 So in the last few minutes, I'm going to ask each of you as you look into the future caring for our patients with obstructive HCM [hypertrophic cardiomyopathy] and non-obstructive HCM, what other things are you excited about? We talked a little bit about the myosin inhibitors, but clearly there are other things that Milind alluded to that are coming down the pike for us. It's an exciting time to be in HCM position. What are the things that you're most looking forward to and Jim, I'll start with you.

 Yeah, thanks very much. I'll put my clinical trial hat on. We've fully enrolled a clinical trial looking at metabolic manipulation of myocardial function using a partial fatty acid oxidase inhibitor in patients with HCM. So approaching the question from a completely different angle that would be additive together with cardiac myosin inhibition, so thinking about newer pathways to address in patients with HCM to improve their symptoms. That's really exciting to me.

 So speaking as a heart failure, transplant cardiologist is what I spend most of my time doing. I think we still have so many unanswered questions in patients with non-obstructive HCM with advanced symptoms. What's the role of guideline directed medical therapy—was just traditional garden variety heart failure with preserved ejection fraction therapy like mineralocorticoid antagonists, angiotensin receptor neprilysin inhibitors, SGLT2 inhibitors. Do they work? Will they be effective in non-obstructive HCM? I think that is an unmet need in a huge space that I'm hopeful in the future we'll have more answers.

 I agree with you completely. That group of patients are perhaps the most difficult and challenging to treat in the clinic and hopefully will make some headway there. Milind, what are you looking forward to?

 I will start with what Michelle alluded to the next frontier is the non-obstructive HCM. So I am not a heart failure transplant doctor, but can mavacamten or CMIs [cardiac myosin inhibitors] work in this space because it's not all about the LVOT [left ventricular outflow tract] obstruction. There are structural changes that are happening, and we are answering this question in an ongoing randomized clinical trial, RCHCM, and there is another one with aficamten, that is being planned coming down the pike. That will help us clear some of that air. Of course, we need to understand the other drugs like SGLT. Could that work? But the bigger picture I think is the genetic space, the gene therapies, the adenovirus-based therapies that can help modulate the deficient protein in the heart of MYBPC3 so that space is active and brewing the business of gene editing CRISPR, etcetera. All these things obviously, I often joke as long as it does not create mutant Ninja Turtles down the road, meaning the uncertain offshoot effects, I think the future is bright. Honestly, I just told this to one of my patients a couple of days ago is that I can excitedly look forward to having a potential cure for this disease before I hang my boots into retirement. So I'm looking forward to all and plus the PROs [patient reported outcomes] and the shared-decision making. The other thing is the HCMR trial, hypertrophic cardiomyopathy registry from NIH which I am also part of, so I have to plug it in. That is going to start reading out in the next year or so that will help understand the risk stratification space a lot more.

 What's left? They've taken all the low hanging fruit And even the high hanging fruit from the tree. No fruit left on the tree.

 You're climbing all the way up the tree to the top.

 No fruit left on the tree. So I would echo what Jim said. I think that the potential for positive remodeling of the left ventricle not only pathologically with hypertrophy, but maybe reducing the progression of fibrosis would be a major advancement. If we can show that a therapy reduces progressive fibrosis that we can see on late gadolinium enhancement, we know its association with worsening progressive heart failure as well as ventricular arrhythmias, that would be a huge benefit. As Milind said that fibrosis is also shown with severe diastolic dysfunction as well, and many of our patients have some symptoms with outflow tract relief from diastolic dysfunction. So I think that is another unmet need. The last thing I would say is you know how normal can we make patients feel? With obstructive hypertrophic cardiomyopathy, will they be safe to be highly competitive, vigorous athletes, even with this condition? Can we really get close to normalizing what they really can do and feel like they can do and want to do?

 Yeah, that's what's a wonderful goal. It is a lofty goal, but one that we may meet. So with that, I'd like to thank you all for joining our panel today. This has been a very rich, informative and lively discussion and thank you audience for watching our HCPLive Peer Exchange®. You can subscribe to the enewsletter and receive other great content right in your inbox. Thanks again everyone.

Transcript is AI-generated and edited for clarity and readability.

Andrew Wang, MD; James Januzzi, MD; Michelle M. Kittleson, MD, PhD; and Milind Desai, MD, MBA, share a look into the future of oHCM treatment.

The Future of oHCM Treatment

Andrew Wang, MD

Counting down the biggest news from major medical meetings, it's the HCPLive Five!

