by Buchi Neita, PA-C, and Takeia Horton, PA-C
At the opening of the Elevate Derm 2025 Fall Conference in Tampa, FL, Hilary Baldwin, MD, Dermatologist and Medical Director of the Acne Treatment & Research Center in Brooklyn, NY, provided an in-depth review of keloids. Dr. Baldwin noted that keloids occur 15 times more frequently in individuals with richly pigmented skin, with common periods of onset including puberty and pregnancy.
Keloids vs. Hypertrophic Scars
Dr. Baldwin outlined key differences between keloids and hypertrophic scars. Keloids typically extend beyond the original area of injury, show predilection for the sternum, shoulders, jawline, and ears, exhibit a familial tendency, may arise years after the inciting injury, and rarely regress without intervention. In contrast, hypertrophic scars remain confined to the borders of the initial trauma, are often found across joints or areas of tension, present within three months of injury, lack a familial component, and tend to improve gradually over time.
When selecting treatment for keloids, Dr. Baldwin encouraged clinicians to consider multiple factors, including patient age, skin pigmentation, and the location, age, and size of the keloid. She also emphasized the importance of incorporating patient goals and their commitment level into the decision-making process. While some individuals desire complete eradication of the scar, others may prioritize symptomatic relief or reduction in the size of the scar.
Dr. Baldwin notes that intralesional (IL) corticosteroids remain a first-line option for keloids that are not ideal candidates for surgical intervention. She recommends the use of high-concentration triamcinolone acetonide (40mg/cc), citing its superior efficacy. Hypopigmentation is a frequently observed outcome and may, in some cases, serve as an indicator of therapeutic response rather than solely an adverse effect. She further reports that IL 5-fluorouracil (5-FU) may be an effective modality for keloid management, particularly when administered in combination with triamcinolone.
Data on IL cryotherapy demonstrates a scar-volume reduction of 51.4%, with lower rates of pain and recurrence compared with contact cryotherapy. For lesions requiring surgical excision, Dr. Baldwin strongly advocates for the use of adjunctive therapies to reduce recurrence risk. Adjuncts include postoperative IL corticosteroids, radiation therapy, and pressure dressings. Finally, Dr. Baldwin highlights reports indicating that both systemic and IL dupilumab (Dupixent, Sanofi and Regeneron) have shown promising efficacy in the treatment of keloids, representing a potential future therapy in keloid management.
Advances in Alopecia Management
Crystal Aguh, MD, a Dermatologist and Associate Professor at Johns Hopkins University in Baltimore, MD, presented an overview of recent advances in the management of alopecia. She began by reviewing topical minoxidil, which remains first-line therapy for androgenetic alopecia (AGA). Dr. Aguh emphasized the benefit of compounding minoxidil with retinoic acid, noting that retinoids may enhance minoxidil’s absorption and potentially improve treatment response. Next, she discussed oral minoxidil, which is increasingly used off-label for hair loss. Low doses are generally well-tolerated, ranging from 0.0625 to 2.5mg daily for women and 2.5 to 5mg daily for men.
Dr. Aguh reviewed the role of oral Janus kinase inhibitors (JAKi) in treating alopecia areata (AA), highlighting the three U.S. Food and Drug Administration (FDA)-approved therapies: baricitinib (Olumiant, Eli Lilly), ritlecitinib (Litfulo, Pfizer), and deuruxolitinib (Leqselvi, Sun Pharma). She noted that certain patient characteristics, such as longer disease duration and greater baseline severity, may predict a poorer response to therapy. Her discussion then shifted to scarring alopecias, including lichen planopilaris (LPP) and central centrifugal cicatricial alopecia (CCCA). She also addressed frontal fibrosing alopecia (FFA), a subtype of LPP that is becoming increasingly prevalent, particularly among individuals of higher socioeconomic status.
Dr. Aguh highlighted emerging evidence supporting the use of topical and oral JAK inhibitors for FFA, which may be effective as monotherapy. For CCCA, she underscored the association with insulin resistance (IR) and diabetes. She recommended routine metabolic screening and noted that patients with IR may benefit from topical metformin 10% applied twice daily or oral metformin 500mg extended-release daily as adjunctive therapy.
