Matthew Zirwas, MD

Segment summary: In the final episode of the series, the discussion turns to therapies currently in development for CSU. The agent generating the most excitement is an investigational anti-Kit monoclonal antibody, the first treatment designed to directly bind and eliminate mast cells rather than simply blocking their activation. Early trial data show strong efficacy, but the drug carries a notable cosmetic side effect: because it also affects melanocytes, a substantial proportion of patients experience hair whitening and skin depigmentation, a tradeoff the panel notes is worth discussing openly with patients before treatment begins.

Emerging Therapies on the Horizon for CSU

This may become the most effective option available once approved, though tolerance for the side effect will vary widely; some patients may be far less concerned about changes in hair or skin pigmentation than others. Beyond this mast cell-depleting agent, a broader pipeline of CSU candidates is moving through preclinical and early clinical phases, and while not all will ultimately succeed, this is characterized as an unusually exciting period for the field. Development also continues within the oral BTK inhibitor class, with next-generation, even more selective agents already being explored.

The discussion closes with reflection on how far CSU management has progressed, from a historically underdiagnosed and undertreated condition to one with multiple safe, effective, and rapidly expanding treatment options. Between the therapies already available and the candidates still in the pipeline, clinicians and patients alike have genuine reason for optimism, and the pace of innovation in CSU shows little sign of slowing as additional mechanisms of action continue to move through clinical development. Thank you for watching this HCPLive Peers & Perspectives series on chronic spontaneous urticaria. Please subscribe to our enewsletter for information on upcoming video series.

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In the final episode of the series, the discussion turns to therapies currently in development for CSU.

Segment summary: In this episode titled “Building Therapeutic Alliance and Addressing Access Barriers in CSU,” the panel focuses on practical strategies for empowering both patients and clinicians earlier in the CSU care journey. Effective communication is framed around three things patients want when they present with CSU: relief of symptoms, an explanation for why this happened, and a sense of control over their condition. Confidently explaining that CSU is autoimmune rather than allergic is emphasized, since most patients arrive assuming a food allergy is to blame.

Building Therapeutic Alliance and Addressing Access Barriers in CSU

Rather than directly contradicting that belief, the panel validates it by introducing newer evidence that diet does play a role, but through salicylate sensitivity rather than true allergy; patients are advised to avoid NSAIDs, aspirin, and other salicylate-containing products, acetaminophen remains safe, and following a low-salicylate diet has been shown in a randomized, placebo-controlled trial to reduce disease severity. This reframing builds a therapeutic alliance by addressing all three of the patient’s underlying concerns without delaying initiation of effective therapy, while still allowing referral to allergy specialists for patients who request it.

The conversation closes on real-world access barriers: it is considerably easier to secure the dermatology-focused biologic and the oral BTK inhibitor for patients because office staff are well versed in those approval processes, whereas the allergy-focused anti-IgE biologic is comparatively harder to navigate due to limited internal experience with its support programs. Both speakers note the added logistical burden of mandated post-injection observation periods for the biologics, despite the absence of any reported anaphylaxis cases in CSU patients receiving these therapies. The episode reinforces that addressing patient concerns directly and removing avoidable access friction are just as important to good outcomes as selecting the right medication. In the next episode, “Emerging Therapies on the Horizon for CSU,” the panel previews investigational agents in the CSU pipeline, including a novel mast cell-depleting antibody and next-generation BTK inhibitors.

In this episode titled “Building Therapeutic Alliance and Addressing Access Barriers in CSU,” the panel focuses on practical strategies for empowering both patients and clinicians earlier in the CSU care journey.

HCPLive Five: Maui Derm NP+PA Summer 2026

, held in Colorado Springs from June 24 to 27, brought together leading dermatologists to address diagnostic and treatment updates across numerous 

, including eczematous dermatitis, rosacea, autoimmune blistering disease, hair loss, and pigmentation disorders. From IL-13 inhibitor response as a patch testing gatekeeper to the expanding oral JAK inhibitor pipeline in vitiligo, this year's sessions reflected how targeted therapies are reshaping diagnostic sequencing across dermatology subspecialties.

 Nickel and ammonium persulfate are the most missed patch test allergens

 Ocular involvement in up to 50% of patients

 Suspect pemphigoid in patients > 65 years with treatment-resistant pruritus

 3 oral JAK inhibitors FDA-approved for severe alopecia areata

 Vitiligo affects up to 1% of population, half before age 20 years

rounds up 5 key takeaways NPs and PAs can apply in practice.

Eczematous Dermatitis: IL-13 Inhibitor Response Guides Patch Testing Decisions

Matthew Zirwas, MD, of Bexley Dermatology, discussed how IL-13 inhibitor response now guides patch testing decisions in eczematous dermatitis. He starts with a detailed history of product and exposure changes, then trials dupilumab or lebrikizumab across 6 weeks and 3 doses before considering patch testing. Nonresponse or worsening signals likely contact dermatitis warranting testing.

Zirwas identified nickel and ammonium persulfate as the 2 most missed allergens, noting dietary nickel can drive systemic contact dermatitis and ammonium persulfate exposure often stems from hot tub chemicals, both frequently excluded from standard patch testing.