HCPLive Five at European Renal Association (ERA) Congress 2025

European Renal Association (ERA) Congress

 is a medical conference bringing together world-renowned experts, researchers, and practitioners in nephrology. ERA Congress 2025 was hosted in Vienna, Austria, and saw more than 10,000 participants from  91 countries around the world, with a record 2835 abstract submissions. This year’s conference was centered around the theme “Game Changers in Nephrology” with the slogan “Beyond Nephrology,” boasting a comprehensive and innovative program exploring the latest advancements and transformative ideas in nephrology.

As part of HCPLive’s on-site coverage, the editorial team conducted expert interviews and reported on timely topics across therapeutic advances, pipeline updates, new renal clinical trial data, and more. In this edition of the HCPLive Five, the team highlights key conversations on pegcetacoplan in 

 and idiopathic immune-complex membranoproliferative glomerulonephritis (IC-MPGN), a trio of 

 drugs in clinical development, and the potential benefits of simultaneous initiation of finerenone (Kerendia) and empagliflozin (Jardiance) in patients with 

Pegcetacoplan Sustains Proteinuria Reductions in C3G, IC-MPGN at 52 Weeks

Extended data from the phase 3 VALIANT trial were presented at ERA 2025 and support the sustained efficacy and safety of pegcetacoplan (Empaveli) in patients with C3G or IC-MPGN, including adolescents and adults with native or transplanted kidneys. The 52-week results show continued proteinuria reduction and eGFR stabilization in both treatment-naïve and crossover groups, reinforcing 26-week data presented at the American Society of Nephrology’s 2024 Scientific Sessions.

In this on-site interview at the meeting, Fadi Fakhouri, MD, PhD, co-lead principal investigator for the VALIANT study and a professor of nephrology at CHUV Lausanne, Switzerland, describes pegcetacoplan’s long-term potential in C3G and IC-MPGN and how the data presented at ERA could shift treatment strategies.

Understanding Zigakibart's Potential in IgA Nephropathy, with Jonathan Barratt, MD, PhD

100-week data from the phase 1/2 ADU-CL-19 trial presented at ERA suggest zigakibart, an APRIL inhibitor under development by Novartis, offers durable reductions in proteinuria and maintains a favorable safety profile in patients with IgAN. In the study, patients experienced a mean 60% reduction in proteinuria from baseline, with 55% achieving proteinuria below 500 mg and 31% below 300 mg, as described by Jonathan Barratt, MD, PhD, the Mayer Professor of Renal Medicine at the University of Leicester, in this interview. Additionally, serum IgA and pathogenic Gd-IgA1 levels dropped by 74%, building on earlier 52-week data showing reductions in IgA, IgM, and IgG of 67%, 78%, and 35%, respectively.

Kidney Compass: CONFIDENCE Trial at ERA 2025, with Rajiv Agarwal, MD, MS

Simultaneous initiation of finerenone (Kerendia) and empagliflozin (Jardiance) in patients with CKD and type 2 diabetes was well-tolerated and resulted in significantly greater reductions in urinary albumin-to-creatinine ratio (UACR) than either agent alone, according to results from the CONFIDENCE trial. During ERA, Kidney Compass host Brendon Neuen, MBBS, PhD, a senior research fellow with the George Institute for Global Health and the director of the Kidney Trials Unit with Royal North Shore Hospital, held a discussion with trial investigators Rajiv Agarwal, MD, Professor Emeritus at Indiana University School of Medicine, about the study results and what they mean for CKD management landscape in real-world settings.

Phase 3 ORIGIN Sets Stage for Atacicept in IgA Nephropathy, with Richard Lafayette, MD

Just days before the ERA 2025, the nephrology community welcomed and celebrated new positive data for atacicept in IgAN in the form of topline results from the phase 3 ORIGIN trial. Announced by Vera Therapeutics on June 02, 2025, the data indicate the trial met its primary endpoint of reduction in proteinuria at week 36, with the atacicept group achieving a 46% reduction from baseline and a statistically significant 42% reduction compared to placebo at week 36.

’s coverage of ERA, we sat down with Lafayette to discuss how this latest data adds to our understanding of atacicept and its potential role in the management of IgAN if it were to receive FDA approval.