In her second lecture, Dr. Aguh shared several clinical pearls related to alopecia. She described the “downy hair sign,” a phenomenon observed in patients with autoimmune disease and afro-textured hair, in which the hair becomes noticeably softer with a diminished curl pattern. This textural alteration is often a marker of active inflammatory disease, and the original curl pattern may return once the underlying condition is adequately controlled.
Dr. Aguh also emphasized that although systemic illness can contribute to hair loss, clinicians frequently overestimate the role of minor variations in iron levels, Vitamin D levels, or thyroid function. She noted that these subtle laboratory abnormalities are rarely the primary drivers of alopecia in most patients. She highlighted that individuals with severe AGA have increased odds of underlying metabolic disease, a relationship likely influenced by Western dietary patterns characterized by high fat and high glycemic intake.
Dr. Aguh recommended screening for IR using the Homeostatic Model Assessment for Insulin Resistance (HOMA-IR). She explained that this approach helps identify patients with metabolic dysfunction who may otherwise appear normal on standard fasting glucose or hemoglobin A1c testing.
Rosacea and Acne Update
Dr. Baldwin presented an overview of rosacea in patients with skin of color, emphasizing that although the condition is not rare in this population, erythema can be more difficult to appreciate in darker skin tones, and misdiagnosis or underdiagnosis is common. She stressed the importance of maintaining a high index of suspicion, particularly when patients report symptoms such as burning, stinging, pruritus, or skin sensitivity. When selecting topical treatment for skin-of-color patients, Dr. Baldwin said it is important to consider vehicle selection to avoid drug-induced irritation and hyperpigmentation. Effective topical options include ivermectin 1% cream, minocycline 1.5% foam, and microencapsulated benzoyl peroxide 5% cream. For patients requiring systemic therapy, Dr. Baldwin recommended several oral agents, including modified-release doxycycline 40mg, low-dose extended-release minocycline 40mg, sarecycline, and isotretinoin for severe or refractory cases.
Finally, Dr. Baldwin stated that no rosacea visit is complete without a detailed skincare discussion. Appropriate skincare can improve signs and symptoms of rosacea and enhance the tolerability of prescription topical medications. She then addressed the inflammatory pathways involved in acne, emphasizing that subclinical inflammation precedes the formation of microcomedones. Dr. Baldwin noted that this inflammatory process persists throughout the entire life cycle of an acne lesion, contributing not only to lesion development but also to scarring, post-inflammatory erythema, and post-inflammatory hyperpigmentation.
Next, she discussed the evolving understanding of Cutibacterium acnes (C. acnes). Rather than viewing the organism solely as a pathogen, Dr. Baldwin highlighted the need to reframe the approach to C. acnes by recognizing the distinction between commensal strains and pathogenic strains that drive acne. Treatment strategies should aim to target pathogenic subtypes or support beneficial subtypes.
Dr. Baldwin concluded by reviewing several promising therapies in the acne treatment pipeline. These include DMT, a once-weekly topical agent derived from the freshwater sponge Spongilla; ASC40, a once-daily oral fatty acid synthase (FASN) inhibitor; and ORI-001, an investigational therapeutic acne vaccine.
Diagnosing and Treating CTDs
Julio A. Gonzalez-Paoli, MD, a Rheumatologist at Florida Medical Clinic Orlando Health in Tampa, FL, gave an in-depth presentation on lupus, dermatomyositis (DM), and other connective tissue disorders (CTDs). He reviewed the proper workup, evaluation, and biopsy findings for the most common CTDs. He highlighted the three different types of lupus and reinforced the fact that acute cutaneous lupus erythematosus (ACLE) has a high likelihood of conversion to systemic lupus (SLE), whereas chronic cutaneous lupus erythematous (CCLE) has a lower likelihood of conversion to SLE, especially in localized discoid lupus erythematosus (DLE).
His discussion also addressed medications associated with lupus manifestations. The most common culprits in drug-induced lupus include hydralazine, procainamide, isoniazid, minocycline, and tumor necrosis factor (TNF)-α, inhibitors. Drugs most likely to trigger subacute cutaneous lupus (SCLE) include hydrochlorothiazide, calcium-channel blockers, ACE inhibitors, proton pump inhibitors, and terbinafine. Importantly, antibodies against the Ro (or SSA) antigen (Anti-Ro/SSA) on the workup are associated with a 1–2% risk of developing atrioventricular block (AVB) in fetuses of positive mothers, and these patients should be connected with high-risk obstetrics and cardiology.
