Matthew Zirwas, MD

The Cost of Delay: How Prior Authorization Is Impacting Dermatology

 today, clinicians have access to an unprecedented array of biologics and targeted treatments designed to dramatically improving outcomes for individuals living with chronic inflammatory skin diseases such as atopic dermatitis, psoriasis, and hidradenitis suppurativa (HS).

However, according to 3 dermatologists interviewed by 

, gaining patients access to these drugs has evolved into a more and more complicated procedure. This, they and others in the field have noted, is due to prior authorization requirements, ‘step therapy’ protocols, and formulary restrictions caused by insurers and pharmacy benefit managers, also known as PBMs.

Prior authorization, the process by which health insurance plans go over and approve or deny various types of covered health services or medications, has evolved from an occasional administrative task into a routine part of practice management in dermatology.

 In this feature, the issues many clinicians have with the prior authorization process is explored, along with the potential need for future reforms.

Harrison Nguyen, MD, MBA, MPH, managing director of Harrison Dermatology & Research Group, was 1 such clinician who spoke with 

 about this complicated process as a substantial burden on both physicians and staff. While physicians may identify the most appropriate medication for a patient early in the visit, Nguyen highlighted the securing of a treatment’s approval as often requiring extensive paperwork, repeated communication with insurers, and dedicated personnel focused solely on navigating the authorization process.

Shannon Trotter, DO, known for her work with DOCS Dermatology Group, spoke with 

 about prior authorization, describing it as having long been a challenge in dermatology, though she highlighted the growing role of artificial intelligence (AI) in the process as both positive and negative. While AI tools can allow practices to better streamline submissions and diminish their own administrative workload, Trotter described insurers as also beginning to use similar technologies, creating what she described as an ongoing back-and-forth between providers and payers.

Outside of administrative burdens, all 3 of these clinicians emphasized the impact these barriers can have on patient care. Trotter pointed to step therapy requirements as a frequent source of delays, noting that patients may be required to try and fail therapies for months prior to gaining access to the medication their clinician originally recommended. During such time, a patient may continue experiencing symptoms that interfere with work, sleep, overall quality of life, or even becoming more debilitating.

Nguyen described formulary changes as also potentially forcing patients to switch from therapies that may already be working well. While some transitions occur without issue, he noted patients with conditions such as atopic dermatitis and HS can sometimes report disease worsening or loss of treatment response when required to shift between treatments for non-clinical reasons. In certain cases, Nguyen noted, interruptions in therapy can make future treatment far more challenging.

Matthew Zirwas, MD, a board-certified dermatologist at Dermatologists of Greater Columbus, spoke even more adamantly against prior authorization as a practice. Zirwas pointed to the growing number of available therapies as having intensified prior authorization challenges. He pointed to PBM rebate structures and limited transparency surrounding formulary decisions as key drivers of the issue, suggesting that treatment preferences often do not align with what clinicians believe is best for patients. Additionally, he noted his own view of the need for reforms that allow for incentives among PBMs to shift, as well as the need for more transparency.

Despite differences in emphasis, all 3 clinicians agreed that reform is needed. Proposed solutions included greater transparency around formulary and rebate decisions, streamlined authorization processes, improved peer-to-peer review systems, and reforms to step therapy requirements.

Overall, each of these 3 leaders in the field spoke in favor of a reduction of unnecessary barriers as helpful to ensure patients are given the right treatment at the right time, while nevertheless expressing the need to preserve access to the therapeutic advances known to have shaped the modern dermatologic landscape.

Disclosures: Trotter, Nguyen, and Zirwas had no relevant disclosures of note.

Amann ST, Shah ED, Wilson LJ. An Overview of the Challenging Process of Prior Authorization: Medical Necessity for a Better Way. Clin Gastroenterol Hepatol. 2024 Dec;22(12):2362-2366. doi: 10.1016/j.cgh.2024.09.001. Epub 2024 Sep 18. PMID: 39303798; PMCID: PMC11604005.

Sharma SP, Russo A, Deering T, Fisher J, Lakkireddy D. Prior Authorization: Problems and Solutions. JACC Clin Electrophysiol. 2020 Jun;6(6):747-750. doi: 10.1016/j.jacep.2020.04.022. PMID: 32553230.

Sampathkumar G. Rethinking prior authorization: bridging clinical needs and administrative burdens. Am J Manag Care. 2026 Feb 1;32(2):e31-e33. doi: 10.37765/ajmc.2026.89883. PMID: 41759204.

Kyle MA, Song Z. The Consequences and Future of Prior-Authorization Reform. N Engl J Med. 2023 Jul 27;389(4):291-293. doi: 10.1056/NEJMp2304447. Epub 2023 Jul 22. PMID: 37486761; PMCID: PMC10676707.