Kidney Compass: Sibeprenlimab and the VISIONARY Trial, with Vlado Perkovic, MBBS, PhD, at ERA 2025

, hosts Brendon Neuen, MBBS, PHD, and Shikha Wadhwani, MD, MS, are joined by Vlado Perkovic, MBBS, PhD, dean and scientia professor of Medicine at UNSW Sydney, as he dives into one of the meeting’s most anticipated releases—

. Less than 2 weeks prior to the presentation, Otsuka Pharmaceutical Co. announced the US Food and Drug Administration had granted priority review for their BLA and the application has been given a target action date of November 28, 2025.

These 5 represent only some of the data the 

 team covered at this year's meeting! Check out more KOL insight and our full conference coverage on our 

From new data for potential IgAN treatments to the use of combination initiation therapy for type 2 diabetes and CKD, here are 5 key updates from the annual meeting.

Brendon Neuen, MD

ACC 2025 Clinical Trials to Watch with Deepak Bhatt, MD, MPH, MBA

Few fields have experienced as much rapid advancement and transformation in recent years as cardiology. With groundbreaking insights into 

 mechanisms driving innovations in treatment, from novel lipid-lowering therapies to next-generation heart failure (HF) management and structural interventions, cardiologists must navigate a landscape of continuous breakthroughs that many specialties would equate to decades’ worth of progress.

These notable advancements in recent years continue to set the stage for the 

American College of Cardiology 74th Annual Scientific Session & Expo

. This year’s meeting, taking place in Chicago from March 29-31, boasts more than 4,750 accepted abstracts, with 1,300 expert faculty and 300 sessions, encompassing 53 late-breaking clinical trials.

A leading subject matter expert in cardiology, Deepak Bhatt, MD, MPH, MBA, director of the Mount Sinai Fuster Heart Hospital and the Dr. Valentin Fuster Professor of Cardiovascular Medicine at Icahn School of Medicine at Mount Sinai, is among the meeting’s planned attendees and presenters at this year’s ACC congress. For more insight into his perspective on this year’s meeting, the editorial team of HCPLive Cardiology spoke with Bhatt to learn what trials he was most looking forward to in Chicago.

Check out a rundown of Bhatt’s top 3 picks and when they are scheduled to be presented in our list below:

The Effect Of Once-weekly Subcutaneous Semaglutide On Functional Capacity In People With Type 2 Diabetes (T2D) And Peripheral Artery Disease (PAD): Primary Results From The Phase 3b, Randomized, Placebo-controlled, Double-Blind Stride Trial

: Saturday, March 29, 2025, from 09:50-10:02 AM CT

: STRIDE (NCT04560998) is a randomized, placebo-controlled, double-blind phase 3b trial evaluating 1 mg once-weekly subcutaneous semaglutide, a glucagon-like peptide 1 receptor agonist (GLP-1 RA) versus placebo, in people with symptomatic PAD (Fontaine IIa claudication) and T2D. Eligible participants were ≥18 years old, had hemodynamically stable PAD, had no planned intervention, and were not receiving a GLP-1 RA.

The primary endpoint is the change in maximum walking distance on a constant-load treadmill (CLT), with secondary endpoints including quality of life and cardiometabolic assessments. STRIDE will provide evidence on functional outcomes with semaglutide in people with PAD and T2D.

Oral Semaglutide Reduces Cardiovascular Events In People With Type 2 Diabetes With Atherosclerotic Cardiovascular And/or Chronic Kidney Disease: Primary Results From The SOUL Randomized Trial

: Saturday, March 29, 2025, from 1:30-1:40 PM CT

: SOUL is a multi-center, international, randomized, double-blind, parallel-group, placebo-controlled, phase 3 cardiovascular outcomes trial assessing the effect of once-daily oral semaglutide (Rybelsus) versus placebo on cardiovascular outcomes in 9650 people with T2D and established cardiovascular disease (CVD) and/or chronic kidney disease (CKD).

Headline results reported by Novo Nordisk found SOUL achieved its primary objective by demonstrating a statistically significant and superior reduction in major adverse cardiovascular events (MACE) of 14% with oral semaglutide treatment compared with placebo.

