Discourses in Dermatology

Antihistamines may address part of the inflammatory process in chronic spontaneous urticaria, while systemic corticosteroids can provide temporary relief, but neither offers an ideal long-term strategy for a chronic, relapsing-remitting disease. Naiem Issa, MD, PhD, examines the limits of repeatedly cycling these therapies, importance of steroid stewardship, and the evolving role of targeted, nonsteroidal treatments that act on specific pathways involved in mast cell activation and degranulation. He reframes escalation as a necessary step toward safer, more durable disease control.

In this Expert Therapeutic Update Session, Scott Gottlieb, MD, discusses ILUMYA® for Medicare patients living with moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy.The presentation focuses on the practical access considerations that often shape biologic selection in older patients, including Medicare Part B coverage, health care provider administration, and the option to use either buy and bill in the office or an alternate site of care. Dr Gottlieb also reviews clinical data from the reSURFACE trials, including long-term efficacy and safety findings, with attention to outcomes in patients aged 65 years and older.For clinicians managing plaque psoriasis in Medicare populations, the session offers a thorough look at how coverage, administration, adherence, and safety considerations can all factor into treatment decisions.

In this closing recap, Elizabeth (Lisa) Swanson, MD, distills the shift many clinicians are making in practice: thinking beyond body surface area, recognizing AD as a chronic inflammatory disease rather than a series of isolated flares, and knowing when the burden of treatment itself signals it’s time to move beyond topicals. The goal, she argues, is not simply controlling a rash, but giving patients a steadier life outside the constant anticipation of the next flare.

In this segment, Linda Stein Gold, MD, reviews pooled data presented at the 2026 Annual Meeting of the American Academy of Dermatology evaluating the efficacy and safety of tapinarof 1% cream in children and adults with atopic dermatitis (AD). The analysis combined findings from the ADORING 1 and ADORING 2 phase 3 clinical trials, providing a broader look at treatment outcomes across patients with moderate to severe disease.Tapinarof and the aryl hydrocarbon receptor pathwayDr Stein Gold begins by reviewing the background of tapinarof, a nonsteroidal topical therapy initially approved in 2022 for psoriasis in adults and later approved in 2024 for atopic dermatitis in patients as young as 2 years of age.Tapinarof functions as an aryl hydrocarbon receptor agonist, representing a novel mechanism of action among topical therapies for AD. Activation of this pathway helps downregulate proinflammatory cytokines, including Th2 cytokines that play a central role in AD pathophysiology. ADORING 1 and ADORING 2 trial designThe pooled analysis incorporated data from ADORING1 and ADORING 2, two identically designed phase 3 studies conducted across different investigators, sites, and patients.Eligible patients were 2 years of age or older with moderate to severe atopic dermatitis, an Eczema Area and Severity Index (EASI) score of at least 6, and body surface area (BSA) involvement ranging from 5% to 35%. Dr Stein Gold notes that patients at the higher end of the BSA range could reasonably be considered candidates for systemic therapy in routine practice. Average baseline BSA involvement across the studies was approximately 16% to 17%.Participants were randomized in a 2:1 ratio to receive tapinarof 1% cream or vehicle once daily for 8 weeks. Investigators evaluated both efficacy and safety outcomes at the conclusion of treatment.The primary endpoint focused on achieving clear or almost clear skin, defined as at least a 2-grade improvement. Additional endpoints included itch reduction, EASI50/75/90 responses, and other standard efficacy assessments.Early efficacy signals observed by week 1Dr Stein Gold highlights that separation between active treatment and vehicle was observed as early as week 1.By week 8, nearly 46% of patients receiving tapinarof achieved clear or almost clear skin in the pooled analysis. Improvements continued consistently throughout the treatment period, with ongoing separation from vehicle across the 8-week study duration.Itch reduction and low pruritus scoresThe analysis also demonstrated early and sustained improvements in itch.Investigators evaluated the standard ≥4-point reduction in peak pruritus numerical rating scale (NRS) scores and observed statistically significant separation from vehicle beginning at week 1. By week 8, just under 60% of patients achieved this level of itch improvement.Dr Stein Gold also points to an additional itch endpoint that is less commonly evaluated in topical AD studies: achievement of a peak pruritus NRS score of 1 or lower, representing minimal or nearly absent itch. Separation from vehicle again emerged by week 1, and by week 8, nearly one-third of patients achieved this low itch threshold.EASI responses across multiple thresholdsThe pooled data also showed robust EASI responses over the course of treatment.Separation from vehicle was observed as early as week 1 for both EASI50 and EASI75 responses. By week 8:~78% of patients achieved EASI50 ~58% achieved EASI75 ~30% reached EASI90 Safety profile remained consistentFrom a safety standpoint, most treatment-emergent adverse events (TEAEs) were reported as mild to moderate in severity.The most commonly reported adverse events included folliculitis, headache, upper respiratory infection, and nasopharyngitis. Discontinuation rates due to TEAEs remained low throughout the studies.Expanding the topical treatment armamentarium in ADIn closing, Dr Stein Gold emphasizes that the pooled ADORING data demonstrate tapinarof cream to be a safe and effective nonsteroidal topical option for patients with moderate to severe atopic dermatitis, including pediatric patients down to age 2.Key takeawaysPooled data from the ADORING 1 and ADORING 2 trials evaluated tapinarof 1% cream once daily in patients aged 2 years and older with moderate to severe atopic dermatitis Tapinarof is a nonsteroidal aryl hydrocarbon receptor agonist that targets inflammatory pathways involved in AD Separation from vehicle was observed as early as week 1 across multiple efficacy endpoints By week 8, nearly 46% of patients achieved clear or almost clear skin Just under 60% of patients achieved a ≥4-point itch reduction, and nearly one-third reached a peak pruritus NRS score of ≤1 Week 8 EASI responses included approximately 78% achieving EASI50, 58% achieving EASI75, and 30% achieving EASI90 Most treatment-emergent adverse events were mild to moderate, and discontinuation rates due to TEAEs were low

