Ramos traces the gap back to adherence. Patients stretch time between washes, rinse too quickly, or avoid medicated shampoos altogether, whether to preserve color, manage texture, or simply keep up with daily life. “Nobody’s leaving it on long enough,” she says. “That’s why I encourage people to use it as a mask.”  

Their conversation then moves beyond ingredients and into behavior. They explore how cultural hair practices, mobility limitations, and cosmetic priorities shape treatment success—often more than the prescription itself. The issue, as Restivo frames it, isn’t a lack of options. It’s asking patients to adopt routines they’re unlikely to follow. 

Ramos’s response was to build something that fits into that reality, like a leave-on, dry formulation designed to extend contact time without disrupting hair care practices. She walks through the thinking behind the formulation—anchored by salicylic acid as a keratolytic and supported by ingredients selected for anti-inflammatory and antimicrobial effects—and why delivery matters just as much as mechanism. 

The conversation broadens into a more practical philosophy of care to meet patients where they are, layer therapies when needed, and think in terms of tools rather than single solutions. Or, as Ramos puts it, “We can lead a horse to water, but we can’t make them drink.”  

It’s a grounded and nuanced look at what happens when we stop blaming the treatment and start redesigning how it’s used. 

The views expressed in this episode are those of the speakers and do not necessarily reflect those of Dermsquared. This program is intended for health care professionals and is provided for educational purposes only.  

 Clinicians are responsible for applying independent clinical judgment in patient care.  

At the center of the discussion is field therapy. While cryotherapy remains useful for isolated lesions, Seiter emphasizes the importance of addressing the underlying field of UV-damaged keratinocytes, much of it invisible. Starting earlier, when photodamage is still mild, can make treatment more tolerable and more sustainable for patients over time. 

From there, the conversation moves into the realities of clinical practice: how to choose between commonly used topicals, how to counsel patients through expected reactions, and how small decisions, including cost, access, and even how instructions are framed, can shape whether a patient is willing to repeat treatment. The goal is not maximal reaction, but a manageable one. 

Prevention threads throughout, from sunscreen counseling to adjunctive options like Polypodium leucotomos and nicotinamide, always with an emphasis on meeting patients where they are. 

The takeaway is a familiar one, but easy to overlook: treating AKs is not just about clearing lesions. It is about recognizing the field early and helping patients stay with a plan they can return to over time. 

The views expressed in this episode are those of the speakers and do not necessarily reflect those of Dermsquared. This program is intended for health care professionals and is provided for educational purposes only.  

 Clinicians are responsible for applying independent clinical judgment in patient care.  

A key takeaway: not every dystrophic nail is fungal. Trauma, biomechanics, gait changes, and footwear can all shape nail morphology in ways that mimic infection. Looking globally at the foot, considering structural deformities, and using tools like dermoscopy can help clinicians avoid reflexively reaching for antifungals when the underlying issue is mechanical. 

The conversation also covers diagnostic confirmation and why proper nail sampling matters. Because fungal infection originates in the nail bed, distal nail plate alone may not provide a useful specimen, a mistake that can lead to false negatives and misdirected treatment.  

From treatment expectations to oral therapy pearls, Dr Vlahovic emphasizes a central principle—nails tell a story. Taking the time to read it carefully can change both the diagnosis and the outcome. 

Through two real-world cases, the conversation explores how hedgehog pathway inhibitors can be used strategically to reduce tumor burden, including in neoadjuvant settings, and how alternative dosing and proactive management of adverse effects (including early L-carnitine use for muscle cramps) may improve tolerability. 

In one case, a large scalp tumor was medically reduced before surgery. In another, systemic therapy helped decrease the number of tumors in a patient with numerous BCCs, allowing for more selective surgical intervention. 

The throughline is clinical judgment. When surgery alone may lead to significant morbidity, systemic therapy can create space for tumor shrinkage, shared decision-making, and more thoughtful sequencing of care. 

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.  

Dr Frey begins by reframing the modern cosmeceutical landscape, emphasizing the increasing scientific rigor behind formulation development—from longevity medicine and cellular senescence to peptides and the expanding role of exosomes. She underscores that many OTC products now reflect years of clinical testing, and that dermatology clinicians are increasingly involved earlier in product conception and validation.  

The discussion then turns to photoprotection, with a particular focus on visible light and hyperpigmentation, especially in skin of color. Drawing on work from Dr Henry Lim’s group, Dr Frey explains how visible light, especially high-energy blue light, stimulates melanogenesis through Opsin 3 activation, stabilizes tyrosinase, and contributes to long-lasting dyspigmentation even with standard sunscreen use. Both speakers emphasize the foundational role of tinted sunscreens containing iron oxides, which block visible light while providing cosmetic camouflage, and discuss practical considerations such as shade matching, seasonal skin tone changes, and adherence.  