First-line treatment for lupus continues to be hydroxychloroquine (HCQ), and there are new options for advanced disease like anifrolumab (Saphnelo, AstraZeneca). For patients presenting with DM, he reinforced the importance of checking a myositis panel. Certain antibodies like MDA5/JO1 have a very high risk for rapidly progressive interstitial lung disease (ILD) and need pulmonary referral with baseline CT and pulmonary function tests (PFTs). Certain antibodies like TIF1/NXP2 are associated with a risk of malignancy and require age-appropriate cancer screenings and CT in the first two to three years along with gynecological evaluation.
The lecture ended with discussion of treatment options for DM, including HCQ, which is still the first-line treatment followed by rituximab, intravenous immunoglobulin (IVIG), and JAKi for skin and musculoskeletal disease.
Treating Psoriatic Disease
Dr. Gonzalez-Paoli also gave a presentation on psoriatic disease. He discussed the domains of psoriatic arthritis (PsA) to include axial disease, skin psoriasis (PsO), peripheral arthritis, nail lesions, dactylitis, and enthesitis. He provided suggestions on tests to order prior to rheumatology referral, including rheumatoid factor (RF), anti-CCP antibody, erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP), and x-rays of hands and feet in peripheral disease. For patients with axial disease, he recommended checking an HLAB27, ESR, CRP, and x-rays of the sacroiliac joint. For patients with spondylitis in PsA, treatment includes NSAIDs, anti-TNFα, JAKi, and interleukin (IL)-17 inhibitors. He stressed the importance of performing a joint examination in all patients with PsO. First-line treatment for PsO is IL-12/23 inhibitors, which have been shown to lower the risk of developing inflammatory arthritis. He also discussed future research focusing on incretin mimetics, glucagon-like peptide-1 (GLP-1) receptor agonists, and others.
Perspectives in Podiatric Dermatology
Larissa Schmidt, DPM, a Podiatrist at Celebration Foot & Ankle Institute in Kissimmee, FL, gave a lecture on the biomechanics in podiatric dermatology. She discussed how structural gait variations can create dermatological issues. Patients with flat feet often develop calluses due to abnormal pressure and friction. Management includes debridement, topical emollients or keratolytics, and offloading with pads, cushions, or structural inserts. For patients with mucoid cysts, Schmidt emphasized the importance of patient education, particularly discussing the high likelihood of recurrence and providing information on ways to prevent infection.
She also reviewed conservative management of hammertoes, including topicals, injectables (corticosteroids for arthritis and botulinum toxin for spasticity), and offloading with pads, cushions, or supportive inserts. Surgical options are available for advanced cases, and in rare situations, primary amputation may be required when both conservative and prior surgical treatments have failed. She advised obtaining x-rays before proceeding with any planned surgical intervention.
Schmidt returned with an informational session on nail disorders. She discussed onychomycosis and treatment options, including topicals and oral antifungals. While systemic agents are more curative, she advised that clinicians consider the patient’s overall health and comorbidities. She discussed nail dystrophies and categorized them by infectious (onychomycosis, pseudomonas, verrucae) or non-infectious (psoriasis, lichen planus, tumors, trauma).
She highlighted the key features of subungual hematomas and emphasized the importance of taking a thorough history to identify potential sources of nail trauma, such as long-distance running, improper shoe fit, and other repetitive traumas. Treatment options include needling, debridement, silicone toe protectors, and adjusting shoe size. Some subungual hematomas may require needling for acute pain relief. If the hematoma is severe, a patient may need nail avulsion, nail bed repair, and x-ray imaging to rule out fracture, as an open fracture may require antibiotic therapy. She reinforced that when treating a patient with recurrent ingrown toenails on the same foot, the differential should include persistent infection as well as tumors and other growths, and imaging is warranted for evaluation.
Exploring the Role of Diet in Eczema Care
Peter A. Lio, MD, Dermatologist and Clinical Assistant Professor of Dermatology & Pediatrics at Northwestern University Feinberg School of Medicine in Chicago, IL, presented on diet in eczema. He highlighted that although many families often view diet as central to atopic dermatitis (AD), strong evidence shows that routine elimination diets do not improve AD and can cause harm, including nutritional deficiencies and even increased risk of food allergy. Food allergies are associated with AD severity, especially in infants. However, 80% do not experience worsening of their AD due to food allergy.