Dapagliflozin In Patients Undergoing Transcatheter Aortic Valve Implantation

Presentation Time: Saturday, March 29, 2025, from 2:15-2:25 PM CT

Presenter: Sergio Raposeiras Roubin, MD, PhD

: Patients undergoing transcatheter aortic valve implantation (TAVI) for aortic stenosis relief are at an elevated risk of developing heart failure (HF) within the first months of intervention. In the Dapagliflozin after Transcatheter Aortic Valve Implantation (DapaTAVI) trial, investigators sought to assess the clinical benefit and safety of dapagliflozin 10 mg/day on mortality and worsening HF in 1020 patients with severe AS undergoing TAVI

For the independent pragmatic, controlled, prospective, randomized, open-label blinded endpoint, multicenter trial in Spain, patients needed a prior history of HF admission plus diabetes mellitus, left ventricular ejection fraction (LVEF) ≤40%, or estimated glomerular filtration rate (eGFR) between 25 and 75 ml/min/1.73 m2.

Relevant disclosures for Bhatt include Amarin, AstraZeneca, Sanofi, Pfizer, Roche, Amgen, and Eli Lilly and Company, among others.

Bonaca MP, Catarig AM, Hansen Y, et al. Design and baseline characteristics of the STRIDE trial: evaluating semaglutide in people with symptomatic peripheral artery disease and type 2 diabetes. Eur Heart J Cardiovasc Pharmacother. 2025;10(8):728-737. doi:10.1093/ehjcvp/pvae071

Oral semaglutide demonstrates a 14% reduction in risk of major adverse cardiovascular events in adults with type 2 diabetes in the SOUL trial. Novo Nordisk. October 21, 2025. Accessed March 21, 2025. 

https://www.novonordisk.com/content/nncorp/global/en/news-and-media/news-and-ir-materials/news-details.html?id=171480

Amat-Santos IJ, Sánchez-Luna JP, Abu-Assi E, et al. Rationale and design of the Dapagliflozin after Transcatheter Aortic Valve Implantation (DapaTAVI) randomized trial. Eur J Heart Fail. 2022;24(3):581-588. doi:10.1002/ejhf.2370

Bhatt previews 3 late-breaking clinical trials being presented at this year's American College of Cardiology Annual Scientific Sessions.

Deepak Bhatt, MD, MPH

Ophthalmologist experts provide an overview of emerging treatments for dry eye disease. 

Emerging Treatments for Dry Eye Disease

Eric Donnenfeld, MD

James Q. Del Rosso, DO, is the research director of JDR Dermatology Research and president of the American Acne and Rosacea Society.

The Medical Sisterhood:  White Coats & Wingmen—How Men Can Uplift Women in Medicine

, host Mona Shahriari, MD, an assistant clinical professor of dermatology at the Yale University School of Medicine and the associate director of clinical trials at Central Connecticut Dermatology Research, spoke alongside James Q. Del Rosso, DO, research director of JDR Dermatology Research and president of the American Acne and Rosacea Society, to discuss the empowerment of women in medicine, the impact of male and female role models for clinicians, and more.

After introducing Del Rosso, Shahriari highlighted her friendship with Del Rosso and their careers in the field of dermatology. She asked Del Rosso to discuss various elements of his extensive career in dermatology and his journey toward becoming a clinician. Del Rosso described his family’s history, including his own Italian-American heritage and his early life in Brooklyn, New York. Del Rosso noted his own access to an array of intelligent role models in his youth, with both male and female figures helping him to shape his future.

Del Rosso touched on various elements of his early career, pointing to his own choices regarding choosing a medical school that fit both his academic and financial needs. He expressed satisfaction at his choice to attend Ohio University Heritage College of Osteopathic Medicine over other academic institutions, highlighting his positive experiences with such figures as Wilma Bergfeld, MD.

Over the course of the episode, the conversation shifted to the unique benefits of having had a variety of influential female role models in one’s younger years. Del Rosso noted that, as a young person, his mother, aunts, and grandparents all set strong examples for him. Shahriari spoke with Del Rosso about his familial history prior to his career in dermatology. Specifically, she spoke to Del Rosso about the profound role his aunt and sister had in his life and in helping to shape him as an individual.

The discussion between Shahriari and Del Rosso further evolved into a conversation regarding pressures faced by women in the field of dermatology and the empowerment of female colleagues by male allies. Del Rosso commented on his own challenges in persevering throughout his career in medicine. The conversation was punctuated with a point about resilience in one's own career, continuing to move forward regardless of the varying opinions and views of others.

 for empowering conversations that will help you build a fulfilling career and life! All episodes of The Medical Sisterhood will be available in a video format via HCPLive.com, with audio-only version available via Apple and Spotify.

Want to join The Medical Sisterhood community? Click here to join our LinkedIn Group!

