In episode 49 of&nbsp;Derms and Conditions, James Q. Del Rosso, DO and Mark Lebwohl, MD discussed the pathophysiology of atopic dermatitis and the role of cytokines in its management.

In episode 49 of Derms and Conditions, James Q. Del Rosso, DO and Mark Lebwohl, MD discussed the pathophysiology of atopic dermatitis and the role of cytokines in its management. Drs. Lebwohl and Del Rosso discussed how specific cytokines can be targeted for a safer treatment of atopic dermatitis. They emphasized that the targeted therapies for atopic dermatitis do not have any boxed warnings and the treatment of cytokines, specifically interleukin-4 (IL-4) and IL-13, can significantly improve itching and dermatitis. Dr. Lebwohl discussed the inhibiting of IL-13 to make atopic dermatitis better and that blocking IL-4 and IL-13 was highly effective for treating atopic dermatitis. In terms of utilizing less targeted therapies, Dr. Lebwohl stated that all the drugs they use work by knocking down IL-13 but with varying side effects. The use of old drugs such as methotrexate and cyclosporine has several side effects, and doctors need to be cautious about their usage.

Atopic Dermatitis: Connections Between Cytokine Inhibition and Clinical Outcomes

Leopharma is driving innovations toward a brighter future within medical dermatology, advancing research and development, and expanding medical education in dermatologic diseases to help better equip clinicians in making informed decisions for their patients. Learn more at Leo Pharma us. That's Leo Harma us and Conditions podcast. So welcome to Derms and conditions. We're here live at winter clinical Miami, and it's exciting to be here doing a live podcast. And I have with me a great friend and colleague and one of the co directors and founders of these meetings, and that's Dr. Mark Webwall. So, Mark, it's great to see you. You haven't aged a bit since this all started 22 years ago, but we've developed a lot of new concepts in treatment. So we talk about cytokines. What we're talking about today is atopic dermatitis and variety of different cytokines and chemical messengers that are involved in the pathophysiology of that disease. So, Mark, when you're with a patient, you're looking at a patient that has atopic dermatitis, regardless of the age or the severity or the duration of the disease. Do you think about specific cytokines in terms of managing the atopidermatitis in that patient? I dream about cytokines. So as you get older, the things you dream about gets narrower and narrower. But indeed, when I see a patient, the beauty that we learn from other diseases is that if you can target a specific cytokine, you end up with usually a safer treatment. And I think the testimony to that is that the targeted therapies for atopic dermatitis don't have any boxed warnings, and it's because they are very targeted. We know what we're blocking. We're not going to get in trouble. And we recognize, and we know that with targeting interleukin four, Il four and IL 13, that those cytokines are very operative in most patients, the majority of patients with atopic dermatitis. And so if you give something that inhibits Il four and IL 13, obviously those patients improve significantly with itching and their dermatitis. But we know that even just inhibition of IL 13 has significant change in those patients. Yeah, very clear that blocking IL 13 is what makes atopic dermatitis better. That is very straightforward. We got lucky when Il four, which was the anti Il four, was the first approved biologic for atopic dermatitis. I think nobody was thinking, or maybe they were already thinking about IL 13, because IL 13 and Il four share the alpha subunit of the Il four receptor. So if you target that, you're going to knock out both. And that was highly effective. We came to realize what Il four did and how it activated, and it's involved in lymph nodes and with some central components of atopic disease. But IL 13 is present in such high concentrations in active lesions and also non lesional skin in atopic patients. It just gets higher. It just appears higher where I O four is somewhat not found as reliably in skin the same way IL 13 is. But going beyond that, going one step further, you mentioned about immunosuppression, the lack of being an immunosuppressive treatment. Yeah. Actually, what you just said is quite important. The package inserts on the biologics for atopic dermatitis do not mention the word immunosuppression. It does not appear there. And, in fact, Emma Gutman in our department has done great work on this. She showed that in atopic skin, Il four is very elevated. When you treat that, when you block Il four, it doesn't lower it below normal. It lowers it down to a normal level. So that's why we're not seeing an increase in infections in patients treated with these drugs. You're turning the volume knob down. You're not shutting the switch off like you might with a corticosteroid therapy that blocks so many different pathways and shuts them down. So what I'd like to do is stop at this point and just read you a message from our sponsor, leopharma. Medical dermatology is fast growing, driven by the promise of new leading medicines. As such, leopharma focuses its resources on investing in medical dermatology, where there are significant unmet medical needs and a high burden of disease. And certainly atopic dermatitis relates to all of that. So when do you consider utilizing less targeted therapies in patients with atopic dermatitis? Interesting question. So, for the drugs we use, whether they be biologics, jack inhibitors, cyclosporin, methotrexate, mycophenola, mofid immunosuppressants, and for the record, I never use the old ones. They're not approved for atopic dermatitis. They were all we had until the first biologics came out. But they all work. And if you looked at how they work, they all actually knocked down IL 13. So they all work by a similar mechanism, but they certainly didn't do that alone. They had a lot of other effects. And, of course, when you use the older drugs, they have a million side effects, and those side effects are real. You use methotrexate. I tell my residents, I used to have a couple of hundred patients on methotrexate. I would periodically wake up at night because I was worried about what was going to happen. So here I'm using an off label drug that's not approved, and you end up wiping out somebody's bone marrow, and you're in trouble with psychosporin. We know that 100% of patients end up developing kidney damage if you stay on it long enough. And interestingly, one of the first patients I treated with the first biologic for atopic dermatitis had been on. He was a lawyer on cyclosporn for about eight years because basically, he said he would rather be in kidney failure than have severe atopic dermatitis. That tells you about how his chart was as thick as a telephone book, an old telephone book, because he was signing all these disclosures. So he's now a devotee to the biologics because they're so targeted and so much safer. The jack inhibitors are safer than the old drugs, for sure. They do have boxed warnings. Those are the only targeted, non targeted therapies that I use for atopic dermatitis. Now, they are affect several cytokines. They're not just targeting. Correct. One or two specific cytokines. Right. And actually, if you look specifically jack one and Jack three inhibition blocks Il four and therefore also blocks IL 13. Those two jack inhibitors are quite effective for atopic dermatitis. Pretty much. I use them when patients fail the biologics. Why is that? The package insert says that you should use other systemic therapies first. And obviously, the only other systemic approved therapies we have are biologics and steroids, which I always avoid using. So let's talk a little bit about vaccinations and how you approach in adult patients. In children, obviously, there are some live vaccines, there's MMR is one of the considerations there where we were cautious about coadministration with live vaccines just because we don't have the data, not because we know anything is going to happen with any of these drugs. But how do you approach the vaccination story when you're treating patients with atopic dermatitis, let's say adults or adolescents? So there is some data that blockade of Il four does not interfere with vaccination. So the response you're looking for in a vaccination, unlike jack inhibitors, where there's some data showing that they do suppress the response to vaccination with the biologics. That data does not exist. In fact, the data says the opposite. However, the package inserts all warn against live vaccines, and that is an issue. Certainly, this came out actually during the yellow fever epidemic in Brazil, where there were patients getting biologics for. I think it was during one of the clinical trials for biologics for atopic dermatitis. So there were 37 or 38 cases, and those patients actually did fine. The worry is, of course, you're suppressing some of the immune system. That's vaguely. And so maybe the vaccine will actually make you sick, and it didn't. And you're modulating in many cases, not necessarily suppressing per se, though I realize some people consider that to be semantics. Now, what about the subject of conjunctivitis? We know that with inhibition of Il four and Il 13, we saw conjunctivitis in patients that were receiving that form of inhibition, but also that about 25, 30% of the patients have allergic, have conjunctivitis related to being atopic. Right. And so that's part of the atopic diaphesis, but some exacerbated or first developed it while they were receiving that inhibition of therapy. What about with IL 13 inhibition versus Il four and IL 13 inhibition? So I'll give you my experience, and there is some data in the literature as well. So, first of all, in my experience and also in the literature, the patients with most severe periocular disease were the ones who got in trouble. And by and large, the conjunctivitis is transient. Even if you don't treat it, it goes away. The usual therapy for. And I must have hundreds of patients on biologics for atopic dermatitis, and I have two in whom I've had to stop the drugs, and I'll tell you their story after. But by and large, there's one study that reported that looked at the question of glaucoma from topical steroids, and you can get glaucoma from topical steroids. So it turns out that there are some topical steroids that do it a little bit less. The topical cyclosporin eyedrops would be ideal. The problem is they're irritating, and they don't work that well. And actually, I've never had one patient with conjunctivitis from any of the biologics for atopic terminus. I've never had one patient respond to topical cyclosporin eyedrops. So pretty much when we have to, we use topical steroids. If we can get away without it. We prefer to. We use a lot of eyedrops. And again, in my experience, topical eyelid ointments, rather than drops work better. And there are these high saline ophthalmic ointments that actually, I think, reduce inflammation and work the best. I know David Cohen has talked about when you're utilizing some of the liquids to not get the bottle that you use repeatedly because there's preservatives in there that are irritating, get the single units because you don't have the preservatives. So benzalconium chloride or other preservatives can be irritating of the eyes in and of themselves. Right. Now, I told you I've had two patients who did not tolerate one of the biologics. We tried the other one. The data would suggest that just blocking IL 13 might cause a little less conjunctivitis. But I can tell you, in my two patients, they both got it when they switched from the Il four blockade to IL 13. So ultimately, those are two patients that had to move to jack inhibitors. So that's going to happen. And the literature certainly supports that. We're doctors. We have to help people in individual situations, and that's going to happen with any therapies, with all therapies that we have. So do you have any final comments, Mark? I mean, to me, my comment would be, we are very fortunate to have some great options now. Yeah, I have to say, I'm sure. Remember the days when you and I, although I avoided it and many of our colleagues, use systemic steroids because the patients were miserable. I used a ton of psychosporin and I worried about it all the time. But here we're using these dangerous drugs, and now suddenly we have drugs where you treat a patient with one injection, and within weeks they are profoundly better. Even within days, you see their itches reduced, they're oozing, and the examiner is changing on their skin. They literally go from something where you're miserable to you hardly notice it. You get about 80% of the benefit within the first four weeks. I agree. And it's all the treatments. It's the biologics, it's the jack inhibitors, and patients who you felt awful for them. They went from looking awful to looking normal. I don't like buzzphrases, but I have to say, game changer definitely applies. Yeah, no question. Definitely a game changer. So thanks, Mark. It's always a pleasure to be with you, and you give historic insights. Right. And so do I, to a significant extent. But I really appreciate your time thanks for having me. I do have a question for you. Sure. And we ask this do you prefer a Chicago deep dish pizza or a New York thin crust? I am embarrassed to say I love deep dish pizza. So you're more to the Chicago side. Even being a New Yorker, that's the first time I've heard that. See, it's good to have options, which is the point of what we're talking about today. Thanks a lot, Mark. Thanks, Jim. So every day, hour and minute, people around the world are suffering from skin conditions, often severe and chronic, impairing their quality of life. Our purpose at leopharma is to help advance the standard of care for the benefit of people with skin conditions, their families, and society through innovative treatment solutions. Thank you for listening to this episode of Derms and Conditions. If you have any questions or comments, please email us at. Podcasts at Fred Health and most importantly, if you like this episode, subscribe to the Derms and Conditions podcast on Apple Podcasts or wherever you get your favorite shows. Thanks for joining us.

From the Research Center to the Clinic: Biologics and Other Systemic Therapies Part 1

In episode 47 of&nbsp;Derms and Conditions, our host James Q. Del Rosso, DO sits down with Alexandra K. Golant, MD to discuss advances in the management of atopic dermatitis.

In episode 47 of&nbsp;Derms and Conditions, our host James Q. Del Rosso, DO sits down with Alexandra K. Golant, MD to discuss advances in the management of atopic dermatitis. &nbsp; They begin by highlighting the landmark approval of dupilumab in 2017 and how it completely revolutionized treatment of the disease at a time when options were very limited. Now, with additional biologics and a few JAK inhibitors on the market, both discuss some tips for choosing between the drug classes based on patient characteristics. Importantly, they also discuss the black box warning for JAK inhibitors and how to counsel patients on what this means. Next, they review some nonsteroidal topical medications including roflumilast, ruxolitinib, and tapinarof and their tolerability and efficacy. Finally, Dr. Golant provides some of her favorite clinical pearls from her years of experience treating atopic dermatitis. Tune in to hear her take on the growing options for atopic dermatitis!

It Is a Better Time for People with Atopic Dermatitis: A "Power Duo" Sorts Through Some Very Effective Options

In episode 46 of&nbsp;Derms and Conditions, our host James Q. Del Rosso, DO, sits down with Joel L. Cohen, MD, founder of AboutSkin Dermatology in Denver, Colorado. The two discuss how Dr. Cohen incorporated laser procedures and cosmetics into his general medical dermatology practice.

In episode 46 of Derms and Conditions, our host James Q. Del Rosso, DO, sits down with Joel L. Cohen, MD, founder of AboutSkin Dermatology in Denver, Colorado. The two discuss how Dr. Cohen incorporated laser procedures and cosmetics into his general medical dermatology practice. Dr. Cohen takes us back to the beginning of how his dermatology career evolved to include integration of devices and cosmetic procedures. He strategically chose an IPL device as his first purchase so that he could treat a variety of conditions important to his patients. He then reviews additional pearls and pitfalls as he looked to expand into other devices. These practical tips range from how to choose a device based on versatility and consumables to how to counsel patients on what to expect throughout the treatment course. The use of devices and procedures in dermatology continues to evolve and expand in clinical applications. If you are looking to add any devices, such as lasers and lights, or cosmetic dermatology into your practice, you won&rsquo;t want to miss this episode with a dermatologist who has extensive expertise and experience in this important area of dermatology.&nbsp;

An Open Dialogue on the Use of Devices in Dermatology

In episode 45 of Derms and Conditions, our host James Q. Del Rosso, DO sits down with Mark Kaufmann, MD, President of the American Academy of Dermatology. &nbsp; The two begin by discussing the many benefits of AAD membership and what the AAD is currently doing to support its members. In an economy that has seen record levels of inflation, physicians have still had to face an 8.5% cut to Medicare reimbursements. Dr. Kaufmann explains how he is working to counteract these cuts, and how you can support this mission by reaching out to him directly to get involved or by donating to the SkinPAC.

In episode 45 of Derms and Conditions, our host James Q. Del Rosso, DO sits down with Mark Kaufmann, MD, President of the American Academy of Dermatology. &nbsp; The two begin by discussing the many benefits of AAD membership and what the AAD is currently doing to support its members. In an economy that has seen record levels of inflation, physicians have still had to face an 8.5% cut to Medicare reimbursements. Dr. Kaufmann explains how he is working to counteract these cuts, and how you can support this mission by reaching out to him directly to get involved or by donating to the SkinPAC. Finally, Dr. Kaufmann shares some of his favorite initiatives that he has worked on and some exciting ideas for the future. You won&rsquo;t want to miss learning about his fruitful tenure as AAD president and everything he has done for the specialty.&nbsp;

What can the AAD do for YOU?

You're listening to the Derms and Conditions podcast. So it's a pleasure to bring up here. We don't need to be over here because we're Mike separately. It's a pleasure to bring behind each other, like some presidential debate. Presidential debate. Not going to be debating the president. So this is actually a live podcast for derms and conditions with Mark Kaufman, who I've known for many years as a friend and a colleague. We work together on things that advance dermatology and cosmetic surgery with different activities, but he has really done a great job so far and is just a great guy and somebody that we can depend on at the American Academy of Dermatology. So let's get the discussion. Mark, you know, things are getting a little tight. Everything's more expensive. So when different requests come in for money, and one of those is AAD dues, I thought about maybe I can save some money and not necessarily be a member of the AAD or other organizations. So if I'm looking at that invoice from the EAD, why should I keep being an AAD member? What, in your mind, what Ead does classically and what you're doing now, moving into the future. So, first of all, thank you for having me here. It's a pleasure to be here. It's great to be at a meeting that it almost seems normal, like Covid never happened. And it's great to see friends and meet new people. So I'm really happy to be here. I think the question is a great one. What does the academy do for me? And I'll be very happy to try and give you a short, concise answer. There are four things that the academy does for its members. They relate to education. You all know there's going to be a big meeting in New Orleans in March, and we hope to see many of you there. We work on advocacy, and I'm going to touch on that a little more. We work on public relations, and I hope to touch on that, too. And we also advocate for research. So there are a lot of things, I don't know if you want me to go into any detail on any of them, pick one that you think is the most important in dermatology right now in terms of what we're facing as a specialty. So the most important now is by far the advocacy realm. We are currently in an election season. And what I think is really important for dermatologists to understand is that it is really important for us to be the best at what we do. And that's why you're here at this meeting to become the best and better at what you do. But at the same time, we also live in a world where politics actually can determine whether or not your life is going to be miserable or you're going to be able to practice the way that you want to, to be able to treat the patients with all the medications that you're hearing about without dealing with some of the hassles that you're hearing about. And more importantly, for the moment, we're also dealing with a reimbursement crisis in medicine, not just in dermatology, but all physicians are faced at the moment with an eight and a half percent cut for next year on Medicare rates. And we're hopeful that we can mitigate that. But I am someone who came in and told people that I don't want mitigation, I want elimination. I want a raise for inflation. And unfortunately, the political realities is that we don't always get that chance. Our legislators, and we just had a legislative conference with 200 people where we went to the hill. But we're getting mixed messages. Some of them are saying that there's just other greater political concerns that they have that are not going to allow for them to get rid of all the cuts. So I would encourage everyone to give to Skinpac to also individually get involved. If you know anyone who's in Congress, or even if you don't know your congresspeople, find out the way to write letters, because the AAd is really working hard for this. But we can't do it alone. We need your help. So I hear often give to skinpac. Can you give some examples of how SkinPac actually makes a difference for dermatology? So we give money to Skimpak or to the Aad to solve some of these issues or combat some of these issues. What's actually done in the trenches for the members? Sure. So the first thing I'll say is, in your question, you said you give money to Skimpac or AAD. It is different when you give money to Skimpac or you give money to AAD. AAD has a philanthropic arm within its 501. I know I'm getting a little technical, but in order to do advocacy on the Hill, we have a separate arm, and that separate arm is a different tax category. So just because, and this is a good point, just because you give money to AAD, none of that is going for advocacy in Washington. We actually can only use the money raised on the other arm, on the association arm. So that's why Skinpac donations are really important because it doesn't come from anywhere else. And what Skimpak lets you do is it doesn't buy votes. We can't go and tell someone, we need you to vote for this, and here's a donation. But it does get us facetime with the legislator. So it gets us meetings with people who we might not otherwise get. And at least you have to be at the table. And what Skimpak does, it gets us a seat at the table. So are there examples you could point out where we've had, even if they were small, wins, where wins actually happened for, you know, on the federal level? We also work a lot at the state level, and we work to get legislation through for shade structures to eliminate tanning bed taxes or to limit the use of tanning beds. On a federal level, we are always advocating for issues that are important to dermatology. And the way that we can talk to the legislators about those issues is through the donations from SkinPAc. So if an individual out here know, like the movie network, right? Was it network? I'm mad as hell and I'm not going to take this anymore. And they want to get involved, what should they do? Should they send an email to you? Do they send an email to somebody specifically at the academy? If they want to have a voice on some particular issue? Anyone who wants to get involved can write an email to me. President@aad.org if it's not me who's going to respond, I can get it to the right person who will respond to you. And we would love to have more people get involved. And really, everyone should get involved now because it really is a moment of crisis right now with reimbursement, and we need all hands on deck. So find out who your congresspeople are. You're going to be getting emails from us, probably from AMa as well, to do a grassroots email to all of your legislators to try and get them to understand that in order for us to keep our doors open, we're going to need not just an elimination of these eight and a half percent cuts, but actually an adjustment upward for inflation. So if someone is contacting a legislator or whoever you're recommending that they contact, how are they not just perceived as, oh, this is just a doctor who, yeah, they've had cuts, but they're still making plenty of money. And why should I feel sorry for them or do anything to help? Any specific things we should say about what dermatologists do that makes a difference with these political individuals? Well, I would stress to them that many times in the past. For those of you old enough in the audience to remember the days of the SGR, the sustained growth factor, which we got eliminated, and remember, it was eliminated on an annual basis. In total, we never got a cut, but we were still getting cut because inflation took place and we were getting cut. That was like death by 1000 cuts, literally. But it was very slow. And we're very good at adapting and working harder and seeing more patients. And you can do that for a while, but at some point you run out of Runway. And the way you run out of Runway quicker is when inflation goes from zero to eight and a half or double digits, which it is, and then you just can't do it anymore. So I would say it's just a matter of math. We can't survive in an inflationary environment with any cuts, let alone the lack of an adjustment upward. So how do we get ahead of it? Let's say people get involved and we have some success, and we reduce some of those rate cuts, we're going to go through this cycle again. And so how do we stay ahead of it all the time rather than just reacting to it on a case by case basis? Any thoughts on that? I know it's difficult. Yeah, that's a tough question. I have my own thoughts. I think in general, I think physicians are weaker because we are specialty driven. In other words, skin pack is dermatology specific. And so every specialty has their own pack. And it's great because you can lobby for your interests, but at the same time, physicians as a group are all splintered. We're not unified. We don't have one PAC that goes to Washington and tell them the realities of economics that are facing us. And I think that actually hurts us. So I'm thinking that in the future, we may need almost a super pack of all the specialty packs in order to go to Washington the way that the hospitals and the nursing homes go to Washington. They go as one entity. They don't go as 30 different entities asking for tiny little things. They go as one entity. And they're only asking for one thing. They're asking for an adjustment for inflation. And you know what? They get it. The hospitals are adjusted for inflation. The nursing homes are adjusted for inflation. The physician fee schedule stays the same. So are different physician groups actually cannibalizing each other where you might have one group primary care or whatever, saying that the dermatologists are fine, but we need the help? So that doesn't sound like a unified voice, if that's what's actually happening. And honestly, I think that gets to the crux of the problem is that physicians have never been a unified group. And so it does make it more difficult, I think, to be able to advocate as physicians when we're all advocating for each other's specialties. So are there ways that maybe some of our patients would understand what we're saying, that you get the patients involved? Absolutely. So how do you do that without seeming self serving? It is difficult. I don't think it's worth telling a patient we're going to get cut. But on the other hand, it is worthwhile if your patient comes, if you have to drop off of certain insurances to have that discussion with a patient who says, how come you're not taking my insurance anymore? I think it's totally fair to say, hey, I'd love to see you, I'd love to take your insurance, but it's just not possible. If you want, you can contact some folks that might be able to change that so that we can get back on the insurance. So is the way they can go to a website or someplace where the academy would then let the patients know, or skinpac would let the patients know what they can do. I may be barking up the road that's not available at the moment, but maybe something we can look at. So what else? Right? It's been an awesome year. It really has. I've been representing the academy all over the country, all over the world. I've been to remarkable places, seen other dermatology societies of other countries and how they work. But probably the most magical trip I took was to a small town in northern Minnesota of Cross Lake, which was really the birthplace of camp discovery. For any of you who know what the program is, it's a program where we send kids with horrible skin disease who suffer from tremendous self esteem issues and think that they're alone in the world. And the academy, through a lot of donations, is able to send these kids for one week to a camp where they feel like they're normal and they're around kids who have similar diseases. And it was really interesting because I was going from one lecture and giving an academy update, and I was on my way to another meeting to talk about burnout. And I tell people on my way to go talk about burnout, I actually found the cure to burnout because we never take the journey with our patient, really. We see the patient, they may have horrible skin disease, we help them, we prescribe, and then they go back to live in their own world, and we don't and to be able to go and to see them living in their world and really getting what they get out of camp Discovery was completely life changing for me. And that's why my main initiative of my presidency has been to try and expand the camp Discovery program, its capacity. And my goal, my stretch goal, is to make it so that every resident in the United States would be able to spend one week out of their three years at Camp Discovery. That would be fantastic. So that's the focus because it goes by fast, right? You have a whole list of things you want to do, and it's really hard to get to all of them. So, Mark, I want to thank you for the effort you put in. It's one year as president, but there's a lot of years building up to that year of hard work in addition to what you've done at the ruck along the way. Appreciate it because it's a lot of hours. I appreciate it. Thank you, Mark. Thank you, Jim. Appreciate it. Pleasure. Appreciate it. Thank you for listening to this episode of Derms and Conditions. If you have any questions or comments, please email us at podcasts at Fred Health and most importantly, if you like this episode, subscribe to the Derms and Conditions podcast on Apple Podcasts or wherever you get your favorite. Thanks for joining us.