In this installment of Discourses in Dermatology, April Armstrong, MD, MPH, reviews a real-world study presented at the American Academy of Dermatology Annual Meeting examining continuity of care among Medicare patients with plaque psoriasis treated with tildrakizumab and other therapeutic classes.Why this population mattersOlder adults with psoriasis represent a clinically complex population. Many patients have longer disease duration, multiple comorbidities, and are managing polypharmacy. These factors, combined with access-related challenges, can make sustained treatment particularly difficult. In this setting, persistence becomes central to long-term disease control.Psoriasis as a chronic disease: why continuity mattersPsoriasis requires consistent, long-term management. While short-term efficacy is important, real-world continuity over time is often what determines whether patients achieve and maintain control.For dermatologists, this shifts part of the clinical focus toward understanding how therapies perform outside of controlled trial settings, particularly in populations where adherence and persistence may be harder to maintain.Study overview: real-world data in an older populationThe study reviewed was a large, longitudinal, claims-based analysis including approximately 17,000 patients across multiple treatment classes, including IL-23 inhibitors, IL-17 inhibitors, TNF inhibitors, and PDE-4 inhibitors. The analysis specifically focused on a Medicare population with plaque psoriasis. Notably, patients had a Charlson Comorbidity Index of approximately 1.2 to 1.3, reflecting a meaningful comorbidity burden.The primary objective was to evaluate treatment persistence and time to discontinuation, with a specific focus on tildrakizumab.Key findings: persistence and time to discontinuationAt 12 months, persistence with tildrakizumab was approximately 70%, compared with roughly 36% to 60% among other therapies evaluated.At 24 months, more than half of patients remained on tildrakizumab, an important observation in a population where long-term continuity is often difficult to achieve.Tildrakizumab demonstrated a median time to discontinuation of approximately 29 months, compared with a range of about 7 to 18 months for other therapies.The role of care delivery and follow-upOne factor highlighted in the discussion is the potential impact of care delivery models. As an in-office, injection-based therapy, tildrakizumab may facilitate more frequent interaction between patients and the health care system.These built-in touchpoints can support ongoing monitoring, reinforcement of treatment plans, and earlier identification of issues that may lead to discontinuation.Clinical perspective: reframing treatment goalsThese findings contribute to a broader shift in how dermatologists think about therapy selection. The question is not only whether a treatment works, but whether patients are able to remain on therapy over time.For older adults with psoriasis, durability and persistence become key considerations alongside efficacy and safety. Data like these can help inform upfront decision-making and set more realistic expectations for long-term management.In a population where treatment discontinuation is common, the level of continuity observed with tildrakizumab may help reframe what sustained management can look like in clinical practice.Key takeawaysMedicare patients with psoriasis often face higher clinical complexity, which can make long-term treatment persistence challenging Real-world continuity of care is a critical component of effective psoriasis management In this large claims-based study, tildrakizumab demonstrated higher persistence at 12 and 24 months compared with other treatment classes Median time to discontinuation was longer with tildrakizumab, suggesting greater durability in this population In-office administration may support continuity through more consistent patient follow-up and engagement These findings highlight the importance of considering persistence and long-term use when selecting therapy for older adults with psoriasis

