Discourses in Dermatology

This Instagram Live session features a practical, results-driven discussion on newer topical therapies for atopic dermatitis, as Dr. Song and Dr. Lio share clinical pearls and real-world decision-making strategies aimed at improving patient outcomes. The conversation sharpens atopic dermatitis treatment discussions and extends key Fall Clinical conference breakthroughs. From emerging topical data to insights on systemic options, the discussion builds on what began in Las Vegas—transforming expert insight into actionable takeaways for clinical practice.

This session concludes the Exploring What's Next In Psoriasis Care Innovation Experience with a practical discussion on how clinicians guide patients through systemic therapy choices for psoriasis. Dr. Shahriari and Dr. Cameron explored how they set expectations, address patient hesitancy, clearly explain oral treatment options, and maintain engagement throughout the treatment journey. The conversation offers a real-world, conversational look at the language and strategies that help patients feel informed, confident, and supported in their care decisions.

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 communicationDr 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 evidenceBoth 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 considerationsThe 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-makingDr 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 takeawaysDermatologic therapies with suicidality warnings remain among the most effective treatments for acne, psoriasis, and HSFDA-required labeling reflects reported events, not proven causal relationshipsConcise, evidence-based counseling helps address patient concerns without overwhelming the visitUntreated inflammatory skin disease often poses greater mental health risks than treatmentWith thoughtful patient communication, clinicians can safely and effectively prescribe these therapies while supporting overall well-beingClick here to view the other videos in the series.

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. Psoriasis and the psychiatric comorbidityIn Part 1, Mark Lebwohl, MD, is joined by Rick Fried, MD, PhD, both a dermatologist and a clinical psychologist, to examine the deep and often underappreciated mental health impact of psoriasis. They open with a reminder that multiple dermatologic diseases influence mental health, with psoriasis being among the most studied but far from the only condition with significant psychiatric burden.Dr Lebwohl also outlines 4 dermatologic therapies that carry warnings related to suicidality: brodalumab, isotretinoin, apremilast, and bimekizumab. He notes that concerns about these warnings can meaningfully impact prescribing behavior.The baseline mental health status of patients with psoriasisDr Fried highlights extensive evidence showing that patients with psoriasis have substantially elevated rates of depression, anxiety, suicidal ideation, and completed suicides. Importantly, he notes psoriasis itself is an independent risk factor for these outcomes.He explains that multiple studies show that when psoriasis improves, associated depression and suicidality often also improve, sometimes dramatically, suggesting that treatment of the skin disease can be a direct, positive intervention for a patient’s mental health.Dr Lebwohl reinforces this point with data from a large survey demonstrating that major depression occurs more frequently among people with psoriasis than in the general US population, illustrating the need for dermatologists to recognize and address this burden.When mental health improves with skin disease controlDrawing from his psychology practice, Dr Fried shares that patients with severe psoriasis who have a history of depression or suicidality often benefit the most from highly effective dermatologic treatment, despite clinicians’ hesitations to prescribe when these treatments carry suicidality warnings. These patients frequently experience relief not only from their skin symptoms but also from the social, emotional, family, and intimate impacts of the disease.By the time patients reach dermatology care, many have endured years of topical prescription and over-the-counter treatment failures. He finds that simply engaging with a clinician who demonstrates empathy and confidence in a treatment plan can be impactful for these patients.The dermatologist’s role: life-saving potential through effective treatmentDr Lebwohl stresses that dermatologists may be uniquely positioned to save lives by rapidly improving severe psoriasis with highly efficacious therapy, even if the medication carries a suicidality warning. He notes that FDA labeling reflects a requirement to list all potential events, not proven causation, and that withholding effective therapy due to fear of labeling language may harm patients who need rapid control the most.Dr Fried agrees, emphasizing transparency and informed consent alongside a broader perspective: while labels enumerate theoretical risks, they do not list the severe consequences of undertreatment, including worsening psychiatric burden.Both clinicians highlight that untreated psoriasis is associated with worsening systemic and psychiatric outcomes and that dermatologists should be motivated to act quickly and aggressively when indicated.Closing thoughtsThey conclude by reviewing data demonstrating that biologics across classes are associated with lower rates of suicidal ideation and completed suicides compared to untreated psoriasis and compared to the general population. Studies from the past 20 years consistently show that untreated psoriasis is associated with more than a doubling in suicidal ideation and an approximate 20% increase in completed suicides.Key takeawaysPsoriasis independently increases the risk of depression, anxiety, suicidal ideation, and suicideEffective treatment, especially biologic therapy, can meaningfully reduce psychiatric symptomsDermatologists play a critical role in addressing both physical disease and its mental health consequencesSuicidality warnings on dermatologic drugs reflect reporting requirements, not proven causalityEarly, effective, empathetic intervention can improve quality of life across emotional, social, and physical domainsClick here to view the other videos in the series.