Editor's note: This summary was created with the help of artificial intelligence.

In this episode, James Q. Del Rosso, DO, joins The Medical Sisterhood for a conversation about empowerment and the benefits of female role models.

The Medical Sisterhood: Men, Medicine, and Their Female Mentors

James Del Rosso, DO

Disease Activity Control of Aflibercept 8 mg in Wet AMD with Jean-Francois Korobelnik, MD

At the 2025 Association for Research in Vision and Ophthalmology (ARVO) Annual Meeting, Jean-Francois Korobelnik, MD, professor of ophthalmology and head of the ophthalmology department at the University Hospital of Bordeaux, presented a post hoc analysis of the results of the PULSAR phase 3 trial to evaluate the magnitude of disease activity (DA) control with aflibercept 8 mg.

PULSAR was a 96-week phase 3 trial investigating the safety and efficacy of aflibercept 8 mg in neovascular age-related macular degeneration (nAMD). It was conducted in response to data from the TENAYA and LUCERNE trials, which examined the DA control exhibited by faricimab treatments. This analysis utilized data from PULSAR and DA control criteria from TENAYA/LUCERNE to determine the DA control magnitude accomplished by aflibercept.

“I am very careful about the interpretation because, as I presented yesterday, [there is] a lot of bias,” Korobelnik told 

. “It’s not exactly the same population of patients. It’s not the same size of the lesions. It’s not the same reading center. It’s very tempting to compare directly, but it is not a head-to-head comparison. Let’s say that it is a suggestion. I think it is helping us, as physicians, understand the trials, but at the same time I think it is preventing us to [reach] a short, robust conclusion.”

At baseline, Korobelnik and colleagues noted that mean choroidal neovascularization (CNV) lesion size was 6.6 mm

 for the aflibercept 8Q16 group in PULSAR and 4.7 mm

 for faricimab in TENAYA/LUCERNE. PULSAR saw 77% of patients with subfoveal CNV at baseline, while TENAYA and LUCERNE had 60% and 63%, respectively.

The proportion of patients not meeting the DA criteria of TENAYA/LUCERNE 8 or 12 weeks after the last initial treatment dose was 64% for aflibercept 8 mg in PULSAR and 45% for faricimab in TENAYA/LUCERNE. No adjustments were made to compensate for fewer initial doses and more severe baseline DA in PULSAR.

Korobelnik and colleagues concluded that, despite fewer initial monthly doses, larger baseline lesion size, and requirement for CNV closer to the center, patients who were given aflibercept 8 mg in PULSAR achieved DA control earlier and in higher proportions than those reported for faricimab in TENAYA/LUCERNE.

Importantly, however, Korobelnik and colleagues urge caution in interpreting the results of this analysis. Although data from TENAYA/LUCERNE and PULSAR were collected and analyzed, no direct comparison between the two studies was made. As a result, any number of potential unidentified limitations, such as demographic variances between study populations and confounding diseases, may distort any direct comparisons made.

To this end, Korobelnik and colleagues urge further study of the two drugs in direct comparison.

“We analyze the subtypes, the size of the lesions, the disease itself, with all the tools that we have," Korobelnik said. "Is it enough to say that it is the same population or that the differences we detect are all the differences that are there? I think so, but I'm not completely sure. That's why, ideally, there is a need for a true head-to-head trial between the two drugs."

Editors' note: Korobelnik reports the following disclosures: AbbVie, Alexion, Apellis, Bayer, Novo Nordisk, Ocular Therapeutix, and others

A PULSAR phase 3 trial post-hoc analysis: Evaluating the timing and magnitude of control of disease activity with aflibercept 8 mg and faricimab, applying similar disease activity criteria across different pivotal Phase 3 trials for nAMD.

 Abstract presented at Association for Research in Vision and Ophthalmology in Salt Lake City, UT, from May 3 - May 8, 2025.

A post hoc analysis of data from the PULSAR trial indicates that patients with aflibercept 8 mg achieved disease activity control early and in high proportion.

Disease Activity Control of Aflibercept 8 mg in Wet AMD, With Jean-Francois Korobelnik, MD

Jean-Francois Korobelnik, MD

Panelists discuss how endothelin receptor antagonism addresses resistant hypertension by blocking one of the most potent vasoconstrictors, reducing smooth muscle hypertrophy and fibrosis, with aprocitentan being the only endothelin receptor antagonist approved for resistant hypertension.

