Clinical Video Library

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As we continue to deepen understanding of the aryl hydrocarbon receptor (AhR), April Armstrong, MD, MPH, and Elizabeth (Lisa) Swanson, MD, explore why AhR has remained a relatively unfamiliar pathway for many clinicians despite years of clinical experience, and further, the relevance it has now. Together, they discuss AhR agonism as a distinct therapeutic approach, its role in immune regulation, skin barrier restoration, and oxidative stress, and how those biologic effects translate into practical treatment decisions. Along the way, they compare AhR with other topical mechanisms, share how their own prescribing has evolved, and look ahead to what this emerging therapeutic class may teach us about inflammatory skin disease beyond today's indications.

In this episode of Topical Conversations, Dawn Merritt, DO, and Neal Bhatia, MD, discuss the management of patients with psoriasis who benefit from a higher-touch approach to care. Their conversation extends beyond selecting an effective biologic to examine how ongoing clinical engagement can support adherence, identify barriers to treatment, and provide opportunities to address the broader health concerns. The speakers also explore how health care professional (HCP)-administered biologics can facilitate regular patient contact and reinforce long-term treatment success.Identifying patients who benefit from closer follow-upDr Bhatia describes the "higher-touch patient" as someone who requires more frequent engagement to remain connected to treatment and achieve the best possible long-term outcomes. Rather than focusing solely on prescribing therapy, he emphasizes understanding where patients are in their treatment journey, discussing their goals, and helping them navigate the lifestyle changes that often accompany psoriasis management.These patients are not defined solely by disease severity. As clinicians develop long-term relationships with their patients, they often recognize social or logistical challenges that can interfere with treatment adherence. Dr Merritt describes a college student whose living situation made storing and self-administering a biologic both impractical and uncomfortable. Transitioning to an in-office administered biologic provided structured follow-up visits that helped keep the patient engaged with treatment.Dr Bhatia highlights similar situations among military personnel, who may face practical barriers to storing injectable medications or concerns about administering injections in shared living environments. For these patients, in-office administration can improve adherence while giving clinicians greater confidence that treatment is being received as intended.Regular touchpoints create opportunities beyond skin clearanceBoth speakers emphasize that scheduled office visits provide opportunities to evaluate much more than psoriasis severity. Dr Bhatia explains that seeing patients regularly allows clinicians to identify factors that may be limiting treatment response, including smoking, obesity, or other lifestyle influences that may not be apparent during less frequent follow-up.These visits also create opportunities to manage persistent symptoms while patients are working toward maximal biologic efficacy. Ongoing assessment of itch, scalp involvement, nail disease, joint symptoms, and oral manifestations allows clinicians to address residual disease, optimize supportive therapies, and better understand how psoriasis is affecting patients' daily lives, including their ability to exercise, work, and maintain overall health.Seeing the whole patientDr Merritt highlights the unique value of regular office visits among Medicare patients, many of whom appreciate returning every 12 weeks for treatment and develop strong relationships with the clinical staff. These encounters often reveal important health or social concerns that might otherwise go unnoticed.She recalls caring for an older patient whose psoriasis remained well controlled but who appeared withdrawn following the recent loss of his wife. During his treatment visit, she recognized signs that he was struggling with nutrition and self-care, ultimately reaching out to family members to help ensure he received additional support beyond dermatologic treatment.Dr Bhatia agrees that subtle changes in a patient's appearance, behavior, or overall well-being are often easier to recognize during in-person visits. He also notes that the broader clinical team can play an important role in identifying concerns that warrant further attention. For patients with metabolic syndrome or elevated cardiovascular risk, these regular encounters provide additional opportunities to remain engaged with their overall health, not just their skin disease.Persistence and adherence with HCP-administered biologicsDr Merritt also discusses real-world evidence suggesting strong treatment persistence with IL-23 inhibitors.While persistence is influenced by multiple factors, both speakers suggest that HCP-administered biologics may contribute by reducing some of the logistical barriers associated with self-administration. For patients who struggle with medication storage, scheduling doses, or treatment adherence, regular in-office administration provides consistent accountability while allowing clinicians to monitor progress throughout therapy.Integrating higher-touch care into a busy practiceProviding individualized care does not necessarily require disrupting clinic efficiency. Dr Bhatia explains that thoughtful scheduling can help match visit length to patient needs. Patients who are stable and doing well may be scheduled early in the day for streamlined appointments, while retirees or patients requiring more extensive discussion may benefit from appointment times that allow for greater flexibility.He also encourages practices to consider travel time, work schedules, and other patient commitments when coordinating visits. These logistical considerations can improve patient satisfaction while maintaining efficient clinic flow.Dr Merritt adds that patients with a history of poor adherence may particularly benefit from the structure provided by regular office visits. For individuals who struggle with remembering to obtain, store, or administer medications, closer clinical follow-up can reduce treatment interruptions and improve long-term disease control.Dr Bhatia concludes by noting that many dermatologists have experienced the frustration of seeing patients return after prolonged gaps in care with uncontrolled psoriasis because treatment was never initiated or maintained. Incorporating office-based therapies when appropriate allows clinicians to maintain closer engagement with selected patients and may improve both adherence and overall outcomes.

A practical discussion of how to recognize CSU, reassess inadequate antihistamine response, and build a more intentional path toward long-term control.By the time many patients with chronic spontaneous urticaria (CSU) reach dermatology, they have already cycled through urgent care visits, repeated corticosteroid bursts, and an exhausting search for a trigger that may never emerge. In this installment of Topical Conversations, Dawn Merritt, DO, and Naiem Issa, MD, PhD, move the discussion beyond recognizing the burden of CSU and into the practical work of diagnosing it, setting expectations, and building a long-term treatment plan. Dr Issa walks through a focused approach to distinguishing CSU from inducible urticaria, including questions about heat, exercise, cold, water, pressure, and dermatographism. Just as important is the reassurance that begins the visit. “Welcome to your destination,” he tells patients—a signal that their disease can be understood and managed, rather than promising some immediate fix.From there, the conversation turns to what happens when appropriately dosed second-generation H1 antihistamines aren’t enough. Drs Merritt and Issa connect mast cell activation and type 2 inflammation to the evolving treatment landscape, then consider how route of administration, dosing burden, anticipated response, and patient preference can shape shared decision-making. As Dr Merritt puts it, “The skin exam captures a moment, but our patient history captures the disease.”It’s a grounded discussion about moving past episodic rescue and toward a more deliberate approach that recognizes CSU as a chronic, relapsing-remitting disease and gives patients a clearer path toward sustained control.