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. The inflammation–depression connectionIn Part 2, Drs Lebwohl and Fried deepen their exploration by discussing the biochemical basis linking psoriasis and depression. Dr Lebwohl begins with an intriguing observation: bupropion, a well-known antidepressant, is also a TNF inhibitor, illustrating biochemical overlap between inflammatory pathways and mood regulation.Some inflammatory mediators elevated in psoriasis are also implicated in depression, suggesting a shared biological landscape beyond the psychosocial burden of visible skin disease.Is depression in psoriasis biologic, psychologic, or both?Dr Fried addresses a longstanding question: are psychiatric symptoms in psoriasis primarily due to disease burden, or are they driven by central biologic mechanisms?He emphasizes that the answer is unequivocally both. Inflammatory cytokines released from skin lesions enter the systemic circulation, cross the blood–brain barrier, and alter neurotransmitter uptake, affecting serotonin, norepinephrine, and dopamine. These changes directly contribute to mood symptoms.This dual mechanism reinforces that addressing inflammation can also address psychiatric symptoms.Future directions: neurotransmitter testing and combined therapiesDr Fried discusses emerging possibilities for objectively measuring neurotransmitters through blood, urine, or imaging strategies. If clinicians could quantify depletion in patients with inflammatory skin disease, they might feel more confident pairing SSRIs or SNRIs with biologics when needed.He highlights growing evidence that depression is, in part, an inflammatory disorder and that antidepressants themselves have anti-inflammatory effects, making them strong potential partners to biologic therapy.Examining suicidality concerns with bimekizumabThe conversation shifts to the suicidality warning for bimekizumab, one of the fastest and most effective psoriasis therapies available. Dr Lebwohl reviews a publication by Blauvelt et al that examined Phase 2 and 3 clinical trial data and found no increased risk of suicidality in patients treated with bimekizumab compared to the general population and compared to patients treated with other IL-17 or IL-23 inhibitors.Despite this, the warning remains on the label, and some clinicians avoid prescribing it. Dr Lebwohl cautions that this hesitancy may prevent high-need patients from accessing a highly effective treatment.Psychological improvement with effective therapyDr Lebwohl closes by sharing another notable trial finding: in pivotal trials, among patients receiving bimekizumab, 93% reported no or minimal depression, compared with 81% of placebo-treated patients. This reinforces that improving skin disease can significantly improve psychological well-being.Key takeawaysPsoriasis and depression may share overlapping inflammatory pathwaysInflammatory cytokines can influence neurotransmitter activity and moodTreating systemic inflammation can improve both skin and psychiatric symptomsClinical trial data show no increase in suicidality with bimekizumab compared with placebo, the general population, or other biologicsClick here to view the other videos in the series.

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. A practical framework for patient conversationsIn Part 3, Drs Lebwohl and Fried turn to the clinician–patient dialogue around therapies that carry suicidal ideation/behavior warnings (SI/B). Dr Lebwohl describes his efficient and effective approach, designed to give patients clarity without overwhelming them.He notes that many patients research their medications and inevitably encounter suicidality language. His strategy involves succinctly explaining that the FDA must list every reported event, even when trial data explicitly state there is no causal association. He then grounds the conversation in data; for example, highlighting that bimekizumab-treated patients demonstrated significantly better mental health outcomes than those on placebo.Reframing the risk: the cost of undertreatmentBoth clinicians emphasize that severe psoriasis itself is associated with increased depression, anxiety, suicidal ideation, and suicide. Effective treatment is a powerful tool for reversing these risks.Dr Lebwohl stresses that when patients are depressed, withholding high-efficacy therapies because of labeling language may cause greater harm. The act of rapidly improving their disease is often the first step toward improving their mental well-being.Communication style: clear, confident, and compassionateDr Fried reinforces the importance of clarity and empathy in these conversations. While shared decision-making is essential, many patients still look to their clinician for a straightforward recommendation.Both experts recommend a structured approach:Acknowledge the SI/B languageExplain the FDA’s reporting requirementsClarify that available data show no causal relationshipHighlight that treating the inflammatory disease can improve mental healthRecommend the therapy you believe is best for the patientThis entire process, Dr Lebwohl notes, takes about one minute in practice.Key takeawaysDermatologists should address SI/B language proactively and confidently with patientsFDA-required labeling reflects reported events, not causationEffective psoriasis treatment reduces psychiatric symptoms and riskClear, compassionate communication strengthens trust and decision-makingPatients often benefit from direct guidance on the clinician’s recommendationClick here to view the other videos in the series.

At Fall Clinical 2025, Peter Lio, MD, explored the changing landscape of topical therapy in atopic dermatitis, emphasizing that topicals remain the cornerstone of treatment—even as new agents expand the toolbox. Here, he highlights the clinician’s role as a “steward of steroids,” and notes the growing importance of nonsteroidal anti-inflammatory agents and value of structured eczema action plans that combine rescue therapy with long-term maintenance to help patients stay clear safely and consistently.

