WCH 2026 Conference Highlights

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

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

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

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

Jerry Shapiro, MD provided a clinical deep dive into cicatricial (scarring) alopecias, underscoring the critical distinction between scarring and non-scarring hair loss: once follicles are destroyed, regrowth is no longer possible. He emphasized the importance of early recognition and aggressive intervention to prevent permanent hair loss. Advanced diagnostic tools were highlighted, including trichoscopy to identify hallmark features such as loss of follicular ostia, perifollicular scale, and blue-grey dots, as well as AI-driven trichometric analysis (HairMetrix) to objectively measure disease progression and guide individualized treatment plans.The session reviewed key lymphocytic scarring alopecias, including lichen planopilaris (LPP), frontal fibrosing alopecia (FFA), and central centrifugal cicatricial alopecia (CCCA). Treatment algorithms for LPP incorporate intralesional triamcinolone acetonide, combination topical therapies, and systemic agents including JAK inhibitors. In FFA, which predominantly affects postmenopausal women and frequently involves eyebrow loss, Dr Shapiro discussed data linking certain sunscreens and moisturizers to increased risk and advised mineral-based alternatives. Facial papules associated with FFA were shown to respond well to oral isotretinoin. For CCCA, emerging data on topical and low-dose oral metformin demonstrated improvement in fibrosis by downregulating profibrotic gene pathways, representing a promising therapeutic advance.Neutrophilic scarring alopecias, including folliculitis decalvans and dissecting cellulitis, were also addressed, with refractory cases responding to biologics such as adalimumab or baricitinib. Practical pearls included the use of low-dose doxycycline to reduce inflammation with fewer gastrointestinal side effects, adjusting intralesional steroid concentrations based on scalp location, and monitoring for rare complications such as central serous chorioretinopathy following steroid injections. Dr Shapiro concluded by cautioning that hair transplantation should only be considered after more than two years of disease quiescence to avoid disease reactivation, reinforcing that in scarring alopecia, success hinges on stopping progression early rather than restoring lost hair.

Scott Elman, MD and Joseph F. Merola, MD emphasized that cutaneous lupus erythematosus (CLE) should not be viewed simply as “systemic lupus of the skin,” as many CLE subtypes have distinct pathogenesis, clinical courses, and treatment needs. They reviewed the major CLE subtypes—acute (ACLE), subacute (SCLE), and chronic (CCLE), including discoid lupus and lupus profundus—and highlighted the wide variability in systemic lupus overlap, ranging from more than 90% in ACLE to approximately 5% in localized discoid disease. Despite this heterogeneity, CLE carries a profound disease burden, with quality-of-life impairment comparable to or worse than major systemic medical conditions.The presenters stressed the importance of structured monitoring to detect evolving systemic disease, introducing the practical “LABS FOR SLE” mnemonic to guide routine evaluation. Treatment was framed as a rapidly evolving ladder, moving well beyond antimalarials alone. While methotrexate and mycophenolate remain important second-line options, newer targeted therapies are reshaping CLE management. Anifrolumab has demonstrated sustained improvements in skin disease by blocking type I interferon signaling, while emerging agents such as litifilimab, deucravacitinib, and enpatoran offer promising, more precise immune modulation with encouraging skin-specific outcomes.The session concluded with a call for strategic, multidisciplinary care. Treatment selection should be guided by comorbidities, systemic involvement, and patient-specific goals, with close collaboration between dermatology and rheumatology to address both systemic risk and skin-driven morbidity such as scarring and dyspigmentation. Drs Elman and Merola reinforced that with growing therapeutic options and better disease understanding, dermatologists are uniquely positioned to lead the comprehensive care of patients with CLE.