This video is Part 2 of a 4-part expert series designed to strengthen clinician confidence in the use of the 31-gene expression profiling (31-GEP) test for prognostic assessment in cutaneous melanoma. Across the series, David Cotter, MD, PhD, addresses common questions and hesitations around molecular prognostic testing to support more consistent and effective integration of 31-GEP into routine dermatologic practice.Expert consensus statementIntegration of 31-GEP testing with traditional staging methods can accurately inform the decision to recommend sentinel lymph node biopsy (SLNB).This consensus statement comes from the expert panel publication “31-Gene expression profiling for cutaneous melanoma: an expert consensus panel” and serves as the foundation for this discussion.SLNB as a critical, but imperfect, decision pointSLNB remains a key step in melanoma staging, but decision-making is not always straightforward in borderline cases. Dr Cotter highlights scenarios frequently encountered in practice, where estimated risk falls near clinical thresholds and management varies.For example:T1B melanomas (0.8–1.0 mm or <0.8 mm with high-risk features): ~5%–10% risk of nodal positivity T2A melanomas (~1.0 mm, nonulcerated): >10% risk of nodal positivityAlthough a ≥10% risk often supports proceeding with SLNB, these estimates are population-based. In practice, patient-specific factors, such as comorbidities or surgical candidacy, introduce additional nuance, contributing to variability in care. The “gray zone” in current guidelinesCurrent guidance generally avoids SLNB in patients with less than a 5% likelihood of nodal positivity. However, this threshold reflects an inherent limitation in the available tools.Among melanomas <1 mm:The average likelihood of nodal positivity is ~5.3% The false-negative rate of SLNB is also ~5% In effect, these values offset one another. Clinically, this means that when SLNB is deferred in this population, a small proportion of patients with occult metastatic melanoma may not be identified at diagnosis. This tradeoff highlights a gap in precision when relying on population-level risk estimates alone. Refining risk stratification with 31-GEP31-GEP testing offers a more individualized approach to risk assessment, particularly in intermediate-risk groups such as T1B melanomas. By incorporating tumor biology, it helps refine which patients may benefit from SLNB.Data discussed in this segment demonstrate that:Use of 31-GEP in T1B patients improves the true-to-false negative ratio to approximately 35:1 When combined with T staging, patients identified as having <5% risk by 31-GEP may safely avoid SLNB without missing node-positive disease These findings suggest that integrating 31-GEP into clinical workflows can improve patient selection and reduce uncertainty in borderline cases. Moving beyond static measures: the role of tumor biologyTraditional staging relies on histopathologic features such as Breslow depth and ulceration; these factors are important, but inherently limited to a single timepoint.31-GEP evaluates gene expression patterns to better characterize tumor behavior. This approach allows clinicians to move beyond population-based estimates and incorporate individualized biologic risk into decision-making.As Dr Cotter describes, the combination of clinicopathologic staging and 31-GEP results supports a more comprehensive and patient-specific framework for care. Key takeawaysSLNB decision-making remains nuanced, particularly in intermediate-risk melanoma Guideline thresholds reflect tradeoffs, including the potential to miss a small subset of node-positive patients31-GEP provides biologic risk stratification, complementing traditional staging measuresIntegration of 31-GEP with T staging can improve patient selection for SLNB and may reduce unnecessary proceduresIndividualized risk assessment is essential, particularly in patients with borderline indications or competing clinical considerations

Psoriasis and psoriatic arthritis are understood as connected but often managed separately. Brad Glick, DO, MPH, walks through why that separation starts to break down in practice. Nearly a third of patients with psoriasis will develop joint involvement, many of whom remain undiagnosed. That reality demands screening become more intentional. Asking about morning stiffness, fatigue, joint swelling, or subtle changes that might otherwise be missed. With an oral TYK2 inhibitor that has demonstrated activity across both skin and joints, the conversation moves from what we treat to how we identify patients, when to intervene, and how we think about psoriasis as a systemic disease from the start.

Omar Noor, MD, focuses on the patients who might otherwise be easy to miss. The small signals that, taken together, start to shift suspicion toward joint disease. It all hinges on asking better questions and asking them consistently. From there, treatment becomes a matter of fit. Oral options don’t replace biologics, and they’re not positioned to outperform other systemic therapies. But they do offer a meaningful option for certain patients, particularly when simplicity, preference, and adherence come into play.

Once you move past mechanism, the question becomes simpler and harder at the same time: where does this actually fit? In this conversation, Benjamin Lockshin, MD, and Michael Cameron, MD, walk through how they’re using TYK2 inhibition in practice—who gets it, when they start, and where it sits alongside biologics and other systemic options. For some patients, it’s a first-line consideration. Those with milder joint involvement alongside psoriasis. Patients who prefer to start with an oral option, or those who don’t quite fit the thresholds that typically push toward biologics. For others, it’s additive—layered onto a biologic in partial responders, used in harder-to-treat areas like palmoplantar disease or in patients where weight may affect response.Running through the discussion is a familiar nuance: when to manage independently and when to refer, how much to act on early or vague joint symptoms, and how to balance simplicity with a growing number of treatment choices. Less about defining a fixed place in the algorithm, more about understanding where it becomes useful across different types of patients.

A simple adjustment in technique that can make a meaningful difference in filler safety.