In this video, Michael Cameron, MD, shares four years of data on TYK2 inhibition in psoriasis care, highlighting the durability and safety that continue to reinforce confidence in this once-daily oral therapy. He explains how TYK2’s selective allosteric mechanism differentiates it from traditional JAK inhibitors—helping to account for its clean long-term safety profile—and discusses where oral therapy fits into practice today. With insights on sustained PASI responses, special-site efficacy, and real-world convenience, Dr. Cameron outlines why TYK2 inhibition remains a distinct and durable option for systemic-eligible patients.

In this video, Ben Lockshin, MD, shares his perspective on the evolving role of oral therapies in psoriasis care. He highlights how a once-daily oral option offers strong efficacy, durability, and safety, while also meeting patient demand for alternatives to injections. With practical insights on tolerability, monitoring, and long-term outcomes, Dr Lockshin explains why oral therapy is becoming an important first-line consideration for patients eligible for systemic treatment.

Update (September 2025): Anzupgo is now commercially available and can be prescribed in the United States. Following FDA approval in July 2025, the therapy has officially entered the market and is accessible to clinicians for eligible patients. Watch as James Q. Del Rosso, DO, reviews clinical trial data, mechanism of action, safety, and more. The US Food and Drug Administration has approved Anzupgo (delgocitinib) cream (20 mg/g) for the treatment of moderate-to-severe chronic hand eczema (CHE) in adults who are not adequately controlled with topical corticosteroids or for whom such treatment is not advisable. This represents the first FDA-approved therapy specifically indicated for CHE. Mechanism of action Anzupgo is a topical pan-Janus kinase (JAK) inhibitor, targeting JAK1, JAK2, JAK3, and tyrosine kinase 2. It modulates multiple cytokine signaling pathways involved in the pathophysiology of CHE via inhibition of the JAK-STAT pathway, with topical administration limiting systemic exposure. Clinical trial insights FDA approval was supported by results from two identical randomized, double-blind, vehicle-controlled trials (DELTA 1 and DELTA 2) involving 960 adults with moderate-to-severe CHE. Primary endpoint: Investigator’s Global Assessment for Chronic Hand Eczema Treatment Success (IGA-CHE TS) at Week 16:DELTA 1: 20% with Anzupgo vs 10% with vehicle (p=0.006)DELTA 2: 29% with Anzupgo vs 7% with vehicle (p<0.0001)Key secondary endpoint (≥4-point reduction in severity of itch and pain as measured by the Hand Eczema Symptom Diary):Itch: 47% of Anzupgo-treated patients in both DELTA 1 and DELTA 2 achieved this reduction at Week 16, vs 23% and 20% with cream vehicle (p<0.0001).Pain: 49% of Anzupgo-treated patients in both trials achieved this reduction at Week 16, vs 28% and 23% with cream vehicle (p<0.0001). Safety profile The safety profile of Anzupgo was comparable to that of vehicle. Adverse events occurring in ≤ 1% of patients included application site pain, paresthesia, erythema, pruritus, and bacterial skin infections. Patients completing 16 weeks of treatment in the DELTA 1 and DELTA 2 trials were eligible to enter DELTA 3, a 36-week open-label extension assessing long-term safety. Product availability Anzupgo has been launched in multiple international markets and is expected to be made available in the US soon.