Boni E. Elewski, MD presented a streamlined, five-step framework for managing onychomycosis, beginning with accurate bedside diagnosis. Key clinical clues include asymmetric nail involvement, a history of tinea pedis, distal onycholysis, and yellow, white, or brown subungual debris. She highlighted specific diagnostic features such as dermatophytomas and collarettes of scale, which can strongly suggest dermatophyte infection. Laboratory confirmation remains essential, with KOH testing or PAS/GMS staining used to identify fungal elements, and fungal culture or PCR required to determine the causative organism. When hyphae are present, the likelihood exceeds 90% that Trichophyton rubrum is responsible.Treatment decisions were framed around disease severity and patient factors, with options including oral therapy, topical therapy, or combination approaches. Oral antifungals such as terbinafine, itraconazole, and fluconazole remain mainstays for moderate-to-severe disease, while topical agents like efinaconazole, tavaborole, and ciclopirox are best suited for mild cases or as adjunctive therapy. Dr Elewski emphasized important safety considerations, particularly with itraconazole, including drug–drug interactions, absorption requirements, and cardiac risk. Monitoring response is critical, as toenails grow slowly; patients should demonstrate several millimeters of healthy new nail growth within 3–4 months of treatment initiation.The session concluded with a focus on preventing reinfection, a common cause of treatment failure. Dr Elewski stressed aggressive management of concomitant tinea pedis and patient education on behavioral modifications, such as avoiding barefoot exposure in public spaces. By combining accurate diagnosis, tailored antifungal therapy, realistic expectations, and preventive strategies, clinicians can significantly improve long-term outcomes in patients with onychomycosis.

Linda Stein Gold, MD reframed rosacea management using the ROSCO 2019 feature-based treatment algorithm, which moves away from traditional subtyping and instead targets individual clinical features. Persistent facial erythema is best addressed with optimized skincare, α-adrenergic agents, or devices, while inflammatory papules and pustules are treated with targeted topical therapies such as ivermectin, azelaic acid, or metronidazole, and systemic agents including doxycycline or isotretinoin. Telangiectasias typically require procedural intervention, and phymatous changes may respond to isotretinoin when inflamed or surgical management when fibrotic.Advances in erythema control were highlighted with α-adrenergic agonists brimonidine and oxymetazoline, both shown to significantly reduce background redness, with practical tips to minimize irritation through conservative dosing. For papulopustular rosacea, Dr Stein Gold emphasized that tetracyclines act through anti-inflammatory rather than antimicrobial effects, paving the way for non-antibiotic formulations. Promising therapies included low-dose extended-release minocycline (DFD-29), which demonstrated early efficacy without disrupting the microbiome, and microencapsulated benzoyl peroxide, designed to reduce irritation while maintaining efficacy. Topical ivermectin was highlighted for its dual anti-inflammatory and anti-parasitic activity and superior performance compared with metronidazole.The session underscored the importance of aiming for complete clearance (IGA 0), as patients who achieve “clear” disease experience longer remission than those who are only “almost clear.” Dr Stein Gold also flagged emerging safety considerations, noting reports of rosacea fulminans and acneiform eruptions following initiation of TYK2 inhibitors in patients with underlying rosacea. Overall, the presentation reinforced that precision, patience, and feature-driven therapy are key to achieving durable rosacea control.

Prince Adotama, MD and Mark Lebwohl, MD provided a comprehensive update on bullous pemphigoid (BP), a rare autoimmune blistering disease that predominantly affects older adults. They reviewed the underlying pathophysiology, in which autoantibodies against BP180 and BP230 disrupt dermal–epidermal adhesion and trigger a robust inflammatory cascade involving eosinophils, neutrophils, and Th2 cytokines such as IL-4 and IL-13. Disease severity closely correlates with elevated IgE levels and eosinophilia, helping explain the intense pruritus and blister formation seen in affected patients. The presenters emphasized that BP often presents atypically, with more than half of patients initially developing nonbullous eczematous or urticarial lesions, underscoring the need for heightened diagnostic suspicion.The session also highlighted growing awareness of drug-induced BP, with more than 50 medications implicated. Notably, DPP4 inhibitors used in type 2 diabetes are associated with a threefold increased risk, and immune checkpoint inhibitors have also been linked to disease onset. While traditional management still includes high-potency topical steroids and short-term systemic corticosteroids with immunomodulators, the treatment landscape is rapidly changing. Dupilumab, approved in June 2025 for adult BP, has demonstrated rapid disease control in the majority of patients, with a favorable safety profile and significant steroid-sparing benefits. Additional targeted options, including omalizumab and rituximab, have shown strong efficacy in selected patients, particularly those with high IgE levels or refractory disease.Overall, the presenters emphasized that targeted biologic therapies are transforming BP care by improving disease control while minimizing the long-term risks of systemic corticosteroids. This shift marks a new era in BP management, prioritizing precision therapy, safety, and durable remission in a vulnerable patient population.

