The Journal of the American Academy of Dermatology published an expert opinion on October 8, 2026, comparing the efficacy and tolerability of hedgehog pathway inhibitors in locally advanced basal cell carcinoma — at a moment when immunotherapy is redrawing the treatment algorithm for the disease.

The paper, available online from JAAD, comes from Sarah H. Millan, Kennedy H. Sun, Marcus Tan, Michael R. Migden and Vishal A. Patel. Migden, of The University of Texas MD Anderson Cancer Center, and Patel have both been central figures in the trial programs that established hedgehog pathway inhibition and, more recently, PD-1 blockade for advanced basal cell carcinoma.

The title itself signals the clinical tension the authors address: hedgehog pathway inhibitors remain a frontline option for locally advanced BCC, but they now operate in what the authors call "the new age of immunotherapy."

What problem does the expert opinion tackle?

Locally advanced basal cell carcinoma presents a persistent therapeutic dilemma. Hedgehog pathway inhibitors — the smoothened-targeting oral class — can shrink tumors that are not amenable to surgery or radiation, but tolerability has always limited their use. Muscle spasms, dysgeusia, alopecia and fatigue drive discontinuation in a substantial share of patients, and clinicians have long lacked a head-to-head framework for choosing among agents in the class.

The authors set out to compare efficacy and tolerability across hedgehog pathway inhibitors and to situate that comparison against the emerging immunotherapy option for the same population. As the subtitle states, this is an expert opinion rather than a new randomized trial — a synthesis intended to guide prescribing decisions.

Why does timing matter?

The publication date is the story's anchor: October 8, 2026. By then, the locally advanced BCC field had moved from a single-class reality to a competitive one, with checkpoint inhibition now an established alternative for patients who fail or cannot tolerate hedgehog therapy.

That shift is exactly what the authors flag in their title. When one class dominated, tolerability comparisons within that class were academic. With an immunotherapy alternative available, the calculus changes: a clinician deciding between continuing a poorly tolerated hedgehog inhibitor and switching classes needs a clearer picture of the relative efficacy and adverse-event profiles of the available agents.

Who should read it?

The piece targets dermatologists managing non-metastatic, surgery-ineligible or radiation-ineligible basal cell carcinoma — the locally advanced population in which hedgehog pathway inhibitors earned their indication. Millan and Sun, the lead authors, position the analysis for practicing clinicians rather than trialists, consistent with JAAD's expert-opinion format.

For skin-cancer terminology precision: this is locally advanced disease, not metastatic BCC, and the comparison concerns the hedgehog inhibitor class as a whole rather than a single agent.

What comes next?

An expert opinion cannot settle comparative questions the way a randomized trial can, and the authors' framing implies the field now needs exactly such data — head-to-head and class-versus-class — as immunotherapy claims a larger share of the locally advanced BCC population.