Topical Conversations

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.

This video is sponsored by Sun Pharma. Its content is editorially independent of the sponsor.In this episode of Topical Conversations, Meena Singh, MD, and Terry Faleye, PA-C, discuss why speed of disease control has become an increasingly important consideration in the management of alopecia areata (AA). As treatment options continue to expand, they explore how earlier signs of response can influence patient confidence, improve treatment persistence, and reshape conversations about what patients can expect during therapy. Using deuruxolitinib as an example, they highlight how evolving efficacy data have changed both provider expectations and the patient experience.The importance of speed in a disease with significant psychosocial impactThe treatment landscape for moderate to severe AA has changed substantially with the availability of multiple FDA-approved Janus kinase (JAK) inhibitors. While efficacy remains the primary goal, Dr Singh and Faleye emphasize that when patients begin to see improvement can be nearly as important as how much improvement they ultimately achieve.For many patients, AA develops suddenly and is accompanied by considerable emotional distress. Faleye notes that many individuals present with little understanding of the disease itself, making education about its chronic nature and treatment course an essential part of the initial visit.The ability to demonstrate visible improvement early in treatment can provide reassurance during what is often an emotionally challenging period. Both speakers describe how even small signs of regrowth can reinforce that treatment is working, helping patients remain engaged and optimistic rather than becoming discouraged after months without visible progress.How earlier responses are changing treatment conversationsHistorically, clinicians often counseled patients that meaningful regrowth might not occur for many months, if at all. Dr Singh notes that this has changed with newer therapies.She discusses how clinical studies of deuruxolitinib demonstrated statistically significant, clinically meaningful hair regrowth as early as 8 weeks, despite the primary efficacy endpoint occurring later in treatment. In her own practice, she has observed patients with extensive scalp involvement experience dramatic improvement within the first few months of therapy, fundamentally changing how she frames expectations at treatment initiation.Faleye similarly points to the secondary efficacy assessments at weeks 8, 12, 16, and 20 as particularly meaningful from a clinical perspective. Seeing evidence of earlier response provides reassurance to both patients and clinicians that therapy is moving in the right direction.She also shares the experience of a patient who had an inadequate response to a different JAK inhibitor but later achieved substantial regrowth after initiating deuruxolitinib, reinforcing her confidence in discussing treatment expectations with appropriate patients.Clinical success and patient-defined success are not always the sameOne of the recurring themes throughout the discussion is that clinicians and patients often define treatment success differently.Dr Singh notes that patients may become excited by the appearance of fine vellus hairs, even though these early changes would not yet represent meaningful terminal hair regrowth from a clinical trial perspective. Nevertheless, these visible signs frequently provide patients with reassurance that treatment is working.Faleye agrees, emphasizing that these seemingly modest improvements often have an outsized effect on treatment adherence. While clinicians recognize that additional regrowth is needed to achieve optimal outcomes, patients may view these early changes as important milestones that motivate them to continue therapy.Recognizing early indicators of responseThe speakers encourage clinicians to look beyond scalp hair counts alone when assessing early treatment response.Dr Singh notes that eyebrow, eyelash, and beard regrowth, even when limited, can represent meaningful early signs that therapy is having an effect. Likewise, a noticeable reduction in hair shedding may precede visible regrowth and can be an encouraging indicator to discuss during follow-up visits.Faleye adds that improvements that may seem minor clinically can carry tremendous significance for individual patients. She recalls an older patient whose primary concern was beard patchiness; seeing early beard regrowth substantially improved the patient's outlook despite relatively modest overall changes.Recognizing and reinforcing these individualized treatment successes can strengthen the therapeutic relationship and support continued adherence while more substantial regrowth develops.Early treatment may help change the long-term trajectoryThe discussion also highlights the importance of identifying and treating AA promptly whenever appropriate.Faleye observes that patients with longstanding disease may be less likely to pursue treatment because of previous disappointments or because they remain unaware that newer therapeutic options are available. At the same time, these individuals can present greater treatment challenges than patients who begin therapy earlier in the disease course.Both speakers emphasize the importance of educating patients about advances in AA management and encouraging timely intervention when indicated.A changing patient experiencePerhaps one of the most meaningful changes, according to Dr Singh, is the transformation she sees in patients between their initial consultation and early follow-up visits. Patients who begin experiencing regrowth within the first few months often return with noticeably greater optimism and confidence, changing the tone of subsequent visits.For both clinicians, the availability of therapies capable of producing earlier, meaningful responses has altered not only treatment strategies but also the overall patient experience. They conclude that recognizing early improvements, setting realistic expectations, and initiating effective therapy promptly can all contribute to better long-term engagement and outcomes for patients with AA.

In this episode of Topical Conversations, Linda Stein Gold, MD, and G. Michael Lewitt, MD, discuss the tolerability profile of tapinarof and how adverse events observed in clinical trials compare with their real-world experience treating patients with plaque psoriasis and atopic dermatitis.Tapinarof, an aryl hydrocarbon receptor (AhR) agonist, was initially approved in 2022 for adults with plaque psoriasis and was subsequently approved for atopic dermatitis in patients as young as 2 years of age. Through modulation of AhR signaling, tapinarof influences multiple pathways relevant to inflammatory skin disease, including cytokine signaling, oxidative stress, and skin barrier function.The discussion focuses on two adverse events that have received particular attention: follicular events and contact dermatitis.Tapinarof and the evolving role of nonsteroidal topical therapyHistorically, nonsteroidal topical therapies have often been incorporated into treatment regimens as adjunctive agents or during topical corticosteroid holidays, helping patients maintain disease control while reducing reliance on corticosteroids.Dr Lewitt notes that tapinarof has been used somewhat differently in clinical practice, serving not only as a maintenance therapy but also as a treatment capable of achieving disease control in appropriate patients. Dr Stein Gold agrees that the availability of newer nonsteroidal topical options has allowed for simpler treatment approaches in some patients, reducing the need for multiple topical medications with different roles within a treatment regimen.Tolerability profile of tapinarofBoth physicians note that application-site stinging and burning have been relatively uncommon in their experience with tapinarof, particularly compared with some earlier nonsteroidal topical therapies.Instead, the adverse events most frequently discussed in relation to tapinarof have been follicular events and contact dermatitis. While these events have been observed in both psoriasis and atopic dermatitis clinical trials, the incidence, severity, and clinical significance warrant closer examination.Folliculitis in plaque psoriasisDr Lewitt reviews findings from the psoriasis clinical trials, where folliculitis was reported in approximately 18% to 24% of patients during the 12-week treatment period.Importantly, the majority of cases were not characterized by inflammatory pustular lesions. Rather, they were more commonly described as hyperkeratotic or keratosis pilaris-like follicular changes. Most events were mild to moderate in severity, and treatment discontinuation due to folliculitis was uncommon.Follicular events in atopic dermatitisThe physicians contrast these findings with those observed in the atopic dermatitis trials, where follicular events were designated as an adverse event of special interest.In the 8-week atopic dermatitis trials, follicular events occurred less frequently than in the psoriasis studies, with reported rates of approximately 9% to 14%. As in the psoriasis trials, most events were mild to moderate in severity; discontinuation rates were below 1%.Dr Lewitt notes that his real-world experience has generally aligned with the clinical trial findings, with follicular events appearing less common among patients with atopic dermatitis than among patients with psoriasis. Dr Stein Gold reports a similar experience, noting that she has not observed folliculitis among her own patients with atopic dermatitis treated with tapinarof.Contact dermatitis: incidence and clinical considerationsContact dermatitis has also been reported during tapinarof treatment.Dr Lewitt notes that in the psoriasis clinical trials, contact dermatitis occurred in approximately 5% to 6% of patients, with discontinuation rates of approximately 1.5%. Based on the clinical characteristics of these reactions, he speculates that at least some cases may have represented irritant rather than allergic contact dermatitis.In the atopic dermatitis trials, rates of contact dermatitis were low, with both event rates and discontinuation rates below 1%. Notably, contact dermatitis was reported more frequently in the vehicle arm than in the tapinarof-treated arm.Dr Stein Gold notes that she has encountered contact dermatitis infrequently in clinical practice, reporting a single case among her patients with psoriasis and none among her patients with atopic dermatitis.Practical considerations for clinical useNeither physician views follicular events or contact dermatitis as a major barrier to prescribing tapinarof. Both note that these adverse events are generally uncommon, typically mild to moderate in severity, and infrequently lead to treatment discontinuation.Dr Lewitt notes that when discussing treatment expectations with patients, he mentions the possibility of these adverse events while emphasizing their generally manageable nature. Practical measures such as applying a thin layer of medication, minimizing application to occluded areas, wearing loose-fitting clothing when appropriate, and applying tapinarof after an emollient may help reduce the likelihood of unwanted drug spread to uninvolved skin.Clinical perspectiveThe discussion highlights that while follicular events and contact dermatitis can occur during tapinarof treatment, both events are typically mild to moderate in severity and rarely result in treatment discontinuation. The incidence of these adverse events appears lower in atopic dermatitis clinical trials than in psoriasis studies, and both physicians report real-world experiences that generally align with those observations.For clinicians considering nonsteroidal topical treatment options for chronic inflammatory skin disease, understanding the nature and clinical relevance of these adverse events may help inform treatment selection and patient discussions.

