Commentary

How do social media trends and influencer driven product fads affect the patterns of contact dermatitis you are seeing?

DR. YU: Social media and influencers are huge marketing opportunities for cosmetic and personal care companies and drive consumer demand. One example from a few years ago is slime as a toy for kids. For a period of time, every kid was making slime at home, resulting in high numbers of hand allergic contact dermatitis. Making slime requires a combination of borax (irritant), glue (irritant and allergen), laundry detergent or dish soap (irritant and allergen), and fragrances (irritant and allergen). This fad has been slowing since I cowrote an article on it (doi:10.1111 /pde.13792). More recently, the rise of “Sephora kids” (preteens and adolescents influenced by social media trends promoting multistep skin care and anti-aging products) has raised concerns about contact dermatitis, as many of these products contain ingredients that can disrupt the skin barrier or trigger sensitization in younger patients.

How can products labeled free of fragrances or preservatives still trigger allergic contact dermatitis?

DR. YU: Fragrances are frequently in the top 10 ingredients that cause allergic contact dermatitis in adults and children. For people with sensitive skin, we almost unequivocally recommend fragrance-free products. Now, not all fragrance-free products are truly free of fragrance allergens. Some fragrance chemicals may be used for another purpose (benzyl alcohol as a preservative, for example), so the product can still be fragrance free even though benzyl alcohol has a fragrance. Most products cannot truly be preservative free if they are expected to have a shelf life. One-time-use products do exist and can be preservative free, but they are very rare and very expensive to manufacture and maintain.

Have you seen spikes in reactions from trendy products like CBD-infused creams, botanical serums, or exfoliating acids?

DR. YU: Not yet, but I would not be surprised that this is rising in prevalence. The issue might not be CBD itself; it’s really the other additives in these CBD products that will cause problems. Looking at some CBD products for sale from major retailers, many contain fragrances such as lemongrass oil and botanical extracts such as calendula that have been noted to cause allergic contact dermatitis.

Do certain patient behaviors (eg, layering multiple natural products, frequent product switching, prolonged leave-on use) increase the risk for ACD?

DR. YU: Absolutely possible. The more products you use, the more likely you will develop allergic contact dermatitis due to increased exposure to potential allergens. We know that leave-on products are higher risk than rinse-offs in general. Furthermore, more products used also increase the risk for irritant dermatitis that might break the skin barrier, increasing the odds that someone will develop allergic contact dermatitis. We see this often with facial skin care products where some people might layer on glycolic acid with retinoid acid with vitamin C oil with kojic acid, etc, all leading to irritation on the face.

How do emerging consumer product trends influence your patch-testing approach?

DR. YU: We try to customize our patch-tested allergens to the patient’s rash and symptoms. If it’s a patient with facial dermatitis, for example, we would patch test the patient to a core allergen series (eg, American Contact Dermatitis Society 90, North American Comprehensive 80, North American Contact Dermatitis Group 80) and add on other supplemental panels including cosmetic series if applicable. It is also preferable to patch test for products that are used and/or suspected of causing the rash. For example, if a blush is a suspected cause of dermatitis, we would certainly patch test to that as well. We generally try to encourage the patient to bring in all their products so we can evaluate them for appropriateness for patch testing.

Which consumer-driven ingredients do you now consider high-yield targets for testing?

DR. YU: Fragrances, preservatives, and botanical extracts are all likely causes of allergic contact dermatitis. We are uncovering new allergens all the time, so testing directly to patient products is also important. Just because something has not been reported to be a contact allergen doesn’t mean it can’t become one.

Have you observed any demographic or cultural trends in patients with allergic contact dermatitis related to consumer products?

DR. YU: There are various papers that outline different allergens in adults vs children vs older adults. However, in general, the prevalence of contact dermatitis is very similar across all age groups and distributions. I do think there are definitely gender and cultural variations. Women are more likely to be allergic to nickel, for example, which is more often found in jewelry. However, there really aren’t studies that demonstrate one population is more likely to develop allergic contact dermatitis than others. It really comes down to exposure. For example, neomycin, which is contained in triple antibiotics in the United States and is sold over the counter, is a common allergen here. However, it’s not readily available in other countries, and therefore, neomycin is a rare allergen in those countries.

Looking forward, which emerging consumer trends do you anticipate will create the next wave of contact dermatitis cases?

DR. YU: We have seen an increase in allergic contact dermatitis in the wearables industry, especially in continuous glucose monitors. They are now being sold over the counter so people without diabetes and without a prescription will be able to purchase them from retailers like Amazon or CVS. The adhesives in these glucose monitors have been shown to cause allergic contact dermatitis in a sizeable number of kids and adults. I suspect this problem will continue to increase with increased exposure to the allergens in these adhesives.

How do social media trends and influencer driven product fads affect the patterns of contact dermatitis you are seeing?

DR. YU: Social media and influencers are huge marketing opportunities for cosmetic and personal care companies and drive consumer demand. One example from a few years ago is slime as a toy for kids. For a period of time, every kid was making slime at home, resulting in high numbers of hand allergic contact dermatitis. Making slime requires a combination of borax (irritant), glue (irritant and allergen), laundry detergent or dish soap (irritant and allergen), and fragrances (irritant and allergen). This fad has been slowing since I cowrote an article on it (doi:10.1111 /pde.13792). More recently, the rise of “Sephora kids” (preteens and adolescents influenced by social media trends promoting multistep skin care and anti-aging products) has raised concerns about contact dermatitis, as many of these products contain ingredients that can disrupt the skin barrier or trigger sensitization in younger patients.

How can products labeled free of fragrances or preservatives still trigger allergic contact dermatitis?

DR. YU: Fragrances are frequently in the top 10 ingredients that cause allergic contact dermatitis in adults and children. For people with sensitive skin, we almost unequivocally recommend fragrance-free products. Now, not all fragrance-free products are truly free of fragrance allergens. Some fragrance chemicals may be used for another purpose (benzyl alcohol as a preservative, for example), so the product can still be fragrance free even though benzyl alcohol has a fragrance. Most products cannot truly be preservative free if they are expected to have a shelf life. One-time-use products do exist and can be preservative free, but they are very rare and very expensive to manufacture and maintain.

Have you seen spikes in reactions from trendy products like CBD-infused creams, botanical serums, or exfoliating acids?

DR. YU: Not yet, but I would not be surprised that this is rising in prevalence. The issue might not be CBD itself; it’s really the other additives in these CBD products that will cause problems. Looking at some CBD products for sale from major retailers, many contain fragrances such as lemongrass oil and botanical extracts such as calendula that have been noted to cause allergic contact dermatitis.

Do certain patient behaviors (eg, layering multiple natural products, frequent product switching, prolonged leave-on use) increase the risk for ACD?

DR. YU: Absolutely possible. The more products you use, the more likely you will develop allergic contact dermatitis due to increased exposure to potential allergens. We know that leave-on products are higher risk than rinse-offs in general. Furthermore, more products used also increase the risk for irritant dermatitis that might break the skin barrier, increasing the odds that someone will develop allergic contact dermatitis. We see this often with facial skin care products where some people might layer on glycolic acid with retinoid acid with vitamin C oil with kojic acid, etc, all leading to irritation on the face.

How do emerging consumer product trends influence your patch-testing approach?

DR. YU: We try to customize our patch-tested allergens to the patient’s rash and symptoms. If it’s a patient with facial dermatitis, for example, we would patch test the patient to a core allergen series (eg, American Contact Dermatitis Society 90, North American Comprehensive 80, North American Contact Dermatitis Group 80) and add on other supplemental panels including cosmetic series if applicable. It is also preferable to patch test for products that are used and/or suspected of causing the rash. For example, if a blush is a suspected cause of dermatitis, we would certainly patch test to that as well. We generally try to encourage the patient to bring in all their products so we can evaluate them for appropriateness for patch testing.

Which consumer-driven ingredients do you now consider high-yield targets for testing?

DR. YU: Fragrances, preservatives, and botanical extracts are all likely causes of allergic contact dermatitis. We are uncovering new allergens all the time, so testing directly to patient products is also important. Just because something has not been reported to be a contact allergen doesn’t mean it can’t become one.

Have you observed any demographic or cultural trends in patients with allergic contact dermatitis related to consumer products?

DR. YU: There are various papers that outline different allergens in adults vs children vs older adults. However, in general, the prevalence of contact dermatitis is very similar across all age groups and distributions. I do think there are definitely gender and cultural variations. Women are more likely to be allergic to nickel, for example, which is more often found in jewelry. However, there really aren’t studies that demonstrate one population is more likely to develop allergic contact dermatitis than others. It really comes down to exposure. For example, neomycin, which is contained in triple antibiotics in the United States and is sold over the counter, is a common allergen here. However, it’s not readily available in other countries, and therefore, neomycin is a rare allergen in those countries.

Looking forward, which emerging consumer trends do you anticipate will create the next wave of contact dermatitis cases?

DR. YU: We have seen an increase in allergic contact dermatitis in the wearables industry, especially in continuous glucose monitors. They are now being sold over the counter so people without diabetes and without a prescription will be able to purchase them from retailers like Amazon or CVS. The adhesives in these glucose monitors have been shown to cause allergic contact dermatitis in a sizeable number of kids and adults. I suspect this problem will continue to increase with increased exposure to the allergens in these adhesives.

How do social media trends and influencer driven product fads affect the patterns of contact dermatitis you are seeing?

DR. YU: Social media and influencers are huge marketing opportunities for cosmetic and personal care companies and drive consumer demand. One example from a few years ago is slime as a toy for kids. For a period of time, every kid was making slime at home, resulting in high numbers of hand allergic contact dermatitis. Making slime requires a combination of borax (irritant), glue (irritant and allergen), laundry detergent or dish soap (irritant and allergen), and fragrances (irritant and allergen). This fad has been slowing since I cowrote an article on it (doi:10.1111 /pde.13792). More recently, the rise of “Sephora kids” (preteens and adolescents influenced by social media trends promoting multistep skin care and anti-aging products) has raised concerns about contact dermatitis, as many of these products contain ingredients that can disrupt the skin barrier or trigger sensitization in younger patients.

How can products labeled free of fragrances or preservatives still trigger allergic contact dermatitis?

DR. YU: Fragrances are frequently in the top 10 ingredients that cause allergic contact dermatitis in adults and children. For people with sensitive skin, we almost unequivocally recommend fragrance-free products. Now, not all fragrance-free products are truly free of fragrance allergens. Some fragrance chemicals may be used for another purpose (benzyl alcohol as a preservative, for example), so the product can still be fragrance free even though benzyl alcohol has a fragrance. Most products cannot truly be preservative free if they are expected to have a shelf life. One-time-use products do exist and can be preservative free, but they are very rare and very expensive to manufacture and maintain.

Have you seen spikes in reactions from trendy products like CBD-infused creams, botanical serums, or exfoliating acids?

DR. YU: Not yet, but I would not be surprised that this is rising in prevalence. The issue might not be CBD itself; it’s really the other additives in these CBD products that will cause problems. Looking at some CBD products for sale from major retailers, many contain fragrances such as lemongrass oil and botanical extracts such as calendula that have been noted to cause allergic contact dermatitis.

Do certain patient behaviors (eg, layering multiple natural products, frequent product switching, prolonged leave-on use) increase the risk for ACD?

DR. YU: Absolutely possible. The more products you use, the more likely you will develop allergic contact dermatitis due to increased exposure to potential allergens. We know that leave-on products are higher risk than rinse-offs in general. Furthermore, more products used also increase the risk for irritant dermatitis that might break the skin barrier, increasing the odds that someone will develop allergic contact dermatitis. We see this often with facial skin care products where some people might layer on glycolic acid with retinoid acid with vitamin C oil with kojic acid, etc, all leading to irritation on the face.

How do emerging consumer product trends influence your patch-testing approach?

DR. YU: We try to customize our patch-tested allergens to the patient’s rash and symptoms. If it’s a patient with facial dermatitis, for example, we would patch test the patient to a core allergen series (eg, American Contact Dermatitis Society 90, North American Comprehensive 80, North American Contact Dermatitis Group 80) and add on other supplemental panels including cosmetic series if applicable. It is also preferable to patch test for products that are used and/or suspected of causing the rash. For example, if a blush is a suspected cause of dermatitis, we would certainly patch test to that as well. We generally try to encourage the patient to bring in all their products so we can evaluate them for appropriateness for patch testing.

Which consumer-driven ingredients do you now consider high-yield targets for testing?

DR. YU: Fragrances, preservatives, and botanical extracts are all likely causes of allergic contact dermatitis. We are uncovering new allergens all the time, so testing directly to patient products is also important. Just because something has not been reported to be a contact allergen doesn’t mean it can’t become one.

Have you observed any demographic or cultural trends in patients with allergic contact dermatitis related to consumer products?

DR. YU: There are various papers that outline different allergens in adults vs children vs older adults. However, in general, the prevalence of contact dermatitis is very similar across all age groups and distributions. I do think there are definitely gender and cultural variations. Women are more likely to be allergic to nickel, for example, which is more often found in jewelry. However, there really aren’t studies that demonstrate one population is more likely to develop allergic contact dermatitis than others. It really comes down to exposure. For example, neomycin, which is contained in triple antibiotics in the United States and is sold over the counter, is a common allergen here. However, it’s not readily available in other countries, and therefore, neomycin is a rare allergen in those countries.

Looking forward, which emerging consumer trends do you anticipate will create the next wave of contact dermatitis cases?

DR. YU: We have seen an increase in allergic contact dermatitis in the wearables industry, especially in continuous glucose monitors. They are now being sold over the counter so people without diabetes and without a prescription will be able to purchase them from retailers like Amazon or CVS. The adhesives in these glucose monitors have been shown to cause allergic contact dermatitis in a sizeable number of kids and adults. I suspect this problem will continue to increase with increased exposure to the allergens in these adhesives.

Recognizing inflammation in darker skin tones has important implications for diagnosis and management of skin disease, particularly in patients with skin of color.¹ In this context, classification systems commonly are used—both in research and clinical practice—to standardize descriptions of skin tone across diverse populations. Fitzpatrick skin type (FST) originally was developed to classify cutaneous response to UV radiation exposure and remains one of the most widely used frameworks in dermatology.² However, FST often is used beyond its intended purpose as a proxy for differentiating skin color and race.^3,4 This mismatch risks obscuring clinically meaningful differences and limiting the accuracy of dermatologic research. Herein, we review the intended use of FST, its limitations in representing skin color and race, and considerations for more accurate characterization of skin pigmentation in clinical practice and research.