Dr. Lio emphasized the barrier hypothesis, in which a compromised skin barrier represents an entry point for food sensitization. By treating the skin effectively and restoring the skin barrier, the risk of sensitization may be reduced. Instead of excluding foods, some interventions, including oolong tea, hempseed oil, L-histidine, Vitamin D, and probiotics (specifically, Lactobacillus and Bifidobacterium), show potential benefits.
Recognizing TSW
Dr. Lio delivered a lecture on the benefits and limitations of corticosteroids, emphasizing that while they offer rapid relief in AD, they may contribute to significant adverse effects when used improperly. He noted that systemic corticosteroids are no longer recommended for routine management of AD due to limited long-term efficacy and safety concerns. Dr. Lio reviewed current guideline recommendations from both the American Academy of Dermatology (AAD) and the Joint Task Force (JTF), which emphasize barrier repair, limited use of topical corticosteroids (TCS), topical non-steroidals, phototherapy, and systemic biologics or JAKi.
A major focus of his lecture was topical steroid withdrawal (TSW), a poorly understood but increasingly recognized adverse effect of TCS use, marked by confluent erythema, burning, stinging, and escalating steroid dependence, most often after prolonged use on the face or genitals. The first step in managing TSW is discontinuing steroid use, followed by phototherapy, dupilumab, and cyclosporine. He also discussed the utility of black tea compresses as an adjunctive therapy, especially for AD or TSW involving the face.
Challenging Cases in Alopecia
Victoria Rita Garcia-Albea, NP, Nurse Practitioner with Lahey Hospital & Medical Center im Burlington, MA, and Keri Holyoak PA-C, MPH, a Physician Assistant with the Dermatology Center of Salt Lake City in Midvale, UT, led a case-based discussion on advances in alopecia management and recognizing diagnostic challenges in hair loss. They noted that nail changes occur in up to 45% of children with alopecia areata (AA), with nail pitting being the most observed finding. There is limited benefit to lab workup. However, thyroid autoantibodies are detected in higher rates of patients with AA and are usually seen in more severe disease.
Pediatric patients with the highest risk of AA are those with concomitant Trisomy 21 or a first-degree relative with autoimmune thyroid disease. Emerging evidence has shown that allergic disease can promote AA in a subset of patients; studies have shown allergen desensitization may reduce the severity of AA in patients with dust mite and other allergies.
A randomized controlled trial of dupilumab showed improvement in patients with AA, with the highest responses in those with high IgE and concomitant AD. They presented updates on JAKi therapy in AA: 42.4% of patients on baricitinib achieved greater than 80% of scalp hair coverage; ritlecitinib showed durable efficacy through 36 months in both adolescents and adults; and Phase 3 trials of deuruxolitinib found that approximately one-third of patients achieved ≥80% scalp regrowth by Week 24.
Attendees also learned about cold-capping as an option to reduce chemotherapy-induced alopecia (anagen effluvium). Finally, the presenters emphasized the significant emotional burden in chronic alopecia, highlighting the importance of addressing quality-of-life (QOL) concerns. Patients may benefit from guidance on wig selection and navigating insurance coverage for cranial prostheses.
Identifying CSU in Practice
Pediatric and Adult Allergist Dareen D. Siri, MD, FAAAAI, FACAAI, FISAAI, of Midwest Allergy Sinus Asthma, SC, in Normal and Springfield, IL, educated the audience on the evaluation and management of urticaria and chronic spontaneous urticaria (CSU). She discussed key characteristics of acute urticaria, including transient wheals lasting less than 24 hours, their migratory and pruritic nature, and the notable lifetime prevalence, with approximately 15–20% of the general population experiencing urticaria at least once. CSU, defined as urticaria persisting for more than six weeks and occurring on most days of the week, is more common in adults and has a female predominance of approximately 2:1.
Dr. Siri mentioned that CSU has a significant impact on QOL and can be associated with comorbidities such as Hashimoto’s thyroiditis, mental health disorders, and chronic inducible urticaria (CIU). Recommended diagnostic tests include TSH thyroid-stimulating hormone (TSH) and thyroxine (free T4), mental health screenings, and provocation tests if CIU is suspected. Red flag signs that warrant further evaluation include lack of itch; presence of pain; inadequate response to high-dose antihistamines; timing of onset linked to foods, drugs, or exposures; and abnormal labs showing eosinophilia, monoclonal gammopathy, elevated inflammatory markers, or systemic symptoms (weight loss, fevers, joint swelling, myalgia, arthralgia, or bone pain).