Wang Y, Levy JF, Mattingly TJ 2nd, Anderson G. Prior Authorization and Associated Delays and Denials of Branded Medication Dispensation. JAMA Health Forum. 2026 Apr 3;7(4):e260760. doi: 10.1001/jamahealthforum.2026.0760. PMID: 41996105; PMCID: PMC13090851.


Videos

This video feature highlights the views of dermatologists on prior authorization, step therapy, and issues related to these processes.

Key Off-Label Treatment Options in Dermatology, With Matthew Zirwas, MD

2026 Society of Dermatology Physician Associates (SDPA)

 Annual Summer Dermatology Conference, dermatologist Matthew Zirwas highlighted several practical off-label treatment strategies during the session 

‘No Label No Trouble: A Panel Review of Off-Label Medication Use,’ 

emphasizing the continued importance of affordable and versatile therapies in dermatology.

Oral roflumilast, a phosphodiesterase-4 (PDE4) inhibitor, is an underappreciated off-label option with efficacy approaching that of some biologic therapies.

Linezolid, an antibiotic more commonly linked with treatment of resistant bacterial infections, can be effective for difficult-to-treat cases of hidradenitis suppurativa and chronic folliculitis.

Generic tofacitinib is a development worth watching in the coming years in the dermatology field.

 following the presentation, Zirwas noted, despite the growing number of targeted therapies entering the field, clinicians will continue to face notable treatment gaps for many dermatologic conditions that lack US Food and Drug Administration (FDA)-approved options.

“I think the most important thing I'd like to get across to people is a drug called oral roflumilast,” Zirwas said. “So, this is a PDE4 inhibitor, just like apremilast, that we use for psoriasis, but it is substantially more effective.”

Off-Label Roflumilast for Psoriasis and Other Conditions:

Zirwas pointed to the presence of oral roflumilast as 1 of the most important takeaways from the session, describing the phosphodiesterase-4 (PDE4) inhibitor as an underappreciated option with efficacy approaching that of some biologic therapies while maintaining a favorable safety profile similar to that of apremilast. According to Zirwas, oral roflumilast offers a unique combination of effectiveness, accessibility, and affordability, with a cash price of only a few dollars per month.

Although psoriasis is 1 potential use case, he suggested the medication may be even more valuable in a variety of inflammatory dermatologic diseases that have limited treatment options, including granuloma annulare, cutaneous lupus, cutaneous dermatomyositis, and palmoplantar pustulosis. He also highlighted its utility as an adjunctive therapy for patients already receiving biologics, noting that it can provide an additional clinical benefit without significantly increasing treatment-related risk.

Off-Label Linezolid for HS and Chronic Folliculitis:

Zirwas also discussed the off-label use of linezolid (Zyvox), an antibiotic more commonly associated with treatment of resistant bacterial infections. He noted that short courses of linezolid can be highly effective for difficult-to-treat cases of hidradenitis suppurativa (HS) and chronic folliculitis, particularly in patients who continue to experience disease activity despite other therapies. Limiting treatment to approximately 10 days, he explained, helps preserve the medication’s favorable safety profile while providing meaningful clinical improvement.

Looking ahead, Zirwas predicted that off-label prescribing will remain an important component of dermatologic practice, largely because many rare or less common skin diseases are unlikely to receive dedicated FDA-approved therapies. He also identified generic tofacitinib as a development worth watching in the coming years, suggesting that lower-cost JAK inhibition could eventually expand treatment options across a broad range of dermatologic conditions.

Disclosures: Galderma Laboratories, L.P, Regeneron Healthcare Solutions, GENZYME CORPORATION, Arcutis Biotherapeutics, Lilly USA, Novartis Pharmaceuticals Corporation, Dermavant Sciences, LEO Pharma, Verrica Pharmaceuticals, Incyte Corporation, AbbVie, and Pfizer.

Zirwas M, Rosen T. No Label No Trouble: A Panel Review of Off Label Medication Use. Presented at SDPA Summer 2026. Jun 10-14, 2026.

Smith T. What Are Some Tips for Off-Label Medication Use in Dermatology? HCPLive. June 11, 2026. Accessed June 11, 2026. 

https://www.hcplive.com/view/what-are-some-tips-off-label-medication-use-dermatology-

In this SDPA Summer Dermatology Meeting interview, Zirwas speaks on treatment gaps for dermatologic conditions and off-label alternatives.

The Top 5 Atopic Dermatitis Studies in the Past 2 Years, with Matthew Zirwas, MD

Top 5 Atopic Dermatitis Studies in the Past 2 Years, with Matthew Zirwas, MD

 studies have been published in the past 2 years, but which ones are the most useful to dermatologists?

At the 2025 New Wave Dermatology meeting in Aventura, Florida, Matthew Zirwas, a dermatologist at Bexley Dermatology, presented the most useful dermatology journal entries in the past year.

