Baseline Screening and Monitoring for Biologics and Small Molecules
Clinical Summary
Biologics & Small Molecules (2026): Evidence-Based Baseline Screening in Dermatology
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TNF inhibitors vs IL-17/IL-23 inhibitors: TB screening is evidence-based for TNF inhibitors (reactivation risk). For IL-17 and especially IL-23 inhibitors, risk appears negligible; International Psoriasis Council and National Psoriasis Foundation consensus argues against routine TB screening with IL-23 agents.
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Mechanism-guided monitoring: Tailor screening to immunosuppressive risk. JAK inhibitors and TNFs warrant closer monitoring/vaccination review; highly targeted IL-23 inhibitors may not require broad baseline screening in low-risk patients.
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Practice implementation: Use class-specific checklists (e.g., JAK baseline labs/vaccines) to avoid “one-size-fits-all” testing; align surveillance with mechanism, patient comorbidities, and cost-conscious care.
Reviewed by Riya Gandhi, MA, Associate Editor of Immunology Group
Dr Scott Elman discusses evidence-based baseline screening and monitoring strategies for biologics and small molecules in dermatology. Learn when tuberculosis and other screenings may be unnecessary—particularly with IL-23 inhibitors—and how to tailor surveillance based on mechanism of action, patient comorbidities, and cost-conscious care.
Scott Elman, MD, FAAD, is an assistant professor of dermatology in the Dr Phillip Frost Department of Dermatology & Cutaneous Surgery at the University of Miami Miller School of Medicine, who also serves as the director of inpatient dermatology services at the University of Miami Hospital.
Transcript
Hi, I'm Dr Scott Elman. I'm an internist and dermatologist. I practice at the University of Miami Department of Dermatology. I'm thrilled to be here at Masterclasses of Dermatology, my favorite meeting of the year.
With expanding use of biologics and small molecules, what baseline screenings are truly evidence-based—and where might we be overtesting?
Dr Elman: This is such a good question. So with the world of expanding molecules, we've got lots of new orals coming. We're very excited about that. We've heard a lot about these at this meeting, but of course, our injectable biologics still are the backbone of our practice of inflammatory skin conditions in 2026. And the challenge that we find as practicing dermatologists is we do a lot of things, but for a lot of these, we do them for no reason. A lot of our screening, for example, tuberculosis screening, is really extrapolated from the TNF inhibitors. And that made sense. TNF inhibitors, blocking those does significantly increase the risk of reactivation of tuberculosis, for example.
Having said that, there's been some great studies that have come out looking at IL-17 inhibitors and even more importantly, IL-23 inhibitors where that risk is negligible and likely those mechanisms are not as important, if not important at all, in managing tuberculosis. And so there's been a new consensus statement that's come out from the International Psoriasis Council, as well as the National Psoriasis Foundation, really arguing against the need to screen for tuberculosis, for example, in IL-23 inhibitors. My hope is that the FDA listens and labels can be changed because I think any screening that we can limit is better for our patients and better for healthcare costs in general as well.
How should clinicians tailor monitoring strategies based on specific mechanisms of action and individual patient comorbidities?
Dr Elman: So this is key. Understanding the mechanism of what medicines we're using really should be the way that we practice screening and vaccination. So some of our medicines really are not immunosuppressive at all. If we think about our very targeted psoriasis, ninja-like medicines like IL-23 inhibitors, very low risk of viral reactivation, maybe we don't have to be screening at all unless someone's really at significant risk. When we think about some of our other medicines though, I think that we do have to think about screening. TNFs is a really important one, and the JAK inhibitors as well. I mean, we do see real immunosuppression, but of course we see efficacy and we use these medicines when we need them to treat our patients with skin disease. So screening is not necessarily a one size fits all. We have to think about the mechanism. And my hope is that guidelines and labels ultimately match practicality with real world evidence, with science evidence.
What practical steps can dermatology practices take to balance patient safety with cost-conscious, streamlined surveillance?
Dr Elman: Of course, we want our patients to be safe and we want the best by our patients. And it can be overwhelming, I think, as a practicing clinician with all of these medicines, all of these molecules and new ones coming out of what do we do? What do we do for good reason? What are we doing for no reason? At the end of the day, we need to keep our patients safe. So I think it would be very helpful, and I kind of have this in my practice as well, is having a checklist for each class of medicine. So I think about certain vaccinations, for example, with my patients who are going to receive a JAK inhibitor, certain baseline monitoring, for example, as well. And again, sometimes we fall into this fallacy of, "If I do it for one, I should do it for all of them." But really it's not evidence-based, it's not cost-conscious care. And our patients appreciate it when we don't over-test and over-treat unnecessarily. So again, for some of our more specific, not immunosuppressive, but more immunomodulatory medications, we likely don't need to be doing all of these things. But of course, everyone's different. It's hard to be very prescriptive about this. I think talking to your patients is really important and understanding their specific risk factors as well. That's the way to practice medicine in 2026 and beyond.
