Derms and Conditions

In this episode of Derms and Conditions, host James Q. Del Rosso, DO, welcomes Joshua Burshtein, MD, chief dermatology resident at the University of Illinois Chicago, to discuss their recent Journal of Clinical and Aesthetic Dermatology publication, Topical Prescription Therapy for Psoriasis: An Expert Position Paper on Limitations of Published Guidelines and Treatment Selection with Updated Recommendations. Their conversation examines the intended role of clinical practice guidelines, the limitations that emerge as therapeutics evolve, and why clinician judgment remains central to individualized psoriasis care.

They begin by defining what treatment guidelines are intended to accomplish: to provide an evidence-based framework for clinicians rather than a rigid set of rules. Dr Burshtein notes that although the paper focuses on topical psoriasis therapies, many of its core principles apply broadly across dermatology, particularly as rapid therapeutic advances challenge the ability of clinical guidelines to remain current.

Dr Del Rosso discusses the downstream effects of this disconnect, noting that guidelines are often treated as mandates by third-party payers despite disclaimers stating that they should not replace clinician judgment. The speakers emphasize that treatment decisions should remain patient-centered, with clinicians, insurers, and manufacturers all contributing to timely access to appropriate care.

They also explore additional limitations of clinical guidelines, including differences in methodology among organizations and the inability of any single document to encompass every available therapy. The discussion concludes with the importance of recognizing bias in guideline development while reinforcing that treatment selection should be guided by clinical evidence, physician expertise, and shared decision-making with the patient.

Tune in to the full episode to hear Drs Del Rosso and Burshtein discuss the evolving role of clinical guidelines, their limitations in everyday practice, and why individualized clinical judgment remains essential to psoriasis care.

In this episode of Derms and Conditions, host James Q. Del Rosso, DO, welcomes Jason Hawkes, MD, MS, for a special Tea with Dr. D edition exploring the immunology that underpins inflammatory skin disease and how a deeper understanding of cytokine biology can inform clinical decision-making.

The discussion begins by challenging the common tendency to classify diseases according to a single "dominant" cytokine or immune pathway. Drs Del Rosso and Hawkes emphasize that while frameworks such as type 1, type 2, and type 3 inflammation are valuable for organizing complex biology, they should be viewed as conceptual models rather than rigid categories, as immune responses are dynamic, overlapping, and highly interconnected.

Using a series of educational slides, Dr Hawkes reviews how naïve T cells differentiate into distinct immune responses after interacting with antigen-presenting cells within the lymph node. He highlights 3 key cytokines that help clinicians remember the major pathways driving differentiation: IL-12 for type 1 inflammation, IL-4 for type 2 inflammation, and IL-23 for type 3 inflammation. These regulatory cytokines shape downstream immune responses that ultimately contribute to diseases such as atopic dermatitis and psoriasis.

A major focus of the episode is the distinct but complementary roles of IL-4 and IL-13 in type 2 inflammation. Dr Hawkes explains why IL-4 serves as the critical regulator of type 2 immune differentiation, functioning within the lymph node to establish the broader immune response, while IL-13 plays a prominent role within peripheral tissues, particularly the skin. He also addresses the misconception that higher tissue expression necessarily indicates greater biologic importance, noting that cytokines often exert profound effects despite relatively low expression levels.

Throughout the discussion, the speakers reinforce that cytokines should not be viewed in isolation. Their overlapping and synergistic effects help explain why patients can present with different clinical manifestations despite sharing common inflammatory mechanisms. Ultimately, the goal is not to identify a universally superior therapeutic target, but to understand each patient's disease biology well enough to select the therapy that best matches their clinical presentation.

Tune in to the full episode to learn more about the foundations of type 1, type 2, and type 3 inflammation, the distinct roles of key cytokines in immune regulation and tissue disease, common misconceptions surrounding cytokine biology, and how a stronger understanding of immunology can support more personalized treatment decisions in everyday dermatology practice.

In this episode of Derms and Conditions, host James Q. Del Rosso, DO, welcomes E. James Song, MD, for a discussion of the IL-23 pathway and its enduring role in psoriasis management. Although therapeutic options continue to expand, IL-23 remains a central target because of its key role in the IL-23/Th17 axis, one of the primary drivers of psoriatic disease.

Dr Song reviews the current IL-23 therapeutic landscape, comparing available agents that target the pathway through different mechanisms. He highlights important distinctions among therapies, including dosing intervals, molecular characteristics, binding affinity, and immunogenicity, while emphasizing that all have demonstrated strong efficacy and favorable safety profiles. The conversation also explores how these pharmacologic differences do—and do not—translate into meaningful clinical differences.