Safety, monitoring, and shared decision-making across biologic and adjunctive careIntegrative care in atopic dermatitis (AD) is not only about what clinicians may add to the treatment plan. It’s about how those recommendations are evaluated, monitored, and shaped around the person expected to follow them.In the final installment of this Topical Conversations series, Cynthia Trickett, PA-C, and Peter Lio, MD, turn to the practical responsibilities that come with combining adjunctive strategies and biologic therapy. Dr Lio discusses the long-term safety experience with biologics while emphasizing the importance of continuing to watch emerging signals with appropriate humility. The same caution extends to supplements, where ingredient quality, contamination, counterfeit products, and inconsistent manufacturing can make a seemingly straightforward recommendation far more complicated. When he does recommend a supplement, he tries to be highly specific about the brand and supplier.The conversation then moves from safety to sustainability. Gentle cleansing, regular moisturizing, reducing environmental irritants, sleep, nutrition, and movement may all support care, but only when they fit the patient’s life. A recommendation that is unaffordable, intolerable, inaccessible, or unrealistic is unlikely to succeed, no matter how sound it appears on paper.That reality also shapes follow-up. Dr Lio describes checking in early with patients who have more severe disease and using the Atopic Dermatitis Control Tool to move beyond a general sense of “better” toward a more structured assessment of whether the disease is truly controlled. Those conversations may reveal that a treatment was never received, not covered, caused stinging or burning, or simply did not fit into the patient’s routine.Ultimately, the episode returns to the foundation of integrative care: listening. “The goal is to get you better,” Dr Lio says. That means giving patients options, inviting them to guide the plan, and remaining flexible enough to adjust when one approach does not fit. Integrative care enhances biologic therapy rather than replacing it, creating a broader and more individualized path toward control.<div class="dsq-quiz"> <div class="dsq-header">QUICK CHECK</div> <div class="dsq-body"> <p class="dsq-question">A patient with atopic dermatitis reports improvement after starting a new treatment, but their ADCT score remains 9. Which response best reflects Dr Lio's approach?</p> <form id="dsqQuizForm1"> <label class="dsq-option"><input type="radio" name="dsqAnswer1" value="A"><span><strong>A.</strong> Continue the current plan unchanged because any subjective improvement indicates adequate control</span></label> <label class="dsq-option"><input type="radio" name="dsqAnswer1" value="B"><span><strong>B.</strong> Discontinue biologic therapy and transition to adjunctive treatments alone</span></label> <label class="dsq-option"><input type="radio" name="dsqAnswer1" value="C"><span><strong>C.</strong> Acknowledge the improvement while discussing whether additional changes are needed to achieve better disease control</span></label> <label class="dsq-option"><input type="radio" name="dsqAnswer1" value="D"><span><strong>D.</strong> Repeat the ADCT only if the patient develops a visible flare</span></label> <button type="button" class="dsq-submit" id="dsqSubmitBtn1">Submit Answer</button> </form> <div id="dsqFeedback1" class="dsq-feedback"> <p id="dsqFeedbackHeader1" class="dsq-feedback-header"></p> <p><strong>Rationale:</strong> Dr Lio describes the ADCT as a practical way to assess whether AD is truly controlled. A score of 7 or greater suggests that control remains inadequate. Even when a patient feels better, the score can support a continued discussion about barriers, adjunctive options, or other treatment adjustments.</p> </div> </div> </div> <div class="dsq-quiz"> <div class="dsq-header">QUICK CHECK</div> <div class="dsq-body"> <p class="dsq-question">Which approach best reflects Dr Lio's guidance when recommending supplements as part of an integrative AD plan?</p> <form id="dsqQuizForm2"> <label class="dsq-option"><input type="radio" name="dsqAnswer2" value="A"><span><strong>A.</strong> Recommend the active ingredient without specifying a product because all formulations are considered equivalent</span></label> <label class="dsq-option"><input type="radio" name="dsqAnswer2" value="B"><span><strong>B.</strong> Encourage patients to choose the least expensive version available from any retailer</span></label> <label class="dsq-option"><input type="radio" name="dsqAnswer2" value="C"><span><strong>C.</strong> Avoid discussing supplements because clinicians cannot reduce any of the associated risks</span></label> <label class="dsq-option"><input type="radio" name="dsqAnswer2" value="D"><span><strong>D.</strong> Be specific about trusted brands and suppliers while acknowledging that quality and contamination concerns may still remain</span></label> <button type="button" class="dsq-submit" id="dsqSubmitBtn2">Submit Answer</button> </form> <div id="dsqFeedback2" class="dsq-feedback"> <p id="dsqFeedbackHeader2" class="dsq-feedback-header"></p> <p><strong>Rationale:</strong> He emphasizes that supplement labels may not reliably reflect product contents and that contamination, poor-quality ingredients, or counterfeit products are possible. When recommending a supplement, Dr Lio tries to be highly prescriptive about the brand and supplier to reduce, although not eliminate, those risks.</p> </div> </div> </div> <script> (function() { function setupQuiz(formId, submitBtnId, feedbackId, feedbackHeaderId, correctAnswer, wrongLabel) { var form = document.getElementById(formId); var submitBtn = document.getElementById(submitBtnId); var feedback = document.getElementById(feedbackId); var feedbackHeader = document.getElementById(feedbackHeaderId); var options = form.querySelectorAll(".dsq-option"); submitBtn.addEventListener("click", function() { var selected = form.querySelector("input:checked"); if (!selected) { alert("Please select an answer before submitting."); return; } var value = selected.value; var isCorrect = (value === correctAnswer); options.forEach(function(opt) { var input = opt.querySelector("input"); if (input.value === correctAnswer) { opt.style.borderColor = "#0E7490"; opt.style.background = "#E6F6F8"; } else if (input.checked && !isCorrect) { opt.style.borderColor = "#C53030"; opt.style.background = "#FDECEC"; } input.disabled = true; }); feedback.style.display = "block"; if (isCorrect) { feedback.style.background = "#E6F6F8"; feedback.style.border = "1px solid #0E7490"; feedbackHeader.style.color = "#0E7490"; feedbackHeader.textContent = "\u2713 Correct!"; } else { feedback.style.background = "#FDECEC"; feedback.style.border = "1px solid #C53030"; feedbackHeader.style.color = "#C53030"; feedbackHeader.textContent = "\u2717 Not quite \u2014 the correct answer is " + correctAnswer + "."; } submitBtn.disabled = true; }); } setupQuiz("dsqQuizForm1", "dsqSubmitBtn1", "dsqFeedback1", "dsqFeedbackHeader1", "C"); setupQuiz("dsqQuizForm2", "dsqSubmitBtn2", "dsqFeedback2", "dsqFeedbackHeader2", "D"); })(); </script> </body> </html> ">