Origins and Intended Use of the FST Scale

Fitzpatrick skin type was developed by Thomas B. Fitzpatrick in the 1970s to guide UVA dosing for psoralen plus UVA therapy in patients with psoriasis.^5,6 The scale was intended to estimate an individual’s erythematous and pigmentary response to UV exposure.^6,7 Early iterations of FST largely were based on lighter skin types, reflecting its initial use in predominantly White populations, which limited representation of the full spectrum of skin tone diversity.⁵

Clinical, Educational, and Research Limitations of FST

Fitzpatrick skin type now is widely, albeit inaccurately, used in both research and clinical practice as a proxy for skin color and race,^7,8 which reflects its ease of use and the lack of standardized alternatives; however, FST does not adequately capture variability in baseline skin pigmentation, undertone, or inflammatory response. These limitations are especially pronounced in phototypes IV to VI, which encompass highly heterogeneous populations. As a result, grouping patients by FST alone to describe skin color and race may obscure important differences and limit meaningful interpretation of clinical and research findings.

Clinically, recognition of dermatologic conditions such as erythema may be more challenging in darker skin tones, in which classic visual cues are less apparent.^1,7 Relying on FST to stratify skin color may further compound diagnostic uncertainty by oversimplifying the cutaneous presentation. In addition, treatment decisions, including laser settings and assessment of pigmentary risk, often are guided by FST despite within-group variability.⁷ Further, educational frameworks that rely heavily on FST may inadequately prepare clinicians to recognize disease across diverse skin tones, contributing to delayed diagnosis and disparities in care in populations with skin of color.

The implications also extend to dermatologic research. Fitzpatrick skin type frequently is used to assess study populations; however, its limited ability to reflect true variation in pigmentation and ethnicity introduces misclassification bias.^3,7 The broad FST scale may group heterogeneous populations, obscuring differences in treatment response. As a result, studies relying on FST to represent skin color or race may have reduced generalizability across diverse populations. Importantly, these limitations are not merely conceptual but may contribute to measurable disparities in dermatologic diagnosis and outcomes.

Rethinking Skin Classification Frameworks

Despite these shortcomings, FST remains deeply embedded in dermatology. Its decades-long use has led to widespread familiarity and integration into clinical guidelines, education, and research. At the same time, the absence of a universally accepted alternative has reinforced the continued use of FST as a proxy for skin color and race.

Alternative strategies for characterizing skin pigmentation include objective measures such as spectrophotometry and melanin index assessment.⁹

Although these approaches may provide more precise quantification of pigmentation, their use may be limited by the need for specialized equipment and reduced feasibility in routine clinical settings. Other proposed approaches incorporate multidimensional factors such as pigmentation, photoreactivity, and genetic ancestry.⁴ While these techniques represent important advances, none has achieved widespread adoption yet, and each presents challenges related to feasibility and standardization.

In the absence of a single ideal system, a more nuanced approach is needed. Fitzpatrick skin type should be used in the context for which it was designed: estimating UV response. Incorporating additional descriptors, including self-identified race and ethnicity, alongside more detailed assessments of pigmentation may improve the accuracy and relevance of both clinical evaluation and research. Combining FST with more precise and inclusive frameworks represents a pragmatic step toward better reflecting patient diversity.

Recognizing inflammation in darker skin tones has important implications for diagnosis and management of skin disease, particularly in patients with skin of color.¹ In this context, classification systems commonly are used—both in research and clinical practice—to standardize descriptions of skin tone across diverse populations. Fitzpatrick skin type (FST) originally was developed to classify cutaneous response to UV radiation exposure and remains one of the most widely used frameworks in dermatology.² However, FST often is used beyond its intended purpose as a proxy for differentiating skin color and race.^3,4 This mismatch risks obscuring clinically meaningful differences and limiting the accuracy of dermatologic research. Herein, we review the intended use of FST, its limitations in representing skin color and race, and considerations for more accurate characterization of skin pigmentation in clinical practice and research.

Origins and Intended Use of the FST Scale

Fitzpatrick skin type was developed by Thomas B. Fitzpatrick in the 1970s to guide UVA dosing for psoralen plus UVA therapy in patients with psoriasis.^5,6 The scale was intended to estimate an individual’s erythematous and pigmentary response to UV exposure.^6,7 Early iterations of FST largely were based on lighter skin types, reflecting its initial use in predominantly White populations, which limited representation of the full spectrum of skin tone diversity.⁵

Clinical, Educational, and Research Limitations of FST

Fitzpatrick skin type now is widely, albeit inaccurately, used in both research and clinical practice as a proxy for skin color and race,^7,8 which reflects its ease of use and the lack of standardized alternatives; however, FST does not adequately capture variability in baseline skin pigmentation, undertone, or inflammatory response. These limitations are especially pronounced in phototypes IV to VI, which encompass highly heterogeneous populations. As a result, grouping patients by FST alone to describe skin color and race may obscure important differences and limit meaningful interpretation of clinical and research findings.

Clinically, recognition of dermatologic conditions such as erythema may be more challenging in darker skin tones, in which classic visual cues are less apparent.^1,7 Relying on FST to stratify skin color may further compound diagnostic uncertainty by oversimplifying the cutaneous presentation. In addition, treatment decisions, including laser settings and assessment of pigmentary risk, often are guided by FST despite within-group variability.⁷ Further, educational frameworks that rely heavily on FST may inadequately prepare clinicians to recognize disease across diverse skin tones, contributing to delayed diagnosis and disparities in care in populations with skin of color.

The implications also extend to dermatologic research. Fitzpatrick skin type frequently is used to assess study populations; however, its limited ability to reflect true variation in pigmentation and ethnicity introduces misclassification bias.^3,7 The broad FST scale may group heterogeneous populations, obscuring differences in treatment response. As a result, studies relying on FST to represent skin color or race may have reduced generalizability across diverse populations. Importantly, these limitations are not merely conceptual but may contribute to measurable disparities in dermatologic diagnosis and outcomes.

Rethinking Skin Classification Frameworks

Despite these shortcomings, FST remains deeply embedded in dermatology. Its decades-long use has led to widespread familiarity and integration into clinical guidelines, education, and research. At the same time, the absence of a universally accepted alternative has reinforced the continued use of FST as a proxy for skin color and race.

Alternative strategies for characterizing skin pigmentation include objective measures such as spectrophotometry and melanin index assessment.⁹

Although these approaches may provide more precise quantification of pigmentation, their use may be limited by the need for specialized equipment and reduced feasibility in routine clinical settings. Other proposed approaches incorporate multidimensional factors such as pigmentation, photoreactivity, and genetic ancestry.⁴ While these techniques represent important advances, none has achieved widespread adoption yet, and each presents challenges related to feasibility and standardization.

In the absence of a single ideal system, a more nuanced approach is needed. Fitzpatrick skin type should be used in the context for which it was designed: estimating UV response. Incorporating additional descriptors, including self-identified race and ethnicity, alongside more detailed assessments of pigmentation may improve the accuracy and relevance of both clinical evaluation and research. Combining FST with more precise and inclusive frameworks represents a pragmatic step toward better reflecting patient diversity.

Recognizing inflammation in darker skin tones has important implications for diagnosis and management of skin disease, particularly in patients with skin of color.¹ In this context, classification systems commonly are used—both in research and clinical practice—to standardize descriptions of skin tone across diverse populations. Fitzpatrick skin type (FST) originally was developed to classify cutaneous response to UV radiation exposure and remains one of the most widely used frameworks in dermatology.² However, FST often is used beyond its intended purpose as a proxy for differentiating skin color and race.^3,4 This mismatch risks obscuring clinically meaningful differences and limiting the accuracy of dermatologic research. Herein, we review the intended use of FST, its limitations in representing skin color and race, and considerations for more accurate characterization of skin pigmentation in clinical practice and research.

Origins and Intended Use of the FST Scale

Fitzpatrick skin type was developed by Thomas B. Fitzpatrick in the 1970s to guide UVA dosing for psoralen plus UVA therapy in patients with psoriasis.^5,6 The scale was intended to estimate an individual’s erythematous and pigmentary response to UV exposure.^6,7 Early iterations of FST largely were based on lighter skin types, reflecting its initial use in predominantly White populations, which limited representation of the full spectrum of skin tone diversity.⁵

Clinical, Educational, and Research Limitations of FST

Fitzpatrick skin type now is widely, albeit inaccurately, used in both research and clinical practice as a proxy for skin color and race,^7,8 which reflects its ease of use and the lack of standardized alternatives; however, FST does not adequately capture variability in baseline skin pigmentation, undertone, or inflammatory response. These limitations are especially pronounced in phototypes IV to VI, which encompass highly heterogeneous populations. As a result, grouping patients by FST alone to describe skin color and race may obscure important differences and limit meaningful interpretation of clinical and research findings.

Clinically, recognition of dermatologic conditions such as erythema may be more challenging in darker skin tones, in which classic visual cues are less apparent.^1,7 Relying on FST to stratify skin color may further compound diagnostic uncertainty by oversimplifying the cutaneous presentation. In addition, treatment decisions, including laser settings and assessment of pigmentary risk, often are guided by FST despite within-group variability.⁷ Further, educational frameworks that rely heavily on FST may inadequately prepare clinicians to recognize disease across diverse skin tones, contributing to delayed diagnosis and disparities in care in populations with skin of color.

The implications also extend to dermatologic research. Fitzpatrick skin type frequently is used to assess study populations; however, its limited ability to reflect true variation in pigmentation and ethnicity introduces misclassification bias.^3,7 The broad FST scale may group heterogeneous populations, obscuring differences in treatment response. As a result, studies relying on FST to represent skin color or race may have reduced generalizability across diverse populations. Importantly, these limitations are not merely conceptual but may contribute to measurable disparities in dermatologic diagnosis and outcomes.

Rethinking Skin Classification Frameworks

Despite these shortcomings, FST remains deeply embedded in dermatology. Its decades-long use has led to widespread familiarity and integration into clinical guidelines, education, and research. At the same time, the absence of a universally accepted alternative has reinforced the continued use of FST as a proxy for skin color and race.

Alternative strategies for characterizing skin pigmentation include objective measures such as spectrophotometry and melanin index assessment.⁹

Although these approaches may provide more precise quantification of pigmentation, their use may be limited by the need for specialized equipment and reduced feasibility in routine clinical settings. Other proposed approaches incorporate multidimensional factors such as pigmentation, photoreactivity, and genetic ancestry.⁴ While these techniques represent important advances, none has achieved widespread adoption yet, and each presents challenges related to feasibility and standardization.

In the absence of a single ideal system, a more nuanced approach is needed. Fitzpatrick skin type should be used in the context for which it was designed: estimating UV response. Incorporating additional descriptors, including self-identified race and ethnicity, alongside more detailed assessments of pigmentation may improve the accuracy and relevance of both clinical evaluation and research. Combining FST with more precise and inclusive frameworks represents a pragmatic step toward better reflecting patient diversity.

The Cutis editorial staff is proud to announce that Vincent A. DeLeo, MD, Editor-in-Chief, was honored with the Master Dermatologist Award at the 2026 Annual Meeting of the American Academy of Dermatology (AAD) in Denver, Colorado.

Presented as part of the AAD’s “Stars of the Academy” program, this award is reserved for physicians whose careers have advanced dermatology through leadership, service, and meaningful contributions to patient care, education, and research. The award reflects Dr. DeLeo’s impact across the specialty.

“Vince’s passion for dermatology has impacted all aspects of our specialty. He has been at the forefront of basic science research, clinical dermatology, education, mentoring, and leadership of specialty organizations and societies.” –Susan C. Taylor, MD

During the presentation, outgoing AAD president Susan C. Taylor, MD, emphasized Dr. DeLeo’s wide-ranging influence, noting his reputation as a researcher, compassionate physician, and skilled diagnostician. He is adept at managing complex cases and improving patient outcomes. Dr. DeLeo is widely recognized for his expertise in contact dermatitis, photomedicine, and photoprotection, as well as for his contributions to dermatologic education.

Beyond his clinical and editorial leadership of Cutis for the past 25 years, Dr. DeLeo is committed to mentorship and leadership by serving on the AAD Board of Directors as well as other specialty organizations such as the American Contact Dermatitis Society.

We congratulate Dr. DeLeo on this well-deserved distinction and thank him for his continued vision and dedication to our readers and the specialty at large.

The Cutis editorial staff is proud to announce that Vincent A. DeLeo, MD, Editor-in-Chief, was honored with the Master Dermatologist Award at the 2026 Annual Meeting of the American Academy of Dermatology (AAD) in Denver, Colorado.

Presented as part of the AAD’s “Stars of the Academy” program, this award is reserved for physicians whose careers have advanced dermatology through leadership, service, and meaningful contributions to patient care, education, and research. The award reflects Dr. DeLeo’s impact across the specialty.

“Vince’s passion for dermatology has impacted all aspects of our specialty. He has been at the forefront of basic science research, clinical dermatology, education, mentoring, and leadership of specialty organizations and societies.” –Susan C. Taylor, MD

During the presentation, outgoing AAD president Susan C. Taylor, MD, emphasized Dr. DeLeo’s wide-ranging influence, noting his reputation as a researcher, compassionate physician, and skilled diagnostician. He is adept at managing complex cases and improving patient outcomes. Dr. DeLeo is widely recognized for his expertise in contact dermatitis, photomedicine, and photoprotection, as well as for his contributions to dermatologic education.

Beyond his clinical and editorial leadership of Cutis for the past 25 years, Dr. DeLeo is committed to mentorship and leadership by serving on the AAD Board of Directors as well as other specialty organizations such as the American Contact Dermatitis Society.

We congratulate Dr. DeLeo on this well-deserved distinction and thank him for his continued vision and dedication to our readers and the specialty at large.

The Cutis editorial staff is proud to announce that Vincent A. DeLeo, MD, Editor-in-Chief, was honored with the Master Dermatologist Award at the 2026 Annual Meeting of the American Academy of Dermatology (AAD) in Denver, Colorado.

Presented as part of the AAD’s “Stars of the Academy” program, this award is reserved for physicians whose careers have advanced dermatology through leadership, service, and meaningful contributions to patient care, education, and research. The award reflects Dr. DeLeo’s impact across the specialty.

“Vince’s passion for dermatology has impacted all aspects of our specialty. He has been at the forefront of basic science research, clinical dermatology, education, mentoring, and leadership of specialty organizations and societies.” –Susan C. Taylor, MD

During the presentation, outgoing AAD president Susan C. Taylor, MD, emphasized Dr. DeLeo’s wide-ranging influence, noting his reputation as a researcher, compassionate physician, and skilled diagnostician. He is adept at managing complex cases and improving patient outcomes. Dr. DeLeo is widely recognized for his expertise in contact dermatitis, photomedicine, and photoprotection, as well as for his contributions to dermatologic education.

