Clinical Pearls From the PDPA Sixth Annual Keystone Dermatology Conference: Day 1

Pregnancy-Safe Options in Inflammatory Diseases

Lauren Miller, PA-C, emphasized the importance of conversations surrounding family planning to ensure safe and effective dermatologic care. She advised that these discussions occur proactively and periodically for patients of childbearing potential. Effective patient education, she noted, promotes safer family planning and better disease control, ultimately leading to healthier pregnancies and smoother postpartum experiences.

When managing psoriasis, Miller noted that narrowband ultraviolet B phototherapy combined with sensible topical therapies serves as the cornerstone of treatment. For systemic management, she noted that TNF-α inhibitors have the most robust pregnancy safety data, with certolizumab offering the lowest placental and breast milk transfer. In cases of atopic dermatitis (AD), dupilumab was identified as a reasonable option for severe disease during pregnancy and lactation when clinically indicated.

Miller also highlighted the inherent risks of undertreating dermatologic conditions and urged clinicians to engage in open, informed discussions with their patients about the available treatment options and their individual risks and benefits.

From Consultation to Transformation: A Multimodal Approach to Aesthetic Dermatology

Kachiu C. Lee, MD, MPH, FAAD, reviewed with attendees that a successful aesthetic consultation begins with a clear understanding of its structure—one that prioritizes patient trust, realistic expectations, and individualized treatment planning. Clinicians must not only assess aesthetic goals but also recognize red flags that may signal unsuitable candidates for cosmetic procedures, such as unrealistic expectations, underlying body dysmorphic tendencies, or external pressures driving the desire for treatment. A thoughtful consultation also includes a review of available cosmetic dermatology modalities and how to combine them effectively. By integrating synergistic treatments such as chemical peels, neuromodulators, fillers, energy-based devices, and topical regimens, clinicians can achieve natural, harmonious results while ensuring patient safety and satisfaction remain at the forefront.

Lee emphasized that although patients might request a specific treatment, their underlying concern could call for a different approach. For example, a patient sought lip filler to address what she described as a “Joker smile.” After careful evaluation, Lee determined that a neuromodulator, rather than filler, was the more appropriate treatment to relax the muscles contributing to her concern. In the end, this thoughtful pivot led to an excellent cosmetic outcome and a very satisfied patient.

Panel Discussion: Beyond the Bedside—Nonclinical Roles and Goals

Miller was joined by Shanna Miranti, PA-C, who took the stage to share their insights on professional growth and leadership. With a combined 40 years of experience in dermatology and leadership, both emphasized the importance of setting clear personal goals and proactively seeking opportunities rather than waiting for them to appear. “Opportunity is for those who seek it out,” they reminded attendees, encouraging active involvement in local and national physician assistant organizations and the use of one’s unique skill sets and passions to drive career advancement.

Miller highlighted that professional engagement can take many forms, even for those who don’t enjoy public speaking, such as serving on advisory boards, contributing data for publications, or consulting. She urged attendees not to wait for permission or invitations to lead.

“Don’t wait to be asked; create your own opportunities. You’re capable of more than you give yourself credit for. Your only limitation is you. Say yes, then figure it out later,” Miller told attendees.

Miranti encouraged attendees to take initiative and find their professional niche, whether by publishing a successful case, writing about a passion, collaborating with peers on projects, attending webinars, or creating a professional LinkedIn presence.

On the topic of work-life balance, Miller offered a grounded perspective: Work-life balance is not a fixed state but a dynamic process. “You’re often juggling many plates,” she said. “You have to be OK with some falling—just know which ones can and cannot break.”

Psoriasis Update: What’s New in 2025

Benjamin Lockshin, MD, FAAD, took the stage, delivering key insights with his characteristic wit. He began by discussing the link between obesity and psoriasis, highlighting that both conditions are associated with higher rates of cardiovascular disease and metabolic syndrome. Lockshin explained that adipose tissue is pro-inflammatory and that body weight is an important consideration when selecting systemic therapies. He emphasized that obesity not only worsens psoriasis severity but can also limit treatment response, whereas lifestyle modifications, including diet, exercise, and intentional weight loss, can improve outcomes. He noted that glucagon-like peptide-1 receptor agonists for weight management have shown promise for patients with psoriasis. However, larger randomized studies are needed.

