Discourses in Dermatology

In this segment, Christopher Bunick, MD, reviews the recently published expert roundtable consensus on the role of aryl hydrocarbon receptor (AhR) agonists in inflammatory skin disease, distilling the publication's nine consensus statements into four overarching themes that define this emerging therapeutic class and its role in clinical practice, with a particular focus on tapinarof. Why this consensus was needed Dr Bunick begins by placing the consensus into the context of recent advances in topical therapy for psoriasis and atopic dermatitis (AD). As awareness of topical steroid stewardship has grown, so too has the need for effective nonsteroidal treatment options that offer novel mechanisms of action, durable efficacy, and favorable long-term safety profiles. According to Dr Bunick, the goal of the expert consensus was to clearly define the role of AhR agonists as a new therapeutic class, explain their unique mechanism of action, provide practical guidance for clinical use, and outline how these agents can support modern approaches to topical steroid stewardship. He summarizes the publication by organizing its nine consensus statements into four key clinical themes. AhR agonists represent a distinct therapeutic class The first major takeaway is that AhR agonists constitute a unique therapeutic class in dermatology, distinguished by a multimodal mechanism of action. Dr Bunick explains that AhR agonists such as tapinarof exert their effects through 3 complementary mechanisms: Immune modulation: AhR activation influences gene transcription across multiple inflammatory pathways, including TH1, TH2, TH17, and TH22 signaling Skin barrier normalization: In addition to modulating inflammation, AhR agonists promote barrier repair by increasing structural proteins such as filaggrin, loricrin, and involucrin while improving tight junction integrity Antioxidant activity: Activation of the NRF2 pathway provides antioxidant effects that complement both immune regulation and barrier normalization Together, these multimodal actions differentiate AhR agonists from both topical corticosteroids and currently available nonsteroidal therapies, supporting their classification as a distinct therapeutic approach. Safety and tolerability support flexible and long-term use Dr Bunick next reviews the consensus statements addressing safety and tolerability. He notes that clinical trial data have demonstrated a favorable safety profile, with mild-to-moderate folliculitis representing the most commonly reported adverse event. In most cases, these events were self-limited and required little or no intervention. Importantly, AhR agonists are not restricted by treatment duration, body surface area, or application site. Dr Bunick highlights the clinical significance of this flexibility, noting that chronic diseases such as psoriasis and AD require therapies that can be used on sensitive areas, including the face and intertriginous regions, as well as over larger body surface areas and for extended periods when clinically appropriate. Defining the role of AhR agonists in clinical practice A central focus of the consensus is clarifying where AhR agonists fit within current treatment algorithms. Dr Bunick explains that the panel supports their use as a first-line topical treatment option for both psoriasis and AD. Their long-term safety profile also makes them well suited for chronic disease management without the need to routinely cycle between therapies. He also discusses their role alongside systemic treatment. Many patients receiving biologic or systemic therapy continue to experience residual localized disease, and AhR agonists provide an effective nonsteroidal option for managing these persistent areas. The consensus also addresses pediatric care. Tapinarof is approved in patients aged 2 years and older with AD, and Dr Bunick emphasizes that its availability expands the range of advanced nonsteroidal options for younger patients with inflammatory skin disease. Finally, he highlights a practical consideration regarding phototherapy. Because preclinical and in vitro studies have demonstrated some UV instability of tapinarof, the consensus recommends applying the medication after phototherapy sessions to preserve product integrity. Supporting topical steroid stewardship The final theme centers on topical steroid stewardship, a concept that Dr Bunick describes as a recurring thread throughout the consensus publication. As clinicians increasingly seek to minimize long-term corticosteroid exposure when appropriate, advanced nonsteroidal therapies offer additional flexibility in managing chronic inflammatory skin diseases. Dr Bunick positions AhR agonists as an important component of this evolving treatment paradigm, providing clinicians with another effective option that can be incorporated into both initial and long-term management strategies. He concludes by encouraging clinicians to review the full consensus publication for more practical guidance for integrating AhR agonists into everyday care for patients with psoriasis and AD.