Skin care, diet, supplements, probiotics, and microbiome-directed strategies in clinical contextAfter establishing why adjunctive strategies matter in atopic dermatitis care, Cynthia Trickett, PA-C, and Peter Lio, MD, turn to the practical questions clinicians hear constantly: Do natural oils have a role? How much does diet really matter? What about probiotics, vitamin D, hypochlorous sprays, or antimicrobial cleansers?For Dr Lio, skin care and barrier repair are so central to the biologic therapy treatment plan that he’s coined the term “Advanced Dermatologic Care,” or ADC, to describe the intentional use of OTC topicals, cleansers, moisturizers, written eczema action plans, and other supportive strategies that help patients and families understand what to do day to day and during flares. The conversation moves through natural oils, black tea compresses, diet myths, the risks of over-restriction, vitamin D supplementation, probiotics, and emerging microbiome-directed approaches, always returning to the same clinical foundation of evidence, safety, practicality, and individualized recommendations that support quality of life.Of the many adjunctive options patients may ask about, Dr Lio says, “part of our job is to try to filter them down into things that have some evidence, that are safe and are practical.” This discussion makes space for it all, and contextualizes what may be overstated, unproven, or potentially harmful. He reminds clinicians not to chase every trend, but to help build an adjunctive plan that protects the barrier, respects the microbiome, and avoids doing harm. Upcoming: In Part 3, Trickett and Dr Lio turn from what clinicians can add to how they can do it safely, with practical guidance on supplement quality, follow-up, treatment monitoring, and patient-led decision-making.

In this episode of Topical Conversations, Tina Bhutani, MD, and Adrian Rodriguez, MD, discuss the growing role of precision medicine in psoriasis management and how predictive testing may help guide biologic selection earlier in the treatment journey. With an expanding range of biologic therapies available for psoriasis, clinicians now have more therapeutic flexibility than ever before. However, as Dr Bhutani notes, one of the persistent challenges in practice is determining which patient is most likely to respond to which therapy before treatment is initiated. The discussion centers on Mind.Px, a predictive test that uses a dermal biomarker patch to help identify the likelihood of response to biologic classes including TNF inhibitors, IL-17 inhibitors, and IL-23 inhibitors. Moving toward precision medicine in psoriasisDr Rodriguez frames Mind.Px within the broader evolution of precision medicine across medicine, noting that while other specialties have increasingly incorporated predictive tools into treatment decision-making, dermatology has historically lacked similar guidance for psoriasis biologic selection. He describes the test as a practical tool to help clinicians identify which biologic class may be the best fit for an individual patient, potentially reducing the need for therapeutic switching and minimizing delays associated with insurance approvals and treatment interruptions. They emphasize that this type of approach may be particularly valuable given the growing number of available biologics and the reality that not every therapy will be effective for every patient.Supporting patient confidence and treatment buy-inBeyond biologic selection itself, the conversation highlights how predictive testing may influence patient engagement and confidence in treatment decisions.Dr Bhutani shares that she often finds the test useful in patients who are hesitant to initiate biologic therapy, including individuals with needlephobia or concerns about long-term treatment commitment. Presenting patients with data suggesting a higher likelihood of response may help reinforce confidence in the treatment plan. Dr Rodriguez discusses a patient case involving a needlephobic frequent traveler who was concerned about treatment selection and dosing logistics. In that scenario, the test supported selection of an IL-23 inhibitor, which aligned both with predicted response and the patient’s lifestyle needs due to its dosing schedule. The speakers also note that the report format itself is intentionally straightforward, categorizing biologic classes as likely responder (R) or nonresponder (NR), making interpretation relatively simple for both clinicians and patients. Applications in biologic-experienced patientsThe conversation also explores how predictive testing may be useful in biologic-experienced patients, particularly in situations involving loss of coverage, waning efficacy, or declining patient confidence after prior treatment challenges. Dr Rodriguez notes that the test can help rebuild patient confidence when prior therapeutic choices have not produced satisfactory outcomes. Similarly, Dr Bhutani explains that she often finds the test especially valuable in experienced patients because she wants to avoid another unsuccessful treatment selection that could further reduce patient engagement. Operational and access considerationsThe discussion next shifts to practical considerations surrounding biologic access and office workflow.Dr Rodriguez highlights the administrative burden associated with biologic switching, including repeat prior authorizations, reassessments, and additional staff workload. Selecting the most appropriate therapy earlier in the process may help reduce some of these operational challenges while also potentially lowering costs associated with cycling through multiple biologics. From a workflow standpoint, Dr Rodriguez notes that implementation in clinic has been relatively streamlined. The test involves application of a dermal patch for several minutes, with a kit provided for return shipment and relatively quick turnaround times. Limitations and future directionsThe speakers also discuss several limitations of the current test.One limitation is the binary responder/nonresponder output. If a patient is predicted to respond to multiple biologic classes, the report does not currently rank therapies or indicate which option may provide the strongest response. Dr Rodriguez also notes that current response categorizations were based on PASI75 thresholds, whereas many clinicians now aim for PASI90-level outcomes in practice. He points to ongoing work evaluating PASI90 data as an important future development. Dr Bhutani further explains that earlier studies suggested stronger predictive performance in patients with more severe disease, although ongoing real-world analyses are evaluating performance in patients with lower disease severity. This may become increasingly relevant as dermatologists consider earlier biologic intervention for patients with lower BSA involvement but high-impact disease in special sites such as the scalp, hands, feet, and genital regions. Key takeawaysPredictive testing may help support biologic selection in psoriasis by identifying likely responders and nonresponders across biologic classes Mind.Px uses a dermal biomarker patch and provides a simplified responder/nonresponder report format for TNF, IL-17, and IL-23 inhibitor categories There are potential benefits for both biologic-naïve and biologic-experienced patients, including improved patient confidence and reduced therapeutic switching Practical advantages may include reduced administrative burden associated with repeated prior authorizations and treatment changes Current limitations include lack of ranked therapeutic recommendations and reliance on PASI75-based response thresholds Ongoing research is evaluating predictive performance in lower-severity psoriasis and incorporating PASI90-level outcomes into future analyses

In this episode of Topical Conversations, Joseph Merola, MD, and Scott Elman, MD, examine the evolving understanding of cutaneous lupus erythematosus (CLE) and its place within the broader spectrum of connective tissue disease. Their discussion highlights the dermatologist’s central role, not only in recognizing and treating skin manifestations, but also in screening for systemic involvement and coordinating care when needed. A disease state in transitionAdvances in understanding the pathophysiology of cutaneous lupus are beginning to translate into therapeutic momentum. What was once a space with limited targeted options is now seeing the emergence of multiple investigational therapies, reflecting a shift toward more mechanism-driven treatment approaches. Clinical identification: recognizing key subtypesCutaneous lupus is often categorized into several major subtypes, each with distinct clinical features:Acute cutaneous lupus: Classically presents with a malar rash that spares the nasolabial folds Subacute cutaneous lupus: Typically papulosquamous or annular, often in sun-exposed areas such as the shoulders and arms; may be drug-induced Chronic cutaneous lupus: The largest category, with discoid lupus as the most familiar subtype; characterized by scarring plaques that can lead to permanent hair loss and disfigurement Recognizing these patterns remains foundational to diagnosis and helps guide both evaluation and management. Screening for systemic disease: a core responsibilityA key theme emphasized in this discussion is the importance of routinely assessing for systemic lupus erythematosus (SLE) in patients with cutaneous disease.Practical screening approaches may include:Laboratory evaluation: ANA testing as an initial screen, along with CBC, CMP, and urinalysis Clinical review of systems: Assessing for joint pain, mucosal involvement, and other systemic symptoms Ongoing surveillance: Repeating assessments every 3 to 6 months, rather than relying on a single evaluation Importantly, a negative initial workup does not exclude future systemic involvement. Dermatologists play a critical role in maintaining longitudinal awareness and determining when to involve rheumatology colleagues. Patient burden: beyond skin findingsThe impact of cutaneous lupus extends well beyond visible disease. Quality-of-life studies suggest that the burden experienced by patients may be comparable to chronic conditions such as hypertension, type 2 diabetes, congestive heart failure, and recent myocardial infarction.This burden reflects both active symptoms and long-term consequences, including scarring and disfigurement Early recognition and appropriate treatment are essential to mitigate these outcomes. Emerging therapies: expanding possibilitiesAfter decades of limited progress, the treatment landscape for lupus is beginning to broaden, with several agents under investigation for cutaneous and systemic disease:Anifrolumab: Approved for SLE, with ongoing phase 3 evaluation in CLELitifilimab: Targets plasmacytoid dendritic cells, with downstream effects on type I interferon and other cytokines Deucravacitinib: Approved for psoriasis, currently under investigation in lupus with early signals in CLE Enpatoran: Early data suggest potential activity in CLE These developments reflect a growing focus on targeted immunologic pathways relevant to both skin and systemic manifestations. Comanagement: aligning dermatology and rheumatologyFor patients with overlapping cutaneous and systemic disease, coordination of care is essential. Thoughtful selection of therapies may allow for alignment across organ systems, with the goal of controlling disease activity while minimizing progression and long-term damage.Dermatologists play a key role in initiating and optimizing treatment for skin disease, monitoring for systemic involvement, and collaborating with rheumatology when indicated As familiarity with these therapies grows, opportunities to refine treatment strategies across specialties are likely to expand. Key takeawaysCutaneous lupus encompasses multiple clinical subtypes, each with distinct presentation and implications for management Dermatologists are central to both diagnosis and ongoing screening for systemic lupus involvement Systemic evaluation should include labs, review of systems, and periodic reassessment over time The burden of disease extends beyond visible lesions, with significant quality-of-life impact and risk of permanent damage A growing pipeline of targeted therapies is beginning to reshape treatment considerations in both CLE and SLE Comanagement with rheumatology is critical for patients with systemic involvement

How complementary strategies can support biologic therapy without replacing evidence-based treatmentAtopic dermatitis (AD) care has changed dramatically in the biologic era, but better options have not eliminated the need for thoughtful adjunctive strategies. In this opening conversation, Cynthia Trickett, MPAS, PA-C, and Peter Lio, MD, begin with the clinical reality many dermatology providers know well: even when biologics are appropriate, effective, and well tolerated, patients may still need more support to control itch, inflammation, barrier dysfunction, sleep disruption, and the day-to-day burden of disease. As Dr Lio puts it, integrative care is not about replacing conventional medicine with “something crazy.” It is about “taking the best of both worlds and putting them together in a coordinated way.”Dr Lio outlines what integrative medicine can mean in AD, from mind-body approaches and botanicals to barrier support, microbiome-directed strategies, and other adjunctive tools that may help patients who are already using topical therapies or systemic agents. The conversation also grounds these approaches in the larger biologic landscape, including IL-4/IL-13, IL-13, and IL-31 pathway targeting, while acknowledging that these therapies, however transformative, are not perfect fits for every patient. Part 1 closes where clinical practice often begins—with the need to layer treatment thoughtfully, safely, and with the patient’s goals and comfort in mind.