Dr. Siri also spoke on the comprehensive patient history for allergy evaluations. She reiterated that the recognition of atopic stigmata, including Dennie–Morgan folds and keratosis pilaris, aids in identifying patients with a history of atopic disease, influencing both diagnosis and management of skin conditions. A key part of the examination includes morphology of skin lesions but also identifying signs of systemic disease such as fever and lymphadenopathy. Baseline lab workup was reviewed and includes complete blood count (CBC) with differential, total IgE levels, and serum immunoglobulins to identify deficiencies that may contribute to skin disease. If immunodeficiency is suspected, it is important to recognize critical warning signs such as frequent infections, poor wound healing, and low immunoglobulins, which raise the suspicion of primary immunodeficiency.
Advanced diagnostic procedures include skin biopsy, which is crucial for diagnosing vasculitis or bullous diseases, flow cytometry to assist in diagnosing cutaneous T-cell lymphoma (CTCL), and other immune dysregulations. Immunotherapy has emerged as a treatment option to desensitize the patient to the allergen and raise the reaction threshold. Management of CSU follows a stepwise approach, beginning with non-sedating H1 antihistamines at standard dosing, followed by dose escalation up to four times the standard dose when symptoms persist. For patients with inadequate control, the next step involves adding a biologic agent such as omalizumab or dupilumab, or initiating the newly approved selective oral Bruton tyrosine kinase (BTK) inhibitor, remibrutinib (Rhapsido, Novartis). In refractory cases, cyclosporine may be considered.
Vitiligo Treatment Strategies
Diego Ruiz Dasilva, MD, FAAD, Dermatologist at Forefront Dermatology in Virginia Beach, VA, and Buchi Neita, PA-C, Physician Assistant at Epiphany Dermatology in Peachtree City, GA, presented a practical overview of vitiligo, emphasizing that it is a chronic autoimmune disease with significant psychosocial impact rather than a cosmetic condition. They distinguished segmental vitiligo from non-segmental vitiligo, the more common immune-driven subtype associated with comorbidities such as hypothyroidism, AA, anemia, psoriasis, and type 1 diabetes. They suggested that diagnosis is largely clinical, aided by Wood’s lamp, with laboratory testing guided by symptoms rather than routine screening.
Treatment options discussed included TCS, topical calcineurin inhibitors (TCI), narrowband UVB (NBUVB) phototherapy, and the FDA-approved ruxolitinib, 1.5% cream (Opzelura, Incyte). Systemic steroids, namely pulse-dosed dexamethasone, may halt rapidly progressive disease. Emerging therapies, particularly oral JAKi such as upadacitinib and ritlecitinib, show promising results. Additional therapies include excimer laser, melanocyte transplantation, and adjunctive supplements such as polypodium leucotomos and ginkgo biloba. They concluded by emphasizing the importance of setting realistic expectations and offering treatment options to patients of all skin types, regardless of skin tone.
CHE Update
Lisa Weiss, PA-C, a Physician Assistant at Goodman Dermatology in Canton and Smyrna, GA, presented on chronic hand eczema (CHE). She discussed the epidemiology of CHE, which is more common in women and occurs in one-third of patients with a history of AD. Associated risk factors include occupations
involving “wet work” or frequent exposure to irritants/allergens, prior or current AD, asthma, or hay fever, and female sex. She emphasized that data suggest that 50% or more patients have mixed clinical subtypes, which adds to diagnostic and treatment challenges. Lifestyle factors such as smoking and stress are triggers that contribute to disease persistence and flares. Treatment options include trigger avoidance, emollients, TCS, TCI, and phosphodiesterase-4 (PDE4) inhibitors, and systemic agents including cyclosporine, methotrexate, biologics, and JAKis. Topical delgocitinib 2% cream (Anzupgo, LEO Pharma) is a new topical pan-JAK inhibitor designed specifically for the treatment of CHE. It has demonstrated efficacy and a favorable safety profile.
