Evolving Treatment Strategies with James Del Rosso, DO

In a preview of sessions to be presented at the upcoming Winter Clinical Miami meeting, James Del Rosso, DO, spoke with Dermatology Times about evolving strategies for managing complex inflammatory skin diseases, with particular emphasis on hidradenitis suppurativa (HS) and atopic dermatitis (AD).

Advancing Care in Hidradenitis Suppurativa

Del Rosso highlighted how the understanding of HS has shifted in recent years. Once approached largely with conventional topical and oral therapies, HS is now recognized as a chronic, systemic inflammatory disease that requires a more comprehensive strategy.

Patients often present with painful nodules and abscesses in intertriginous areas such as the axillae, inframammary regions, and groin. Beyond physical symptoms—including drainage, malodor, and scarring—the psychosocial burden can be substantial. Del Rosso emphasized the importance of addressing not only active inflammation but also long-term disease progression, including the prevention of sinus tract formation and irreversible scarring.

Systemic therapies, including biologic agents targeting TNF and IL-17 pathways, have expanded the therapeutic landscape. However, he underscored that medical management is only one component. Procedural interventions, including deroofing and excision in selected patients, remain important tools. Just as critical is a thoughtful discussion of modifiable risk factors—particularly smoking and excess weight—which may exacerbate inflammatory burden and influence outcomes.

A recurring theme was the need for meaningful patient engagement. Many individuals with HS have experienced years of therapeutic frustration. Establishing trust, prioritizing current symptom control, and aligning on realistic goals are essential to re-engaging patients in care.

Nuanced Risk Assessment in Atopic Dermatitis

In a separate session, Del Rosso addressed therapeutic decision-making in moderate to severe AD. Case-based discussions focused on young women who may be candidates for Janus kinase (JAK) inhibitors but also have independent risk factors for venous thromboembolism (VTE), such as smoking or oral contraceptive use.

Clinical trial data with abrocitinib were reviewed, including a subset of women who were smokers and on oral contraceptives. In that cohort, no VTE events were observed, though the overall message was one of individualized risk stratification rather than reassurance alone. Patients who experienced thrombotic events in broader datasets typically had additional risk factors, such as obesity, immobility, or prior thrombotic history.

Toward Precision Treatment Selection

The discussion also explored emerging diagnostic tools, including a personalized AD inflammatory profile test developed by Castle Biosciences. By characterizing the relative contribution of Th2 versus non–Th2 pathways, such testing may help clinicians anticipate response to biologics targeting IL-4 and IL-13 versus JAK inhibition. Approximately one-quarter of patients may demonstrate a more heterogeneous inflammatory signature, potentially influencing therapeutic choice and expected speed of response.

Across both disease states, the overarching message was pragmatic and patient-centered: understand the biology, assess comorbidities and risk factors, and partner with patients to select therapies that align with both disease severity and individual circumstances.