The Spot Check

A biopsy is only as useful as the tissue you send, and information that travels with it. In this episode of The Spot Check, Jamie Restivo, PA-C, is joined by dermatologist and dermatopathologist John Griffin, MD, for a practical look at what happens between the clinic and the microscope, and how more thoughtful biopsy technique can lead to clearer answers when the diagnosis is anything but straightforward.  Dr. Griffin starts with a deceptively simple question: where is the pathology? Thinking about whether a process lives in the epidermis, dermis, or deeper in the fat can change the type and depth of biopsy needed before the blade ever touches the skin. From autoimmune blistering disease and connective tissue disorders to vasculitis and alopecia, they work through the details that matter, including lesion age, biopsy depth, specimen selection, and occasions when one sample may tell a very different story.  They also take on some of the diagnoses that can be particularly difficult to capture. For suspected cutaneous T-cell lymphoma, Dr Griffin explains why multiple biopsies may be more important than choosing between a broad shave and punch alone, recent topical steroid use that can obscure the lymphocytes needed for diagnosis, and the reasons a more raised or indurated lesion may offer a better target. The conversation also moves through pigmented lesions and recurrent pigment within a scar, where knowing the history of a prior biopsy can materially change how the dermatopathologist interprets what is under the microscope.  But the larger lesson goes beyond biopsy technique. Dr. Griffin asks clinicians to think of the pathology requisition as a consultation, not a one-way lab order. A photograph, a precise description, a meaningful differential, or a phone call when the report does not fit the patient can all add context that histology alone cannot provide. As he puts it, the clinician sees patterns on the patient, and the pathologist sees patterns under the microscope. Getting to the right diagnosis often depends on making sure those two pictures line up. 

For years, topical nonsteroidals largely occupied a supporting role in inflammatory skin disease—the option between steroid courses or when steroids simply weren’t a good fit. Tapinarof has helped change that calculus.  In this episode of The Spot Check, Jamie Restivo, PA-C, sits down with dermatologist Nick Brownstone, MD, to look beyond the “steroid-sparing” label and into how he actually thinks about tapinarof in psoriasis and atopic dermatitis. They begin with its aryl hydrocarbon receptor mechanism and what Dr Brownstone calls its “triple threat”: modulation of inflammatory pathways, effects on the skin barrier, and antioxidant activity. From there, the conversation moves quickly into the decisions that matter once a prescription leaves the exam room.  What exactly are those follicular events described in the psoriasis trials, and should clinicians think of them as traditional infectious folliculitis? Why were contact dermatitis rates lower in the atopic dermatitis studies than might be expected? How does burning and stinging compare with older nonsteroidal topicals? And when one of these reactions does occur, what does it actually mean for treatment?  Perhaps most useful is the discussion of what happens after patients get clear. Dr Brownstone and Jamie unpack the treatment-free intervals observed in psoriasis and atopic dermatitis and how a treat-until-clear, stop, monitor, and restart-with-flare approach can change the conversation around chronic topical therapy. They close with the details that often determine whether any regimen succeeds at all: a thin layer, once-daily application, choosing a time that fits the patient’s routine, and counseling clearly enough that patients know what to expect without making treatment more complicated than it needs to be. 

The treatment can be clinically sound, thoughtfully selected, and clearly prescribed. But if the patient doesn’t use it, none of that matters. In this episode of The Spot Check, Jamie Restivo, PA-C, is joined by Steve Feldman, MD, PhD, to explore one of the most persistent challenges in dermatology—adherence, and the surprisingly powerful role human behavior plays in whether a treatment plan succeeds.  Drawing from behavioral economics, Dr Feldman explains why patients don’t always make decisions through the rational risk-benefit calculus clinicians might expect. Together, he and Jamie look at some of the most common barriers to adherence, including overly complex regimens, treatment discomfort, and the perception that a therapy simply isn’t working. Their discussion moves quickly from theory to practical application; simplifying topical regimens, anticipating issues before they cause a patient to stop treatment, and thinking carefully about how risk and expectations are framed.  But some of the most useful interventions may be much smaller. Medication placed on top of one’s socks or at the bedside can make treatment harder to overlook by tying it to an existing habit. A seven-day pill container removes the need to remember whether today’s dose was taken. Written instructions account for what Dr Feldman calls the “curse of knowledge,” the tendency for clinicians to underestimate how difficult even seemingly simple directions can be to absorb outside of the exam room. These environmental cues and habits can make treatment easier to remember and harder to ignore.  Underlying it all is a concept Dr Feldman returns to throughout the conversation, accountability. Trust between clinician and patient creates the foundation, but the expectation of follow-up may be what turns intention into action. Rather than simply handing over a prescription and reconnecting months later, even the anticipation of a check-in can change behavior. For clinicians managing chronic disease, it is a reminder that adherence may depend not only on what we prescribe, but on how we design the experience around it. 

