Derms and Conditions

In this episode of Derms and Conditions, host James Q. Del Rosso, DO, welcomes back Jason Hawkes, MD, MS, for the second installment of their discussion on the “cytokine soup” underlying inflammatory skin diseases. Building on their previous conversation about type 2 inflammation, they turn their attention to type 1 and type 3 inflammatory pathways, examining how these immune responses contribute to disease manifestations and influence therapeutic approaches. Dr Hawkes begins by clarifying the terminology surrounding T-helper cell populations and broader inflammatory pathways, including the distinction between Th1, Th2, and Th17 responses and type 1, type 2, and type 3 inflammation. He explains how immune cells develop distinct inflammatory profiles and why understanding the signals that drive these responses is increasingly important as targeted therapies continue to expand. The conversation then shifts to psoriasis, a prototypical type 3 inflammatory disease, and the complexities that arise when multiple inflammatory pathways contribute to a patient's clinical presentation. Dr Hawkes discusses how the immune mechanisms underlying plaque psoriasis may differ from those involved in psoriatic arthritis, helping explain why skin and joint responses to treatment do not always align. The clinicians also examine how differences in inflammatory pathways contribute to infection susceptibility in psoriasis and atopic dermatitis, as well as certain adverse effects associated with targeted therapies. Finally, Drs Del Rosso and Hawkes explore the immunologic diversity of psoriasis, from classic plaque disease to guttate, pustular, erythrodermic, and paradoxical presentations. They discuss how a better understanding of the inflammatory mechanisms underlying these distinct phenotypes may help explain variations in clinical presentation and response to treatment, bringing dermatology closer to more individualized therapeutic decision-making. Tune in to the episode for a clinically grounded discussion of inflammatory pathways, the relationship between immune signaling and disease manifestations, and why understanding the science behind targeted therapies can help dermatologists make sense of what they observe in everyday practice.

In this episode of Derms and Conditions, host James Q. Del Rosso, DO, welcomes Scott Elman, MD, to examine whether laboratory monitoring requirements for systemic dermatologic therapies reflect current evidence. With some prescribing recommendations rooted in data from more than a decade ago, the clinicians discuss where routine testing remains warranted, where it may be unnecessary, and how dermatologists can balance patient safety with the burden of excessive monitoring. Dr Elman begins by examining laboratory monitoring practices for atopic dermatitis therapies, highlighting important distinctions between biologics targeting IL-4, IL-13, and IL-31 and Janus kinase (JAK) inhibitors. While routine laboratory monitoring may offer limited clinical value for certain biologics, JAK inhibitors warrant a different approach given their safety profiles. He discusses the rationale for baseline screening and follow-up testing, while questioning the value of repeated testing in patients without changes in risk factors or exposure. The conversation then shifts to psoriasis, where recommendations for tuberculosis and hepatitis screening have historically been influenced by experience with tumor necrosis factor inhibitors. Dr Elman highlights emerging evidence and recent guidance challenging the need for routine tuberculosis testing with IL-17 and IL-23 inhibitors. The clinicians also clarify the distinction between hepatitis screening and liver function testing, emphasizing the importance of evaluating risk according to therapeutic class rather than applying uniform monitoring requirements. Beyond laboratory testing, Drs Del Rosso and Elman explore the value of interdisciplinary collaboration when managing patients with complex comorbidities, including inflammatory bowel disease. They discuss how coordination with other specialists can support treatment decisions without unnecessarily limiting therapeutic options. Tune in to the episode for a practical discussion of evidence-based laboratory monitoring, the potential consequences of unnecessary testing, and how individualized assessment, appropriate co-management, and attention to overall patient health can inform systemic treatment decisions in dermatology.

In this episode of Derms and Conditions, host James Q. Del Rosso, DO, welcomes E. James Song, MD, to discuss the clinical utility of narrowband UVB (NB-UVB) phototherapy and how advances in home-based devices are addressing longstanding barriers to its use. From psoriasis and vitiligo to atopic dermatitis and other inflammatory skin conditions, they examine where phototherapy fits into modern treatment strategies and how guided home-based treatment can expand access while reducing the burden on patients and practices.  Dr Song begins with an overview of the UV spectrum and why NB-UVB, particularly wavelengths of 311 to 313 nm, offers a favorable balance of therapeutic efficacy and tolerability. The discussion then turns to advances in home phototherapy technology, including a device that uses patient-reported responses to previous treatments to automatically calculate subsequent doses. Referencing findings from the LITE trial, which compared home-based and office-based phototherapy for psoriasis, the clinicians discuss the evidence supporting the safety, effectiveness, and improved treatment adherence associated with home use.  Beyond psoriasis, Dr Song highlights applications in atopic dermatitis, cutaneous T-cell lymphoma, and pruritic conditions, with particular emphasis on the underutilization of NB-UVB in vitiligo. He describes its potential to complement topical and systemic therapies, encouraging clinicians to consider phototherapy as an adjunct rather than an alternative to other treatment modalities.  The conversation also addresses practical considerations for incorporating home phototherapy into clinical care, including prescribing workflows, insurance coverage, and access for patients who live far from treatment centers. Drs Del Rosso and Song review important precautions involving photosensitizing conditions and medications, along with practical strategies for optimizing treatment response, including the use of emollients and adjustments to patient positioning.  Tune in to the episode for a closer look at how home-based NB-UVB phototherapy is changing the logistics of light-based treatment, the clinical scenarios in which it may be particularly valuable, and what dermatologists should know when incorporating it into patient care. 