Alexandra Golant, MD and E. James Song, MD reviewed chronic hand eczema (CHE) as a heterogeneous and often refractory condition, defined by disease lasting longer than three months or recurring multiple times within a year. They emphasized that CHE is frequently multifactorial, with nearly half of patients exhibiting overlapping subtypes such as atopic and irritant contact dermatitis. Despite varied clinical presentations, inflammation across CHE subtypes is largely driven by cytokines signaling through the JAK-STAT pathway, helping explain the chronicity and treatment resistance seen in many patients.Accurate diagnosis remains essential and includes distinguishing etiologic subtypes from clinical morphologies, along with routine consideration of patch testing to identify relevant allergens. However, the presenters noted that allergen avoidance alone often provides incomplete relief, underscoring the need for more effective therapies. A major advance discussed was the approval of delgocitinib 2% cream in 2025, a topical pan-JAK inhibitor for adults with moderate-to-severe CHE inadequately controlled with topical corticosteroids. Data from the DELTA trials demonstrated significant improvements in skin clearance, itch, and pain across multiple CHE subtypes, including hyperkeratotic disease, with minimal systemic absorption and a favorable safety profile.Additional emerging options were also reviewed, including topical ruxolitinib for rapid itch reduction, biologics such as dupilumab and tralokinumab for atopic-driven disease, and investigational oral agents like abrocitinib and roflumilast. The session concluded with practical management pearls, emphasizing the limitations of long-term topical corticosteroid use and the importance of individualized, subtype-driven treatment strategies to achieve durable control and improved hand function.

The presentation positioned interleukin-13 (IL-13) as a dominant cytokine in atopic dermatitis, driving inflammation, barrier dysfunction, dysbiosis, and chronic itch. Unlike IL-4, IL-13 remains elevated even in nonlesional, normal-appearing skin, helping explain persistent disease activity between flares. IL-13 levels closely correlate with both disease severity and chronicity, and its direct role in itch signaling makes it a key therapeutic target in AD.Differences among IL-13–directed biologics were reviewed, including dupilumab, which blocks IL-4 and IL-13 signaling via IL-4Rα, and the IL-13 - specific agents tralokinumab and lebrikizumab, which bind distinct sites on the IL-13 cytokine. Notably, lebrikizumab demonstrates substantially higher binding affinity for IL-13 and offers dosing flexibility, with data supporting every-four-week and even extended every-eight-week maintenance dosing in select patients. Age approvals also vary, with dupilumab approved down to infancy, while tralokinumab and lebrikizumab are approved for adolescents and adults.The session addressed real-world management challenges, including treatment switching. Data from the ADapt trial showed that patients discontinuing dupilumab due to ocular or facial adverse events experienced effective disease control after switching to lebrikizumab without recurrence of those side effects. Emerging evidence also suggests JAK inhibitors may be particularly helpful for resolving dupilumab-associated ocular and facial inflammation. Looking ahead, several next-generation IL-13 - targeted therapies, including trispecific agents, are in development, signaling continued refinement of precision therapy in AD.