Rosacea Staging: From Pediatric Erythema to Phymatous Disease

Hilary Baldwin, MD, from Atantla Health, used a single composite patient to trace rosacea from pediatric erythema through adult flushing, papulopustular disease, and late-stage phymatous and ocular involvement, matching treatment to each stage. Pediatric rosacea, affecting 4% or fewer children, is often missed because red cheeks appear benign. Background erythema responds to alpha agonists, flushing requires oral carvedilol or botulinum toxin, and telangiectasias need energy-based treatment. Papulopustular disease is the most treatable, with ivermectin, topical minocycline, and newer sub-antimicrobial oral options like Emrosi. Ocular rosacea responds to tetracyclines and topical ivermectin.

Pemphigus, Pemphigoid: Diagnosing Atypical Blistering Disease Presentations

Donna Culton, MD, PhD, of UNC School of Medicine, addressed atypical presentations of autoimmune blistering diseases. Pemphigus often presents with chronic oral ulcers rather than classic flaccid blisters, while pemphigoid may have a prodromal phase resembling urticaria or eczematous dermatitis. Culton advised suspecting non-bullous pemphigoid in patients > 65 years with pruritic disease unresponsive to first-line treatment. She cautioned that serology can be falsely negative, particularly in anti-p200 pemphigoid, and that perilesional biopsy is essential for direct immunofluorescence. Following dupilumab's 2025 FDA approval for bullous pemphigoid, NPs and PAs can initiate treatment earlier, reserving referral for treatment failure or diagnostic uncertainty.

Hair Loss Treatment: JAK Inhibitors and Oral Minoxidil Reshape Care

Benjamin Ungar, MD, of Mount Sinai's Alopecia Center of Excellence, called JAK inhibitors the biggest advance in hair loss treatment over the past 2 years, reshaping care for alopecia areata and scarring alopecia. 3 oral JAK inhibitors, baricitinib, ritlecitinib, and deuruxolitinib, are FDA-approved for severe AA, and Ungar's long-term data show no meaningful increase in cardiovascular or thromboembolic risk despite class-wide boxed warnings. He favors oral JAK inhibitors as first-line systemic therapy over traditional immunosuppressants. Low-dose oral minoxidil is increasingly used across hair loss subtypes, with hypertrichosis as the most common side effect. Ungar views nutraceuticals as adjunctive, useful mainly for patients with underlying nutrient deficiencies.

Vitiligo, Melasma: Pigmentation Treatment Pipeline Advances

George Martin, MD, of the Dermatology and Laser Center of Maui, reviewed advances in vitiligo and melasma treatment. Topical ruxolitinib remains the only FDA-approved topical vitiligo therapy, showing durable, increasing repigmentation through 2 to 3 years of treatment, though extensive disease above 50% body surface area requires additional systemic therapy. Oral JAK inhibitors, including povorcitinib, ritlecitinib, and upadacitinib, are advancing in additional late-stage trials and are expected to replace pulse-dose dexamethasone for widespread active disease.

For melasma, Martin emphasized combining lightening topicals with procedural treatment, noting current sunscreens inadequately block visible light despite its role in pigmentation.

5 dermatology takeaways from Maui Derm NP+PA Summer 2026, covering eczematous dermatitis, rosacea, blistering disease, hair loss, and pigmentation disorders.

Segment summary: This episode titled “Evaluating Biologic Options and Monitoring Response in CSU,” focuses on outcomes data for the biologic targeting the IL-4 receptor pathway, dupilumab. Over a 24-week horizon, overall efficacy is broadly comparable to remibrutinib, but the path to improvement looks different: the BTK inhibitor produces a sharp separation from placebo within about four weeks, while the biologic shows a more gradual, steady improvement that takes closer to four months to reach a similar plateau.

Evaluating Biologic Options and Monitoring Response in CSU

Dupilumab’s decade-long track record is highlighted, with millions of patients treated across other approved indications, and it appears even better tolerated in urticaria than in atopic dermatitis, where conjunctivitis is a known side effect that does not appear in CSU patients. As with the other advanced options, about two-thirds of patients do well while roughly one-third require a change in therapy. Patient preference ultimately hinges on desired speed of onset, route of administration, comorbid atopic conditions, and, for younger patients, age-based approval differences, noting dupilumab’s recent approval down to age two, though both speakers acknowledge seeing few or no pediatric CSU cases in their own practices.

On monitoring, a consistent 12-week follow-up across all three advanced therapy classes is used to decide whether to continue or switch, since waiting longer only prolongs patient suffering if a drug is not working. It is also routine to confirm that patients have not quietly discontinued their background antihistamine, which can mimic treatment failure. Finally, with three effective advanced options now available, cyclosporine use has become rare, with only one current patient remaining on it as an adjunct after a partial response to biologic therapy. In the next episode, “Building Therapeutic Alliance and Addressing Access Barriers in CSU,” the panel shares strategies for educating patients about the autoimmune and dietary aspects of CSU and discusses real-world coverage and access challenges.

This episode titled “Evaluating Biologic Options and Monitoring Response in CSU,” focuses on outcomes data for the biologic targeting the IL-4 receptor pathway, dupilumab.

Matthew Zirwas, MD

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