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&#039;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&#039;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&#039;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&#039;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?

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&#039;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&#039;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.

In this episode of Business Unblemished, Erik Domingues, MD, sits down with Mark Kaufmann, MD, to unpack the coding strategies, buy-and-bill models, and overlooked CPT opportunities that can help dermatology practices stay afloat in the face of shrinking reimbursements and rising costs.They discuss how to:Use underutilized codes like G2211 to capture the full scope of careDetermine when buy-and-bill strategies are worth the riskAvoid common pitfalls that lead to lost revenueRecognize how accurate, complete coding can safeguard independent practiceAs Dr Kaufmann puts it: inflation is squeezing physicians, but smarter billing may be the key to better survival.

In this episode of Business Unblemished, Dr Stephen Lewellis, founder of Above & Beyond Dermatology, interviews Jamie Danley, Chief Human Resources Officer at Advanced Dermatology and Cosmetic Surgery, on how best to translate practice principles between small and large dermatology practices.Part one of this two-part episode, Dr Lewellis and Jamie discuss how to achieve employee engagement and establish culture across practice sizes, including the importance of defining culture and its role in creating a thriving practice.

In part two of this episode of Business Unblemished, Dr Stephen Lewellis and Jamie Danley continue their conversation about growing and evolving a small practice into a larger practice. They discuss ways of achieving buy-in from employees, empowering team members, and establishing culture based on a firm conviction in a practice's core values.

In this episode of Business Unblemished, Dr Dawn Merritt and Dr Aaron Farberg discuss how to efficiently implement photodynamic therapy (PDT) for actinic keratosis (AK) in dermatology practices. They address common misconceptions about PDT’s cost, logistical challenges, and practical strategies to maximize both its clinical and financial value.Why use PDT for actinic keratosis?PDT is an effective field therapy for actinic keratosis. While individual lesions can be treated with cryotherapy, many patients require broader treatment, making PDT an excellent in-office option.Dr Merritt, an early adopter of PDT, has integrated the treatment into all 10 of her practice locations, where it is performed daily. Dr Farberg strongly believes every dermatology practice should offer PDT, noting that dermatologists are likely to see multiple patients every day who could benefit from it. While topical therapies remain a viable and effective option, PDT offers greater control over treatment application and adherence, ensuring patients receive consistent and effective care.Optimizing workflow and staffingDr Merritt emphasizes that proper scheduling is key to ensuring PDT does not disrupt clinic flow. Instead of scheduling PDT as a physician-led appointment, she recommends setting it up as a nurse visit:Medical assistants (MAs) handle the setup and patient preparationThe physician only needs to be present for consent, curettage, and product application, allowing them to continue seeing other patients while the PDT session runs in the backgroundDr Farberg adds that while MAs can manage most of the process, physicians should personally apply and initiate PDT for optimal reimbursement and quality of care. A simple way to improve efficiency is to provide patients with a bell to call for assistance while MAs manage other tasks such as prior authorizations or patient paperwork.Space considerations for PDT implementationOne common concern among dermatologists considering PDT is space requirements. However, PDT does not require a dedicated room:Dr Merritt recommends using a nurse visit room or an overflow exam room to allow smooth patient flowDr Farberg has successfully implemented PDT in small rooms, demonstrating that space limitations should not deter practices from considering the serviceAddressing cost concerns and maximizing revenueFor newer or smaller practices, the upfront cost of PDT equipment may feel like a barrier. However, both doctors emphasize that PDT is a long-term revenue generator:Established practices can confidently invest, knowing they will recoup costs over timeNew practices with tighter budgets can explore equipment rental options, which allow them to offer PDT without large upfront costsDr Merritt routinely budgets for PDT when opening a new office because she knows its profitability and value to patients.Educating patients about PDTDr Merritt emphasizes that patient education is crucial for successful PDT integration. She advises new practices to:Create a simple handout explaining what patients can expectAlways schedule 2 PDT treatments upfront, with a third follow-up visit 8 weeks later for evaluation.Dr Farberg finds that offering multiple field therapy options allows patients to choose what works best for them, though many prefer PDT due to its ease of use and convenience.Training staff to promote PDTDr Merritt utilizes rolling screen advertisements in her offices to inform patients about PDT before their appointment. Additionally, she has trained her MAs with instructional videos that cover:PDT setup and applicationHow to explain the procedure to patientsWhen to involve the physician during treatmentThis structured approach ensures the entire team is aligned and helps patients feel more comfortable with the procedure.Identifying ideal candidates for PDTDr Merritt has a simple rule of thumb for determining when to recommend PDT:If she has to freeze more than what fits on one hand, the patient needs field therapy—and PDT is her first choiceDr Farberg also sees PDT as a built-in marketing tool; patients who receive it often remark that they have never had it offered at other dermatology offices. These patients share their positive experiences with friends, bringing in new patients and strengthening practice growth.PDT remains one of the most effective and well-established treatments for AK field therapy. While some dermatologists hesitate due to logistical concerns, both Dr Merritt and Dr Farberg emphasize that with proper implementation, PDT can enhance patient care while becoming a valuable revenue stream.Key takeawaysPDT offers precise, in-office field therapy for patients with AKWith efficient scheduling, PDT can be integrated seamlessly into any practice workflowSpace constraints should not deter practices from offering PDTThe cost of PDT equipment is quickly recouped, and rental options are availableA well-trained team and patient education help maximize PDT’s impact