Beyond his clinical and editorial leadership of Cutis for the past 25 years, Dr. DeLeo is committed to mentorship and leadership by serving on the AAD Board of Directors as well as other specialty organizations such as the American Contact Dermatitis Society.

We congratulate Dr. DeLeo on this well-deserved distinction and thank him for his continued vision and dedication to our readers and the specialty at large.

Military service members are at high risk for skin cancer due to unique occupational and environmental exposures, particularly in the aviation community, in which high-altitude flying, prolonged outdoor aircraft maintenance, physical training, field exercises, and deployments limit access to shade and opportunities for sunscreen reapplication. During deployment or field operations, service members may operate in environments with limited access to SPF products, particularly if sunscreen is not included among personal items.

Research on sun protection strategies and skin cancer risk factors in military personnel is critical to improving prevention, particularly given the higher incidence of melanoma in this population. A 2010 retrospective tumor registry review from the Department of Defense and the National Cancer Institute found higher melanoma rates in military personnel compared with the general population among individuals aged 45 to 49 years (33.62 vs 27.49), 50 to 54 years (49.76 vs 32.18), and 55 to 59 years (178.48 vs 39.17).¹

This article discusses barriers to sun protection in military populations, evaluates sunscreen availability in military exchanges, and considers implications for policy and prevention.

Barriers to Sun Protection and Sunscreen Use

According to Rosenberg et al,² the cause of higher rates of skin cancer among military service members may be multifactorial, including financial barriers to sunscreen use, limited education on photodamage, and insufficient emphasis on sun protection during demanding operational or training activities. Veterans of Operation Enduring Freedom and Operation Iraqi Freedom who were surveyed about UV exposure and sunscreen indicated that 23% (49/211) received education about skin cancer but less than 30% (60/211) used sunscreen consistently during deployment due to lack of access, which has been reported previously.³ Sunscreen adherence also may be reduced in this population due to factors such as skin irritation, cost, poor cosmetic acceptability, and lower utilization among male service members. In their literature review of 9 publications pertaining to skin cancer risk through December 2016, Riemenschneider et al¹ noted that male service members comprised 85% of the US military in 2014, and men statistically have lower rates of sunscreen use than women.

Sunscreen Availability and Product Analysis in Military Exchanges

Sunscreen is an important component of skin care for skin cancer prevention. More consistent use has been noted in households with annual incomes of $60,000 or higher.⁴ Sunscreen product availability has not been evaluated in the military community. Exchange stores are military equivalents of commercial chain stores where service members can purchase tax-free items. The Marine Corps Exchange (MCX) operates on 18 large active-duty bases worldwide. Patrons include active-duty service members from any branch, veterans, and family members. Officials from the MCX headquarters approve and maintain items sold on base. Although product availability may vary by location, standardization is maintained through vendor agreements influenced by customer demand and includes both exchange-branded and private-label products.⁵

In a review of 96 sunscreen products at Marine Corps Air Station Cherry Point MCX, 62.5% (60/96) met American Academy of Dermatology guideline criteria (SPF ≥30, broad-spectrum UVA/UVB protection, and water resistance of 40-80 minutes).⁶ Of all products, 79.1% (76/96) were SPF 30 or higher, 76.0% (73/96) were water-resistant, and all provided broad-spectrum protection. Lotion formulations comprised 62.5% (60/96), and the mean price per ounce was $11.96. Opportunities for product expansion include increased availability of options for sensitive skin, as mineral sunscreens comprised 14.6% (14/96) of products; greater variety of products marketed to men, which accounted for 5.2% (5/96); and improved representation for service members with skin of color, as tinted formulations comprised 2.1% (2/96).⁶

Implications for Policy and Operational Readiness

Given these data, future studies should evaluate sunscreen purchasing behaviors among US service members to determine MCX utilization and whether product selection is driven by active-duty demand or broader consumer purchasing patterns. If product offerings are driven by the civilian customer base, this may result in a lack of tailored options for military service members who are most at risk for high UV exposure. If the MCX does not meet the needs of service members adequately or is inaccessible due to cost or inventory limitations, it highlights a weakness in skin cancer prevention.

Future research should explore not only sunscreen purchasing behavior among service members but also barriers to access and compliance with sun protection measures, as these insights are critical for informing effective policy that balances personal responsibility with institutional support. This could help with advocacy efforts for more effective, readily available options on base. It also could strengthen the argument for alternative strategies to complement sunscreen use, such as a sunscreen allowance, inclusion of sunscreen with provided uniforms and equipment, patient education, work breaks, sun-protective uniform items, and designated shade areas at work.⁶

Final Thoughts

Policy changes such as routine provision of sunscreen through supply chains, issuing sunscreen with uniforms, or providing a sunscreen stipend could remove financial and logistical barriers to consistent use of sunscreen in military populations. These measures could be impactful during field operations, deployments, and training in austere environments, where commercial purchasing options are limited and UV exposure is high. A proactive approach to sun safety could demonstrate a commitment to preserving the current health and operational readiness of active-duty service members while reducing future financial burdens of skin disease and helping promote wellness in this population during retirement. As with ear protection, uniforms, and eyewear, sunscreen should be considered a standard component of operational readiness.

Military service members are at high risk for skin cancer due to unique occupational and environmental exposures, particularly in the aviation community, in which high-altitude flying, prolonged outdoor aircraft maintenance, physical training, field exercises, and deployments limit access to shade and opportunities for sunscreen reapplication. During deployment or field operations, service members may operate in environments with limited access to SPF products, particularly if sunscreen is not included among personal items.

Research on sun protection strategies and skin cancer risk factors in military personnel is critical to improving prevention, particularly given the higher incidence of melanoma in this population. A 2010 retrospective tumor registry review from the Department of Defense and the National Cancer Institute found higher melanoma rates in military personnel compared with the general population among individuals aged 45 to 49 years (33.62 vs 27.49), 50 to 54 years (49.76 vs 32.18), and 55 to 59 years (178.48 vs 39.17).¹

This article discusses barriers to sun protection in military populations, evaluates sunscreen availability in military exchanges, and considers implications for policy and prevention.

Barriers to Sun Protection and Sunscreen Use

According to Rosenberg et al,² the cause of higher rates of skin cancer among military service members may be multifactorial, including financial barriers to sunscreen use, limited education on photodamage, and insufficient emphasis on sun protection during demanding operational or training activities. Veterans of Operation Enduring Freedom and Operation Iraqi Freedom who were surveyed about UV exposure and sunscreen indicated that 23% (49/211) received education about skin cancer but less than 30% (60/211) used sunscreen consistently during deployment due to lack of access, which has been reported previously.³ Sunscreen adherence also may be reduced in this population due to factors such as skin irritation, cost, poor cosmetic acceptability, and lower utilization among male service members. In their literature review of 9 publications pertaining to skin cancer risk through December 2016, Riemenschneider et al¹ noted that male service members comprised 85% of the US military in 2014, and men statistically have lower rates of sunscreen use than women.

Sunscreen Availability and Product Analysis in Military Exchanges

Sunscreen is an important component of skin care for skin cancer prevention. More consistent use has been noted in households with annual incomes of $60,000 or higher.⁴ Sunscreen product availability has not been evaluated in the military community. Exchange stores are military equivalents of commercial chain stores where service members can purchase tax-free items. The Marine Corps Exchange (MCX) operates on 18 large active-duty bases worldwide. Patrons include active-duty service members from any branch, veterans, and family members. Officials from the MCX headquarters approve and maintain items sold on base. Although product availability may vary by location, standardization is maintained through vendor agreements influenced by customer demand and includes both exchange-branded and private-label products.⁵

In a review of 96 sunscreen products at Marine Corps Air Station Cherry Point MCX, 62.5% (60/96) met American Academy of Dermatology guideline criteria (SPF ≥30, broad-spectrum UVA/UVB protection, and water resistance of 40-80 minutes).⁶ Of all products, 79.1% (76/96) were SPF 30 or higher, 76.0% (73/96) were water-resistant, and all provided broad-spectrum protection. Lotion formulations comprised 62.5% (60/96), and the mean price per ounce was $11.96. Opportunities for product expansion include increased availability of options for sensitive skin, as mineral sunscreens comprised 14.6% (14/96) of products; greater variety of products marketed to men, which accounted for 5.2% (5/96); and improved representation for service members with skin of color, as tinted formulations comprised 2.1% (2/96).⁶

Implications for Policy and Operational Readiness

Given these data, future studies should evaluate sunscreen purchasing behaviors among US service members to determine MCX utilization and whether product selection is driven by active-duty demand or broader consumer purchasing patterns. If product offerings are driven by the civilian customer base, this may result in a lack of tailored options for military service members who are most at risk for high UV exposure. If the MCX does not meet the needs of service members adequately or is inaccessible due to cost or inventory limitations, it highlights a weakness in skin cancer prevention.

Future research should explore not only sunscreen purchasing behavior among service members but also barriers to access and compliance with sun protection measures, as these insights are critical for informing effective policy that balances personal responsibility with institutional support. This could help with advocacy efforts for more effective, readily available options on base. It also could strengthen the argument for alternative strategies to complement sunscreen use, such as a sunscreen allowance, inclusion of sunscreen with provided uniforms and equipment, patient education, work breaks, sun-protective uniform items, and designated shade areas at work.⁶

Final Thoughts

Policy changes such as routine provision of sunscreen through supply chains, issuing sunscreen with uniforms, or providing a sunscreen stipend could remove financial and logistical barriers to consistent use of sunscreen in military populations. These measures could be impactful during field operations, deployments, and training in austere environments, where commercial purchasing options are limited and UV exposure is high. A proactive approach to sun safety could demonstrate a commitment to preserving the current health and operational readiness of active-duty service members while reducing future financial burdens of skin disease and helping promote wellness in this population during retirement. As with ear protection, uniforms, and eyewear, sunscreen should be considered a standard component of operational readiness.

Military service members are at high risk for skin cancer due to unique occupational and environmental exposures, particularly in the aviation community, in which high-altitude flying, prolonged outdoor aircraft maintenance, physical training, field exercises, and deployments limit access to shade and opportunities for sunscreen reapplication. During deployment or field operations, service members may operate in environments with limited access to SPF products, particularly if sunscreen is not included among personal items.

Research on sun protection strategies and skin cancer risk factors in military personnel is critical to improving prevention, particularly given the higher incidence of melanoma in this population. A 2010 retrospective tumor registry review from the Department of Defense and the National Cancer Institute found higher melanoma rates in military personnel compared with the general population among individuals aged 45 to 49 years (33.62 vs 27.49), 50 to 54 years (49.76 vs 32.18), and 55 to 59 years (178.48 vs 39.17).¹

This article discusses barriers to sun protection in military populations, evaluates sunscreen availability in military exchanges, and considers implications for policy and prevention.

Barriers to Sun Protection and Sunscreen Use

According to Rosenberg et al,² the cause of higher rates of skin cancer among military service members may be multifactorial, including financial barriers to sunscreen use, limited education on photodamage, and insufficient emphasis on sun protection during demanding operational or training activities. Veterans of Operation Enduring Freedom and Operation Iraqi Freedom who were surveyed about UV exposure and sunscreen indicated that 23% (49/211) received education about skin cancer but less than 30% (60/211) used sunscreen consistently during deployment due to lack of access, which has been reported previously.³ Sunscreen adherence also may be reduced in this population due to factors such as skin irritation, cost, poor cosmetic acceptability, and lower utilization among male service members. In their literature review of 9 publications pertaining to skin cancer risk through December 2016, Riemenschneider et al¹ noted that male service members comprised 85% of the US military in 2014, and men statistically have lower rates of sunscreen use than women.

Sunscreen Availability and Product Analysis in Military Exchanges

Sunscreen is an important component of skin care for skin cancer prevention. More consistent use has been noted in households with annual incomes of $60,000 or higher.⁴ Sunscreen product availability has not been evaluated in the military community. Exchange stores are military equivalents of commercial chain stores where service members can purchase tax-free items. The Marine Corps Exchange (MCX) operates on 18 large active-duty bases worldwide. Patrons include active-duty service members from any branch, veterans, and family members. Officials from the MCX headquarters approve and maintain items sold on base. Although product availability may vary by location, standardization is maintained through vendor agreements influenced by customer demand and includes both exchange-branded and private-label products.⁵

In a review of 96 sunscreen products at Marine Corps Air Station Cherry Point MCX, 62.5% (60/96) met American Academy of Dermatology guideline criteria (SPF ≥30, broad-spectrum UVA/UVB protection, and water resistance of 40-80 minutes).⁶ Of all products, 79.1% (76/96) were SPF 30 or higher, 76.0% (73/96) were water-resistant, and all provided broad-spectrum protection. Lotion formulations comprised 62.5% (60/96), and the mean price per ounce was $11.96. Opportunities for product expansion include increased availability of options for sensitive skin, as mineral sunscreens comprised 14.6% (14/96) of products; greater variety of products marketed to men, which accounted for 5.2% (5/96); and improved representation for service members with skin of color, as tinted formulations comprised 2.1% (2/96).⁶

Implications for Policy and Operational Readiness

Given these data, future studies should evaluate sunscreen purchasing behaviors among US service members to determine MCX utilization and whether product selection is driven by active-duty demand or broader consumer purchasing patterns. If product offerings are driven by the civilian customer base, this may result in a lack of tailored options for military service members who are most at risk for high UV exposure. If the MCX does not meet the needs of service members adequately or is inaccessible due to cost or inventory limitations, it highlights a weakness in skin cancer prevention.

Future research should explore not only sunscreen purchasing behavior among service members but also barriers to access and compliance with sun protection measures, as these insights are critical for informing effective policy that balances personal responsibility with institutional support. This could help with advocacy efforts for more effective, readily available options on base. It also could strengthen the argument for alternative strategies to complement sunscreen use, such as a sunscreen allowance, inclusion of sunscreen with provided uniforms and equipment, patient education, work breaks, sun-protective uniform items, and designated shade areas at work.⁶

Final Thoughts

Policy changes such as routine provision of sunscreen through supply chains, issuing sunscreen with uniforms, or providing a sunscreen stipend could remove financial and logistical barriers to consistent use of sunscreen in military populations. These measures could be impactful during field operations, deployments, and training in austere environments, where commercial purchasing options are limited and UV exposure is high. A proactive approach to sun safety could demonstrate a commitment to preserving the current health and operational readiness of active-duty service members while reducing future financial burdens of skin disease and helping promote wellness in this population during retirement. As with ear protection, uniforms, and eyewear, sunscreen should be considered a standard component of operational readiness.