This video is sponsored by Sun Pharma. Its content is editorially independent of the sponsor. In this video segment, Rahul Ladwa, Medical Oncologist, reviews the updated ≥2-year follow-up results from the pivotal open-label study evaluating cosibelimab in advanced cutaneous squamous cell carcinoma (cSCC).For dermatologists increasingly involved in the longitudinal management of high-risk and advanced cSCC, this discussion offers practical context on efficacy and safety, particularly in an older, comorbid population where tolerability matters.From limited options to immune checkpoint inhibitionUntil the emergence of immune checkpoint inhibitors, systemic options for advanced cSCC were limited. PD-1 pathway blockade significantly shifted the treatment paradigm.Cosibelimab is currently the only FDA-approved PD-L1 inhibitor for advanced cSCC. Unlike PD-1 inhibitors, cosibelimab directly blocks PD-L1 and also targets B7.1, enhancing T-cell activation. In addition, its fully human monoclonal antibody structure enables antibody-dependent cellular cytotoxicity, offering a mechanistic distinction within the immunotherapy landscape.The agent received FDA approval in 2024 following results from its pivotal phase 1 program in advanced malignancies, including cSCC.Study design: pivotal phase 1 programThis was a multicenter, global, nonrandomized phase 1 study with 2 components:Part 1: Dose evaluation in advanced malignanciesPart 2: Dose expansion cohorts in advanced cSCCCohortsGroup 1: Metastatic cSCC (800 mg IV every 2 weeks)Group 2: Locally advanced, inoperable cSCC (800 mg IV every 2 weeks)Group 3: Metastatic cSCC (1200 mg IV every 3 weeks)A total of 192 patients were enrolled:78 in Group 158 in Group 256 in Group 3Efficacy analyses focused on Groups 1 and 2. Safety was evaluated across all 3 cohorts.Primary endpointOverall response rate (ORR)Independent central radiologic review (RECIST v1.1)WHO digital classification (including photography-based assessment)The JAAD update incorporated:An additional 16 months of follow-upUpdated safety analyses (measured by treatment-emergent adverse events)Patient populationAmong 109 efficacy-evaluable patients:Median age: 70sPredominantly male and CaucasianMost had ECOG 0–1Many had prior surgery or radiotherapyFew had received prior systemic therapyEfficacy: responses that deepen over timeOverall response rateMetastatic cSCC (Group 1): 50%Locally advanced cSCC (Group 2): 54.8%Complete response ratesGroup 1: 12.8%Group 2: 25.8%Notably, complete response rates improved compared to the initial publication:Group 1 increased from 7.7%Group 2 increased from 9.7%This suggests that responses continue to deepen with extended follow-up, a clinically meaningful observation for dermatologists monitoring patients over time.Safety: a critical consideration in this populationTreatment-emergent adverse events were common, as expected with immunotherapy. However, Grade 3 immune-related AEs only occurred in about 3.6% of patients.In an elderly population with frequent comorbidities, tolerability is especially important. Adverse events can have outsized impact in patients with baseline cardiovascular, pulmonary, metabolic, or transplant-related complexities.Dr Ladwa emphasizes that safety must be weighed carefully in patients with complex comorbidities like immunosuppression or organ transplantation; in such scenarios, nuanced risk–benefit discussions remain essential.Key takeawaysCosibelimab is the only FDA-approved PD-L1 inhibitor for advanced cSCCUpdated ≥2-year follow-up data demonstrate:ORR ~50–55%Increasing complete response rates over timeGrade 3 immune-related AEs occurred in 3.6% of patientsSafety profile is particularly relevant in older, comorbid patientsUnderstanding mechanism and long-term data can support confident multidisciplinary discussions and prescribing decisionsFor additional details, clinicians are encouraged to review the full publications accompanying this analysis.

When does timing actually change outcomes in hidradenitis suppurativa? Dr. Brownstone walks through why earlier intervention with secukinumab may shift the trajectory, not just the symptoms.In this overview, Nicholas Brownstone, MD, focuses on a post hoc analysis from the SUNSHINE and SUNRISE trials, looking at how disease duration and severity shape response to secukinumab. The signal is consistent: patients treated earlier in their disease course, particularly those with less advanced Hurley staging, were more likely to reach higher thresholds of response, including HiSCR100. It’s a useful reframing of a familiar challenge in HS. Not just whether a therapy works, but when it’s introduced, and what may be lost as disease progresses. Watch the breakdown, then explore the full poster for a closer look at the data.

How quickly can we meaningfully change symptoms in CSU, and does it last? Dr. Brownstone breaks down what the REMIX data suggest about speed, durability, and real-world relevance.In this explainer, Nicholas Brownstone, MD, walks through pooled phase 3 data from REMIX-1 and REMIX-2, focusing on what clinicians tend to notice first: how fast patients feel better. Improvements in UAS7, itch, and hive severity begin as early as week 1, with separation from placebo that continues through week 24 and holds out to week 52. Just as important, patients who started on placebo and later transitioned to remibrutinib reached similar levels of symptom control by the end of the study—pointing to both consistency and durability over time. The full poster adds context on safety and tolerability, but the takeaway here is straightforward: rapid onset paired with sustained control in a population that often cycles through incomplete responses.