In this video, Dr James Song, Director of Clinical Research and Associate Chief Medical Officer at Frontier Dermatology, provides an in-depth look at Bimzelx (bimekizumab), a novel biologic with 5 approved indications, including 3 with significant impact on dermatology: plaque psoriasis, psoriatic arthritis, and hidradenitis suppurativa (HS).Dr Song explores Bimzelx’s unique position as the first and only FDA-approved dual inhibitor of IL-17A and IL-17F, explaining the science behind this innovative mechanism of action. He discusses how this approach delivers rapid and sustained efficacy, a consistent safety profile, and robust clinical outcomes, with key highlights including improvements in PASI scores, durability of response, and real-world insights into patient care.Watch the full video to learn why Dr Song considers Bimzelx a valuable option for psoriasis management and a powerful tool for dermatologists aiming to achieve enhanced patient outcomes.IMPORTANT SAFETY INFORMATIONSuicidal Ideation and BehaviorBIMZELX may increase the risk of suicidal ideation and behavior (SI/B). A causal association between treatment with BIMZELX and increased risk of SI/B has not been definitively established. Prescribers should weigh the potential risks and benefits before using BIMZELX in patients with a history of severe depression or SI/B. Advise monitoring for the emergence or worsening of depression, suicidal ideation, or other mood changes. If such changes occur, instruct to promptly seek medical attention, refer to a mental health professional as appropriate, and re-evaluate the risks and benefits of continuing treatment.InfectionsBIMZELX may increase the risk of infections, including serious infections. Do not initiate treatment with BIMZELX in patients with any clinically important active infection until the infection resolves or is adequately treated. In patients with a chronic infection or a history of recurrent infection, consider the risks and benefits prior to prescribing BIMZELX. Instruct patients to seek medical advice if signs or symptoms suggestive of clinically important infection occur. If a patient develops such an infection or is not responding to standard therapy, monitor the patient closely and do not administer BIMZELX until the infection resolves.TuberculosisEvaluate patients for tuberculosis (TB) infection prior to initiating treatment with BIMZELX. Avoid the use of BIMZELX in patients with active TB infection. Initiate treatment of latent TB prior to administering BIMZELX. Consider anti-TB therapy prior to initiation of BIMZELX in patients with a past history of latent or active TB in whom an adequate course of treatment cannot be confirmed. Closely monitor patients for signs and symptoms of active TB during and after treatment.Liver Biochemical AbnormalitiesElevated serum transaminases were reported in clinical trials with BIMZELX. Test liver enzymes, alkaline phosphatase, and bilirubin at baseline, periodically during treatment with BIMZELX, and according to routine patient management. If treatment-related increases in liver enzymes occur and drug-induced liver injury is suspected, interrupt BIMZELX until a diagnosis of liver injury is excluded. Permanently discontinue use of BIMZELX in patients with causally associated combined elevations of transaminases and bilirubin. Avoid use of BIMZELX in patients with acute liver disease or cirrhosis.Inflammatory Bowel DiseaseCases of inflammatory bowel disease (IBD) have been reported in patients treated with IL-17 inhibitors, including BIMZELX. Avoid use of BIMZELX in patients with active IBD. During BIMZELX treatment, monitor patients for signs and symptoms of IBD and discontinue treatment if new onset or worsening of signs and symptoms occurs.ImmunizationsPrior to initiating therapy with BIMZELX, complete all age-appropriate vaccinations according to current immunization guidelines. Avoid the use of live vaccines in patients treated with BIMZELX.MOST COMMON ADVERSE REACTIONSMost common (≥ 1%) adverse reactions in plaque psoriasis and hidradenitis suppurativa include upper respiratory tract infections, oral candidiasis, headache, injection site reactions, tinea infections, gastroenteritis, herpes simplex infections, acne, folliculitis, other candida infections, and fatigue.Most common (≥ 2%) adverse reactions in psoriatic arthritis include upper respiratory tract infections, oral candidiasis, headache, diarrhea, and urinary tract infections.Most common (≥ 2%) adverse reactions in non-radiographic axial spondyloarthritis include upper respiratory tract infections, oral candidiasis, headache, diarrhea, cough, fatigue, musculoskeletal pain, myalgia, tonsillitis, transaminase increase, and urinary tract infections.Most common (≥ 2%) adverse reactions in ankylosing spondylitis include upper respiratory tract infections, oral candidiasis, headache, diarrhea, injection site pain, rash, and vulvovaginal mycotic infection.

In this video, Dr Mona Shahriari, dermatologist and Assistant Clinical Professor at Yale University, explores tapinarof cream 1%, or VTAMA, a novel topical treatment for plaque psoriasis. She discusses VTAMA's unique mechanism as an aryl hydrocarbon receptor agonist, which specifically targets key pathways involved in psoriasis—reducing inflammation and oxidative stress and improving skin barrier function.Dr Shahriari reviews VTAMA alongside traditional corticosteroids, highlighting its lack of systemic side effects, absence of usage restrictions, and suitability for sensitive skin areas. Dr Shahriari also details VTAMA’s accessibility, including the patient savings program. Watch the full video to see why Dr Shahriari considers VTAMA a new standard in psoriasis care, offering patients a powerful option for managing their condition.IMPORTANT SAFETY INFORMATIONVTAMA cream is for use on the skin (topical) only. Do not use VTAMA cream in your eyes, mouth, or vagina. Adverse Events: The most common adverse reactions (incidence ≥ 1%) in subjects treated with VTAMA cream were folliculitis (red raised bumps around the hair pores), nasopharyngitis (pain or swelling in the nose and throat), contact dermatitis (skin rash or irritation, including itching and redness, peeling, burning, or stinging), headache, pruritus (itching), and influenza (flu). Indication: VTAMA® (tapinarof) cream, 1% is an aryl hydrocarbon receptor agonist indicated for the topical treatment of plaque psoriasis in adults.You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

In this video, Dr Mona Shahriari, dermatologist and Assistant Clinical Professor at Yale University, explores tapinarof cream 1%, or VTAMA, a novel topical treatment for plaque psoriasis. She discusses VTAMA's unique mechanism as an aryl hydrocarbon receptor agonist, which specifically targets key pathways involved in psoriasis—reducing inflammation and oxidative stress and improving skin barrier function.Dr Shahriari reviews VTAMA alongside traditional corticosteroids, highlighting its lack of systemic side effects, absence of usage restrictions, and suitability for sensitive skin areas. Dr Shahriari also details VTAMA’s accessibility, including the patient savings program. Watch the full video to see why Dr Shahriari considers VTAMA a new standard in psoriasis care, offering patients a powerful option for managing their condition.IMPORTANT SAFETY INFORMATIONVTAMA cream is for use on the skin (topical) only. Do not use VTAMA cream in your eyes, mouth, or vagina. Adverse Events: The most common adverse reactions (incidence ≥ 1%) in subjects treated with VTAMA cream were folliculitis (red raised bumps around the hair pores), nasopharyngitis (pain or swelling in the nose and throat), contact dermatitis (skin rash or irritation, including itching and redness, peeling, burning, or stinging), headache, pruritus (itching), and influenza (flu). Indication: VTAMA® (tapinarof) cream, 1% is an aryl hydrocarbon receptor agonist indicated for the topical treatment of plaque psoriasis in adults.You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