In this installment of Discourses in Dermatology, Steven Feldman, MD, discusses adherence as a multifactorial component of psoriasis management and considers how treatment administration may factor into individualized biologic selection. Drawing on experiences from clinical practice, he illustrates how adherence challenges can extend beyond whether a patient simply remembers to take a medication. When the right treatment is not enough Early in his career, Dr Feldman recalls thinking that successful psoriasis management would largely come down to making the correct diagnosis and prescribing an effective treatment. Clinical experience quickly demonstrated that treatment selection was only part of the equation. This was particularly apparent among patients with limited disease who were prescribed topical therapies but did not improve as expected. Poor adherence to topical treatment is well recognized, and Dr Feldman emphasizes the importance of making treatment as manageable as possible for patients. In some difficult-to-treat cases, this may contribute to the decision to consider systemic therapy rather than relying on a topical regimen that a patient may struggle to maintain. Adherence remains relevant with biologic therapy Although adherence to systemic injectable therapies may be better than adherence to topical treatment, it is not necessarily perfect. When a patient with moderate to severe psoriasis does not achieve the anticipated response to a biologic, or initially responds and later loses efficacy, Dr Feldman argues that adherence should remain among the factors clinicians consider before concluding that the therapy itself has failed. With self-administered biologics, adherence can also encompass more than receiving the prescribed dose on schedule. Proper delivery, storage, handling, and administration all become part of the equation. A medication delivered to a patient's home, for example, must be stored according to its prescribing information. Dr Feldman notes that clinicians may assume these instructions are being followed correctly, but medications may be inadvertently exposed to inappropriate temperatures or undergo repeated changes in storage conditions. When instructions do not translate into practice Dr Feldman shares memorable examples that illustrate how differently patients may interpret seemingly straightforward instructions. In one case, a patient who had been taught injection technique using an orange subsequently injected the medication into an orange and ate it. In another, a patient instructed to inject into an area without psoriasis chose the scalp because it was the only unaffected area, repeatedly hitting bone and bending the needle. While unusual, these examples reinforce a broader point: prescribing a treatment and explaining how to use it do not guarantee that it will be administered as intended. Misunderstandings, treatment logistics, storage, and administration technique can all introduce variability between the regimen clinicians prescribe and the treatment patients actually receive. Reducing adherence-related variability For some patients, in-office administration offers an opportunity to remove several of these variables. Dr Feldman explains that he favors IL-23 inhibitors in his approach to psoriasis and considers the availability of an in-office treatment option particularly relevant when adherence or medication handling is a concern. Among IL-23 inhibitors, tildrakizumab is administered by a health care provider. This allows the clinical team to oversee storage, handling, and administration and provides greater certainty that scheduled doses are being given as intended. Dr Feldman considers this approach particularly useful when a patient's treatment history raises questions about adherence, including situations in which therapies appear to work initially and then repeatedly lose effectiveness. Rather than viewing an inadequate response solely as pharmacologic failure, he encourages clinicians to consider whether factors surrounding medication use or handling could be contributing to the outcome. Looking beyond efficacy when selecting treatment Adherence is influenced by behavioral, logistical, and treatment-related factors, all of which can ultimately affect outcomes. Dr Feldman's examples illustrate why evaluating treatment response may require looking beyond the efficacy of the medication itself to consider what happens between prescribing a therapy and the patient actually receiving it. For patients in whom self-administration or medication handling presents a concern, provider-administered therapy may offer one way to reduce that uncertainty. Incorporating these considerations into biologic selection can help clinicians match not only the medication, but also its mode of administration, to the individual patient.

A patient can look better and still be developing new disease. Dr Khattri considers what meaningful control in CLE looks like over time, from what happens between visits to the outcomes that matter beyond visible improvement. Her approach brings the conversation back to a deceptively simple question: is the treatment changing the patient’s experience of the disease, or only the examination in front of us?

A clinic visit offers a snapshot, but cutaneous lupus progresses through flares clinicians may never see and changes that can remain after active inflammation has settled. Dr Khattri considers what gets missed when we rely too heavily on the examination alone, including scarring, hair loss, pigmentary change, and the ways patients experience the disease outside the clinic.