Hair loss can’t be evaluated well from the scalp alone. In this hair and scalp exam video, Garland James, PA-C, walks through a practical approach to evaluating hair loss in clinic, from taking a focused history and asking about styling practices to looking for signs of inflammatory and noninflammatory alopecia. She also emphasizes the parts of the exam that can easily be missed: asking permission before touching the hair, photographing the scalp for comparison, recognizing when biopsy may be needed, and building a treatment plan with the patient instead of around them. Use the accompanying Hair and Scalp Exam: A Practical Clinical Guide for PAs and NPs as a quick reference for assessing hair practices, tension patterns, density and distribution, dermoscopic clues, and care considerations in textured hair. Question: In the video, James emphasizes that the clinical history can help guide the hair loss exam. Which of the following is most relevant to ask before examining the scalp? Whether the patient prefers prescription or over-the-counter treatment Current and recent hair care practices, including protective styles and duration of wear Whether the patient has used cosmetic hair coloring in the past 10 years Whether the patient is willing to stop all styling during treatment Rationale: Rationale: Hair practices can help explain the pattern of hair loss and should be discussed before the exam. The accompanying guide also notes that hair practices often explain the pattern and recommends asking about recent styling changes, current routine, symptoms, and prior treatments. document.querySelectorAll('.mcq-block').forEach(function(block) { const correct = block.getAttribute('data-correct'); const form = block.querySelector('.mcq-form'); const feedback = block.querySelector('.mcq-feedback'); const resultText = block.querySelector('.mcq-result'); form.addEventListener('change', function(e) { const selected = e.target.value; // Log to console (optional) console.log("Selected answer:", selected); // Show feedback feedback.style.display = 'block'; if (selected === correct) { resultText.textContent = "Correct!"; resultText.style.color = "green"; } else { resultText.textContent = "Incorrect"; resultText.style.color = "red"; } }); }); .mcq-block { padding: 1rem; border: 1px solid #ddd; border-radius: 10px; margin: 1.5rem 0; background: #fafafa; } .mcq-question { margin-bottom: 0.75rem; } .mcq-feedback p { margin: 0.3rem 0; } Question: During the exam, which finding would most strongly support considering biopsy for possible inflammatory or scarring alopecia? Diffuse shedding without scalp symptoms Mixed hair shaft diameters consistent with miniaturization Perifollicular erythema or scaling with concern for scarring disease Mild dandruff without tenderness or visible inflammation Rationale: In the video, James notes that if the exam raises concern for an inflammatory component that could lead to scarring, biopsy should be strongly considered. She also cautions that biopsy location matters; avoid areas that are already fully scarred and sample near active inflammation when possible. document.querySelectorAll('.mcq-block').forEach(function(block) { const correct = block.getAttribute('data-correct'); const form = block.querySelector('.mcq-form'); const feedback = block.querySelector('.mcq-feedback'); const resultText = block.querySelector('.mcq-result'); form.addEventListener('change', function(e) { const selected = e.target.value; // Log to console (optional) console.log("Selected answer:", selected); // Show feedback feedback.style.display = 'block'; if (selected === correct) { resultText.textContent = "Correct!"; resultText.style.color = "green"; } else { resultText.textContent = "Incorrect"; resultText.style.color = "red"; } }); }); .mcq-block { padding: 1rem; border: 1px solid #ddd; border-radius: 10px; margin: 1.5rem 0; background: #fafafa; } .mcq-question { margin-bottom: 0.75rem; } .mcq-feedback p { margin: 0.3rem 0; }

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Register now! Patient Access Management Summit (PAMS) in ChicagoWhere: The Westin Michigan Avenue Chicago909 North Michigan AvenueChicago, IL 60611When: April 25, 2026Earn up to $500 in consulting fees!$200 for completing C-PAM Foundational curriculum$200 for attending the sessions in full$100 for completing a post-conference evaluation

Register now! Patient Access Management Summit (PAMS) in ChicagoWhere: The Westin Michigan Avenue Chicago909 North Michigan AvenueChicago, IL 60611When: April 25, 2026Earn up to $500 in consulting fees!$200 for completing C-PAM Foundational curriculum$200 for attending the sessions in full$100 for completing a post-conference evaluation

Register now! Patient Access Management Summit (PAMS) in ChicagoWhere: The Westin Michigan Avenue Chicago909 North Michigan AvenueChicago, IL 60611When: April 25, 2026Earn up to $500 in consulting fees!$200 for completing C-PAM Foundational curriculum$200 for attending the sessions in full$100 for completing a post-conference evaluation

Register now! Patient Access Management Summit (PAMS) in ChicagoWhere: The Westin Michigan Avenue Chicago909 North Michigan AvenueChicago, IL 60611When: April 25, 2026Earn up to $500 in consulting fees!$200 for completing C-PAM Foundational curriculum$200 for attending the sessions in full$100 for completing a post-conference evaluation

In this episode of Under Your Skin, host Dr Nicholas Brownstone sits down with Dr Susan Taylor to get her perspectives on the evolving field of dermatology. Dr Taylor shares her thoughts on the growing role of teledermatology, the pressing issue of reimbursement that challenges the sustainability of dermatology practices, and how she personally finds balance in her demanding career. The rise of teledermatology Dr Taylor emphasizes the growing significance of teledermatology, particularly since the onset of the COVID-19 pandemic. She highlights that teledermatology has become an essential tool for improving patient access to dermatologic care. For patients who find it challenging to take time off work, teledermatology offers a convenient alternative. They can easily consult with dermatologists during their lunch breaks or even from a private space in their workplace. Dr Taylor stresses that the key benefit of teledermatology is its ability to increase and improve access to dermatologic care, a factor that remains crucial in today's health care landscape. A critical issue facing dermatology Dr Taylor identifies reimbursement as the most critical issue currently confronting dermatology. She points out that while other health care sectors, such as hospitals and skilled nursing centers, have received inflationary updates in their reimbursements, dermatologists have not seen similar adjustments. The lack of updates in Medicare reimbursements has created a significant financial strain on dermatology practices. Dr Taylor warns that this could ultimately affect the quality of care patients receive. The financial pressure makes it increasingly difficult for private practitioners to keep their practices open, pay their staff, and maintain the necessary resources to provide patient care. She underscores that advocating for better reimbursement rates should be the top priority for the American Academy of Dermatology and dermatologists nationwide. Balancing work and relaxation Dr Taylor then shares her personal approach to unwinding after a long day. She enjoys walking to and from work, which helps her process the events of the day and decompress. Additionally, she finds relaxation in spending quality time with her husband, particularly by going out to dinner together. This routine allows her to maintain a healthy work-life balance and recharge for the challenges of the next day.