Rationale for Targeting the Endothelin Pathway In RH

Video content above is prompted by the following: 

The endothelin pathway represents an innovative therapeutic target in resistant hypertension (RH) management, addressing a potent vasoconstrictor mechanism left unopposed by traditional ACD therapy. Endothelin-1 is one of the most powerful vasoconstrictors in the human body, causing arterial constriction, smooth muscle hypertrophy, reduced vascular compliance, and progressive fibrosis that contributes to both blood pressure elevation and target organ damage.

Aprocitentan represents the first endothelin receptor antagonist specifically approved for resistant hypertension treatment, offering a unique mechanism of action distinct from existing antihypertensive drug classes. Unlike other endothelin receptor antagonists like bosentan and macitentan (used for pulmonary hypertension), aprocitentan is specifically indicated for systemic hypertension and provides both renal and vascular benefits through dual endothelin receptor blockade.

The endothelin pathway’s role in resistant hypertension extends beyond simple vasoconstriction, contributing to microvascular dysfunction, inflammatory processes, and progressive vascular remodeling that perpetuates hypertension despite conventional treatment. By targeting this pathway, aprocitentan addresses fundamental pathophysiologic mechanisms underlying treatment resistance, offering hope for patients who remain uncontrolled despite optimal conventional therapy and providing clinicians with an additional tool in their therapeutic armamentarium.

Lance Sloan, MD

Improving Eye Care Access in Underserved Communities with Lerato Landela, B.Optom

2025 American Optometric Association Conference

 in Minneapolis, MN, Lerato Landela, B.Optom, a PhD candidate and final-year student lecturer at the University of Johannesburg, presented her research regarding 

 service utilization of underserved people living in Diepsloot, South Africa.

Lack of access to healthcare resources is a significant issue worldwide, growing steadily along with the global population. Recent studies have cited health literacy, socioeconomic status, and financial limitations as primary barriers to access; millions of Americans, primarily in marginalized ethnic groups, do not have the health insurance necessary to cover routine eye care.

Landela spoke on the living conditions of the town, explaining that residents are often forced to choose between eye care and having a meal.

“The reason why I would say the types of dwellings affect their access to healthcare is because of the socioeconomic conditions they face,” Landela said. “If you’re living in a shack, for instance, there’s food scarcity. A lot of people are unemployed, so when they have to choose between eye care and what they’re going to eat for dinner at night, 9 out of 10 times they’re going to choose to have food.”

Landela also discussed the possibility of extrapolating these findings nationally and globally. The poverty faced in Diepsloot is largely due to healthcare restructuring, but the living conditions are mirrored in underserved communities around the world.

“I would say on a national scale because South Africa is unique in that the healthcare system is still being re-engineered. We don’t have a national healthcare insurance yet,” Landela said. “It is currently being worked on, but it’s not where we need to be and it hasn’t been instituted yet.”

Landela noted various demographic disparities between groups making use of ocular healthcare in Diepsloot, which can likewise be applied on a larger scale.

“What I’ve picked up on is that a lot of females are the ones who are accessing their healthcare services. Males, not so much. They usually come when it’s too late or right at the end,” Landela said. “Ethnicity-wise, because South Africa is very diverse, especially due to urbanization, we have a mixture of people from different ethnicities. I found that more African people were predominant in that particular community, and they are the ones who are mostly affected.”

Landela also investigated the community’s awareness of the optometric resources available to them. She commented on the significant

“I found that their knowledge is very good,” Landela said. “They do know that it’s a pertinent part of the quality of their lives. However, because there are no services, the access is a problem.”

Landela spoke to actionable approaches to improving access to healthcare in similar communities. She called for optometrists to provide more direct care for patients who are unable to seek it out themselves.

“I would say clinicians should get on the ground more, because the need is there, and we need to do our bit as healthcare professionals to assist communities in whatever way we can," Landela wrote. "So even if you're in private practice, get out there, do your bit for the global community, because that is where the needs are."

Landela L. Evaluation of eye-care service utilization patterns in an urban slum: development of strategies to improve optometric care in an urban slum. Abstract presented at the 2025 American Optometric Association Conference in Minneapolis, MN, June 25-28, 2025.

Elam AR, Tseng VL, Rodriguez TM, et al. Disparities in Vision Health and Eye Care. Ophthalmology. 2022;129(10):e89-e113. doi:10.1016/j.ophtha.2022.07.010

Landela’s research on an impoverished community in South Africa encourages clinicians to help similar populations get the care they need.