The American Academy of Dermatology’s 2026 Annual Meeting in Denver, Colorado, showcased advances in clinical practice and dermatology research. Selected key updates are summarized here for concise review of emerging dermatology data relevant to clinical practice.

AI Holds Promise in Dermatology, Issues Remain to be Addressed

Artificial intelligence (AI) is rapidly advancing in dermatology, improving image analysis, clinical decision support, and workflow efficiency; however, concerns remain about ethical use, training gaps, and potential skill loss among clinicians. While AI may enhance productivity and care, experts emphasize the need for cautious implementation, education, and ongoing evaluation of real-world performance.

Phase 2b Findings Support Novel Agent to Treat Alopecia Areata

A phase 2b trial of rezpegaldesleukin for severe alopecia areata showed considerably greater reductions in SALT scores vs placebo over 36 weeks, with higher response rates and no treatment plateau. The biologic, which enhances regulatory T-cell activity, demonstrated a favorable safety profile, with mainly mild injection-site reactions and no new safety signals.

JAK Inhibitors: Identifying Ideal Candidates and Putting Real-World Risks in Context

Emerging evidence suggests Janus kinase (JAK) inhibitors are safer in dermatology than early rheumatoid arthritis data indicated. Risks for cardiovascular events, thrombosis, and malignancy appear low and largely driven by baseline patient factors. With appropriate screening and monitoring, these agents can be used safely in most patients with inflammatory skin diseases.

Nemolizumab Phase 2 Findings Positive for Children 2-11 Years Old With Atopic Dermatitis

A phase 2 open-label study of nemolizumab in children aged 2 to 11 years with moderate to severe atopic dermatitis showed notable improvements in skin clearance, disease severity, and itch with weight-based dosing. Responses were rapid, durable through 52 weeks, and consistent with prior data, with no new safety signals identified in this population.

Melasma: A New Era of Topical Treatment Options Galore

Melasma treatment is rapidly expanding beyond traditional agents such as hydroquinone and triple combination therapy, with newer topicals including tranexamic acid, cysteamine, azelaic acid, thiamidol, and emerging compounds showing variable efficacy. While promising, evidence is still evolving, and combination regimens plus strict photoprotection remain the cornerstone of management.

Weight-Loss Drug–Biologic Combination Boosts Relief in Psoriatic Arthritis

In a phase 3b trial, combining tirzepatide with ixekizumab significantly improved joint and skin outcomes in patients with psoriatic arthritis and overweight/obesity (P<.05) compared with ixekizumab alone (P<.001). The combination yielded higher American College of Rheumatology and Psoriasis Area and Severity Index response rates, early symptom improvement, and meaningful weight loss, with safety profiles consistent with known effects.

Tips on Using Biologics for Psoriasis in Context of HIV

Evidence for biologic use in HIV-positive patients with moderate to severe psoriasis is limited, but available case reports suggest tumor necrosis factor inhibitors and newer IL-targeted biologics are generally effective without major impacts on viral load or CD4 counts. Experts recommend prioritizing nonimmunosuppressive options and coordinating care with HIV specialists due to potential infection risks.

Upadacitinib Results in Significant Improvements in Nonsegmental Vitiligo in Phase 3 Studies

Two phase 3 trials showed that the Janus kinase 1 inhibitor upadacitinib significantly improved repigmentation outcomes in adolescents and adults with nonsegmental vitiligo vs placebo over 48 weeks (P<.0001 for both), with a higher proportion achieving clinically meaningful reductions in Vitiligo Area and Severity Index scores. Benefits increased over time without plateau, and no new safety signals were identified.

The American Academy of Dermatology’s 2026 Annual Meeting in Denver, Colorado, showcased advances in clinical practice and dermatology research. Selected key updates are summarized here for concise review of emerging dermatology data relevant to clinical practice.

AI Holds Promise in Dermatology, Issues Remain to be Addressed

Artificial intelligence (AI) is rapidly advancing in dermatology, improving image analysis, clinical decision support, and workflow efficiency; however, concerns remain about ethical use, training gaps, and potential skill loss among clinicians. While AI may enhance productivity and care, experts emphasize the need for cautious implementation, education, and ongoing evaluation of real-world performance.

Phase 2b Findings Support Novel Agent to Treat Alopecia Areata

A phase 2b trial of rezpegaldesleukin for severe alopecia areata showed considerably greater reductions in SALT scores vs placebo over 36 weeks, with higher response rates and no treatment plateau. The biologic, which enhances regulatory T-cell activity, demonstrated a favorable safety profile, with mainly mild injection-site reactions and no new safety signals.

JAK Inhibitors: Identifying Ideal Candidates and Putting Real-World Risks in Context

Emerging evidence suggests Janus kinase (JAK) inhibitors are safer in dermatology than early rheumatoid arthritis data indicated. Risks for cardiovascular events, thrombosis, and malignancy appear low and largely driven by baseline patient factors. With appropriate screening and monitoring, these agents can be used safely in most patients with inflammatory skin diseases.

Nemolizumab Phase 2 Findings Positive for Children 2-11 Years Old With Atopic Dermatitis

A phase 2 open-label study of nemolizumab in children aged 2 to 11 years with moderate to severe atopic dermatitis showed notable improvements in skin clearance, disease severity, and itch with weight-based dosing. Responses were rapid, durable through 52 weeks, and consistent with prior data, with no new safety signals identified in this population.

Melasma: A New Era of Topical Treatment Options Galore

Melasma treatment is rapidly expanding beyond traditional agents such as hydroquinone and triple combination therapy, with newer topicals including tranexamic acid, cysteamine, azelaic acid, thiamidol, and emerging compounds showing variable efficacy. While promising, evidence is still evolving, and combination regimens plus strict photoprotection remain the cornerstone of management.

Weight-Loss Drug–Biologic Combination Boosts Relief in Psoriatic Arthritis

In a phase 3b trial, combining tirzepatide with ixekizumab significantly improved joint and skin outcomes in patients with psoriatic arthritis and overweight/obesity (P<.05) compared with ixekizumab alone (P<.001). The combination yielded higher American College of Rheumatology and Psoriasis Area and Severity Index response rates, early symptom improvement, and meaningful weight loss, with safety profiles consistent with known effects.

Tips on Using Biologics for Psoriasis in Context of HIV

Evidence for biologic use in HIV-positive patients with moderate to severe psoriasis is limited, but available case reports suggest tumor necrosis factor inhibitors and newer IL-targeted biologics are generally effective without major impacts on viral load or CD4 counts. Experts recommend prioritizing nonimmunosuppressive options and coordinating care with HIV specialists due to potential infection risks.

Upadacitinib Results in Significant Improvements in Nonsegmental Vitiligo in Phase 3 Studies

Two phase 3 trials showed that the Janus kinase 1 inhibitor upadacitinib significantly improved repigmentation outcomes in adolescents and adults with nonsegmental vitiligo vs placebo over 48 weeks (P<.0001 for both), with a higher proportion achieving clinically meaningful reductions in Vitiligo Area and Severity Index scores. Benefits increased over time without plateau, and no new safety signals were identified.

The American Academy of Dermatology’s 2026 Annual Meeting in Denver, Colorado, showcased advances in clinical practice and dermatology research. Selected key updates are summarized here for concise review of emerging dermatology data relevant to clinical practice.

AI Holds Promise in Dermatology, Issues Remain to be Addressed

Artificial intelligence (AI) is rapidly advancing in dermatology, improving image analysis, clinical decision support, and workflow efficiency; however, concerns remain about ethical use, training gaps, and potential skill loss among clinicians. While AI may enhance productivity and care, experts emphasize the need for cautious implementation, education, and ongoing evaluation of real-world performance.

Phase 2b Findings Support Novel Agent to Treat Alopecia Areata

A phase 2b trial of rezpegaldesleukin for severe alopecia areata showed considerably greater reductions in SALT scores vs placebo over 36 weeks, with higher response rates and no treatment plateau. The biologic, which enhances regulatory T-cell activity, demonstrated a favorable safety profile, with mainly mild injection-site reactions and no new safety signals.

JAK Inhibitors: Identifying Ideal Candidates and Putting Real-World Risks in Context

Emerging evidence suggests Janus kinase (JAK) inhibitors are safer in dermatology than early rheumatoid arthritis data indicated. Risks for cardiovascular events, thrombosis, and malignancy appear low and largely driven by baseline patient factors. With appropriate screening and monitoring, these agents can be used safely in most patients with inflammatory skin diseases.

Nemolizumab Phase 2 Findings Positive for Children 2-11 Years Old With Atopic Dermatitis

A phase 2 open-label study of nemolizumab in children aged 2 to 11 years with moderate to severe atopic dermatitis showed notable improvements in skin clearance, disease severity, and itch with weight-based dosing. Responses were rapid, durable through 52 weeks, and consistent with prior data, with no new safety signals identified in this population.

Melasma: A New Era of Topical Treatment Options Galore

Melasma treatment is rapidly expanding beyond traditional agents such as hydroquinone and triple combination therapy, with newer topicals including tranexamic acid, cysteamine, azelaic acid, thiamidol, and emerging compounds showing variable efficacy. While promising, evidence is still evolving, and combination regimens plus strict photoprotection remain the cornerstone of management.

Weight-Loss Drug–Biologic Combination Boosts Relief in Psoriatic Arthritis

In a phase 3b trial, combining tirzepatide with ixekizumab significantly improved joint and skin outcomes in patients with psoriatic arthritis and overweight/obesity (P<.05) compared with ixekizumab alone (P<.001). The combination yielded higher American College of Rheumatology and Psoriasis Area and Severity Index response rates, early symptom improvement, and meaningful weight loss, with safety profiles consistent with known effects.

Tips on Using Biologics for Psoriasis in Context of HIV

Evidence for biologic use in HIV-positive patients with moderate to severe psoriasis is limited, but available case reports suggest tumor necrosis factor inhibitors and newer IL-targeted biologics are generally effective without major impacts on viral load or CD4 counts. Experts recommend prioritizing nonimmunosuppressive options and coordinating care with HIV specialists due to potential infection risks.

Upadacitinib Results in Significant Improvements in Nonsegmental Vitiligo in Phase 3 Studies

Two phase 3 trials showed that the Janus kinase 1 inhibitor upadacitinib significantly improved repigmentation outcomes in adolescents and adults with nonsegmental vitiligo vs placebo over 48 weeks (P<.0001 for both), with a higher proportion achieving clinically meaningful reductions in Vitiligo Area and Severity Index scores. Benefits increased over time without plateau, and no new safety signals were identified.

How might AI enhance the detection of key histologic features in drug eruptions compared to traditional microscopy?

DR. BRIDGES: AI offers the potential to enhance detection of histologic features in drug eruptions by systematically analyzing entire whole-slide images. Convolutional neural networks and attention-based models can identify subtle or focal findings such as scattered dyskeratotic keratinocytes, focal spongiosis, early interface change, rare eosinophils, or microvascular injury, which may be overlooked during routine microscopy due to sampling limitations. This capability is particularly relevant in drug eruptions, where histologic changes often are heterogeneous and patchy.

AI-generated attention heatmaps can highlight diagnostically relevant regions across the slide, improving consistency and completeness of slide reviews. While AI has demonstrated high sensitivity and specificity in broader dermatopathology tasks, particularly neoplastic conditions, drug eruption–specific validation data are currently lacking. As such, the most realistic application at present is AI functioning as a sensitivity-enhancing adjunct or “second reader,” improving consistency and completeness of slide review while preserving expert human interpretation.

Which histologic patterns in drug eruptions are hardest to quantify, and how could AI help standardize their assessment?

DR. BRIDGES: AI-based image analysis can standardize the assessment of histologic patterns through objective reproducible quantification. Deep learning algorithms can segment epidermal and dermal compartments, identify inflammatory cell types, and calculate metrics such as eosinophil density per unit area, percentage of epidermis with vacuolar alteration, or number of affected vessels. Studies in quantitative immunohistochemistry demonstrate high accuracy for tissue segmentation and cell counting, suggesting feasibility for similar applications in inflammatory dermatopathology. While these tools would not replace diagnostic interpretation, they could provide standardized measurements that enhance reproducibility and improve clinicopathologic correlation.

What training challenges must be addressed in AI and drug eruption histology?

DR. BRIDGES: Training AI models for drug eruption histopathology faces several challenges, including the limited availability of high-quality, well-annotated datasets, as most existing AI dermatopathology research focuses on neoplastic conditions. Drug eruptions also exhibit marked histologic heterogeneity, ranging from spongiotic and lichenoid to vasculitic and cytotoxic patterns, often with significant overlap. Accurate labeling, therefore, requires robust clinicopathologic correlation, including medication history, timing, laboratory data, and clinical outcomes—information that is often incomplete or retrospective.

Inaccurate or inconsistent annotations can significantly degrade model performance, and expert disagreement in borderline cases further complicates the creation of reliable ground truth. Additionally, training data may reflect institutional or demographic biases, risking unequal performance across patient populations. Addressing these challenges will require multicenter collaboration, standardized annotation protocols, inclusion of diverse patient cohorts, and careful attention to bias mitigation. At present, these barriers place drug eruption AI firmly in the investigational rather than clinical domain.

How important is AI explainability in the interpretation of diagnostic suggestions?

DR. BRIDGES: Explainability is essential for trust, particularly in the evaluation of drug eruptions, where diagnostic decisions can have serious clinical consequences. Dermatopathologists must understand which histologic features are driving an AI model’s assessment to ensure that conclusions align with morphologic reality and clinicopathologic reasoning. Explainable AI tools (such as attention heatmaps, feature importance rankings, and methods like Shapley Additive Explanations or Local Interpretable Model-Agnostic Explanations) can help clarify which histologic features are driving the AI model’s assessment.

Without transparency, AI systems function as “black boxes,” limiting their utility in high-stakes settings where diagnostic accountability and clinical communication are paramount. Explainability also supports appropriate skepticism, allowing pathologists to recognize when model outputs may be unreliable due to artifacts, atypical patterns, or out-of-distribution cases. In cases of drug eruptions—where diagnosis relies on combining histology, clinical timing, and medication history—explainability is essential for proper use.

How could AI pattern recognition be integrated into your workflow to enhance diagnostic efficiency and accuracy? What safeguards would be required?