 He reviewed dermatologic uses for metformin, potential mechanisms of pimozide in delusions of parasitosis, ways to boost JAK inhibitor response in alopecia totalis, and treatments for burning mouth syndrome.

sat down with Zirwas at the meeting to discuss these highlights and his other talk on how to streamline the 

first 4 visits when diagnosing spongiotic dermatitis

. He also shared his picks for the top 5 atopic dermatitis studies published in the past 2 years.

“There have been some incredibly interesting new things, especially around atopic dermatitis,” Zirwas said. “[The most important finding is] that we are terrible at diagnosing it. As dermatology providers, we misdiagnose 2 out of 3 people who have atopic dermatitis. Instead of calling it atopic dermatitis, we're diagnosing it as dermatitis, unspecified. That needs to stop.”

Zirwas explained that adult atopic dermatitis is often misdiagnosed because the wrong criteria are used. While the Hanafin and Rajka criteria from the 1980s work well for children, they fall short in adults. Instead, he said dermatologists should follow the American Academy of Dermatology guidelines.

The difference lies in pathogenesis: genetics drive pediatric atopic dermatitis, but skin damage underlies adult cases. Zirwas pointed to toluene diisocyanate (TDI), a chemical in car exhaust and nylon and polyester clothing, as a major factor for skin damage.

“That explains why atopic dermatitis has been becoming more common, particularly since the 1970s, because the 1970s car exhaust changed to start to have this TDI in it, and that was because they put catalytic converters on cars,” Zirwas said. “Second, nylon and polyester became much more common in clothing, and residual TDI in nylon and polyester clothing is the other big driving factor for this acquired atopic dermatitis.”

Variation in clinical presentation of pediatric-onset and adult-onset atopic dermatitis: a retrospective, single-center, chart review of adults with atopic dermatitis from the United States

This retrospective review compared clinical features of adult- vs pediatric-onset AD. Adults had less flexural involvement and more nummular eczema and extensor surface involvement, with fewer personal or family histories of atopic disease.

Exposure to isocyanates predicts atopic dermatitis prevalence and disrupts therapeutic pathways in commensal bacteria

This study identified diisocyanates as strong predictors of atopic dermatitis. These chemicals disrupt beneficial lipid production and therapeutic modeling of 

 and commensal Staphylococcus. Diisocyanates demonstrated a temporospatial and epidemiological association with atopic dermatitis.

The 2023 Annual Report of DataDerm: The database of the American Academy of Dermatology

DataDerm, the American Academy of Dermatology’s massive dermatology database, included data from 14.2 million unique patients and 53.5 million visits in 2022. This report analyzed longitudinal care patterns for common dermatologic conditions, with emphasis on skin cancer.

Cohort studies on 71 outcomes among people with atopic eczema in UK primary care data

Using UK primary care data, investigators compared 3.6 million people with eczema to 16.8 million controls. They found eczema was strongly associated with hodgkin's lymphoma, alopecia areata, Crohn Disease, urticaria, coeliac disease, ulcerative colitis, autoimmune liver disease, and irritable bowel syndrome.

Association of air pollution and genetic risks with incidence of elderly-onset atopic dermatitis: A prospective cohort study

A UK Biobank study found both air pollution and genetics independently increased the risk of elderly-onset AD, but pollutants had a stronger effect than genetic predisposition.

Other useful dermatology journal entries published in the past 2 years that Zirwas presented are reported 

Relevant disclosures for Zirwas include Galderma Laboratories, L.P, Regeneron Healthcare Solutions, GENZYME CORPORATION, Arcutis Biotherapeutics, Lilly USA, Novartis Pharmaceuticals Corporation, Dermavant Sciences, LEO Pharma, Verrica Pharmaceuticals, Incyte Corporation, AbbVie, and PFIZER.

Zirwas M. The Most Useful Journal Articles of the Last 2 Years. Presented at the 2025 New Wave Dermatology at Aventura, Florida.

Munayco Maldonado G, Foy V, Tai H, Chiesa Fuxench ZC. Variation in clinical presentation of pediatric-onset and adult-onset atopic dermatitis: a retrospective, single-center, chart review of adults with atopic dermatitis from the United States. 

. 2024;316(7):409. Published 2024 Jun 15. doi:10.1007/s00403-024-03008-x

Zeldin J, Chaudhary PP, Spathies J, et al. Exposure to isocyanates predicts atopic dermatitis prevalence and disrupts therapeutic pathways in commensal bacteria. 

. 2023;9(1):eade8898. doi:10.1126/sciadv.ade8898

Van Beek MJ, Swerlick RA, Daveluy S, et al. The 2023 Annual Report of DataDerm: The database of the American Academy of Dermatology. 