There was a time when treating atopic dermatitis (AD) meant managing the peaks—calming a flare, then waiting for the next one to arrive. But as Elizabeth (Lisa) Swanson, MD, and E James Song, MD, describe, the disease doesn’t really turn off. AD settles, simmers, then resurfaces, more like a smoldering fire than something episodic. And once you start to see it that way, the goal becomes about stabilizing what’s happening over time instead of reacting to the moment.In this conversation, Drs Swanson and Song work through their approaches in clinic: lowering the threshold for biologics, rethinking what “controlled” actually means, and recognizing how much of the disease lives outside of what’s visible. The aim is getting patients off the rollercoaster, reducing the constant negotiation with their skin, and moving toward something steadier, more livable, and more honest to the disease itself.

This video is sponsored by Sun Pharma. Its content is editorially independent of the sponsor. In this episode of Topical Conversations, Aaron Farberg, MD, joins George Monks, MD, to examine the clinical and logistical realities of transitioning patients from general dermatology to Mohs surgery. Their discussion highlights how evolving treatment options, referral timing, and multidisciplinary coordination influence decision-making, particularly when patients present with complex disease or are already receiving systemic therapy. The patient journey: from suspicion to surgical planningThe conversation begins with a practical overview of the typical pathway to Mohs surgery. After identifying a suspicious lesion, dermatologists confirm the diagnosis via biopsy and then guide patients through treatment options, including Mohs when appropriate.A central theme is expectation setting. Patients diagnosed with skin cancer often anticipate rapid surgical intervention; however, real-world scheduling constraints mean wait times of several weeks are common. In many cases of basal cell carcinoma (BCC), a delay of up to approximately 2 months may be clinically acceptable, while higher-risk tumors, such as certain squamous cell carcinomas or melanomas, require more urgent prioritization.Patients are encouraged to remain engaged during this interval, reporting any changes such as growth, bleeding, or pain. This ongoing communication can help dermatologists reassess urgency and facilitate expedited care when needed. Managing complexity: when and how to engage Mohs surgeonsFor borderline or complex cases, early collaboration with Mohs surgeons is emphasized. Prereferral discussions, which can be supported by clinical images and patient history, can help ensure appropriate patient selection and avoid delays associated with suboptimal referrals.This bidirectional communication is increasingly important as treatment decisions become more nuanced. In some cases, Mohs surgeons may refer patients back to dermatologists for consideration of systemic therapy prior to surgery, reinforcing the importance of shared decision-making across specialties. Expanding the toolbox: the role of systemic therapiesThe growing availability of systemic therapies, including immunotherapies and targeted agents, has broadened management strategies for advanced or high-risk skin cancers.Hedgehog inhibitors (HHIs), for example, have become an important option for advanced BCCs that may not be ideal candidates for immediate surgery or radiation. In select cases, systemic therapy may be used in a neoadjuvant approach to reduce tumor burden and improve surgical feasibility.This approach can also help address practical challenges such as surgical wait times. Initiating systemic therapy during this interval may allow for disease control while optimizing the timing and extent of surgery. However, these decisions require careful coordination and individualized assessment.Importantly, clinicians note that response to HHIs is often evident within the first 1 to 2 months, which can help guide ongoing management. In patients who respond well, continued therapy may be appropriate, while nonresponders may be redirected toward surgical management. Addressing clinical uncertainty: skip lesions and treatment timingThe discussion also addresses concerns around “skip lesions,” particularly in the context of preoperative systemic therapy. While discontinuous tumor spread is a theoretical consideration, both clinicians note that it is not commonly observed in their practices and is not a primary deterrent to systemic use.Greater concern is placed on delays in definitive treatment, which may increase the risk of tumor progression or spread. This reinforces the importance of timely referral and meticulous surgical technique, particularly in cases where tumor margins may be less predictable.Careful clinical assessment, including thorough inspection and adjunctive tools when appropriate, remains essential in these scenarios. Looking ahead: integrating new tools with established standardsWhile Mohs surgery remains a cornerstone of cutaneous oncology, the integration of systemic therapies is reshaping how dermatologists approach complex cases. This discussion highlights the importance of flexibility in treatment planning, balanced with a continued emphasis on evidence-based care and procedural precision.Above all, consistent and proactive communication remains central to optimizing patient outcomes in this evolving landscape. Key takeawaysMohs surgery pathways often involve wait times of several weeks; proactive expectation setting is essential for patient management Ongoing communication during the referral interval allows for reassessment of urgency and potential prioritization Early collaboration with Mohs surgeons can improve patient selection and streamline care in complex or borderline cases Systemic therapies, including HHIs and immunotherapies, are expanding options for advanced disease and may be used in select neoadjuvant scenarios Concerns about skip lesions exist, but appear less clinically significant than ensuring timely and definitive treatment Clear, direct communication among care team members remains a critical component of optimal patient outcomes

This video is sponsored by Sun Pharma. Its content is editorially independent of the sponsor. In this episode of Topical Conversations, Vishal Patel, MD, and David Miller, MD, PhD, examine how the management of cutaneous squamous cell carcinoma (cSCC) has shifted from a specialty-specific approach to a truly multidisciplinary model. Their discussion centers on how dermatologists partner with surgeons, radiation oncologists, and medical oncologists to manage increasing disease complexity, while remaining actively involved from diagnosis through long-term surveillance.cSCC as a team-based diseasecSCC is no longer solely a dermatologic or surgical problem. While many tumors remain straightforward to manage, more advanced cases increasingly require coordination across multiple specialties. Drs Patel and Miller emphasize that optimal outcomes, particularly in high-risk or advanced disease, depend on early collaboration and thoughtful sequencing of surgery, radiation, and systemic therapy.A wide and heterogeneous clinical spectrumThey reinforce the broad clinical range of cSCC, spanning low-risk tumors to locally advanced disease, perineural invasion, recurrent tumors, nodal involvement, and metastatic spread. Dermatologists are often the point of entry, responsible for diagnosis, initial risk stratification, and determining when escalation is needed. However, Dr Miller notes that no single specialty holds all the answers and that successful management hinges on assembling the right combination of modalities for each patient.Recognizing complexity and when to expand the teamA central challenge for dermatologists is identifying when a case is becoming more complex. Dr Patel outlines red flags that should prompt earlier multidisciplinary engagement, including rapid tumor growth, recurrence, deep invasion, perineural symptoms, and tumors in anatomically challenging locations. Dr Miller adds immunosuppression, multiple recurrences, and nodal disease as signals that early collaboration may meaningfully alter the treatment trajectory.Both stress the importance of not waiting until options are limited. Early input from surgery, radiation oncology, and medical oncology allows for better planning around margins, adjuvant therapy, and systemic treatment considerations.The dermatologist’s role beyond referralThe conversation challenges the notion that dermatologists step back once oncology becomes involved. Dr Patel highlights the dermatologist’s ongoing role in managing field cancerization, monitoring for secondary primaries, and providing long-term surveillance. Dr Miller adds that patients often place deep trust in their dermatologists, positioning them to reinforce education, address concerns, and help manage skin-related adverse events even when another specialist is leading systemic therapy.Multidisciplinary decision-making in real-world practiceWhile formal tumor boards are ideal, Dr Patel acknowledges that they are not always feasible. Dr Miller describes practical alternatives, such as informal case discussions via email, phone calls, or brief in-person conversations to align on sequencing, goals of care, and follow-up responsibilities. Both note that time constraints and fragmented care can be mitigated by cultivating a reliable network of colleagues and maintaining proactive communication.Where systemic therapy fitsSystemic therapy has become an integral part of modern cSCC management rather than a last-line option. Dr Miller reiterates that timing and sequencing are critical, whether systemic therapy is used before surgery, after radiation, or as a standalone approach. Patel adds that even when dermatologists are not prescribing these agents, understanding when they are appropriate helps guide referrals and set realistic patient expectations.Cosibelimab in the multidisciplinary frameworkThe discussion turns to PD-1 inhibition, now well established in advanced cSCC. Dr Patel notes that response and tolerability vary, particularly in older patients with comorbidities. Dr Miller points to emerging data suggesting cosibelimab, a PD-L1 inhibitor, may offer a favorable tolerability and safety profile, an important consideration in real-world populations.They emphasize that familiarity with where cosibelimab may fit, whether alongside surgery or radiation, or in unresectable or metastatic disease, allows dermatologists to better guide referrals, support shared decision-making, and manage skin-related adverse events. Even when medical oncologists lead systemic therapy, ongoing dermatologic involvement remains essential as the PD-1 and PD-L1 inhibitor landscapes continues to mature.Communication, coordination, and the patient experienceFrom the patient’s perspective, multidisciplinary care can feel either reassuring or overwhelming. Dr Miller stresses that clear handoffs, consistent messaging, and defined follow-up plans are critical to maintaining trust, particularly in advanced disease, where treatment plans may evolve over time.Common pitfalls and practice pearlsDr Patel cautions that dermatologists may underestimate how quickly cSCC can progress once advanced and how impactful early multidisciplinary input can be. Common pitfalls include delayed referrals, unclear ownership of follow-up, and assumptions that another provider is monitoring the patient.Both physicians highlight simple but effective strategies: clear documentation, direct communication with key colleagues, and staying engaged even after referral. These steps can significantly improve care coordination and outcomes.Key takeawayscSCC management has become increasingly multidisciplinary, particularly for high-risk and advanced diseaseDermatologists play a central role across the continuum, from diagnosis and risk stratification to surveillance and adverse event managementEarly recognition of complexity and timely multidisciplinary engagement can expand treatment options and improve outcomesSystemic therapy is now part of integrated cSCC care, with timing and sequencing determined collaborativelyFamiliarity with agents such as cosibelimab helps dermatologists guide referrals and support patient educationClear communication, defined follow-up responsibilities, and ongoing dermatologic involvement are critical to patient experience and care quality