In this episode of Under Your Skin, host Nicholas Brownstone, MD, gets to know David Pariser, MD, a practicing dermatologist for over 40 years and the senior physician at Pariser Dermatology Specialists. They discuss a valuable tip for improving practice efficiency, Innovations on the horizon for dermatology, and the diverse appeal of the specialty. A strategic addition to the workflow to improve efficiency Dr Pariser has significantly improved his efficiency by incorporating medical scribes into his workflow. These scribes accompany the practitioner into the treatment room for each patient visit. While the doctor engages with the patient, the scribe diligently documents the encounter using macros, ensuring that the note is often completed by the time the doctor leaves the room. This system allows the doctor to electronically sign off on the note, send prescriptions immediately, and complete billing processes before the patient exits the office. This approach has been transformative, enabling Dr Pariser to see more patients without compromising the quality of care. With an EHR system, it typically takes about 3 minutes to document a patient’s chart. For a dermatologist seeing 30 patients, that adds up to 1.5 hours of charting. By utilizing scribes, this time can be redirected towards seeing additional patients, easily offsetting the cost of hiring a scribe and enhancing overall practice efficiency. Outlook on the future of dermatology Dr Pariser is particularly enthusiastic about the advancements in personalized medicine. Precision diagnostic testing and testing to help identify the most effective medications for individual patients, represents the future of dermatologic care. This approach promises to tailor treatments to each patient's unique needs, enhancing outcomes and optimizing therapeutic strategies. The unique rewards of dermatology Dr Pariser's passion for dermatology stems from its diverse and dynamic nature. Dermatology is a "cradle-to-grave" specialty, encompassing surgery, pathology, cosmetics, pediatrics, and adult care. Dermatologists manage a wide spectrum of medical and surgical conditions, ensuring that every day is different and every patient encounter is unique.

In this episode of Under Your Skin, host Dr Nicholas Brownstone explores the future of dermatology with past President of the American Academy of Dermatology Dr Mark Kaufmann, MD, FAAD. Together, they speculate on the integration of telehealth and technology into dermatologic practice and the potential impact on patient care over the next decade. Telehealth: necessity or preference? During the COVID-19 pandemic, telehealth emerged as a necessary tool rather than an optional clinical offering. Dr Kaufmann reflects on this period, acknowledging that while many practitioners and patients may have initially viewed telehealth with skepticism due to technological limitations, its adoption was crucial for the continuity of patient care. Looking ahead, he sees telehealth evolving into a sophisticated triage mechanism, efficiently identifying patients who require urgent in-person consultations while providing virtual care for others. Integrating technology into dermatologic practice Dr Kaufmann acknowledges the increasing role of technology in dermatology. He notes that while some fear that technology and artificial intelligence have the potential to replace jobs, he believes that technology will serve as a valuable assistant, particularly in addressing cognitive challenges that many doctors face rather than replacing procedural aspects of care. He predicts that incorporating technology into clinical activities will become standard practice, enhancing rather than supplanting the role of dermatologists and other medical staff. The future of dermatology: a technological evolution Discussing the next decade, Dr Kaufmann highlights the dynamic nature of health care evolution, noting that while practitioners may not always dictate practice changes, the demand for quality dermatologic care remains constant. Driven by patient preferences and technological advancements, the delivery of care is poised for transformation. Dr. Kaufmann speculates on the influence of patient preferences, noting the inclination of younger generations towards virtual interactions. As technology continues to advance, the landscape of dermatology will evolve, offering exciting prospects for practitioners and patients alike.

In this episode of Under Your Skin, host Nicholas Brownstone, MD, chats with James Q. Del Rosso, DO, who shares anecdotes and insights from his dermatology career on rare diseases, the benefits of being a dermatologist, and the outlook on treatments for challenging conditions. Encounters with a rare disease Dr Del Rosso recounts an anecdote from his internship when he encountered a patient with a rare disease he had never seen before—cytophagic histiocytic panniculitis (CHP). Despite its rarity, Dr Del Rosso encountered CHP again the following year, where, as a first-year resident, he was able to surprise a leading dermatologist by correctly diagnosing this rare condition. The dermatologist’s advantage Dr Del Rosso highlights the autonomy and diversity the field offers. Dermatologists have the flexibility to cater to patients of all ages and can choose to specialize in various areas such as cosmetic, medical, or surgical dermatology. This autonomy extends to their practice setting and scheduling, allowing for a fulfilling and adaptable career. Advancing care for challenging conditions Discussing areas where better medications are needed, Dr Del Rosso reflects on past challenges with conditions like hidradenitis suppurativa, vitiligo, and alopecia areata, where treatment options were limited. However, he expresses optimism about recent advancements in medication development, particularly in JAK inhibitors and monoclonal antibodies. He emphasizes the significant strides being made, providing much-needed additions to the dermatologist’s toolbox when treating patients with these challenging conditions