DR. BRIDGES: In the near term, AI pattern recognition can be useful as an assistive tool rather than a diagnostic authority. One potential application is pre-screening whole-slide images to flag cases with features such as prominent interface change, increased keratinocyte necrosis, eosinophil-rich infiltrates, or vascular injury, prompting expedited review in clinically concerning scenarios. During sign-out, AI overlays could aid efficiency by highlighting rare but relevant features and providing quantitative summaries that support standardized reporting.

Safeguards are essential. AI systems must be validated across diverse practice settings, staining protocols, and scanning platforms. Human oversight is mandatory, with the dermatopathologist retaining full diagnostic responsibility. AI involvement should be clearly documented for medicolegal transparency, and performance should be continuously monitored to detect algorithmic drift as new drug eruption patterns emerge. Given current limitations, AI is best viewed as a tool to refine and support expert judgment, not replace it.

What data-sharing or privacy challenges must be addressed to develop robust AI models for diverse drug-eruption histopathology?

DR. BRIDGES: Developing robust AI models for drug eruptions requires large diverse datasets, raising significant privacy and governance challenges. Rigorous de-identification protocols, clear informed consent frameworks, and strong institutional oversight are therefore essential. Multicenter collaborations must employ secure data-use agreements and governance structures that clearly define access, ownership, and downstream use of data.

Ensuring equitable representation is equally critical, as underrepresentation of certain populations may lead to biased performance and disparities in care. Standardized data formats and interoperable systems are needed to facilitate collaboration while preserving security. Transparent governance structures, clear rules regarding data use, and trust-building with patients and institutions will ultimately determine willingness to participate. Addressing these challenges is foundational to advancing AI research in drug eruptions responsibly and ethically.

How might AI enhance the detection of key histologic features in drug eruptions compared to traditional microscopy?

DR. BRIDGES: AI offers the potential to enhance detection of histologic features in drug eruptions by systematically analyzing entire whole-slide images. Convolutional neural networks and attention-based models can identify subtle or focal findings such as scattered dyskeratotic keratinocytes, focal spongiosis, early interface change, rare eosinophils, or microvascular injury, which may be overlooked during routine microscopy due to sampling limitations. This capability is particularly relevant in drug eruptions, where histologic changes often are heterogeneous and patchy.

AI-generated attention heatmaps can highlight diagnostically relevant regions across the slide, improving consistency and completeness of slide reviews. While AI has demonstrated high sensitivity and specificity in broader dermatopathology tasks, particularly neoplastic conditions, drug eruption–specific validation data are currently lacking. As such, the most realistic application at present is AI functioning as a sensitivity-enhancing adjunct or “second reader,” improving consistency and completeness of slide review while preserving expert human interpretation.

Which histologic patterns in drug eruptions are hardest to quantify, and how could AI help standardize their assessment?

DR. BRIDGES: AI-based image analysis can standardize the assessment of histologic patterns through objective reproducible quantification. Deep learning algorithms can segment epidermal and dermal compartments, identify inflammatory cell types, and calculate metrics such as eosinophil density per unit area, percentage of epidermis with vacuolar alteration, or number of affected vessels. Studies in quantitative immunohistochemistry demonstrate high accuracy for tissue segmentation and cell counting, suggesting feasibility for similar applications in inflammatory dermatopathology. While these tools would not replace diagnostic interpretation, they could provide standardized measurements that enhance reproducibility and improve clinicopathologic correlation.

What training challenges must be addressed in AI and drug eruption histology?

DR. BRIDGES: Training AI models for drug eruption histopathology faces several challenges, including the limited availability of high-quality, well-annotated datasets, as most existing AI dermatopathology research focuses on neoplastic conditions. Drug eruptions also exhibit marked histologic heterogeneity, ranging from spongiotic and lichenoid to vasculitic and cytotoxic patterns, often with significant overlap. Accurate labeling, therefore, requires robust clinicopathologic correlation, including medication history, timing, laboratory data, and clinical outcomes—information that is often incomplete or retrospective.

Inaccurate or inconsistent annotations can significantly degrade model performance, and expert disagreement in borderline cases further complicates the creation of reliable ground truth. Additionally, training data may reflect institutional or demographic biases, risking unequal performance across patient populations. Addressing these challenges will require multicenter collaboration, standardized annotation protocols, inclusion of diverse patient cohorts, and careful attention to bias mitigation. At present, these barriers place drug eruption AI firmly in the investigational rather than clinical domain.

How important is AI explainability in the interpretation of diagnostic suggestions?

DR. BRIDGES: Explainability is essential for trust, particularly in the evaluation of drug eruptions, where diagnostic decisions can have serious clinical consequences. Dermatopathologists must understand which histologic features are driving an AI model’s assessment to ensure that conclusions align with morphologic reality and clinicopathologic reasoning. Explainable AI tools (such as attention heatmaps, feature importance rankings, and methods like Shapley Additive Explanations or Local Interpretable Model-Agnostic Explanations) can help clarify which histologic features are driving the AI model’s assessment.

Without transparency, AI systems function as “black boxes,” limiting their utility in high-stakes settings where diagnostic accountability and clinical communication are paramount. Explainability also supports appropriate skepticism, allowing pathologists to recognize when model outputs may be unreliable due to artifacts, atypical patterns, or out-of-distribution cases. In cases of drug eruptions—where diagnosis relies on combining histology, clinical timing, and medication history—explainability is essential for proper use.

How could AI pattern recognition be integrated into your workflow to enhance diagnostic efficiency and accuracy? What safeguards would be required?

DR. BRIDGES: In the near term, AI pattern recognition can be useful as an assistive tool rather than a diagnostic authority. One potential application is pre-screening whole-slide images to flag cases with features such as prominent interface change, increased keratinocyte necrosis, eosinophil-rich infiltrates, or vascular injury, prompting expedited review in clinically concerning scenarios. During sign-out, AI overlays could aid efficiency by highlighting rare but relevant features and providing quantitative summaries that support standardized reporting.

Safeguards are essential. AI systems must be validated across diverse practice settings, staining protocols, and scanning platforms. Human oversight is mandatory, with the dermatopathologist retaining full diagnostic responsibility. AI involvement should be clearly documented for medicolegal transparency, and performance should be continuously monitored to detect algorithmic drift as new drug eruption patterns emerge. Given current limitations, AI is best viewed as a tool to refine and support expert judgment, not replace it.

What data-sharing or privacy challenges must be addressed to develop robust AI models for diverse drug-eruption histopathology?

DR. BRIDGES: Developing robust AI models for drug eruptions requires large diverse datasets, raising significant privacy and governance challenges. Rigorous de-identification protocols, clear informed consent frameworks, and strong institutional oversight are therefore essential. Multicenter collaborations must employ secure data-use agreements and governance structures that clearly define access, ownership, and downstream use of data.

Ensuring equitable representation is equally critical, as underrepresentation of certain populations may lead to biased performance and disparities in care. Standardized data formats and interoperable systems are needed to facilitate collaboration while preserving security. Transparent governance structures, clear rules regarding data use, and trust-building with patients and institutions will ultimately determine willingness to participate. Addressing these challenges is foundational to advancing AI research in drug eruptions responsibly and ethically.

How might AI enhance the detection of key histologic features in drug eruptions compared to traditional microscopy?

DR. BRIDGES: AI offers the potential to enhance detection of histologic features in drug eruptions by systematically analyzing entire whole-slide images. Convolutional neural networks and attention-based models can identify subtle or focal findings such as scattered dyskeratotic keratinocytes, focal spongiosis, early interface change, rare eosinophils, or microvascular injury, which may be overlooked during routine microscopy due to sampling limitations. This capability is particularly relevant in drug eruptions, where histologic changes often are heterogeneous and patchy.

AI-generated attention heatmaps can highlight diagnostically relevant regions across the slide, improving consistency and completeness of slide reviews. While AI has demonstrated high sensitivity and specificity in broader dermatopathology tasks, particularly neoplastic conditions, drug eruption–specific validation data are currently lacking. As such, the most realistic application at present is AI functioning as a sensitivity-enhancing adjunct or “second reader,” improving consistency and completeness of slide review while preserving expert human interpretation.

Which histologic patterns in drug eruptions are hardest to quantify, and how could AI help standardize their assessment?

DR. BRIDGES: AI-based image analysis can standardize the assessment of histologic patterns through objective reproducible quantification. Deep learning algorithms can segment epidermal and dermal compartments, identify inflammatory cell types, and calculate metrics such as eosinophil density per unit area, percentage of epidermis with vacuolar alteration, or number of affected vessels. Studies in quantitative immunohistochemistry demonstrate high accuracy for tissue segmentation and cell counting, suggesting feasibility for similar applications in inflammatory dermatopathology. While these tools would not replace diagnostic interpretation, they could provide standardized measurements that enhance reproducibility and improve clinicopathologic correlation.

What training challenges must be addressed in AI and drug eruption histology?

DR. BRIDGES: Training AI models for drug eruption histopathology faces several challenges, including the limited availability of high-quality, well-annotated datasets, as most existing AI dermatopathology research focuses on neoplastic conditions. Drug eruptions also exhibit marked histologic heterogeneity, ranging from spongiotic and lichenoid to vasculitic and cytotoxic patterns, often with significant overlap. Accurate labeling, therefore, requires robust clinicopathologic correlation, including medication history, timing, laboratory data, and clinical outcomes—information that is often incomplete or retrospective.

Inaccurate or inconsistent annotations can significantly degrade model performance, and expert disagreement in borderline cases further complicates the creation of reliable ground truth. Additionally, training data may reflect institutional or demographic biases, risking unequal performance across patient populations. Addressing these challenges will require multicenter collaboration, standardized annotation protocols, inclusion of diverse patient cohorts, and careful attention to bias mitigation. At present, these barriers place drug eruption AI firmly in the investigational rather than clinical domain.

How important is AI explainability in the interpretation of diagnostic suggestions?

DR. BRIDGES: Explainability is essential for trust, particularly in the evaluation of drug eruptions, where diagnostic decisions can have serious clinical consequences. Dermatopathologists must understand which histologic features are driving an AI model’s assessment to ensure that conclusions align with morphologic reality and clinicopathologic reasoning. Explainable AI tools (such as attention heatmaps, feature importance rankings, and methods like Shapley Additive Explanations or Local Interpretable Model-Agnostic Explanations) can help clarify which histologic features are driving the AI model’s assessment.

Without transparency, AI systems function as “black boxes,” limiting their utility in high-stakes settings where diagnostic accountability and clinical communication are paramount. Explainability also supports appropriate skepticism, allowing pathologists to recognize when model outputs may be unreliable due to artifacts, atypical patterns, or out-of-distribution cases. In cases of drug eruptions—where diagnosis relies on combining histology, clinical timing, and medication history—explainability is essential for proper use.

How could AI pattern recognition be integrated into your workflow to enhance diagnostic efficiency and accuracy? What safeguards would be required?

DR. BRIDGES: In the near term, AI pattern recognition can be useful as an assistive tool rather than a diagnostic authority. One potential application is pre-screening whole-slide images to flag cases with features such as prominent interface change, increased keratinocyte necrosis, eosinophil-rich infiltrates, or vascular injury, prompting expedited review in clinically concerning scenarios. During sign-out, AI overlays could aid efficiency by highlighting rare but relevant features and providing quantitative summaries that support standardized reporting.

Safeguards are essential. AI systems must be validated across diverse practice settings, staining protocols, and scanning platforms. Human oversight is mandatory, with the dermatopathologist retaining full diagnostic responsibility. AI involvement should be clearly documented for medicolegal transparency, and performance should be continuously monitored to detect algorithmic drift as new drug eruption patterns emerge. Given current limitations, AI is best viewed as a tool to refine and support expert judgment, not replace it.

What data-sharing or privacy challenges must be addressed to develop robust AI models for diverse drug-eruption histopathology?

DR. BRIDGES: Developing robust AI models for drug eruptions requires large diverse datasets, raising significant privacy and governance challenges. Rigorous de-identification protocols, clear informed consent frameworks, and strong institutional oversight are therefore essential. Multicenter collaborations must employ secure data-use agreements and governance structures that clearly define access, ownership, and downstream use of data.

Ensuring equitable representation is equally critical, as underrepresentation of certain populations may lead to biased performance and disparities in care. Standardized data formats and interoperable systems are needed to facilitate collaboration while preserving security. Transparent governance structures, clear rules regarding data use, and trust-building with patients and institutions will ultimately determine willingness to participate. Addressing these challenges is foundational to advancing AI research in drug eruptions responsibly and ethically.

Sunscreen continues to be the foundation of successful skin cancer prevention. Daily sunscreen application and reapplication are recommended to prevent all types of skin cancer, with the strongest body of evidence supporting prevention of squamous cell carcinoma.¹ Sunscreens have been used safely for decades; since my last update in 2024,² no evidence of harm has emerged, despite the fact that organic (chemical) sunscreen filters are absorbed systemically.³

So, what’s happening with sunscreen in 2026? Let’s review some hot news and fresh controversies.

