Clinical Pearls from the PDPA Sixth Annual Keystone Dermatology Conference: Day 2

Management of Hidradenitis Suppurativa in Special Patient Populations: A Case-Based Approach

Sherry Yang, MD, delivered an engaging, case-based lecture on the management of hidradenitis suppurativa (HS), emphasizing the impact of hormonal factors on disease expression. She highlighted that up to 60% of women experience menstrual flares and reviewed the role of combination oral contraceptive pills in treatment. Yang encouraged clinicians to gain confidence in prescribing contraception or collaborate with specialists to prevent treatment delays.

She discussed the bidirectional link between polycystic ovary syndrome (PCOS) and HS, reviewed the Rotterdam diagnostic criteria, and noted that patients with PCOS are excellent candidates for combination oral contraceptives, drospirenone, spironolactone, and metformin. Family planning considerations were addressed, including the variable course of HS during pregnancy. Yang shared a practical discontinuation timeline: 1 month for spironolactone and isotretinoin, 1 week for oral tetracyclines, and discontinuation upon pregnancy confirmation for IL-17 inhibitors.

Safe options during pregnancy included topical and intralesional corticosteroids, oral cephalexin, metronidazole, and clindamycin for rescue therapy, and metformin and TNF-α inhibitors for maintenance therapy.

Yang also presented a case of HS in a transgender male, continuing testosterone while adding combined oral contraception and isotretinoin after multiple treatment failures. She concluded by discussing HS tarda, which manifests as disease onset after age 60, and lastly, reminded attendees of the therapeutic value of secondary intention healing.

Common Nail Clinic Consults and How I Manage Them

Adam Rubin, MD, took to the stage with his signature blend of expertise, humility, and engaging clinical insight. He began with an overview of onychomycosis, underscoring the importance of proper sample collection for accurate diagnosis.

“Not every nail disorder is fungal,” he reminded attendees, encouraging routine testing rather than empirical treatment. Among topical therapies, efinaconazole 10% solution was highlighted for achieving higher complete and mycologic cure rates compared to other options. Rubin also discussed oral terbinafine dosing strategies, including therapeutic adjustments for resistant infections.

He then reviewed the presentation and management of dermatophytoma, emphasizing that physical removal of the fungal mass, whether through surgical or chemical avulsion, is essential. Topical therapy, rather than oral, remains preferred in these cases due to the limited biofilm penetration of oral therapies. Chemical avulsion using 40% urea cream under occlusion was discussed as a practical, non-surgical alternative. Rubin cautioned that persistent nail changes despite therapy warrant further evaluation for alternative diagnoses, including malignancy. He reminded clinicians that onychomycosis may coexist with benign or malignant nail tumors, a consideration especially critical in immunosuppressed patients.

Turning to melanonychia, Rubin advised clinicians to view a triangular-shaped pigmented band as a warning sign of evolving pathology and possible malignancy. Dermoscopic clues were reviewed: regular lines may indicate a nail nevus, while a grayish background with thin gray lines is suggestive of a benign lentigo, drug-induced pigmentation, or ethnic pigmentation. He concluded with pearls on onycholysis, emphasizing the importance of behavioral modification and regular nail trimming as cornerstone management strategies.

Surgical Pearls

Mark Abdelmalek, MD, delivered an insightful hour-long session on surgical pearls, opening with the often-overlooked importance of high-quality clinical photography. He emphasized capturing “mole constellations” and clearly marking lesions to ensure accurate identification between biopsy and excision. Abdelmalek shared his own checklist system designed to reduce medical errors and streamline workflow, along with photos of his surgical tray setups that his team uses to maintain efficiency and consistency.

On preoperative preparation, he advised that hair removal prior to procedures is generally unnecessary. When needed, clipping is preferred over shaving to prevent microabrasions and reduce infection risk. A practical pearl he shared: wrap Hypafix tape around a gloved hand to collect stray hairs before surgery.