In this episode of Dermbusters, host Nicholas Brownstone, MD, and guest Dr Gabriela Maloney, DO, tackle common dermatologic myths often heard from their patients. Dr Maloey provides practical advice for clinicians to effectively counsel patients on 2 key topics: the link between diet and acne and the belief that sunscreen applications leads to vitamin D deficiency. Myth 1: Fried foods and chocolate increase the risk of acne Dr Maloney addresses the long-standing belief that diet, particularly fried foods and chocolate, plays a significant role in acne development. Historically, a 1969 study concluded that there was no direct link between acne and diet, which shifted the focus away from dietary factors. However, recent studies have revisited this topic, with some suggesting that foods high in glycemic index and fat content might exacerbate acne. Specifically, interventional studies have indicated that reducing glycemic load can potentially decrease inflammation and acne severity. Tips for counseling patients: Focus on glycemic index: Advise patients to pay attention to their diet’s glycemic index, which may be more relevant to acne management than specific foods like chocolate or fried items. Encourage a healthy diet: Recommend a balanced diet while still allowing flexibility for individual preferences, such as gluten-free or keto diets. Follow treatment plans: Emphasize the importance of adhering to prescribed acne treatments, as dietary changes alone are unlikely to resolve acne completely. Myth 2: Wearing sunscreen leads to vitamin D deficiency A common concern is that sunscreen use can lead to vitamin D deficiency. Dr Maloney explains that this fear should not prevent patients from using sunscreen and highlights that diet plays a crucial role in maintaining adequate vitamin D levels. Tips for counseling patients: Emphasize the role of diet: Explain that vitamin D can be adequately obtained through a balanced diet, eliminating the need to forego sunscreen. Highlight the risks of sun exposure: Stress that the risk of skin cancer from sun exposure outweighs the risk of vitamin D deficiency from using sunscreen. Tune in to the episode to hear Dr Maloney and Dr Brownstone provide valuable insights for dermatologists to guide patients more effectively and counter common misconceptions.

In this episode of Dermbusters, host Nicholas Brownstone, MD, sits down with Brandon Adler, MD, to address some common misperceptions they often hear from their patients. Dr Adler shares how he tackles 2 pressing concerns that dermatologists frequently encounter from their patients: the efficacy and safety of natural products, and the concerns surrounding ingredients in sunscreens. Myth 1: Natural products are always better There is a growing trend among patients towards seeking out natural products, both homemade and store-bought, with the belief that they are inherently better and safer than traditional products. Drawing from his experience running a contact dermatitis clinic, Dr Adler shares that he often sees patients who develop allergic reactions to natural ingredients, such as essential oils. Tips for counseling your patients: Explain that studies demonstrate the rates of contact allergy and irritation are at least comparable between natural and traditional products Mention that while natural products can be effective, each patient is unique and may develop sensitivities or allergies to certain ingredients Dispel the belief that natural always equals good; to illustrate the point effectively, share an analogy relating natural products to poison oak, which, while natural, is not something you want on your skin Myth 2: Harmful ingredients in sunscreens outweigh its benefit Many patients voice concerns about harmful ingredients in sunscreens, with some avoiding sunscreen use altogether to mitigate risks. Dr Adler shares a few tips on how he talks to patients on this issue. Tips for counseling your patients: Explain that while chemical or organic blockers found in many sunscreens have been shown in studies to be systemically absorbed into the body, there is no evidence of any associated adverse effects to date, and these agents have been used safely for decades For patients still concerned about systemic absorption, recommend zinc- and titanium-based physical or mineral sunscreens, which have not shown to be absorbed and therefore don’t carry the same potential implications as chemical blockers For patients with environmental concerns, physical sunscreens can also be recommended Emphasize that the risk of skin cancer is significantly greater than the potential risk of harmful ingredients in sunscreens Tune in to the episode to hear Dr Adler’s approach to individualized patient care and hear his practical solutions for addressing common patient concerns.

In this episode of Dermbusters, host Nicholas Brownstone, MD, chats with acne and rosacea expert Emmy Graber, MD, MBA, about some common misperceptions they often hear from their patients. Dr Graber shares some tips on counseling patients on 2 topics: how diet impacts acne and advising patients on isotretinoin to wait 6 to 12 months before getting cosmetic procedures. Myth 1: Fried and fatty foods cause acne. Dr Graber addresses the widespread belief among patients that fried and fatty foods can induce acne. She acknowledges the challenges of studying diet’s impact on acne but shares a few tips on counseling patients based on published data. Tips for counseling your patients: Explain to patients that while some studies suggest a correlation between high-glycemic foods and acne for some individuals, the association is not universal Emphasize the role of dairy products, particularly skim milk products, in exacerbating acne for some patients For patients who can identify specific dietary triggers, give them the option of avoiding that food Emphasize the uniqueness of individual responses to dietary triggers rather than making blanket statements Myth 2: Patients must wait at least 6 months following the use of isotretinoin before having any cosmetic or surgical procedures. Dr Brownstone and Dr Graber then discuss advising patients on isotretinoin on the often-recommended waiting period before undergoing any cosmetic or surgical procedures. Dr Graber challenges the traditional notion of waiting 6 to 12 months, relating a few discussion points to share with patients. Tips for counseling your patients: Cite a systematic review of over 32 studies and 1400 procedures1 that found no evidence supporting the need for a prolonged delay for cosmetic procedures following isotretinoin use Advise patients that procedures like visible light lasers, hair removal, superficial chemical peels, and fractional and ablative lasers are safe while on isotretinoin Counsel patients to follow the waiting period and delay more intense procedures like nonfractional lasers, deep dermabrasions, and deep chemical peels until there is more data available to support the safety of such procedures while on isotretinoin Mention potential benefits of pulsed dye laser treatments for acne for patients concurrently on isotretinoin, noting not only safety but potentially improved outcomes Tune in to the episode to hear the full details on Dr Graber’s informed approach to counseling patients that embraces evidence-based practices to optimize care. Reference Spring LK, Krakowski AC, Alam M, et al. Isotretinoin and timing of procedural interventions: a systematic review with consensus recommendations. JAMA Dermatol. 2017;153(8):802-809. doi:10.1001/jamadermatol.2017.2077