In this episode of Topical Conversations, Dawn Merritt, DO, sits down with Naiem Issa, MD, to explore how dermatologists think about managing atopic dermatitis (AD) over years, not weeks. Their discussion centers on durability, consistency, and the patient experience, and how those factors shape treatment decisions in real-world practice. Using therapies such as tralokinumab as reference points, they examine what sustainable disease control truly looks like for chronic inflammatory disease.Thinking beyond short-term endpointsWhen asked what matters most when choosing a therapy for AD, Dr Issa reflects on the tension between modern expectations for rapid improvement and the long-term nature of chronic inflammatory disease. While regulatory pathways emphasize short-term endpoints to determine whether a drug moves forward, the clinical reality is that patients often require treatment over the long haul.Early improvement is important, but Dr Issa emphasizes that lack of immediate response does not necessarily signal failure. Given the chronicity and complexity of AD, there are situations where allowing more time on therapy is appropriate, particularly when the treatment is well tolerated.Setting expectations for a chronic diseaseDr Merritt highlights the importance of patient education and expectation-setting, particularly for individuals who have previously relied on fast-acting but unsustainable options such as steroids. Both clinicians stress the need to reframe the conversation. AD is not curable; it must be managed. The goal is to identify therapies that are safe and effective over time, rather than those that simply offer rapid but temporary relief.Explaining the biology to support patienceDr Issa notes that bringing biology into the conversation can help patients understand why durability matters. Rather than “setting off an atomic bomb” on the immune system, modern systemic therapies aim to target specific pathways involved in disease pathophysiology.Helping patients understand that targeted immunomodulation works differentlyand can make waiting feel like a purposeful investment rather than a setback.Why IL-13 inhibition may matter for long-term controlThe conversation then turns to treatment selection, with a focus on IL-13 inhibition. Dr Issa explains that while IL-4 has long been recognized as part of AD pathophysiology, growing evidence suggests IL-13 plays a central role in driving disease.With direct IL-13 blockade, clinicians may avoid some of the effects observed with therapies that inhibit both IL-4 and IL-13. Dr Issa references clinical experience and published cases in which patients switching from IL-4 blockade to tralokinumab experienced resolution of arthralgias. He also discusses head and neck dermatitis, including instances of de novo head and neck involvement reported with certain therapies, which can influence treatment choice when considering holistic patient care.Avoiding unnecessary treatment switchingDr Merritt notes that clinicians can sometimes be too quick to switch therapies in response to flares or adverse events. Frequent switching may introduce additional risk and uncertainty without improving long-term outcomes.Dr Issa describes his approach as selecting therapies early that are designed for sustainability. The goal is to reduce risk while optimizing results in a single, cohesive strategy. In his clinical experience, tralokinumab has the potential to support this approach, including for patients who require a switch from another biologic.The role of dosing flexibility in long-term adherenceDrawing from her own practice, Dr Merritt shares that patients who remain on tralokinumab through the initial 16 weeks may transition to once-monthly dosing. While the concept of long-term therapy can initially be difficult for patients to accept, the possibility of reduced dosing frequency can help ease concerns and improve adherence.Dr Issa reinforces this point with clinical trial data, noting that patients who transitioned from every-2-week dosing to every-4-week dosing after 16 weeks maintained similar efficacy. He further highlights data showing that a subset of patients who discontinued therapy maintained clear or almost clear skin, or achieved EASI-75, for the remainder of the year.He frames this as a practical question for patients: if there were a 1-in-4 chance of maintaining control after stopping therapy, would that be worth it? Dr Merritt notes that, in her experience, most patients would accept those odds.Building a plan for the long termThe discussion concludes with a shared emphasis on early selection of therapies that balance efficacy, tolerability, and durability. Lowering the risk of adverse events, minimizing unnecessary switching, and giving patients a realistic path toward long-term control, including the possibility of dose reduction or sustained remission, are central to this approach.The clinicians end by emphasizing that durability is not just a clinical endpoint; it is a strategy that supports better outcomes, better patient relationships, and more sustainable management of chronic inflammatory disease.Key takeawaysAtopic dermatitis requires long-term management, not short-term thinkingEarly efficacy matters, but durability and tolerability often matter more over timeSetting realistic expectations helps patients stay engaged with chronic disease therapyAvoiding unnecessary treatment switching can reduce risk and improve continuity of careDosing flexibility and the potential for sustained control can improve patient acceptance and adherence

In this episode of Topical Conversations, G. Michael Lewitt, MD, joins David Cotter, MD, to examine a common yet underrecognized challenge in atopic dermatitis (AD) management: how to care for patients who respond to systemic therapy but fall short of full clearance. The discussion focuses on identifying partial responders, optimizing ongoing treatment, determining when to adjust or transition therapies, and navigating conversations about realistic expectations and long-term disease control.Rethinking AD as a systemic diseaseDrs Lewitt and Cotter open the discussion by addressing a foundational challenge in AD care: helping patients understand that it’s not simply a “skin problem,” but a systemic inflammatory disease with diverse clinical expressions. He notes that conversations about systemics flow naturally from an assessment of severity, treatment goals, and disease impact. Patients often voice concerns about “immunosuppression,” and Dr Lewitt suggests reframing this as “immunomodulation” instead, helping patients understand mechanism, safety, and expected outcomes. He also stresses that severity assessment should not rely exclusively on Eczema Area and Severity Index scores or body surface area (BSA) affected; high-impact areas and patient-perceived burden often tip the scale toward systemic therapy.The role of topicals in a systemic eraAlthough systemic therapy is appropriate for many patients, Dr Cotter emphasizes that topical therapy remains central. Tapinarof, ruxolitinib, and other topical options can serve both as initial therapy and as “touch-up paint” during systemic treatment. He routinely checks whether partial responders have tapered or discontinued their topicals, an often-overlooked contributor to perceived loss of efficacy with systemics.Managing partial or nonrespondersThe clinicians then move into the core challenge: patients who respond incompletely or lose response over time.Dr Cotter describes his decision-making framework for adding, subtracting, or switching therapies. When patients improve but plateau (better itch control, reduced BSA, milder disease but persistent burden), he discusses next steps. Options include cycling biologics, switching classes, or transitioning to a small molecule. He highlights available evidence, particularly a head-to-head trial showing that patients with inadequate response to dupilumab were more likely to improve when switched to upadacitinib.Another strategy involves using a JAK inhibitor as a short-term “fire extinguisher” for severe flares or rapid symptom control, followed by a transition back to a biologic for long-term maintenance, a preferred option over prednisone in his practice.When patients want to stop systemic therapyA common scenario is the patient who feels markedly better and asks whether treatment can be discontinued. Dr Cotter frames this as “forever for now,” emphasizing patient autonomy while counseling on likely outcomes.He discusses differences by class:JAK inhibitors typically show loss of benefit within days of discontinuationSome biologics (lebrikizumab, dupilumab, tralokinumab) may allow a significant proportion of responders to maintain stable disease for up to a year off therapyBefore stopping outright, he often also negotiates dose interval extension (eg, dupilumab every 3 weeks instead of every 2; tralokinumab every 4 weeks instead of every 2; lebrikizumab every 4 weeks or even every 8 weeks in selected responders instead of every 2) with his patients.Closing thoughtsDr Cotter closes by highlighting the advantage of today’s toolkit: the flexibility to mix and match systemic and nonsteroidal topical therapies. This allows clinicians to tailor care, maintain long-term control, and address breakthrough disease with precision and safety.Key takeawaysAD must be framed as a systemic inflammatory disease to guide patient acceptance of systemic therapyDisease severity assessment should incorporate quality of life, high-impact areas, and patient-reported burden, not just EASI or BSATopicals remain essential for priming treatment, supporting systemics, and managing breakthrough diseaseFor partial responders, evaluate adherence to topicals before modifying systemic therapySwitching options include biologic-to-biologic transitions, class switching, or moving to small molecules; existing head-to-head data can help guide choicesJAK inhibitors can serve as short-term rescue agents before returning to biologics for long-term maintenanceWhen patients want to stop therapy, consider interval extension before discontinuation and counsel on expected durability of response by therapeutic classCombining systemics with modern, nonsteroidal topicals allows individualized, long-term disease control