Abdelmalek reviewed the fundamentals of elliptical excision, emphasizing that the length of the excision should be approximately three to four times its width to achieve optimal cosmetic results. Attention to labeling was underscored with his memorable rule, “No label, no specimen!” reinforcing that a specimen should never be placed in an unmarked container.

He also discussed sharps management, recommending that instruments be grouped together for better visibility and to minimize needle stick injuries. For patients with suspected lidocaine allergy, an uncommon occurrence, he suggested referral for allergy testing. In rare circumstances where anesthetic cannot be used, saline may suffice for a biopsy, though he cautioned, “Be fast!”

Undermining excisions, Abdelmalek explained, helps reduce wound tension, improve tissue approximation, and prevent scar depression and spreading. For hemostasis, his advice was simple yet effective: pause and apply pressure - patience often achieves the best results.

He concluded his lecture with examples of excellent cosmetic outcomes and a final pearl for surgeons: invest in a blade remover, a small cost for safety and adequate preservation of surgical tools.

New Trends in Acne and Rosacea

Shanna Miranti, PA-C, opened her 30-minute session with a review of the four pillars of acne pathogenesis and the therapies that address each. She emphasized the importance of targeting as many pillars as possible without overcomplicating the regimen, noting that early intervention and diligent sunscreen use to reduce dyschromia are essential for treatment success.

Miranti highlighted clascoterone as the only topical agent proven to reduce excess sebum, recommending twice-daily application for best results. Isotretinoin, she noted, remains the only oral therapy that addresses all four pathogenic pillars of acne.

Special consideration was given to topical therapies in skin of color. Trifarotene 0.005% cream has demonstrated efficacy in reducing acne-associated postinflammatory hyperpigmentation, while tazarotene 0.045% was also shown to improve hyperpigmentation in this population. Miranti further recommended tazarotene 0.045% as an ideal post-isotretinoin maintenance therapy to address acne sequelae, including postinflammatory erythema, hyperpigmentation, and scarring, and to prevent acne recurrence. She advises initiating topical therapy the night after the final isotretinoin dose.

Transitioning to rosacea, Miranti reviewed its multifactorial pathogenesis involving inflammatory cytokines, genetic susceptibility, microbiome alterations, neurocutaneous triggers, and barrier dysfunction. Successful management, she noted, requires a multimodal approach with additional emphasis placed on gentle skincare and trigger avoidance. She concluded by highlighting the newly approved low-dose oral minocycline hydrochloride 40 mg as a promising option, demonstrating superior outcomes compared to traditional low-dose doxycycline.

Boxed Warnings in Dermatology: What Does the Evidence Say?

Nicholas Brownstone, MD, delivered a compelling session on the history, interpretation, and clinical implications of Food and Drug Administration (FDA) boxed warnings (BWs). Introduced in 1979, BWs are federally regulated and may be based on either clinical data or serious animal toxicity in the absence of human evidence. Brownstone reminded attendees that a definitive causal relationship is not required to warrant a boxed warning. More than 400 medications currently carry BWs, which are rarely revised, and approximately 10% of drugs acquire a warning post-approval. Notably, 2023 marked a surge in new therapeutics and a corresponding 40% of all existing boxed warnings, largely driven by postmarketing safety data.

Brownstone reviewed the evidence behind warnings for brodalumab, Janus kinase (JAK) inhibitors, and topical calcineurin inhibitors. In discussing brodalumab for psoriasis, he emphasized that clinical trials did not exclude patients with psychiatric histories or risk factors for suicide. Among 4,464 global participants, 3 suicides were confirmed, each associated with identifiable external stressors: financial difficulties, impending incarceration, and social isolation in a patient with a known history of depression. He urged clinicians to contextualize such events, noting that neither IL-17A inhibitors nor brodalumab crosses the blood–brain barrier and that data do not support a causal link between IL-17 inhibition and depression or suicidality.

Regarding JAK inhibitors, Brownstone highlighted that current US boxed warnings are not evidence-based for dermatologic use. The most consistent adverse effects supported by data include acne, nausea, headache, herpes simplex, zoster, and eczema herpeticum. He contrasted dermatology patients, typically healthier, with those in rheumatology trials, where higher baseline risks contribute to greater adverse events. Proper patient selection, he stressed, is key to minimizing risk. International labeling varies: Japan includes infection and malignancy warnings with uncertain causality, while European inserts flag additional caution in elderly patients and those with risk factors.