In episode 44 of&nbsp;Derms and Conditions, our host James Q. Del Rosso, DO sits down with April Armstrong, MD, MPH and David Cohen, MD, MPH, live at Winter Clinical Hawaii 2023 to discuss highlights from the meeting.

In episode 44 of Derms and Conditions, our host James Q. Del Rosso, DO sits down with April Armstrong, MD, MPH and David Cohen, MD, MPH, live at Winter Clinical Hawaii 2023 to discuss highlights from the meeting.
The trio reviews important tips from a variety of topics, ranging from contact dermatitis to psoriasis. Many lectures from this meeting focused on the new biologics and JAK inhibitors available to treat inflammatory conditions such as psoriasis and atopic dermatitis. The group unpacks important considerations for each of these medications and how to effectively use them to improve patient outcomes. Finally, they discuss deucravacitinib and its unique mechanism of action of TYK2 inhibition. Tune in to hear our KOLs recap some of the best clinical pearls from the meeting! <img style="max-width: 100%; height: auto;" src="https://mcusercontent.com/5ceb5997cef08be00c9571c4f/images/bd289527-b8c1-02b5-36aa-26548c4f1ca1.png" alt="Live Episode Recording at WCH23" /> FINANCIAL DISCLOSURES: JAMES DEL ROSSO, DO: CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). DAVID COHEN, MD, MPH: Consultant and Honorarium: Ferndale Laboratories, Asana Medimetriks [past] Leo UCB Novartis Dermavant FSJ FIDE. (FIDE receives industry sponsorship from AbbVie, Almirall, Amgen, Arcutis, Bausch and Lomb, Bristol-Myers Squibb, Celgene Dermavant, Dermira, Janssen, Kyowa Hakko Kirin, LEO, Lilly, Novartis, Ortho Dermatologics, Pfizer, Sanofi Genzyme, Regeneron, Sun Pharma, UCB, Valeant) Cosmetic Ingredient Review (CIR) Stock or stock options: Dermira [past], Medimetriks [past], Brickell Biotech [past], Kadmon, Evommune, Timber Board of Directors: Kadmon, Timber, Evommune, Dermira-[Past] APRIL ARMSTRONG, MD, MPH: Research investigator and/or scientific advisor to AbbVie, Almirall, Arcutis, ASLAN, BI, BMS, EPI, Incyte, Leo, UCB, Janssen, Lilly, Nimbus, Novartis, Ortho Dermatologics, Sun, Dermavant, Dermira, Sanofi, Regeneron, Pfizer, and Modmed.

Highlights of Winter Clinical Hawaii 2023

You're listening to the Derms and Conditions podcast in our third season with Derms and Conditions podcast, which we're very proud of. And I know you're going to learn a lot today, so let's get started. I have April Armstrong and David Cohen back from by topular demand, and I have to tell you, you better be sharp today because I've been here for a week, and I've been using that shower gel, and it says that I am enriched by flaxseed extract, white tea, and vitamin e. So I am pumped up with this stuff. Where do we start? You're better than you've ever been because of that. Now, the question is, how is it applied? And we got into that during the meeting. A bit on application technique, of course. I think what we did get to talk a little bit about is things like contact dermatitis really do reflect what we do on a daily basis. And I did want to highlight that. Of course, if you don't have contact dermatitis, this is just of interest for those that have eczema or poorly controlled dermatitis, where you really have to stop and think what, from the outside might be provoking it just to draw the highlight back. For those that weren't at the lecture, the 2023 allergen of the year by the American Contact Dermatitis Society was lanolin. Right. And got a mixed response from the group. Right. Some, I think, thrilled with it and some maybe not so much. But remember, lanolin is going to bring on dermatitis in a pretty slow onset. It's not going to be one of these fiery, quick onset, like maybe hair dye or poison ivy. So I think those who have dermatitis on their lips, eyelids, groins, even before you go to the patch test, consider that lanolin may be an issue. Most of us use lanolin products very safely, not an issue for most of us. So I don't want there to be hyperbole or over exaggeration of the importance of it. But lanolin creeps in. And when you have a lanolin allergic patient, get rid of lanolin and amercol containing products. So, April, any thoughts on that or anything else that you uncovered that you found in the meeting? Yeah. Thank you for inviting an adult to this conversation. And now I'm going to shift. She's sassy, isn't she? I'm going to shift the focus from the method of application to maybe talking about some of the wonderful psoriasis tips that we learned from our colleagues. Dr. Lovewall, Dr. Bhutani, and so forth. We now know, for example, for topical therapies, non steroidal topical therapies, we're actually looking at longer term results. So, for example, at this very meeting, we have topical roflumalast being studied and shown that it can maintain its clear or almost clear results for a median of at least ten months. So that's helpful. And I think for topinorov, about half of the patients achieve BSA, 1% or less, which is a very stringent criteria for topicals and nevertheless, even for a nontopical therapy. So we're seeing non steroidal topical therapies with good efficacy and as well as tolerability with longer term results. So one of the double edged swords I think about with that is if we tell people that you can use this and you're going to have months that you're clear without using it, or do we want to be cautious about patients stopping treatment and then going back to square one, or we might want them to be using things, continue to use these therapies, since they do have the absence of side effects that you would have with the corticosteroid. So how do you see you're going to integrate that into your patient recommendations? Yeah, I think that's a great question asked by an adult. I want to. You're getting there, actually. Studies have shown if you want to treat the patients to clear, and then you can essentially try to stop. And then in the study that we've seen is that they then start as soon as they find any disease activity, at least for topical roflumalast, my recommendation is that you treat the person continuously to clear and then perhaps use them on the weekends as a proactive therapy to decrease flares. Yeah, I'm a strong believer in proactive therapy. So, David, I'm picturing this Allergen of the year scenario, and have you ever had a time where you had an allergen of the year, and then you looked out the window of your office in New York and there were dermatologists picketing against the allergen of the year? Any challenges there? Now you get some feedback about it. Remember, I'm the messenger most of the time. And this is a group at the american contact Dermatitis Society coming up with this. But the idea is just to draw some attention to the various allergens. You look at the ingredient lists of all these products and you just wonder, what are the important ones? What are the ones I need to think about? When do I need to test for them? So I get some adverse feedback every now and again, and Lanolin provided some of that. If I could just dovetail onto the last remarks before on the topicals, as I kind of sat through winter clinical, which really spanned the entirety of my week, taking care of patients with dermatology. If I would reflect, I might say, if 2010 to 2020 was the decade for psoriasis, where everything changed, the paradigms changed, what is 2020 to 2020, 30 going to look like? And I think that's probably going to be the decade of atopic dermatitis. We heard more talks on hydratinitis uppertiva, and we keep hearing more and more about evolving therapies. Jocelyn Kirby discussed the use of sporanolactone and metformin. These are drugs that we have experience with. We're adding them on, but I might say alopecia, ariata, vitiligo. And this is sort of the wringer here. Will this decade be the decade of topicals coming back? Because how do we integrate these new topicals that are more effective than any prior topicals we had other than super potent topical steroids? Where will they fit in and how will we use them? And I don't think there's a clear answer on that, but I think they need to get integrated pretty strongly. I think the safety of them is just so important because it gives you, like, with super potent topical corticosteroids, you still always have that in the back of your head. Even if you're telling a patient, use this twice a week, what are they really doing? And you don't have this concern with the newer agents, but why don't we move on to some of the systemic treatments? I think it's really important. We have a lot of discussion about Janus kinase inhibitors, and I think we need to have an open mind on how to approach them and really understand the patient populations and their potential risks of potential problems. But the agents that we do have, like the monoclonal antibodies that we have for atopic dermatitis, are highly effective. And we don't want to necessarily be thinking, oh, they're going by the wayside now because of Janus kinase inhibitors, because that's not true either. So, April, where do you see this going? Yeah, I think when we're looking at, for example, for atopic dermatitis, we have, for example, dupilumab, well established, and we also have trailokinumab now showing the 3.5 year data showing very good efficacy and safety. And then we have lebrechizumab, which is il 13 inhibitor as well. That is probably likely to be approved this year, that adding to our armamentarium. So I would think that our choices are actually, there are quite a few of them. And I think patient selection is going to be key. When we think of our Jack kinase inhibitors, our understanding of the safety profile, we know it works very well in ad at the doses that we're looking at. And I think the safety profile is something we're continuously learning. And I think the good message in that is that when we look at ad populations, specifically some of the black box warnings that was put on these medications from other indications and other populations seem to are not as relevant to our patient population. That being said, I think a good monitoring would be helpful. And then Jim, you and Nick and I, we created this jack inhibitor handout which I think would be very helpful for our clinicians, which talks about the monitoring guidelines, but the clinical mean, that's such an important part of it. So taking the time to just find out the key things, you need to know what's going on with the patient. So David, I know you have a lot of challenges. You get a lot of patients referred to you that have been managed by other clinicians, very good clinicians, that have difficult to treat inflammatory dermatoses, psoriasis, atopic dermatitis, dermatitis nos. So what's your feeling about these different treatments that are coming along? Right. And that comment about dermatitis nos is not a flippant comment, right? Because I think when we look at plaque psoriasis, we understand the pathophysiology, at least as it stands now, pretty well. It's il 23 th 17, it's got close linkages. And when you flip on those links, you can really influence the disease. Very much the problem when you have a patient with dermatitis, you send a biopsy and it comes back spongiotic dermatitis with a list of at least five exematist disorders like atopic derm, numular allergic irritant contact, derm id reactions, spongiotic drug reactions. You wonder if the pathophysiology of all these are the same, and they may not be. And of course, I think our first line of defense now are drugs that came out that really had very clean safety profiles. Right. Very easy to use. So dupilumab and trailokinumab I think are really good. Go to when you have a spongiotic dermatitis that you haven't really clearly demonstrated as allergic contact or it doesn't appear to be, and then the question will be, do you move from one biologic to the other. Right. So we have two now. There's going to probably be a third soon. And where do you pivot into jacks. Right. And I think some sooner than later and depends on the severity and the conditions involved. Their labels, those jack labels suggest that you'd fail a systemic therapy. That doesn't necessarily mean a biologic therapy. It could be cyclosporin, methotrexate, mycophenylate, and I dare say prednisone. Right. The guidelines of care don't suggest the use of prednisone for the long term management, but that's probably used more often. I agree. You mentioned. I agree. I think it's easy to be up on a stage and say, don't use prednisone for eczema. But I don't think there's anyone in the room who has not written systemic steroids for an exematus flare to get a bridge to some control. So I think that's the reasonable way to do it. And then when you pick your right patient, the ones that have the fewest comorbidities, that may put you at risk for some of those black box warnings. And I know we do talk about those black box warnings as being seen more commonly in other disorders. We saw it with tofacidinib at 20 milligrams a day in inflammatory bowel disease. But I would suggest that almost every black box warning has occurred in eczema trials. Right. In one way or the other, and many with comorbidities that might put them at risk. So younger patients, those with less mace event potential, I think they're good choices. The jacks are the most spectacularly speedy and effective drugs we have available to us. And it's just a risk benefit for each patient. Right. So we'll see how they play out in the total paradigm of what we use. But they're here and they're really valuable. One of the things that Linda and I did in a session this morning is try to get people out of the weeds of getting caught up on how to monitor. I think it's pretty straightforward, the monitoring recommendations, and really not a lot different than what we would be doing with cyclosporin or some of the other agents that we used and just keep an eye on it and follow through with it. April, what's your feeling? Because I get this question a lot, and I'm sure others do. What's your feeling about inhibiting tyrosine kinase two and is lightening up on the monitoring really something that we should feel comfortable with, or what's your sense on that? Yeah, I think when we were thinking about tyrosine kinase two, tick two, most of the development in the oral realm in psoriasis right now is actually directed against tyrosine kinase two, and importantly to the allosteric domain to make it more, even more specific. And what we saw clinically, too, no black mox warning with the approved ducravisitnib, for example, as an oral therapy, is acknowledgment, I think, by the FDA, after evaluating the evidence, seeing that the safety profile of a very specific tick two inhibitor being different from the jack one, two or three inhibitor. So I think that's something that's important. And I think we now have more oral choices, not only for psoriasis, but also beginning for psoriatic arthritis as well. So I think those are some things to mention. I think orally, we also saw at this meeting, presentation of a premalass being studied in kids six years and above. So really oral therapies, we traditionally think of them mostly studying in adult population. I think that's another shift that we're going to see also newer oral therapies being studied in people. I believe Mark Lebwald talked about oral apromolastin treating some other less common diseases that we're not likely going to see FDA approval for because they're more rare, but always go to the literature to look for those sorts of things. But we have other disease states, right? We have lichen planus being looked at with topic aruxalitnib and even some of the oral tick two agents. Hydratinitis, I think, is one that I'd like to at least touch upon. And don't forget, bimikizumab, very likely coming for psoriasis, and good data on psoriatic arthritis and also evaluation inhibiting 17 a and f. And hopefully we'll have approval for that soon for psoriasis, with excellent data, as you know. But what about some of these other disease states in terms of how we visualize treating them, things like hydratinitis and alopecia, that we now have a lot of hope for patients that we were desperate before. Yeah. Any thoughts on those, David? Yeah, I think the evolution of the development of drugs for hydroadinitis is really going in the proper direction. Right. We're getting a better understanding of pathophysiology of the disease because of some of these drug development. And we heard a lot during this meeting about the Il 17s really evolving in this area. I think generally, dermatologists have more comfort level going long on IL 17s as opposed to long on, say, tnfs, if you had that option. And I was really happy to hear about that. And again, not to belabor the point, but the utilization of topicals and some systemic drugs early in the course may be very valuable, because once you have the tracks and the scars down, there's not going to be much you can do with that, with a systemic agent. Right. When we're looking at the patient from the surface, we're looking in the axilla, and we're seeing those inflamed abscesses and things, we're not necessarily seeing what's going on under the surface, but these things are forming, and then when they finally emerge, it's too late. And so that's where I think that's a disease that you really want to get systemic therapy going early. What about will end with alopecia ariata? Any thoughts about the use of Janus kinase inhibitors or other therapies there? Yeah, I think what we've seen so far, with our approval of barricitinib in alopecia ariata has really brought changes for our patients. And one thing that I think as a field that we are now struggling with. What about those who have had alopecia ariata for a very long time? Right. So we see efficacy, good efficacy, in patients who have had it for a number of years, but beyond, let's say beyond ten years, it's quite difficult. So I think we're still looking at those specific patient populations. But certainly, I think it has been a game changer for a lot of patients with alopecia ariata at the current time, you still need continued use to maintain the efficacy, which I think takes a little bit of education with our patients. But I think as a field, we're also looking at more difficult to treat scarring alopecia. So frontal fibrosis, alopecia, LPP with dutasteride, or any other therapies I think was mentioned were some of the pearls. And right around the corner, we have another agent riddle sit nib for alopecia, which is a Jack three tech, so it's a different kinase. So Oxfordy Ox 40 ligands are coming for atopic Derma. The learning is not going to stop, and it's very fascinating. And even lupus is being looked at with tick two and some other agents. So I think it's very exciting. So thanks, David. Thanks so much, Jim. We ask if people want anybody else, and they keep coming back to you. So it's always backed by top of the man. Thank you very much. Turn into Derms and Conditions podcast. They come regularly by going to Apple Podcasts or wherever you get your favorite shows. Thank you. That's.

In episode 43 of&nbsp;Derms and Conditions, our host James Q. Del Rosso, DO, sits down with Bruce Strober, MD, PhD, a Clinical Professor of Dermatology at Yale University. The two discuss some of the newest advances in psoriasis management.
They start with an overview of therapies with new mechanisms of action and discuss other medications that are in the pipeline. Dr. Strober then provides important tips for screening for psoriasis comorbidities. Since at least 1 in 5 patients will get significant psoriatic arthritis, and patients with moderate to severe psoriasis are at increased risk for cardiac events, Dr. Strober emphasizes that working with other specialists is critical to ensure comprehensive care.

In episode 43 of&nbsp;Derms and Conditions, our host James Q. Del Rosso, DO, sits down with Bruce Strober, MD, PhD, a Clinical Professor of Dermatology at Yale University. The two discuss some of the newest advances in psoriasis management.
They start with an overview of therapies with new mechanisms of action and discuss other medications that are in the pipeline. Dr. Strober then provides important tips for screening for psoriasis comorbidities. Since at least 1 in 5 patients will get significant psoriatic arthritis, and patients with moderate to severe psoriasis are at increased risk for cardiac events, Dr. Strober emphasizes that working with other specialists is critical to ensure comprehensive care.
Finally, Dr. Strober reviews the many benefits of deucravacitinib (SOTYKTU), including its once-daily oral dosing, excellent safety profile, and lack of lab monitoring. He notes that deucravacitinib is very effective, even more so than methotrexate, and comparable to cyclosporine but without all of the side effects. He discusses the unique mechanism of action of TYK2 inhibition and how this targeted action limits the drug&rsquo;s side effects and allows it to avoid the black box warning that other JAK inhibitors carry. Tune in to this episode to learn more about this new drug that Dr. Strober believes will revolutionize psoriasis management.&nbsp;

What's New and Hot in Psoriasis Management

Season 3

The&nbsp;Derms and Conditions&nbsp;Podcast had a very&nbsp;successful year in 2022! Many discussions took place covering a wide range of topics in dermatology,&nbsp;including new published information, treatments, technologies, medications, and&nbsp;practical tips to improve the overall performance of your practice.&nbsp;Derms and Conditions&nbsp;wraps up the year by summarizing valuable insights and information for dermatology practitioners.

The&nbsp;Derms and Conditions&nbsp;Podcast had a very&nbsp;successful year in 2022! Many discussions took place covering a wide range of topics in dermatology,&nbsp;including new published information, treatments, technologies, medications, and&nbsp;practical tips to improve the overall performance of your practice.&nbsp;Derms and Conditions&nbsp;wraps up the year by summarizing valuable insights and information for dermatology practitioners.
Host James&nbsp;Q. Del Rosso, DO,&nbsp;explains the value of occasionally going back and listening to past episodes as&nbsp;some "pearls" always seem to emerge that were missed during the initial&nbsp;listening of the podcast. Some of the greatest hits from episodes released in 2022 were highlighted. This includes perspectives on managing actinic keratoses (Dr. Mark G. Lebwohl, MD), a review of the "STOP" approach to rosacea which incorporates effective patient collaboration (Dr. Julie C. Harper, MD), ways to integrate aesthetic and cosmetic dermatology into your medical dermatology practice (Dr. Patricia K. Farris, MD), and a discussion of how tumescent anesthesia can expand the range of procedures that dermatologists can effectively and safely perform in the office (Dr. Sandra Lee, MD).
&nbsp;Many thanks for listening and we look forward to Season 3 in 2023.
&nbsp;

Greatest Hits from Derms and Conditions 2022

In episode 41 of&nbsp;Derms and Conditions, our host James Q. Del Rosso, DO brings back a prior podcast guest in Brad P. Glick, DO, a member of the board of directors of the AAD and National Psoriasis Foundation as well as the residency program director at Larkin Palm Springs in Miami. The two discuss psoriasis management and the utility of anti-TNF drugs.

<div class="raw-html-embed"><div class="flex justify-center"><a href="https://cvent.me/KYRPdz" target="_blank"><button class="h-10 flex items-center justify-center gap-2 cursor-pointer h-[60px] align-items: center; outline-none rounded py-5 px-4 font-semibold bg-blue-250 hover:bg-blue-200 text-white">Download ODOMZO Handout</button></a></div></div>&nbsp;<div class="raw-html-embed"><div class="flex justify-center"><a href="https://cvent.me/KYRPdz" target="_blank"><button class="h-10 flex items-center justify-center gap-2 cursor-pointer h-[60px] align-items: center; outline-none rounded py-5 px-4 font-semibold bg-blue-250 hover:bg-blue-200 text-white">Download ODOMZO Cheat Sheet</button></a></div></div>&nbsp;In episode 41 of Derms and Conditions, our host James Q. Del Rosso, DO brings back a prior podcast guest in Brad P. Glick, DO, a member of the board of directors of the AAD and National Psoriasis Foundation as well as the residency program director at Larkin Palm Springs in Miami. The two discuss psoriasis management and the utility of anti-TNF drugs. Dr. Glick emphasizes that TNF inhibitors remain a very important part of our psoriasis therapeutic armamentarium despite newer drugs coming to the market. About 30% of psoriasis patients will get psoriatic arthritis and TNF inhibitors are very effective at treating both skin and joint disease. In addition, TNF inhibitors are used to treat inflammatory bowel disease as well and are often selected by Dr. Glick to treat psoriasis if there is a family history of IBD. Dr. Glick provides several valuable tips on recognizing the most common signs and symptoms of psoriatic arthritis and quickly but effectively screening patients at every visit. He also discusses several common clinical scenarios and how to choose the right drug for the right patient. Finally, he provides his thoughts on biosimilars and how they stack up against their counterparts. Tune in to learn more from an accomplished psoriasis veteran! FINANCIAL DISCLOSURES: James Q. Del Rosso, DO CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Brad P. Glick, DO, MPH N/A

A Blast From The Past: Remembering the Importance of TNF Inhibition in Psoriatic Disease

In Episode 40 of Derms and Conditions, our host James Q. Del Rosso, DO sits down with Whitney A. High, MD, JD, a Professor of Dermatology and Pathology at the University of Colorado. The two discuss blastic plasmacytoid dendritic cell neoplasm (BPDCN), a highly aggressive and fatal malignancy that can be very challenging to diagnose.

In Episode 40 of Derms and Conditions, our host James Q. Del Rosso, DO sits down with Whitney A. High, MD, JD, a Professor of Dermatology and Pathology at the University of Colorado. The two discuss blastic plasmacytoid dendritic cell neoplasm (BPDCN), a highly aggressive and fatal malignancy that can be very challenging to diagnose.
Dermatologists are in a great position to make the initial diagnosis of this rare disease as it involves the skin in 80-90% of cases. Dr. High discusses several clinical pearls about BPDCN including how it presents, important considerations for the dermatopathologist, and the best techniques to biopsy the lesion in order to maximize diagnostic yield. Finally, he reviews the next steps in disease management once the diagnosis is made. Dermatologists can have a significant impact on patient outcomes with BPDCN by making the diagnosis early, so tune in to this episode to learn more! FINANCIAL DISCLOSURES: JAMES DEL ROSSO, DO: CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Whitney A. High, MD, JD No financial relationships to disclose&nbsp;

Bringing a Rare Disease to Light

In episode 39&nbsp;of&nbsp;Derms and Conditions, our host James Q. Del Rosso, DO sits down with Jennifer Cather, MD, a dermatologist and Medical Director at Mindful Dermatology and Modern Research Associates in Dallas, Texas. She and Dr. Del Rosso discuss the exciting new Mind.Px test that can noninvasively obtain a sample of a patient&rsquo;s transcriptome to help determine which biologic they will optimally respond to.

In episode 39&nbsp;of&nbsp;Derms and Conditions, our host James Q. Del Rosso, DO sits down with Jennifer Cather, MD, a dermatologist and Medical Director at Mindful Dermatology and Modern Research Associates in Dallas, Texas, and a good friend of Dr. Del Rosso.
Dr. Cather is an expert in psoriasis as she is currently managing over 1,700 patients on systemic therapy. She and Dr. Del Rosso discuss the exciting new Mind.Px test, a dermal biomarker patch developed by Mindera Health that can noninvasively obtain a sample of a patient&rsquo;s transcriptome to help determine which biologic they will optimally respond to. Dr. Cather describes how Mind.Px can limit trial-and-error through a targeted approach. Many patients lose faith in psoriasis medications after multiple treatment failures, so data from this test can uncover which drug class, either TNF-inhibitors, IL-17 inhibitors, or IL-23 inhibitors, will work best for them. Precision medicine is a hot new topic with a lot of new information to navigate, so tune in to this episode to learn Dr. Cather&rsquo;s tips on using the Mind.Px test to improve your psoriasis patients&rsquo; outcomes! FINANCIAL DISCLOSURES JAMES DEL ROSSO, DO: CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Jennifer Cather, MD 
CONSULTANT
Abbvie, Amgen, Lilly.