Literature Lessons
Ted Rosen, MD, FAAD, Professor of Dermatology at Baylor College of Medicine in Houston, TX, delivered a clinical evidence review with practical application tips. Dr. Rosen recommends clinicians avoid recommending long-term uninterrupted antihistamine use, particularly cetirizine or levocetirizine, as the FDA has warned about rare but severe rebound pruritus. New research out of Sweden showed that exposure to estrogen hormone replacement therapy (HT) may increase the risk of skin cancer in women. Clinicians should recognize HT as a potential risk factor and ensure routine surveillance. He reviewed a study showing that transplant patients undergoing Mohs micrographic surgery may have a higher risk of complications and recommended closer post-operative follow-up.
When evaluating volar melanotic macules, he emphasized an important distinction: While these lesions are more common in individuals with skin of color, macules located on the arch should raise suspicion for syphilis, whereas benign variants more often appear on the heel or ball of the foot. When assessing patients with suspected CTCL, look for a “notch sign,” which is a notch of normal skin extending into an erythematous patch. Additional data reviewed showed higher rates of rosacea in women using hormone-based intrauterine devices (IUDs). For patients with refractory rosacea, he recommended inquiring about IUD type and considering a switch to a copper IUD when appropriate. Finally, he presented encouraging findings on the use of GLP-1 agonists in hidradenitis suppurativa (HS). Patients receiving GLP-1 therapy demonstrated improved weight loss, reduced flares, and fewer new lesions, suggesting a potential anti-inflammatory benefit in HS management.
Antibiotic Stewardship in Dermatology
Dr. Rosen also educated the audience about the importance of antibiotic stewardship to prevent antimicrobial resistance. He reminded providers that in 2023, there were over 1.3 million deaths directly attributable to antibiotic microbial resistance, which is the most pressing threat to the health of patients. Global resistance rates to mupirocin are up from 8% to more than 40%, and he recommends use of alternatives like ozenoxacin. For acne and rosacea, he recommends against always providing doxycycline and instead using a narrow-spectrum antibiotic like sarecycline, which lowers the risk of antimicrobial resistance. He recommends that providers should practice good antibiotic stewardship, including controlling the source of infection, providing antibiotics only when needed, using alternative prescription when possible, and providing appropriate antibiotic dose and duration. He also recommends cultures to verify diagnosis and susceptibility whenever possible and always reassessing after culture results.
Pigmentary Disorders in Practice
Rebecca Hartman, MD, MPH, FAAD, Assistant Professor of Dermatology at Harvard Medical School and Director, Melanoma Epidemiology, at Brigham and Women’s Hospital in Boston, MA, shared practical pearls for managing pigmented lesions. She reviewed criteria for referring to a pigmented lesion clinic, including a personal history of malignant melanoma (MM), multiple primary MM, numerous (>50) nevi, and a history of multiple dysplastic nevi (DN). Dr. Hartman emphasized that while DN are common, their malignant potential is low; most melanomas arise de novo (77%), and the annual transformation rate of DN to MM is estimated at only 1 in 10,000. Mild and moderate DNs carry particularly low risk.
For biopsy technique, she recommended saucerization shave removal with a 2mm margin and sufficient depth into the deep dermis (at least 1mm), which successfully removes approximately 90% of DN. Larger or deeper lesions may warrant punch biopsy or narrow elliptical excision. In her practice, mild or moderate DN without residual pigmentation does not require re-excision. Severe DN, however, may require conservative re-excision with 2–5mm margins. Dr. Hartman discussed dermoscopy for MM and recommended use of the two-step algorithm.
Biopsy tips include that if you transect a MM, perform a deeper biopsy and send a note to the pathologist. She advised erring on the side of caution; if a transected MM has a Breslow depth of 0.5mm, consideration should be given to discussing sentinel lymph node biopsy (SLNB). Finally, she highlighted genetic considerations: Patients with three or more primary invasive melanomas and/or pancreatic cancer in first- or second-degree relatives should undergo germline genetic testing for MM predisposition syndromes.
Dr. Hartman also gave a lecture focused on non-melanoma skin cancer (NMSC). She shared that Mohs micrographic surgery provides the highest cure rates, typically 98–99%. However, nonsurgical treatments for squamous cell carcinoma in situ (SCCiS) and superficial basal cell carcinoma (sBCC) may be preferable in select patient populations, including those of advanced age, patients with significant comorbidities, increased bleeding or infection risk, cognitive impairment such as dementia, or those whose social or living situations limit post-operative care. Photodynamic therapy (PDT), topical field treatments (5-fluorouracil [5-FU], imiquimod), and radiation therapy remain important options for these scenarios, balancing efficacy with patient safety and QOL.