Bullous pemphigoid (BP) management has changed dramatically over the past several decades. What was once a treatment landscape dominated by systemic corticosteroids has steadily evolved as clinicians have gained a deeper understanding of the disease itself.In this conversation, Prince Adotama, MD, Assistant Professor at NYU Grossman School of Medicine, sits down with Naveed Sami, MD, Professor of Dermatology and Medicine at the University of Central Florida, to discuss how the science behind BP is reshaping clinical care. The two walk through how advances in immunology—particularly the recognition of IL-4 and IL-13 signaling in BP—have opened the door to more targeted therapies designed to control disease without broadly suppressing the immune system.The discussion also highlights why treatment decisions in BP are rarely straightforward. Many patients are older and medically complex, often managing multiple comorbidities and medications. In this setting, clinicians must weigh disease control against safety, considering not only efficacy but also the risks associated with steroids, immunosuppressive therapies, and polypharmacy.Drs Adotama and Sami also explore where newer biologic therapies are beginning to fit into the treatment landscape, including the recent FDA approval of dupilumab for bullous pemphigoid. Along the way, they discuss practical clinical considerations, from treatment response and remission goals to the role of combination therapy and emerging therapies on the horizon.Together, their conversation reflects a broader shift in dermatology. As our understanding of disease biology improves, treatment strategies are becoming more precise, more individualized, and increasingly focused on improving both disease control and quality of life for patients living with BP.

Bullous pemphigoid (BP) is often suspected clinically but confirming the diagnosis and deciding how to treat it requires a thoughtful, stepwise approach.In this video, Naveed Sami, MD, Professor of Dermatology and Medicine at the University of Central Florida, walks through what happens after bullous pemphigoid enters the differential. From biopsy and immunofluorescence testing to the role of serologic markers, he outlines how clinicians can establish the diagnosis with confidence before moving into treatment decisions.Dr Sami also discusses the broader clinical picture that often accompanies BP. Because many patients are older and medically complex, treatment choices must balance disease control with safety. He reviews how clinicians typically assess disease severity, when traditional therapies such as systemic corticosteroids or antibiotic–nicotinamide combinations may be considered, and how emerging targeted approaches are beginning to shift the treatment landscape.Ultimately, managing BP requires more than recognizing the disease itself. It means understanding the patient in front of you—their comorbidities, medications, and risk profile—and choosing therapies that control disease while minimizing harm.

Nicholas Brownstone, MD, walks us through the four-year efficacy and safety data for continuous secukinumab in moderate to severe hidradenitis suppurativa (HS), drawing directly from the SUNSHINE and SUNRISE core and extension trials. His overview focuses on clinically meaningful endpoints reported through Week 204, including sustained HiSCR responses over time, persistent reductions in draining tunnel count, and tolerability over four years of continuous treatment, which is especially relevant in a chronic, relapsing disease where patients often need long-term therapy.

Nicholas Brownstone, MD, takes a closer look at what disease activity actually does over time in chronic spontaneous urticaria (CSU), drawing on two Phase 3 analyses from the REMIX-1 and REMIX-2 program. Rather than focusing on a single endpoint, he walks through patient-level shifts in UAS7 disease activity bands, tracing how patients moved from severe or moderate disease toward well-controlled states and complete response across 52 weeks of treatment with remibrutinib. The video highlights how quickly these changes emerged, often within the first week, and how they were sustained through the open-label extension, including among patients who initially received placebo and later transitioned to active therapy. Together, the data offer a clinically grounded view of response durability, variability, and real-world relevance for an oral BTK inhibitor in patients with CSU who remain symptomatic despite second-generation H1 antihistamines.

In a hands-on Winter Clinical workshop, Michelle Tarbox, MD, walked through practical ways to get more out of every dermoscopic exam, focusing less on memorizing patterns and more on how and when to use specific techniques.She revisits one of the most common pitfalls in dermoscopy: relying on a single viewing mode. By deliberately toggling between polarized and non-polarized light, clinicians can surface different diagnostic clues—using non-polarized dermoscopy to better visualize milia-like cysts and comedo-like openings, and polarized dermoscopy to highlight vessels and chrysalis structures.Dr. Tarbox also discusses contact versus non-contact dermoscopy, emphasizing that each has distinct clinical advantages depending on what you’re evaluating. For suspected actinic keratoses on the head and neck—particularly pigmented AKs that can mimic lentigo maligna—she recommends starting with dry, non-polarized dermoscopy to identify characteristic surface scale. In contrast, pigmented lesions benefit from contact or polarized dermoscopy, which allows clearer visualization of deeper structures across both benign and malignant neoplasms.Lastly, she clarifies an important diagnostic distinction: chrysalis structures are only visible with polarized light, while a negative pigment network represents a separate finding that serves as a warning signal for potential melanoma. Taken together, these are small technical adjustments with meaningful clinical impact and reminders that dermoscopy works best when approached deliberately, with flexibility and context.