Even The Best Can Get Better:&nbsp; Observations From A Seasoned Veteran of Psoriasis Treatment

In Episode 38 of Derms and Conditions, our host James Q. Del Rosso, DO sits down with Chris Bunick, MD, PhD, an Associate Professor of Dermatology at Yale University. The two discuss the important topic of antibiotic stewardship in Dermatology.

In Episode 38 of Derms and Conditions, our host James Q. Del Rosso, DO sits down with Chris Bunick, MD, PhD, an Associate Professor of Dermatology at Yale University. The two discuss the important topic of antibiotic stewardship in Dermatology.
Dr. Bunick begins by sharing his unique background and how he became interested in structural biology and the way medications work at a molecular level. Once he discovered his passion for Dermatology, he turned his attention to understanding antibiotics and how resistance develops. In this episode, he reviews new data on the effects antibiotics have on our microbiome and overall health. He also discusses sarecycline and how its unique properties compared to other tetracyclines help limit resistance and adverse effects. Since Dermatologists prescribe more antibiotics than any other specialty, this is definitely an episode you won&rsquo;t want to miss! FINANCIAL DISCLOSURES JAMES DEL ROSSO, DO: CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). CHRIS BUNICK, MD, PhD: Chris Bunick, MD, PhD, has served as an investigator for Almirall; a consultant for AbbVie, Almirall, Arcutis, LEO Pharma, Sanofi-Regeneron, and UCB; and a speaker for and received honoraria from Allergan, Almirall, LEO Pharma, and UCB.

Can We Take The "Anti" Out of Antibiotic Use in Dermatology?

In episode 37 of&nbsp;Derms and Conditions, our host James Q. Del Rosso, DO sits down with April W. Armstrong, MD, MPH and David E. Cohen, MD, MPH live at Fall Clinical 2022 in Las Vegas, NV to discuss highlights from the meeting.

In episode 37 of Derms and Conditions, our host James Q. Del Rosso, DO sits down with April W. Armstrong, MD, MPH and David E. Cohen, MD, MPH live at Fall Clinical 2022 in Las Vegas, NV to discuss highlights from the meeting. This is a very unique episode of Derms and Conditions filled with clinical pearls for four conditions! Dr. Armstrong discusses two biologics that have great data for prurigo nodularis as well as a new topical JAK inhibitor for vitiligo. Dr. Cohen highlights some advances for atopic dermatitis while revealing the highly anticipated 2023 allergen of the year. Finally, the two share their thoughts on the landmark approval of deucravacitinib for psoriasis. Don&rsquo;t miss hearing our KOLs discuss its novel mechanism, efficaciousness, and safety profile so that you can confidently answer your patients&rsquo; questions about this new therapy. Tune in today! <img style="max-width: 100%; height: auto;" src="https://fchealth-assets.s3.amazonaws.com/episode37-DC-fc22.jpg" alt="Live Episode Recording at FC22" /> FINANCIAL DISCLOSURES: JAMES DEL ROSSO, DO: CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). DAVID COHEN, MD, MPH: Consultant and Honorarium: Ferndale Laboratories, Asana Medimetriks [past] Leo UCB Novartis Dermavant FSJ FIDE. (FIDE receives industry sponsorship from AbbVie, Almirall, Amgen, Arcutis, Bausch and Lomb, Bristol-Myers Squibb, Celgene Dermavant, Dermira, Janssen, Kyowa Hakko Kirin, LEO, Lilly, Novartis, Ortho Dermatologics, Pfizer, Sanofi Genzyme, Regeneron, Sun Pharma, UCB, Valeant) Cosmetic Ingredient Review (CIR) Stock or stock options: Dermira [past], Medimetriks [past], Brickell Biotech [past], Kadmon, Evommune, Timber Board of Directors: Kadmon, Timber, Evommune, Dermira-[Past] APRIL ARMSTRONG, MD, MPH: Research investigator and/or scientific advisor to AbbVie, Almirall, Arcutis, ASLAN, BI, BMS, EPI, Incyte, Leo, UCB, Janssen, Lilly, Nimbus, Novartis, Ortho Dermatologics, Sun, Dermavant, Dermira, Sanofi, Regeneron, Pfizer, and Modmed.

Highlights of Fall Clinical 2022: The Hits Just Keep On Coming!

You're listening to the Derms and Conditions podcast. So welcome to Derms and conditions. This is a live performance of derms and conditions we have, backed by popular demand, we did this, went to clinical meeting in Hawaii, and it was with April Armstrong and David Cohen, and they were so well received that we brought them back again. I have a funny feeling they might be a fixture, but they're certainly back for the second year. Now a message from our advertiser. Bristol Myers squib at last. So tick two, which is ducravacitinib, a new FDA approved treatment option. To learn more, visit www.sotictuhcp.com. That's spelled www.sotyktuhcp.com. So, April, I'm going to ask you to start off. What we do here is we look at highlights from the meeting, and April and David, throughout the meeting, they listen to different presentations and write down things that they really think are important and clinically relevant to you as dermatologists. So, April, what struck your fancy? Yeah, there are several areas that really caught my attention, and one thing is we have our new approval for pariegal nodulers, for example, with dupilumab, for patients with or without atopy. So that's very important. There's also the discussion of the nemolisumab data, phase three data, which looked great for paragonodularis as well. So I think those would be wonderful options for our patients with this very difficult to treat disease. David, anything that hit you as being clinically relevant and important? Well, I want to point out, having come to this meeting almost since the beginning, I cannot remember a period of time where we've packed so much new information into so short a period of time. Right. We have new approvals for atopic dermatites. We have two jack inhibitors, we have an il 13 inhibitor, we have two new topicals in psoriasis. We got a new topical in atopic dermatitis all in the last year. And it's really amazing that we're able to cover that all here. So I think those highlights are the big ones for me. And trying to sort of drink from the fire hose of information coming in that is so entirely clinically relevant. This is not theoretical stuff. This is going live in your office on Monday. Right. What really hits me is that two disease states that I've always found to be very difficult. And almost before I walk in the room, I feel badly, because I never really thought I was going to be able to do much to help people was vitaligo, and patients that had rapidly progressive or severe alopecia because it was so difficult to get these patients better. But we now have FDA approved treatments, treatments that have established efficacy. They have their benefits versus risks and certainly don't work in everyone, but it's great to have those advances. Yeah. And Simal Desai and pearl grimes covered it. I think they pretty much call this a historic time for vitiligo. Right. So I remember them highlighting, of course, topical ruxolitinib, which has been a major breakthrough. Twice daily, up to 10% of body surface area having real material and clinically relevant improvement, particularly on areas like head and neck, with some caution about expectations in April areas. Right. I think another thing I took home from them was don't forget about the other therapies that we've been using for a while, the topical corticosteroids, the topical tacrolimus, and, of course, phototherapy, all as adjunctive now to a brand new FDA approved topical medicine. Keeping in mind how long it might take for patients to get better, this is something that's a matter of months as opposed to a matter of weeks. Exactly. Right. So, April, let's come back to you. I'm sure you saw more things that you liked in the program. Yes, I saw a lot of things that I liked in the program, I think. And, Jim, you alluded to earlier regarding hair. Right. Hair disorders in alopecia ariata, we really dove deeply on the use of varicitinib. Two milligram, how one starts with two milligram, then go to four milligram if necessary. But also, very importantly, for those patients who may be on tofacitinib already, how do you transition them from tofacitinib to berry, which is very interesting. So perhaps for those patients who are getting results on TOFA, but to now transition to an FDA approved therapy, 1 may want to do it slowly so they don't get disappointed. Now, April, you've heard of psoriasis, right? You're familiar with psoriasis. Can you give us some information on new advances in psoriasis? Yes, very exciting new developments in psoriasis, first in the development of non steroidal medications. So we've seen the approval of topinorov, which is a non steroidal in psoriasis, as well as then following that, just a few months later, the approval also of a topical rofumalast. And what was shown is that now we have topical therapies that are non steroidal, much stronger in efficacy than the ones that we had before. Right. I feel comfortable saying that, because even though we don't have head to head data, we've observed the results with the previous treatments that were non steroidal compared to what we saw in these studies. And you feel very comfortable saying that they work faster and better than the previous ones? Well, you're right. We don't have head to heads. But what we do have with our prior therapies are clinical trials that harms with the steroid, with adjunctive therapy. And the differences between adding those non steroidals on were very marginal. These are demonstrative results compared to placebo and deltas, between placebo and active that we had not seen before with topical therapies. Both of those therapies that April mentioned really have notable efficacy once daily and in cream formats that patients could use on regular body sites. But they could put it on their face, they could put it in intriguinous areas, and it's going to work. And if any of the things that you hear about at the meeting, those are the ones that are going to be right out of the gate on Monday morning, you can go live on because of their ease of use. And if patients continue to use them, you're not concerned about how long they're using it or if they're putting it on a different area. In terms of side effects. One of the things that was interesting to me was when we think about oral Janus kinase inhibitors, right? They advances in atopic dermatitis and some other areas, alopecia areata. But one place where they've lagged behind until recently is in psoriasis, right? And some were even evaluated and were not approved for psoriasis. So it was interesting that when we saw decravacitinib get FDA approval, I think everybody was anticipating that the box warnings were going to be there, and it turned out that they're not. So what's behind that, in your mind, April, in terms of that difference? I think the difference is data. I think a decision was made that's evidence based. And what we see is that ducravacitinib has a very unique mechanism of action where it binds to the allosteric. It's an allosteric binding, so it really binds to distinct sites from where other jack inhibitors that we have may bind. And clinically, what we see is a profile, an efficacy profile that's superior to a premalass in this head to head evaluation, and also demonstrate a safety profile where we have really laboratory parameters similar to a premilas, as well as placebo. And I think this is a time. I think that's why the community is very excited. I think FDA recognized these features of the medication and being the once daily medication, an oral medication that needed no titration that patients can take with or without food. It really offers a significant new option in oral realm for our psoriasis patients and being metabolized by several different enzymes. We're not concerned about drug, drug interactions. Absolutely. I think April got exactly right and I don't think it would have been a surprise to anyone in this room or at that conference when there was welling anticipation on what the label was going to look like. Right. I mean, the jacks as a class are spectacularly efficacious, right. But they require patient selection and monitoring. And the question would be, would a tick two orally available medicine look like a jack label or not? And I think this was a perfect situation of really understanding the mechanism of the target that any company would look for and reverse engineering to specifically go after your target whilst not going after off target areas and worked. The question would be, would it deliver? And it did deliver. And we're looking at efficacies almost two x of what we were used to orally. Well, it had to go from the basic science that suggested this to turning out in the clinical studies, which is really what it did. Yeah. And I shall say I think that is a significant development for our other oral medications, such as a premalass, for example. We also saw discussion of the data in adolescent pediatric populations. And so I think that's interesting. That's great that we have more options for oral options for our younger patients as well. Well, it's nice to have different options. We know what a premolast does and what it doesn't do. And now we have another option to consider that we're learning about. And I think it's great. I think it is important to know that patients have to get a baseline tb test or it's recommended in the label they do and have periodic lipids tested, but you don't need a complete blood cell count. Every patient has to get liver enzymes or whatever. I'm going to take a break for a moment and we'll get back to our discussion. Let's pause for a message from our advertiser, Bristol Myers Squibb, who invites you to learn more about sotiktu, which is the kravacitinib, a new FDA approved treatment option, by visiting www.sotictuhcp.com. I'll spell it for you. Www.sotyktuhcp.com so, David, was there anything else in the meeting? That couple of things. Number one, we've spoken about some of them, but for the first time ever, we're seeing new drugs come on the market with active comparators. We never had that before. Right. We have jack inhibitors for atopic dermatitis with a comparator to the foundational biologic therapy, dupilumab. When did we ever get that kind of information before? And I really like the format you guys put together, putting Simal Desai and Ali Galan in a boxing match, going after each other, trying to figure out which drugs should you use for atopic dermatitis, jack inhibitors or biologic drugs? Well, I'm going to tell you that was my idea, and it was supposed to be me, but I got boxed out by Simal. So what are you going to do? Well, this guy's going to be president of the AAD. What are you going to do? So, April, any thoughts from you? Yes. So a few things. One is when we're looking at Hydranita Separativa, I think the big splash there is that we have data from Sekukinumab's pivotal studies, which showed that Q two week dosing of secucunumab worked well for patients with HS. The Q four week data, they show positive results in one of the two studies. So I think that is quite notable. I also love Dr. Elusky, Bonnie Elusky's talk in terms of minoxidil, right? Oral minoxidil, that's talk of the town. And she brought her own experience where you take the 2.5 milligram oral tablet, you cut it in quarters, give it a quarter of them, which is zero point 65 to start in women, and you use half, 1.25 to start in men, and then to see how they may do with that starting dose, and then decide whether to adjust that accordingly. So, David, we're waiting bated breath to hear about the allergen of the year. I know that's why most people come to full clinical. It's probably the only reason for some of them. And I will say for the last three years prior, we had some allergens of the year that were a little difficult to digest or to immediately take into clinic. But the 2023 allergen of the year was lanolin. It's going to be lanolin. Right. And I think the only people who know that right now are the people who attended fall clinical because it just kind of broke. And so Lanolin is derived from sheep. Sheep sebum. Right. And it's incredibly pervasive in personal care products. And the truth is, Lanol feels wonderful when it goes on irritated skin. It's a reason why it's been used for a really long time. The issue is, if we take a look at lanolin allergic patients, you tend to find a disproportionate number of them that have chilitis, lip dermatitis, dermatitis in their groin, in the anal area. And that's the time where the clinician takes a pause and say, we have some recalcitrant disease. It's not responding to some topical steroids. What may be fueling this, and it may be sometimes as simple as, let's pull back the lanolin product, let's continue our therapies, as we're doing before, and see if we can make some headway. So I think it was a wonderful allergen of the year and immediately actionable. What about the difference between lanolin and lanolin alcohol? Yeah, pretty much. Yeah, I know. So I think anytime you see on a package lanolin, lanolin alcohol, amarcol, wool, wax, wool alcohol, you're going to have to assume that's going to be lanolin based. The question on the degree of refinement is going to be so difficult clinically that I think you're just going to wind up avoiding that one for now. Right. But this is one of those allergens where you don't need to immediately go to patch testing on it. Now, one other caveat. Sometimes lanolin on intact skin, you're checking it on the anticubital faucet and nothing's happening, and you're making an assumption they're not allergic to it. That may be a little bit of a paradox. Lanolin can take a while to come on and a while to go away, and it tends to bother irritated skin. So one of the things I noticed before we wrap up is none of the highlights that either of you mentioned came from any of my presentations. I guess I'll have to do better next year. So I want to thank both of you for helping out with this. I think it's great. Great pearls for everyone. And so we'll end with now a message from our advertiser at last. So tick two, which is ducravisitinib, now approved as a treatment option by the Food and Drug Administration. Bristolmeyersquib invites you to learn more by visiting www.sotictuhcp.com, spelled www.sotyktuhcp.com, and for all of you out there. We're going to be coming around, and maybe you'll be lucky enough to get a derms and conditions hat, which we started. And April, I know you'll sport this extremely well. It's a derms and conditions shirt. Oh, thank you very much. Why don't you stand up and sport it? David, the same for you. Thank you. And Jim, your talks are highlights. My talks are highlights. Thank you, David. You made up for it. Thank you for listening to this episode of Derms and Conditions. If you have any questions or comments, please email us at podcasts at Fred Health. And most importantly, if you like this episode, subscribe to the Derms and Conditions podcast on Apple Podcasts or wherever you get your favorite shows. Thanks for joining us.

In episode 36 of&nbsp;Derms and Conditions, our host James Q. Del Rosso, DO sits down with Dr. Linda Stein-Gold, the Director of Dermatology Clinical Research and the Division Head of Dermatology at Henry Ford Health. The two discuss various topical treatment options in the management of psoriasis.

In episode 36 of Derms and Conditions, our host James Q. Del Rosso, DO sits down with Dr. Linda Stein-Gold, who is the Director of Dermatology Clinical Research and the Division Head of Dermatology at Henry Ford Health. The two discuss various topical treatment options in the management of psoriasis.
Dr. Stein-Gold begins by reiterating that despite the development of new systemic therapies, topical therapy remains a mainstay in psoriasis management. She discusses a new formulation of betamethasone dipropionate that uses an emollient spray to deliver the corticosteroid into the superficial aspects of the skin while limiting deeper penetration and systemic absorption. Another option to limit adverse effects is decreasing the concentration of the corticosteroid, and Dr. Stein-Gold describes a clinical trial that compared clobetasol 0.025% and 0.05% and showed that the lower concentration had similar efficacy but a much better safety profile. This episode is filled with clinical pearls for treating psoriasis and improving patient outcomes.

The Gold Standard of Topical Therapy in Psoriasis

In celebration of National Daughters Day on September 25, we have a special episode of&nbsp;Derms and Conditions! Our host James Q. Del Rosso, DO, sits down with Dee Anna Glaser, MD, and her two daughters, Katherine and Ella.

In celebration of National Daughters Day on September 25, we have a special episode of Derms and Conditions! Our host James Q. Del Rosso, DO, sits down with Dee Anna Glaser, MD, and her two daughters, Katherine and Ella. &nbsp; Many in the Dermatology community know Dr. Glaser as she is very involved at conferences and is a leader in hyperhidrosis. But many may not know that both of her daughters are also dermatologists. The three of them share their path to dermatology and how they independently discovered their passion for the field.&nbsp; &nbsp; In this episode we diverge from the usual discussion of clinical conditions and get a unique view into the Glasers&rsquo; family dynamic and the impact that dermatology has had on these brilliant women.

All in the Family: Keeping Up with the Glasers

In episode 34, host James Q. Del Rosso, DO sits down with Joslyn Sciacca Kirby, MD, MEd, MS, to discuss Hidradenitis Suppurativa and the difficulty that they, along with many Dermatologists, face in treating it.

In Episode 34 of&nbsp;Derms and Conditions, our host James Q. Del Rosso, DO sits down with Joslyn Sciacca Kirby, MD, MEd, MS, who is an Associate Professor of Dermatology at Penn State Health. The two discuss Hidradenitis Suppurativa and the difficulty that they, along with many Dermatologists, face in treating it. They begin by pointing out all of the treatment modalities that have historically been used and how some are still effective, while others should be retired, especially when facing severe or refractory disease. Dr.&nbsp;Kirby&nbsp;then shares some of her preferred topical and systemic therapies and how to select the right drug for the right patient. Finally, she relays that there is hope for the future in treating HS, as she personally participates in clinical trials for new monoclonal antibodies that have shown promising results. You don&rsquo;t want to miss this episode filled with pearls on treating one of the most stubborn dermatologic conditions. FINANCIAL DISCLOSURES JAMES DEL ROSSO, DO: CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Joslyn R. Sciacca Kirby, MD, MEd SPEAKER AbbVie GRANTS Incyte CONSULTANT AbbVie, Bayer, ChemoCentryx, InflaRx, Janssen, Moonlake, Novartis, UCB

The Story So Far: How One Thoughtful Dermatologist&nbsp;Is UnFOLDing the Challenges of "HS"

In episode 33 of&nbsp;Derms and Conditions, host James Q. Del Rosso, DO sits down with April W. Armstrong, MD, MPH, Professor of Dermatology and Associate Dean at the University of Southern California and discuss&nbsp;the different members of the JAK family and how they enhance different intracellular signals.

In episode 33 of Derms and Conditions, our host James Q. Del Rosso, DO sits down with April W. Armstrong, MD, MPH, Professor of Dermatology and Associate Dean at the University of Southern California. The two discuss the Janus tyrosine kinase (JAK) pathway and how JAK inhibitors have become a useful tool in treating several chronic dermatologic conditions. Dr. Armstrong notes that different members of the JAK family pair in different ways and therefore enhance different intracellular signals. In fact, these pairings are why certain JAK inhibitors are used for certain disease states and subsequently lead to a variety of adverse effects. Dr. Armstrong emphasizes the importance of knowing which JAK molecule the drug acts upon and the associated side effects for clinical monitoring. She highlights that one member of the JAK family, TYK2, can have a more targeted effect based on where the molecule is inhibited and therefore lead to fewer adverse effects. She discusses an example of a common case encountered in practice and some of the relative and absolute contraindications to starting a JAK inhibitor. You won&rsquo;t want to miss these important pearls that can help you navigate this complex but exciting area of therapeutics. JAMES DEL ROSSO, DO FINANCIAL DISCLOSURES: CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). APRIL ARMSTRONG, MD, MPH FINANCIAL DISCLOSURES: Research investigator and/or scientific advisor to AbbVie, Almirall, Arcutis, ASLAN, BI, BMS, EPI, Incyte, Leo, UCB, Janssen, Lilly, Nimbus, Novartis, Ortho Dermatologics, Sun, Dermavant, Dermira, Sanofi, Regeneron, Pfizer, and Modmed.

Fundamentals of JAK Inhibitors and What Makes Them TYK

In episode 32 of&nbsp;Derms and Conditions, James Q. Del Rosso, DO chats with Brad P. Glick, DO, MPH and they discuss the advantages of topical therapies and their pivotal role in managing chronic diseases, even in the setting of significant advances in targeted systemic therapy.

In episode 32 of Derms and Conditions, our host James Q. Del Rosso, DO, chats with Brad P. Glick, DO, MPH, the residency program director at Larkin Palm Springs in Miami. Dr. Glick and Dr. Del Rosso discuss the advantages of topical therapies and their pivotal role in managing chronic diseases, even in the setting of significant advances in targeted systemic therapy. Dr. Glick emphasizes that the adjunctive use of topical and systemic therapies is key to obtaining and maintaining clearance. Next, they discuss the new combination of betamethasone dipropionate and calcipotriene cream and the unique formulation used to deliver the two very different medications effectively and synergistically. Finally, Dr. Glick weighs in on the age-old debate: New York or Chicago-style pizza? You've got to hear this! FINANCIAL DISCLOSURES: James Q. Del Rosso, DO CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Brad P. Glick, DO, MPH N/A

A Topical Makeover: Taking Something Good and Making it Even Better

In this episode of Derms &amp; Conditions, James Q. Del Rosso, DO gleans up-to-date practical information on hair loss from Natasha Mesinkovska, MD, PhD, based on her extensive clinical and research experience in&nbsp;this area of dermatology.

In this episode of Derms &amp; Conditions, James Q. Del Rosso, DO gleans up-to-date practical information on hair loss from Natasha Mesinkovska, MD, PhD, based on her extensive clinical and research experience in this area of dermatology. Several entities and challenges are discussed with tips on both diagnosis and management. The latter half focuses on alopecia areata, including its relationships to both atopy and autoimmune disease. The episode concludes with how Dr. Mesinkovska integrates oral JAK inhibitors into her management plan. This discussion is loaded with pearls! FINANCIAL DISCLOSURES: James Q. Del Rosso, DO CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo).

Tying Up The Loose Ends With Managing Hair Loss: Practical Advice That Will Help Right Now

In Episode 30 of Derms and Conditions, host James Q. Del Rosso, DO speaks with Joseph Merola, MD, MMSc, a board certified rheumatologist and dermatologist. They discuss the diagnosis and management of cutaneous lupus and key diagnostic tips for psoriatic arthritis.

In Episode 30 of Derms and Conditions, host James Q. Del Rosso, DO speaks with Joseph Merola, MD, MMSc, a board certified rheumatologist and dermatologist who is an Associate Professor of Dermatology at Harvard Medical School. Dr. Merola and Dr. Del Rosso first discuss the diagnosis and management of cutaneous lupus with a special focus on drug-induced lupus. Next, Dr. Del Rosso asks Dr. Merola about dermatomyositis including tips on diagnosis and which laboratory tests are best to order. Finally, Dr. Merola ends the episode with a focus on psoriatic arthritis, including key diagnostic tips to help differentiate it from other arthritic disorders. FINANCIAL DISCLOSURES: James Q. Del Rosso, DO CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Joseph F. Merola, MD, MMSc Consultant/Investigator and/or Research funding&mdash;Amgen, BMS, Avotres, AbbVie, Dermavant, Eli Lilly, Novartis, Janssen, UCB, Sanofi, Regeneron, Biogen, Pfizer, Leo Pharma.

The Smartest One in the Rheum: A Conversation with Joseph Merola, MD, MMSc

In Episode 29 of Derms and Conditions, our host James Q. Del Rosso, DO speaks with Peter Lio, MD, about useful patient questionnaires that he uses in his practice, his use of the ADCT (Atopic Dermatitis Control Tool), and other impactful clinical pearls.

