Part 4: How Dermatologists Approach SI/B Warnings in Daily Practice

This 4-part video series brings together leading dermatologists to explore the intersection of mental health and chronic skin disease, a connection that continues to gain recognition in both research and clinical practice. Across the series, experts examine how psychiatric comorbidities influence dermatologic outcomes, review data on the mental health impact of chronic inflammatory conditions, and discuss how dermatologists can thoughtfully address these concerns in patient care.  

In this final installment, Mark Lebwohl, MD, welcomes Andrea Murina, MD, to reflect on the themes from the first 3 videos and to discuss how suicidality warnings influence real-world dermatology practice. Their conversation offers a clinic-centered perspective on how to address these warnings efficiently, accurately, and compassionately with patients.

Balancing efficacy, safety, and communication

Dr Lebwohl begins by reviewing the 4 dermatologic therapies with suicidality warnings (brodalumab, apremilast, isotretinoin, and bimekizumab), and asks Dr Murina how these labels affect prescribing in her clinic. She shares that it is, in fact, very easy to prescribe these medications because they are among the most effective treatments available for psoriasis, acne, and hidradenitis suppurativa (HS). For her, addressing suicidality warnings head-on has become routine. Echoing insights from earlier discussions with Dr Fried, she emphasizes that these warnings reflect reported events rather than causal relationships and that the therapeutic benefits of these agents often far outweigh theoretical risks. Effective counseling, she notes, is a central part of patient care.

Practical counseling: efficient, clear, and grounded in evidence

Both clinicians agree that dermatologists rarely have significant time to discuss labeling language in depth. Instead, they focus on straightforward, data-based explanations. Dr Lebwohl shares that for apremilast and bimekizumab, where the data show no increased risk of suicidality, he typically does not raise the issue unless patients ask. When they do, he explains that in bimekizumab trials there was only one reported case of completed suicide, and no causal link has been established.

Dr Murina takes a similar approach, reassuring patients that available evidence does not support a drug-related risk and redirecting the conversation to the well-documented mental health burden of the diseases being treated. For patients with severe psoriasis, acne, or HS, untreated disease often exerts far greater psychological and quality-of-life consequences than the medications themselves.

Medication-specific considerations

The clinicians then walk through specific agents:

• Brodalumab: Because of the REMS program requirements, Dr Lebwohl spends more time counseling patients, though he notes that trial data showed improved mental health outcomes compared with placebo. He emphasizes that the suicides observed in development were far more likely related to lifestyle and baseline psychiatric factors than to the drug.
• Isotretinoin: Given public awareness and concerns around teratogenicity, he routinely reviews safety considerations. In practice, he finds patients overwhelmingly pleased with its effectiveness.
• Apremilast and bimekizumab: Dr Murina shares that she tends to do minimal counseling unless patients raise concerns. For bimekizumab, especially in HS where treatment options are limited and disease burden is high, she is confident in framing it as a highly efficacious choice that can rapidly improve quality of life.

Across all medications, she asks simple, direct questions at follow-up visits (“How has your mood been?” “Feeling down or less interested in activities?”) and reassures patients that she is part of their care team and prepared to adjust therapy if needed.

Striking the right balance: guidance and shared decision-making

Dr Murina expresses the importance of shared decision-making but also highlights the need for clinicians to have a clear, confident treatment recommendation. Dr Lebwohl adds that many patients already recognize the emotional toll of their psoriasis or HS and welcome highly effective treatment even when a label contains a warning.

They close by reminding colleagues that these medications are straightforward to prescribe and that package inserts reflect FDA reporting requirements, not proven causality. With thoughtful, efficient counseling, dermatologists can help patients access effective therapy without unnecessary hesitation.

Key takeaways

• Dermatologic therapies with suicidality warnings remain among the most effective treatments for acne, psoriasis, and HS
• FDA-required labeling reflects reported events, not proven causal relationships
• Concise, evidence-based counseling helps address patient concerns without overwhelming the visit
• Untreated inflammatory skin disease often poses greater mental health risks than treatment
• With thoughtful patient communication, clinicians can safely and effectively prescribe these therapies while supporting overall well-being

Click here to view the other videos in the series.