Matthew Vesely, MD delivered a focused update on the rapidly evolving treatment landscape for immunobullous diseases, emphasizing that bullous pemphigoid (BP) has firmly entered the targeted-therapy era. BP, driven by IgG and IgE autoantibodies against BP180 and BP230, is now treated with biologic agents that more precisely address type 2 inflammation. A major milestone is the FDA approval of dupilumab in June 2025, which blocks IL-4 and IL-13 signaling and achieved disease control in nearly 90% of patients within four weeks. Additional targeted options such as omalizumab, particularly effective in IgE-mediated disease, along with IL-13 inhibitors and JAK inhibitors, are expanding steroid-sparing strategies for BP management.In contrast, pemphigus remains more challenging than anticipated. Rituximab continues to be the cornerstone of therapy, with long-term data confirming superior remission rates compared with corticosteroids alone. Encouraging studies of ultralow-dose rituximab suggest similar efficacy with potentially improved safety. However, the session also addressed recent setbacks, noting the failure of phase 3 trials for efgartigimod and rilzabrutinib, leading to discontinuation of development for pemphigus. Looking ahead, Dr Vesely highlighted emerging precision approaches, including deeper B-cell–directed therapies such as daratumumab and investigational cellular therapies, with the ultimate goal of biomarker-driven maintenance to prevent relapse. While not yet ready for routine practice, these advances signal continued progress toward more personalized care in immunobullous disease.

Neal Bhatia, MD opened by underscoring the growing global burden of non-melanoma skin cancer (NMSC), which now causes more annual deaths than melanoma. Because the vast majority of invasive squamous cell carcinomas arise from background actinic damage and clinicians cannot predict which individual AK will progress, he emphasized a proactive field-treatment strategy rather than lesion-by-lesion destruction. Advances in topical therapy support this approach, including tirbanibulin 1% ointment, now approved for larger treatment fields and shown to induce apoptosis with less inflammation, and combination calcipotriol plus 5-fluorouracil, which enhances antitumor immunity and significantly lowers long-term SCC risk.Photodynamic therapy (PDT) remains a highly effective field treatment, with pivotal studies of 10% ALA gel plus red light demonstrating durable clearance rates exceeding 80% at 12 months. Expanded FDA approval now allows treatment of larger surface areas with excellent tolerability, and PDT continues to show strong efficacy in facial SCC in situ and superficial basal cell carcinoma. Dr Bhatia addressed common barriers to PDT adoption, particularly treatment-related pain, sharing practical mitigation strategies such as cooling measures, antihistamines, anxiolytics, and emerging short-contact protocols that preserve efficacy while improving patient comfort, especially on the face.The session concluded with pragmatic office pearls, including structuring PDT as a dedicated service line with streamlined scheduling, seasonal timing considerations, and appropriate CPT coding when clinicians directly administer therapy. Dr Bhatia emphasized that when used thoughtfully, PDT is not only an effective AK treatment but also a powerful preventive tool against future skin cancer.

Hadar Lev-Tov, MD reframed the management of severe hidradenitis suppurativa (HS) by cautioning against the common “beginner error” of relying on single-agent therapy. HS is a multifactorial disease driven by follicular occlusion, rupture, chronic inflammation, and sinus tract formation, requiring clinicians to address multiple disease drivers simultaneously. Effective management often involves combination therapy that integrates medical treatments such as antibiotics, biologics, and hormonal agents with procedural interventions, intralesional steroids, antiseptic washes, and laser or surgical approaches to achieve meaningful disease control.For patients with Hurley stage II or III disease, Dr Lev-Tov highlighted the role of specialized inpatient care to disrupt the vicious cycle of recurrent flares and emergency department visits. Data demonstrate that dermatology-led admissions significantly reduce length of stay compared with internal medicine services and facilitate earlier initiation of biologic therapy after discharge. He also stressed the importance of correctly defining disease flares, noting that true flares represent measurable increases in inflammatory lesions rather than slow or incomplete response to therapy, and emphasized setting realistic expectations and appropriate follow-up intervals early in care.Procedural excellence was highlighted with deroofing as a tissue-sparing option for selected lesions, showing high patient satisfaction and durable non-recurrence rates. Additional considerations included addressing patient-driven dietary modifications, acknowledging limited HS-specific evidence, and incorporating clinical trial enrollment early in the treatment course. Dr Lev-Tov concluded that successful HS management requires coordinated, aggressive, and individualized care to achieve durable improvement in this challenging patient population.