As for topical calcineurin inhibitors, Brownstone reaffirmed that current evidence does not support a causal relationship between their use and the development of lymphoma.

He concluded with recommendations to the FDA, calling for a shift in terminology from “warning” to “special consideration” or “advisory,” and urging that all labeling be grounded in robust, evidence-based data rather than extrapolated class effects. Brownstone closed on a lighthearted note, sharing a photo from his travels to Spain and reminding colleagues to “stop and smell the roses” along the way.

Practical Psychodermatology

Brownstone returned to the stage for his final lecture to share pearls in practical psychodermatology, opening with a powerful reminder: “Skin disease may not be life-threatening, but it is often life-ruining.” He urged clinicians to lead with empathy, noting that chronic itch alone can diminish quality of life to the same degree as heart failure, stroke, and emphysema. Citing JAMA Dermatology, Brownstone highlighted the association between atopic dermatitis (AD) and suicidality, emphasizing that early-onset AD affects not only patients but entire families, disrupting sleep, finances, and child behavior.

Addressing acne, he described its profound effect on identity and self-esteem, often exacerbated by social media. Brownstone warned against “empathic failure,” reminding clinicians that even a single breakout can feel devastating to a patient and that emotional distress is often disproportionate to visible disease severity.

He then turned to psoriasis, a lifelong condition he encourages patients to view as “what I have, not what I am.” This highly visible disease, he noted, can deeply affect work, relationships, and social interaction. Even with clear skin, many patients live in constant fear of relapse. HS, he added, brings its own psychological and sexual challenges. Pain, malodor, and lesions in intimate areas can cause distress and contribute to sexual dysfunction, with erectile dysfunction affecting more than half of male patients.

In discussing management strategies, Brownstone advocated for a collaborative, non-paternalistic approach. “I won’t give up on you if you don’t give up on me,” he tells patients, underscoring the importance of partnership and persistence. He encouraged clinicians to proactively escalate therapy when quality of life is compromised and to involve mental health professionals without hesitation.

When addressing delusions of parasitosis, Brownstone emphasized the importance of rapport: “Rapport first, medication later.” Building trust may require multiple visits, and clinicians should maintain open body language and a positive attitude. He recommended offering a thorough workup, as delusional parasitosis can be secondary to underlying conditions such as severe iron deficiency anemia. Brownstone reassures patients that management is often “trial and error,” describing their condition as “mysterious” and focusing the discussion on relief rather than determining the precise etiology. He stressed the value of validating patients’ distress while guiding them toward recovery.

For treatment, he highlighted pimozide as an effective and well-tolerated option. Because it carries an FDA indication for Tourette’s syndrome, it avoids the stigma often associated with antipsychotic medications. Brownstone explains that pimozide “kills parasites,” referencing in-vitro evidence to support this phrasing, helping patients to accept therapy more comfortably.

How to Hack Your Accutane Prescribing

In her next session, Miranti shared practical strategies for efficient and effective isotretinoin management. She emphasized the value of standardized protocols within the electronic medical record for scheduling, documentation, and pharmacy coordination tailored to both initiation and follow-up visits, as well as patient gender. Collaborating with specialty pharmacies familiar with isotretinoin protocols and maintaining reliable stock, she noted, is key to avoiding treatment delays, particularly for female patients navigating iPLEDGE requirements.

Miranti recommends that pharmacies process prescriptions in the following order for best results: Absorica LD 32 mg, Absorica 40 mg, Accutane (Journey brand), and Claravis, reserving the latter for Medicaid patients when it is the sole formulary option.