In a live patient workshop at Winter Clinical Hawaii, Glynis Ablon, MD, walked through her approach to injectables. First, she always starts with what the patient wants, then steps back to evaluate facial structure from skin to bone.Rather than treating surface concerns in isolation, Dr. Ablon emphasizes understanding facial morphology, the layered anatomy of aging, and the importance of symmetry when planning fillers and neuromodulators. That requires aligning vision with the patient early, staging treatments over time to avoid overcorrection, and reassessing goals at follow-up visits.She also reminds clinicians that injectables are just one part of a broader aesthetic strategy—often working alongside lasers and other modalities to address texture, laxity, and overall skin quality. The goal is not simply technical precision, but outcomes that feel natural for patients and sustainable for physicians.

Bullous pemphigoid (BP) is most often a disease of older adults—patients who frequently carry multiple comorbidities and have limited tolerance for broad immunosuppression. For years, systemic corticosteroids remained the mainstay of treatment, despite well-known safety concerns in this vulnerable population.In this video, Prince Adotama, MD, Assistant Professor at NYU Grossman School of Medicine, shares clinical perspectives on how BP presents in real-world practice and how newer targeted options are changing the treatment landscape. From recognizing nonclassic presentations to navigating emerging therapies, Dr Adotama walks through key considerations for safely managing BP today.

In this video segment, George Han, MD, PhD, explores whether the site of biologic administration meaningfully influences adherence, persistence, and long-term outcomes in plaque psoriasis. Using tildrakizumab as a real-world case study, he reframes in-office administration from a perceived inconvenience into a potential clinical advantage, supported by emerging adherence and persistence data.At the heart of the discussion is a familiar tension in psoriasis care: most biologics are self-administered at home, but does administration site actually matter when it comes to keeping patients on therapy and maintaining durable disease control?Adherence: removing the guessworkDr Han emphasizes a reality dermatology providers see often: for most patients, starting a biologic for psoriasis is a long-term, often lifelong, commitment. While patients may achieve clearance and feel confident early on, interruptions in therapy are common. When biologics are stopped, relapse is typical, and when the same drug is restarted, it may not work as well as before, potentially due to anti-drug antibodies or other factors.This creates a clinical challenge. When medications are self-administered at home, missed or misfired doses may not come to light until disease worsens. In contrast, in-office administration gives providers confidence in when and how doses are delivered, with clear documentation and fewer unknowns.That clarity becomes especially important when a patient is not responding as expected. Is the issue loss of efficacy, or was adherence inconsistent? In-office dosing removes one major variable from that equation.Persistence: staying on therapy long termDr Han distinguishes adherence from persistence, noting that persistence refers to how long a patient remains on a given therapy. Despite consistent counseling on the importance of staying on biologics, real-world data suggest that approximately half of patients discontinue treatment within one to two years.1,2Persistence matters clinically and economically. Switching biologics increases the risk of adverse effects and is costly, with first-year biologic expenses typically higher than subsequent years. From both a patient-care and practice perspective, keeping patients on an effective therapy is a priority.Across treatment classes, persistence challenges remain. Studies show that oral systemic therapies fare only modestly better, with adherence around 58%, and more than half of patients discontinuing within 6 months,3,4 often due to tolerability issues such as gastrointestinal side effects or headaches, based on Dr Han’s clinical experience.In-office administration as a clinical advantageDr Han highlights real-world data on tildrakizumab, an IL-23 inhibitor indicated for health care provider administration. In observational studies, more than half of patients remained on therapy at 12 months, with a median time to discontinuation of approximately 22 months, alongside high adherence rates.5He suggests that in-office administration plays a meaningful role. Scheduled visits allow practices to proactively manage logistics, coordinate access and paperwork, send reminders, and ensure doses are administered correctly and on time. This infrastructure supports adherence while reducing the burden on patients who may be hesitant, forgetful, or uncomfortable with self-injection.Dr Han also notes the opportunity to maximize these visits by pairing injections with skin exams or disease check-ins, improving continuity of care. For patients with prior suboptimal responses, in-office dosing removes uncertainty and allows providers to focus on true treatment efficacy rather than adherence concerns.A broader perspectiveDr Han concludes by emphasizing that the expanding psoriasis armamentarium has meaningfully improved clearance rates, durability, and quality of life for patients. As clinicians, the goal is not only to select an effective therapy, but also to choose a delivery model that aligns with patient behavior and real-world needs.For patients who struggle with self-administration or consistency, bringing treatment into the office can be a practical, patient-centered strategy to support adherence, persistence, and long-term outcomes.Key takeawaysAdherence and persistence remain major challenges in psoriasis care, regardless of treatment classIn-office administration removes uncertainty around dosing and helps clarify whether lack of response reflects adherence or true treatment failureReal-world data on tildrakizumab suggest strong adherence and persistence, potentially supported by clinician-administered dosing and structured follow-upFor patients who struggle with self-injection or consistency, in-office administration can be a practical strategy to support durable long-term outcomesReferences:Doshi JA, Takeshita J, Pinto L, et al. Biologic therapy adherence, discontinuation, switching, and restarting among patients with psoriasis in the US Medicare population. J Am Acad Dermatol. 2016;74(6):1057-1065.e4. doi:10.1016/j.jaad.2016.01.048Yeung H, Wan J, Van Voorhees AS, et al. Patient-reported reasons for the discontinuation of commonly used treatments for moderate to severe psoriasis. J Am Acad Dermatol. 2013;68(1):64-72. doi:10.1016/j.jaad.2012.06.035Das AK, Chang E, Paydar C, Broder MS, Orroth KK, Cordey M. Apremilast Adherence and Persistence in Patients with Psoriasis and Psoriatic Arthritis in the Telehealth Setting Versus the In-person Setting During the COVID-19 Pandemic. Dermatol Ther (Heidelb). 2023;13(9):1973-1984. doi: 10.1007/s13555-023-00967-3. Erratum in: Dermatol Ther (Heidelb). 2023 Sep;13(9):1985. doi: 10.1007/s13555-023-00984-2. PMID: 37392261; PMCID: PMC10442297.Schmidt L, Wang CA, Patel V, et al. Early Discontinuation of Apremilast in Patients with Psoriasis and Gastrointestinal Comorbidities: Rates and Associated Risk Factors. Dermatol Ther (Heidelb). 2023;13(9):2019-2030. doi:10.1007/s13555-023-00975-3Han G, Zanardo E, Simpson R, et al. Treatment patterns in patients with moderate-to-severe psoriasis treated with biologics. Poster presented at: American Academy of Dermatology Annual Meeting; March 2025; Orlando, FL.