Daniela Kroshinsky, MD, MPH delivered a comprehensive clinical update on the diagnosis and management of lichenoid diseases, including lichen planus (LP), lichen planus pigmentosus (LPP), and immune checkpoint inhibitor–associated lichenoid eruptions. Dr Kroshinsky reviewed the heterogeneity of LP subtypes and emphasized the importance of evaluating for mucosal involvement, which can occur in a majority of patients with cutaneous disease and may carry risks such as dysphagia, strictures, and squamous cell carcinoma.Systemic treatment options for refractory LP were highlighted, with particular focus on emerging data for Janus kinase (JAK) inhibitors and oral apremilast. Evidence from a systematic review of 56 patients demonstrated that JAK inhibitors produced clinical responses within days to weeks across LP subtypes, though patient selection remains important given reported risks of venous thromboembolism, cardiovascular events, malignancy, and serious infection. A pilot study of apremilast in moderate-to-severe cutaneous LP showed improvement in all treated patients by 12 weeks, with headaches and nausea identified as the most frequent adverse effects. Traditional systemic agents, including cyclosporine, were also reviewed as effective options with rapid onset when appropriately dosed and monitored. Dr Kroshinsky also addressed management strategies for lichenoid eruptions associated with immune checkpoint inhibitors, which can occur in up to 17% of patients receiving immunotherapy. Long-term systemic corticosteroids were discouraged due to potential attenuation of antitumor efficacy, with low-dose methotrexate and systemic retinoids identified as commonly used nonsteroidal maintenance therapies. Emerging biologic options were discussed with emphasis on using the most targeted therapy possible to limit broader immune suppression. The presentation concluded with therapeutic updates for LPP, underscoring the importance of early intervention and reviewing data supporting isotretinoin, oral tranexamic acid, and low-fluence Q-switched Nd:YAG laser toning as treatment options for stable disease.

Todd Schlesinger, MD emphasized that optimal reconstruction begins before the first incision, with careful attention to tissue mechanics and wound tension. He highlighted practical techniques such as identifying lines of maximal extensibility rather than relying solely on relaxed skin tension lines, maintaining closure tension below 4 N/cm to prevent hypertrophic scarring, and strategic undermining to preserve perforator vessels. Flap refinements, including the use of M-plasty at pivot points, were presented as effective methods to improve reach and reduce contour deformities, while advanced suturing techniques such as the set-back dermal approach were shown to offload tension and promote durable eversion.The session also addressed situations in which grafts offer advantages over flaps, particularly in cosmetically sensitive areas or medically complex patients. Key pearls included epidermal fenestration to prevent graft lift-off and the use of vacuum-assisted bolsters during the critical first 72 hours to support graft imbibition. Postoperative scar optimization strategies were reviewed, including prolonged taping for mechanical support and proactive counseling that scar maturation may take up to 18 months, helping to align patient expectations with normal wound biology.Beyond reconstruction, Dr Schlesinger stressed the importance of integrated oncologic planning. Surgeons were cautioned against operating first in advanced disease, instead coordinating neoadjuvant systemic therapy or radiation when appropriate and using immunostains for precise melanoma margin assessment. Regulatory updates on skin substitutes and the role of adjuvant photodynamic therapy for surrounding actinic damage further reinforced a comprehensive, multidisciplinary approach to skin cancer management.