From there, the conversation expands into adjunctive skincare across common inflammatory conditions, including acne, rosacea, atopic dermatitis, and melasma. Dr Frey reviews the emerging role of microbiome-targeted acne therapies, such as bacteriophage-based products that selectively reduce pathogenic C. acnes without disrupting beneficial phylotypes. She also highlights barrier-supportive cleansers and moisturizers, emphasizing patient experience, tolerability, and cost accessibility as key drivers of adherence.  

The episode closes with a thoughtful examination of novel pigment-targeting and barrier-repair strategies, including thiamidol as a human tyrosinase inhibitor for melasma and lentigines, DNA repair enzyme sunscreens for high-risk patients with actinic damage, and sodium hypochlorite washes as a modern, approachable alternative to traditional bleach baths in atopic dermatitis and other inflammatory conditions.  

Dr Frey’s central message is clear; patients are already using OTC skincare, and when clinicians guide those choices intentionally, cosmeceuticals can meaningfully enhance outcomes, tolerability, and long-term disease control. 

Dr Green traces phototherapy’s evolution from the cumbersome Goeckerman tar regimens of the 1990s to today’s safe, targeted narrowband UVB devices (310–312 nm), which drastically limit carcinogenic wavelengths and offer a more precise inflammatory response. “Phototherapy of the 1990s is not the phototherapy we use today,” he emphasizes, calling it a niche therapy that remains the best choice for very specific patient groups.  

Together, Restivo and Green outline where light treatment truly shines: guttate psoriasis, pregnancy, pediatric cases, episodic flares, extensive vitiligo, severe pruritus, and moderate plaque disease that is too widespread for topicals but not appropriate for biologics. Narrowband UVB, Green stresses, is “local therapy that leads to a systemic immune response,” allowing treatment without placing medication into the body.  

The conversation then shifts to at-home phototherapy, a modality Dr Green once avoided due to safety concerns, user error, and poor adherence. That changed with modern guided systems that mimic in-office decision-making through dose-adjusted protocols, Fitzpatrick-based starting points, and real-time compliance reporting back to the prescriber. Green highlights findings from the landmark LITE study, led by Joel Gelfand, MD, which showed home treatment to be non-inferior to office-based phototherapy, equally safe, and three times more likely to be completed, across diverse skin types.  

He concludes with a pragmatic reminder: clinicians no longer need light boxes in their offices to prescribe phototherapy. “Phototherapy is for everyone,” Green says. “It’s an older therapy that’s now a new therapy because of the technology… We’ve taught an old dog new tricks.” 

Dr Galimberti emphasizes the importance of distinguishing AKs from “dry skin,” reminding listeners that these are pre-cancerous lesions with the potential to progress to squamous cell carcinoma, which is responsible for more deaths annually than melanoma. Together, he and Restivo unpack the art and science of combining cryotherapy and field therapy, with data showing a reduced burden of both pre-cancerous and cancerous lesions when these treatments are paired. “This is a chronic condition,” Dr Galimberti notes. “We need to treat for now and for the future.” 

The conversation explores how photodynamic therapy (PDT) fits into the AK treatment paradigm, offering controlled, in-office precision with cosmetic benefits and no risk of scarring. Dr Galimberti outlines his evolving patient-selection criteria, insights on optimizing incubation times, and the growing promise of painless PDT. He also shares pragmatic workflow pearls, like scheduling PDT and follow-up appointments simultaneously, to improve adherence and outcomes. 

Listeners will gain a grounded, practice-ready framework for treating AKs holistically: balancing efficacy, tolerability, and patient experience while addressing both visible and subclinical disease. 

Together, they review the AD treatment landscape and current gaps in therapies. Lockshin outlines the promise of OX40 inhibition as a potential step toward true disease modification, with less frequent dosing and durable remission that could reshape long-term disease management. 

Restivo and Lockshin walk listeners through the immunologic mechanisms at play, breaking down how OX40 and its ligand function as upstream co-stimulatory molecules driving inflammation, barrier dysfunction, and itch. They compare emerging agents rocatinlimab and amlitelimab, explaining how each targets a different side of the OX40 pathway, and discuss early data showing high EASI-90 to EASI-100 responses and sustained clearance even after treatment withdrawal. 

Their conversation delves into what makes these agents distinct from JAK inhibitors and biologics, emphasizing that OX40 inhibition appears to rebalance rather than deplete T cells, with minimal immunosuppression and a favorable safety profile so far. Lockshin shares practical considerations around patient selection, dosing convenience, and future applications beyond AD—including prurigo nodularis, alopecia areata, and potential oncologic uses. 

The discussion closes on a forward-looking note: OX40 may be dermatology’s first real leap toward immune reprogramming. As Lockshin puts it, “good things are worth the wait,” and OX40 inhibition could mark the next chapter in changing the course–not just the symptoms—of atopic dermatitis. 