In this episode of Derms and Conditions, host James Q. Del Rosso, DO, welcomes Cory Rubin, MD, for a candid look at the business of dermatology. Drawing on his experience building an independent practice, Dr Rubin discusses what it takes to move from clinician to practice owner, from the freedom to pursue new opportunities to the responsibility of leading a team, managing finances, and making decisions that extend far beyond patient care. Dr Rubin begins by sharing what motivated him to establish his own practice, including his interest in complex medical dermatology and clinical research and his desire for greater freedom to pursue those interests. He emphasizes that independence comes with significant responsibility: Practice ownership requires commitment, resilience, and a willingness to accept both the benefits and consequences of the decisions you make. The conversation turns to lessons Dr Rubin has learned as a leader. While clinical practice often rewards quickly identifying a problem and acting on it, he found that business decisions sometimes require slowing down, listening, and allowing time before choosing a course of action. He discusses the importance of consistency in setting expectations for staff, developing a strong workplace culture, and training PAs and NPs over time rather than expecting immediate independence. Drs Del Rosso and Rubin also explore the operational considerations of incorporating clinical research into a dermatology practice, including the need for appropriately trained research staff and clear separation of clinical and research functions. They close with Dr Rubin’s approach to structuring interactions with pharmaceutical representatives and his broader perspective on practice ownership as an ongoing process of adaptation and learning. Tune in to the episode for an inside look at the realities of building and running a dermatology practice, the lessons that come with leadership, and why setbacks can become some of the most valuable experiences for a practice owner.

In this episode, host James Q. Del Rosso, DO, welcomes dermatologist and rheumatologist Joseph Merola, MD, to discuss the diagnosis and management of dermatomyositis (DM). From subtle cutaneous clues and systemic involvement to malignancy risk, myositis-specific antibodies, and an expanding treatment pipeline, Dr Merola highlights what dermatologists should recognize when DM enters the differential. DM can present with classic findings such as Gottron papules, heliotrope rash, and the shawl sign, but other clues may be less obvious. Dr Merola discusses pruritic scalp disease, eyelid edema, linear extensor erythema, and nailfold capillary changes, as well as photodistributed eruptions that may be difficult to distinguish from cutaneous lupus. Beyond the skin, he outlines 5 areas to consider when evaluating patients with DM: cutaneous findings, muscle weakness, inflammatory arthritis, lung involvement, and malignancy. The conversation moves from clinical assessment to diagnostic workup, including evaluation of proximal muscle weakness, the importance of asking about dysphagia, and the role of CK and aldolase. Dr Merola also explains when EMG, MRI, or muscle biopsy may add value and when classic skin findings combined with weakness and/or elevated muscle enzymes may provide sufficient diagnostic information. Dr Del Rosso and Dr Merola also discuss malignancy risk and the clinical information provided by myositis-specific antibodies. Anti-TIF1γ and anti-NXP2 can signal greater malignancy risk, while anti-MDA5 is associated with clinically amyopathic disease and heightened concern for interstitial lung disease. Dr Merola considers how these findings can help inform risk assessment, screening, and collaboration with rheumatology and other specialties. Finally, they review the treatment of both cutaneous and muscle disease, from photoprotection and established systemic therapies to JAK inhibition and emerging targeted treatments. Dr Merola reflects on a growing therapeutic pipeline* for a disease in which cutaneous involvement, in particular, has historically been challenging to manage. Tune in to the episode for a clinically focused discussion of recognizing dermatomyositis, assessing systemic and malignancy risk, interpreting antibody profiles, and navigating treatment as new therapeutic options emerge. *This episode was recorded prior to FDA approval of brepocitinib. The FDA has since approved brepocitinib for use in the United States.