In this episode of Dermbusters, host Nicholas Brownstone, MD, sits down with Katherine Glaser, MD, a dermatologic surgeon specializing in Mohs surgery, about some common misperceptions heard from both colleagues and patients. Dr Glaser shares some insights on 2 frequently misunderstood topics: the use of lidocaine with epinephrine in the fingers and toes and the role of sunscreen in vitamin D absorption. Myth 1: Dermatologists should not use lidocaine with epinephrine in the fingers and toes. Contrary to a commonly held belief among dermatologists, Dr. Glaser emphasizes that there is robust data supporting the safe use of lidocaine with epinephrine in the fingers and toes. Despite concerns about vascular ischemia and resulting necrosis, studies from both dermatology and plastic surgery literature demonstrate the safety of lidocaine with epinephrine. Tips for advising colleagues: Share the existing data and research findings that support the safe use of lidocaine with epinephrine in the fingers and toes Highlight the lack of reported cases of ischemia with traditional lidocaine with epinephrine and contrast it with cases involving other substances, high concentrations of epinephrine, and improper tourniquet use Emphasize the importance of adhering to safe injection practices, proper dosage, and avoiding direct arterial injection to mitigate any potential risks Myth 2: Sunscreen should not be used because it prevents absorption of vitamin D. Next, Dr Glaser addresses a common myth that dermatologists often hear from their patients: that they shouldn’t use sunscreen because it prevents them from absorbing an adequate amount of vitamin D. While sunscreen does block the UVB rays that aid in vitamin D synthesis, the AAD advises against UV exposure solely for the purpose of absorbing vitamin D. Tips for counseling your patients: Explain that while sunscreen may affect vitamin D absorption, it's not a reason to skip it Highlight alternative sources of vitamin D, such as diet and supplements Encourage wearing sunscreen consistently and correctly Stress the importance of protecting the skin from harmful UV rays to prevent skin damage and reduce the risk of skin cancer

Mona Shahriari, MD and Susan C. Taylor, MD presented a visual and clinically focused guide to diagnosing prurigo nodularis in skin of color, highlighting its neuroimmune pathophysiology, disproportionate disease burden, distinct clinical features in melanin-rich skin, and the rapid, durable efficacy of newly approved targeted biologics.Raj Chovatiya, MD, PhD and Mona Shahriari, MD presented an interactive, case-based session focused on optimizing atopic dermatitis treatment through mechanism-driven biologic selection, individualized dosing strategies, and practical management of real-world clinical challenges.

Steven Daveluy, MD, James Q. Del Rosso, DO and Andrea T. Murina, MD provided a clinically focused update on hidradenitis suppurativa, emphasizing early intervention, integration of biologic and procedural therapies, and emerging targeted treatments.Shawn Kwatra, MD and Dawn Merritt, DO provided a clinically focused update on chronic spontaneous urticaria, reviewing autoimmune mechanisms, stepwise treatment strategies, and emerging biologic and BTK-targeted therapies.

Final day highlights from Miami! Our Day 3 recap video captures the closing masterclasses, final clinical pearls, and the community connections that defined our last day in Miami.

April W. Armstrong, MD, MPH, reviewed major recent developments shaping modern psoriasis management, beginning with the first consensus definition of on-treatment remission established through a Delphi process led by the National Psoriasis Foundation. This consensus defines remission as maintaining BSA 0% or IGA 0 for at least six months, providing a standardized, clinically meaningful target for long-term disease control and a consistent benchmark for evaluating durability across therapies and clinical trials.Dr Armstrong also highlighted emerging oral therapies that are redefining expectations for systemic treatment. Icotrokinra, a novel targeted oral peptide that selectively inhibits IL-23 signaling, demonstrated superior efficacy compared with deucravacitinib in the ICONIC-ADVANCE trials, achieving higher rates of IGA 0/1 and PASI 90 at Weeks 16 and 24. Additional ICONIC data showed robust PASI 90 responses in adults and durable maintenance of PASI 75 and PASI 90 through 52 weeks in adolescents, supporting both potency and durability across age groups. Long-term extension data for the TYK2 inhibitor deucravacitinib demonstrated stable efficacy and a favorable safety profile through five years, including benefit in patients with psoriatic arthritis. Dr Armstrong also reviewed emerging data for highly selective TYK2 inhibitors such as envudeucitinib, which achieved stringent treat-to-target thresholds in a majority of patients at one year. Together, these advances reflect a shift toward precise, durable, and patient-friendly oral therapies that align with newly established remission goals in psoriasis.

Chronic spontaneous urticaria (CSU) affects up to 80% of patients with chronic urticaria and is defined by recurrent hives and/or angioedema lasting longer than six weeks without an identifiable trigger. Naiem Issa, MD, and Dawn Merritt, DO, reviewed key clinical features, including pruritic wheals and angioedema that often burn and may persist for up to 72 hours. They emphasized use of the 7-Day Urticaria Activity Score (UAS7) as the gold standard for assessing disease severity and treatment response. The presenters also highlighted the autoimmune underpinnings of CSU, driven by both IgE-dependent and IgE-independent mechanisms that activate mast cells and basophils.Management was framed as a clear treatment ladder, starting with second-generation H1 antihistamines and rapid up-dosing when control is inadequate. If symptoms persist after 2–4 weeks, escalation to advanced therapies such as omalizumab, dupilumab, or remibrutinib is recommended, with cyclosporine reserved for refractory disease. Emerging data for dupilumab demonstrated meaningful reductions in itch and hives regardless of baseline IgE, while remibrutinib showed rapid onset of action, with more than half of patients achieving well-controlled disease within three weeks. The session closed with practical pearls: escalate early, continue antihistamines when adding biologics, maintain therapy for 6–12 months after complete clearance, and reassure patients that CSU is not allergy-driven despite common triggers like stress or heat.

Lawrence F. Eichenfield, MD, provided an engaging overview of how pediatric dermatology is rapidly evolving, with a focus on improving long-term outcomes through earlier diagnosis and more targeted therapies. In pediatric psoriasis, he emphasized the growing demand for effective oral options beyond traditional immunosuppressants. Promising phase 2 data were presented for icotrokinra, a novel oral IL-23 receptor–blocking peptide that achieved clear or almost clear skin in nearly 90% of adolescents by 24 weeks, with a favorable safety and tolerability profile. These results signal a potential shift toward convenient, noninjectable systemic options for children.Juvenile lichen sclerosus was highlighted as a frequently underrecognized condition with important lifelong implications. Dr Eichenfield underscored that lichen sclerosus rarely resolves at puberty, with most patients continuing to have active disease and structural changes into adolescence and adulthood. He stressed the importance of early recognition and sustained treatment with super–high-potency topical corticosteroids, even in asymptomatic patients, noting that consistent therapy significantly reduces long-term anatomic damage.The session concluded with advances in precision medicine and evolving disease definitions. In atopic dermatitis, the Identity Study was introduced as a novel approach using noninvasive gene expression profiling to predict which children are most likely to respond to JAK inhibitors versus Th2-targeted therapies, allowing for faster clearance and improved itch control. Dr Eichenfield also discussed the shift from Mycoplasma-induced rash and mucositis to reactive infectious mucocutaneous eruption, reflecting the broader range of infectious triggers now recognized. Management focuses on treating the underlying infection and controlling severe mucositis with systemic anti-inflammatory or immunomodulatory therapies, reinforcing the need for timely diagnosis and aggressive intervention in complex pediatric cases.