Patients with low-risk tumors (SCCiS, sBCC, not transected at the base) would be good candidates for topical NMSC treatment. Locations such as the eyelid or scalp make these tumors higher risk, necessitating Mohs treatment. Topical 5-FU is approved for sBCC twice daily for three to six weeks and for four to six weeks for SCCiS. Close follow-up, three months after completion of treatment, is recommended to ensure efficacy. 5-FU with calcipotriene showed superiority over 5-FU alone in treated SCCiS. Imiquimod showed superiority over 5-FU alone for the treatment of sBCC. Nicotinamide 500mg twice daily has been shown to reduce risk of NMSCs with a 14% reduction in skin cancer risk. For NMSC on the face or those with numerous actinic keratoses (AKs) and history of SCC, it is recommended to use topical chemoprevention with compounded 5-FU/calcipotriol twice daily for four days.
Infectious Diseases in Dermatology
Robert G. Micheletti, MD, Associate Professor of Dermatology and Medicine at the Hospital of the University of Pennsylvania in Philadelphia, PA, presented an update on infectious diseases in dermatology. He noted that preventable illnesses such as measles have resurged, largely due to declining vaccination rates, and emphasized the need for more surveillance and rapid outbreak response. He also reviewed data showing that leprosy cases are on the rise and are now considered endemic in parts of the Southeastern US, particularly in Central Florida.
Dr. Micheletti discussed updates on the current outbreak of mpox (previously known as monkeypox), which is more transmissible and virulent than the strain seen in 2022. Several cases have been reported in the US since early 2025. Dr Micheletti then shifted to discussing resistant fungal infections, particularly Trichophyton indotineae, which presents with widespread, inflamed tinea and responds poorly to terbinafine. Suspected cases should be confirmed by DNA sequencing, and itraconazole 200mg daily for four to 12 weeks is the treatment of choice. Dr. Micheletti expressed concerns that proficiency in provider-performed microscopy is a declining skill, despite its value. He encouraged clinicians to strengthen these skills, as microscopy plays a key role in the rapid, bedside diagnosis of a range of skin diseases.
Dermatologic Emergencies: What to Know and Do
Next, he presented on dermatologic emergencies. He emphasized the importance of recognizing red flags such as systemic symptoms, immunosuppression, and violaceous or necrotic lesions, which may signal life-threatening disease. He presented a case of Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome as a severe hypersensitivity reaction typically occurring weeks after initiating high-risk medications including anticonvulsants, sulfonamides, vancomycin, minocycline, and allopurinol. Work-up is likely to elicit eosinophilia and elevated liver enzymes, and management requires immediate cessation of the culprit drug and systemic steroids.
Dr. Micheletti also reviewed Stevens–Johnson Syndrome (SJS), stressing timely diagnosis, prompt discontinuation of the offending agent, and urgent transfer to an ICU or burn unit for supportive care. He discussed anti-MDA-5 dermatomyositis, a subtype characterized by cutaneous ulcerations and a high risk of rapidly progressive interstitial lung disease, stressing the need for urgent referral. Lastly, Dr. Micheletti presented a case of a necrotic ulceration that had been repeatedly and aggressively treated as an infection but was ultimately diagnosed as pyoderma gangrenosum. The delayed diagnosis led to significant morbidity, highlighting the need to reconsider the differential diagnosis when wounds fail to improve, and to maintain a low threshold for biopsy.
For his final lecture, Dr. Micheletti presented an update on HS, emphasizing its burden on patients and the healthcare system. He noted a seven-to-10-year delay to diagnosis, which often results in increased morbidity and disease progression. He notes high emergency department (ED) utilization, with patients often not being referred to dermatology.
HS carries a profound psychosocial burden, with disproportionately high rates of depression, anxiety, sexual dysfunction, and opioid use. Lifestyle considerations were reviewed, including benefit from reducing dairy and refined carbohydrates. He emphasized the importance of screening for the known 19 HS comorbidities, including other follicular occlusion disorders (acne, dissecting cellulitis), mental health conditions (anxiety, depression, substance abuse), inflammatory diseases (inflammatory bowel disease, arthritis), and metabolic and cardiovascular disorders (obesity, diabetes, hypertension, dyslipidemia, and cardiovascular disease).