Regarding the risk of hepatitis B virus reactivation, Lockshin reviewed data by drug class: TNF-α inhibitors carry the highest risk, followed by IL-12/23 and IL-17 inhibitors, whereas IL-23 inhibitors demonstrate the lowest risk. Lockshin also summarized the International Psoriasis Council’s updated classification criteria for systemic therapy. According to the guidelines, patients must meet at least 1 of 3 criteria: involvement of high-impact sites (face, scalp, genital, palmoplantar, nails, or intertriginous areas), more than 10% body surface area affected, or failure to respond to topical therapy.

He concluded by emphasizing that adequate vitamin D status may play an important role in the prevention of mortality and cardiovascular disease among individuals with psoriasis.

2025 Atopic Dermatitis Update

Lockshin returned to educate attendees on key updates in the AD landscape. He reinforced points from Miller, noting that data on dupilumab use in pregnancy are reassuring. Dupilumab has been shown to improve AD severity during pregnancy without increasing major maternal, fetal, or labor complications, and it does not appear to raise the risk of spontaneous abortion. Lockshin also highlighted that 2 ongoing observational studies are further monitoring the safety of dupilumab in patients who are pregnant.

Lockshin emphasized the strong relationship between AD and sleep disruption, which contributes to reduced quality of life, higher rates of anxiety and depression, and increased daytime dysfunction. He also noted that AD and attention-deficit/hyperactivity disorder (ADHD) are independent risk factors for each other, highlighting the importance of screening patients, especially those with severe disease or significant sleep issues, for ADHD symptoms. Early, targeted interventions and multidisciplinary care are critical to address both dermatologic and neuropsychiatric comorbidities.

Regarding infection risk, Lockshin explained that IL-4 and IL-13 inhibitors significantly reduce the risk of skin infections, whereas Janus kinase (JAK) inhibitors can increase rates of herpes zoster and herpes simplex virus. Preventive measures such as daily moisturizers, regular bathing, and diluted bleach baths remain important components of AD management. Finally, Lockshin reviewed emerging systemic treatment options for AD, including therapies targeting the OX40/OX40 ligand pathway, as well as delgocitinib, a recently FDA-approved topical treatment for chronic hand eczema.

Cutaneous Adverse Drug Eruptions

Misha Rosenbach, MD, captivated attendees with a complex yet engaging lecture delivered with his signature flair. He began by reviewing morbilliform eruptions, which present as blanchable erythematous macules and papules. These eruptions account for 75% to 90% of all cutaneous adverse drug reactions and typically occur 4 to 14 days after initiating a new medication, though they may appear 1 to 2 days after discontinuation. Rosenbach noted that in hospitalized patients, lesions often develop on dependent areas such as the back, whereas in the outpatient setting, they more commonly appear on pressure sites. Among the most frequent culprits are antibiotics, antiepileptic agents, and allopurinol. He recommended discontinuing all nonessential medications and emphasized obtaining a thorough drug history to identify the offending agent. If the eruption involves the mucosa, palms, soles, or face and becomes vesicular, he cautioned clinicians to consider alternative diagnoses, such as Stevens-Johnson syndrome.

Rosenbach highlighted that drug reactions with eosinophilia and systemic symptoms can resemble a severe morbilliform eruption with marked facial involvement. He emphasized that this rash typically spares the orbital rim and appears intensely erythematous. Prompt recognition is critical. He urged clinicians to make the diagnosis and either initiate systemic corticosteroids and refer to the emergency department (ED) or send patients directly to the ED, noting that treatment often requires up to 2 months of steroids.

He then reviewed acute generalized exanthematous pustulosis, clarifying that the pustules seen in this condition are not folliculocentric. Rosenbach concluded by discussing the wide spectrum of cutaneous reactions associated with oncologic therapies. These agents, he explained, “unleash the immune system” to fight cancer, resulting in numerous off-target skin manifestations. Importantly, such eruptions may indicate good drug efficacy, and in many cases, clinicians can treat through them without discontinuing the oncologic medication.

Complex Medical Dermatology

Rosenbach, a staple of Keystone Dermatology, kept the audience engaged with his dynamic talk on complex medical dermatology. He opened the session with a review of urticaria and its clinical mimickers before discussing the association between bullous pemphigoid and DPP-4 inhibitors. When addressing Sweet syndrome, he described the lesions as “juicy,” presenting as erythematous nodules or plaques.