In this episode of Topical Conversations, Bruce E. Strober, MD, PhD, joins April Armstrong, MD, MPH, to explore the origins and clinical relevance of the suicidal ideation and behavior (SI/B) warning in the bimekizumab label. With bimekizumab now approved in dermatology for adults with moderate to severe plaque psoriasis and moderate to severe hidradenitis suppurativa (HS), many clinicians are asking whether this warning reflects a meaningful safety signal or a cautious interpretation of tightly monitored trial data.Where did the SI/B language come from?Dr Armstrong explains that the warning appears in the “Warnings and Precautions” section, advising clinicians to weigh risks and benefits in patients with a history of severe depression or SI/B and to monitor for new or worsening symptoms. Importantly, the label states that a causal association has not been established.She explains the likely origin of the language: highly sensitive, prospective monitoring in the bimekizumab trials. Compared with older psoriasis studies, these trials used more rigorous tools, such as the Columbia Suicide Severity Rating Scale (C-SSRS), capturing even passive ideation. In psoriasis trials, SI/B rates were 1.8% for bimekizumab vs 0.6% for placebo, but with wide confidence intervals crossing 1, signaling no clear statistical difference.In HS trials, confidence intervals were again wide and without consistent patterns in suicidal behavior. Across psoriatic arthritis, ankylosing spondyloarthritis, and nonradiographic axial spondyloarthritis studies, short-term data did not show elevated SI/B rates with bimekizumab.Interpreting the findings: context is criticalDr Strober emphasizes that no suicides occurred in the trials; the flagged events involved passive ideation captured through structured questionnaires and not clinical suicide attempts or behaviors.To contextualize, Dr Armstrong reviews background SI/B rates in psoriasis. Patients with psoriasis exhibit roughly double the risk of suicidal ideation and elevated risk of attempts vs the general population, particularly in patients with moderate to severe disease. Across psoriasis studies, SI/B event rates range from 0.1%–0.5% per 100 patient-years.Bimekizumab’s aggregated phase 2/3 psoriasis data show an SI/B rate of ~0.13% per 100 patient-years, aligning with background disease rates.How does bimekizumab compare with other biologics?Notably, SI/B rates for bimekizumab appear comparable to, or lower than, rates reported in trials of IL-17 inhibitors (such as secukinumab and ixekizumab) and IL-23 inhibitors. Dr Strober highlights that nothing in the bimekizumab dataset distinguishes it from patterns seen with other biologics across clinical development programs.Insights from depression measures in the trialsDr Armstrong points out that depression severity, measured by PHQ-9, improved substantially with bimekizumab in clinical trials. Additional key details include no dose–response relationship for SI/B, no clustering shortly after dosing, and many events adjudicated as not drug-related.Long-term extension and emerging real-world data have not revealed a new or consistent SI/B signal.A clinician’s approach to counseling and monitoringDr. Armstrong closes by noting that depression severity improved, on average, for bimekizumab-treated patients as measured by PHQ-9 scores. Still, because the language appears in the label, she recommends dermatologists approach patient discussions with clarity: contextualize the data, acknowledge the broader mental health burden in psoriasis, and continue standard monitoring for mood changes as part of comprehensive care.Key takeawaysThe bimekizumab SI/B warning is precautionary, and a causal relationship has not been establishedEvent rates in bimekizumab trials align with background SI/B rates expected in moderate–severe psoriasis populationsNo completed suicides or clear dose-related patterns were identified across the clinical programComparable or lower SI/B rates have been observed relative to other IL-17 and IL-23 inhibitorsPHQ-9 scores improved with treatment, suggesting overall positive effects on patient well-beingClinicians should contextualize the label language when counseling patients, especially given psoriasis’ intrinsic psychiatric comorbidity burdenStandard monitoring for depression remains appropriate, but current evidence does not indicate a unique or elevated SI/B risk with bimekizumab

In this Experiences episode of Topical Conversations, Mona Shahriari, MD, Associate Clinical Professor of Dermatology at Yale University, and Jason Hawkes, MD, Chief Scientific Officer and investigator at the Oregon Medical Research Center, explore the evolution of oral therapy in psoriasis care, from the early days of apremilast to the growing impact of selective TYK2 inhibition.Together, they trace how the field has moved from broad, nonspecific PDE4 blockade to the more targeted, allosteric TYK2 mechanism that bridges IL-23 and IL-17 signaling. Dr Hawkes outlines how TYK2 inhibition can influence downstream pathways, including IL-12 and type I interferons, potentially extending benefits beyond skin disease. The discussion also highlights recent data in psoriatic arthritis and real-world safety outcomes, with consistent tolerability and durable efficacy across challenging sites like scalp, nails, and palms.Both clinicians emphasize practical considerations—how to identify appropriate candidates for oral therapy, manage expectations around treatment onset, and communicate the distinct safety profile and monitoring needs of TYK2 inhibitors. They close by looking ahead to next-generation orals, including second-generation TYK2 inhibitors and oral IL-23 receptor blockers, which are narrowing the gap between biologic and oral efficacy.A grounded, forward-looking conversation on how oral innovation continues to reshape the psoriasis treatment landscape.

In this episode of Topical Conversations, Matthew Zirwas, MD, and Raj Chovatiya, MD, discuss one of the most important, and sometimes underappreciated, aspects of atopic dermatitis (AD) management: rapid itch relief. Despite the progress made with targeted therapies, many dermatologists may still overlook how profoundly itch drives disease burden, adherence, and patient trust. Drs Zirwas and Chovatiya share practical approaches for evaluating itch severity, setting realistic expectations, and understanding how new-generation therapies are impacting the conversation around early symptom improvement.Why itch still warrants more attention in ADDespite the numerous treatment options for AD, Drs Zirwas and Chovatiya agree that itch remains an under-discussed symptom during dermatology visits. Dr Chovatiya points out that while dermatologists often assume they’re addressing itch adequately, in practice, they may not be asking the right questions about itch severity or fully exploring its impact on quality of life.Dr Zirwas adds that while the Numeric Rating Scale (NRS) for itch is useful in research, it’s less practical in routine clinical settings where patients are seen only every few months. Instead, he recommends a more straightforward, contextual approach: asking patients whether their itch is none, mild, moderate, or severe. He likens mild itch to a single mosquito bite, moderate to 20 mosquito bites or some poison ivy, and severe to widespread poison ivy or hundreds of bites. Framing the question this way, he explains, helps patients describe their experience more accurately and meaningfully.The broader impact: itch as a holistic problemDr Chovatiya emphasizes that itch is not a surface-level symptom, but rather drives a cascade of issues including sleep disturbance, fatigue, mood changes, anxiety, and depression. Persistent itch can also erode trust between patients and providers when relief isn’t achieved quickly enough, leading to frustration with otherwise effective treatment plans.Both dermatologists stress that understanding itch’s impact on quality of life is essential not only for patient empathy but also for maintaining long-term treatment adherence.A new era of therapies and a shift in expectationsThe landscape of AD therapy has evolved dramatically, introducing multiple biologic and small-molecule options that challenge old assumptions about speed and safety. Dr Chovatiya notes that dermatologists historically viewed biologics as “safe but slow,” but that perception no longer holds true. Today’s therapeutic arsenal includes IL-4/IL-13 inhibitors, IL-13 inhibitors, IL-31 inhibitors, and potentially soon, OX40 inhibitors, which are all capable of rapid and meaningful itch improvement.When discussing the pace of itch relief, both agree that while oral JAK inhibitors may deliver the fastest onset, biologics now demonstrate impressive early itch improvement as well. Dr Chovatiya points to real-world data showing that many patients experience noticeable relief early in their biologic therapy, not just lesion improvement.Tralokinumab and rapid itch reliefDr Zirwas highlights that among available biologics, tralokinumab provides balanced performance across efficacy, safety, and speed. He notes that data from the ECZTRA trials demonstrated separation from placebo within the first few doses, confirming that tralokinumab delivers meaningful early itch relief while maintaining long-term control and a favorable safety profile.While tralokinumab has sometimes been perceived as slow-acting, both dermatologists emphasize that this perception is not supported by clinical or real-world evidence. In practice, all approved biologics, including tralokinumab, can provide rapid and sustained itch improvement.Early itch relief is foundational to effective careDrs Zirwas and Chovatiya conclude that early itch relief is not just about comfort; it’s a cornerstone of patient satisfaction, adherence, and confidence in treatment. For patients with moderate to severe AD, agents like tralokinumab demonstrate that it’s possible to achieve rapid itch relief, visible skin improvement, and long-term disease control, all while maintaining a strong safety profile.Key takeawaysItch assessment deserves more attention: Despite being the hallmark symptom of AD, many dermatologists don’t ask enough about itch severity or its daily impact on quality of lifeQualitative scales may be more practical than numeric ones: Replacing the Numeric Rating Scale with simple categories paired with real-life comparisons helps patients describe their itch more accuratelyItch affects more than the skin: Persistent itch contributes to sleep loss, mood changes, and diminished confidence in treatment, highlighting the need for early and meaningful reliefModern therapies deliver faster relief than once believed: Biologics such as tralokinumab have shown clinically relevant itch improvement within the first few dosesBalance matters: Choosing treatments that address itch, skin clearance, safety, and adherence supports both short-term comfort and long-term control in patients with moderate-to-severe AD

