Derms and Conditions

In this episode of Derms and Conditions, host James Q. Del Rosso, DO, examines the pathophysiology of acne vulgaris, tracing how advances in our understanding of the disease have shaped treatment approaches. He reviews the four key components of acne development—sebum production, follicular hyperkeratinization, Cutibacterium acnes proliferation, and inflammation—with particular attention to the role of androgens in initiating the cascade of events that leads to acne lesion formation. Dr Del Rosso begins with a historical perspective on acne management, discussing how early treatment strategies focused primarily on reducing bacterial proliferation and follicular hyperkeratinization. He revisits the introduction of benzoyl peroxide, topical retinoids, and antibiotics, highlighting how subsequent research revealed additional mechanisms of action, including the direct anti-inflammatory properties of retinoids and tetracycline antibiotics. The discussion then turns to the role of the skin as an endocrine organ and its ability to locally produce androgens from circulating precursors. Dr Del Rosso explains how androgen receptor activation stimulates sebaceous gland activity, contributing to increased sebum production and creating conditions that favor Cutibacterium acnes proliferation and inflammation. Importantly, these processes can occur even in patients with normal circulating androgen levels. Building on these mechanisms, Dr Del Rosso considers how available therapies address different components of acne pathophysiology. He discusses the introduction of topical clascoterone, an androgen receptor inhibitor, as an opportunity to target the sebum-related component of acne development alongside established topical therapies. He also reviews the distinct role of oral isotretinoin and its effects across multiple pathogenic pathways. Tune in to the episode for a closer look at how the interconnected mechanisms of acne development inform treatment selection, the rationale for combining therapies with complementary mechanisms of action, and how this understanding can support discussions with patients about their treatment regimens.

In this episode of Derms and Conditions, host James Q. Del Rosso, DO, welcomes Vivian Shi, MD, to discuss the changing treatment landscape of hidradenitis suppurativa (HS), emerging therapeutic approaches, and the potential to transform long-term outcomes through earlier intervention. Reflecting on what she describes as a renaissance in HS care, Dr Shi discusses how the field has progressed from limited treatment options to an expanding therapeutic arsenal. Unlike psoriasis and atopic dermatitis, HS can leave irreversible scarring and structural skin damage even after inflammation is controlled. Dr Shi envisions a future in which earlier, more effective treatment may prevent patients from developing tunnels and other permanent sequelae, fundamentally changing the course of the disease. A central challenge, however, is recognizing when to intervene. Dr Shi advocates for reconsidering how moderate HS is defined, emphasizing that even a limited number of inflammatory lesions or a single tunnel may warrant escalation of therapy. She and Dr Del Rosso also examine the multiple barriers to timely care, from access to knowledgeable clinicians and specialists to medication approvals and surgical services. Looking ahead, Dr Shi highlights several promising therapeutic developments, including sonelokimab, an investigational IL-17A/F-targeting nanobody, and povorcitinib, an oral JAK inhibitor. She also discusses the potential of B-cell–targeted approaches and the importance of understanding HS as a heterogeneous disease that may ultimately require more individualized treatment strategies. Tune in to the episode to hear Dr Shi's perspective on the future of HS management, why redefining moderate disease could help clinicians identify opportunities for earlier intervention, and how an expanding therapeutic toolbox may bring the field closer to preventing irreversible disease progression.

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.