In Episode 29 of Derms and Conditions, our host James Q. Del Rosso, DO speaks with Peter Lio, MD, Clinical Assistant Professor of Dermatology and Pediatrics at Northwestern University in Chicago, IL. The episode begins with Dr. Del Rosso asking Dr. Lio about useful patient questionnaires that he uses in his practice. Dr. Lio then discusses his use of the ADCT (Atopic Dermatitis Control Tool) which helps assess the waxing/waning nature of the disease. Next, Dr. Lio discusses his use of alternative medications in dermatology and the criteria he uses for selection of these therapies. Specifically, the use of coconut oil is highlighted. Dr. Lio ends the episode by offering some tips on how to select the appropriate patient and properly counsel them on JAK Inhibitors for the treatment of Atopic Dermatitis. Finally, don't miss the ending where we learn about Dr Lio's passion for Pizza, his crust preference, and which pizza place in the US has 'changed his life'. FINANCIAL DISCLOSURES: James Q. Del Rosso, DO CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). PETER LIO, MD Speaker: Regeneron/Sanofi Genzyme, Pfizer, Eli Lilly, LEO, Galderma, and L'Oreal Advisory Board: Almirall, ASLAN Pharmaceuticals, Dermavant, Regeneron/Sanofi Genzyme, Pfizer, LEO Pharmaceuticals, AbbVie, Eli Lilly, Micreos, L'Oreal, Pierre-Fabre, Johnson &amp; Johnson, Level Ex, KPAway, Unilever, Menlo Therapeutics, Theraplex, IntraDerm, Exeltis, AOBiome, Altus Labs, Galderma, Verrica, Arbonne, Amyris, Bodewell, YobeeCare, Burt's Bees, My-Or Diagnostics, and Kimberly-Clark. Research: AOBiome, Regeneron/Sanofi Genzyme, and AbbVie Patent Holder: Theraplex AIM (Patent Pending) Stockholder: Micreos, YobeeCare, and Altus Labs, KPAway, LearnSkin

Thick or Thin? Lessons with Peter Lio on Atopic Dermatitis and Other Impactful Pearls

In Episode 28 of&nbsp;Derms and Conditions, our host James Q. Del Rosso, DO speaks with Ted Lain MD, MBA, about the business of dermatology and how dermatologists can become better educated in&nbsp;this area

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In Episode 28 of Derms and Conditions, our host James Q. Del Rosso, DO speaks with Ted Lain MD, MBA, who is the Chief Medical Officer at Sanova Dermatology. During this episode, Dr. Lain shares how he became interested in the business of dermatology early in his career, along with his consistent dedication to being a very knowledgeable and competent dermatologist. He offers some available resources for dermatologists who want to become better educated in the business area. The discussion emphasizes the central importance of quality patient care in any business model of dermatological practice. Finally, Dr. Lain offers some important tips and considerations for new dermatologists who are entering into practice. Financial Disclosures: James Q. Del Rosso, DO CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Ted Lain, MD, MBA None.
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Knowing the Business of Dermatology Involves More Than Just Being a Good Doctor: One Dermatologist Shares His Success Story

In Episode 27 of Derms and Conditions, James Q. Del Rosso, DO speaks with Gary Goldenberg, MD about precision medicine in the field of dermatology. Dr. Goldberg discusses his use of electric impedance spectroscopy technology on his decision to biopsy pigmented skin lesions that are suspicious for melanoma.

In Episode 27 of Derms and Conditions, our host James Q. Del Rosso, DO speaks with Gary Goldenberg, MD who is in Private Practice in New York, NY and serves as Assistant Clinical Professor of Dermatology at The Icahn School of Medicine at Mount Sinai Hospital. Dr. Del Rosso and Dr. Goldenberg spend the episode discussing precision medicine in the field of dermatology. Dr. Goldenberg discusses his use of electric impedance spectroscopy technology on his decision to biopsy pigmented skin lesions that are suspicious for melanoma. Next, Dr. Goldenberg discusses the use of precision medicine in helping to select the correct psoriasis biologic. Dr. Goldenberg stresses that precision medicine is a useful tool in dermatology but decisions must be made in conjunction with clinical judgment. The episode ends with Dr. Del Rosso highlighting some of the advantages precision medicine may have in selecting biologic medications for psoriasis. Financial Disclosures: James Q. Del Rosso, DO CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Gary Goldenberg, MD Consultant: AbbVie, Allergan, Amgen, ALMA, Almirall, Bayer, Castle Biosciences, Celgene, Dermira, Eclipse, Galderma, Genentech, GSK/Stiefel, Intraderm, ISDIN, Janssen, Leo, Menlo, Novartis, Pharaderm, Pfizer, Ranbaxy, Regeneron/Sanofi, Scibase, Suneva, TEVA, Valeant/Ortho Dermatologic, Verrica Speakers&rsquo; Bureau or Honoraria: AbbVie, ALMA, Bayer, Celgene, Dermira, LEO, Merz, Novartis, Pharmaderm, Pfizer, Regeneron/Sanofi Other Financial Benefit: BOD-Verrica

How Precision Medicine is Revolutionizing Dermatology

In Episode 26 of Derms and Conditions, our host James Q. Del Rosso, DO talks with board-certified dermatologist Sandra S. Lee, MD who is well known as &ldquo;Dr. Pimple Popper&rdquo;, a global social media and television star.

In Episode 26 of Derms and Conditions, our host James Q. Del Rosso, DO talks with board-certified dermatologist Sandra S. Lee, MD who is well known as &ldquo;Dr. Pimple Popper&rdquo;, a global social media and television star. Dr. Del Rosso starts by asking Dr. Lee about her family background related to dermatology. The discussion moves to later in her career when, as a practicing dermatologist, she fortuitously found her way within the world of being a "star" on social media and TV. While Dr. Lee embraced this opportunity, it was not without its challenges. Dr. Lee addresses how she controlled blending her media life and image with her active dermatology practice and how she dealt with certain challenges and criticisms that she faced along the way. Their discussion concludes with highlighting an important area of education in office-based surgery that Dr. Lee is passionate about: practical and effective use of tumescent anesthesia by dermatologic surgeons for large surgical excisions. FINANCIAL DISCLOSURES: JAMES DEL ROSSO, DO: CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). SANDRA S. LEE: N/A

Beyond the "Pimple Popper" Persona: A Closer Look at Sandra Lee, MD

In Episode 25 of Derms and Conditions, our host James Q. Del Rosso, DO speaks with Leon H. Kircik, MD about topical therapies for psoriasis and why vehicle matters.

In Episode 25 of&nbsp;Derms and Conditions, our host James Q. Del Rosso, DO speaks with Leon H. Kircik, MD, a Clinical Professor of Dermatology at the Icahn School of Medicine at Mount Sinai in New York City who also has a private practice in Louisville, Kentucky. Throughout the episode, Drs. Del Rosso and Kircik discuss topical therapy of psoriasis. Specifically, Dr. Kircik highlights why the vehicle matters when choosing a topical therapy and why topical therapy is still important in the current clinical landscape. Additionally, Drs. Del Rosso and Kircik discuss different formulations of topical therapies along with their advantages and disadvantages. 
Financial Disclosures:
 JAMES DEL ROSSO, DO:&nbsp;
CONSULTANT/ADVISOR&nbsp;
Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo)&nbsp;
SPEAKER BUREAU&nbsp;
Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo)&nbsp;
RESEARCH INVESTIGATOR&nbsp;
Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo).&nbsp;
 LEON KIRCIK, MD
CONSULTANT/ADVISOR&nbsp;
Abbvie, Allergan, Inc., Almirall, Amgen, Inc., Arcutis, Biogen-Idec, BMS, Celgene, Cipher, Connetics Corporation, Dermavant, Dermira, Dr. Reddy&rsquo;s Lab, Eli Lilly, Galderma, Genentech, Inc., GlaxoSmithKline, PLC, Johnson &amp; Johnson, Leo, Merck, Novartis AG, Promius, Stiefel Laboratories, Inc., Sun Pharma, Taro, UCB, Valeant Pharmaceuticals Intl.
SPEAKER BUREAU&nbsp;
Abbott Laboratories, Allergan, Inc., Almirall, Amgen, Inc., Cipher, Connetics Corporation, Dermavant, Dermira, Eli Lilly, Galderma, Genentech, Inc., GlaxoSmithKline, PLC, Johnson &amp; Johnson, Leo, PharmaDerm, Serono (Merck Serono International SA), Stiefel Laboratories, Inc., Sun Pharma, Taro, UCB, Valeant Pharmaceuticals Intl.
RESEARCH INVESTIGATOR&nbsp;
Abbvie, Allergan, Inc., Almirall, Amgen, Inc., Arcutis, BMS, Boehringer-Ingleheim, Breckinridge Pharma, Celgene, Centocor, Inc., Cellceutix, Combinatrix, Connetics Corporation, Coria, Dermavant, Dermira, Dow Pharmaceutical Sciences, Inc., Dr. Reddy&rsquo;s Lab, Eli Lilly, Galderma, Genentech, Inc., GlaxoSmithKline, PLC, Idera, Johnson &amp; Johnson, Leo, Maruho, Merck, Medicis Pharmaceutical Corp., Novartis AG, Promius, PharmaDerm, Pfizer, Stiefel Laboratories, Inc., Sun Pharma, UCB, Valeant Pharmaceuticals Intl., XenoPort.

Finding the Right Formula with Topical Corticosteroid Therapy

In Episode 24 of Derms and Conditions, our host James Q. Del Rosso, DO talks with Julie C. Harper, MD who is in private practice in Birmingham, AL and is a recent past-President of the American Acne and Rosacea Society. Dr. Del Rosso and Dr. Harper spend the episode discussing important considerations in the diagnosis and treatment of rosacea.

In Episode 24 of Derms and Conditions, our host James Q. Del Rosso, DO talks with Julie C. Harper, MD who is in private practice in Birmingham, AL and is a recent past-President of the American Acne and Rosacea Society. Dr. Del Rosso and Dr. Harper spend the episode discussing important considerations in the diagnosis and treatment of rosacea. Emphasis is placed on noting the sources of facial redness in rosacea so that treatment selection can be optimized. Dr. Harper includes practical tips for treating a rosacea patient who presents with both persistent facial erythema and papules/pustules and concludes the episodes presenting her "STOP" mnemonic when seeing a rosacea patient in the office.&nbsp; &nbsp; Financial Disclosures: JAMES DEL ROSSO, DO:&nbsp; CONSULTANT/ADVISOR&nbsp; Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo)&nbsp; SPEAKER BUREAU&nbsp; Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo)&nbsp; RESEARCH INVESTIGATOR&nbsp; Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo).&nbsp; JULIE C. HARPER, MD&nbsp; Grant/Research Support:&nbsp; Almirall&nbsp; Consultant:&nbsp; Almirall, Cutera, EPI, Galderma, LaRoche Posay, Ortho, Sun, Vyne&nbsp; Speakers&rsquo; Bureau or Honoraria:&nbsp; Almirall, EPI, Galderma, Journey, Ortho, Sun, Vyne

How Can You Stop Seeing Red When Facing Up To Rosacea?

In Episode 23 of Derms and Conditions, our host James Q. Del Rosso, DO talks with Patricia Farris, MD who is in practice in Old Metairie, Louisiana. Dr. Farris talks about building a successful aesthetic dermatology practice, selling skincare products, and offers tips on office dynamics.

In Episode 23 of Derms and Conditions, our host James Q. Del Rosso, DO talks with Patricia Farris, MD who is in practice in Old Metairie, Louisiana. Dr. Farris begins the episode discussing tips on how to build a successful aesthetic dermatology practice. She also offers helpful tips on office dynamics. Dr. Del Rosso asks Dr. Farris to give some advice on how to sell skin care products in a clinical practice setting. The episode ends with Dr. Farris discussing important considerations when selling a dermatology practice to a private equity group. FINANCIAL DISCLOSURES: JAMES DEL ROSSO, DO: CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). PATRICIA FARRIS, MD: Co-founder of RegimenMD and serves as a consultant and/or advisory board member for Neutrogena, Neostrata, Skinceuticals, Fig-1 Skincare, Nutraceutical Wellness, and U.SK Under Skin.

What Type Of Practice Is Right For You?

In Episode 22 of Derms and Conditions, our host James Q. Del Rosso, DO talks to Nicholas Brownstone, MD who is a fellow at the National Society for Cutaneous Medicine and managing editor of SKIN: The Journal of Cutaneous Medicine.

In Episode 22 of Derms and Conditions, our host James Q. Del Rosso, DO talks to Nicholas Brownstone, MD who is a fellow at the National Society for Cutaneous Medicine and managing editor of SKIN: The Journal of Cutaneous Medicine. Dr. Brownstone presents some helpful information about SKIN and highlights the benefits that it can provide to the busy, practicing dermatologist. Dr. Del Rosso asks Dr. Brownstone to review some key articles in the journal's history which includes topics such as "maskne" and the effect of diet on hidradenitis suppurativa. Dr. Brownstone spends the next part of the episode discussing his recent clinical management recommendations article on delusions of parasitosis. He offers some tips and tricks to help dermatologists manage these often difficult patients. Finally, the episode ends with Dr. Brownstone discussing some exciting new updates with the journal. This is an episode you won't want to miss! Resources/Links: Maskne: Exacerbation or Eruption of Acne During the COVID-19 Pandemic <a href="https://jofskin.org/index.php/skin/article/view/953" target="_blank">https://jofskin.org/index.php/skin/article/view/953</a> Nutrition Education Toolbox for Hidradenitis Suppurativa <a href="https://jofskin.org/index.php/skin/article/view/1207" target="_blank">https://jofskin.org/index.php/skin/article/view/1207</a> Best Practices for Management of Delusions of Parasitosis <a href="https://jofskin.org/index.php/skin/article/view/1346" target="_blank">https://jofskin.org/index.php/skin/article/view/1346</a> FINANCIAL DISCLOSURES: JAMES DEL ROSSO, DO: CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Nicholas Brownstone, MD None.

How to Win with SKIN

You're listening to the Derms and Conditions podcast. Hello, everyone, and welcome to another great episode of Derms and Conditions. And I have with me just a great guy. Hi. I'd like to say he's a great fellow. His name is Dr. Nick Brownstone. He's based in New York City. He is a melanoma fellow at the National Society of Cutaneous Medicine. And I'll spare you my introduction and get right to talking to, you know, Nick, tell us what you're doing and how you got to this position of melanoma fellow in New York and some of the exciting things you're working on. Thank you, Dr. Del Rosso. First of all, it's great to be here. I'm a big fan of the podcast. I listen every week, and it gives me great tips that I can use the next day in the clinic. So thank you for being a great host. Really happy to be here today. I'm currently a melanoma and skin cancer fellow with Dr. Darryl Regal in New York, New York. And I get to do a lot of really neat things, treat skin cancers in clinic, perform clinical research and clinical trials. And one of the most interesting things is serving as the managing editor of Skin, the Journal of Cutaneous Medicine, which you're one of the editors in chief of. So can you talk to us about? Is there anything new that's any breakthrough that we need to know as clinicians that are practical in the clinic with melanoma? Most of the articles that we've been publishing in skin revolve around all different types of disease states, and melanoma is definitely one of them. And there's been a lot of interesting articles talking about genomic testing for melanoma. And, in fact, me and my colleagues will be writing a clinical management recommendations in the upcoming issue, helping clinicians to integrate these tests into their practice. So what that's going to do is the clinicians that aren't necessarily spending every day or a lot of their days on just this area can go to that article and get some practical information on how they can apply it in their clinical practices and when it will be applicable and when it may not be helpful. So that sounds like it's going to be a very welcome article. That's right. One of the best things about skin, and I really want to take this episode for the listeners to really let them know how they could use skin in their practice and how it could help them on a daily basis. And one of the best things about skin is these clinical management recommendations, which is always the first article of each issue, and again, we have a kol in the field write about a couple pages on a very salient topic within the dermatology community. For example, melanom and genetic testing, or the most recent one was treatment of psoriasis. Beyond biologic therapy, which is a very popular topic. It gives some tips on things other than the biologics, because we hear a lot about the biologics. But you mentioned an interesting acronym, KOL, which I believe stands for key opinion leader. But I always thought of it as you could keep them on the list, or if they don't quite cut it, you could kick them off the, you know, they better do a good job when they put that article together. Otherwise, Nick Brownstone, they're going to get the cut, right, Nick? Well, kol to me means keeping them off the list, so you better behave. Otherwise you're off the list. That's right. Exactly. So let's talk about some of the articles in skin. I got an opportunity to review some of them for a presentation. And can you highlight some of the articles that you felt were the most meaningful or very meaningful to clinicians? Yeah, I'd be happy to. The goal of skin is to rapidly disseminate dermatological information, both new information and information that's been taught before. But we want to re highlight one of the most popular articles we had in the history of the journal was an article on mask knee during the Covid-19 pandemic. It was a short article, but it just reviewed some of the salient points regarding the pathophysiology and etiology of acne and some ways to treat it. Really well received. The second article, too, which I thought was really unique and interesting, was entitled Nutrition Education toolbox for hydrogenized suppertiva. And this was in the May 2021 issue. And what the authors did is they provided tools for both physicians and patients to facilitate evidencebased nutrition education in HS through collaboration with dermatologists, registered dietitians, and a culinary specialist. So a really unique collection of individuals. And in this article, they looked at foods to avoid and reviewed the evidence. For example, they discussed that refined carbohydrates could lead to hyperinsulinemia, which may exacerbate a follicular occlusion in hydratinitis. So again, a really practical and highly received article. What I liked about that article was when you have someone come in and a lot of the patients with hydratinitis suprativa are overweight, and it can be somewhat a sensitive issue to be talking to somebody about that without making them feel like you're putting them down or weight is a sensitive subject for a lot of people, and doing it as a clinician as a means of trying to help them get their condition better without making them feel overly sensitive or embarrassed about it. The patient feel embarrassed about it. What I liked about it is there were some excellent handouts in that article that the reader can print out and utilize in their practice, and I found that many of them were very well written. So it was practical from that standpoint. The handouts in that article I thought were fantastic. So I wanted to make sure that you get that information out there, because there was extremely practical article on an area that we and clinicians, we're focusing on. What treatment do we use? What therapies have they had? Should we get them started on a biologic agent? We're thinking about it in that classic medical perspective, but they were practical areas that even our staff can sit down and discuss with these patients. Right. A diet and dermatology is obviously a very big field. Patients come in, they ask about diet and acne, they ask about diet and psoriasis, even diet and atopic dermatitis. So I think these issues are great issues to bring up, and we definitely need more studies for these types of things. So what about some of the other articles? Because you're digging into it and going through them and helping put that journal together, which people see the final copy. But there's so much work behind any of the journals out there in the information that gets in there just to mistypos, little typographical errors. When you're trying to proofread something is challenging. And so are there any other articles that really stood out to you? Yeah, there's a lot of articles, a lot of great information being published in this journal. The journal is published bimonthly, which means every other month. One article I'd like to highlight is actually an article that I wrote, and it got really great comments on it. I had done some previous training at UCSF in inflammatory skin disease. One of my mentors was Dr. John Ku, who's board certified in both psychiatry and dermatology. And we did a lot of work together on delusions of parasitosis or Morgellon's disease. So one of the articles that I wrote, and this was in the September 2021 issue, as the clinical management recommendations was best practices for management of delusions of parasitosis. And it really helps physicians in, really, I would say a couple of pages, become more comfortable working with these patients, because building rapport and not making them upset is really the most important thing with these types of encounters. I think a lot of clinicians in their mind are thinking, how do I manage this? And you almost want to back away from it, right? You feel badly feeling that way, but that's not the kind of patient that many dermatologists want to see in their practice, admittedly, because they struggle with managing it and they struggle with telling the patient, I think you need to see a psychiatrist and the patient getting angry and that sort of thing. So are there practical recommendations in that article? Can you give me an example of one of the practical recommendations? Absolutely. And it's absolutely correct what you said. The issue is that you turn down the patient, don't want to see the patient, it's fine. But then they're going to end up in your colleague's office, and these patients kind of bounce around in the community. So really, with just a few simple management techniques, we could really improve the care of all these patients. And really with these patients, the key is to just listen to them and be empathetic and tell them that I don't know what's causing this disease. Okay. I can't tell you. If you want to see a parasitologist, entomologist, that's fine, but I have something that can help you. And if you're willing to engage in a trial and error, a medication regimen with me, I'm pretty sure I can cure you. And of course, in the article, we discussed the medications, namely pemizide, which is really effective for this condition. And the most important thing about pemizide is it has no fda us psychiatric indication. So the patients uniquely accept this type of therapy. And in my experience, after seeing these patients every week for about two years, it really leads to a cure. Are there any particular adverse effects or drug interactions? Because it's not a drug that we write often. And myself, if I'm writing a medication or prescribing a medication that I haven't used a lot, I don't want to miss something that's going to harm the patient. So what suggestions do you have about that? Another really good point to bring up. Luckily, Pimazot is a really safe medication. It's technically considered a first generation antipsychotic. But in my experience, in Dr. Ku's over 30 years experience, he's rarely had any significant side effects. You should, in older patients, get an EKG to make sure there's no QT prolongation. And then after you start the medication, there's really? Really. No major side effects. Maybe a little bit of restlessness, a little bit of tiredness, and you can have them take the medication in the morning or at night because of that. And it's extremely, extremely rare. But the feared complication is tardive dyskinesia, which was thought to be irreversible. This is, of course, uncontrollable movements of the head, neck, arms and legs. Dr. Ku and I performed a worldwide literature search, and we couldn't find one case that was directly caused by pymizide for delusional parasitosis resulting in tartar dyskinesia. In fact, to make clinicians even more comfortable for the first time ever, two new medications have recently come out that are now treatments for tardive dyskinesia, which should help clinicians feel more comfortable prescribing the medication in the first place. Right. So if the patient does happen to develop it, there are some treatments. We don't want the patient to have the problem in the first place, but they have a significant problem that you're treating. And so if you leave that delusions of parasitosis there, how often, let's say you have a patient with delusions of parasitosis that goes on and on to different clinicians or different. They seek help in different areas, and they don't get that help. What happens to them? They keep going around to different clinicians, to entomologists, parasitologists, infectious disease, until somebody can give them an answer that they want to hear. Sometimes all they want to hear is that their problem is being caused by a parasite. And we, as physicians, obviously can't tell them that's the case, because it's not. But one trick that works really well is to minimize the etiology and maximize the fact that this problem is making their life a living hell. And if we focus on that, we want to get their life back on track, then we can kind of get the patients more on our side and accepting of therapy. Is this the type of patient that is going to get so frustrated they're going to harm themselves or they're going to become suicidal, or do they just keep going on and on and on on this hamster wheel? In very, very rare cases, the patient may feel suicidal, but I have not seen that personally. And Dr. Koop, maybe a couple of times in his career, his 30 year career, seen these patients, have seen a patient who was suicidal from it. But what the patients do do is they will take the time to write to physician governing bodies, complaining about the care that they got. And a lot of times, physicians these days are community rated in terms of their reimbursement, where if their scores fall below their colleagues, they may get dinged financially. So it's another reason why, let's say you don't want to take care of these patients, which is fine. You really should know how some basic tips to handle them so not to be penalized financially, right? Yeah. We're getting hit from all different directions. Who's going to take care of us when we go and say, I'm depressed about getting dinged when I didn't deserve it? That's a story for another day. That's a whole nother podcast. That's a whole nother podcast. So I know that you said that I asked some really good questions and made some great observations. Did that surprise you that Jim del Rosso did that, Nick? Not surprised at all. Not surprised at all. So what's next for Nick Brownstone? Before we wrap up today, do you have something you're working on now with Dr. Regal or with someone else? Because you obviously got very motivated to put out some really good information out there for, you know, I want to take these last few minutes to wrap up and just let you know about the exciting stuff we have going on with skin. We introduced two new sections to the journal. One is called skim images, clinical images, and dermatology. And what this is is a picture of a unique, interesting, or rare dermatological disease. And we really want the submitter to really highlight why this is essential to the journal's readership. What can be learned of it, whether it's a rare disease or a disease that was rare, that's now becoming popular again in today's society. And the next one is dermatological dilemmas, which is an academic style. Grand rounds where someone with a very difficult patient case submits the patient history and asks a couple of questions that we have a key opinion leader answer. And so I think that'll be a really nice part of the journal, too. I don't think any other journal really has a section like that. There are some case studies and things, but we all have those challenging cases that stop us in the course of the day and we all struggle with. So it will be nice to see that you had something else you wanted to wrap up. Yeah. Two more quick things. One is we've really expanded the resident fellow board, the medical student board, and we have an undergraduate student on our board, too, because Skin is really committed to education, and I'm working with the residents and fellows mentoring the medical students and the undergraduate student to teach them how to perform high quality article reviews. And the last thing I'll say before I get wrapped up here is we're going to introduce something called the looking forward to yesterday's series in skin. We have so much great information that's been published in the past, and I want the readers to reengage with these articles. So what we're going to do, starting probably in January, is when the new issue is released. We're going to have about a five question quiz, and the answers will come from the old issues, and the first person who responds correctly will win a gift card. And my hope is that readers will look at the old issues and say, oh, this article is interesting. I didn't see it there. I'm going to go ahead and read this now and learn something new. I think that's fantastic because we have these piles of journals now. We do a lot of things online, obviously, but they sort of sit there, and in those journals there's a lot of great information that's often forgotten. So I think that's great. I think your excitement is actually getting me all excited. I feel like I'm being a little bit too lazy lately. I got to go out there and start reading some of those old journals again. So thanks a lot, Nick. If I can help you in any way, be sure to reach out. And it's very exciting what you're doing with skin and with the other things that you're working on. You really are a good fellow. I'll have to tell Daryl about that. I appreciate that. And yeah, again, really happy to be on the podcast. Thanks for the opportunity. If I have my own podcast one day, I think you'll be the first guest of honor. Well, I would be honored to be part of your podcast series. So anyway, take care. And I want to thank our listeners for listening, and I hope you get an opportunity to look over skin and even contribute to some of the ways that Nick Brownstone's talked about. Thank you. Thank you for listening to this episode of Derms and Conditions. If you have any questions or comments, please email us at podcasts at Fred Health and most importantly, if you like this episode, subscribe to the Derms and Conditions podcast on Apple Podcasts or wherever you get your favorite shows. Thanks for joining us.

