make you suspect a patient is not satisfied or is overwhelmed by topical regimens, even if they report “doing fine”?

1:51

What subtle cues, behavioral or clinical, make you suspect a patient is not satisfied or is overwhelmed by topical regimens, even if they report “doing fine”?

3

Are dermatologists sometimes too cautious about systemic therapy in limited BSA disease?

2:04

Are dermatologists sometimes too cautious about systemic therapy in limited BSA disease?

4

What do you emphasize early on so patients understand how improvement with apremilast may differ from topical treatments?

2:34

What do you emphasize early on so patients understand how improvement with apremilast may differ from topical treatments?

5

What strategies have you found helpful for minimizing early discontinuation related to gastrointestinal side effects with apremilast?

2:55

What strategies have you found helpful for minimizing early discontinuation related to gastrointestinal side effects with apremilast?

6

Do you ever use apremilast in combination with topical therapy, and if so, in what scenarios?

1:29

Do you ever use apremilast in combination with topical therapy, and if so, in what scenarios?

7

When apremilast first launched, how was it positioned, and what do we understand differently now?

1:55

When apremilast first launched, how was it positioned, and what do we understand differently now?

8

How do you frame quality-of-life impact when requesting coverage for ruxolitinib?

0:50

How do you frame quality-of-life impact when requesting coverage for ruxolitinib?

9

When do bridge programs make the most clinical sense for patients?

0:35

When do bridge programs make the most clinical sense for patients?

10

How do you document treatment goals when requesting newer therapies?

0:36

How do you document treatment goals when requesting newer therapies?

11

How do you document medical necessity when disease severity seems borderline?

1:03

How do you document medical necessity when disease severity seems borderline?

12

What clinical language resonates most with payers during prior authorization review?

1:07

What clinical language resonates most with payers during prior authorization review?

13

How do you document body surface area or lesion burden for ruxolitinib coverage decisions?

1:04

How do you document body surface area or lesion burden for ruxolitinib coverage decisions?

14

When might ruxolitinib cream be appropriate earlier in the treatment pathway?

1:04

When might ruxolitinib cream be appropriate earlier in the treatment pathway?

15

What is the single most meaningful management decision that becomes clearer after genomic testing?

0:45

What is the single most meaningful management decision that becomes clearer after genomic testing?

16

Where do you think clinicians are most likely to misinterpret or overextend genomic test results?

1:21

Where do you think clinicians are most likely to misinterpret or overextend genomic test results?

17

What type of patient with atopic dermatitis makes you consider the use of AdvanceAD-Tx?

1:19

What type of patient with atopic dermatitis makes you consider the use of AdvanceAD-Tx?

18

Where in the treatment journey do you see the AdvanceAD-TX test fitting? Before escalation, after failure, or selectively?

0:44

Where in the treatment journey do you see the AdvanceAD-TX test fitting? Before escalation, after failure, or selectively?

19

What can AdvanceAD-TX tell you that clinical phenotype alone does not?

1:36

What can AdvanceAD-TX tell you that clinical phenotype alone does not?

20

How can the AdvanceAD-TX test help dermatologists narrow biologic or JAK inhibitor selection in ambiguous cases?

0:55

How can the AdvanceAD-TX test help dermatologists narrow biologic or JAK inhibitor selection in ambiguous cases?

21

Has testing with AdvanceAD-TX ever shifted you away from your initial treatment choice?

1:11

Has testing with AdvanceAD-TX ever shifted you away from your initial treatment choice?

22

Has the DecisionDx Melanoma test influenced your imaging threshold in select patients?

2:03

Has the DecisionDx Melanoma test influenced your imaging threshold in select patients?

23

How do you approach situations where genomic risk classification from DecisionDx Melanoma and AJCC staging don’t align?

3:30

How do you approach situations where genomic risk classification from DecisionDx Melanoma and AJCC staging don’t align?

24

How does the DecisionDx-SCC test influence referrals to surgical oncology or radiation oncology?

1:18

How does the DecisionDx-SCC test influence referrals to surgical oncology or radiation oncology?

25

Have there been cases where DecisionDx-SCC reclassified a tumor you initially considered low or intermediate risk? How did that change management?

2:01

Have there been cases where DecisionDx-SCC reclassified a tumor you initially considered low or intermediate risk? How did that change management?

26

Has MyPath meaningfully reduced the number of wide excisions you perform for ambiguous lesions?