In this installment of Discourses in Dermatology, Aaron Farberg, MD, gives an in-depth overview of the MyPath Melanoma test, a gene expression profile (GEP) test designed to aid in the diagnosis of ambiguous cutaneous melanocytic lesions and inform patient management and treatment decisions. Dr Farberg explains the importance of ancillary testing, particularly in cases where there is a lack of clinicopathological correlation, and how the MyPath Melanoma test can provide objective information to help clinicians classify ambiguous lesions of unknown potential. He also details how to incorporate the test into clinical practice, gives an overview of the MyPath Melanoma report guide, and details the patient-focused financial assistance and insurance billing services available. Finally, he reviews the case of a 27-year-old woman with a high clinical concern for melanoma and atypical histopathology, detailing how the MyPath Melanoma test impacted diagnosis and clinical care in a real-world example.

In this installment of Discourses in Dermatology, G. Michael Lewitt, MD, and Omar Noor, MD, FAAD, discuss bimekizumab, highlighting the remarkable patient outcomes observed in their clinical practices, how it stands out in a crowded treatment landscape, and its significant implications for psoriasis management. A unique mechanism of action Psoriasis intricately involves pathways like IL-23, IL-17, and TNF alpha, with specific immune cells perpetuating the inflammatory cascade. Recognizing the diverse isomers of IL-17, particularly IL-17A and IL-17F, forms the foundation of bimekizumab's approach. Unlike other medications that target solely IL-17A or the IL-17 receptor, bimekizumab is a pioneering treatment that addresses both IL-17A and F, presenting a novel mechanism of action. Histological studies reveal elevated levels of IL-17F in psoriatic lesions, underscoring the significance of dual IL-17A and F inhibition. By precisely targeting these predominant isoforms, bimekizumab demonstrates enhanced efficacy in mitigating inflammation. Patient success stories in clinical practice Highlighting patient anecdotes, Dr Noor and Dr Lewitt underscore bimekizumab’s efficacy in challenging cases, from individuals resistant to conventional therapies to those weary from a carousel of treatments. Both Dr Lewitt and Dr Noor share that their patients on bimekizumab showed significant clearance of psoriatic lesions by the time they returned for a 4-week follow-up and were able to rekindle a sense of optimism toward their treatment journeys after multiple failed responses to other therapies. Counseling patients on adverse events Addressing concerns about adverse events, Dr Noor advocates for comprehensive patient communication. Acknowledging the increased rates of anxiety and depression at baseline in patients with psoriasis, he emphasizes the importance of prioritizing discussions on emotional well-being alongside treatment efficacy. He encourages colleagues to address any relevant medical history of major depressive disorders or antidepressant use to ensure bimekizumab is the right fit for a given patient. An approach to monitoring In terms of monitoring, Dr Noor adheres to standard biologics protocols, conducting CBC, CMP, and QuantiFERON-TB Gold tests at baseline along with an acute hepatitis panel to exclude the possibility of hepatitis B in patients. Dr Noor’s personal recommendation is to follow up with another CMP or LFT at 6 to 12 weeks, and if levels remain stable, repeat yearly going forward. A convenient dosing schedule The recommended dosing schedule for bimekizumab is administration of 320 mg (two 160-mg injections) at weeks 0, 4, 8, 12, and 16, then every 8 weeks thereafter. Notably, this dosing schedule is unique to bimekizumab, offering an appealing option to patients who are concerned about the frequency of medication administration. This approach not only enhances patient compliance but also accommodates individual needs, particularly in the case of overweight patients who may need to remain on an every-4-week dosing schedule. Standing out in a crowded landscape Drs Lewitt and Noor conclude their discussion by reflecting on the crowded psoriasis treatment landscape. Despite the many options available, they acknowledge that persistent unmet needs remain. They remark that bimekizumab stands out by effectively addressing these needs through its distinct mechanism of action, rapid efficacy, and favorable safety profile, allowing them to maintain the commitment to prioritizing patient well-being amid the evolving landscape of psoriasis therapeutics.