Sunscreen Doping Is Pervasive

Sunscreen “doping” signifies the sneaky addition of UV filters that have not been approved by the US Food and Drug Administration (FDA) into sunscreens under the guise of inactive ingredients. Why would a manufacturer do such a thing? To enhance a sunscreen’s UV absorption without having to increase the concentration of zinc oxide/titanium dioxide (which creates an undesirable white cast) or exceeding the maximum permitted concentration of chemical active ingredients.^4,5 In a 2025 analysis of the top 150 sunscreens sold on Amazon, 48.3% contained these covert UV filters, including almost half of those marketed as mineral-only products.⁶ The most prevalent doping ingredient was butyloctyl salicylate, which is chemically and functionally related to the FDA-approved chemical UV filter octisalate (ethylhexyl salicylate).⁵

The practice of sunscreen doping is deceptive. Can a product be accurately marketed as mineral sunscreen if it contains ingredients that function as chemical UV filters but are not classified as active ingredients by the FDA? The bigger picture is that sunscreen doping is a symptom of regulatory malaise specific to the United States. Regulation of sunscreens as over-the-counter drugs plus the FDA’s stringent requirements for UV filters to be generally recognized as safe and effective (GRASE) have stymied the approval process to the extent that no new active ingredients have been approved since 1999.² The FDA allows 16 active ingredients compared to about 30 in Europe and Asia—not for lack of safety evaluations prior to approval in those regions.⁷ In the United States, getting a new active sunscreen ingredient approved is far more onerous and costly than the streamlined processes that are in place abroad. This restricts sunscreen innovation; in particular, the US market lacks the wide variety of international options for protection against long-wave UVA radiation, remaining limited to just avobenzone and zinc oxide. Since long-wave UVA plays a major role in photoaging, this represents a gap in protection compared to international sunscreen offerings.^1,7 Due to domestic sunscreen limitations, some Americans have turned to purchasing non–FDA-approved sunscreens abroad or through online channels.⁸

New Sunscreen Filter Pending Approval, and Hope for Regulatory Changes

Let’s move on to a more positive development. A new sunscreen filter is actually nearing approval in the United States! Bemotrizinol, also known as bis-ethylhexyloxyphenol methoxyphenyl triazine, is a broad-spectrum chemical UVA/UVB blocker that would represent the first new active ingredient to become available in the United States since 1999.⁹ It satisfies the FDA requirement for minimal systemic absorption and GRASE status and has been used with a clean safety record since 2000 in Europe.¹⁰ The icing on top is that bemotrizinol seems to be minimally allergenic, with only a few published reports of contact dermatitis over several decades of use.^11,12

Yes, as I write, the FDA is on the cusp of approving bemotrizinol, a great broad-spectrum sunscreen ingredient, to one day be added to the products on our shelves. The cynic in me can’t help but point out that it took more than 20 years of effort and an estimated $20 million to get us to this point of near-approval of one new sunscreen filter.¹³

Perhaps things won’t be so difficult in the future. In late 2025, the bipartisan Supporting Accessible, Flexible, and Effective (SAFE) Sunscreen Standards Act was signed into law.¹⁴ The SAFE Sunscreen Standards Act calls on the FDA to be more flexible and allow for the use of real-world evidence and observational studies to demonstrate safety and effectiveness of active ingredients used in sunscreens. We can only hope that real change is forthcoming and that future sunscreen approvals won’t require decades of work and millions of dollars, as in the case of bemotrizinol.

Daily Sunscreen Use Linked to Reduction in Vitamin D Levels

The UVB wavelengths that cause sunburn overlap with those that initiate vitamin D production in the skin, generating concerns about sunscreen use reducing vitamin D levels. Nevertheless, in 2019, expert opinion and a systematic literature review determined that routine use of sunscreen was unlikely to be associated with a reduction in vitamin D levels.^15,16 However, a major limitation at that time was a lack of studies examining vitamin D status in individuals using high–sun protection factor (SPF) sunscreens.

Now we have results from the first field study assessing the impact of long-term daily application of higher SPF sunscreen on vitamin D levels. In the Australian Sun-D Trial, Tran et al¹⁷ randomly assigned 639 participants to either an intervention group (routine application of SPF 50+ sunscreen on days forecasted to have a UV index ≥3) or a control group (discretionary sunscreen use). Vitamin D levels were measured at baseline in the winter/spring, at the end of summer, and then at the end of the following winter. At the end of summer, vitamin D levels increased in both groups but less in the intervention group, then decreased similarly in both groups by winter. Routine sunscreen application was associated with a decrease of 5.2 nmol/L (2.1 ng/mL) in vitamin D levels, which the authors rightfully considered to be modest. Additionally, vitamin D deficiency (defined as <50 nmol/L [<20 ng/mL]) was detected in more of the intervention group compared to the control group (45.7% vs 36.9%). The study reasonably concluded that sunscreen continues to be essential in preventing skin cancers but regular users may require vitamin D testing and/or supplementation.¹⁷

Looking Ahead

In this update, I discussed several important pieces of sunscreen news. If you check your favorite mineral sunscreen’s ingredients list, odds are you will find it also contains inactive doping ingredients shown to secretly enhance UV protection. Perhaps manufacturers won’t have to dope sunscreens in the United States forever if regulatory reforms facilitate the approval of active ingredients such as bemotrizinol used safely in other countries without huge investments of time and money. For daily sunscreen users, consider checking and/or empirically supplementing vitamin D.

None of this should discourage us from recommending regular consistent sunscreen application and reapplication to our patients. There continues to be a lack of evidence of harms associated with systemic absorption of chemical UV filters in humans, and sunscreen will continue to function as an indispensable component of skin cancer prevention for the foreseeable future.

Sunscreen continues to be the foundation of successful skin cancer prevention. Daily sunscreen application and reapplication are recommended to prevent all types of skin cancer, with the strongest body of evidence supporting prevention of squamous cell carcinoma.¹ Sunscreens have been used safely for decades; since my last update in 2024,² no evidence of harm has emerged, despite the fact that organic (chemical) sunscreen filters are absorbed systemically.³

So, what’s happening with sunscreen in 2026? Let’s review some hot news and fresh controversies.

Sunscreen Doping Is Pervasive

Sunscreen “doping” signifies the sneaky addition of UV filters that have not been approved by the US Food and Drug Administration (FDA) into sunscreens under the guise of inactive ingredients. Why would a manufacturer do such a thing? To enhance a sunscreen’s UV absorption without having to increase the concentration of zinc oxide/titanium dioxide (which creates an undesirable white cast) or exceeding the maximum permitted concentration of chemical active ingredients.^4,5 In a 2025 analysis of the top 150 sunscreens sold on Amazon, 48.3% contained these covert UV filters, including almost half of those marketed as mineral-only products.⁶ The most prevalent doping ingredient was butyloctyl salicylate, which is chemically and functionally related to the FDA-approved chemical UV filter octisalate (ethylhexyl salicylate).⁵

The practice of sunscreen doping is deceptive. Can a product be accurately marketed as mineral sunscreen if it contains ingredients that function as chemical UV filters but are not classified as active ingredients by the FDA? The bigger picture is that sunscreen doping is a symptom of regulatory malaise specific to the United States. Regulation of sunscreens as over-the-counter drugs plus the FDA’s stringent requirements for UV filters to be generally recognized as safe and effective (GRASE) have stymied the approval process to the extent that no new active ingredients have been approved since 1999.² The FDA allows 16 active ingredients compared to about 30 in Europe and Asia—not for lack of safety evaluations prior to approval in those regions.⁷ In the United States, getting a new active sunscreen ingredient approved is far more onerous and costly than the streamlined processes that are in place abroad. This restricts sunscreen innovation; in particular, the US market lacks the wide variety of international options for protection against long-wave UVA radiation, remaining limited to just avobenzone and zinc oxide. Since long-wave UVA plays a major role in photoaging, this represents a gap in protection compared to international sunscreen offerings.^1,7 Due to domestic sunscreen limitations, some Americans have turned to purchasing non–FDA-approved sunscreens abroad or through online channels.⁸

New Sunscreen Filter Pending Approval, and Hope for Regulatory Changes

Let’s move on to a more positive development. A new sunscreen filter is actually nearing approval in the United States! Bemotrizinol, also known as bis-ethylhexyloxyphenol methoxyphenyl triazine, is a broad-spectrum chemical UVA/UVB blocker that would represent the first new active ingredient to become available in the United States since 1999.⁹ It satisfies the FDA requirement for minimal systemic absorption and GRASE status and has been used with a clean safety record since 2000 in Europe.¹⁰ The icing on top is that bemotrizinol seems to be minimally allergenic, with only a few published reports of contact dermatitis over several decades of use.^11,12

Yes, as I write, the FDA is on the cusp of approving bemotrizinol, a great broad-spectrum sunscreen ingredient, to one day be added to the products on our shelves. The cynic in me can’t help but point out that it took more than 20 years of effort and an estimated $20 million to get us to this point of near-approval of one new sunscreen filter.¹³

Perhaps things won’t be so difficult in the future. In late 2025, the bipartisan Supporting Accessible, Flexible, and Effective (SAFE) Sunscreen Standards Act was signed into law.¹⁴ The SAFE Sunscreen Standards Act calls on the FDA to be more flexible and allow for the use of real-world evidence and observational studies to demonstrate safety and effectiveness of active ingredients used in sunscreens. We can only hope that real change is forthcoming and that future sunscreen approvals won’t require decades of work and millions of dollars, as in the case of bemotrizinol.

Daily Sunscreen Use Linked to Reduction in Vitamin D Levels

The UVB wavelengths that cause sunburn overlap with those that initiate vitamin D production in the skin, generating concerns about sunscreen use reducing vitamin D levels. Nevertheless, in 2019, expert opinion and a systematic literature review determined that routine use of sunscreen was unlikely to be associated with a reduction in vitamin D levels.^15,16 However, a major limitation at that time was a lack of studies examining vitamin D status in individuals using high–sun protection factor (SPF) sunscreens.

Now we have results from the first field study assessing the impact of long-term daily application of higher SPF sunscreen on vitamin D levels. In the Australian Sun-D Trial, Tran et al¹⁷ randomly assigned 639 participants to either an intervention group (routine application of SPF 50+ sunscreen on days forecasted to have a UV index ≥3) or a control group (discretionary sunscreen use). Vitamin D levels were measured at baseline in the winter/spring, at the end of summer, and then at the end of the following winter. At the end of summer, vitamin D levels increased in both groups but less in the intervention group, then decreased similarly in both groups by winter. Routine sunscreen application was associated with a decrease of 5.2 nmol/L (2.1 ng/mL) in vitamin D levels, which the authors rightfully considered to be modest. Additionally, vitamin D deficiency (defined as <50 nmol/L [<20 ng/mL]) was detected in more of the intervention group compared to the control group (45.7% vs 36.9%). The study reasonably concluded that sunscreen continues to be essential in preventing skin cancers but regular users may require vitamin D testing and/or supplementation.¹⁷

Looking Ahead

In this update, I discussed several important pieces of sunscreen news. If you check your favorite mineral sunscreen’s ingredients list, odds are you will find it also contains inactive doping ingredients shown to secretly enhance UV protection. Perhaps manufacturers won’t have to dope sunscreens in the United States forever if regulatory reforms facilitate the approval of active ingredients such as bemotrizinol used safely in other countries without huge investments of time and money. For daily sunscreen users, consider checking and/or empirically supplementing vitamin D.

None of this should discourage us from recommending regular consistent sunscreen application and reapplication to our patients. There continues to be a lack of evidence of harms associated with systemic absorption of chemical UV filters in humans, and sunscreen will continue to function as an indispensable component of skin cancer prevention for the foreseeable future.

Sunscreen continues to be the foundation of successful skin cancer prevention. Daily sunscreen application and reapplication are recommended to prevent all types of skin cancer, with the strongest body of evidence supporting prevention of squamous cell carcinoma.¹ Sunscreens have been used safely for decades; since my last update in 2024,² no evidence of harm has emerged, despite the fact that organic (chemical) sunscreen filters are absorbed systemically.³

So, what’s happening with sunscreen in 2026? Let’s review some hot news and fresh controversies.

Sunscreen Doping Is Pervasive

Sunscreen “doping” signifies the sneaky addition of UV filters that have not been approved by the US Food and Drug Administration (FDA) into sunscreens under the guise of inactive ingredients. Why would a manufacturer do such a thing? To enhance a sunscreen’s UV absorption without having to increase the concentration of zinc oxide/titanium dioxide (which creates an undesirable white cast) or exceeding the maximum permitted concentration of chemical active ingredients.^4,5 In a 2025 analysis of the top 150 sunscreens sold on Amazon, 48.3% contained these covert UV filters, including almost half of those marketed as mineral-only products.⁶ The most prevalent doping ingredient was butyloctyl salicylate, which is chemically and functionally related to the FDA-approved chemical UV filter octisalate (ethylhexyl salicylate).⁵

The practice of sunscreen doping is deceptive. Can a product be accurately marketed as mineral sunscreen if it contains ingredients that function as chemical UV filters but are not classified as active ingredients by the FDA? The bigger picture is that sunscreen doping is a symptom of regulatory malaise specific to the United States. Regulation of sunscreens as over-the-counter drugs plus the FDA’s stringent requirements for UV filters to be generally recognized as safe and effective (GRASE) have stymied the approval process to the extent that no new active ingredients have been approved since 1999.² The FDA allows 16 active ingredients compared to about 30 in Europe and Asia—not for lack of safety evaluations prior to approval in those regions.⁷ In the United States, getting a new active sunscreen ingredient approved is far more onerous and costly than the streamlined processes that are in place abroad. This restricts sunscreen innovation; in particular, the US market lacks the wide variety of international options for protection against long-wave UVA radiation, remaining limited to just avobenzone and zinc oxide. Since long-wave UVA plays a major role in photoaging, this represents a gap in protection compared to international sunscreen offerings.^1,7 Due to domestic sunscreen limitations, some Americans have turned to purchasing non–FDA-approved sunscreens abroad or through online channels.⁸

New Sunscreen Filter Pending Approval, and Hope for Regulatory Changes

Let’s move on to a more positive development. A new sunscreen filter is actually nearing approval in the United States! Bemotrizinol, also known as bis-ethylhexyloxyphenol methoxyphenyl triazine, is a broad-spectrum chemical UVA/UVB blocker that would represent the first new active ingredient to become available in the United States since 1999.⁹ It satisfies the FDA requirement for minimal systemic absorption and GRASE status and has been used with a clean safety record since 2000 in Europe.¹⁰ The icing on top is that bemotrizinol seems to be minimally allergenic, with only a few published reports of contact dermatitis over several decades of use.^11,12

Yes, as I write, the FDA is on the cusp of approving bemotrizinol, a great broad-spectrum sunscreen ingredient, to one day be added to the products on our shelves. The cynic in me can’t help but point out that it took more than 20 years of effort and an estimated $20 million to get us to this point of near-approval of one new sunscreen filter.¹³

Perhaps things won’t be so difficult in the future. In late 2025, the bipartisan Supporting Accessible, Flexible, and Effective (SAFE) Sunscreen Standards Act was signed into law.¹⁴ The SAFE Sunscreen Standards Act calls on the FDA to be more flexible and allow for the use of real-world evidence and observational studies to demonstrate safety and effectiveness of active ingredients used in sunscreens. We can only hope that real change is forthcoming and that future sunscreen approvals won’t require decades of work and millions of dollars, as in the case of bemotrizinol.

Daily Sunscreen Use Linked to Reduction in Vitamin D Levels

The UVB wavelengths that cause sunburn overlap with those that initiate vitamin D production in the skin, generating concerns about sunscreen use reducing vitamin D levels. Nevertheless, in 2019, expert opinion and a systematic literature review determined that routine use of sunscreen was unlikely to be associated with a reduction in vitamin D levels.^15,16 However, a major limitation at that time was a lack of studies examining vitamin D status in individuals using high–sun protection factor (SPF) sunscreens.

