Warts, HS, and Pediatric Patch Testing with Dr. Liszewski
In this second installment of conference coverage from Elevate-Derm in San Diego, Dr. Walter Liszewski tackled some of the toughest everyday problems in general dermatology, starting with warts in immunocompromised patients. His practical point: the HPV vaccine can be effective even when warts already exist, and there's evidence to support trying it. For transplant patients, he checks with the transplant team first, knowing the patient may not mount a proper antibody response, but reasoning it's at least something worth attempting given how stubborn warts are in this group.
On hidradenitis suppurativa, Liszewski argued that the right time to start systemic therapy is earlier than most clinicians think. Once you're seeing extensive scarring and tunnel formation, you're already dealing with structural morbidity. His ideal window is when a patient has recurrent nodules and abscesses despite topical or oral therapy, but before the tunneling and scarring set in — 'once the gene is out of the bottle, it's hard to get it back in.' He generally avoids chronic oral and IV antibiotics, calling them an unsustainable long-term solution, though he'll use topical clindamycin with benzoyl peroxide or chlorhexidine washes and a short oral course during a bad flare.
For patch testing in kids, Liszewski prefers actual patch testing using a dedicated pediatric series — one his colleague Jeff created several years ago — because children react to different allergens than adults and have less surface area for testing. Once a child reaches about 11 or 12, he switches to the standard adult series.
AI, Atopic Dermatitis, and Psoriasis Updates with Dr. April Armstrong
Dr. April Armstrong from UCLA said she now sees one or two patients per clinic arriving with AI-generated information, and she doesn't discourage it — she meets patients where they are, noting many already suspect the AI could be wrong, which is why they came to her. She cautioned that AI tools offering diagnostic or management recommendations generally fall under FDA regulation as medical devices, and that the source data training many triage apps varies tremendously, with some not yet validated on large data sets. On ambient scribing, she noted it can reduce clinician burden, and interestingly her older faculty have embraced it more than younger ones — but she stressed notes must be proofread. Her most frustrating part of AI: 'AI can always sound very confident even though it is wrong.'
For refractory atopic dermatitis, Armstrong doesn't use a predetermined length for combination therapy. She waits until the patient achieves clear or almost clear and stable control, then begins to taper the agent that contributes least to long-term goals — especially ones with higher safety concerns or lab monitoring needs. She thinks the field is moving closer to a 'treat to clear' model for AD as the toolbox and pipeline expand, though it isn't quite where psoriasis is yet.
On psoriatic disease, Armstrong walked through the evolving stance on TB screening. Newer recommendations suggest that for patients without baseline TB risk factors, pre-treatment TB testing may be unnecessary for IL-17 and IL-23 inhibitors — based on real-world data where missed pre-treatment evaluations didn't lead to increased reactivation. She emphasized, however, that drug labels still require pre-treatment TB for most biologics, so clinicians must still do it in practice. She defined high risk as travel to or contact with people from TB-endemic areas. She also noted oral candidiasis was seen in the ORCA study of the newer IL-17 A&F agent, but most cases were mild and did not lead to discontinuation.
Dermpath Pearls with Dr. Maria Robinson
Dr. Maria Robinson, a board-certified dermatologist and dermatopathologist, offered concrete biopsy guidance. Most rashes are best sampled with a 4 mm punch that actually goes all the way through — a superficial punch doesn't count. The exception she highlighted is mycosis fungoides, where a broad shave gives more surface area to look for atypical lymphocytes at the dermal-epidermal junction. If you see 'epidermotropism' on a report, most dermatopathologists are considering MF in the differential, though it may take multiple biopsies to confirm.
For scalp alopecia workups, Robinson explained vertical sectioning (epidermis to subcutis) versus horizontal sectioning (cutting left to right), noting pathologists vary in preference and many read both. Clinicians can call the lab ahead to learn how specimens are processed, request both methods, and should do a larger punch — she suggested a 6 mm — so the specimen can be split for both. She also encouraged sending clinical photos, whether through the EMR or even a cell phone picture (with sign-off) tucked into the biopsy bag.
Robinson reminded listeners that partially treated rashes can blunt diagnostic histologic features — even hyphae in tinea — so biopsy the least-treated lesion and tell the lab if it's been treated. For an evolving eruption like PLEVA, she welcomes multiple biopsies across different stages and sites: 'I personally would rather have more information than less.' On melanocytic lesions, she emphasized that sampling error is the biggest challenge and a biopsy isn't meant to fully remove the lesion. Re-pigmentation in a scar becomes a problem when no one knows what was there before, so documenting prior biopsies and relying on clinical judgment to re-biopsy anything atypical is key.
Surgical and High-Risk Skin Cancer Management with Dr. Ashley Elsensohn
Dr. Ashley Elsensohn, a Mohs surgeon and dermatopathologist, walked through pre-operative essentials. The key vital sign is blood pressure, with a general cutoff around 180/120 — recheck and let the patient relax if they're above it, though there's less evidence to stop surgery if that's their known baseline. For anxious patients she feels comfortable prescribing an anxiolytic at consultation, often Valium 5 mg (most evidence) or Ativan taken one to two hours before, always requiring a driver and someone to stay with them all day. The main reason to control blood pressure isn't just intraoperative bleeding (often managed with epinephrine) but the increased risk of cardiovascular events like heart attack and stroke afterward.
On hedgehog inhibitors, Elsensohn said Mohs or excision can be done during or after therapy, timed around the six-to-eight-month mark when maximum tumor shrinkage occurs, since most patients only tolerate the drug about a year. Because tumors regress spottily rather than contiguously, she emphasized cutting out the original footprint at its largest size — making pre-treatment photos and location documentation critical. For large, high-risk squamous cell carcinomas, intraoperative staging by sending the bulk deep tissue to pathology can reveal depth and large-caliber perineural invasion that the initial biopsy missed, changing staging and decisions about adjuvant radiation.
Elsensohn sees a clear role for dermatology PAs and NPs as stewards for the roughly 1% of truly aggressive tumors. For patients on immunotherapy like cemiplimab, APPs perform skin cancer screenings, watch for immune-related adverse events such as rashes and blisters, and triage referrals to medical oncology, ENT, or radiation oncology. She noted NCCN guidelines recommend field therapy for high-burden patients — sunscreen counts and reduces skin cancer by about 50%, with 5-FU plus calcipotriene preferred given the data, plus acitretin for advanced patients, which itself requires the monitoring and follow-up APPs are well-positioned to manage. She also flagged surgical fatigue in patients with basal cell nevus (Gorlin) syndrome, where guidelines support more ED&C and not Mohs for every small lesion.