April W. Armstrong, MD, MPH, Editor-in-Chief of Dermatology Online Journal, presented a curated review of notable and high-interest articles recently published in Dermatology Online Journal and SKIN, highlighting atypical case reports and emerging therapeutic approaches for refractory dermatologic conditions. Dr Armstrong emphasized how these publications surface early clinical insights and practical lessons that can inform real-world dermatology practice.The presentation featured several complex diagnostic cases drawn from recent publications, including a pediatric patient with painful facial ulcers initially resembling pyoderma gangrenosum who was ultimately diagnosed with granulomatosis with polyangiitis after biopsy and imaging, underscoring the importance of reconsidering diagnoses in refractory ulcerative disease. Additional cases included Parry Romberg syndrome presenting as progressive facial atrophy, with complete cutaneous resolution reported following treatment with upadacitinib. Together, these cases illustrated how uncommon diseases may present subtly and evolve over time, requiring reassessment when standard therapies fail.Dr Armstrong also highlighted published case reports describing off-label use of targeted therapies, particularly Janus kinase inhibitors, across a range of inflammatory and immune-mediated conditions. Examples included reports of abrocitinib for localized granuloma annulare, upadacitinib for pyoderma gangrenosum and drug-induced subacute cutaneous lupus erythematosus, as well as ivermectin for childhood granulomatous periorificial dermatitis refractory to conventional therapy. Emerging topical approaches were also reviewed, including roflumilast cream for cutaneous lichen planus in patients with limited tolerance for topical corticosteroids. Collectively, these articles highlight how peer-reviewed case literature can expand therapeutic considerations for rare and treatment-resistant disease.

Mark D. Kaufmann, MD delivered a detailed analysis of the economic realities facing dermatology in 2026, focusing on reimbursement trends, inflation, and key CPT coding updates that directly affect clinical practice. Dr Kaufmann emphasized that although demand for dermatologic care continues to grow, declining Medicare reimbursement, particularly when adjusted for inflation, represents one of the most significant threats to the sustainability of independent practices.A central theme of the presentation was the long-term erosion of physician payment. Dr Kaufmann reviewed data showing that the Medicare physician conversion factor in 2026 remains lower than levels seen more than two decades ago, translating to a substantial inflation-adjusted decrease in reimbursement. He highlighted how common dermatologic procedures, including Mohs surgery and destruction of premalignant lesions, have experienced significant real-dollar payment declines over time. The presentation also outlined important 2026 coding updates, including the removal of the term “acne surgery” in favor of CPT 10040 for extractions, new restrictions on ultrasound image guidance billing for superficial radiation therapy, and updated payment rates for skin substitute products. Utilization challenges were also discussed, including overestimation of the complexity add-on code G2211.Dr Kaufmann concluded by emphasizing that while the need for high-quality dermatologic care will persist, practice models must evolve to remain financially viable. He encouraged clinicians to move beyond basic billing practices by fully understanding the fee schedule, appropriately applying complexity codes when assuming ongoing care, and leveraging medical billing strategies such as buy-and-bill models to help offset continued reimbursement pressure.

Roger I. Ceilley, MD presented an update on advances in sunscreen technology, focusing on emerging strategies that go beyond ultraviolet (UV) blocking to address cumulative photodamage. Dr Ceilley reviewed data from a 12-week clinical study evaluating a tinted mineral-based SPF50 sunscreen formulated with photolyase, antioxidants, and peptides, highlighting the concept of combining photoprotection with active DNA repair support in daily practice.The pilot study included 20 adults with Fitzpatrick skin types II–IV who applied the sunscreen daily for 12 weeks. Investigator assessments demonstrated progressive aesthetic improvement, with over half of participants showing improvement by Week 6 and more than 80% by Week 12 based on the Investigator Global Aesthetic Improvement Scale. Patient-reported outcomes mirrored these findings, with a majority reporting improved skin appearance over the study period. Statistically significant improvements were also observed in skin radiance, overall facial aesthetics, and skintone evenness, as measured by standardized grading scales.Dr Ceilley emphasized that while endogenous DNA repair mechanisms exist, they may be insufficient to fully counteract ongoing UV exposure. The study supports the role of sunscreens that incorporate photolyase, antioxidants, and peptides as well-tolerated daily options that both protect against UV radiation and address visible signs of photoaging. These findings highlight an evolving approach to photoprotection that integrates prevention and repair within a single topical formulation.