1:51

Has MyPath meaningfully reduced the number of wide excisions you perform for ambiguous lesions?

27

In the evaluation of melanocytic lesions suspicious for melanoma, how do you decide when diagnostic ambiguity is acceptable versus when additional molecular data is necessary?

1:06

In the evaluation of melanocytic lesions suspicious for melanoma, how do you decide when diagnostic ambiguity is acceptable versus when additional molecular data is necessary?

28

What patient conversations tend to trigger that shift from topical-only management to a systemic like apremilast?

0:42

What patient conversations tend to trigger that shift from topical-only management to a systemic like apremilast?

29

How do you position apremilast for patients who are not ready for injections but are clearly undertreated with topicals alone?

0:44

How do you position apremilast for patients who are not ready for injections but are clearly undertreated with topicals alone?

30

When patients move from years of topical management to apremilast, what expectation resets are most important to prevent early disappointment or discontinuation?

0:36

When patients move from years of topical management to apremilast, what expectation resets are most important to prevent early disappointment or discontinuation?

31

In what situations does apremilast still meaningfully improve a patient’s experience of managing their disease?

0:41

In what situations does apremilast still meaningfully improve a patient’s experience of managing their disease?

32

How do you introduce the idea of systemic therapy to patients who don’t view their disease as “severe”?

1:04

How do you introduce the idea of systemic therapy to patients who don’t view their disease as “severe”?

33

In your experience, what helps patients stay engaged during the early weeks after moving to systemic therapy?

0:51

In your experience, what helps patients stay engaged during the early weeks after moving to systemic therapy?

34

What clinical details make an appeal letter more persuasive?

1:46

What clinical details make an appeal letter more persuasive?

35

What supporting materials help overturn a denial?

1:17

What supporting materials help overturn a denial?

36

When do you escalate from prior auth to formal appeal?

1:42

When do you escalate from prior auth to formal appeal?

37

What’s one documentation habit that consistently improves approvals?

1:24

What’s one documentation habit that consistently improves approvals?

38

How do you document steroid failure before prescribing ruxolitinib cream?

1:40

How do you document steroid failure before prescribing ruxolitinib cream?

39

What helps secure coverage for ruxolitinib in step therapy plans?

1:33

What helps secure coverage for ruxolitinib in step therapy plans?

40

What documentation details helps support approval for ruxolitinib cream?

0:59

What documentation details helps support approval for ruxolitinib cream?

41

Can EHR templates improve access for new therapies like ruxolitinib?

0:43

Can EHR templates improve access for new therapies like ruxolitinib?

42

What are common documentation mistakes that delay access to newer topicals?

0:53

What are common documentation mistakes that delay access to newer topicals?

43

What’s key to documenting steroid failure or intolerance clearly?

1:10

What’s key to documenting steroid failure or intolerance clearly?

44

How do you talk to patients when access issues delay treatment?

1:18

How do you talk to patients when access issues delay treatment?

45

What’s your top access tip for new clinicians balancing care and paperwork?

1:11

What’s your top access tip for new clinicians balancing care and paperwork?

46

How does the MyPath Melanoma test differ from standard histopathologic evaluation?

1:12

How does the MyPath Melanoma test differ from standard histopathologic evaluation?

47

When should dermatologists consider the use of MyPath Melanoma test for a suspicious lesion?

1:20

When should dermatologists consider the use of MyPath Melanoma test for a suspicious lesion?

48

How should MyPath Melanoma test results be interpreted, especially when the result is not clearly benign or malignant?

0:57

How should MyPath Melanoma test results be interpreted, especially when the result is not clearly benign or malignant?

49

What logistical considerations should dermatologists keep in mind when ordering MyPath Melanoma?

1:00

What logistical considerations should dermatologists keep in mind when ordering MyPath Melanoma?

50

In what clinical scenarios might a dermatologist consider ordering MyPath Melanoma for a melanocytic lesion?

1:22

In what clinical scenarios might a dermatologist consider ordering MyPath Melanoma for a melanocytic lesion?

51

Can you describe how MyPath Melanoma adds clinical value when evaluating melanocytic lesions that are not clearly malignant?

1:26

Can you describe how MyPath Melanoma adds clinical value when evaluating melanocytic lesions that are not clearly malignant?

52

How does a positive or negative MyPath Melanoma result impact your treatment recommendations?