In episode 21 of Derms and Conditions, our host James Q. Del Rosso, DO speaks with Mark Lebwohl, MD, Dean for Clinical Therapeutics and&nbsp;Chairman Emeritus at Icahn School of Medicine at Mount Sinai. Dr. Lebwohl discusses field treatments of actinic keratosis (AK).

In episode 21 of Derms and Conditions, our host James Q. Del Rosso, DO speaks with Mark Lebwohl, MD, Dean for Clinical Therapeutics and&nbsp;Chairman Emeritus at Icahn School of Medicine at Mount Sinai. Dr. Lebwohl discusses field treatments of actinic keratosis (AK). He also discusses the benefits and disadvantages of imiquimod, 5-FU and tirbanibulin. Specifically, the anticipated reactions of topical AK treatments are highlighted. Advice on medication coverage is discussed next. After the patient receives the medication, Dr. Lebwohl ends the episode by giving some tips on treatment with topical AK therapies. FINANCIAL DISCLOSURES: JAMES DEL ROSSO, DO: CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Mark Lebwohl, MD Mark Lebwohl is an employee of Mount Sinai and receives research funds from: Abbvie, Amgen, Arcutis, Boehringer Ingelheim, Dermavant Sciences, Eli Lilly, Incyte, Janssen Research &amp; Development, LLC, Leo Pharmaceuticals, Ortho Dermatologics, Pfizer, and UCB, Inc. Dr. Lebwohl is also a consultant for Aditum Bio, Allergan, Almirall, Arcutis, Inc., Avotres Therapeutics, BirchBioMed lnc. BMD Skincare, Inc., Boehringer-Ingelheim, Bristol-Myers Squibb, Cara Therapeutics, Castle Biosciences, Corrona, Dermavant Sciences, EMD Serono, Evelo Biosciences, Facilitation of International Dermatology Education, Foundation for Research and Education in Dermatology, Helsinn Therapeutics, Inozyme Pharma, Kyowa Kirin, LEO Pharma, Meiji Seika Pharma, Menlo, Mitsubishi, Neuroderm, Pfizer, Promius/Dr. Reddy's Laboratories, Theravance, and Verrica.

When Cryotherapy Alone Gets Too Cold: Topical Field Therapy for Actinic Keratoses

This episode is sponsored by Almerals and Conditions podcast. Hello, everyone, and welcome today to another edition of Derms and Conditions. And I'm very excited. We have a powerhouse in dermatology today, a colleague and great friend, Dr. Mark Leball, who's a leader in dermatology, practicing dermatology, teaching dermatology. So we're going to have a great program today. And Mark is dean for clinical therapeutics at the Icon School of Medicine at Mount Sinai in New York City and chair emeritus of dermatology. So, Mark, emeritus means you're pretty smart, right? So we'll have a good program. Mean, it's the first time I've been introduced as a powerhouse, but that's probably because I'm here in my sweatsuit lifting, you know, you're pumping up. So we're going to talk about actinocaratosis today, Mark, and obviously, I know you've been involved in research over the years. Everybody thinks about you with psoriasis and skin turnal medicine and that sort of thing. But you've done a lot, did a lot of teaching and publications on ectenocytosis. So how do you look at the landscape right now with where we are with field therapies? Because we obviously know we have targeted therapies and directed therapies like cryotherapy, which treats a lesion that we can see. But let's focus more on field therapies for actinocaritosis, how you integrate them and how you see the landscape. Sure. Let me say by way of introduction, even though psoriasis is my main area of research, probably the diagnosis I see most often is actinocaratosis. It's just incredibly common. And, in fact, decades ago, we were the first to treat actinocaratosis with Amikamod. It was one of my early publications, and I vividly remember I was actually the first patient to use it for an actinocaratosis on myself. And I told our dean at the time, who gave me permission to tell the story and use his name, but he know lots of actinocaratosis and many squamous cell carcinomas, and he would have multiple squamous cells a year. And he asked me for some samples. And back then at Mount Sinai, we could give out samples. We still actually can. We figured out how to do that. But I gave him some samples, and he calls me four weeks later and he know, I think you better take a look at that. And he was using it every day as I was as well. And it worked quickly. When you use it every day. But his whole scalp was one boggy, oozing crust and he did not get another squamousil or actinic for five years. And so we knew we were onto something. We then did a bilateral comparison trial, showed dramatic differences, and ultimately published a multicenter trial, which then led to approval for AKS. The pharmaceutical company that made it three m at the time had sales and its use for genital warts had sales of about, I think it was twelve and a half million dollars a year. A year after it got approved for aks, it was 250,000,000. So it was really a boon to them, but really a boon to our patients. Very good treatment for aks. We then published the New England Journal article on picato. Ever since then, we've had a major interest in aks. So you asked me about field therapies, and as you know, the most common field therapy used is not a field therapy, it's a treatment of individual lesions, and that's cryotherapy. And I don't think that it is just because it's reimbursed extra by Medicare. I think it's because it's easy. It's in everybody's office, it takes a few seconds and you focus on a single lesion so you don't have to warn the patient about some bad reaction they're going to get all over. The problem with field therapy is with individual lesion therapy, is that you are getting rid of that lesion temporarily. The recurrence rate is very high and the patient's going to crop up with a new AK right next to it. So I think my use of cryotherapy is perhaps a little more limited than most, but I use cryotherapy like everybody else does. The field therapies that we use are a couple of the ones we just mentioned. Picado is not available anymore because there are a number of reasons, but I think there was a somewhat unfair New England Journal of Medicine article which almost said it didn't work. Compared to Amicomod, PDT and five fu, the treatment used most widely, although not by much more than a Michel mod, is five fu. It's used twice a day, it's approved for four weeks and I use it for four weeks. If you use it for two weeks, you're not going to get as good a response. And what those patients have in common is an awful reaction. And when you get that awful reaction, the patients actually do well. The recurrence rate know, certainly in my experience, not what the New England Journal reported. But they cheated in that article because they allowed the patients to spot treat with cryotherapy and other treatments in the follow up period for that study. But the recurrence rates, in my view, are similar between five fluorior, amiquamod, which also gives a bad reaction. And the two have in common the amiquamod and the five fu, is that they go on for many weeks. So the patients are always kind of irritated and not doing well. Diclofenac, which has the brand name solarase, is much gentler. It's used twice a day for three months, but it's less effective. I think that PDT has a major advantage in that it's given once the patients get a bad reaction, which lasts a week or maybe a little longer than a week, but then that's gone and you're done with it. And it also has a very good response. Many of the people who use it repeat it several times a year to maintain that response. But it is a treatment I use often as well. And most recently we have turbinibulin, which is a treatment I really like because it is much less irritating than, for example, picado, or five fu, actually, than all of the treatments that we have, except diclofenac, which is very gentle but less effective. It has efficacy rates that are as good as any of the treatments I just mentioned, but with much less irritation. So the patients are over it in five days and are pretty happy with it. They use it, they apply it for five days. They have usually milder reactions because it's more of an effect on the apoptosis, not as much cytokine release and stimulating inflammation. I mean, we know with five of you being chemotherapeutic, you expect to get that reaction because of the mechanism, and it tends to be more painful than the other treatments. I agree with you. If you sure change, and there's data to show if they use it for less of a duration, they don't go the full four weeks, their response rate goes down. So I had a patient, too, like yours, mark, that when I first saw him, he had such extensive involvement on his scalp with ectinocaratosis, had some thicker areas. I first was going to biopsy, thinking, oh, some of these might be SCC incitu or something. Then I thought about it and said, what am I going to do with it? Anyway, there's no end to this. I treated them with the Michelamod and he came back, and that time it was three times a week. I had him do it. He did it for about a month, and he had such a brisk reaction. It wasn't extremely painful. It was uncomfortable. But once he cleared, he didn't have anything for the few years after that that I saw him. So getting that reaction with a Mikwamod is helpful. It's just a lot for people to go through, and you have to have the downtime, especially if it's an exposed area. With tuberenobulin, the reactions are seen maybe after about seven days, and they're usually gone within one to two weeks, similar to ingenl mebutate, Picado, which you mentioned. But I think Picado got some more brisk reactions than to Beolin. What's your feeling about that? Yeah, I'm actually giving a lecture on that, where we line up the phase three results of the two drugs. And, in fact, ingenl mebutate, which was a favorite drug of mine, I used it a lot, and the reason I liked it, it was you got it over with quickly. So a lot of my patients who work in public positions, or some of them are on television or they interact with people every day, can't take six weeks off or four weeks off to go through imicomat or five fluorocyl. And so ingeal mebutate was a perfect drug for them. Turbinibulin has even less irritation than ingenl mebutate, and that comes across very clearly when you line up the local skin reactions from the two, phase three, pivotal trials. It's a very well tolerated drug and a very effective drug. I've had patients who have been on all the treatments and clearly prefer that. And very recently, I had a patient who, because of the cost of it, asked to be given five fu. He came back to me and he said, I'm never going back to five fu. I'm going to spend the money on turbine abulin. That's another issue, by the way, because you go to one drugstore and it's $1,200, you go to another drugstore and it's $25. So it has some of the Medicare issues where they don't necessarily honor coupons unless the pharmacy has an arrangement with the company that makes it. A lot of the insurance companies don't want to pay for turbanibulin because they have not agreed to get a big discount or rebate. And the company instead makes it to a local pharmacy that will sell it at a huge discount. So specialty pharmacies in that situation, rather than randomly selecting a pharmacy. So, Mark, we're going to take a break at the moment. We're certainly going to get back to this because we're in the heat of the discussion for a word from our sponsor. We would like to thank Almeral for being today's sponsor. So, Mark, now we're at a very important part of our discussion is you get the prescription for the patient. I agree with you. Patients only have to apply the tobanobulin. It comes in the sachets. They could spread easily over the cosmetic unit or the anatomic unit that they're treating, the scalp, the know where the drug is FDA approved once a day for five days, and then they're done with what they have to actively do. And then they just ride it out, usually with not much visible. If it is, it's certainly less than what we see with five fu, typically with a micromod, and even with ingenl mebutate. So the downtime is a lot less. But they have to be able to get it. And in my experience, if they just take the prescription, or nowadays we don't have a prescription pad, we have a suggestion that we make, right? We go through the EMR, and it's just randomly to a pharmacy that they want us to send it to. They're often going to run into problems with being told it's not covered, it's out of stock, it's $1,000 or $800 or whatever. But specialty pharmacies make a big difference, especially with access to the banabulin. So can you expound upon that? Because I know you've had some interesting experiences in the New York area. Yeah, I feel very strongly about it. I'll actually never have a patient. The patients will demand, oh, no, send it to my pharmacist. He's my friend. And what happens is the average pharmacist in the US gets a high proportion of their income as a payment from insurance companies to not prescribe medications. And the reason the insurance companies do that is they try to extort payoffs. And I'm not going to use the word discount to rebate. They call it discounts to rebates, but it's really payoffs from the pharmaceutical companies. And for a drug like turbineibulin, for example, they might ask for a payoff of over $1,000 when the drug costs $1,200. And so the pharmaceutical company is not going to agree to that. And instead, what they'll do is make an arrangement where they pay a certain amount of money to a local pharmacy in New York. We have something called Manhattan apothecary there's another one called apotheco. There's a third one called AMA. And there are many pharmacies around the country that make their own arrangements directly with the pharmaceutical company, and they will always honor the prescription. So if the patient has the right insurance, and there are some Medicares that actually are the right insurance, so we're able to get it a lot of the time from Manhattan apothecary, which is the one I use. I don't have any financial conflict with them. But wherever you live, find that pharmacy. They almost always deliver. So even if my patient lives in, for example, New Jersey or Connecticut, which is miles away from Manhattan, they will deliver within a day to those patients, and they will charge the discounted price, which comes out to $25. So I send all my turbanibulin prescriptions through that particular pharmacy. And we have specialty pharmacies, a few that we use in the area. And we essentially say to the patient, if you're going to force it upon another pharmacy, you're likely not going to be able to get it. And I can't guarantee how quickly we're going to be able to get this resolved for you. It's going to sit on a pile of these kind of situations that just back up our office. So we encourage them. And I could rarely have had a patient been adamant about still send it to their pharmacy of choice. Once you explain it to them, sometimes the patients are looking at you as if you're getting some kind of kickback from it, and I make it clear that that is not the case. I want you to get the best medicine that I want for your situation, that you want also for your situation, and then it's not a problem. But people are suspicious of where the money is going nowadays, and I understand that they hear a lot of bad press out there about things that are going on. So now when you see the patient, you get them treated, and you're down the line. They come back six months later. How often might you repeat a therapy such as this for a patient, or does it depend on the patient? So it depends on the individual patients. So in the clinical trials, two things they did in the clinical trials, they brought patients back at day 57 to see how they were doing. That was their primary endpoint. And if you look at the graph, if you come back at two weeks, you get a reduction in aks. Come back at four weeks, you get more of a reduction in aks. So the day 57 was actually a very wise move. I actually bring my patients back often somewhere in there, I might say, come back to me between six and eight weeks, because I'd like them to see that they are much better. And I find that a convenient time. If they have many aks left, then I will bring them back and do it again. You can get the medication refilled as often as once a month. So there's enough in there to treat the better part of a face. There's certainly enough in there to treat the whole scalp, even though in the clinical trials, they were limited to 25. It's five x five centimeter square, roughly. And I'll tell you why they came up with the five x five, because that was part of the original approval process for amiquamod, when the FDA viewed actinocaratosis as a very serious disease, and they considered one remaining actinocaratosis as a treatment failure because it was a precursor to a squamous cell carcinoma, which could be deadly. And there's actually data supporting that, that it is a precursor to a squamous cell carcinoma. In fact, Scott Denhardt published an article where he showed that metastatic squamous cell carcinomas, if you went back to the primary lesion, two thirds of the time, arose within actinic keratosis. So you can understand the FDA's point of view, though I think it's flawed. If somebody had 100 aks and you got rid of 99 of them, that was a treatment failure. So in order to overcome the. Because it's unlikely that if someone has 100 aks, you will get rid of 100% of them. To overcome that, we created a scenario where you treated a five x five square centimeter box that had between six and eight aks. And so the chance of getting rid of eight aks now is much higher. And that's why these all come now in little packets, where you treat a small part of the face or scalp, but it turns out there's enough in there, if you spread it thinly, that you can treat a whole face or a whole scalp. When you say treat a small area, talking about the clinical trials, but the approval is to treat the entire. Like, if you're treating the forehead. Treat the entire forehead, right? Yeah. The dilemma is it comes in these packets. So unless you use more than one at a time, which is not approved, you're going to end up doing it five days in a row on a limited area. So often we'll treat the forehead and cheeks for a month, and then a month later, we'll treat the scalp. The same is true for the other therapies that we use. A Michelad five fu is more liberal because it was approved before these rules. So you can treat a large area. The same is true for PDT. The way the machine is constructed, we pretty much can only do face or scalp in one setting, and then a month later we do the other one. Yeah, I find with the packets that you get that each five day treatment session, you can treat that whole cosmetic area as long as the patient's not globbing it on a small area, and then you don't treat it every day for a month. With the brannobulin, you're treating it for the five days, and then you see the patients back and you might have a couple of lesions left and you might just freeze those. Or certainly down the line. If patients that we have some patients that are constantly genetically programmed to keep reforming actinocaratosis, they can have another course of treatment when they need it. It's really a lifelong patient once they develop actinocaratosis, you agree? Yes. So I will say the average patient gets it once and then a year later we might give it to them again. There are some patients whom I've done twice a year. I had one patient on a micromod who I have not seen since the pandemic. And when he comes back to me, I will be switching him to turbinabulin and have him do the five day thing. And he has actinix all over his arms, all over his legs, all over his face and scalp. And basically we treat one body site at a time and rotate the body sites, and he's done actually very well with that. That's good. Well, Mark, thanks so much for your time today. I know you're busy. I know how busy you are. So we really appreciate your time. Thank you very much. Thanks for having me. Thank you for listening to this episode of Derms and conditions. If you have any questions or comments, please email us at. Podcasts at Fred Health and most importantly, if you like this episode code, subscribe to the Derms and Conditions podcast on Apple Podcasts or wherever you get your favorite shows. Thanks for joining us. We would like to thank Almarol for sponsoring today's episode.

In episode 20 of&nbsp;Derms and Conditions, host James Q. Del Rosso, DO speaks with Lisa Swanson, MD and has given her the moniker, "The Adele of Dermatology". Dr Swanson spends the episode discussing many high yield and practical tips when treating pediatric dermatology patients.

In episode 20 of Derms and Conditions, host James Q. Del Rosso, DO speaks with Lisa Swanson, MD and has given her the moniker, "The Adele of Dermatology". Dr Swanson spends the episode discussing many high yield and practical tips when treating pediatric dermatology patients. She first discusses her favorite treatment for warts, including how to treat warts of both the hands and face. Next, Dr. Del Rosso asks Dr. Swanson how she counsels parents about changing&nbsp;nevi in their&nbsp;children. She continues with her tips on counseling parents on sunscreen use in children. She ends the episode with a discussion of the use of propranolol&nbsp;in the treatment&nbsp;of pediatric hemangiomas and emphasizes&nbsp;how clinically safe this treatment is. FINANCIAL DISCLOSURES: JAMES DEL ROSSO, DO: CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). LISA SWANSON, MD: SPEAKER 
&bull; Almirall
&bull; Amgen
&bull; Janssen
&bull; Lilly
&bull; Novartis
&bull; Ortho Dermatologics
&bull; Pfizer
&bull; Sanofi Regeneron
ADVISORY BOARD ATTENDEE
&bull; Janssen
&bull; Lilly
&bull; Ortho Dermatologics
&bull; Sanofi Regeneron
&bull; Cassiopea

Pertinent&nbsp;Pediatric&nbsp;Pearls That Will Make Your Life Easier

In episode 19 of Derms and Conditions, our host James Q. Del Rosso, DO speaks with David Cohen, MD, MPH and April Armstrong, MD, MPH in front of a live audience during the 2022 Winter Clinical Dermatology Conference from Koloa, Hawaii. Dr. Del Rosso asks his two guests what they thought were the highlights from the many great lectures delivered at this meeting.

In episode 19 of Derms and Conditions, our host James Q. Del Rosso, DO speaks with David Cohen, MD, MPH and April Armstrong, MD, MPH in front of a live audience during the 2022 Winter Clinical Dermatology Conference from Koloa, Hawaii. Dr. Del Rosso asks his two guests what they thought were the highlights from the many great lectures delivered at this meeting. Dr. Cohen discusses updates in the treatment of Chronic Spontaneous Urticaria and specifically mentions the use of omalizumab. Dr. Armstrong highlights a new cream based formulation of calcipotriene-betamethasone and two new non-steroidal topical options for the treatment of psoriasis in the pipeline. Dr. Armstrong also highlights pearls from Dr. Kirby's lecture on HS including the use of antibiotics and proper injections techniques for steroids. The episode ends with Dr. Cohen's discussion of the allergen of the year and Dr. Armstrong's discussion on the use of oral minoxidil in the treatment of hair loss.
 <img style="max-width: 80%; height: auto; display: block; margin: 5px auto;" src="https://fchealth-assets.s3.amazonaws.com/dc-recording-wc22.jpg" alt="live recording at WC22 in Hawaii" /> FINANCIAL DISCLOSURES: JAMES DEL ROSSO, DO: CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). DAVID COHEN, MD, MPH: Consultant and Honorarium: Ferndale Laboratories, Asana Medimetriks [past] Leo UCB Novartis Dermavant FSJ FIDE. (FIDE receives industry sponsorship from AbbVie, Almirall, Amgen, Arcutis, Bausch and Lomb, Bristol-Myers Squibb, Celgene Dermavant, Dermira, Janssen, Kyowa Hakko Kirin, LEO, Lilly, Novartis, Ortho Dermatologics, Pfizer, Sanofi Genzyme, Regeneron, Sun Pharma, UCB, Valeant) Cosmetic Ingredient Review (CIR) Stock or stock options: Dermira [past], Medimetriks [past], Brickell Biotech [past], Kadmon, Evommune, Timber Board of Directors: Kadmon, Timber, Evommune, Dermira-[Past] APRIL ARMSTRONG, MD, MPH: Research investigator and/or scientific advisor to AbbVie, Almirall, Arcutis, ASLAN, BI, BMS, EPI, Incyte, Leo, UCB, Janssen, Lilly, Nimbus, Novartis, Ortho Dermatologics, Sun, Dermavant, Dermira, Sanofi, Regeneron, Pfizer, and Modmed.

