Clinical Pearls from the 2025 Fall Clinical PA/NP Meeting: Day 2

Image Credit: Dermatology Times

Immunology 101: The Pathways Driving Dermatologic Therapies

Jason Hawkes, MD, MS, FAAD, captivated the audience with a dynamic lecture on the role of immunology in dermatologic disease. He explained that dysregulated type 2 immune responses are central to conditions like atopic dermatitis (AD), asthma, chronic spontaneous urticaria (CSU), prurigo nodularis, and bullous pemphigoid. Key cytokines involved include IL-4, IL-5, IL-13, and IL-31, and are the basis for multiple targeted therapies, including dupilumab, which already holds several FDA approvals with more likely on the horizon. In AD, IL-4, IL-13, and IL-31 drive itch and inflammation, making them prime biologic targets. Hawkes also reviewed how aberrant type 1 immune responses are linked to conditions such as psoriatic arthritis, inflammatory bowel disease, allergic contact dermatitis, and contact urticaria, each involving specific cytokines now targeted by novel therapeutics. Finally, he addressed type 3 immune dysregulation, which is central to diseases like plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis. Here, IL-17 and IL-23 inhibitors have shown significant therapeutic efficacy.

Don’t Hit The Road JAK!

TJ Chao, PA-C, and Dermsquared Advisory Board Member, delivered an insightful review of the JAK-STAT pathway and its relevance in treating a range of dermatologic conditions, including atopic dermatitis, alopecia areata, and chronic hand eczema. He noted that JAK inhibitors are under investigation for challenging-to-treat diseases such as vitiligo, lichen planus, and dermatomyositis, areas where current therapies often fall short. Chao also addressed the numerous black box warnings associated with JAK inhibitors and shared his thoughtful, patient-centered approach to discussing these risks in clinical practice.

Rooting for Better Outcomes: Elevating Care in Alopecia Areata

Tiffany Mayo, MD, provided a comprehensive overview of JAK inhibitors for the treatment of alopecia areata. She emphasized thoughtful patient selection and the need to recognize the significant psychosocial burden of the disease, even in seemingly “mild” cases of alopecia areata. Mayo outlined the necessary lab work prior to initiating therapy, as well as ongoing monitoring during therapy. She urged clinicians not to discontinue treatment prematurely, noting continued improvements can be seen over 52 weeks and meaningful outcomes can be achieved in those experiencing a delay in response. Early signs of treatment response include eyebrow hair regrowth and improvement in nail pitting. Lastly, she highlighted the importance of staying on the drug in order to sustain results and addressed a frequent patient concern: whether treatment can be discontinued after reaching their desired outcome.

Panel Discussion: Spotlight on IL-13: Long-term Strategies in the Management of Moderate-to-Severe Atopic Dermatitis with Alexandra Golant, MD, Benjamin Lockshin, MD, and Andrew Blauvelt, MD, MBA

In this session, experts reviewed the significant burden of itch in AD and the importance of optimizing treatments that effectively target the various cytokines implicated in the pathophysiology of the disease. The American Academy of Dermatology (AAD) Guidelines pertaining to systemic therapies for AD were discussed, highlighting the strong recommendation for both biologics and JAK inhibitors. Clear skin and optimal itch control are the desired endpoints for this disease and these can be achieved with the right therapies. Due to the heterogeneity of this disease, there may be some trial and error as it pertains to individual treatment response. Importantly, lack of response to one biologic does not rule out success with another. As the session concluded, panelists expressed optimism about the future of AD treatment, highlighting that therapies hold the potential not only for long-term remission but may also be disease-modifying.

Panel Discussion: Chronic Spontaneous Urticaria, What You Need to Know with Jason Hawkes, MD, MS, and Kristin Sokol, MD, MS, MPH

Panelists reviewed the diagnostic approach to CSU, emphasizing that extensive workups, once routinely performed, are often unnecessary for making this clinical diagnosis. The discussion included current FDA-approved and emerging therapies, with Hawkes and Sakol highlighting the importance of up-titrating antihistamines, specifically cetirizine and fexofenadine, up to 4 times the standard dose when clinically appropriate. They recommended gradually increasing the dose every few days, based on patient response. Hawkes also emphasized flexible, symptom-driven dosing throughout the day for optimal control. Lab work, such as CBC, CMP, and thyroid function tests, was advised only when clinically indicated. Panelists noted a growing trend of dermatology providers managing CSU directly, rather than referring exclusively to allergists.

What’s New in the Medicine Chest

James Del Rosso, DO, FAAD, FAOCD, dazzled attendees as he presented a Dermsquared staple, “What’s New in the Medicine Chest?” He kicked off his session by announcing that tirbanibulin 1% ointment is FDA-approved for field treatment of actinic keratoses (AKs) on the face and scalp, up to 100 cm², making it a practical option for real-world use. Del Rosso cleverly likened cryotherapy for AKs to “plucking weeds,” while field therapy targets “what’s percolating beneath the surface”. Yet another memorable pearl to take back to the clinic. Del Rosso covered nuances in treatment options for AD and discussed a recent FDA approval: roflumilast 0.3% foam, now cleared for use in both scalp and body psoriasis, offering a versatile new option for challenging areas. He concluded his session by reviewing the efficacy and safety of bimzekizumab in patients with moderate-to-severe hidradenitis suppurativa (HS).