In this episode of Topical Conversations, Daniel Butler, MD, joins Adam Friedman, MD, to focus on an often under-recognized group: older adults with atopic dermatitis (AD). They explore why late-onset AD after 65 is more common than many clinicians may assume, how pruritus frequently outpaces visible inflammation in this cohort, and therapeutic considerations when dexterity limits, comorbidities, and polypharmacy complicate care.AD beyond childhoodDr. Friedman recalls the “rule of 3” from training when it comes to patients with childhood-onset AD: one third improve over time, one third remain the same, one third worsen; he also notes that approximately 20% of adults develop AD de novo, including those ≥65. In susceptible patients, skin senescence, barrier decline, and pH shifts can tip genetics into clinical disease. He emphasizes that recognizing new-onset AD or AD-like phenotypes in older adults and identifying it correctly is essential.Pruritus out of proportionDrs Friedman and Butler then highlight age-related presentation differences: in older adults, AD often manifests as more papular, less scaly, truncal-predominant disease with pruritus out of proportion to modest visible inflammation. They emphasize that this itch–rash discordance can lead clinicians to underestimate disease burden and its impact on sleep, mood, and daily functioning.Practical barriers: polypharmacy, access, applicationThey next discuss the importance of appropriately matching therapy to real-world constraints. They explain how polypharmacy can turn multistep topical regimens into the familiar “bag of creams” problem; twice-daily application may be unrealistic given mobility, reach, or vision limitations, and even injectables require assessing dexterity, comfort with needles, bruisability and infection risk, and the availability of caregiver support.Choosing treatments that work for this populationDrs Butler and Friedman agree that modern biologics have been transformative for AD treatment, with minimal drug–drug interactions, simple dosing intervals, and strong antipruritic/anti-inflammatory effects often reducing the need for multiple topicals or daily pills. Conversely, off-label antipruritics like gabapentinoids and SSRIs may pose renal and sedation risks in older adults.Closing pearls and “theranostics”They conclude their discussion with some practical pearls for managing this population, commenting that marked itch with modest dermatitis warrants a thoughtful differential, considering conditions like nonbullous pemphigoid and malignancy-related pruritus. After excluding more serious conditions, targeted biologics like dupilumab, lebrikizumab, and nemolizumab can act as “theranostics,” with response supporting a type 2 endotype and a lack of response redirecting the workup. Although older adults were under-represented in pivotal trials, Dr Friedman closes by emphasizing that dermatologists can be confident in safety and effectiveness in practice for this population.Key takeawaysAD can begin after 65: don’t dismiss late-onset disease in older adultsItch may far exceed visible inflammation: prioritize patient-reported pruritus and its impact on quality of lifeMatch regimen to reality: consider dexterity, vision, caregiver support, and polypharmacyBiologics can fit well for older adults: few interactions, interval dosing, strong itch and skin controlBe cautious with off-label antipruritics: renal/sedation risks are higher in this groupUse “theranostics “wisely: targeted biologic response can clarify the immunologic driver after serious causes are excluded

In this episode of Topical Conversations, Nicholas Brownstone, MD, is joined by Peter Lio, MD, for a candid fireside chat on systemic therapies for atopic dermatitis (AD). Together, they explore why these treatments remain underutilized, how dermatologists can better identify systemic candidates, and what expanding therapeutic options mean for personalized patient care.Why systemic therapy remains underusedDr Lio emphasizes that dermatology has only had FDA-approved systemic options for AD for about a decade. Before that, therapies were mostly off-label and carried significant safety concerns. Despite advances, hesitation persists, often due to lingering perceptions of systemics as high-risk. While topical therapies remain foundational, Dr Lio argues that dermatologists should raise their expectations: improvement alone is not enough if patients still struggle with sleep, concentration, or recurrent flares.Recognizing candidates for systemic therapySystemic therapy candidacy extends beyond visible lesions. Dr Brownstone stresses the importance of a full history and physical exam, while Dr Lio highlights tools such as the Atopic Dermatitis Control Tool to uncover quality-of-life impairments that might otherwise be missed. Sensitive areas, such as the face and hands, can also justify systemic consideration even in patients who appear mild or moderate by standard measures.Overcoming hesitation and leveraging biologicsTraditional systemic agents like methotrexate or cyclosporine created a culture of caution due to safety concerns. Today’s biologics for atopic dermatitis (dupilumab, lebrikizumab, tralokinumab, and nemolizumab) offer safer, more convenient alternatives. Dr Lio notes that all are effective and generally well tolerated, with subtle differences in efficacy, speed of response, and side effect profiles that can guide treatment selection. Importantly, dermatologists can reassure patients about the possibility of dose spacing or eventual pauses once durable control is achieved.Looking ahead: patient-centered goalsBoth dermatologists agree that systemic therapy allows for elevated treatment targets, shifting from “good enough” improvement to clear skin and normalized quality of life. Positive patient experiences with systemic therapies build trust, improve adherence, and empower dermatologists to offer individualized care strategies.Key takeawaysSystemic underuse: Despite multiple safe and efficacious systemic agents now approved, many patients with AD patients remain undertreated; dermatologists should consider whether their patients’ disease burden justifies escalationRecognizing systemic candidates: Look beyond objective scores; QoL measures and disease location matter.Biologics today: Modern systemic therapies are safe, effective, and more convenient than older optionsPersonalized treatment choices: Each biologic offers unique attributes that can be tailored to patient needsTreatment flexibility: Dose spacing or temporary pauses may be possible in well-controlled patients

In this episode of Topical Conversations, E. James Song, MD, speaks with Tina Bhutani, MD, about bimekizumab and its growing list of indications, including psoriasis, psoriatic arthritis (PsA), axial spondyloarthropathies, and hidradenitis suppurativa (HS), highlighting how this therapy may help dermatologists address the multifaceted needs of patients.Why another biologic?Dr Song opens by noting that bimekizumab is now the twelfth biologic approved for psoriasis, prompting the question of why additional biologics are still needed. Dr Bhutani stresses that despite the abundance of options, many patients cycle through therapies due to inadequate response or secondary failure. Moreover, patients often present with comorbidities such as joint disease that require broader treatment coverage, demonstrating the value of having multiple biologics available to personalize care.Bimekizumab in psoriatic arthritisPsA presents unique challenges, with many patients responding inconsistently or slowly to traditional therapies. Dr Bhutani explains that even when skin clearance is achieved, joint symptoms often remain uncontrolled. They explain that bimekizumab provides another option for these patients, adding to the armamentarium for both dermatologists and rheumatologists managing PsA.Addressing axial spondyloarthropathiesThe conversation turns to axial disease, specifically radiographic axial spondyloarthritis (axSpA, also known as ankylosing spondylitis) and nonradiographic axSpA (nr-axSpA). Dr Bhutani explains that these conditions involve inflammation of the central joints, particularly the spine and sacroiliac joints. Historically, treatment was limited until radiographic changes became apparent.Dr Song highlights the significance of bimekizumab’s approval for nr-axSpA, which allows earlier intervention before structural damage occurs. He contrasts IL-23 inhibitors, which have limited efficacy in axial disease, with IL-17 inhibitors like bimekizumab, which demonstrate consistent benefit across both peripheral and axial domains. Together, Drs Song and Bhutani emphasize that bimekizumab covers nearly all GRAPPA domains (skin, nails, enthesitis, dactylitis, peripheral joints, and axial disease) making it a versatile option for patients with overlapping manifestations.Expanding to hidradenitis suppurativaThe discussion closes with a look at bimekizumab’s approval in HS, a often difficult condition to manage. Dr Bhutani shares her clinical experience, noting rapid improvements in pain and inflammatory lesions, with the potential to reduce long-term complications such as scarring and tunneling. She emphasizes that patients with HS stand to benefit greatly from having more therapeutic options in what remains an area of significant unmet need.Key takeawaysOngoing need for new biologics: Despite many approved options, patients often require alternative therapies due to nonresponse or secondary failurePsA management: Bimekizumab offers an additional option for patients with joint diseaseAxial disease coverage: Approval in nr-axSpA allows earlier intervention and highlights IL-17 inhibitors as more effective than IL-23 inhibitors in axial domainsComprehensive domain coverage: Bimekizumab has potential to address nearly all GRAPPA domains, offering broad utility in patients with overlapping manifestationsHS treatment: Bimekizumab provides meaningful benefit in a challenging disease, with potential to improve quality of life and prevent long-term complications