Highlights from the 2022 Winter Clinical Dermatology Conference - Hawaii

You're listening to the Derms and Conditions podcast. So we're going to get started with our production here. My name is Jim Dorasso, and it's a pleasure to bring with me today David Cohen, who you all know from New York, and April Armstrong from the other coast down there in Southern California, and that we're now in our second year of Derms and Conditions podcast. We're very proud today to have this live edition. We've started 2022 with episode number 18 with Jason Hawks, and that's already up and running. But I do want to say to take a minute to thank Insight dermatology, the sponsor of Highlights of Winter Clinical 2022, which is this episode. Learn more about Insight's innovative approach to treatment at www. Dot Insight. That's capital Incyte.com dermatology. So we're going to get started with highlights of winter clinical 2022. And I'm going to ask David Cohen, who actually was the lead off hitter of Derms and Conditions podcast with our first two episodes. When we started, David, in listening to the presentations at the meeting, what stuck out in your mind as being something that you felt was really important? So, Jim, as you mentioned a little earlier, this meeting was so packed with pearls and new data, I mean, we could probably do a half a dozen podcasts. I think just from a medical dermatology standpoint, there's a number of lectures there. But Dawn Salmons spoke about chronic area. I think it's one of those areas we don't think a lot about in dermatology, but we deal with daily, and we get distracted by all the advances in psoriasis and eczema. She pointed out a couple of important things, omaluzumab, Zolair, which we know about for years, not something we use in the dermatology office very much because we're concerned about anaphylaxis. But the labels changed. And now, after three supervised doses, patients can self administer at home. I think that's really going to open it up for us a bit more. We also saw over the summer dupilumab issuing data on chronic spontaneous erticaria, the new name for chronic erticaria, chronic spontaneous erticaria, demonstrating sort of two x, the improvement over antihistamines. And then she spoke about some development drugs like ligalizumab, remibbrutinib, which is an oral brutin kinase inhibitor, and tezapellumab, which is being used in asthma. So this area of medical dermatology is expanding really at a great clip. And in dermatology I think we ought to be taking advantage of that. I think about this a lot when I'm seeing patients in the office. Whatever disease they have, I'm thinking, is there anything new in the last week that I haven't heard about yet because there's expansion of so much information in so many areas. So, April, you're a crowd favorite with your podcast that we had. So I'm going to ask you what stuck out in your mind from this meeting. Yeah, I will say, like David, there were so many things that stood out at the meeting because it was just full and packed with great information, something that I think you actually, Jim, and as well as Neil simal and I talked about, were some of the advancement in topical therapies in psoriasis, including, for example, now we have a calcipo triang betamethasone cream that's quite stable and then, well, tolerating in our patients that we have available for them. In addition to that coming up, we will also hopefully see two nonsteroidal options for patients with plaque psoriasis. One is tipinorov and the other one is roflumolast. Different mechanism, action, but certainly very exciting for patients with psoriasis. One thing that Dr. Bonnie Elewski had highlighted in her talk, for example, for oral therapies for psoriasis, she pointed out that premilas now is approved for psoriasis patients of all disease severity. So we recall that it used to be approved just for moderate to severe disease. Now it also includes mild, moderate, as well as severe disease. So I think that is also quite exciting. And then finally, we'll have a tick two inhibitor that will join our really toolbox, that will offer very efficacious and with good safety profile as an oral option for patients with psoriasis. Is there anything unique about the binding with the tick two inhibitor, the allosteric binding, that it appears it may be different in terms of its profile from the other Janus kinase inhibitors? Yes, absolutely. So this one is quite unique in that the mechanism, action for ducravacitinib, this particular tick two inhibitor, actually binds to the regulatory domain versus the catalytic domain where most of the jack inhibitors bind. And because of that specific binding and that specific mechanism of action, we see it really in the safety profile. When you look at the laboratory work that was done in the patients in the clinical trials, they were very similar to patients who have taken placebo. I just wanted to point out I had similar highlights that April brought out with the tuna topicals. I think all the excitement over the last ten years has been on moderate to severe disease with biologic and systemic drugs. But most of the cases we see in dermatology are mild to moderate. We want to deploy topical therapies and topical steroids, mainstay a therapy most of the time. But the two new topicals April mentioned really had consequential efficacy. Real, like checking the steroids at the door for long term use. And then we had topical ruxalidinib this year, which had really impressive results on efficacy. I think it's a real change in our waiting time. We wait ten years for a good topical, and now we might have three amazing ones for pretty broad spectrum of use in the office. Now, I think it's great that we've had roxalitinib approved topically for atopic dermatitis. It offers us a lot of advantages in treating. That's a difficult disease. These patients are fighting this over a prolonged period of time. And even with the best of therapies, we have systemically for psoriasis, and even atopic dermatitis patients still carry some disease with them. The majority of them have carried some disease where we need topical therapy. So, April, I'm going to go back to you and see if you have anything else you want to bring forth or certainly David. David, did you have anything on your plate? Yeah, well, a number of things, but time will limit us. Brian Berman mentioned the tibinibulin known as clyceri, and the package insert has discussed 25. Really liked his very practical approach with the digital imaging, allowing one of those sachets to cover a full scalp. I think it's just a very practical way of looking at it that I can deploy in real life, in real time. Well, you know, you're not just going to put it on 25 cm². That's hardly a field treatment. But the FDA does mandate the protocol be done that way, so you don't have a choice. So we're going to take another quick pause here to thank insight dermatology, the sponsor of today's program. Learn more about how insight is changing the face of research in dermatology at www.insight.com forward slash dermatology. So, April, now we'll turn it back to you and see what else you picked up at the meeting, because there are quite a few highlights. Yes. So when we're thinking about hydratinitis separativa, and I think we heard great talks from Dr. Kirby from this meeting. I think we learned a lot in terms of the management, one in terms of the medical management and the other in terms of some of the procedural management. When we think about the use of oral antibiotics, for example, in our HS patients, we oftentimes think about tetracycline class or beyond that, clindamycin plus rifampin. But I think also considering the use of, for example, agents that are more broad acting in terms of covering both gram negative and gram positive organisms. So things like amoxicillin plus clavulonic acid and potentially some fluoroquinolones can be quite helpful. I'm very encouraged to see in the biological realm for HS. For example, we have the advent of IL 17 inhibitors and IL one inhibitor in the pipeline that will be additional biologic options, hopefully in the near future, in addition to our TNF inhibitor, adolemab, which is currently the only approved biologic for HS. And then finally, I learned a tip that when you inject these HS lesions, perhaps if you use five milligram per mil concentration, that may be a little too low. So I think Jocelyn was talking about using ten to 20 megs per mil concentration and then inject a good one to two mils into these lesions, into these highly inflammatory nodules or abscesses, to really get those lesions down. So getting into the nitty gritty details, to understand the amount of concentration of the intralesional Kenlock we need to inject, I thought was very helpful, actually. We use evidence based medicine, and my evidence on that was one colleague that I respect a lot, that treats a lot of hydratinitis told me a few years back, he said, inject ten, even 20 milligrams per cc. And I've been using that routinely, evidence based one doctor, but he was right, and it turned out to be very, very helpful. David, any other? I guess, Jim, just parlaying the discussion about the antibiotics, Julie Harper and you were talking about the more limited antibiotic spectrum of serocycline, which we like to be mindful of once we're having patients with acne on antibiotics for three and four months. So it may be a little bit easier decision when you're wanting a little bit longer and not just blasting the broad spectrum of the microbiome. I mean, it's difficult because it's easy to sit in the boardroom and tell people, don't do something more than three or four months. But when you have patience with the realities of what you're experiencing in practice, it's not always that easy to stop things and go to other things, especially when patients are having success. So the decision ultimately has to be a wise one, but we have to respect what antibiotics are doing and respect antibiotic resistance. Anything else, David? I know you, David, took a lot of notes. I'm very proud. I was sitting and taking notes. Obviously very gratuitous, though. The allergen of the year for 2022 was aluminum. I think not the most exciting allergen of the year, but it's one we have to think about. It became an allergen of the year largely because the old fin chambers were aluminum, and kids started to noted reactions to the chambers themselves so people would patch test and see multiple positive reactions. Didn't make any sense. And aluminum is an adjuvant, it's an immune booster in vaccines. And some kids, and I've seen this a number of times, get these exematus plaques over the vaccination site, hot warm areas, and even granulomatous nodule lesions from aluminum hypersensitivity. However, other than this academic interest, I think it doesn't touch us most of the time, and it's just one that'll make it into the record books and move on. I don't see much aluminum allergy under arms from deodorants and antiperspirants. So I was going to say, david, I'm really happy that aluminum was the allergen of the year, because when I first got here, and this is a bad image of Jim del Rosso in the shower, but you taught me at another meeting that always look at what's in there, like the shampoo, and it was cocoa mango. And I'm thinking, gee, I hope cocoa mango is not the allergen. No, that it wasn't. We'd all be in trouble here if cocoa and mango cocoa mango allergy. So I feel better now about what they have in the hotel. So, April, we're going to move back to you. Anything else exciting? Oh, first, I would say that your mango smell is quite good here. Yes. I really thought that the tip that was given on oral minoxidil for patients with androgenetic alopecia was wonderful. We think about topical minoxidil for these patients all the time. But also Dr. Eluski alluded to that you can use oral minoxidil, and there are some case reports supporting that. And the dose that for men is 2.5 milligram, and they can come in 2.5 milligram tablets, so they can take that. And for women, it's half of that. So you can get a pill cutter, cut that in half to help treat the androgenic alopecia and I will say, maybe one of my last tips is from Dr. Abair, which I think I might use on my children as well. She said that a child cannot cry and try to blow out a candle or purse their lip to blow out the candle at the same time. So if you have a crying child in your office and you try to get them to stop crying and tell them to pretend to blow out a birthday candle. So I thought that was a great tip, that I can try it out on my kids and hopefully not my spouse. I think if I tried that at home with my wife or adult daughters, I wind up with a pie in my face, I think, pretty sure, yeah, blow out this candle. Don't yell at me. I think it's important that when we look at topical agents for acne, we actually do have one that has a mechanism of action that we haven't had, and that's the androgen receptor inhibitor with topical closcodarone. And I still have people coming up to me, even at this meeting saying, can we use that in men? And absolutely, it's topical. There's no real concern about systemic activity. And androgens are part of the pathophysiology in everyone, in both males and females. So you don't have to be concerned about using that in males, being a topical agent. Any final words from either of you? I'll start with you, David. Yeah. I just wanted to shout out the lecture I heard from pearl grimes on hyperpigmentation. Right. She spoke about cystamine, which we kind of knew about for a little while. But what really moved me, she's a luminary in pigmentary disorders, and like all of us, we've seen tinia versa colar patients get hypopigmentation from their infections with malassesia. And she's looking at sort of purifying malassesia extracts to parlay that against hyperpigmentation. And I just thought that was a brilliant clinical observation that she's going to try to turn into something that may be useful, akin to minoxidil being used for hypertension and creating hair. Hair growth. Right. I think she's really a great example of using a clinical observation to try to solve a problem. Well, it's interesting because azalaic acid, which can result in some hypopigmentation if you're treating hyperpigmented skin, is actually one of the acids that's produced by malassesia when you have that phase of that infection. So I think that's interesting. Pearl Grimes is the one who taught me way back about using topical retinoids in patients with darker skin, where a lot of people were afraid of doing it. You get your pearls from Pearl, that's for sure. So we'll end up with Dr. Armstrong to give us some final tips. And as I'll say, Dr. Grimes is a fellow Angelino, so I'm very glad to have her in our area. I will say that another tip that I found was very helpful is from Dr. Colion, who said that in your practice, try to put up a staff bulletin board where staff can put up. You can put brief announcements, but also staff members can put up pictures of their children so that you share a little bit of your life with the other staff. And it can be in an area only that staff can see. But it can really help boost the morale in the office, and I feel like we all need that during this time. That's certainly for sure. So I want to say thanks again to Insight dermatology, the sponsor of highlights of Winter Clinical 2022. Be sure to drop by their booth here at winter clinical or check out their website@www.insight.com, dermatology. And remember, you could subscribe to Derms and Conditions podcast at Apple Podcasts or wherever you get your favorite shows. Keep listening because you're going to learn from people like the ones that are to my right here and to my left. Thank you very much.

James Q. Del Rosso, DO speaks with Jason Hawkes, MD, MS, FAAD, Assistant Professor of Dermatology at the University of California, Davis. Dr. Hawkes discusses his unique background and he offers advice to early career and resident dermatologists regarding building a successful career.&nbsp;

In episode 18, our first episode of Season 2 of Derms and Conditions, our host James Q. Del Rosso, DO speaks with Jason Hawkes, MD, MS, FAAD, who is an&nbsp;Associate Professor of Dermatology at the University of California, Davis. Dr. Hawkes discusses his unique background and he offers advice to early career and resident dermatologists regarding building a successful career. Dr. Hawkes stresses that his basic&nbsp;science and clinical&nbsp;trials background has made him a better clinician. The episode ends with discussion of a difficult dermatology case and Dr. Hawkes highlights the importance of interdisciplinary&nbsp;care.&nbsp; Financial Disclosures JAMES DEL ROSSO, DO FINANCIAL DISCLOSURES: CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Jason E. Hawkes, MD, MS Advisory Boards/Consultant: AbbVie Arcutis Boehringer Ingelheim Janssen LearnSkin LEO Lilly Novartis Pfizer Regeneron-Sanofi Genzyme UCB VisualDx Medical/Scientific Board: National Psoriasis Foundation (NPF) Stock Ownership/Equity: Regeneron Pharmaceuticals (Spouse, employment)

Establishing Connections in Career Development and Patient Care: One Dermatologist&rsquo;s Success Story

You're listening to the Derms and Conditions podcast. So welcome to another exciting episode of Derms and Conditions. And I'm here live in the studio with Dr. Jason Marks, who's an associate professor of dermatology at University of California, Davis. And he has a very interesting background. He spent time at Rockefeller University with Jim Krueger and doing a lot of laboratory work and interesting work in immunology and also working at Mount Sinai with Mark Lewall and colleagues there. And a little less than three years ago has gone out to California. So he spanned across the country, and now he's practicing dermatology and teaching at UC Davis. So welcome, Jason. It's great to have you here this morning. Oh, thanks for having me, Jim. I'm excited to have this conversation today. Well, you should be excited because we have a lot of exciting things to talk about, I think so. I think getting to know you, which I've really enjoyed over the last year or so, you have a very interesting background that I thought it would be good to share with other dermatologists at some point and tell me about how you made this transition, because you're young in dermatology and you have interest in academics and in basic science, but you also have strong interest in being a clinician. And so in speaking, especially to younger dermatologists in the earlier parts of their career, that getting out of their residency, they did all this studying, they have all this background that deciding whether they should go academic or private, as if it's all or none on either side. Can you explain how you've made that transition and combined both? Because I think what you've done is very interesting. Yeah, I think you mentioned it where initially, I think early medicine was that you get in school, you know exactly what you're going to do. You're already differentiated, that you're going to run a lab and everything's clear, and you just follow the path and meet the milestones. And I think what we've learned, I think it's been put on the millennials or Gen Z, et cetera, that that group doesn't really know what they want to do and they bounce around. But I actually think that that fits a lot of where I was, is that there wasn't one thing that just made me so excited that I wanted to do it every single day of my life. And that was true. As I went through undergrad and medical school, I found interest in a lot of different activities, and that included research. It included patient care. I think dermatology for me was a natural fit that way, because we had adult patients, we had pediatrics, we had some procedures, we had pathology. I wouldn't have been a good pathologist every single day because I liked patient interaction. But dermatology brought in multiple aspects, and I think to mirror that interest in dermatology where I had the variety of activities, that's really what I did with the experiences and opportunities I sought after. I spent time at the NIH as a medical student, took a year off in the Howard Hughes program at the NIH, and studied micrornas in non dermatologic conditions because I didn't have the perception I was going to go into dermatology yet. So that was sort of a landmark experience for me, showing sort of that translation between the science and human clinical care. I did mouse model research when I was at the University of Utah, looking at psoriasiform dermatitis and mice and how that might translate to humans and learning the differences between models of disease and humans. And that was very interesting. I did clinical trials when I was in University of Utah, but also in New York City at the Rockefeller University, and to see how that world worked, interact with industry. So all of those experiences might make it look like it's undifferentiated path, but all of those layers have added to my interest, and all of those have value. I think it's okay to not have something that's 100% of your time, because I think overall, it's made me a better clinician, having had those experiences at the basic science level or the clinical trials level. So I think it's okay to have those broad interests, and I encourage young physicians and trainees to actually experience those because they'll add to future activities. So how do you come about getting those opportunities, though? I mean, they just don't fall on you. You had to pursue them. And what you just described sounds like half of someone's career. How much time was that compressed into? Because you're in Utah, you're with Kruger, you're at NIH. I mean, that sounds like years and years of know a lot of them. You're doing two for one, right? So, for me, in medical school, I did take the one year off to do that research fellowship, but for me, I needed to answer an important question, which was that did I want to run a lab or see patients? Because the system really drives you in one direction. It's very difficult to be a successful NIH physician and not do that 100% of the time because the people you're competing with are doing it. 100% of the time. And so while we talk about it being a hybrid, there's really a conflict. So for me, I needed to know early on in my career if I wanted to be in the lab 100% of the time. So that one year off was definitely extra time, but all of the other experiences I really included into my training. So during residency in dermatology, I had, rather than doing a traditional three years of training, I did what we call a two plus two program, which is I did two years of traditional clinical training, but my second two years. So again, one extra year, I spent time doing research, clinical trials, et. So two extra years, when you get to that point, and you might say that the three years I spent in New York City in my master's of clinical investigation was extra time, but it was a paid position. I made money. I lived in New York, had a great experience. And so for me, that was really an advancement of my career, because I was seeing patients at Mount Sinai with Mark Lebwall and his group, and I was learning how to practice dermatology. So to be paid and work and learn, it didn't feel like extra time, because once I was ready to get into the position I'm in now, I had all the tools that I felt like I could manage any patient that walked into the clinic. So to me, it was maybe two years of extra time. There's an opportunity cost there, but I think in the long run, that will be regained. Well, it's time well spent, because if you're setting yourself up for the right choice and that lasts many years, it's like picking the right partner in life. Right. And sometimes it takes a little bit longer, but then when it's the right situation, it works for years, and it gives you a much better life. So tell me about this position you're in now, because I think your patients that you see are very thankful. I've talked to you about cases which we'll get into your knowledge base, and how you manage patients is so comprehensive. So you're in a situation now where you have academics and teaching, but you're basically also in private practice. You're out in the trenches treating patients. You're not just in a center that gets a referral, and you never see the patient back for six months, a year, if ever. So explain how colleagues can find that type of situation. Yeah, and I think to also go back and incorporate a prior question you asked is, how do you find these opportunities? I think some actually do come to your doorstep. You've got to kind of pay attention. You just have to make the decision to accept it or not accept it. And some of them, I think you have to have the conversation with people and explain your interests. Right. You have to start to differentiate yourself and say, this is what makes me tick. This doesn't. And a lot of those conversations led my supervisors, leaders, mentors say, hey, you should really think about x, y, or z. Right? So I really think that's important. And I think in answering your second question here, which is, what's my position like here at UCavis? And it seems to be a hybrid that was also sort of born out of a conversation about what I really wanted to do. I knew very early on, after some of these experiences that I'd had in my training, that I didn't want to see patients every single day in a five day a week practice just wall to wall with patients because that sort of made it difficult to find time to really think and digest the literature and answer important questions. I enjoyed writing, so I needed that time. So this really kind of came out of that conversation of having patient care because I think we need to apply the science that we learn, but we also need that time to think and digest. The, the, you know, practice model I have here is that I'm affiliated with the university, the department of Dermatology in Sacramento, and I'm down there one day where I work with residents and fellows, et cetera. But those other days I'm at an outpatient clinic. It's an affiliated clinic with UC Davis, but it's really a multi specialty clinic where there's Ent, there's GI, there's primary care, and I'm the only dermatologist there. So I get those direct referrals. Sometimes same day referrals are within a day or two. And that's been really interesting to see that really, when you say down in the trenches, sometimes at academic centers, we don't see a lot of the basic early presentations because they take a long time to get to us. But out in the community practices, I see these patients that are new diagnoses or just happening, new onset, et cetera, and that's been really interesting. And then I still have a day and a half where I'm not doing any clinical activities. That is just academic time. So I have at least 30% of my time where I can work with industry or as a medical board member of the National Psoriasis foundation. We do a lot of work together. So those are days where I can sort of work on the other side of that brain, for me, that's the creative thinking, learning side. So for me, it really does bring all aspects of what I'd done prior into one position, and it's really satisfying to have the variety for me. Well, you're the architect of that to a significant degree just by how it happens, because you said something very important earlier. You said that people worked with you, and then they started to see this in you, and then they start telling you, hey, have you ever thought about this? Or I know somebody, you should give them a call. And it just builds, but it's you presenting to them your level of interest. So if you just sit there like a bump on a log and you don't express anything to the person you're working with, it's hard to get them motivated about offering some options. So what I'd like to do is ask you about. I know that you talked to me at one time about a very interesting case of a patient that presented with. They had chronic sinusitis with nasal polyps, and they had asthma, and they sort of had a complicated situation. They weren't a classic exemnist dermatitis presentation. They were more of a pariginist type of presentation. And can you just end today by explaining how you sorted through that case and managed it? Because I thought that was a very interesting case. Yeah. So there's a case we published, and it was an older gentleman that had had virtually no dermatology history, but had had a long history with multiple specialties for multiple allergic related diseases. So he had suffered with very severe asthma, requiring multiple hospitalizations, er visits. So he was managed by an allergist, he had an Ent that was managing his chronic rhinocitis with nasal polyps. He had had multiple surgeries for the polyps. He had had a severe aspirin induced hypersensitivity, also managed with allergy. And those three conditions together fit with a diagnosis called sampter's triad, which is probably not as common to the dermatology specialty in more ent and or allergy. So this patient, who'd had this long allergy history, would never interacted with dermatology, was sent to dermatology for these very paridic, sort of red to violacious plaques, mostly on the arms and the trunk, and they were worried that he'd had some infection. He had had a knee surgery that had MRSA, complicated by MRS infection, and they were wondering if this could be related. And so it was his first time to dermatology. When this patient walked in, it was clear that what he was dealing with was parigonodularis. And so what we really wanted to do is think about how we could manage his condition in a way that might also help some of his other conditions. And he was really a magical patient in terms of his treatment response because we were able to get him approved for dupliumab or dupixent, given his other allergy conditions. But what was amazing, within about three weeks, he called me and his skin was completely clear. But what was most interesting to me is that about a month later, I got a call from his ENT surgeon saying, whatever you did to this guy, don't stop because all of his polyps are shrinking. He's off his medications. His allergist talked about how his asthma is well controlled. They stopped all of his oral steroids. What interesting about this patient was that even though he had had these separate diseases, it was clear that he had one common pathway that was shared between all these diseases. That one drug, one targeted, very safe agent, was able to get his skin clear, but then have a huge impact in all of these other conditions. So it really kind of gets us back to thinking about how we can interact with these non dermatology specialties, who might see these patients that have these allergic related conditions, that one treatment that's targeted can really help multiple areas. So it really kind of opened me up to these conversations to have with other specialists about what patients we might share that together we can think of care strategies that will be better for them. Overall, I find that it's very rewarding. I have an allergist, immunologist, the guy's a phenomenal physician, that we share patients and actually also a rheumatologist. When you start getting into psoriasis, psoriatic arthritis, and some of these other areas, and I find it very rewarding to share patients with them. So I think that's a great way to end our conversation. And that is an article that is published that people can look up. It was in the journal American Academy of Dermatology, one of the case reports, the Jad case report. So, Jason, I know you have a busy day of patients today. You're probably not in the lab today or doing your academic side work, so I'll let you go. Really, thanks a lot. It was great to talk to you, and I'm sure I'll see you soon. Appreciate it. Thanks, Jamie. It was fun. Thank you for listening to this episode of Derms and Conditions. If you have any questions or comments, please email. Email us at podcasts at Fred Health. And most importantly, if you like this episode, subscribe to the Derms and Conditions podcast on Apple Podcasts or wherever you get your favorite shows. Thanks for joining us.

Season 2

Episode 17 of Derms and Conditions has our host James Q. Del Rosso, DO speaking with April Armstrong, MD, MPH, Professor of Dermatology at The University of Southern California. In this episode, Dr. Del Rosso and Dr. Armstrong discuss high yield pearls in managing difficult and treatment resistant cases of atopic dermatitis and psoriasis.

Episode 17 of Derms and Conditions has our host James Q. Del Rosso, DO speaking with April Armstrong, MD, MPH, Professor of Dermatology at The University of Southern California. In this episode, Dr. Del Rosso and Dr. Armstrong discuss high yield pearls in managing difficult and treatment resistant cases of atopic dermatitis and psoriasis.
Specifically, they discuss bridging&nbsp;a patient to dupilumab with cyclosporine, how to effectively&nbsp;switch between different biologic therapies for psoriasis,&nbsp;and how to use apremilast effectively in patients with severe psoriasis. Finally, Dr. Del Rosso asks Dr. Armstrong about best practices for vaccination in patients on oral and biologic therapies for psoriasis&nbsp;and atopic dermatitis.&nbsp; Financial Disclosures JAMES DEL ROSSO, DO FINANCIAL DISCLOSURES: CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). APRIL ARMSTRONG, MD, MPH FINANCIAL DISCLOSURES:
Research investigator and/or scientific advisor to AbbVie, Almirall, Arcutis, ASLAN, BI, BMS, EPI, Incyte, Leo, UCB, Janssen, Lilly, Nimbus, Novartis, Ortho Dermatologics, Sun, Dermavant, Dermira,&nbsp; Sanofi, Regeneron, Pfizer, and Modmed.