Lerato Landela, B.Optom

When to Move from Topical to Systematic Therapy for Acne, With Shanna Miranti, MPAS, PA-C

At the 2025 New Wave Dermatology meeting in Aventura, Florida, Shanna Miranti, MPAS, PA-C, a physician assistant at Riverchase Dermatology, presented on when to move from topical to systemic therapy for 

HCPLive sat down with Miranti during the meeting to discuss the 4 pillars of acne pathogenesis—excess sebum production, follicular hyperkeratinization, inflammation, and cutibacterium acne—and how to choose the best acne treatment regimen for your patient.

“What's most important is to make sure that we as providers are treating as many of these 4 pillars as possible,” Miranti said.

Isotretinoin, an oral retinoid, targets all 4 pillars of acne pathogenesis. This is currently the top acne treatment on the market, but new therapies are on the horizon.

The American Academy of Dermatology updated their 2016 acne guidelines in 2024, which now recommends limiting systemic antibiotic use to limit the development of resistance and to use concomitant benzoyl peroxide. The US Food and Drug Administration (FDA) approved many acne medications since 2019, including Aklief (trifarotene, a topical photostable retinoid), Amzeeq (topical minocycline), Arazlo (tazarotene 0.045%, a topical photostable retinoid), Seysara (saracycline, oral antibiotic), Winlevi (clascoterone, a topical anti-androgen), Twyneo (tretinoin 0.1%/ BPO 3%), and Cabtreo (Clindamycin 1.2%, Adapalene 0.15%, BPO 3.1%). With so many options available, Miranti said you should not just prescribe generic tretinoin.

When considering patient treatment options, Miranti recommended looking at each pillar individually. For instance, the only topical therapy that works for excessive sebum and oily skin is clascoterone, an androgen receptor blocker.

“If we can stop the sebum production and block those androgens, we will have a lot less acne in the future,” she said.

Systematic therapies for sebum production include isotretinoin, spironolactone (50 mg QD-BID), and oral contraceptive pills.

With the next pillar— follicular hyperkeratinization—retinoids work the best at opening the micromedone and a plugged follicle. Patients could use topical retinoids, such as tretinoin, adapalene, tazarotene, and trifarotene. However, due to potential irritation of retinoids, Miranti said dermatologists should counsel patients on protecting the skin barrier through moisturization.

Other than retinoids, patients could be prescribed azelaic acid or isotretinoin.

The next pillar is inflammation, managed by topical retinoids, topical antibiotics, topical dapsone, azelaic acid, and clascoterone. Systematic therapies for inflammation include isotretinoin, doxy, mino, sarecycline, spironolactone, and oral contraceptive pills.

“The earlier we can stop…inflammation, the better we can prevent scarring for our acne patients,” Miranti said.

The last pillar, cutibacterium acnes, can be treated with topical antibiotics (clindamycin with benzoyl peroxide, minocycline 4%), and systemic therapies of sarecycline, doxy, mino, and tetracycline, taken alongside benzoyl peroxide.

Miranti explained that patients will need to switch to systemic therapy if topical therapy does not control new active breakouts, breakouts are following a hormonal pattern, an acute situation such as stress or sports is causing a worsening of the inflammatory lesions, or when any scarring is present.

Treating the 4 pillars can help determine whether a patient needs to move from topical to systemic therapies.

“If we think of the four pillars of acne pathogenesis as four legs of a table, it makes sense that a table cannot stand up on one leg alone and a table would be very unbalanced on just 2 legs alone, 3 legs,” Miranti said. “Things do work on a tripod quite well, but of course, the 4 legs or 4 pillars are going to give you the most sturdy balance of a table. So, we really should try to choose medications or therapies for our patients that check all 4 boxes of the 4 pillars of acne pathogenesis, and we want to do that with the least amount of products possible.”

Miranti S. Acne: Moving Away from Topicals to Systemic Therapy. Presented at 2025 New Wave Dermatology from May 15 - 17, 2025 in Aventura, Florida.

Relevant disclosures for Miranti include Galderma Laboratories,Incyte Corporation, Verrica Pharmaceuticals, Ortho Dermatologics, a division of Bausch Health US, Almirall, and Arcutis Biotherapeutics.

At 2025 New Wave Dermatology, HCPLive spoke with Miranti on treating the 4 pillars of pathogenesis, including sebum production, inflammation, and more.

Authors