Hear from Dr. James Q Del Rosso as he walks through recent advances in the treatment of bullous pemphigoid, with a focus on how dupilumab is reshaping disease management strategies for adult patients.

This video is sponsored by Sun Pharma. Its content is editorially independent of the sponsor.This expert video series is designed to support dermatologist confidence in the use of Hedgehog inhibitors (HHIs) for the management of locally advanced basal cell carcinoma (laBCC). In this segment, Shannon Trotter, DO, reviews key findings from the 2025 Journal of Drugs in Dermatology (JDD) expert consensus panel, addressing common questions around patient selection, efficacy, safety, and practical differences between the two available HHIs, vismodegib and sonidegib.With two HHIs now available, dermatologists are increasingly tasked with distinguishing how these agents compare, when to use them, and how to counsel patients effectively. Dr Trotter walks through three foundational consensus statements to help guide real-world decision-making.Defining locally advanced BCC: why consensus mattersBefore reviewing treatment guidance, Dr Trotter notes that there is no single, universally accepted definition of laBCC. Disease classification often reflects a combination of tumor-related and patient-related factors, including tumor size, anatomic location (particularly high-function or cosmetically sensitive areas such as the eyelids, nose, ears, and lips), aggressive histologic subtypes, and patient suitability for surgery or radiation. This variability underscores the need for consensus-driven guidance to support consistent and confident care.Consensus statement 1Basal cell carcinoma surgery can lead to aesthetic and functional morbidity when tumors are in anatomically sensitive areas or large size. Hedgehog inhibitors can be used to decrease the size of tumors prior to surgery or as a primary treatment so that surgical outcomes are functionally and aesthetically optimized.Dr Trotter emphasizes that many patients present with BCC in locations where surgery may result in significant functional impairment or cosmetic morbidity. In these cases, HHIs can be used neoadjuvantly to shrink tumors prior to surgery or as primary therapy when surgery is not optimal.Clinical trials of both approved HHIs have demonstrated meaningful and durable responses in laBCC. Although there are no head-to-head trials comparing vismodegib and sonidegib, analyses using comparable RECIST criteria show similar complete response rates. These data support the use of HHIs not only as adjuncts to surgery, but also as effective primary treatment options for appropriately selected patients.Consensus statement 2Patients should be counseled about the most common potential side effects of alopecia, taste alterations, and muscle spasms. Other less common adverse events include but are not limited to, gastrointestinal disorders.Historically, tolerability has been a major reason for treatment interruption or discontinuation with HHIs. Dr Trotter stresses the importance of early, proactive counseling to improve adherence. The most common adverse effects include alopecia, dysgeusia, muscle spasms, and fatigue, and patients benefit from understanding not only what to expect, but when side effects are likely to occur.She explains that differences in molecular structure contribute to variation in side effect onset between agents, with vismodegib typically associated with earlier onset and sonidegib with later onset. Practical mitigation strategies may include preventive or early interventions for muscle cramps, dietary counseling for taste changes, and discussion of options for alopecia. Setting expectations and distinguishing between preventable versus manageable effects can meaningfully improve persistence with therapy.Consensus statement 3Sonidegib is associated with a lower rate of and longer median time to onset of adverse effects than vismodegib.Dr Trotter reviews data showing that sonidegib is associated with lower rates of muscle spasms, dysgeusia, and alopecia, as well as a longer median time to onset of these adverse effects compared with vismodegib. These differences are attributed to distinct pharmacokinetic and molecular properties.Clinically, this matters when tailoring therapy. Patients doing well on vismodegib may continue treatment, while those struggling with tolerability may benefit from switching to sonidegib. Understanding these distinctions allows dermatologists to individualize therapy rather than abandoning HHI treatment altogether.Key takeawaysLocally advanced BCC lacks a single definition, making consensus-driven guidance essentialHedgehog inhibitors can be used as neoadjuvant or primary therapy to optimize functional and aesthetic outcomesBoth approved HHIs demonstrate meaningful and durable efficacy in laBCCEarly, proactive counseling on side effects improves adherence and persistenceSonidegib is associated with lower rates and delayed onset of common adverse effects compared with vismodegibUnderstanding practical differences between HHIs supports individualized, patient-centered treatment decisionsFor additional consensus statements and deeper discussion, clinicians are encouraged to review the full 2025 JDD consensus publication.

