What Are Some Tips for Off-Label Medication Use in Dermatology?

At the 2026 Society of Dermatology Physician Associates (SDPA) Annual Summer Dermatology Conference in Denver, veteran dermatologist Ted Rosen, MD, of the Baylor College of Medicine, spoke in a presentation focused on practical, off-label treatment strategies for some of dermatology's most frustrating and difficult-to-manage conditions.¹

The session was titled ‘No Label No Trouble: A Panel Review of Off-Label Medication Use,’ and it pointed to what Rosen referred to as "simple, safe, and cheap" therapeutic approaches. These methods were highlighted to provide dermatology clinicians additional options when conventional treatments do not work, are not well-tolerated, or are inaccessible to patients.

Rosen drew on his years of experience, reviewing a wide array of disease states encountered by dermatologists, physician associates (PAs), and nurse practitioners (NPs) in everyday practice. Conditions highlighted by Rosen and his co-host included Grover disease, tinea versicolor, morphea, alopecia areata, Kaposi sarcoma, recalcitrant warts, and several genital dermatologic disorders. The following represent a set of notable recommendations:

Off-Label Tips for Treating Tinea Versicolor:

“Here’s my alternative to using ketoconazole for tinea versicolor: fluconazole,” Rosen explained. “Two doses, 300 milligrams. Once you wait 1 or 2 weeks, do another 300 milligrams; it's a 94% cure rate, with almost no significant drug interactions anymore, because they used to interact with certain diabetes drugs…It works very well, not quite as well as ketoconazole, but almost as well.”

Throughout the presentation, Rosen spoke about some of the lesser-known uses of established therapies, providing attendees with his own clinical anecdotes and evidence from available dermatologic literature to support off-label approaches not yet reflected in formal treatment guidelines. Another condition he touched upon was Zoon’s balanitis, also known as plasma cell balanitis, for which Rosen provided several recommendations.

Off-Label Tips for Treating Zoon’s Balinitis:

Rosen described Zoon’s balanitis as largely a diagnosis of exclusion that can mimic other conditions, including candidiasis, squamous cell carcinoma, psoriasis, and even syphilis. Histologically, Rosen noted biopsy specimens characteristically show a dense plasma cell infiltrate, prompting clinicians to rule out syphilis with serologic testing. While traditional management options include circumcision, mid- to high-potency topical corticosteroids, and topical calcineurin inhibitors, Rosen noted his own reservations regarding chronic steroid implementation.

Rosen described calcineurin inhibitors as potentially causing bothersome burning sensations among patients. Instead, he pointed to topical mupirocin 2% ointment as his preferred treatment, noting its benefits. Applied 2 - 3 times each day for approximately 3 - 4 months, mupirocin has, in Rosen’s experience, led to lesion resolution with minimal recurrence. This makes it a simple and well-tolerated off-label option for patients with the condition.

Off-Label Tips for Treating Alopecia Areata:

In another portion of his talk, Rosen acknowledged approved Janus-kinase (JAK) inhibitors have become an effective type of agent for alopecia areata but noted some patients’s remaining hesitancy to implement them because of the boxed warnings included in prescribing information. As an alternative, Rosen pointed to off-label use of fexofenadine, a histamine H1 receptor antagonist widely used by Japanese dermatologists as a first-line treatment for alopecia areata.

While the treatment’s exact mechanism is unclear, Rosen suggested it may be related to mast cell stabilization or inhibition of mast cell degranulation. He emphasized that fexofenadine is inexpensive, readily available, well tolerated, and suitable for long-term use, typically at doses of 120–180 mg daily in adult patients. To support its potential utility, Rosen shared his own clinical experience after reviewing reports from Japan, describing positive experiences treating those with newly diagnosed alopecia areata using fexofenadine monotherapy, without topical corticosteroids, intralesional injections, or other adjunctive therapies.

While acknowledging the potential for spontaneous regrowth in alopecia areata, Rosen highlighted his own observations of substantial hair regrowth in multiple patients and estimated that between two-thirds and three-quarters of patients with new-onset disease in his practice experienced regrowth with fexofenadine treatment.

Overall, this discussion underscored the value of therapeutic creativity in dermatology, especially when managing individuals with refractory disease or limited options for treatment of their diseases. Rather than focusing solely on newly approved agents, Rosen et al explored how familiar medications can be repurposed to address challenging clinical scenarios, providing attendees practical pearls that could be readily incorporated into patient care.

Disclosures: Rosen previously reported serving on consultant/advisory boards for Genzyme-Sanofi, Verrica Pharmaceuticals, Almirall, Bausch + Health, and DermTech.

References

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