Dr Dinehart, one of the first fellowship-trained Mohs surgeons in Arkansas, shares his firsthand experience with vismodegib and sonidegib, emphasizing that PAs and NPs are ideal prescribers for these agents and should feel confident managing this patient population. He addresses common misconceptions about efficacy and tolerability head-on, noting that “These drugs work—and they work in more than 90% of patients.” 

Together, they explore clinical indications for sonidegib and discuss expanding the mindset beyond large, neglected tumors. Dinehart urges clinicians to consider HHIs for older adults, nursing home residents, patients with multiple lesions, or those who simply prefer to avoid surgery or radiation. “Shrinkage”, he reminds listeners, is always a win—improving quality of life and often allowing for simpler, less invasive procedures down the line. 

Supplemental Clinical Resources:

To support adoption of HHIs in everyday practice, Dr Dinehart has provided two references: 

Sonidegib Quick Reference Sheet: summarizes key prescribing information, laboratory guidance, drug-interaction tables, and L-carnitine dosing details for muscle-cramp prevention. 

HHI Dosing Calendar: a visual schedule illustrating his modified twice-weekly regimen to aid patient counseling and adherence tracking. 

For clinicians who have additional questions or would like to discuss treatment approaches, Dr Dinehart welcomes inquiries at smdinehart@gmail.com. 

Together, they unpack the science behind type 2 inflammation and the mechanisms that make dupilumab effective across eight FDA-approved indications, including atopic dermatitis, asthma, chronic rhinosinusitis with nasal polyps, eosinophilic esophagitis, prurigo nodularis, bullous pemphigoid, and chronic spontaneous urticaria (CSU). Mastro offers a practical breakdown of type 2 cytokine activity and discusses how targeting these pathways drives disease control across skin, lung, and GI conditions. 

The pair discuss first-line use of dupilumab in AD, emphasizing its safety profile, FDA approval down to 6 month of age, and ability to treat multiple comorbidities. They also explore new territory with bullous pemphigoid, reviewing data from the ADEPT trial, the challenges of oral corticosteroids in elderly patients, and how dupilumab might offer a safer, targeted alternative. 

Mastro shares thoughtful insights on treating prurigo nodularis, advocating for aggressive, empathetic care and cautioning clinicians not to delay treatment as a biopsy is not necessary to make this diagnosis. He stresses the importance of documenting thoroughly and recognizing PN even in the absence of nodules. 

The episode concludes with a discussion on chronic spontaneous urticaria (CSU), including diagnostic criteria, evolving treatment approaches, and patient expectations. They push back on outdated, exhaustive lab workups and advocate for focused history-taking and up-dosing antihistamines before initiating biologic therapy. 

With clinical pearls throughout—including how to frame conversations with patients about long-term therapy, how to document for coverage, and when to lead with systemic options—this extensive conversation offers a masterclass in therapeutic decision-making, delivered with humor, heart, and high-level clinical insight. 

From new systemic therapies like OX40 ligand and oral IL-23 inhibitors to the expanding role of GLP-1 medications in inflammatory skin diseases, they break down what’s next in derm. The pair also touch on tech innovations like virtual reality in the treatment room, the rise and fall of teledermatology, and how social media is shaping (and sometimes skewing) the skincare conversation. 

Plus, don’t miss their fun game segments, where they dish on trends they’d “treat, trial, or trash,” and reveal their derm word associations in “Spot On.” 

Whether you’re tuning in for clinical insights, career inspiration, or perspectives on emerging trends, this episode has what you need to stay current and continue growing in your practice. 

Tune in to gain insights into the importance of educating patients about both the benefits and risks of JAK inhibitors and hear success stories and practical tips for providers to build confidence in prescribing these therapies.

FCPANP offers PAs and NPs an opportunity to enhance their clinical skills through a thoughtfully crafted learning experience. The agenda features succinct lectures covering a diverse array of topics, brimming with clinically relevant insights and practical guidance on professional development. The program also features interactive panel sessions, Q&A segments, a live patient demonstration, and ample networking opportunities to equip participants with invaluable skills to elevate patient care.

Tune into the episode for an in-depth preview of what awaits at FCPANP. Don't miss out on this exceptional opportunity to broaden your expertise, connect with fellow professionals, and make a powerful impact on patient lives. For virtual attendance, register today using promo code SPOTCHECK24 to receive free access to FCPANP.

IDS is an exclusive learning opportunity for PAs and NPs seeking to expand their knowledge of inflammatory diseases in dermatology and the ever-expanding treatment landscape. The dynamic agenda includes didactic lectures, an impactful patient interview highlighting the psychosocial impact of inflammatory diseases, and interactive breakout sessions offering practical demonstrations and hands-on experiences, empowering attendees with valuable skills to elevate patient care.

Tune in to the episode for a full rundown of what to expect at IDS, and don't miss out on this unparalleled opportunity to expand your knowledge, network with peers, and make a tangible difference in the lives of patients with inflammatory diseases. Register today using the promo code IDS24RIGEL to secure your seat at IDS 2024!