1:27

How does a positive or negative MyPath Melanoma result impact your treatment recommendations?

53

What role do you see molecular diagnostics playing in the early detection and management of melanoma over the next 5 to 10 years?

1:03

What role do you see molecular diagnostics playing in the early detection and management of melanoma over the next 5 to 10 years?

54

What makes some melanocytic lesions difficult to diagnose based on histopathology alone?

0:56

What makes some melanocytic lesions difficult to diagnose based on histopathology alone?

55

What are the biggest challenges in managing atypical melanocytic lesions with ambiguous histology? With Dr. Moody

1:13

What are the biggest challenges in managing atypical melanocytic lesions with ambiguous histology? With Dr. Moody

56

What makes a sunscreen well formulated from both a clinician and patient perspective?

1:44

What makes a sunscreen well formulated from both a clinician and patient perspective?

57

How do ingredients beyond UV filters, like antioxidants or moisturizers, enhance photoprotection?

0:48

How do ingredients beyond UV filters, like antioxidants or moisturizers, enhance photoprotection?

58

How do you identify sunscreens that offer reliable broad-spectrum protection beyond SPF ratings?

1:07

How do you identify sunscreens that offer reliable broad-spectrum protection beyond SPF ratings?

59

What makes a sunscreen particularly effective for pigment protection or visible-light defense?

0:59

What makes a sunscreen particularly effective for pigment protection or visible-light defense?

60

What is Helioplex technology, and how does it improve stability and UV coverage?

0:52

What is Helioplex technology, and how does it improve stability and UV coverage?

61

Why does a higher SPF still matter in real-world use?

1:11

Why does a higher SPF still matter in real-world use?

62

What is your take on the role of antioxidants in photoprotection?

0:45

What is your take on the role of antioxidants in photoprotection?

63

What are your go-to strategies for improving sunscreen adherence in daily life?

1:24

What are your go-to strategies for improving sunscreen adherence in daily life?

64

Are there any patient groups you feel are undercounseled when it comes to the risks of photodamage?

1:38

Are there any patient groups you feel are undercounseled when it comes to the risks of photodamage?

65

Which common medications increase photosensitivity, and how should this shape your counseling?

1:46

Which common medications increase photosensitivity, and how should this shape your counseling?

66

How do you approach treating acne without compromising the skin barrier, especially in patients with sensitive skin?

1:00

How do you approach treating acne without compromising the skin barrier, especially in patients with sensitive skin?

67

Why is salicylic acid a useful ingredient in acne cleansers, and how can formulation approaches improve its delivery?

0:46

Why is salicylic acid a useful ingredient in acne cleansers, and how can formulation approaches improve its delivery?

68

What role does the skin barrier play in acne pathophysiology, and how should it influence treatment selection?

1:06

What role does the skin barrier play in acne pathophysiology, and how should it influence treatment selection?

69

Are there specific ingredients or technologies that help balance acne treatment with barrier preservation?

0:53

Are there specific ingredients or technologies that help balance acne treatment with barrier preservation?

70

What are hydrophobically modified polymers, and what role do they play in cleanser tolerability?

0:45

What are hydrophobically modified polymers, and what role do they play in cleanser tolerability?

71

What role do hydrocolloidal patches play in an acne routine, and when do you typically recommend them?

0:50

What role do hydrocolloidal patches play in an acne routine, and when do you typically recommend them?

72

What’s the clinical significance of using 2% salicylic acid in combination with polymeric cleansing technology?

0:52

What’s the clinical significance of using 2% salicylic acid in combination with polymeric cleansing technology?

73

How can dermatologists help patients pair prescription acne medications with over-the-counter products that protect the skin barrier?

0:55

How can dermatologists help patients pair prescription acne medications with over-the-counter products that protect the skin barrier?

74

What role does patient education play in making sure over-the-counter products support rather than interfere with prescription therapies?

0:41

What role does patient education play in making sure over-the-counter products support rather than interfere with prescription therapies?

75

What is the "retinol sandwich" method for managing acne?

1:55

What is the "retinol sandwich" method for managing acne?

76

What are the practical advantages of prescribing the 350 mg packet of tirbanibulin over the 250 mg?

1:27

What are the practical advantages of prescribing the 350 mg packet of tirbanibulin over the 250 mg?

77

In terms of a clearance timeline, what expectations should clinicians set with themselves and with patients starting tirbanibulin, especially when comparing it with therapies like 5-FU?