Rosenbach then delved into the intricate nature of pyoderma gangrenosum (PG), emphasizing that it remains a diagnosis of exclusion. He highlighted pathergy as a key diagnostic finding and described PG as a rapidly progressive necrolytic ulcer with irregular, violaceous, and undermined borders. Cribriform scarring may be seen at sites of healed lesions, and the condition responds well to systemic corticosteroids. He also noted the frequent association between PG and inflammatory bowel disease.

The lecture concluded with a review of dermatomyositis and its hallmark cutaneous features, including Gottron papules and signs, heliotrope rash, V and shawl signs, periungual erythema and telangiectasia, dystrophic cuticles, psoriasiform scalp eruption, poikiloderma, and calcinosis cutis. Rosenbach also discussed that certain serologic subtypes—specifically TIF1γ and NXP2—carry an increased risk of malignancy.

Scarring Alopecia

John Seykora, MD, PhD, began his presentation by reviewing the HoVert technique, a biopsy method in which a 4-mm punch specimen is sectioned to yield both horizontal and vertical tissue samples for microscopic evaluation. He explained that this dual-plane approach can be particularly valuable in differentiating between lichen planopilaris (LPP) and lupus erythematosus.

Seykora then turned his attention to central centrifugal cicatricial alopecia (CCCA), describing it as a chronic, progressive form of central scalp hair loss that expands centrifugally. Clinically, CCCA presents with a shiny scalp and marked follicular dropout. Although most prevalent among women of African descent, it has also been reported in men and individuals of other races. Hair breakage, he noted, may serve as an early and subtle indicator. Seykora emphasized that biopsies should be obtained at the active margin rather than from the scarred center of the lesion and highlighted emerging evidence supporting JAK/STAT pathway modulation as a promising therapeutic avenue for CCCA.

LPP was reviewed next, with Seykora describing its classic “footprint in the snow” appearance and characteristic perifollicular erythema and hyperkeratosis. He went on to discuss frontal fibrosing alopecia, noting that although its pathogenesis remains uncertain, hallmark findings include the lonely hair sign, progressive frontal hairline recession, and perifollicular erythema and hyperkeratosis. Atrophy and facial vellus papules may also occur, and involvement can extend beyond the frontal scalp to include the eyebrows, occipital scalp, and other body sites.

In discussing discoid lupus erythematosus, Seykora highlighted the diagnostic carpet tack sign and the characteristic spectrum of erythema, hypopigmentation, and hyperpigmentation. He pointed out that lesions within the conchal bowls can serve as a valuable diagnostic clue. The session concluded with a review of traction alopecia, featuring the fringe sign and the dermoscopic flambeau sign, which appears as white torchlike tracks with casts encircling the proximal hair shaft in the direction of hair pull. Seykora closed on an optimistic note, emphasizing the growing role of precision medicine in identifying novel therapeutic targets for scarring alopecias.

Nonscarring Alopecia

Seykora closed out the first day of the Keystone Dermatology Conference with an engaging review of nonscarring alopecias. He began by discussing androgenetic alopecia, outlining current therapeutic strategies and key clinical features, such as variable hair shaft caliber on dermoscopy, part widening in women, and classification using the Hamilton-Norwood Scale in men.

He then reviewed telogen effluvium (TE), describing it as a common, diffuse, nonscarring alopecia that is typically self-limited and often triggered by stress. In acute TE, hair loss tends to be generalized, whereas chronic TE more commonly involves temporal thinning. Seykora noted that topical minoxidil can be variably effective and advised clinicians to counsel patients about increased shedding upon initiation, a sign that the treatment is working.

To conclude, Seykora presented several illustrative cases. He highlighted that loose anagen hair syndrome may present with hair that fails to grow long, and that microscopic examination of a hair pull often reveals a distinctive “hockey stick” morphology. He also reviewed Chediak-Higashi syndrome, characterized by silvery hair due to giant melanosomes formed from abnormal melanosome aggregation.

Jamie Restivo, MPAS, PA-C, is a board-certified dermatology physician assistant practicing in Enola, Pennsylvania, and current president of the Pennsylvania Dermatology Physician Assistants. She is also a PA/NP Emerge and LEAP Faculty, as well as the host of The Spot Check podcast.