In this episode of Discourses in Dermatology, Alice Gottlieb, MD, PhD, and James Q Del Rosso, DO, discuss bimekizumab, which has emerged as a distinctive and highly efficacious treatment option for psoriasis. Tune in to hear their comments on its unique features, efficacy, safety profile, and dosing advantages. What makes bimekizumab different? Dr Gottlieb describes the unique features that distinguish bimekizumab from other psoriasis treatments, noting the high level of efficacy that has been demonstrated in rigorous comparator studies and shown to be more efficacious than adalimumab and secukinumab. It is also currently the only IL-17 blocker with every-8-weeks dosing, which puts it in the range of the IL-23 blockers. Bimekizumab also possesses a novel mechanism of action as an IL-17A and F blocker, whereas agents like secukinumab and ixekinumab are IL-17A blockers only. Efficacy Dr Gottlieb notes that the majority of patients on bimekizumab reach PASI 75 by week 4, with Dr Del Rosso commenting that 4 out of 10 have been shown to achieve PASI 90 after a single dose. In a New England Journal of Medicine comparator study, 86% of patients taking bimekizumab achieved PASI 90 vs 47% of patients on adalimumab. Safety profile Candida In clinical trials, candida infections occurred more frequently in the bimekizumab group than in the placebo group, however, Dr Gottlieb notes that bimekizumab is a more potent drug than ixekinumab or secukinumab, thus a higher incidence of candida is to be expected and not cause for concern. Suicidal ideation and behavior Regarding the package insert statements on depression and suicide, Dr Gottlieb notes that the associated confidence interval numbers reflect that these potential adverse effects do not pose a significant concern. Liver function Treatment with bimekizumab was associated with increased incidence of liver enzyme elevations compared to treatment with placebo in randomized clinical trials. However, Dr Gottlieb notes that there have been rigorous double-blind, placebo-controlled comparator studies on bimekizumab against adalimumab, secukinumab, and ustekinumab, and bimekizumab did not demonstrate a higher incidence of liver function issues, with the incidence being low across all drugs in the studies. Tuberculosis Evaluating patients for tuberculosis prior to initiating treatment with bimekizumab is required; Dr Gottlieb typically opts to repeat the screen once per year. Inflammatory bowel disease Inflammatory bowel disease (IBD) has been reported in patients treated with IL-17 blockers, though Dr Gottlieb comments that the risk is relatively minimal. However, she notes that for patients with active IBD or a strong family history of IBD, she would likely consider an alternative therapy. Dosing The recommended dosing schedule for bimekizumab is administration of 320 mg (two 160-mg injections) at weeks 0, 4, 8, 12, and 16, then every 8 weeks thereafter. Dr Gottlieb remarks that this dosing schedule is one of the most notable advantages of bimekizumab, noting that it is currently the only IL-17-targeting agent that allows an every-8-weeks dosing schedule at maintenance. She commends the flexibility of adjusting dosing to every 4 weeks for patients weighing ≥120 kg. Key points: Bimekizumab has demonstrated better efficacy than adalimumab and secukinumab in comparator studies Bimekizumab possesses a novel mechanism of action as both an IL-17A and F blocker Potential adverse effects such as candida infections, suicidal ideation and behavior, and liver biochemical abnormalities may not pose significant cause for concern in patients taking bimekizumab For patients with active IBD or a strong family history of IBD, alternative therapies may be considered The recommended dosing for bimekizumab is a major advantage over other treatments, offering a convenient and flexible schedule