Panel Discussion: The Clinician’s Case-Based Guide to Gene Expression Profiling in Skin Cancer Management with Darrell Rigel, MD, MS, and Harrison Nguyen, MD, MBA, MPH, FAAD

Panelists emphasized the value of Castle Biosciences’ molecular testing in skin cancer management, highlighting the DecisionDx-Melanoma 31-gene expression profile (GEP) for invasive melanoma and the 40-GEP test for cutaneous squamous cell carcinoma (SCC). These tests support personalized, risk-aligned management by guiding clinical surveillance and treatment decisions. Both have been associated with improved patient outcomes and enhanced survival through more tailored care strategies.

Panel Discussion: Real-World Data and Patient Perspectives: A Guide for PAs and NPs in Actinic Keratosis Care with Darrell Rigel, MD, MS, and Brian Berman, MD, PhD

Panelists emphasized the importance of field cancerization in the management of AKs. They reviewed a range of FDA-approved topical therapies, comparing treatment regimens and differences in efficacy. Tirbanibulin 1% ointment received particular praise, with the AAD issuing a strong recommendation in 2022 based on high-certainty evidence for its use in field therapy. Its 5-day application schedule, favorable tolerability, and efficacy make it a practical option for many patients. The session also covered photodynamic therapy (PDT), including strategies for achieving in-office “painless” PDT through reduced incubation times.

Panel Discussion: Getting a Handle of Hidradenitis Suppurativa Through Holistic Management with Tiffany Mayo, MD, MS, and Andrea Murina, MD

In this expert-led session, panelists reviewed the evolving therapeutic landscape for the management of HS, highlighting the various investigational biologics and small-molecule inhibitors. Data on secukinumab and bimekizumab were discussed, particularly their impact on pain and reductions in draining tunnel counts. Panelists emphasized that 4 to 6 months is an appropriate time frame to evaluate treatment response, and recommended re-evaluating the therapeutic approach if little to no improvement is observed. While systemic therapies are effective at reducing inflammation and flares, they may not improve existing scarring and sequelae from long-standing, inadequately treated disease, underscoring early appropriate therapy in HS.

Panel Discussion: Crack That Case: Individualizing Care in Psoriasis with Andrew Blauvelt, MD, MBA, and Harrison Nguyen, MD, MBA, MPH

Panelists opened the session by comparing how psoriasis severity is defined across different frameworks. In clinical trials, “mild” disease is classified as involving less than 10% body surface area (BSA), “moderate” as 10–20%, and “severe” as greater than 20%. In contrast, the National Psoriasis Foundation defines mild disease as <3% BSA, moderate as 3–10%, and severe as >10% BSA. These classifications, while standardized, present real-world challenges such as the exclusion of patients from clinical trials, product label restrictions, and insurance denials for systemic therapy based solely on BSA thresholds. Panelists emphasized that these metrics often fail to reflect the full patient impact of psoriasis, particularly in cases affecting sensitive or visible areas, or where significant quality-of-life disruptions occur despite low BSA involvement. Biologic therapies were praised for their targeted mechanisms, strong safety profiles, and efficacy. Beyond skin clearance, biologics were also recognized for their systemic benefits; some have shown improvements in lipid-rich atherosclerosis after 1 year of treatment, reinforcing the understanding that psoriasis is a systemic inflammatory disease, not just a skin condition.

Beyond the Salary: Navigating Contracts, Benefits, and What Really Matters

Kasey D’Amato, PA-C, MPAP, delivered an insightful talk on PA and NP contracts, highlighting the variety in compensation structures and benefits packages. She instructed attendees to “negotiate like a boss,” highlighting the importance of understanding one’s full value, not just in revenue generation, but also in one’s broader contributions to a practice. She emphasized that successful negotiations should strive to create a “win-win” for both parties and urged clinicians to clearly identify their own priorities in an effort to build long-term career satisfaction and success. She concluded her talk with a powerful reminder from Sean Rad: “Data beats emotions,” underscoring the importance of backing up one’s worth with both qualitative and quantitative metrics.

Viable Strategies for Using JAK Inhibitors in Vitiligo with James Del Rosso, DO, FAAD, FAOCD, and Benjamin Lockskin, MD

Panelists discussed the often overlooked comorbidities associated with vitiligo, including anxiety, depression, autoimmune thyroid disease, alopecia areata, and diabetes mellitus. They reviewed both traditional and emerging treatment options for this condition. Clinicians were encouraged to exercise patience when it comes to repigmentation.

Top Psychiatric Tips to Optimize Your Patient Interactions

Evan Rieder, MD, board-certified dermatologist and psychiatrist, captivated the audience with his top tips for facing daily challenges in the clinic. He emphasized the importance of transparent communication with patients and reminded clinicians to clearly set expectations for each visit. He also reviewed how providers can optimally structure their schedules with consideration for end-of-day appointments given to those patients who may need more time. Rieder reviewed tricks to reduce anxiety during procedures, such as “verbal valium,” patient-selected music, and deep breathing. His insights balanced high-quality dermatologic care with provider well-being, two priorities that often feel at odds but can, and should, coexist in harmony.

Jamie Restivo, MPAS, PA-C, is a board-certified dermatology physician assistant practicing in Enola, Pennsylvania, PA/NP Emerge and LEAP Faculty, and current president of the Pennsylvania Dermatology Physician Assistants (PDPA).