Alopecia areata (AA) may be measured by the percentage of scalp hair loss, but the numbers don’t tell a full story. A patient with limited visible involvement may still be experiencing profound changes in confidence, relationships, identity, and daily life.  In this episode of The Spot Check, Jamie Restivo, PA-C, is joined by Matthew Brunner, PA-C, for a walk through the alopecia areata patient journey, from initial assessment and treatment selection to baseline testing, follow-up, and long-term management with deuruxolitinib (Leqselvi).  Brunner begins with the SALT score, explaining how it gives clinicians an objective way to quantify scalp hair loss and track response over time. But severity should also account for rapid progression, eyebrow or eyelash involvement, previous treatment response, and psychosocial burden. Alopecia areata is not cosmetic. It’s a chronic autoimmune disease that can disrupt a patient’s fundamental sense of self.  When considering a JAK inhibitor, Brunner recommends moving beyond a rigid treatment ladder. Patient goals, medical history, comorbidities, reproductive plans, previous therapies, and tolerance for risk all belong in the discussion. Counseling should be deliberate, not rushed. “This isn’t a conversation you have standing with your patient,” he says.  The episode also gets into the practical details of starting deuruxolitinib, including baseline labs, tuberculosis and viral hepatitis screening, vaccination status, pregnancy considerations, lipid monitoring, and the CYP2C9 genotype testing required before treatment. Brunner then outlines his approach to follow-up, using SALT scores, photography, adherence checks, and subtle signs of improvement such as fine vellus hairs, reduced shedding, or early eyebrow and eyelash regrowth.  Just as important is preparing patients for the pace of treatment. “This is a marathon, it’s not a sprint,” Brunner says. Meaningful regrowth may take months, and improvement doesn’t mean the disease has been cured.  From patient selection and safety counseling to the first signs of response, this episode provides a grounded framework for treating alopecia areata earlier, monitoring it thoughtfully, and helping patients stay the course.   Disclaimer: This episode of The Spot Check is supported by an industry sponsor. Topic areas and guest participation may be informed by sponsor interest. The sponsor may have had the opportunity to review the content for medical accuracy; however, the clinical discussion and opinions expressed are those of the host and guests.  This program is intended for health care professionals and is provided for educational purposes only. It should not be interpreted as medical advice. Clinicians are responsible for reviewing prescribing information and applying independent clinical judgment within their scope of practice. 

Sunscreen counseling may have once been simple, but the work has become a bit more complex. These days, patients come in with many great questions. What does “sensitive skin” really mean? Is baby sunscreen different? Do sprays work? Are mineral sunscreens safer? What about vitamin D, sunscreen absorption, and “clean” beauty claims?  In this episode of The Spot Check, Jamie Restivo, PA-C, is joined by Zoe Diana Draelos, MD, one of dermatology’s leading voices in photoprotection, cosmetic science, and skin care research, for a practical, myth-clearing conversation on sunscreen science and patient counseling.  Dr Draelos begins by decoding the language patients see on sunscreen labels. “Sensitive skin on a sunscreen label means absolutely nothing,” she explains, from a regulatory standpoint, though many products marketed this way tend to rely on mineral filters such as zinc oxide and titanium dioxide and may undergo sensitive skin panel testing. Baby sunscreen, she adds, is also more about marketing and store placement than a distinct formulation category.  The conversation moves from labels to what actually happens when patients use sunscreen. Most sunscreen failures are not failures of the product but failures of application, like too little product, skip areas, lack of a continuous film, water exposure, rubbing off, sweating, and missed reapplication. Spray sunscreens require particular care, too. Spray sunscreens require particular care, too. The practical takeaway is clear: spray, rub, spray, rub, spray, rub to build an even, protective layer.  The episode also tackles SPF selection, reapplication, mineral versus chemical filters, tinted sunscreens, eye irritation, vitamin D concerns, and ingredient safety. Higher SPF provides a greater margin of error because “no one ever applies a sunscreen optimally,” she says. And when patients worry that sunscreen prevents vitamin D production, she recommends checking levels and using oral supplementation rather than relying on sun exposure.  Finally, they discuss the FDA approval of bemotrizinol, the first new sunscreen filter approved in the U.S. in more than 25 years. Photostable, broad spectrum, and already used globally, bemotrizinol may help usher in a new era of sunscreen formulation in the United States.  From marketing claims to real-use counseling, this episode gives dermatology clinicians practical language and clinically grounded pearls to help patients choose, apply, and actually use sunscreen more effectively.