In this installment of Discourses in Dermatology, Dr Andrew Blauvelt, a dermatologist from Portland, Oregon and investigator at Oregon Medical Research Center, sits down with Dr Jason Hawkes, a medical dermatologist from Sacramento, California, to discuss the pathogenesis of psoriasis. Over the course of their conversation, they provide an overview of the immunology of psoriasis, explore the relationship between IL-23 and IL-17, highlight the isoforms that dermatologists need to know, and examine the role of TNF in the pathogenesis of psoriasis.Overview of the immunology of psoriasisDr Hawkes begins with a high-level overview and considers the primary signal that drives the clinical features of psoriasis dermatologists see in the clinic. He notes that IL-17, both IL-17A and IL-17F, is the cytokine that drives the hyperproliferative effects in psoriasis, with IL-23 helping sustain those T cells and making high levels of IL-17. He comments that this serves as the predominant role of what drives psoriasis.Another aspect he considers is the skin once it’s been activated. Once it’s in the hyperproliferative state, it begins making its own signals like IL-17C, IL-19, and CCL20, which go back to the immune system to reactivate dendritic cells and T-cells. This is a feed-forward cycle that begins with the IL-23 and IL-17 axis activating the skin cells and signals coming back that activate the dendritic cells and T cells further, creating a chronic cycle of disease. This serves as the framework by which we can then examine the nuances of psoriasis.Key points:IL-17 (both A and F) is the cytokine that drives the hyperproliferative effects in psoriasisIL-23 helps to sustain T-cells and make high levels of IL-17The IL-23 and IL-17 axis activates skin cells with signals coming back that activate dendritic cells and T cells, which creates a feed-forward cycle that promotes a chronic cycle of disease The relationship between IL-23 and IL-17Dr Hawkes remarks that he views IL-23 as the regulatory signal that helps T cells differentiate into IL-17-producing T cells. Th17 is commonly discussed, but T-17 must also be mentioned since it includes both the CD4+ and CV8+ T cells. He summarizes the relationship between IL-23 and IL-17 by explaining that IL-23 is upstream of IL-17 and helps T cells differentiate into IL-17 high-producing cells. From IL-17-producing T cells, we see both IL-17A and IL-17F. Dr Hawkes also mentions IL-17C, which is produced by keratinocytes as opposed to IL-17A and F which come from T cells.Key pointsIL-23 is the regulatory signal that helps T cells differentiate into IL-17-producing cellsIL-17A and IL-17F come from IL-17-producing T cellsIL-17C is produced by keratinocytes Isoforms that dermatologists need to knowDr Blauvelt comments on the number of different isoforms included in A though F and asks Dr Hawkes which key IL-17 cytokines are important for dermatologists to know about when it comes to the pathogenesis of psoriasis.Dr Hawkes explains that there are 6 dimeric cytokines in the IL-17 family, IL-17 A through IL-17 F. These cytokines can pair, so there may be an IL-17 AA homodimer or an AF for example, which is relevant in driving psoriasis. He notes that not much is known about IL-17 B, D, E.He identifies 3 cytokines that are important for dermatologists to pay attention to. IL-17A and IL-17 F are primarily produced by the T cells. The AA homodimer, the AF heterodimer, and the FF homodimer are the key signals from the T cell compartment.From the keratinocytes, we see IL-17 C.He remarks that we don’t yet know the role of the other IL-17 cytokines play in psoriasis, but IL-17 A, F, and C drive the predominant features we see in the immune compartment and in the keratinocyte or epidermal compartment.Key pointsThere are 6 dimeric cytokines in the IL-17 family (A-F)These cytokines can pair, which is relevant in driving psoriasisIL-17A, F, and C drive the predominant features of psoriasis The role of TNF in psoriasis pathogenesisDr Blauvelt continues the conversation by introducing tumor necrosis factor (TNF). He believes TNF is made all over as opposed to specifically upstream, midstream, or downstream and asks Dr Hawkes for his input on where TNF fits into the psoriasis pathogenesis picture.Dr Hawkes agrees and describes TNF as a very potent proinflammatory signal and a cytokine that changes thousands of genes compared to hundreds with IL-17 and IL-23. This creates a big activating system. There are portions of it upstream; plasmacytoid dendritic cells make high levels of interferon and the myeloid or mature dendritic cells make high levels of TNF, but we also see TNF working much further downstream.He references research from Dr James Krueger’s laboratory that has shown IL-17 has its own impact on the skin as does TNF being proinflammatory, but together, that synergy creates a much more powerful impact. We see other cytokines as working with those predominant signals with IL-23 and IL-17, and they’re working to potentiate or amplify the proinflammatory effect.Dr Hawkes notes that many residents have asked how TNF inhibitors work if IL-23 and IL-17 are so central. He replies that the blockade of TNF helps to indirectly reduce levels of IL-17 because it’s an upstream signal like IL-23. By blocking it, it also blocks the potentiating effects and magnifying synergistic effects that IL-17 has on the skin driving hyperproliferation. Because it’s broad acting, it works in different levels.He also comments on the downside of TNF having that broader impact versus more targeted agents. He describes this as immune collateral damage, but it’s also not a very strong potent inhibitor of that central pathway of IL-17 and IL-23. Those targeted agents have a better way of shutting off the driving signal.Dr Blauvelt concludes by describing TNF blockers as anti-inflammatory in general, which is why they work for a variety of inflammatory diseases. and IL-17s and IL23s as much more targeted to psoriatic inflammation, which is why we don’t see a lot of the side effects seen with TNF blockers.Key pointsTNF is a potent proinflammatory signal and cytokine that changes thousands of genes, creating a large activation systemThe synergy between IL-17 and TNF creates a powerful impactTNF indirectly reduces levels of IL-17, thus blocking magnifying synergistic effects that IL-17 has on driving hyperproliferationThe broad impact of TNF can be described as immune collateral damageIL-17s and IL-23s are much more targeted to psoriatic inflammation versus TNF blockers, which are anti-inflammatory in general