Susan C. Taylor, MD, presented a comprehensive update on contemporary melasma management, emphasizing evolving concepts in pathogenesis and evidence-based treatment strategies. Dr Taylor reviewed the growing understanding that melasma is a multifactorial disorder driven by ultraviolet and visible light exposure, epidermal melanocyte activation, and clinically relevant vascular component characterized by increased vessel number, density, and angiogenesis. These mechanisms help explain disease chronicity, relapse, and treatment A central focus of the presentation was the international Delphi consensus on melasma management, developed by 38 experts from 11 countries to standardize diagnosis, monitoring, and treatment. The consensus identified Wood’s lamp examination as a favored method for assessing extent and severity, with dermoscopy accepted for differential diagnosis. Photoprotection was emphasized as foundational therapy, with the “ideal” sunscreen providing protection against UVA, UVB, and visible light, and optional inclusion of antioxidants or depigmenting agents to enhance efficacy. For treatment, triple-combination therapy with hydroquinone, tretinoin, and fluocinolone acetonide was reaffirmed as the gold-standard first-line option for moderate-to-severe melasma, while azelaic acid, antioxidants, and non-hydroquinone agents were highlighted as alternatives or maintenance options. Oral tranexamic acid, chemical peels, microneedling, and energy-based devices were reserved for refractory disease within a stepwise algorithm. Dr Taylor also reviewed comparative clinical trial data for newer non-hydroquinone therapies. A randomized non-inferiority trial demonstrated that a 2-Mercaptonicotinoyl Glycine–containing serum achieved similar improvements in mMASI compared with hydroquinone 4%, with fewer local reactions. Additional studies showed that thiamidol and topical metformin produced MASI reductions comparable to hydroquinone-based regimens, supporting their role as effective alternatives in select patients. Collectively, the data reinforce a modern treatment framework that combines standardized photoprotection, targeted topical therapy, and vascular-directed interventions to address both pigment production and relapse risk in melasma.

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Take a peek at the atmosphere and buzz in the conference rooms, exhibit hall, and receptions from Fall Clinical 2025 in Las Vegas!

Shawn G. Kwatra, MD, presented a compelling session on the evaluation and management of chronic itch, underscoring its profound impact on patient quality of life. Chronic pruritus, he noted, impairs quality of life to a degree comparable to that of stroke and more than conditions such as heart failure with an implantable defibrillator or patients on hemodialysis. Despite being one of the most common symptoms in dermatology, pruritus often remains diagnostically elusive and therapeutically challenging. Through a series of illustrative cases, Dr Kwatra emphasized that chronic itch can be the first sign of systemic disease and requires careful evaluation beyond the skin. Dr Kwatra discussed emerging insights into the genetic and immunologic underpinnings of chronic itch, including a potential polygenic risk association in prurigo nodularis. He reviewed targeted treatments such as dupilumab, which has shown efficacy for chronic itch of various etiologies, and low-dose naltrexone, which modulates μ-opioid signaling and inflammatory mediators to relieve refractory scalp pruritus and symptoms in conditions such as epidermolysis bullosa. Additionally, he provided a practical framework for laboratory and clinical evaluation, including eosinophil counts and screening for systemic causes when the origin of itch is unclear. Concluding with complex cases of widespread pruritic dermatoses, Dr Kwatra illustrated how integrating immune profiling and genomic analysis can identify dominant cytokine pathways (IL-13, IL-17) and guide rational biologic therapy selection.

Alexandra Golant, MD, Mona Shahriari, MD, and G. Michael Lewitt, MD, presented a session focused on the evolving role of interleukin-13 (IL-13) inhibition in atopic dermatitis, sharing new insights, case experiences, and strategies for optimizing treatment in clinical practice.Dr Golant opened by underscoring the central role of IL-13 in atopic dermatitis pathophysiology. Elevated across age groups and skin tones in patients with atopic dermatitis, IL-13 drives barrier disruption, decreases filaggrin expression, and fuels pruritus and lichenification. She reviewed case examples, including an adolescent with long-standing disease who achieved rapid and sustained improvement on lebrikizumab. Dr Golant emphasized how patient-defined goals such as comfort at school, confidence in social settings, and reduced topical burden align with the responses seen in trials. Early and aggressive targeting of IL-13 was presented as a way to meet both clinical and quality-of-life outcomes.Dr Shahriari expanded on the comparative efficacy of IL-13 biologics, highlighting pivotal data from SOLO, ADvocate, ECZTRA, and long-term extension studies. Both lebrikizumab and tralokinumab demonstrated durable control, with maintenance of EASI90 and pruritus relief extending beyond 2 years. She also addressed switching strategies, noting that patients discontinuing dupilumab for adverse events often achieved better outcomes on lebrikizumab compared with those stopping for inadequate response. Dr Shahriari presented cases of patients with dupilumab-associated ocular surface disease whose symptoms resolved when transitioned to tralokinumab or Janus kinase inhibitors, underscoring the importance of individualized sequencing.Dr Lewitt concluded with a practical perspective on integrating IL-13 inhibitors into daily practice. He illustrated this with a young adult patient who prioritized clearance of hand and facial dermatitis with minimal treatment burden. After 16 weeks of lebrikizumab, both skin clearance and pruritus improved markedly, restoring confidence and function. Dr Lewitt highlighted safety profiles across the IL-13 inhibitor class, emphasizing that adverse events are generally manageable and that selective inhibition may be particularly appealing when patients prefer targeted therapy without systemic immunosuppression. Looking forward, the faculty noted that biologics with extended half-lives, bispecific antibodies, and oral agents may further expand long-term disease control options.