You've Got One Shot To Get It Right with April Armstrong, MD, MPH

This episode is sponsored by Aquaphor, the number one dermatologist recommended brand for minor wound care and dry, cracked skin. With 30 years of patient experience and 24 safety and efficacy studies, aquaphor healing ointment has been synonymous with improving skin health. This episode of derms and conditions includes information discussed at the time of recording. New information may have emerged since that time. You're listening to the Derms and Conditions podcast. Hello, everyone. This is Jim del Rosso, a dermatologist in Las Vegas, Nevada, involved in a lot of research at our JDR dermatology research and also with advanced dermatology and cosmetic surgery. So I like to talk about research, but also a lot about treating patients, which I do quite a bit. And we run into a lot of questions in clinical practice, even those of us that are involved in certain areas, there's never a lack of need for new information. And that's why today we're talking to Dr. April Armstrong. She's professor of dermatology and associate dean at University of Southern California. And she's also one of the more recent program chairs of the fall and winter clinical dermatology meetings, and we're happy to have her on board with that. So, April, it's great to have you on today. Great. Thanks so much for having me here. I'm very excited to be here. Well, I know you're going to help me with some areas that I know I struggle with. So the first question has to do with, you have a patient that you've been managing with difficult atopic dermatitis, and you may have that patient on a systemic treatment, let's say cyclosporin, which I think would be a good example, with a variety of different topicals. And now you're getting to the point where you're thinking about, and they've made the decision. They agree with you. Let's talk about going on, on depiliumab injections. How do you bridge patients from cyclosporin to depiliumab? And if there are any other systemic treatments you want to address in doing, know, feel free to do that. Great question, Jim. So I would say for a patient that you have on cyclosporin, that patient is probably, I would say, pretty hot in terms of their atopic dermatitis. And you've decided that you're going to take that patient to dupilumab. One of the things that I would typically do is by the time when you prescribe dupilomab to when the patient gets dupilmab, that can range anywhere between a week to possibly a few weeks. And I typically would actually continue them on cyclosporin and usually at the bid dosing. So typically, when I dose a patient on cyclosporin for atopic dermatitis or psoriasis, the reason that they're dosed is because they can be quite severe. So I would do five milligrams per kilogram and then do that divided dosing, and I will continue that, typically until they get dupilumab, if it's not, for example, too protracted. And then once they are on dupilumab, there's oftentimes an overlap, and I oftentimes observe how they do on that overlap. If they start to improve significantly, let's say about 50% improvement, then I start to taper cyclosporin first from bid dosing to QD dosing. And you can do that for about two weeks or so. And then you taper down to every other day dosing for another two weeks or so. But you're still at your five milligram per kilogram, but you're giving that in a single dose or you're giving half of the original dose. So I'm still doing the five milligram per kilogram, but giving it at the different frequencies of dosing. Okay. All right. Yeah. And then I will continue that. And typically, I will say about a month or two into their dupilumab dose. And obviously, each person is different, then this tapering of cyclosporin would be complete, and then they would be transitioned onto dupilumab solely, perhaps in combination with a topical agent. So at some point, you're going to be judging, are they getting the effect of depiliumab such that you're going to maintain them on depiliumab as opposed to the cyclosporin they were on, which, obviously, if it was, it could have been doing great. But you're at the point where you're concerned about how long they're going to be on cyclosporin. When do you decide if the dupillumab is going to be enough? Because they're on the combination for a while, correct? That's correct. And oftentimes, I will decide if dupilumab is sufficient around two months time period, because if they're on combination therapy, I would expect significant improvement from both therapies. Makes sense. So the next question I have is with regard to if you have a patient on one of the injectable biologics for psoriasis and feel free to distinguish between the different classes of those drugs, whether it's anti tnF, anti IL 17, anti IL 23, whatever. And you have the patient's on one, and for whatever reason, they're having an adverse effect or they're not getting the benefit you expect them to be getting, you are going to switch them to another injectable biologic. How do you go about that? Do you give break periods between them, depending which ones they were on, or do you just stop one and start the other? Yeah, that's a great question. And that's a question I oftentimes do get from my colleagues quite a bit. So we now have a lot of options. So switching is actually more common than before. And oftentimes, the way I think about this is that a person needs to switch from one biologic to another because the first biologic is not working optimally for the person. And from my experience, and I have psoriasis clinic, both at, for example, the La county clinic setting, as well as in the tech school medicine private setting, what I've observed over the years is that biologics actually have a lot of flexibility and a lot of give. So oftentimes one can actually switch immediately to another biologic without having to have a period in which there could potentially be a gap. And the reason for that is that most of our biologics are dosed optimally to a level of controlling psoriasis, but not to the level of significant immunosuppression. So as a result of that, when you're thinking about coming off of one biologic and starting on another, and it could be as soon as the very next day, let's say the patient just had a dose of eustachinumab. I'm just using that, for example. And then you decide to switch that person to, for example, ixicizumab. And then oftentimes, it's difficult to know when the patient will actually receive that next dose. The first shot of executionab, the biologics have so much give that. I often tell my patient, even if the next dose, even if the executionab comes the next day, the day after you inject yourself with eustachinumab, that we have enough room, flexibility, that you can actually go ahead, dose that, get that loading dose in. That's another question I get a lot. When you switch, do you need to load the patient? I will say, yes, absolutely. Still load the patient. So that's the approach that I've taken. And the key thing is side effects. I haven't seen significant side effects or that's greater than what's expected of how we use biologics with that particular regimen. So that's interesting. You're not waiting until you would have given the next dose of eustachinumab to start the other biologic. So you're just starting them right away. And that would be true of any of the biologics we have, whether they're anti tnfs or Il twelve, twenty three s or twenty three s. You would be the same general guide. That's correct. And I found that that oftentimes work quite well in terms of controlling psoriasis and that I haven't seen much side effect with that particular approach. Well, I did learn something there. I have to say, I appreciate your compliment earlier, but I always wondered about when to start and stop. So I have another question. I have a fair number of people that been treated with oral aprimolast, and some of them do extremely well. Some of them you have the problems of GI side effects, occasionally headache that gets in the way of continuing it. But many people work past that, and some of them do good, but they still have some resistant psoriasis. I think we all recognize the range of what oral apprelas does. There's been more and more discussion about utilizing it in combination with other therapies. And I've seen data with phototherapy. I've seen some mention, usually an anti TNF like adolemab. I've seen some in the literature, and I know the corona registry, or at least talking to Bruce Strober, there's been a lot of different combinations that have been used, but not enough to really publish with anything specific. What's been your experience and what are your feelings about when you have a patient on oral aprimalast? They're doing okay, but you really need to step up to the next level to try to get better control of their psoriasis. What's your feeling on that? Yeah, so, Jim, I think, first of all, the combination therapies with a premilast that you spoke about, I think that can work well for a lot of patients, and certainly we have some data to support its use with various biologics. I would say on average, in terms of the additional benefit that one can get from a premolast, if we're talking about at least 75% improvement or posey 75 as a benchmark, I will say with addition of a premolast, you can probably get 20% sort of more people that achieving that benchmark, just as kind of my personal estimate. So there is a benefit. There is some limitation to that benefit. So if a patient is on monotherapy with a premolast and that hasn't worked well for the patient, my approach would be to consider a different primary monotherapy for that patient, typically a biologic agent. I oftentimes think about a premalast if it has worked well as monotherapy, keep patients on a premolast. If it hasn't, switch to, let's say, a biologic. But also premalast can be useful as an adjunctive therapy added onto a biologic. If you don't want to switch that primary biologic, the problem oftentimes will be the payers. They will recognize that the patient is on both medications, and they may give you some grief for that. But this is a patient that's doing between those two, right. It's not that you're thinking, oh, they didn't respond favorably to a premalast. You were hoping for more, but they're doing okay. They're getting some improvement, but you're really hoping for more. You would still think about going to another primary monotherapy, or this is not having a biologic and adding the premilast. This is the patients already on the oral apremalass. So does that question make sense? Because that's a lot of the patients, I think, in that situation, yeah. So in those patients who are not optimally managed or not too happy with a premolast, even though they do see some improvement, I would try to also optimize their topical therapy. So if they're a premolast and topical therapy both in combination is not giving them what they're looking for, then I would switch to switch, and you'd circumvent having to deal with covering two systemic medications and the payers, et cetera. Aquaphor is a proud supporter of the dermatology community and helping dermatologists achieve their therapeutic goals. So I have another question for you because I still find that the recommendations are sometimes confusing. Can you give any general that are also specific enough recommendations on vaccinations? And let's talk about adult patients, because obviously it can get a little bit more confusing in the pediatric group with different vaccination schedules and things. Adult patients that you're putting on a biologic, an injectable biologic, or this could be some of the other systemic immunosuppressives, and as we move along, even Janus kinase inhibitors. The recommendations with regard to. But let's focus on the biologics that we have now, the injectable biologics about recommendations on vaccination. Let's assume the patient hasn't started the biologic, and then we can talk about if they're already on one and you want to give them a vaccine. Absolutely. So very important topic, especially the time that we live in right now. Maybe I'll have us really think about that in terms of biologic. First of all, treating if a patient needs to get a killed vaccine versus a live attenuated vaccine. So for patients who haven't started any biologics in either situations, on any vaccines, the recommendation is always try to get the vaccine first before you start the biologic, if you can. And that's a general recommendation. Now, the harder part is what happens if they are already on the biologic, which is actually these days the majority of the case, and they need to get a vaccine. Now, for those who want to receive killed vaccine, in those cases, the biologics, you can continue the biologic without disruption to receive those kill vaccines. So that is nice and sort of straightforward. The part that's not so straightforward is live vaccines with regards to biologics, all of the biologics that we currently have have a warning in the package insert that says that live vaccines should be avoided. Well, in real life, guess what? Sometimes you have to have the live vaccines, or the benefit risks really outweigh having the live vaccines. And oftentimes in those cases, it would really depend on the situation. So the general recommendation, and we've looked at these data closely as part of the National Psoriasis foundation medical board effort, is that you would want to wait. So you want to hold a biologic in a person about to receive a live vaccine for about two half lives prior to administering the live vaccine, and then after the administration of the live vaccine, then you wait about two to four weeks before you restart that biologic. And the reason for this particular logic is twofold. One, with the live vaccines, it's not only about whether you can get the body to mount enough good vaccine response, but also it's about the safety as well. So this recommendation is being drafted, and it accounts for the different lengths and levels of viremia that attenuated but live vaccine can have in the body. So as a general rule, again, if you have to get a live vaccine in those with biologics, consider holding the biologic for about two half lives prior to getting the live vaccine. And after getting the live vaccine, then wait two to four weeks before restarting the biologic. And that would apply. We're using biologics as a general term, but obviously there's differences between them. Are we talking about the biologic injectable biologics that we typically use for psoriasis, like anti tnfs, antial seventeen s, twenty three s, whatever, and also depiliumab? Or are we only talking about the biologics that we use for psoriasis? Yeah, so, right now, my discussion is mostly centered around biologic for psoriasis, because we have a bit more data around that. Whether to give live vaccines with dupilumab is a little bit uncertain. But I think the approach that I just talked about is overall a conservative approach. And it's something I think we're all looking or going to examine a little bit further with regards to pillamab, that helps a lot. What about vaccines that need to be repeated with a second vaccine vaccination shot, like zoster, or even Covid vaccines? Right. So, for Covid vaccines, there has been a lot of different conversations, but very little data. And the reason it's confusing is because different entities also have recommendations that sort of conflict with one another. But overall, what I wanted to say is that the International Eczema Council have a pretty, I thought, useful, simple, but broad statement about COVID vaccines and the use of immunomodulatory or immunosuppressive agents. So what they say is that anytime you get a vaccine, COVID vaccine, and all of our Covid vaccines are currently killed vaccines. So each time you get any dose of that, you want to wait one week after each vaccination before you administer, whether it's oral or injectable immunomodulatory agents. And the reason for that is to try to enhance the vaccine response. So I think that's a general role that's quite reasonable. And in a world where we have lack of a lot of data, would help ensure our patients to get good vaccine response without significantly impacting their disease activity. And if we look a little bit further, I would say the National Psoriasis foundation make a bit more nuanced recommendations for the COVID vaccines. And the reason for that is that we have a bit more data and more data from rheumatology world to inform our recommendations as well. So the NPF recommends that for the killed vaccines, including Covid vaccines, that nothing different needs to be done with any of the biologics with regards to the timing of the biologic. And when you administer the vaccine, where it's different oftentimes is with methotrexate and jack inhibitors. And the recommendation there is to, after each shot of the vaccine of the COVID vaccine, you want to wait two weeks before you give methotrexate. And for jack inhibitors, you want to wait one week before you restart jack inhibitors. And the rationale for that is for the body to have a good immune response to the vaccine. If the patients are on either of those, let's say they were on methotrexate and you stopped it, how long would they have to be off of it before you would give the vaccine? You don't have to stop the methotrexate or jack inhibitors before you give the vaccine so they can continue that up to the time they get the vaccine. And then for methotrexate, wait two weeks after the vaccine to restart, after each dose of vaccine to restart. And for jack inhibitors, wait one week post vaccine before you restart. That this gives us some reasonable guidance and probably will change a little bit down the line, and we'll hopefully come to you for updates on this at another point in time when we have more scientific information. Well, April, this has been very helpful to me. I'm writing down you like to have something reasonably concrete that you can work with, and you're giving some time frames and some reasonable recommendations that I know will be very helpful to me. So I appreciate your time and I guaranteeing you that we are going to come back to you for another one of these discussions. Thanks a lot and you have a great day. Thank you, Jim. It was a pleasure talking with you. We want to thank everyone for listening to derms and conditions this year, in 2021, and we're looking forward to 2022. But right now, we wish all of you a happy holiday season. Take care and stay healthy and happy. On behalf of Aquaphor, we thank you for joining this week's episode. Recommend Aquaphor healing ointment for postprocessure wounds and the treatment of dry, cracked, irritated skin.

Episode 16 of Derms and Conditions has our host James Q. Del Rosso, DO speaking with Matthew Zirwas, MD about pruritus. Dr. Zirwas discusses the topical treatment of pruritis and offers a unique combination topical regimen that he often uses for his patients. He also presents some tips and tricks for treating Pruritus Ani.

Episode 16 of Derms and Conditions has our host James Q. Del Rosso, DO speaking with Matthew Zirwas, MD about pruritus. Dr. Zirwas discusses the topical treatment of pruritis and offers a unique combination topical regimen that he often uses for his patients. He also presents some tips and tricks for treating Pruritus Ani. Dr. Del Rosso and Dr. Zirwas also discuss a new non-steroidal, topical agent for pruritus. Dr. Zirwas discusses, in detail, the hypothesized mechanism of action for this novel agent and shares his success using it in his clinic. Finally, he briefly mentions some alternative oral agents for the pruritic patient. Financial Disclosures JAMES DEL ROSSO, DO FINANCIAL DISCLOSURES: CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). MATTHEW ZIRWAS, MD FINANCIAL DISCLOSURES: Regeneron / Sanofi - Speaker, consultant, investigator Fit Bit - Consultant Genench / Novartis - Speaker L&rsquo;Oreal - Consultant Menlo - Consultant AsepticMD - Part Owner Leo - Investigator, Consultant Janssen - Investigator Incyte - Investigator Foamix - Investigator UCB - Investigator Pfizer - Investigator, consultant Lilly - Investigator, consultant Asana - Investigator Avillion - Investigator Ortho Derm - Consultant Abbvie - Investigator Edessa Biotech - Investigator Galderma - Investigator Dermavant - Investigator Arcutis - Investigator, Consultant Sol-Gel - Consultant Bausch Health - Consultant EPI Health - Consultant, Investigator

Clinical Pearls That You're "Itching" To Hear

In episode 15, James Q. Del Rosso, DO chats with Anthony Rossi about Brigham and Women' Hospital squamous cell carcinoma staging system, tips on treating keratoacanthomas of the lower extremities with subcutaneous methotrexate, and more.

Episode 15 of Derms and Conditions, has our host James Q. Del Rosso, DO speaking with Anthony Rossi, MD, a Mohs Surgeon at Memorial Sloan Kettering Cancer Center in New York City. First Dr. Rossi discusses the use of the AJCC and Brigham and Women's Hospital squamous cell carcinoma staging system. Next Dr. Del Rosso asks Dr. Rossi for tips on treating keratoacanthomas of the lower extremities with subcutaneous methotrexate. Finally, Dr. Rossi discusses the use of immunotherapy in treating squamous cell carcinoma. Financial Disclosures James Q. Del Rosso, DO CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Non Relevant Disclosures for Anthony M. Rossi, MD: Evolve CME: Consultant; Almirall: Consultant; Mavig: Travel; Merz: Consultant; Dynamed: Consultant; Canfield Scientific: Consultant; Allergan Inc: Advisory Board; Evolus: Consultant; Biofrontera: Consulatant; Quantia MD: Consultant; Lam Therapeutics; Consultant; Regeneron; consultant; Cutera, consultant; Skinfix, advisor; L&rsquo;oreal, travel, DAR companies: Founder ASLMS: A Ward Memorial Research Grant Skin Cancer Foundation: Research Grant Regen: Research / Study Funding LeoPharma: Research / Study Funding Biofrontera: Research Study Funding Editorial Board: Lasers in Surgery and Medicine; CUTIS Editorial Board: Journal of the American Academy of Dermatology (JAAD); Dermatologic Surgery Board Member: ASDS Committee Member and / or Chair: AAD; ASDS; ASLMS This research was funded, in part, by NIH/NCI Cancer Center Support Grant P30 CA008748. The funder had no role in the design and conduct of the study: collection, management, analysis, and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.

The Scoop on Squamous Cell Carcinoma&nbsp;