Now we have results from the first field study assessing the impact of long-term daily application of higher SPF sunscreen on vitamin D levels. In the Australian Sun-D Trial, Tran et al¹⁷ randomly assigned 639 participants to either an intervention group (routine application of SPF 50+ sunscreen on days forecasted to have a UV index ≥3) or a control group (discretionary sunscreen use). Vitamin D levels were measured at baseline in the winter/spring, at the end of summer, and then at the end of the following winter. At the end of summer, vitamin D levels increased in both groups but less in the intervention group, then decreased similarly in both groups by winter. Routine sunscreen application was associated with a decrease of 5.2 nmol/L (2.1 ng/mL) in vitamin D levels, which the authors rightfully considered to be modest. Additionally, vitamin D deficiency (defined as <50 nmol/L [<20 ng/mL]) was detected in more of the intervention group compared to the control group (45.7% vs 36.9%). The study reasonably concluded that sunscreen continues to be essential in preventing skin cancers but regular users may require vitamin D testing and/or supplementation.¹⁷

Looking Ahead

In this update, I discussed several important pieces of sunscreen news. If you check your favorite mineral sunscreen’s ingredients list, odds are you will find it also contains inactive doping ingredients shown to secretly enhance UV protection. Perhaps manufacturers won’t have to dope sunscreens in the United States forever if regulatory reforms facilitate the approval of active ingredients such as bemotrizinol used safely in other countries without huge investments of time and money. For daily sunscreen users, consider checking and/or empirically supplementing vitamin D.

None of this should discourage us from recommending regular consistent sunscreen application and reapplication to our patients. There continues to be a lack of evidence of harms associated with systemic absorption of chemical UV filters in humans, and sunscreen will continue to function as an indispensable component of skin cancer prevention for the foreseeable future.

Accessible and effective mental health services are a vital component of the Veterans Health Administration (VHA) mission to provide exceptional care that improves veterans’ health and well-being. Veterans are seeking mental health care at the VHA at significantly higher rates than in previous years. From 2009 through 2024, the number of veterans who received direct mental health care from the VHA increased 78%.¹ The proportion of veterans enrolled in the VHA who also received direct mental health care expanded from 23% of total enrollees in 2009 to 33% in 2024. The increase in VHA mental health care delivery is also reflected in the number of outpatient mental health care and treatment visits at the VHA, which increased from 12.7 million to 21.5 million over the same period.

The Sergeant First Class (SFC) Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act of 2022 expanded eligibility for VHA services, including mental health care and counseling, to new cohorts of toxic-exposed veterans. From 2022 to 2024, > 680,000 veterans enrolled in VHA care, and 45% of those were PACT Act-eligible cohorts.² Research highlighted the high prevalence of physical and psychiatric comorbidities in toxic-exposed veterans.³ As such, the VHA may face greater demand for direct mental health care with these newly eligible cohorts of veterans.

Veterans often have mental health conditions (eg, depression, posttraumatic stress disorder [PTSD]), substance use disorders (SUDs), unique military experiences (eg, deployments), and injuries and illnesses (eg, traumatic brain injury [TBI]) that increase the complexity of their clinical presentation. The varied nature of these mental health conditions, as well as veterans’ unique military-related experiences, necessitates specialized centers focused on distinct high-priority areas of mental health in the VHA.

A series of public laws charged the US Department of Veterans Affairs (VA) with developing specialized mental health Centers of Excellence (CoEs) focused on high-priority areas of veteran mental health. The first of these laws, Public Law 98- 528, established the National Center for PTSD (NCPTSD), which opened in 1989.⁴ In 1996, Congress established specialized mental health CoEs known as Mental Illness Research, Education, and Clinical Centers (MIRECCs) across the VHA.⁵ To address the unique needs of post-9/11 veterans, 3 additional specialized centers were established in 2005.⁶ Finally, under the authority of the Secretary of the VA, specialized mental health CoEs were established to focus on SUD and integrated health care.

There are 17 geographically diverse mental health CoEs and MIRECCs across the VA (Table). CoEs are embedded in VA medical centers (VAMCs) with strong medical school academic affiliations. Organizational oversight of the CoEs is provided by the VA Office of Mental Health and Office of Suicide Prevention, respectively. As part of the oversight process, CoEs submit annual reports detailing their advancements in research, education and training, and clinical activities, as well as participate in a peer-reviewed renewal process.

These specialized centers are united in a shared tripartite mission to generate new knowledge about the causes and treatments of mental health conditions, to educate and train VHA clinicians and personnel, and to develop and implement innovative clinical programs within the VHA. This combined focus on research, education, and improved clinical care reduces the time from discovery to implementation and improves the health and well-being of veterans.

Examples of this acceleration translation from scientific discovery to clinical practice are evident throughout mental health CoEs. The NCPTSD is a leader in research on PTSD and traumatic stress. Its work led to the development of national training programs for VHA clinicians, facilitating the broad dissemination of efficacious PTSD treatments across the enterprise.⁷ Researchers at the Veterans Integrated Service Network (VISN) 21 Sierra Pacific MIRECC identified depression as a significant risk factor for dementia and subsequently launched the first multisite trial of repetitive transcranial magnetic stimulation (rTMS) in the VHA in 2012 (CSP #556: the effectiveness of rTMS in depressed VA patients).⁸ This project laid the groundwork for the national clinical rTMS program launched in 2017, which is now clinically available at 60 VAMCs. In the largest pragmatic randomized clinical trial of its kind, the VISN 4 Philadelphia and Pittsburgh MIRECC found that pharmacogenomic testing significantly reduced the number of prescription medications with predicted drug-gene interactions and improved clinical outcomes among veterans with depression.⁹

Mental health CoEs are also leaders in suicide prevention, a top clinical priority for the VHA. The VISN 2 New York MIRECC developed Project Life Force, a safety planning skills group for veterans with suicidal ideation, now implemented across 10 VAMCs, including telehealth hubs, outpatient settings, and veteran peer programs.¹⁰ The VISN 2 CoE for Suicide Prevention and VISN 19 Rocky Mountain MIRECC coordinate key suicide prevention services for VA, including the analysis of suicide surveillance data; evaluation of national VA suicide prevention initiatives; the support of veterans, families, and clinicians; and enhanced access to evidence-based treatments for at-risk veterans.

Mental health CoEs are a key operational partner in VHA treatment of SUDs. The CoEs in Substance Addiction Treatment and Education (CESATEs) are national resources dedicated to improving the quality, clinical outcomes, and cost-effectiveness of VHA SUD treatment. CESATEs developed and implemented a national rollout of an effective treatment for stimulant use disorders, training staff at > 120 VA programs. The VISN 1 Mid-Atlantic MIRECC’s focus on SUD and comorbid/co-occurring mental health conditions has highlighted the significant prevalence of these conditions and the impact they have on treatment response.¹¹

Serious mental illness (SMI) (eg, schizophrenia, schizoaffective disorder) impacts up to 5% of veterans.¹² VISN 22 Desert Pacific MIRECC has developed interventions to improve the lives of veterans with SMI. Its research established supported employment as an effective intervention to improve outcomes in veterans with psychotic disorders and supported its implementation in the VHA.¹³ Peer specialists are a cornerstone in the VHA commitment to recovery-oriented services for veterans with SMI. VISN 5 Capitol MIRECC has long championed research, clinical training, and educational activities that contributed to the effective deployment of peer specialists across the VHA enterprise.

Veterans have unique military-related experiences (eg, deployment, traumatic stress, transition to civilian status) and injuries and illnesses (eg, TBI, posttraumatic headaches) that significantly impact their mental health and quality of life.

The period between active duty and transition to civilian status is a critical time in a veteran’s life. The VISN 17 CoE Veteran Sponsorship Initiative connects veterans with VA care within 30 days postdischarge, with the option of additional support in the community. The VISN 22 CoE for Stress and Mental Health (CESAMH) develops, evaluates, and disseminates diagnostics and treatments for veterans affected by traumatic events and brain injuries, with a unique focus on supporting their whole health needs. The VISN 6 Mid-Atlantic MIRECC leads the ongoing VISN-6 Post-Deployment Mental Health (PDMH) study, the largest biorepository of post-9/11 veterans. PDMH has greatly expanded the understanding of the unique needs of post-9/11 veterans, with > 100 peer-reviewed publications to date. Veterans with mild TBI frequently experience chronic posttraumatic headaches that can be disabling and nonresponsive to treatment. The VISN 20 Northwest MIRECC demonstrated that prazosin, a repurposed, low-cost, widely available, nonaddictive medication, can safely and effectively reduce the frequency of these headaches and improve functional impairment in veterans and active-duty service members.¹⁴

Increased and enhanced access to effective mental health treatment is a priority for VA. In 2007, the VA launched the National Primary Care Mental Health Integration program, which integrated mental health services into primary care settings. The Center for Integrated Healthcare (CIH) has supported the VA in these efforts. In 2024, CIH trained > 5000 health care staff on high-fidelity integration of behavioral health and medical care. VA has also focused on increasing access to mental health services via expanded telehealth offerings. The VISN 16 MIRECC, with its unique focus on increasing access to care for rural veterans via distance-based and digital health technology, supported the VA Offices of Mental Health and Connected Care to virtualize mental health care and promote adoption and sustained use of VA Video Connect across the enterprise.

Specialized MH CoEs are uniquely equipped to support the VHA in providing training and education to VA clinicians, veterans, care partners and family members, and the community on high-priority mental health topics. Education is a core component of the MH CoEs tripartite mission. As such, MH CoEs offer national trainings, conferences, consultation services, clinical demonstration projects, development of clinical dashboards and toolkits, and public awareness campaigns. Researchers, educators, and clinicians at the CoEs frequently serve as subject matter experts on topics aligned with their respective missions. Several national rollout programs that disseminated evidence-based treatments for mental health conditions to the field (eg, cognitive behavioral therapy for depression, cognitive behavioral therapy for insomnia, and prolonged exposure) were developed at specialized CoEs.

The VHA provides advanced training, residencies, and fellowships to > 120,000 trainees annually. Many of these trainees choose to remain at the VA. Seven of 10 VHA psychologists and 6 of 10 VHA physicians trained within the VHA prior to their employment.¹⁵ The MH CoEs and MIRECCs play an important role in preparing these trainees for VHA mental health careers. These centers are funded to provide advanced postdoctoral training to physicians as well as allied health professionals in clinical and counseling psychology, social work, pharmacy, and nursing. Training is not limited to postdoctoral fellows: graduate students, residents, and interns from affiliated accredited training programs may rotate through mental health CoEs each academic year.

Conclusions

For > 30 years, mental health CoEs have brought thousands of veterans advanced treatments for their mental health needs and helped reduce death by suicide. The centers have a bright future ahead, harnessing advances in artificial intelligence and genomics to permit the matching of the individual veterans to the treatment most likely to benefit them. Precision medicine, as espoused by the Hannon Act, will not only encourage the efficient use of health care resources but also rapidly reduce pain in veterans with mental health and SUDs.

Accessible and effective mental health services are a vital component of the Veterans Health Administration (VHA) mission to provide exceptional care that improves veterans’ health and well-being. Veterans are seeking mental health care at the VHA at significantly higher rates than in previous years. From 2009 through 2024, the number of veterans who received direct mental health care from the VHA increased 78%.¹ The proportion of veterans enrolled in the VHA who also received direct mental health care expanded from 23% of total enrollees in 2009 to 33% in 2024. The increase in VHA mental health care delivery is also reflected in the number of outpatient mental health care and treatment visits at the VHA, which increased from 12.7 million to 21.5 million over the same period.

The Sergeant First Class (SFC) Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act of 2022 expanded eligibility for VHA services, including mental health care and counseling, to new cohorts of toxic-exposed veterans. From 2022 to 2024, > 680,000 veterans enrolled in VHA care, and 45% of those were PACT Act-eligible cohorts.² Research highlighted the high prevalence of physical and psychiatric comorbidities in toxic-exposed veterans.³ As such, the VHA may face greater demand for direct mental health care with these newly eligible cohorts of veterans.

Veterans often have mental health conditions (eg, depression, posttraumatic stress disorder [PTSD]), substance use disorders (SUDs), unique military experiences (eg, deployments), and injuries and illnesses (eg, traumatic brain injury [TBI]) that increase the complexity of their clinical presentation. The varied nature of these mental health conditions, as well as veterans’ unique military-related experiences, necessitates specialized centers focused on distinct high-priority areas of mental health in the VHA.

A series of public laws charged the US Department of Veterans Affairs (VA) with developing specialized mental health Centers of Excellence (CoEs) focused on high-priority areas of veteran mental health. The first of these laws, Public Law 98- 528, established the National Center for PTSD (NCPTSD), which opened in 1989.⁴ In 1996, Congress established specialized mental health CoEs known as Mental Illness Research, Education, and Clinical Centers (MIRECCs) across the VHA.⁵ To address the unique needs of post-9/11 veterans, 3 additional specialized centers were established in 2005.⁶ Finally, under the authority of the Secretary of the VA, specialized mental health CoEs were established to focus on SUD and integrated health care.

There are 17 geographically diverse mental health CoEs and MIRECCs across the VA (Table). CoEs are embedded in VA medical centers (VAMCs) with strong medical school academic affiliations. Organizational oversight of the CoEs is provided by the VA Office of Mental Health and Office of Suicide Prevention, respectively. As part of the oversight process, CoEs submit annual reports detailing their advancements in research, education and training, and clinical activities, as well as participate in a peer-reviewed renewal process.

These specialized centers are united in a shared tripartite mission to generate new knowledge about the causes and treatments of mental health conditions, to educate and train VHA clinicians and personnel, and to develop and implement innovative clinical programs within the VHA. This combined focus on research, education, and improved clinical care reduces the time from discovery to implementation and improves the health and well-being of veterans.

Examples of this acceleration translation from scientific discovery to clinical practice are evident throughout mental health CoEs. The NCPTSD is a leader in research on PTSD and traumatic stress. Its work led to the development of national training programs for VHA clinicians, facilitating the broad dissemination of efficacious PTSD treatments across the enterprise.⁷ Researchers at the Veterans Integrated Service Network (VISN) 21 Sierra Pacific MIRECC identified depression as a significant risk factor for dementia and subsequently launched the first multisite trial of repetitive transcranial magnetic stimulation (rTMS) in the VHA in 2012 (CSP #556: the effectiveness of rTMS in depressed VA patients).⁸ This project laid the groundwork for the national clinical rTMS program launched in 2017, which is now clinically available at 60 VAMCs. In the largest pragmatic randomized clinical trial of its kind, the VISN 4 Philadelphia and Pittsburgh MIRECC found that pharmacogenomic testing significantly reduced the number of prescription medications with predicted drug-gene interactions and improved clinical outcomes among veterans with depression.⁹

Mental health CoEs are also leaders in suicide prevention, a top clinical priority for the VHA. The VISN 2 New York MIRECC developed Project Life Force, a safety planning skills group for veterans with suicidal ideation, now implemented across 10 VAMCs, including telehealth hubs, outpatient settings, and veteran peer programs.¹⁰ The VISN 2 CoE for Suicide Prevention and VISN 19 Rocky Mountain MIRECC coordinate key suicide prevention services for VA, including the analysis of suicide surveillance data; evaluation of national VA suicide prevention initiatives; the support of veterans, families, and clinicians; and enhanced access to evidence-based treatments for at-risk veterans.

