Screening in the Biologic Era: Are Dermatologists Over- or Under-Monitoring in 2026?
Scott Elman, MD, FAAD, posed a timely question at the 2026 Masterclasses in Dermatology Annual Meeting: In the era of TNF-α, IL-17, IL-23, IL-4/13, IL-31, TYK2, and JAK inhibitors, are we screening too much—or not enough?
“What a time to be a dermatologist!” he remarked, citing the expanding armamentarium and high biologic utilization in dermatology. Yet as therapeutic options have grown, so too has the monitoring burden, often without clear evidence to guide practice.
Dr Elman framed screening through a risk-stratified lens. Step 1: Determine the drug class. Step 2: Assess tuberculosis (TB) risk factors. Step 3: Evaluate hepatitis B (HBV) and hepatitis C (HCV) risks. Step 4: Review vaccination status. Step 5: Perform drug-specific labs, primarily for JAK inhibitors.
Infection reactivation risk varies by mechanism of action. TNF inhibitors have a well-documented risk of HBV and TB reactivation. JAK inhibitors also carry risk. By contrast, IL-17 and IL-23 inhibitors show “no meaningful increase in TB reactivation” in pooled analyses and international consensus statements. In a Taiwanese cohort of 1525 patients with psoriatic disease and HBV/HCV, HBV reactivation rates ranged from 17% (TNF inhibitors) to 5% (IL-23 inhibitors), with prophylactic antivirals protective.
Importantly, updated National Psoriasis Foundation and International Psoriasis Council position statements now suggest that routine latent TB testing is not required for IL-17 or IL-23 inhibitors, except in endemic regions or in patients with additional risk factors.
Laboratory monitoring practices are highly variable. In a cohort of 122,308 patients starting systemic therapy, pretreatment complete blood cell count testing ranged from 41% to 69%, TB testing 11% to 59%, and hepatitis screening 13% to 41%. Monitoring rates during therapy were even lower.
Evidence supporting routine lab monitoring is limited. In a retrospective analysis of 199 psoriasis patients on long-term TNF inhibitors or ustekinumab, only 15 grade III–IV laboratory abnormalities occurred over 340 treatment-years, with just 2 requiring biologic modification. “Unguided monitoring of other routine laboratory parameters is unnecessary under long-term biologic treatment.”
Vaccination gaps were another concern. Real-world vaccination rates among biologic users were strikingly low, approximately 9% for influenza, 6% to 7% for zoster, and 16% for pneumococcal vaccines. “A 20-year tertiary center dataset shows that most biologic patients do not receive recommended vaccines. And this includes vaccines that reduce all-cause morbidity, not just drug-related risks,” Dr Elman noted. “Dermatologists must integrate vaccine review into biologic workflows.”
For more meeting coverage, visit the Masterclasses in Dermatology newsroom.
Reference
Elman S. To screen or not to screen: that is the question. Presented at: Masterclasses in Dermatology; February 19–22, 2026; Sarasota, FL.