Ideal isotretinoin candidates include those who have failed appropriate guideline-directed therapies, exhibit scarring, or are dissatisfied with current regimens. She advised avoiding treatment in patients who are pregnant, lactating, or planning pregnancy within the next year, as well as in cases of liver disease, alcoholism, or poorly controlled diabetes. Prepubescent males and patients motivated by peer influence rather than medical indication should also be approached cautiously. Importantly, Miranti emphasized that a history of depression or inflammatory bowel disease is no longer considered a contraindication, as no causal link has been established. Her “Do’s and Don’ts” list offers actionable counseling points.

Do: obtain bloodwork a few days before visits, use two forms of contraception for female patients, stay hydrated, wear sunscreen, and keep the skin and lips moisturized. Don’t: consume alcohol, take acetaminophen, donate blood, or wax.

Setting realistic expectations is critical, Miranti noted. Patients often don’t achieve full clearance until months 4 or 5. During the first 3 months, roughly one-third of patients purge, one-third remain stable, and one-third do not purge. Regular photography helps track progress and reinforce what “normal” improvement looks like.

For dosing, Miranti recommends starting all patients at 40 mg daily, then titrating to 1 mg/kg, continuing therapy for at least 5 months or until a cumulative dose of 120–150 mg/kg is reached. Patients should remain clear for 1 month before discontinuation. She favors Absorica LD for repeat courses and notes that concurrent spironolactone can help mitigate early flares. Continuation of topical therapy during treatment may also enhance outcomes.

Miranti advises stopping isotretinoin once patients reach 20 weeks, achieve the cumulative target, and remain clear for 1 month. If needed, dose adjustments are appropriate: “One or 2 more months now are better than a full repeat course later,” she reminded attendees. To maintain results, she recommends initiating tazarotene 0.045% lotion (Arazlo) the night after the final dose to extend remission, prevent recurrence, and address residual erythema, pigmentation, and scarring.

Practical Dermoscopy

Jennifer Stein, MD, PhD, captivated attendees with an engaging deep dive into the art and science of dermoscopy, an essential tool in the early detection and management of skin cancer. She emphasized that every clinician should strive to master dermoscopy to improve diagnostic accuracy and patient outcomes.

Stein guided the audience through the challenges of assessing facial, acral, and mucosal lesions, areas that demand precision given their unique histologic anatomy and cosmetic sensitivity. Missteps in these regions can lead to unnecessary biopsies, making pattern recognition vital.

In her discussion of lentigo maligna (LM), Stein reminded clinicians that LM “follows the hair follicles,” explaining why key dermoscopic clues are often perifollicular. Diagnostic features include gray dots, asymmetric follicular openings, rhomboidal structures, and homogeneous areas that fail to “respect” or obliterate follicular patterns. While gray pigmentation is nonspecific, she cautioned, “If you see gray, don’t look away.” Other hallmark signs include the “circle-in-a-circle” pattern and the memorable warning, “pink and brown should make you frown.”

For pigmented actinic keratoses, Stein highlighted the presence of scale and rosettes under dermoscopy. She added a vivid clinical pearl: seborrheic keratoses that darken near the hairline after hair dye exposure resemble “an English muffin soaking up jam.”

Turning to acral dermoscopy, Stein simplified interpretation with the phrase, “furrows are fine, ridges are risky.” The ink furrow test, she explained, helps distinguish these structures when patterns appear ambiguous. She showcased benign physiologic volar melanotic macules in skin of color in contrast with acral melanomas, which typically present as outlier lesions.

Her discussion of acral congenital melanocytic nevi introduced the “peas in a pod” designation: a combination of parallel furrow and crista-dotted patterns, both benign. “Dots on the ridge are okay,” she clarified, “but a parallel ridge pattern is not.” Stein also noted that congenital nevi often fade with time, whereas an acquired globular pattern should raise concern for acral melanoma.

Finally, Stein explored mucosal dermoscopy. Melanotic macules usually appear structureless or exhibit a benign “fish-scale” pattern, while mucosal melanomas often reveal a multicomponent architecture.

Stein closed by reminding clinicians that dermoscopy is a craft honed through practice and persistence. She encouraged the use of serial photography to accelerate learning and applauded online educational platforms such as Dermoscopedia.org for those eager to refine their diagnostic eye.

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.