Derms and Conditions

In this episode of Derms and Conditions, host James Q. Del Rosso, DO, delivers a solo “Spilling the Tea” segment exploring clinical observations that may warrant a closer look. He examines dermatomyositis findings that can mimic more common conditions, nuances in prescribing language, the importance of a thorough hidradenitis suppurativa (HS) examination, and an unexpected case of rhabdomyolysis, highlighting details that can change how clinicians approach diagnosis and patient management.

Dr Del Rosso begins with scalp pruritus as a potential manifestation of dermatomyositis. He reviews images showing how scalp involvement may resemble seborrheic dermatitis or psoriasis, with findings such as erythema, scaling, and hair thinning. He also examines nailfold changes, including prominent capillaries, capillary dropout, and abnormal cuticles, that can provide additional diagnostic clues. Recognizing these findings is particularly important given the potential systemic implications of dermatomyositis.

The discussion then turns to limitations of use in prescribing information stating that certain therapies are “not recommended” in combination with other agents. Dr Del Rosso distinguishes this language from a formal contraindication and discusses the importance of understanding the evidence behind labeling when making treatment decisions.

In HS, he emphasizes the value of a complete skin examination, including areas patients may initially be reluctant to expose. Assessing and palpating lesions can help distinguish active inflammatory findings, including abscesses, nodules, and draining tunnels, from established fibrotic or scarred disease.

Finally, Dr Del Rosso shares the case of a 42-year-old woman receiving JAK inhibitor therapy who developed markedly elevated creatine kinase and rhabdomyolysis. Although her medication presented one possible explanation, further investigation revealed that she had gone several weeks without levothyroxine for hypothyroidism, another potential contributor. The case illustrates the importance of considering the full clinical picture when evaluating an unexpected finding or adverse event.

Tune in to the episode for clinical observations that encourage a closer look at what may initially seem straightforward, from recognizing less familiar disease presentations and interpreting prescribing information precisely to conducting a thorough examination and considering multiple explanations for an unexpected finding.

In this episode of Derms and Conditions, host James Q. Del Rosso, DO, welcomes Andrea Murina, MD, to discuss the early recognition and management of scarring alopecias. Their conversation explores why these conditions can be missed in their earliest stages, the clinical clues that help distinguish scarring from nonscarring alopecias, and approaches to diagnosis and treatment aimed at preventing permanent hair loss.

Dr Murina reflects on how outdated perceptions that little could be done once scarring occurred motivated her to focus on these conditions. She explains that recognizing patients earlier in the disease course provides an opportunity to intervene before irreversible follicular destruction develops, setting the stage for a discussion of the timing, patterns, and diagnostic tools that support earlier diagnosis.

They review the major categories of cicatricial alopecia, highlighting the relative ease of identifying neutrophilic disorders such as folliculitis decalvans and dissecting cellulitis, while noting that early lymphocytic disorders such as central centrifugal cicatricial alopecia (CCCA) and frontal fibrosing alopecia may initially resemble more common nonscarring conditions.

Dr Murina next overviews the value of trichoscopy. She explains how dermatoscopic findings, including perifollicular scale, telangiectasias, follicular plugs, and changes in hair diameter, can help distinguish scarring from nonscarring alopecias, guide biopsy decisions, and improve biopsy yield by identifying the most inflamed follicles for sampling.

The episode also reviews treatment strategies for common scarring alopecias. For CCCA, Dr Murina typically begins with topical and intralesional corticosteroids, adding doxycycline and antifungal shampoos when appropriate. For lichen planopilaris, she follows a similar approach while incorporating systemic therapies such as hydroxychloroquine, finasteride, or dutasteride. The discussion concludes with discoid lupus erythematosus, where she emphasizes that early treatment with high-potency topical and intralesional corticosteroids, along with appropriately dosed hydroxychloroquine, can produce meaningful improvement.

Tune in to the episode to hear Dr Del Rosso and Dr Murina share diagnostic pearls, trichoscopic clues, biopsy strategies, and treatment approaches that can help clinicians identify scarring alopecias earlier and intervene before permanent hair loss occurs.

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.