The appearance of cutaneous lupus can vary drastically, particularly when erythema is muted or pigmentary change is more prominent. Saakshi Khattri, MD, a dermatologist and rheumatologist, looks at the conditions CLE can resemble, nuances of presentation in skin of color, and the critical importance of recognizing the disease earlier.

In this episode of Discourses in Dermatology, Ali Shahbaz, MD, reviews the biology of the aryl hydrocarbon receptor (AhR) pathway and its relevance in atopic dermatitis (AD), using tapinarof as an example of a first-in-class topical therapy that targets this mechanism. Rather than focusing solely on the pharmacology of a single agent, the discussion explores why AhR has emerged as an important therapeutic target and how a growing understanding of skin barrier dysfunction is reshaping the management of inflammatory skin disease. Atopic dermatitis: More than inflammation alone Historically, atopic dermatitis has been viewed primarily as an inflammatory disease. While inflammation remains a central feature, advances in our understanding of AD have highlighted a second, equally important component: skin barrier dysfunction. Dr Shahbaz explains that effective management of AD requires consideration of both of these interconnected processes. Alongside established therapies such as topical corticosteroids and calcineurin inhibitors, newer nonsteroidal agents have expanded treatment options by targeting additional aspects of disease pathophysiology, including restoration of skin barrier function. The biology of the aryl hydrocarbon receptor The aryl hydrocarbon receptor is a ligand-activated transcription factor that functions as a molecular sensor within cells. In its inactive state, AhR resides in the cytoplasm. When activated by a ligand, it dissociates from its associated protein complex, translocates into the nucleus, dimerizes with the aryl hydrocarbon receptor nuclear translocator (ARNT), and regulates the transcription of numerous target genes. One of the distinguishing features of AhR is the remarkable diversity of molecules capable of activating it. These ligands originate from a variety of sources, including environmental pollutants, ultraviolet light photoproducts, microbial metabolites, micropeptides, and tryptophan-derived compounds. Because the skin serves as the body's primary interface with the external environment, AhR is continuously exposed to signals from multiple sources. Connecting AhR biology to skin barrier function For dermatologists, one of the most clinically relevant aspects of AhR biology is its role in regulating proteins that maintain skin barrier integrity. Dr Shahbaz highlights filaggrin as a particularly important example that plays a critical role in maintaining the epidermal barrier. He also notes that AhR signaling influences additional structural proteins, including loricrin and involucrin, reinforcing the concept that skin barrier integrity depends on multiple coordinated components. Rather than viewing AD solely through an immunologic lens, clinicians can also appreciate its structural component, recognizing that barrier dysfunction contributes meaningfully to disease activity. Restoring barrier function as part of disease management The skin barrier serves as the body's first line of defense against environmental insults. According to Dr Shahbaz, restoring and maintaining barrier homeostasis represents an important therapeutic objective in inflammatory skin diseases such as AD. Focusing only on inflammatory pathways may overlook opportunities to improve disease control by addressing the structural abnormalities underlying barrier dysfunction. Supporting barrier restoration therefore complements anti-inflammatory treatment and reflects a more comprehensive approach to disease management. AhR within the broader inflammatory network AhR signaling does not function in isolation. Dr Shahbaz discusses its relationship to the broader network of inflammatory pathways involved in AD and psoriasis, including cytokines such as IL-4, IL-13, and IL-31. Appreciating how these pathways intersect provides additional context for understanding the rationale behind emerging targeted therapies. He notes that tapinarof represents the first topical AhR agonist approved for both atopic dermatitis and plaque psoriasis, introducing a novel therapeutic mechanism into dermatology. Helping patients understand their disease Beyond understanding the underlying biology, Dr Shahbaz emphasizes the importance of patient education. Explaining why AD develops and how skin barrier dysfunction contributes to disease can help patients better understand the rationale for treatment selection. As nonsteroidal topical therapies continue to expand, a clearer understanding of disease mechanisms allows clinicians to connect advances in pathophysiology with practical treatment decisions and more meaningful conversations with patients.