This video is Part 1 of a 4-part expert series designed to strengthen clinician confidence in the use of the 31-gene expression profiling (31-GEP) test for prognostic assessment in cutaneous melanoma. Across the series, David Cotter, MD, PhD, addresses common questions and hesitations around molecular prognostic testing to support more consistent and effective integration of 31-GEP into routine dermatologic practice.Expert consensus statementMultiple studies (including prospective studies) have demonstrated clinical efficacy for the 31-GEP test in providing consistent and accurate prognostic information for invasive melanoma.This consensus statement comes from the expert panel publication “31-Gene expression profiling for cutaneous melanoma: an expert consensus panel” and serves as the foundation for this discussion.Addressing historical hesitancy around prognostic testingIn this video, Dr Cotter reviews the consensus findings and addresses why prognostic testing has historically been met with some skepticism in dermatology. Unlike diagnosis and treatment, which are central to dermatology training, prognostication has not traditionally played a major role in clinical decision-making for melanoma.While dermatologists are accustomed to robust clinical trial data guiding therapeutic choices, applying a similar evidence-based framework to prognostic tools has felt less intuitive. Dr Cotter emphasizes that the growing body of data supporting 31-GEP directly addresses these concerns and supports its clinical validity and real-world relevance.The evidence base supporting 31-GEPMore than 50 peer-reviewed publications have evaluated the 31-GEP test across retrospective studies, cohort analyses, and prospective datasets. Collectively, these studies demonstrate the test’s ability to identify patients at increased risk for sentinel lymph node positivity, recurrence, distant metastasis, and melanoma-specific mortality beyond traditional clinicopathologic factors.Dr Cotter highlights a pivotal 2023 prospective real-world study that linked outcomes from prospectively tested patients with data from the SEER database. The study confirmed that the test performed in real-world settings as predicted by earlier retrospective trials. Patients with a Class 2B result demonstrated approximately a 7-fold increased risk of death from metastatic melanoma. Importantly, patients who underwent 31-GEP testing also showed a 29% decreased likelihood of dying from melanoma overall.Updated prospective data and clinical interpretationDr Cotter also reviews updated data presented at ASCO 2025, which included additional patients and extended follow-up. The updated analysis confirmed consistent test performance while refining risk estimates. Patients who underwent 31-GEP testing demonstrated a 32% increased likelihood of survival compared with prior estimates of 29%.Notably, Class 2B patients were shown to have a 4-fold increased risk of death from metastatic melanoma, compared with the previously reported 7-fold risk. Dr Cotter suggests this shift may reflect earlier identification of high-risk patients and more appropriate downstream interventions, including surveillance imaging, sentinel lymph node biopsy, and consideration of adjuvant or neoadjuvant therapy.What clinical efficacy means for prognostic testingClinical efficacy for a prognostic test refers to consistent, reproducible performance that clinicians can rely on when making management decisions. Dr Cotter emphasizes that reproducibility across independent studies is essential for building confidence.He reviews data demonstrating that traditional AJCC 8 staging alone may fail to adequately risk-stratify certain early-stage patients. In SEER-based analyses, stage IA and IB patients did not always separate cleanly by outcomes. When 31-GEP results were layered onto standard staging, meaningful risk stratification emerged.Why this matters in clinical practiceDr Cotter brings the discussion back to day-to-day practice. While Stage I melanoma is associated with approximately 98% melanoma-specific survival, the remaining 2% represent a substantial number of patients nationally. Among the estimated 70,000 to 80,000 Stage I melanoma diagnoses each year in the US, this translates to 1400 to 1600 melanoma-related deaths that are not adequately predicted by standard staging alone.The 31-GEP test provides additional prognostic information to support decisions around follow-up intensity, referral to surgical or medical oncology, and surveillance imaging. Dr Cotter notes that he now uses the test routinely for all patients with melanoma in his practice because of its impact on clinical decision-making.Key takeawaysThe 31-GEP test has demonstrated consistent clinical efficacy across retrospective and prospective studiesProspective real-world data confirm that 31-GEP performs as predicted outside of clinical trial settingsUpdated ASCO data suggest improved survival among tested patients, possibly reflecting more informed clinical interventionThe test augments AJCC 8 staging by identifying high-risk patients within early-stage melanomaPrognostic insight from 31-GEP can inform surveillance, referral, and treatment discussions in routine practice