Mental health CoEs are a key operational partner in VHA treatment of SUDs. The CoEs in Substance Addiction Treatment and Education (CESATEs) are national resources dedicated to improving the quality, clinical outcomes, and cost-effectiveness of VHA SUD treatment. CESATEs developed and implemented a national rollout of an effective treatment for stimulant use disorders, training staff at > 120 VA programs. The VISN 1 Mid-Atlantic MIRECC’s focus on SUD and comorbid/co-occurring mental health conditions has highlighted the significant prevalence of these conditions and the impact they have on treatment response.¹¹

Serious mental illness (SMI) (eg, schizophrenia, schizoaffective disorder) impacts up to 5% of veterans.¹² VISN 22 Desert Pacific MIRECC has developed interventions to improve the lives of veterans with SMI. Its research established supported employment as an effective intervention to improve outcomes in veterans with psychotic disorders and supported its implementation in the VHA.¹³ Peer specialists are a cornerstone in the VHA commitment to recovery-oriented services for veterans with SMI. VISN 5 Capitol MIRECC has long championed research, clinical training, and educational activities that contributed to the effective deployment of peer specialists across the VHA enterprise.

Veterans have unique military-related experiences (eg, deployment, traumatic stress, transition to civilian status) and injuries and illnesses (eg, TBI, posttraumatic headaches) that significantly impact their mental health and quality of life.

The period between active duty and transition to civilian status is a critical time in a veteran’s life. The VISN 17 CoE Veteran Sponsorship Initiative connects veterans with VA care within 30 days postdischarge, with the option of additional support in the community. The VISN 22 CoE for Stress and Mental Health (CESAMH) develops, evaluates, and disseminates diagnostics and treatments for veterans affected by traumatic events and brain injuries, with a unique focus on supporting their whole health needs. The VISN 6 Mid-Atlantic MIRECC leads the ongoing VISN-6 Post-Deployment Mental Health (PDMH) study, the largest biorepository of post-9/11 veterans. PDMH has greatly expanded the understanding of the unique needs of post-9/11 veterans, with > 100 peer-reviewed publications to date. Veterans with mild TBI frequently experience chronic posttraumatic headaches that can be disabling and nonresponsive to treatment. The VISN 20 Northwest MIRECC demonstrated that prazosin, a repurposed, low-cost, widely available, nonaddictive medication, can safely and effectively reduce the frequency of these headaches and improve functional impairment in veterans and active-duty service members.¹⁴

Increased and enhanced access to effective mental health treatment is a priority for VA. In 2007, the VA launched the National Primary Care Mental Health Integration program, which integrated mental health services into primary care settings. The Center for Integrated Healthcare (CIH) has supported the VA in these efforts. In 2024, CIH trained > 5000 health care staff on high-fidelity integration of behavioral health and medical care. VA has also focused on increasing access to mental health services via expanded telehealth offerings. The VISN 16 MIRECC, with its unique focus on increasing access to care for rural veterans via distance-based and digital health technology, supported the VA Offices of Mental Health and Connected Care to virtualize mental health care and promote adoption and sustained use of VA Video Connect across the enterprise.

Specialized MH CoEs are uniquely equipped to support the VHA in providing training and education to VA clinicians, veterans, care partners and family members, and the community on high-priority mental health topics. Education is a core component of the MH CoEs tripartite mission. As such, MH CoEs offer national trainings, conferences, consultation services, clinical demonstration projects, development of clinical dashboards and toolkits, and public awareness campaigns. Researchers, educators, and clinicians at the CoEs frequently serve as subject matter experts on topics aligned with their respective missions. Several national rollout programs that disseminated evidence-based treatments for mental health conditions to the field (eg, cognitive behavioral therapy for depression, cognitive behavioral therapy for insomnia, and prolonged exposure) were developed at specialized CoEs.

The VHA provides advanced training, residencies, and fellowships to > 120,000 trainees annually. Many of these trainees choose to remain at the VA. Seven of 10 VHA psychologists and 6 of 10 VHA physicians trained within the VHA prior to their employment.¹⁵ The MH CoEs and MIRECCs play an important role in preparing these trainees for VHA mental health careers. These centers are funded to provide advanced postdoctoral training to physicians as well as allied health professionals in clinical and counseling psychology, social work, pharmacy, and nursing. Training is not limited to postdoctoral fellows: graduate students, residents, and interns from affiliated accredited training programs may rotate through mental health CoEs each academic year.

Conclusions

For > 30 years, mental health CoEs have brought thousands of veterans advanced treatments for their mental health needs and helped reduce death by suicide. The centers have a bright future ahead, harnessing advances in artificial intelligence and genomics to permit the matching of the individual veterans to the treatment most likely to benefit them. Precision medicine, as espoused by the Hannon Act, will not only encourage the efficient use of health care resources but also rapidly reduce pain in veterans with mental health and SUDs.

Accessible and effective mental health services are a vital component of the Veterans Health Administration (VHA) mission to provide exceptional care that improves veterans’ health and well-being. Veterans are seeking mental health care at the VHA at significantly higher rates than in previous years. From 2009 through 2024, the number of veterans who received direct mental health care from the VHA increased 78%.¹ The proportion of veterans enrolled in the VHA who also received direct mental health care expanded from 23% of total enrollees in 2009 to 33% in 2024. The increase in VHA mental health care delivery is also reflected in the number of outpatient mental health care and treatment visits at the VHA, which increased from 12.7 million to 21.5 million over the same period.

The Sergeant First Class (SFC) Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act of 2022 expanded eligibility for VHA services, including mental health care and counseling, to new cohorts of toxic-exposed veterans. From 2022 to 2024, > 680,000 veterans enrolled in VHA care, and 45% of those were PACT Act-eligible cohorts.² Research highlighted the high prevalence of physical and psychiatric comorbidities in toxic-exposed veterans.³ As such, the VHA may face greater demand for direct mental health care with these newly eligible cohorts of veterans.

Veterans often have mental health conditions (eg, depression, posttraumatic stress disorder [PTSD]), substance use disorders (SUDs), unique military experiences (eg, deployments), and injuries and illnesses (eg, traumatic brain injury [TBI]) that increase the complexity of their clinical presentation. The varied nature of these mental health conditions, as well as veterans’ unique military-related experiences, necessitates specialized centers focused on distinct high-priority areas of mental health in the VHA.

A series of public laws charged the US Department of Veterans Affairs (VA) with developing specialized mental health Centers of Excellence (CoEs) focused on high-priority areas of veteran mental health. The first of these laws, Public Law 98- 528, established the National Center for PTSD (NCPTSD), which opened in 1989.⁴ In 1996, Congress established specialized mental health CoEs known as Mental Illness Research, Education, and Clinical Centers (MIRECCs) across the VHA.⁵ To address the unique needs of post-9/11 veterans, 3 additional specialized centers were established in 2005.⁶ Finally, under the authority of the Secretary of the VA, specialized mental health CoEs were established to focus on SUD and integrated health care.

There are 17 geographically diverse mental health CoEs and MIRECCs across the VA (Table). CoEs are embedded in VA medical centers (VAMCs) with strong medical school academic affiliations. Organizational oversight of the CoEs is provided by the VA Office of Mental Health and Office of Suicide Prevention, respectively. As part of the oversight process, CoEs submit annual reports detailing their advancements in research, education and training, and clinical activities, as well as participate in a peer-reviewed renewal process.

These specialized centers are united in a shared tripartite mission to generate new knowledge about the causes and treatments of mental health conditions, to educate and train VHA clinicians and personnel, and to develop and implement innovative clinical programs within the VHA. This combined focus on research, education, and improved clinical care reduces the time from discovery to implementation and improves the health and well-being of veterans.

Examples of this acceleration translation from scientific discovery to clinical practice are evident throughout mental health CoEs. The NCPTSD is a leader in research on PTSD and traumatic stress. Its work led to the development of national training programs for VHA clinicians, facilitating the broad dissemination of efficacious PTSD treatments across the enterprise.⁷ Researchers at the Veterans Integrated Service Network (VISN) 21 Sierra Pacific MIRECC identified depression as a significant risk factor for dementia and subsequently launched the first multisite trial of repetitive transcranial magnetic stimulation (rTMS) in the VHA in 2012 (CSP #556: the effectiveness of rTMS in depressed VA patients).⁸ This project laid the groundwork for the national clinical rTMS program launched in 2017, which is now clinically available at 60 VAMCs. In the largest pragmatic randomized clinical trial of its kind, the VISN 4 Philadelphia and Pittsburgh MIRECC found that pharmacogenomic testing significantly reduced the number of prescription medications with predicted drug-gene interactions and improved clinical outcomes among veterans with depression.⁹

Mental health CoEs are also leaders in suicide prevention, a top clinical priority for the VHA. The VISN 2 New York MIRECC developed Project Life Force, a safety planning skills group for veterans with suicidal ideation, now implemented across 10 VAMCs, including telehealth hubs, outpatient settings, and veteran peer programs.¹⁰ The VISN 2 CoE for Suicide Prevention and VISN 19 Rocky Mountain MIRECC coordinate key suicide prevention services for VA, including the analysis of suicide surveillance data; evaluation of national VA suicide prevention initiatives; the support of veterans, families, and clinicians; and enhanced access to evidence-based treatments for at-risk veterans.

Mental health CoEs are a key operational partner in VHA treatment of SUDs. The CoEs in Substance Addiction Treatment and Education (CESATEs) are national resources dedicated to improving the quality, clinical outcomes, and cost-effectiveness of VHA SUD treatment. CESATEs developed and implemented a national rollout of an effective treatment for stimulant use disorders, training staff at > 120 VA programs. The VISN 1 Mid-Atlantic MIRECC’s focus on SUD and comorbid/co-occurring mental health conditions has highlighted the significant prevalence of these conditions and the impact they have on treatment response.¹¹

Serious mental illness (SMI) (eg, schizophrenia, schizoaffective disorder) impacts up to 5% of veterans.¹² VISN 22 Desert Pacific MIRECC has developed interventions to improve the lives of veterans with SMI. Its research established supported employment as an effective intervention to improve outcomes in veterans with psychotic disorders and supported its implementation in the VHA.¹³ Peer specialists are a cornerstone in the VHA commitment to recovery-oriented services for veterans with SMI. VISN 5 Capitol MIRECC has long championed research, clinical training, and educational activities that contributed to the effective deployment of peer specialists across the VHA enterprise.

Veterans have unique military-related experiences (eg, deployment, traumatic stress, transition to civilian status) and injuries and illnesses (eg, TBI, posttraumatic headaches) that significantly impact their mental health and quality of life.

The period between active duty and transition to civilian status is a critical time in a veteran’s life. The VISN 17 CoE Veteran Sponsorship Initiative connects veterans with VA care within 30 days postdischarge, with the option of additional support in the community. The VISN 22 CoE for Stress and Mental Health (CESAMH) develops, evaluates, and disseminates diagnostics and treatments for veterans affected by traumatic events and brain injuries, with a unique focus on supporting their whole health needs. The VISN 6 Mid-Atlantic MIRECC leads the ongoing VISN-6 Post-Deployment Mental Health (PDMH) study, the largest biorepository of post-9/11 veterans. PDMH has greatly expanded the understanding of the unique needs of post-9/11 veterans, with > 100 peer-reviewed publications to date. Veterans with mild TBI frequently experience chronic posttraumatic headaches that can be disabling and nonresponsive to treatment. The VISN 20 Northwest MIRECC demonstrated that prazosin, a repurposed, low-cost, widely available, nonaddictive medication, can safely and effectively reduce the frequency of these headaches and improve functional impairment in veterans and active-duty service members.¹⁴

Increased and enhanced access to effective mental health treatment is a priority for VA. In 2007, the VA launched the National Primary Care Mental Health Integration program, which integrated mental health services into primary care settings. The Center for Integrated Healthcare (CIH) has supported the VA in these efforts. In 2024, CIH trained > 5000 health care staff on high-fidelity integration of behavioral health and medical care. VA has also focused on increasing access to mental health services via expanded telehealth offerings. The VISN 16 MIRECC, with its unique focus on increasing access to care for rural veterans via distance-based and digital health technology, supported the VA Offices of Mental Health and Connected Care to virtualize mental health care and promote adoption and sustained use of VA Video Connect across the enterprise.

Specialized MH CoEs are uniquely equipped to support the VHA in providing training and education to VA clinicians, veterans, care partners and family members, and the community on high-priority mental health topics. Education is a core component of the MH CoEs tripartite mission. As such, MH CoEs offer national trainings, conferences, consultation services, clinical demonstration projects, development of clinical dashboards and toolkits, and public awareness campaigns. Researchers, educators, and clinicians at the CoEs frequently serve as subject matter experts on topics aligned with their respective missions. Several national rollout programs that disseminated evidence-based treatments for mental health conditions to the field (eg, cognitive behavioral therapy for depression, cognitive behavioral therapy for insomnia, and prolonged exposure) were developed at specialized CoEs.

The VHA provides advanced training, residencies, and fellowships to > 120,000 trainees annually. Many of these trainees choose to remain at the VA. Seven of 10 VHA psychologists and 6 of 10 VHA physicians trained within the VHA prior to their employment.¹⁵ The MH CoEs and MIRECCs play an important role in preparing these trainees for VHA mental health careers. These centers are funded to provide advanced postdoctoral training to physicians as well as allied health professionals in clinical and counseling psychology, social work, pharmacy, and nursing. Training is not limited to postdoctoral fellows: graduate students, residents, and interns from affiliated accredited training programs may rotate through mental health CoEs each academic year.

Conclusions

For > 30 years, mental health CoEs have brought thousands of veterans advanced treatments for their mental health needs and helped reduce death by suicide. The centers have a bright future ahead, harnessing advances in artificial intelligence and genomics to permit the matching of the individual veterans to the treatment most likely to benefit them. Precision medicine, as espoused by the Hannon Act, will not only encourage the efficient use of health care resources but also rapidly reduce pain in veterans with mental health and SUDs.