1:44

In terms of a clearance timeline, what expectations should clinicians set with themselves and with patients starting tirbanibulin, especially when comparing it with therapies like 5-FU?

78

How do you counsel patients and colleagues about the timeline of response, given that visible skin reaction may not appear immediately?

2:00

How do you counsel patients and colleagues about the timeline of response, given that visible skin reaction may not appear immediately?

79

When might you choose tirbanibulin over 5-FU for AK field therapy?

2:17

When might you choose tirbanibulin over 5-FU for AK field therapy?

80

How do you approach field therapy in actinic keratosis, and where does tirbanibulin fit into that strategy?

2:05

How do you approach field therapy in actinic keratosis, and where does tirbanibulin fit into that strategy?

81

How do you advise scheduling follow-up visits for patients on tirbanibulin, knowing pivotal trial endpoints extended to 57 days?

2:11

How do you advise scheduling follow-up visits for patients on tirbanibulin, knowing pivotal trial endpoints extended to 57 days?

82

What were the key findings of the PROAK study, and how did its results inform our understanding of tirbanibulin’s impact on patient quality of life?

1:52

What were the key findings of the PROAK study, and how did its results inform our understanding of tirbanibulin’s impact on patient quality of life?

83

What is the estimated risk of progression from actinic keratosis to squamous cell carcinoma, and how does lesion count affect this risk?

2:17

What is the estimated risk of progression from actinic keratosis to squamous cell carcinoma, and how does lesion count affect this risk?

84

How can dermatologists decide between lesion-directed and field-directed therapies when treating actinic keratosis?

2:37

How can dermatologists decide between lesion-directed and field-directed therapies when treating actinic keratosis?

85

What advancements in the understanding of actinic keratosis pathophysiology or treatment are shaping future management approaches?

2:00

What advancements in the understanding of actinic keratosis pathophysiology or treatment are shaping future management approaches?

86

Is home-based NB-UVB a challenge to prescribe for clinicians?

0:26

Is home-based NB-UVB a challenge to prescribe for clinicians?

87

What practical steps can a dermatologist take to start prescribing a home-based NB-UVB device?

0:48

What practical steps can a dermatologist take to start prescribing a home-based NB-UVB device?

88

What are the key benefits of home-based NB-UVB devices?

1:17

What are the key benefits of home-based NB-UVB devices?

89

Is home-based NB-UVB better suited for localized disease or widespread conditions?

1:01

Is home-based NB-UVB better suited for localized disease or widespread conditions?

90

Is home-based NB-UVB device setup difficult for patients?

1:01

Is home-based NB-UVB device setup difficult for patients?

91

How does guided dosing mode on newer devices improve safety and reduce uncertainty for both patients and dermatologists?

0:48

How does guided dosing mode on newer devices improve safety and reduce uncertainty for both patients and dermatologists?

92

How straightforward is the prescribing and enrollment process for at-home phototherapy?

0:24

How straightforward is the prescribing and enrollment process for at-home phototherapy?

93

Why has phototherapy declined in use, and are the main barriers clinical or logistical?

2:06

Why has phototherapy declined in use, and are the main barriers clinical or logistical?

94

What practical considerations should dermatologists keep in mind when setting up a patient with an at-home phototherapy unit?

1:37

What practical considerations should dermatologists keep in mind when setting up a patient with an at-home phototherapy unit?

95

What kind of clearance rates can be expected in psoriasis with NB-UVB phototherapy?

1:29

What kind of clearance rates can be expected in psoriasis with NB-UVB phototherapy?

96

What differentiates IL-13 from IL-4 in the progression of AD?

1:22

What differentiates IL-13 from IL-4 in the progression of AD?

97

How do you identify and manage itch-dominant AD patients?

1:57

How do you identify and manage itch-dominant AD patients?

98

How can dermatologists more effectively measure and monitor treatment success beyond traditional scaling/scoring tools?

2:15

How can dermatologists more effectively measure and monitor treatment success beyond traditional scaling/scoring tools?

99

What role does proactive vs reactive therapy play in maintaining long-term disease control in AD?

1:34

What role does proactive vs reactive therapy play in maintaining long-term disease control in AD?

100

What factors can help dermatologists determine which cytokine pathway to target when selecting a therapy for AD?

2:58

What factors can help dermatologists determine which cytokine pathway to target when selecting a therapy for AD?

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