The conversation also explores patient access, with Drs Del Rosso and Song discussing how route of administration and insurance coverage can significantly influence treatment selection, particularly for Medicare beneficiaries. They examine the practical advantages of health care provider-administered therapy, including more reliable treatment delivery, closer patient follow-up, and reduced financial barriers for some patients.

The discussion also addresses expectations for treatment response, emphasizing that IL-23 inhibitors may require more time than other biologic classes to achieve maximal benefit. Dr Song shares practical insights into assessing early improvement, counseling slower responders, and supporting long-term treatment persistence.

The episode concludes with a review of the safety profile of IL-23 inhibitors, including their role in psoriasis with peripheral psoriatic arthritis, while discussing areas where these therapies remain more limited, such as axial disease and uveitis.

Tune in to the full episode to learn more about the IL-23 pathway, the similarities and distinctions among available therapies, practical access considerations, and setting realistic expectations for treatment response in everyday psoriasis care.

In this episode of Derms and Conditions, host James Q. Del Rosso, DO, welcomes Alexandra Golant, MD, for a discussion on the evolving role of topical therapies in atopic dermatitis (AD). While systemic therapies have transformed care for patients with moderate to severe disease, this discussion explores how topical treatments remain essential, not only for managing flares but also for maintaining long-term disease control.

Dr Golant reflects on how the topical treatment landscape has changed over the past several years. After decades in which topical corticosteroids remained the cornerstone of therapy, recent advances have introduced multiple nonsteroidal options with distinct mechanisms of action and improved suitability for chronic, proactive management.

The conversation explores where topical corticosteroids continue to fit in modern AD management. Rather than viewing steroids as obsolete, Dr Golant advocates for a balanced approach that considers efficacy, access, and appropriate stewardship. She emphasizes that corticosteroids remain valuable for short-term use but encourages clinicians to transition thoughtfully to nonsteroidal therapies when appropriate.

Dr Del Rosso and Dr Golant also review the expanding range of nonsteroidal topical therapies, including JAK inhibitors, PDE4 inhibitors, and the first-in-class aryl hydrocarbon receptor (AhR) agonist, tapinarof. Because AhR agonism represents an unfamiliar mechanism for many clinicians, Dr Golant explains how activation of this pathway not only reduces inflammatory signaling but also supports skin barrier function and antioxidant activity, helping address multiple aspects of AD pathophysiology.

The discussion also examines emerging clinical experience with tapinarof in AD, including its once-daily dosing, favorable safety profile, and potential to provide durable disease control in some patients. Dr Golant highlights the importance of challenging outdated assumptions that nonsteroidal therapies are slower or less effective than topical corticosteroids, noting that newer agents can achieve meaningful improvements in itch and skin clearance while providing flexibility for long-term management.

Tune in to the full episode to hear Drs Del Rosso and Golant discuss how they incorporate modern topical therapies into real-world AD management, where corticosteroids still have an important role, and why advances in nonsteroidal treatments are changing the way clinicians approach both acute flares and long-term disease control.

In this episode of Derms and Conditions, host James Q. Del Rosso, DO, welcomes Walter Liszewski, MD, for a discussion on the role of patch testing in patients with atopic dermatitis (AD), from the fundamentals of testing and interpretation to its application in patients with persistent or incomplete responses to therapy.

Dr Liszewski explains why allergic contact dermatitis is frequently overlooked in dermatology practice and how it commonly overlaps with AD and irritant contact dermatitis. Because these conditions often appear clinically similar, Dr Liszewski explains that, unlike AD or irritant contact dermatitis, allergic contact dermatitis has a diagnostic test available, making patch testing an important tool when the underlying cause of eczema is uncertain.

The conversation explores when patch testing should be considered in light of the absence of formal guidelines, with Dr Liszewski sharing his practical approach to identifying patients who may benefit from testing and how it can fit into the management of patients who continue to experience residual eczema despite advanced therapies. He also discusses the different reasons biologic-treated patients may have persistent disease and how patch testing can help distinguish allergic contact dermatitis from a more complex inflammatory phenotype.

Dr Liszewski reviews practical considerations for preparing patients for patch testing, including which medications should be discontinued beforehand and which can generally be continued. He explains why he typically does not stop biologic therapy before testing, while outlining situations in which temporary interruption may be appropriate. The discussion also covers newer molecular testing that may provide additional information in difficult cases and introduces the "paraben paradox," an important concept illustrating how impaired skin barrier function can influence allergic responses.

Tune in to the episode to gain a clearer understanding of when patch testing should be considered in patients with AD, learn how to approach patients with persistent or partial treatment responses, and learn practical considerations for preparing patients and optimizing test accuracy.