As new nonsteroidal topical therapies continue to reshape the management of inflammatory skin disease, understanding why they work has become just as important as knowing that they work. In this discussion, April Armstrong, MD, explores the aryl hydrocarbon receptor (AhR) pathway and explains why it represents more than another anti-inflammatory mechanism. From immune modulation and barrier restoration to antioxidant activity, she connects the biology of AhR agonism to the clinical outcomes dermatologists see in practice."Think about AhR...it's not a single inflammatory switch," says Dr Armstrong. Instead, she describes a pathway that helps restore skin homeostasis through multiple complementary mechanisms, offering insight into how tapinarof differs from traditional topical therapies and what that distinction may mean for long-term disease management, steroid stewardship, and patient care.

This video is Part 3 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 statementThere is a statistically significant improvement in assessing prognosis when adding 31-GEP results to AJCC8 staging.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.AJCC8 provides the foundation, but not the complete pictureDr Cotter emphasizes that AJCC8 remains the cornerstone of melanoma staging, providing a standardized framework for estimating prognosis and guiding management. However, like any population-based staging system, it cannot fully capture the biological variability among individual tumors.He argues that meaningful gaps remain in traditional risk assessment. Although stage I melanoma is generally associated with an excellent prognosis, a small subset of patients will still progress to metastatic disease. Likewise, patients initially diagnosed with stage I or II melanoma ultimately account for the majority of melanoma-related deaths in the United States, demonstrating the need for tools that can identify higher-risk individuals earlier in the disease course.Dr Cotter also highlights data suggesting that conventional staging alone may not adequately distinguish outcomes within early-stage disease, reinforcing the limitations of relying exclusively on AJCC8 for prognostic assessment.Refining prognosis by incorporating tumor biologyAccording to Dr Cotter, adding 31-GEP testing to AJCC8 staging allows clinicians to better distinguish patients with favorable versus unfavorable tumor biology within the same clinical stage.He reviews studies showing that 31-GEP refines risk within each AJCC8 stage. Across stage I, II, and III disease, patients with Class 1A results consistently demonstrate better melanoma-specific survival than stage-matched patients with Class 2B results. These findings suggest that molecular profiling can identify biologically aggressive tumors that are not fully distinguished by clinicopathologic staging alone.Using prognostic information to individualize managementFor Dr Cotter, improved prognostic discrimination translates into more personalized clinical decision-making.He explains that 31-GEP results influence several aspects of patient management, including follow-up intensity, surveillance strategies, and referral patterns. For example, a patient with a relatively thin melanoma who would not traditionally be considered for sentinel lymph node biopsy (SLNB) may warrant referral to surgical oncology if a high-risk molecular profile suggests greater metastatic potential.Similarly, patients with negative SLNB results but high-risk 31-GEP findings may still benefit from referral to medical oncology for consideration of additional surveillance or systemic treatment discussions. Dr Cotter emphasizes that node-negative status does not eliminate metastatic risk and believes molecular prognostic information can help identify patients who may require closer monitoring despite otherwise reassuring staging.Surveillance imaging in molecularly high-risk patientsDr Cotter also reviews evidence supporting surveillance imaging for patients identified as high risk by 31-GEP testing.He discusses a multicenter study of SLNB-negative patients in which individuals with elevated-risk 31-GEP results underwent scheduled surveillance imaging, while a matched comparison group received imaging only after symptoms developed. Routine imaging identified metastatic disease substantially earlier, with patients presenting with lower tumor burden at the time of detection than those undergoing reactive imaging.He notes that earlier detection was also associated with improved survival at follow-up, supporting the concept that identifying metastases while patients remain asymptomatic may create opportunities for earlier therapeutic intervention.For Dr Cotter, these findings illustrate how molecular risk stratification may help identify patients who could benefit from surveillance strategies beyond those typically recommended based on AJCC8 staging alone.Integrating AJCC8 and 31-GEP into clinical practiceIn closing, Dr Cotter describes AJCC8 as the essential framework for melanoma staging, while viewing 31-GEP testing as an additional layer of prognostic refinement that individualizes risk assessment.Rather than replacing traditional staging, he believes combining clinicopathologic information with molecular profiling provides a more complete understanding of each patient's risk. This integrated approach can help guide decisions regarding referral for SLNB, surveillance imaging, follow-up intensity, and multidisciplinary management, allowing clinicians to tailor care according to both stage and tumor biology.

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.