In this installment of Discourses in Dermatology, Dr. George Han, Director of Clinical Research at Northwell Health in New York, sits down with Dr. Andrew Blauvelt, Investigator at Oregon Medical Research Center, to discuss the genetic, environmental, and lifestyle factors that influence psoriasis. They also explore the comorbidities associated with psoriasis and how they play into the role of psoriatic disease.The role of genetics in psoriasisDr. Han begins by asking Dr. Blauvelt what role genetics really plays in the development of psoriasis.Dr. Blauvelt references the first genetic study published on psoriasis, spearheaded by Danish researchers in the Faroe Islands in 1963, which found evidence of a genetic component to psoriasis in the local island population. He also comments on a key study examining identical twins that revealed strong evidence in favor of a genetic component to psoriasis.Dr. Blauvelt notes that while there is a genetic component to psoriasis, it’s not a Mendelian disease. Rather, there are 70 to 80 susceptibility genes that have been identified that either confer a risk for psoriasis or confer some protection.With those factors considered, he explains to his patients that while there is indeed a significant genetic component, it does not account for the entire picture of psoriasis. He estimates that approximately 40% of patients have a family history of the condition but suggests that even those without a family history may still have a genetic predisposition due to a combination of genes inherited from their parents. To summarize, he reiterates that psoriasis is a complex condition with a genetic component with other factors also involved in its development.Key pointsA seminal study demonstrating the genetics of psoriasis was conducted by Danish researchers on the Faroe Islands in 1963Twin studies have also revealed strong evidence in favor of a genetic component to psoriasisPsoriasis is not a Mendelian disease, but is influenced by 70 to 80 susceptibility genesWhile there is a significant genetic component to psoriasis, it does not account for the entire pictureEnvironmental influences on psoriasisDr. Han continues the conversation by asking Dr. Blauvelt about the environmental influences on psoriasis that may encourage psoriasis in susceptible individuals.Dr. Blauvelt replies by giving more background on the genetics of psoriasis, explaining that there are 2 types of psoriasis as it relates to genetics. The first type is a result of genes that tend to run in families, with HLA-Cw6 being the most common. With this type, there is usually an earlier onset in the late teens or early 20s. The second type tends to manifest in the early 40s, and those patients tend not to have a family history of the condition. Rather, this type of psoriasis tends to be more associated with metabolic syndrome, diabetes, or hypertension.Dr. Blauvelt then begins delving into some of the well-known influences on psoriasis, including stress, infections like strep throat, and certain medications. He specifically mentions lithium and interferon stimulators, remarking that Aldara cream can stimulate psoriasis locally.He comments that the most common influences on psoriasis he has seen in his career have been strep throat, stress, and cold weather. He advises patients that any kind of stressor on the body, whether emotional or physical stress from temperature, medication, or infection, can trigger the psoriasis immune response.Key pointsInfluences on psoriasis can include stress, infections, and certain medicationsLithium and interferon stimulators can affect psoriasisCold weather can also trigger the psoriasis immune responseComorbidities of psoriasisDr. Blauvelt comments that the list of comorbidities associated with psoriasis has become quite long and can be overwhelming for healthcare providers who are unsure how to counsel patients on this topic.He describes his approach to speaking with patients and how he always discusses the 2 most important psoriasis comorbidities, psoriatic arthritis and heart disease, at their first visit. When discussing psoriatic arthritis, he explains that it is the most common comorbidity and will affect treatment choice, and that is an important facet for patients to consider and understand. In his experience, some patients with psoriasis are unaware that they are at risk for arthritis and thus it should be discussed early on.Dr. Blauvelt also makes sure to discuss heart disease with his patients and emphasize the seriousness of it. He references the literature that is now available on psoriasis as an independent risk factor for heart disease and says it also suggests that the risk of heart disease can be reduced if an impact can be made on the skin.He mentions large databases that suggest TNF blockers may reduce the risk of cardiovascular events but that we don’t yet have that same kind of data for IL-17s and IL-23s. He also references studies conducted at the NIH that put patients on biologics for one year and measured their atherosclerotic plaques. Those studies demonstrated that IL-17 blockers were the best class of drugs in terms of improving atherosclerosis in patients with psoriasis. While they don’t prevent heart attack and stroke, it’s strong evidence that these therapies are having positive outcomes.Key pointsThe long list of comorbidities associated with psoriasis can make it overwhelming to counsel patientsThe 2 most important comorbidities to discuss with patients are psoriatic arthritis and heart diseasePsoriatic arthritis should be discussed with patients at their first visit, since it’s the most common comorbidity and can affect treatment choiceLiterature suggests that psoriasis is an independent risk factor for heart disease and that the risk of heart disease can be reduced if an impact can be made on the skinLarge databases suggest TNF blockers may reduce risk of cardiovascular eventsNIH studies demonstrated that IL-17 blockers were the best class of drugs in improving atherosclerosis in patients with psoriasisMental health as a comorbidity of psoriasisDr. Han continues the conversation by asking Dr. Blauvelt his thoughts on mental health and psoriasis and how he approaches this discussion with patients.Dr. Blauvelt references his involvement in one of the first multidisciplinary clinics for psoriasis in the United States that included dermatology, rheumatology, and psychiatry. When he asked patients about their mental health, they often reported they were depressed and anxious due to the condition. He found many were hesitant to be referred to the psychiatry clinic because they felt that if their psoriasis cleared, their mental health would improve, which demonstrates there is a component to the condition that can cause angst and depression.He remarks that practitioners can assume quality of life is impaired for patients with psoriasis and that patients are likely to score poorly on quality-of-life measures and depression scales. He emphasizes that this should not be ignored and that it’s important to listen to patients and monitor for signs of severe depression and suicidal ideation. Dr. Han concludes by agreeing on the importance of listening and caring for the whole patient.Key pointsThere is a component to psoriasis that can cause angst and depression among patients with the conditionPatients with psoriasis will often have impaired quality of life and score poorly on quality-of-life measures and depression scalesIt’s vital to listen to patients and monitor them for signs of severe depression and suicidal ideation