In this episode of Topical Conversations, Nicholas Brownstone, MD, sits down with Dawn Merritt, DO, to discuss the often-overlooked impact of atopic dermatitis (AD). While dermatologists may see a rash that appears mild, for many patients the disease affects far more than the skin, touching sleep, mental health, cognitive function, and overall quality of life across all age groups.Pediatric burdenDr Merritt emphasizes that pediatric patients and their families face a unique set of challenges. Children with AD often require multiple prescriptions per year, and caregivers may spend more than 10 hours weekly managing symptoms. This burden extends beyond the patient, commonly affecting parents’ time, energy, and mental health.The itch burden and mental healthPruritus is central to the disease burden in AD. Studies show patients with itch experience worse quality of life than those with chronic conditions like heart failure or stroke. Sleep disruption from itch can contribute to depression, anxiety, and even suicidal ideation. Dr Merritt notes that over 85% of patients with moderate-to-severe AD report at least itch or sleep disturbance as a symptom.Impact on school performanceChildren with AD may miss school due to rash, infection, or poor sleep. Even when present, they often struggle to concentrate (presenteeism), which can affect academic performance and self-confidence.Asking the right questionsBoth speakers stress the importance of asking beyond “How are you doing?” to uncover a patient’s full burden of AD. Specific questions about sleep, school, itch severity, and mental health allow patients and families to share concerns not visible on exam. Simple tools such as the Atopic Dermatitis Control Test or the PHQ-2 depression screen can help integrate formalized assessments into a busy clinic.Systemic therapies and emerging dataFor patients with significant quality-of-life impairment, Dr Brownstone recommends considering systemic therapy and referral to mental health support. Emerging data highlight that systemic biologics, such as dupilumab, may not only control skin symptoms but may also potentially improve growth outcomes and reduce ADHD medication needs in pediatric patients. A new therapeutic landscape for pediatric patientsSystemic options for AD have been expanding rapidly. Dupilumab is approved for patients as young as 6 months, while biologics such as lebrikizumab, nemolizumab, and tralokinumab are available for patients aged 12 and older. Compared to the limited options of the past, Dr Brownstone describes this as a “golden age” for pediatric AD management.Addressing comorbidities and empowering familiesDrs Brownstone and Merritt conclude their discussion by emphasizing that effective care includes addressing comorbidities such as sleep disturbance and depression. Dr Merritt also uses simple, relatable tools, like asking children to grade their AD with a letter grade, which helps track disease burden across visits. Both recommend connecting families to resources such as the National Eczema Association to provide education and empowerment.Key takeawaysAD can impact far more than the skin, affecting sleep, mental health, school performance, and family well-beingPruritus is a key driver of quality-of-life impairment and may be linked to higher rates of depression and suicidalityAsking specific, pointed questions or using simple screening tools can help clinicians uncover the true burden of disease for their patientsSystemic therapies like dupilumab are transforming pediatric AD care and may offer benefits beyond skin clearanceFor patients with even mild-appearing rashes but severe life impact, systemic agents or mental health referrals should be consideredProviding families with trusted resources, such as the National Eczema Association, can help foster education, empowerment, and adherence

From Skin to Joints: Clinical Impact of a Dual-Targeted ApproachIn this episode of Topical Conversations, Erin Boh, MD, and Benjamin Lockshin, MD, discuss the role of bimekizumab (Bimzelx), the first dual IL-17A/F inhibitor, in the management of patients with psoriasis (PsO) and psoriatic arthritis (PsA). The conversation highlights how this mechanism of action has the potential to reshape treatment strategies, particularly for patients with both extensive skin involvement and active joint disease.Treatment considerations in PsO and PsADr Boh explains that her initial considerations include the extent of skin involvement and the presence of comorbidities such as joint disease. These parameters help guide whether therapy should be directed primarily toward skin, joints, or both. She emphasizes a patient-centered approach directed by understanding whether skin or joint symptoms are the main driver of discomfort.For patients with both extensive skin and joint disease, she typically favors IL-17 inhibitors or IL-23 inhibitors over TNF inhibitors, noting that TNFs may struggle to achieve high levels of skin clearance in such cases.Advances with bimekizumabDr Lockshin notes that while treatments over the past 2 decades have been highly effective for skin clearance, progress in joint clearance has been more limited. Bimekizumab introduces a new approach with its dual inhibition of IL-17A and IL-17F, demonstrating robust results in both skin and joints.He highlights that bimekizumab is the first drug to use an American College of Rheumatology criteria for 50% response (ACR50) score as a primary endpoint in PsA trials, providing a more meaningful measure of response compared to ACR20. Clinical trial data showed achievement of ACR20, ACR50, and ACR70 responses in some patients faster than in timelines observed with other agents.Dr Boh agrees, noting that while other IL-17 inhibitors are effective for joint disease, there are subsets of patients who respond incompletely. In her view, bimekizumab represents not only a new drug but a new therapeutic class, with the potential to maximize outcomes in patients who do not achieve adequate improvement with IL-17A inhibition alone.Practical implications and switching therapyBoth Dr Boh and Dr Lockshin emphasize the potential benefit of of switching therapy. Dr Lockshin states he has no reservations about moving patients from a TNF inhibitor to an IL-17, or from an IL-17A inhibitor to dual IL-17A/F blockade with bimekizumab.Dr Boh highlights the potential role of bimekizumab when combination therapy is otherwise limited by access or insurance barriers. For example, if a patient has partial response to an IL-17A, switching to bimekizumab may offer greater improvement without the need for additional agents.Patient-centered decision-makingThe discussion concludes with a reminder from Dr Boh that treatment decisions should be patient-first: the patient comes first, the disease second, and the drug third. With an expanding set of options, including bimekizumab, dermatologists are better positioned to tailor treatment to each patient’s unique presentation, balancing efficacy across both skin and joint disease while considering mechanisms of action and long-term outcomes.Key takeawaysInitial considerations: Treatment decisions in PsO and PsA begin with assessing the extent of skin involvement and the presence of joint diseaseDual inhibition: Bimekizumab targets both IL-17A and IL-17F, offering robust efficacy in skin and joint clearanceClinical trials: In bimekizumab trials for PsA, ACR50 was used as a primary endpoint, a more clinically meaningful measure than ACR20Therapeutic flexibility: Switching from TNF inhibitors or single-pathway IL-17 inhibitors to bimekizumab can maximize outcomes without requiring combination therapyPatient-centered care: The patient’s priorities drive treatment (skin versus joints), with bimekizumab representing an option that addresses both domains effectively

In this episode of Topical Conversations, Graham Litchman, DO, MS, and Naiem Issa, MD, discuss the role of Janus kinase (JAK) inhibitors in atopic dermatitis (AD). These agents are increasingly valued for their efficacy and safety in clinical practice. A key advantage is the ability to individualize therapy through dose escalation, allowing JAK inhibitors to support a more personalized approach to managing this heterogeneous condition.Safety considerationsDr Litchman and Dr Issa review the safety profile of JAK inhibitors, noting that these medications are widely used and generally well tolerated. Large-scale studies of abrocitinib and upadacitinib, encompassing thousands of patients across multiple countries, support their safety and efficacy.Dr Issa emphasizes the importance of proactively addressing the boxed warning during patient discussions. Many patients will review the package insert and raise concerns, so he begins the conversation by explaining the history and context behind the warning. The boxed warning stems from the ORAL Surveillance study of tofacitinib vs TNF inhibitors in patients with rheumatoid arthritis aged 50 and older with cardiovascular comorbidities; many of these patients were on concomitant methotrexate and often corticosteroids. This population differs significantly from typical patients with AD.The “big 5” risks listed in the boxed warning (infection, major adverse cardiovascular events, thrombosis, sudden death, and malignancy) are framed as “reports” associated with JAK inhibitors, not as placebo-controlled findings. Dr Issa notes that clarifying this nuance helps patients understand the data in context and alleviates concerns. Dr Litchman adds that while these conversations can be complex, the majority of AD patients are not the same as the population studied in ORAL Surveillance, and most tolerate JAK inhibitors well in practice.Personalized treatment and dosing strategiesBoth experts highlight the role of JAK inhibitors in moving toward personalized medicine for AD, a heterogeneous and fluctuating disease. Treatment plans can be tailored based on individual patient needs, with the ability to adjust dosing when necessary.Data from studies such as the JADE and LEVEL UP trials support flexible dosing. For example, abrocitinib can be initiated at 100 mg daily, with evidence supporting escalation to 200 mg if additional efficacy is needed. Upadacitinib has a similar dose-response profile, with starting doses of 15 mg and higher efficacy seen with 30 mg. Importantly, long-term safety data have not shown an increased risk of adverse events of special interest when escalating to higher doses.In practice, Dr Issa often re-evaluates patients within 2 weeks, especially those with itch-dominant disease, and escalates dosing earlier if needed, supported by lab monitoring. Biological and mechanistic insightsBeyond clinical outcomes, Dr Litchman highlights emerging data on gene expression changes with JAK inhibitors. Studies suggest that these therapies, like biologics, may help normalize core gene sets associated with AD, particularly those related to itch pathways and skin barrier function. Observing both clinical improvements in itch and skin clearance, alongside genomic changes, reinforces confidence in the biological rationale for JAK inhibitor therapy.Key takeawaysSafety in context: Boxed warnings stem from rheumatoid arthritis data; most patients with AD tolerate JAK inhibitors wellFlexible dosing: Clinical trials support dose escalation (eg, increasing abrocitinib dosage from 100 mg to 200 mg or upadacitinib from 15 mg to 30 mg) without added long-term safety signalsBiologic rationale: Emerging gene expression data support the mechanistic role of JAK inhibitors in normalizing AD pathwaysFor a closer look at how dose escalation can influence outcomes in practice, explore a case report authored by Graham Litchman, DO, MS. It details a 25-year-old patient with longstanding, refractory atopic dermatitis who achieved complete clearance on abrocitinib following dose adjustment, with before-and-after photos documenting the clinical response.