Dr. Micheletti summarized current medical therapies, including antibiotics, hormonal agents such as spironolactone or metformin, and biologics. Surgical management, including deroofing of sinus tracts, remains an important treatment, offering low recurrence and high patient satisfaction. Finally, he emphasized a personalized, combination-based treatment approach and expressed optimism about the expanding therapeutic pipeline.
Challenging Cases in Dermatology
Lisa Weiss, PA-C, along with Justin Love, MPA, PA-C, Physician Assistant at Loma Linda University Health in Loma Linda, CA, led a panel discussion reviewing challenging cases from clinical practice. They discussed the importance of providing accurate clinical information when submitting specimens for pathology. Dermatopathological diagnostic accuracy increased from 53% to 78% when clinical information was provided. Love presented a case of Parry–Romberg syndrome (progressive hemifacial atrophy), highlighting the appropriate diagnostic workup, including MRI, and the multidisciplinary approach required. Weiss discussed a case illustrating the importance of past medical history during a dermatologic evaluation.
A patient presenting with arm papules and a history of uterine fibroids was ultimately diagnosed with Reed’s syndrome (Hereditary Leiomyomatosis and Renal Cell Carcinoma). This diagnosis emphasized the importance of evaluating the whole patient and necessitated referral for imaging due to increased risk of renal cell carcinoma (RCC) and increased risk of MM. The panel also highlighted the importance of maintaining vigilance for MM in pediatric patients. Pediatric MM, though rare, is the most common skin cancer in children and often does not conform to the traditional ABCDE criteria. Proposed pediatric-specific criteria include Amelanotic, Bleeding or Bump, Color uniformity, De novo appearance and Diameter, and Evolution. Lesions may mimic benign growths such as warts or pyogenic granulomas, reinforcing the importance of biopsying suspicious lesions regardless of patient age.
Practicing Patient-Centered Communication
Kenneth E. Korber, PA-C, MHPE, DFAAPA, Physician Assistant and Clinical Assistant Professor at Touro University’s PA Program in Chicago, IL, presented The Art of Patient-Centered Communication, emphasizing that effective communication is essential for building trust, improving adherence, enhancing patient outcomes, reducing medical errors, and increasing health equity. He highlighted the impact of low health literacy, noting that many patients struggle to obtain, understand, and act on health information, particularly those facing language barriers, cultural differences, limited education, or cognitive challenges. Korber outlined common communication barriers, complex medical terminology, and time constraints, and emphasized strategies to improve understanding: using plain language, applying the teach-back method (having the patient repeat information in their own words to confirm their understanding), incorporating visual aids and written materials, and tailoring education to individual cultural and language needs.
Psychodermatology Pearls
Patricia M. Delgado, DNP, AGPCNP, DCNP, PMHNP, Nurse Practitioner with Sunrise Skin & Wellness in St. Petersburg, FL, closed out the conference with a lecture on psychodermatology and the interaction between the skin and the mind mediated by the neuro-immuno-cutaneous-endocrine (NICE) network. She discussed the importance of trauma-informed dermatology and explaining action before touching, obtaining consent, and respecting boundaries. She advised empowering the patient by offering choice and shared decision-making, and by validating and acknowledging visible suffering.
Recommendations for dermatological care for patients with delusions of parasitosis included ruling out infestation, using neutral language, and building trust. In patients with burning scalp syndrome, providers should discuss gentle scalp care, discontinuation of irritating products, educating the patient on the skin–psyche connection, and considering treatment with topical gabapentin. Make sure to screen patients for depression, anxiety, and stress factors, and how this condition affects their life. For patients with “tanorexia,” educate on the endorphin/dopamine loop and offer sunless tanning options. For those with suspected body dysmorphic disorder, she advised avoiding unnecessary cosmetic procedures, conducting sensitive screening, and considering referral for cognitive behavioral therapy with or without a Selective Serotonin Reuptake Inhibitor (SSRI), depending on severity.
About the authors
Buchi Neita, PA-C, is a Physician Assistant at Epiphany Dermatology in Peachtree City, GA.
Takeia Horton, PA-C, is a Dermatology Physician Assistant in Atlanta, GA.