. 2024;91(5):904-909. doi:10.1016/j.jaad.2024.05.096

Matthewman J, Schultze A, Strongman H, et al. Cohort studies on 71 outcomes among people with atopic eczema in UK primary care data. 

. 2024;15(1):9573. Published 2024 Nov 6. doi:10.1038/s41467-024-54035-1

Gu X, Jing D, Xiao Y, et al. Association of air pollution and genetic risks with incidence of elderly-onset atopic dermatitis: A prospective cohort study. 

. 2023;253:114683. doi:10.1016/j.ecoenv.2023.114683

Zirwas shares top dermatology studies, highlights AD misdiagnosis, and reveals how pollution and fabrics may trigger adult-onset atopic dermatitis.

The First 4 Visits When Treating Spongiotic Dermatitis, With Matthew Zirwas, MD

Diagnosing spongiotic dermatitis relies on ruling out other dermatologic diseases. At the 2025 New Wave Dermatology meeting in Aventura, Florida, Matthew Zirwas, MD, a dermatologist at Bexley Dermatology, broke down what the first 4 visits for diagnosing 

HCPLive sat down with Zirwas at the meeting to discuss these 4 visits, what dermatologists should do in situations where a patient has a non-specific rash, and when a wood lamp should be used to find the area to scrape in scabies.

“Whenever a new patient presents with spongiotic dermatitis, it can be overwhelming because we're so used to thinking about it in terms of: what are all the different things that could be doing this? Could it be contact dermatitis? Could it be atopic dermatitis? Could it be scabies? Could it be CTCL? Could it be dermatitis unspecified? What the heck is going on?” Zirwas said. ‘It really helps to have an almost algorithmic approach where you say, ‘Okay, first visit,’ and this is really the way that I think about it.”

Breaking the steps into 4 visits helps make the diagnosis more manageable, easier to see. During the first visit, Zirwas said you should assume your patient has contact dermatitis and get them away from any potential contact allergen, such as soaps or moisturizers. A patient should be treated as if they do have this contact dermatitis, whether that is with a topical or systemic steroid.

Patients could be treated with either clobetasol/moisturizer mix QD M-F, moisturizer only on Saturday and Sunday; 720 fexofenadine in the morning, consider 20 mg cetirizine in the evening; strontium cream or pramoxine cream for PRN use; and oral ceramide, oral probiotic (10 Strain), and melatonin 5-10 mg. You should see this patient anywhere between 4 to 8 weeks later to see if the medication improved their symptoms.

“If they are like, ‘Oh my God, it all cleared up. I don't even need to use that cream anymore.’ Great, it was contact DERM,” Zirwas said. “You can decide if you want to patch tests in to try and figure out what it was, or if you want to just let them continue to use low allergenicity products.”

Zirwas said you could consider tapering cetirizine or making steroid topical PRN if a patient does well after the treatment regimen.

However, if a patient is not dramatically better at that second visit, then you should assume the patient has atopic dermatitis and treat accordingly. Patients could be treated with mirtazapine 15 mg qhs if they want a sleep aid and duloxetine 30 mg qhs if they don’t need help with sleep. Zirwas recommends stopping topical steroids and antihistamines. Dermatologists should explain that mirtazapine, an old antidepressant, is not for depression but for itch nerve endings. During his presentation, Zirwas said mirtazapine was the most effective oral medication he has seen for itch.

If treatment for atopic dermatitis did not work by the third visit, 3 – 4 months later, that is when you may consider dermatologic conditions, such as unusual contact dermatitis, scabies, or CTCL. You could also switch a patient from mirtazapine to duloxetine or vice versa. You could also consider a commercial tanning bed (3-5 times a week for 20 visits) or in-office NBUVB. Patients who are getting better could go to a commercial tanning bed 1 – 2 times a week, long-term.

At this point, Zirwas said you should strongly consider a biopsy or a comprehensive patch test and then wait for the fourth visit. If the biopsy does not show CTCL or scabies, you should assume the patient has atopic dermatitis again and try alternative atopic dermatitis. You should also stop mirtazapine or duloxetine and consider gabapentin or pregabalin.

“We can only really be sure about what type of dermatitis it is by seeing what results in the patient getting better,” Zirwas said. “And so, [during] each of those visits, there's a different [one] we're going to try. We're going to try this if that didn't work, we're going to try this. If that didn't work, we're going to try this….it really does make for the most efficient way to conduct the visits and get the patients better.”

Zirwas, M. The First 4 Visits in the Itchy Patient. Presented at the 2025 New Wave Dermatology meeting in Aventura, Florida, on May 17, 2025. 

Zirwas outlines a 4-visit approach to diagnosing spongiotic dermatitis, helping dermatologists manage uncertain rashes more effectively.