In this episode of Topical Conversations, Laura Ferris, MD, and Désirée Ratner, MD, discuss approaches to identifying and managing high-risk cutaneous squamous cell carcinoma (cSCC), with a focus on integrating traditional staging systems and molecular testing to guide treatment decisions.Defining high-risk cSCC Historically, high-risk cSCC was defined by a combination of clinical and histologic features, such as tumor location on the head or neck, ill-defined borders, aggressive growth patterns, immunosuppression, or perineural invasion. The NCCN has since formalized a list of high-risk features, and staging systems such as AJCC and BWH now provide structured frameworks for evaluation. While these systems differ (for example, BWH includes poor differentiation as a criterion while AJCC does not) both have improved risk prediction compared to earlier approaches. Molecular testing with the 40-GEP assay Molecular assays such as the 40-GEP test offer additional prognostic refinement by evaluating gene expression within an individual tumor. The test categorizes patients as Class 1 (low risk), Class 2A (intermediate but clinically comparable to high risk in AJCC/BWH), or Class 2B (very high risk). Both physicians note the value of this tool in identifying patients who may benefit from closer surveillance or more aggressive therapy, as well as in de-escalating treatment for patients with low-risk results. Implications for treatment decisions Data suggest that patients with Class 2B tumors have significantly lower metastasis-free survival compared with Class 1 tumors, particularly in high-risk NCCN groups. Retrospective evidence indicates that Class 2B patients may derive the greatest benefit from adjuvant radiation therapy. Conversely, a Class 1 result may support omitting radiation in favor of close monitoring. The test also informs decisions regarding alternative systemic treatments such as immunotherapy for patients who are not candidates for radiation. Multidisciplinary integration and clinical pearls Dr Ratner emphasizes the benefit of sharing 40-GEP results with multidisciplinary oncology teams to individualize treatment plans and emphasizes ensuring adequate tissue sampling to allow molecular testing. The clinicians emphasize that results can be unexpected, even for experienced clinicians; thus, incorporating both staging systems and molecular tools can help optimize outcomes through more precise risk stratification and tailored management strategies. Key takeaways High-risk cSCC classification is evolving, with AJCC and BWH staging systems providing structured frameworks for clinical and histologic risk assessment The 40-GEP molecular assay refines prognosis by evaluating gene expression, categorizing patients into low, intermediate, or very high-risk groups Class 2B tumors as defined by the 40-GEP test carry a significantly higher risk of recurrence and metastasis and may benefit most from adjuvant radiation Class 1 results can support de-escalation of therapy in patients who may otherwise be overtreated Molecular results can inform multidisciplinary discussions and guide individualized treatment strategies

In this episode of Topical Conversations, Naiem Issa, MD, and Christopher Bunick, MD, discuss their publication in the Journal of Drugs in Dermatology that highlighted a remarkable case of rapid plaque psoriasis clearance with bimekizumab. They explore the patient case, the mechanism of action driving the rapid response, key clinical insights, and future applications of bimekizumab in psoriatic arthritis (PsA) and hidradenitis suppurativa (HS). Rapid clearance in a treatment-naïve patient Dr Issa describes a male patient in his 30s with over 50% body surface area involvement who had classic plaque psoriasis but had been treatment-naïve for several years after moving to the US. After starting bimekizumab, the patient returned 3 days later, reporting rapid improvement, with plaques melting away and pruritus significantly improved within 24 hours. By 72 hours, 90% of his body had cleared, and within a week, his skin was completely clear, with no residual itching. Dr Issa notes that such rapid improvement is rare with biologic therapies and highlights the potential for bimekizumab to dramatically alter disease progression and patient quality of life. Dr Bunick emphasizes the underrecognized burden of itch in psoriasis, often associated more with atopic dermatitis than psoriasis, reflecting that bimekizumab’s efficacy in reducing both plaques and pruritus so quickly suggests it is a powerful option for improving patient outcomes. Why does bimekizumab work so quickly? Dr Bunick attributes bimekizumab’s rapid and sustained clearance to its unique mechanism of action. Unlike other IL-17 inhibitors, bimekizumab targets both IL-17A and IL-17F. While IL-17A is more potent, IL-17F is more abundant in psoriatic plaques, and inhibiting both cytokines leads to a stronger anti-inflammatory effect. Dr Issa highlights head-to-head trials comparing bimekizumab to adalimumab, ustekinumab, and secukinumab, all of which demonstrated bimekizumab’s superior response rates at 4 weeks. Additionally, IL-17F inhibition has been linked to rapid transcriptional changes in psoriasis plaques, supporting the observed early clearance seen in clinical practice. This challenges the traditional dogma that skin takes time to recover after inflammation subsides. Dr Bunick suggests that some patients may be capable of achieving near-immediate clearance, a paradigm shift in how dermatologists approach biologic response timelines. Addressing safety concerns Mood and suicidal ideation and behavior While bimekizumab’s prescribing information includes a warning for suicidal ideation and behavior, Dr Issa notes that in pivotal trials, Patient Health Questionnaire-9 scores, which assess the degree of depression severity, tended to improve in patients treated with bimekizumab compared to placebo. Dr Bunick compares this to oral isotretinoin, where concerns about depression often contrast with real-world improvements in patient mood and quality of life. As psoriasis improves, sleep, confidence, and social interactions also improve, often leading to better overall mental well-being. Oral and corporal candidiasis Candidiasis is the most common side effect associated with IL-17 inhibitors, but Dr Issa reassures that it is manageable with fluconazole or topical ketoconazole and rarely leads to treatment discontinuation. Dr Bunick explains that oral candidiasis tends to occur once or twice in early treatment but does not persist in most patients. However, if candidiasis is recurrent, alternative treatments may be considered. Expanding beyond psoriasis: bimekizumab in PsA and HS With additional FDA approvals for PsA and HS, bimekizumab is positioned to expand its role in dermatology. Dr Issa highlights that IL-17A and IL-17F levels are significantly elevated in HS, making bimekizumab a logical therapeutic option. For PsA, Dr Bunick emphasizes the importance of dermatologists "owning" psoriatic arthritis—as experts in skin disease, dermatologists should be actively involved in joint disease management as well. Bimekizumab’s efficacy in both psoriasis and PsA provides an opportunity to optimize care for patients with both skin and joint involvement. Positioning bimekizumab in the treatment landscape With IL-23 inhibitors already used for PsA, dermatologists may be wondering how bimekizumab should be positioned within the treatment landscape. Dr Bunick points to the ongoing BE BOLD trial, a direct head-to-head comparison of bimekizumab vs risankizumab in PsA, which will provide valuable insights into IL-17 vs IL-23 inhibition in psoriatic arthritis. Key takeaways In a case study, bimekizumab demonstrated rapid plaque clearance, with a treatment-naïve patient achieving full clearance within a week Its dual inhibition of IL-17A and IL-17F differentiates bimekizumab from other IL-17 inhibitors Safety concerns such as suicidal ideation and behavior and candidiasis are manageable, with mood improvements observed in clinical trials Bimekizumab is now approved for PsA and HS, making it a promising option beyond psoriasis A head-to-head trial with an IL-23 inhibitor (BE BOLD trial) will provide critical insights for PsA management

In this episode of Topical Conversations, David Rosmarin, MD, joins Mary Gail Mercurio, MD, to discuss practical approaches to treating atopic dermatitis (AD) with dupilumab. The conversation covers treatment selection, patient counseling, insurance navigation, and evolving data on safety and adjunctive options. When to initiate systemic therapy Both note that the threshold for initiating systemic therapy, particularly dupilumab, has decreased as confidence in its safety and efficacy continues to grow. The broad range of FDA-approved indications, including approval down to 6 months of age, can help reassure patients who are hesitant to begin biologic therapy. The lack of lab monitoring requirements is also a significant benefit for both patients and clinicians. Patient counseling and injection hesitancy Patient hesitation around injectables can often be addressed through hands-on education and support from office staff. Dr Mercurio highlights the importance of in-office instruction in the use of the injection device. The growing body of safety data in pregnancy is also discussed, with both clinicians emphasizing the importance of forthcoming registry data and growing real-world evidence supporting dupilumab’s use during pregnancy. Follow-up and documentation Follow-up frequency varies based on patient preference and disease severity, often extending to 6 to 12 months once stable. Both clinicians document body surface area (BSA), symptom severity, and impact on quality of life, such as interference with sleep or daily functioning. Insurance considerations While dupilumab is typically approved without significant barriers, both clinicians note challenges when BSA is below 10%. Documenting involvement of high-impact areas like the face and hands and the broader impact on quality of life can aid in securing coverage. Assessing response and treatment duration The decision to continue or switch therapy is patient-specific. Some improvement may be expected within 3 months; if no response is observed by 3 to 4 months, a change in therapy may be warranted, especially in more severe cases. Mild cases may allow for a longer trial period before considering alternative options. Adjunctive therapies and managing residual disease For patients with residual symptoms despite dupilumab, both clinicians use topical therapies—steroids or nonsteroidals—based on body site. Phototherapy is viewed as a beneficial option but may be inaccessible due to cost or insurance limitations. Tapinarof and roflumilast are emerging nonsteroidal options, though access can be restricted by formulary status. Approach to acute flares In select cases, a short course of oral corticosteroids may be used to control acute flares while initiating dupilumab, helping to bridge the gap until biologic response is achieved. Looking ahead The discussion concludes with anticipation for new therapeutic options, including oral JAK inhibitors, oral STAT6 inhibitors, and other novel mechanisms. Dupilumab remains a foundational therapy in AD management, with new data, particularly regarding pregnancy safety and additional indications, expected to further shape clinical practice. Key takeaways Dupilumab is increasingly used earlier in the treatment course of AD due to a favorable safety profile and lack of lab monitoring requirements Patient education and support can ease concerns around injectable administration Documentation of quality-of-life impact and involvement of special sites can improve insurance approval likelihood, particularly for patients with <10% BSA involvement Adjunctive therapies, including topical agents and phototherapy, are frequently used to manage residual disease Treatment response is typically evaluated within the first 3 to 4 months to guide continuation or change in therapy