You're listening to the Derms and Conditions podcast. Hello, Dr. Jim del Rosso, based in Las Vegas, Nevada, where I'm primarily involved in dermatology research at JDR Dermatology Research, and also the senior vice president of clinical research and strategic development for advanced dermatology and cosmetic surgery and involved in a lot of clinical initiatives. And this is one of them that's very important to me. Derms and Conditions podcast. And we have a great guy and a very knowledgeable guy that I got to know, actually, when he was a resident under Vince deleo in New York, and he moved on to get a lot of training in cutaneous oncology and moe surgery. It's Dr. Anthony Rossi, based in my hometown in New York, and he practices out of Sloan Kettering cancer Center in Manhattan. So welcome today, Anthony. I'm glad you could make it. Thanks so much, Dr. Del Rosso. It's always great to see you and just hang out and chat. I call him Anthony, and because I'm an old man, he calls me Dr. Del Rosso, but that's okay day. Anyway, so reason why I'm calling you today is I've been noticing in the literature, and, yes, I still read the journals, and, like we all try to do, try to keep up with the barrage of information, and there really has been literally a plethora of information on squamous cell carcinoma, a lot more talking about staging or grading, looking at the behavior of squamous cell carcinoma. When I started out, there was squamous cell carcinomas. Certain sites might metastasize. You get concerned about bigger tumors or maybe less differentiation, et cetera, but that was it. We didn't really talk much more about it, but now it's being looked at a lot more in depth, and we also have some non surgical therapies. So can you go over your perception of sort of the breadth of squamous cell carcinomas, and what are some of the presentations and maybe even histological features that go into it? I think we're all in a busy practice. It's not only great to try to keep up with the literature, but there's so much out there now with squamous cell, and it's really becoming really popular topic, not only for research, but also for targeted therapies and immunotherapy, which is really interesting. So I think for me, it's always important that when I see squamous cell, that I really try to think about it as what type of squamous cell is this. Is this going to be a bad player, or is this going to be someone that does really well? And I do mose. So, oftentimes we are only seeing the tip of the iceberg before we actually get to the real part of the tumor in mo surgery. So when we're approached with these, we usually have a biopsy report that might say squamous cell carcinoma, invasive, well differentiated, but that could only be the top. And so I think it's important for all of us in dermatology to start thinking about the staging system for cutaneous squains. And really, how do you do that? How do you do the staging? Yeah, I think the AJCC eight is now out. And even as importantly, the brigham and women's hospital by Dr. Chris Schmaltz has really highlighted a way to differentiate bad squamous cell carcinomas from ones that might behave better. And if anyone hasn't seen those recently, they did make changes to the AJCC. So the 8th edition is a bit different. So I can run it through. Basically, a t one tumor stage is anything less than 2 cm in clinical diameter. So that's something we could all look at, measure, and take note of a t two. Now, in the AJCC, eight is anything greater than 2 cm, but less than 4 cm. So they're really going by size cut off for the tumor stages. A t three, this is where it gets interesting. Is greater than 4 cm, greater than or equal to 4 cm in clinical diameter, or anything that has minor bone erosion, or perinaural invasion or deep invasion. So that's kind of nebulous. But when they talk about perinural invasion, they're talking about nerves that are greater than 0.1 millimeter in diameter, or deep invasion, which is like greater than 6 mm in depth. So really into the subcutaneous fat and beyond. And then t four A, which is the next category, would be really gross cortical bone involvement or marrow invasion. So that's a much deeper one. And then t four B is anything with skull based invasion. So those are higher grade. So what about anatomic location? Because I remember so called high risk areas, the hands, the lip, even the ear. And is that independent of size, or. I mean, I'm trying to imagine a four centimeter lesion on the lip would size adjust downward based on the anatomic location. It's interesting because the AJCC is really for head and neck cancers, which is interesting because they're not going by even the smaller areas around the face, like the mask like areas around the eyes or the lips, like you said, perinasal, the ears. But when we look at the NCCN, the NCCN does list different anatomical areas as high risk versus low risk. We use the staging classification for more prognostic information, but we use NCCN to really guide our behavior, guide our treatment options. So it's really putting these all together. That's super. Know what's interesting is you mentioned perineural invasion, which with, you know, raises a red flag. With basal cell, it can, but with squamous cell certainly does. And I remember when I started out in mersurgy in my first year, I had a patient that had a squamous cell carcinoma on the nasal aila area, where more used to often seeing basal cell carcinomas. But she had a squamous cell carcinoma, and there was a superficial biopsy. And I went ahead and did mo surgery, and later on, she developed some symptoms. And in going back, we looked at it, and there was this very small area of perineural invasion. And I remember the pathologist saying, that was on my sections. Okay, that was on me. It was a very small area. And so now I was really concerned about it. It was my first year in practice, and the pathologist, I brought it to a tumor board, get people's opinion. Do we radiate? What do we do? And the pathologist said, well, the most sections, I don't have those. They're gone. They're frozen sections, and they have the cut, but we don't have a block. And I learned from that that if I had any type of squamous cell that I sensed had any depth, I would take a debulk specimen, and I'd either cut through it myself and look at it, but even more so, I'd send it. Not as a stage, that would be improper billing, but I would send it. So I had that block to the pathology lab in case you needed to look backwards. Have you ever ran into any situation like that? I don't want you to admit that you missed the case like I did early on, but it happens to us, and we have to handle it. But have you seen cases like that with perineural invasion? Oh, for sure. So that's a huge point, Jim. I mean, it's really important, especially when you're doing mos. If you get an outside biopsy that says, like, sec, well differentiated, but your layer of Mose shows, like, a poorly differentiated squamous cell invading the fat, you think there's perineural there because there's a lot of inflammation. I think that's really appropriate. And our guidelines from the AAD, even Moe's college, it's okay to submit the tumor debulk for permanent sectioning because they're going to be able to bread loaf that they're going to be able to use immunostains if they want to, and really measure out the diameter of the nerve, because that's also very important in squamous cell. If you have a nerve that's involved that's greater than 0.1 in the deep dermis or the fat, it might behoove you to use adjuvant radiation post surgery, even if you get clear margins. So that could be a tipping point to actually use adjuvant radiation. Yeah, because the squamous cell, any tumor that is perineural invasion doesn't necessarily go fully circumferential. And there may be an area where you're not seeing the underside of it, your cut is missing that area. So the clear margins doesn't mean that you're fully clear. Any other type of tumors where you basal cell, same thing with perineural. We're not so keen on jumping to adjuvant radiation with perineural in basal cell because the studies haven't shown that we necessarily need to. But if there is extensive perinaural invasion in your basal cell, it's something to definitely consider and to at least talk with the radiation oncologist. There might be other risk factors like lymphovascular invasion or immunosuppression of the host. And those are other things that could tip you over to actually give adjuvant radiation in squamous cell, we know it can make a difference. So more work needs to be done on basal. I remember a case that there was a superficial biopsy that was read as basal cell carcinoma, and then once the mo surgeon got into it, they saw fair amount of perineural invasion and the histology changed. It was a microcystic ednexal carcinoma, and the biopsy was very superficial. And looking at it, you would think it could be a basal cell carcinoma. So sometimes there are bad actors. One of the things that I do, and I was wondering your thoughts on this with squamous cell carcinoma, any squamous cell carcinoma, I always palpate regional lymph nodes at baseline and then on follow up, because if you do get a metastasis of regional lymph nodes and you don't have that in the record, I always felt like, well, don't you know that you should be evaluating for this? And we might forget to do that. Right? Yeah. I mean, in a busy clinic, definitely. I think it's important, because if you're going to catch a local spread to lymph node, you can hit it on clinical exam, and you can feel it when it's there. So it brings up a good point, because Chris Schmaltz at the Brigham, she developed the Brigham and women's hospital staging system for squamous cell, and it can be a bit more sensitive than the AJCC in actually teasing out the really bad players in squamous cell because she uses a different scoring system for tumor grade. It's basically just based on risk factors. So the risk factors there. And it could be a little bit easier to use as a dermatologist as well. The risk factors are greater than 2 cm in diameter, poorly differentiated histology, perinaural invasion greater than zero one, or tumor invasion beyond the subcutaneous fat. And if you hit two or three high risk features, that'll give you a score in the Brigham and women's as t two b. And Dr. Schmaltz has shown that a t two b can actually have a higher rate of lymph node metastasis. And so I think when you're playing with those, when you see those, we really have to be on the lookout. Yeah. Anthony, be careful. You're making it seem like we should have interviewed. She's like, she's amazing. She's one of our dermatologists. You should definitely interview her. I appreciate it. So now let's talk about some tumors on the lower extremity in older patients, or really in very tight areas, but thinking about older patients that may have several other risk factors, and at times, I've actually used intralesional methotrexate on some of these lesions and have gotten excellent clinical results. I don't have data out five years or ten years, but was surprised at how good they respond in patients where you're really concerned about surgery because of their medical condition and other factors. Have you done that at all? Yeah. So for any carado acanthomas that are like classic kas, they erupt. I do offer interlegional methotrexate because I actually did publish a study in derm surge about injecting these with interlegional methotrexate, and we did show a high clinical response and so resolution with them. The caveat was, the ones that didn't respond are the ones that you should be wary of because those in my small case series had perineural invasion, or they were poorly differentiated at the base, and they were painful. They were much more painful than the others. So can you explain how you do it, the dosing, how often you give it, and how you clinically evaluate response versus a non responder? Sure. So if you have someone, especially on the lower legs, very sun damaged skin, they can develop kas, especially around other sites of trauma. If I see a classic ka, sometimes I'll take a biopsy. Most of the time, I'll take a biopsy, actually, and it'll show the ka features. And so I basically use methotrexate 25 migs in one ML, and I inject at the base of the carado acanthoma and usually at the perimeter as well. So right into the lesion at the center and then at the four quadrants in the perimeter. I do draw back on the plunger just to make sure we're not in a vessel, just because we don't want to necessarily inject into a vessel. And then I actually will do this every four weeks for three treatments. And what's the amount that you're giving the milligrams you're giving per injection? I give 25 milligrams in one ML. So, 1. Are you giving it into the middle portion of the tumor, trying to get to the depth? Yes, I give it in the center and then in all four quadrants at the perimeter at the base of the lesion. Okay. How many times will you do it? I'll do it up to three times. Yeah. Four weeks apart to see, but you should be seeing clinical resolution through each point. Okay. So you should see a response after the first injection, and maybe if you didn't, you might try one more, and that's it. If it doesn't respond, you're done, right? Yeah, exactly. For us in this study, I did, actually, when I was a fellow at Memorial, we saw the ones that weren't responding were associated with more pain or really rapid regrowth, and you could tell that they were just regrowing and getting larger. And then when we did sample the base or we did Mos on them, they basically showed poor differentiation or perinaural invasion. So I wanted to ask you two other things. The first thing, before we get to the PD one, inhibitors, I wanted to ask you your use of those and pros and cons. But we also now have testing not only on melanoma, where you can take the block, but testing where you can get different types of genetic testing to look at classify the behavior of squamous cell carcinoma. It's newer, but I was wondering if you can elaborate on that. Where should I be thinking about doing that? I think it's still really, a lot of research has been going into this, about looking at the molecular characteristics of squamous cells. Squamous cell is a really mutated tumor. It's highly, highly mutated. It has a high mutation burden, about like 30 to 60 per megabase, whereas melanoma has like about 13 per megabase. So the idea that squamous cell is highly mutated, so people are looking into the different sort of gene expression in squamous cell carcinoma. We don't use it right now in clinical practice, but I know more research has been given to that. It's something that may be right around the corner and pay attention to that. So I do have two other questions for you before I let you get back to your patients. And I file my notes away here that I'm taking, so I don't forget. What about the PD one inhibitors? Where do you see those being used? What's the upside? What are some of the concerns, toxicities or things, drug interactions, whatever, that we need to be concerned about? It's a wide question, so let it rip. No, yeah, I mean, PD one inhibition is very exciting. I mean, we saw how much improvement we got in melanoma, and so it made sense that it's now being explored for many, many different cancers, because basically we're harnessing the immune system to unleash onto these tumors and to attack them. And the idea stems from that. Squamous cell has a high mutation burden. We do see the presence of tumor infiltrating lymphocytes in biopsies, and that has been researched into. Immunosuppression is actually a risk factor for developing squamous cells. And we know there's direct immunosuppressive effects of uv radiation. So all of this has led to using PD one inhibition in squamous cell and submiplamab is now FDA approved. As part of disclosure, I have been on advisory boards for submiplumab in squamous cell, so that's good to say. But, yeah, it's really interesting because basically submipomab is a monoclonal antibody that binds to the program depth receptor one. That's the PD one in the receptor, and it basically blocks this PD one, PDL one pathway, and that's going to help, not suppress the immune system's response. To the cancer that happens normally. And so by allowing the immune system to basically unleash and to attack these tumor cells, we're seeing quite a good response, a better response than we've seen with cytotoxic chemotherapies or EGFR inhibitors. So in the main study, the objective response was about 50 in the phase one study, and then in the phase two metastatic study, it was about 47. The percent of the patients. Is that percentage. Yes, exactly. And what about toxicity, or how are they administered? And what toxicities do you have to look out for? Yeah, exactly. They're infusion, and the toxicities are not something you can just brush off. I think more dermatologists are very comfortable now with hedgehog inhibitors for basal cell, where the toxicity, once we stop it, they go away. The dyscusia, the alopecia, the muscle cramps in hedgehog inhibitors. But for PD one inhibition, the immune adverse events or the autoimmune adverse events can be lifelong. And it's something that has to be really considered and thought about, because not only do you get common adverse events like diarrhea, fatigue, rash is very highly associated, but you can get these autoimmune thyroiditis, you can destroy the pituitary gland. We can really see some autoimmune issues that can be permanent, and so we can't take that lightly. I would say not. Well, this has been very helpful to me, and I really appreciate it, and looking forward to seeing you at an upcoming meeting, and that was great information. Appreciate it. Thank you. Dr. Del Rosa, always a pleasure. Thank you for listening to this episode of Derms and Conditions. If you have any questions or comments, please email us at. Podcasts at Fred Health and most importantly, if you like this episode, subscribe to the Derms and Conditions podcast on Apple Podcasts or wherever you get your favorite shows.

In episode 14, James Q. Del Rosso, DO and&nbsp;George Han, MD discuss a treatment tip for the management of pyogenic granulomas in children&nbsp;and biologic therapy for psoriasis. They also cover use of adalimumab during surgery, risk of TB reactivation, and risk of malignancy. Dr. Han also&nbsp;shares his experience with telemedicine and how dermatologists can help shape its uncertain future.

Episode 14 of Derms and Conditions, has our host James Q. Del Rosso, DO speaking with George Han, MD, PhD, Associate Professor in the Department of Dermatology at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. First Dr. Han discusses a treatment tip for the management of pyogenic granulomas in children, then he addresses questions about biologic therapy for psoriasis. Topics include the use of adalimumab during surgery, risk of TB reactivation, and risk of malignancy. Dr. Han ends the episode by sharing his experience with telemedicine and how dermatologists can help shape its uncertain future. FINANCIAL DISCLOSURES James Q. Del Rosso, DO CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). George Han, MD, PhD Consultant, Speaker, or Research Support from Celgene, Janssen, Lilly, MC2, Pfizer, UCB, Boehringer Ingelheim, Bond Avillion, Athenex, Amgen, Abbvie, Regeneron/Sanofi, LEO Pharma, Ortho Dermatologics, BMS, Sun Pharma, Dermavant, Dermtech, MedX, Novartis, and Castle Biosciences

A Potpourri of High Yield Pearls

Live from The Wynn Hotel and Casino in Las Vegas, NV, episode 13 of Derms and Conditions, has our host James Q. Del Rosso, DO speaking with Bruce Strober, MD, PhD in person at the 2021 Fall Clinical Dermatology Conference discussing older biologic agents in psoriasis and how JAK inhibitors offer improved efficacy while not compromising on safety.

Live from The Wynn Hotel and Casino in Las Vegas, NV, episode 13 of Derms and Conditions, has our host James Q. Del Rosso, DO speaking with Bruce Strober, MD, PhD in person at the 2021 Fall Clinical Dermatology Conference. First Dr. Strober discusses older biologic agents in psoriasis and how JAK inhibitors offer improved efficacy while not compromising on safety. Dr. Strober further discusses in depth how certain JAK inhibitors interact with TYK2 and what he thinks are the most important points regarding this pathway in psoriasis pathophysiology. Finally, Dr. Strober discusses in detail why allosteric binding offers improved specificity in JAK inhibition. FINANCIAL DISCLOSURES James Q. Del Rosso, DO CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Bruce Strober, MD, PhD Consultant and Advisory Boards Consultant (honoraria): AbbVie, Almirall, Amgen, Arcutis, Arena, Aristea, Asana, Boehringer Ingelheim, Immunic Therapeutics, Bristol-Myers-Squibb, Connect Biopharma, Dermavant, EPI Health, Equillium, Evelo Biosciences, Janssen, Leo, Eli Lilly, Maruho, Meiji Seika Pharma, Mindera Health, Novartis, Pfizer, UCB Pharma, Sun Pharma, Regeneron, Sanofi-Genzyme, Ventyxbio, vTv Therapeutics Investigator AbbVie, Dermavant, Dermira, Cara Stock Options Connect Biopharma, Mindera Health Speaker AbbVie, Amgen, Eli Lilly, Janssen, Sanofi-Genzyme/Regeneron Investigator: Dermavant, AbbVie, CorEvitas Psoriasis Registry, Dermira, Cara, Novartis Scientific Co-Director CorEvitas Psoriasis Registry Editor in Chief Journal of Psoriasis and Psoriatic Arthritis

How to Avoid Getting "Tyked" Off When Learning About New JAK Inhibitors In Psoriasis

You're listening to the Derms and Conditions podcast. Hello, I'm Jim del Rosso, a dermatologist from Las Vegas, Nevada. And where here at the fall, clinical dermatology at the win. And we have the Derms and Condition podcast, which this is number 13. So we've had, I think, a very successful year with these particular podcasts, which we'll talk a little bit more about later. But before we get started, I want to mention now, let's pause for a message from our advertiser. Bristol Myers Squibb is exploring trailblazing research in technology, which starts with illuminating the role of tick two in psoriasis. Start exploring the tick two pathway by visiting www.ticktu.com. That's spelled www dot Tyk two. So it's a pleasure to have today a guy that I have tremendous respect for, that I've known for quite some time, that's well known in dermatology, primarily in the area of psoriasis, but certainly some other areas. And that's Bruce Grover. So, Bruce, it's great to have you here today. Thank you. It's my pleasure. I know you're going to elucidate people on this area. So let's talk about psoriasis and really what's happened with the advances over time. And on one of the calls I had with David Cohen that we had with the podcast, he made the statement that there's been a difference in the progress between atopic dermatitis and psoriasis. He said, with the development of biologic treatment, the first agent that came out was a big jump that obviously had tremendous efficacy and safety, et cetera. But with psoriasis, it was a slower development from the first agents that we had that have marched along to different mechanisms of action. I'd like to get your perception of that right. Exactly. You know, when I started seeing patients as my own dermatologist, not in residency, I was impressed with Enbrel and raptiva and Amaviv. But by any measure, over the years, we've come to use more advanced medications, increasingly more effective, more targeted. And the most important aspect of this is the more advanced the drugs have become. They haven't compromised with regard to safety. So we've gotten increased efficacy and, in my opinion, better safety and more convenient dosing. So incrementally, over many, many developments over about two decades, there's been steady improvement, almost as if what you think is good this year, well, just wait till next year, was always the thought process, whereas atopic dermatitis, I understand what David is saying the first biologic out is a very impressive drug, and it's going to be hard and very safe and very safe, and it's going to be hard to see that kind of evolution in atopic dermatitis therapies that we saw over the psoriasis timeline. So the advances in psoriasis, I think, have been related to advances in the basic science to look at the mechanisms of action of these different agents that target, more specifically, certain receptors or cytokines that lead to the manifestations of psoriasis. In fact, the initial drugs that were developed for psoriasis, the tnf inhibitors, which were very successful, were developed for other disease states like rheumatoid arthritis and gastrointestinal diseases. And then all of a sudden, the newer drugs, really, beginning with eustachinumab stellara, were developed solely for psoriasis. And that became a trend where the first indication for a drug was a psoriasis indication, and then other indications fell behind that. So that was a flipping of the equation that made me feel very happy that companies saw psoriasis as an important first step in developing a new medication. So we've had the advances with these injectable biologics, but in the wings, we've always had certain oral agents that we use that are approved, methotrexate, cyclosporin, that have their benefits and certainly their baggage. But now that we're getting into this world of Janus kinase inhibition, we have oral drugs that are being developed, and certainly there are differences, they're not all created equal, there are differences between them. But one of the areas that I think is people have questions about, and I know I do, is with inhibiting tick two as compared to the other Janus kinase inhibitors. So can you talk about some of the things that you think are important about tick two as a pathway and what might be different in terms of the inhibition of tick two? Firstly, as long as I've been working with jack inhibitors, the goal has always been very to be selective, right? Every company that makes a jack inhibitors always say, we are very selective. We only hit this Jack kinase or we only hit these two. But it was not always realized to be the case that early jack inhibitors were actually, as I say, more promiscuous. They would block a bunch of the family members and in so doing, no doubt, they got efficacy out of the drug. But there would be safety concerns because it's clear that touching the jack one through three family creates greater risk for patients. So the tick two inhibitory mechanism became attractive, because if you knock out tick two's ability to signal, then you essentially can just target psoriasis pathophysiology, because downstream of tick two are the pathways for il 1223 and interferon. And if you could leave alone the other Jack kinases, you could still get good psoriasis efficacy. And lo and behold, the studies of decravacitinib, which is really the paradigm of tick two inhibition, displayed that very selective inhibition of tick two without touching jack one through three gives efficacy in psoriasis that's really measurably good. Beats placebo, beats a premolast in a head to head, but also leaves out the other activities that blocking jack kinase might come along with, such as laboratory monitoring. It appears that from the studies that venous thromboembolism, arterio thromboembolism are not a part of its adverse event profile. Lipid abnormalities. If you look at the laboratory readouts from studies in psoriasis and also psoriatic arthritis, there doesn't seem to be any measurable difference between what's happening with the patients getting tick two and patients getting a premolast and a placebo. It seems to be very comparable laboratory profiles, which makes me believe, and I'm only speaking for myself, but laboratory monitoring for decravacitinib is likely not required, like it might be for another jack inhibitor. We'll see what happens with further data, but you're not certainly promising, so I'm going to ask you to hold a second. And now let's pause for a message from our advertiser. Bristol Myers Squibb is exploring trailblazing research and technology, which starts with illuminating the role of tick two in psoriasis. Start exploring the tick two pathway by visiting www.ticktu.com spell www dot tyk two. So let's go a little bit further. I remember I was listening to someone talk and they were discussing this, and I'm like, you got to remember, when I was a resident, there weren't a lot of moving parts. You just had basal keratinocytes going to the surface and they got shed and we knew there were these t cells and b cells. We didn't know about all these moving parts and cytokines. And now they're talking about Il this and Il that and this receptor. And then they said something about allosteric binding. What does that mean? Well, essentially, if you think about tic two, it has two major domains. It has its catalytic domain, which mediates phosphorylation of target proteins and that allows signaling downstream, but it has a regulatory domain. Many proteins have regulatory domains that, if altered through binding of a ligand like a drug, the regulatory domain can essentially cause the catalytic domain to malfunction. It doesn't allow it to phosphorylate targets. So it's an indirect approach to blocking an enzyme, a protein, but not touching its catalytic domain. That's allisteric inhibition in a nutshell. And if you can do that, you stay away from domains of proteins that are shared across families. The catalytic domain of tick two is shared with the other jack members and probably defines it. But that would help the selectivity. Yes, exactly. If you bind the allosteric domain, which isn't shared by other members of the family, you have a specific targeted area of the protein that isn't found in other Jack kinases, and therefore the drug will specifically bind tick two alone. So this is becoming like an aha moment when the light bulb goes on. It's definitely making a lot of sense. So I certainly appreciate that. So now let's pause for a message from our advertiser. Bristol Meyer Squibb is exploring trailblazing research and technology, which starts with illuminating the role of tick two in psoriasis. Start exploring the tick two pathway by visiting www.ticktu.com spell www dot tyk two. So, Bruce, I want to thank you for your time today. I know you have a lot of the things you like to be doing, but I appreciate your time. And I guarantee your phone will be ringing again with another call from Jim del Rosso saying, help. Help me understand this. You can have me on speed dial, and the caller id comes up and I accept it right away. I have two people on the dial, you and Mark Lebore. I made the cut. That's great. Thanks a lot. Yep, my pleasure. So, if you are interested in previous editions of Derms and Conditions podcasts or this current one, which you can access down the line, all of them, go to fallclinical health or go to apple podcasts or any place where you get your favorite shows. These are archived, and you can go back and listen to any of these podcasts, including the one with Dr. Strober today. Thank you very much.

In episode 12 of Derms and Conditions, host James Q. Del Rosso, DO speaks with Brent Moody, MD about basal cell carcinoma. Dr. Moody discusses the importance of reviewing the pathology when treating a basal cell carcinoma, especially if significant inflammation is present.

In episode 12 of Derms and Conditions, host James Q. Del Rosso, DO speaks with Brent Moody, MD about basal cell carcinoma. Dr. Moody discusses the importance of reviewing the pathology when treating a basal cell carcinoma, especially if significant inflammation is present. Dr. Moody also discusses the use of hedgehog inhibitors and the role they play in the treatment. He reviews indications, side effects, and important pearls when teaching medical students and residents about the surgical and medical treatment of basal cell carcinoma. Financial Disclosures: James Q. Del Rosso, DO CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Brent Moody, MD SPEAKER&nbsp; Genentech

Don't "Hedge" Your Bets When Treating Basal Cell Carcinoma

This episode is sponsored by Genentech, a biotechnology company dedicated to pursuing groundbreaking science to discover and develop medicines for people with serious or life threatening diseases. You're listening to the Derms and Conditions podcast. Hello, this is Dr. Jim Delrasso in Las Vegas, Nevada, where I'm involved in JDR dermatology research and also senior vice president of clinical research and strategic development for advanced dermatology and cutaneous surgery. But we're not here to talk about me. We're here to talk to Dr. Brent Moody, who is joining us from an exciting city, but not only known for music, but also has some people that are pretty good in Dermato oncology, which is an area that he's focused on, does dermatology and mo surgery in Nashville, Tennessee. So welcome, Brent, and it's great to have you here. Thanks. I'm honored to speak with you today, Jim. So I know this is going to be very valuable, certainly to and something that a lot of people don't know. And it's one of the reasons why I'm calling you, because you are doing mo surgery and dermatologic surgery and cutaneous oncology predominantly in what you do in clinical practice. I've been a general dermatologist who was trained in Mo surgery. I did a fellowship in Mo surgery years back, but incorporated that as part of my general dermatology practice and would do it with some other clinicians. But I've forgotten some things, or I've lost track of some things with a variety of different interests over the year. That's why I'm calling you today, because I have some questions about management of non melanoma skin cancers, is what I want to focus on. And one of the things I remember back when I was a fellow, Ron Siegel, the guy who trained me, great guy at Ohio State, he said, well, he got a call from Ron Wheland, who is very well known at that time, who was putting together a textbook, and he wanted someone to write management of basal cell carcinoma. So Ron looked at me and said, guess what your fellowship project is, and got very involved in looking at a lot of detail and a lot of references on basal cell carcinoma. And one of the things that really rang true with me is that all basal cell carcinomas are obviously not created equal, and there are certain histologic subtypes which are more aggressive, potentially, in terms of extensive spread beyond what you visibly see. For someone like myself, who's doing a lot of general dermatology and assume that I'm not someone that does most surgery in this case. Right. Are there histologic subtypes that clinicians should hold their dermatopathologists accountable for, assuming there's an adequate biopsy to give them direction in terms of what the biologic nature of that basal cell is going to be, in terms of subclinical spread or extension of the type of lesion or even greater perineural invasion? Yeah, absolutely. Whenever I'm confronted with a patient with basal cell carcinoma, I mean, step one is to look at the cancer, see how big it is, see where it's located, look at the patient, how old is the patient, what's their general health, the things that we all do every day as dermatologists. But then, really, I got to focus in on that pathology report, and this is where having a great dermatopathologist and a good relationship with the dermatopathologist really makes a big difference in figuring out how to approach any particular skin cancer. So, for basal cell carcinoma, I want to look at things like, if they comment on depth of invasion, if they comment on a known histologic subtype that we generally recognize can be a little more aggressive, and those are going to be buzzwords. You look for infiltrative morphe form, micronodular basosquamis. Certainly, if perineural invasion is noted, you need to be aware of that. It doesn't have quite the same implications as it does with squamous cell carcinoma. But those are some of the things, certainly, that if you see that in a path report, you need to factor that in your thinking and decision making with that patient. Do you give any credence to. And this is something I always wondered about, and my thinking about it and what I've read has changed over the years, the amount of inflammation within the tumor. And I used to think, well, that's the body trying to fight it, but we know that that's not necessarily the case with basal. Does it matter to you if it's basically devoid of inflammation or if there's a lot of inflammation within the lesion with basal cell carcinoma? Not particularly, other than I'm already thinking. If that's noted on the pathology report, I need to go back and say, does this patient have an underlying condition I need to be aware of? Does this patient have cll that maybe is undiagnosed? We've had instances where the first indication that a patient has a blood cancer comes from a skin biopsy specimen that's just full of lymphocytes. So something like that may be important. But also, if I'm thinking this patient is going to be a good candidate for most surgery, I'm thinking, is that inflammation going to make looking at those slides more challenging? Is perhaps that inflammation going to mask tumor? So I think in the realm of basal sarcarcinoma, I don't really worry about it from an aggressiveness standpoint of that tumor or a patient morbidity or mortality standpoint, but it can have some practical implications to treating that patient. So what about mixed histology or even the depth of a biopsy? And one of the things that I'm cautious with when training residents or students or even physician assistants and nurse practitioners that are just starting out in dermatology, they may be gun shy about scarring patients, but if they don't get an adequate depth to a biopsy, obviously you can get the wrong read, but you're not necessarily going to get a true read on the histology, and you may miss some of their mixed histology in the deeper aspects of the tumor. How often do you run into that? When you get referrals and you're looking at the original report that suggests a non aggressive tumor, and it turns out to be more aggressive? Yeah, frequently, we'll find the more aggressive aspects of a tumor are deeper in the tumor, so you got to be aware of that. And when you're confronted with a basal sarcarcinoma and you have a path report that indicates it would be a more superficial tumor, you have to make sure that that's really going to be reflective of the entire histology of that tumor. And sometimes you honestly just don't know until you get into it. And I agree with you, depth of biopsy is important. If you're suspecting a lesion may be deeper, it really helps to get into the dermis to get a better sample to help you with that. So let's move on to some newer areas. We're getting more into some medical therapies for nonmelanoma skin cancers. Obviously, we all have a lot of background on surgery and understand where mo surgery is valuable, but with the hedgehog inhibitors, can you basically give, in a nutshell, explain for me? So I understand these. What are they actually doing within basal cell carcinoma? So, the basic science on hedgehog inhibitors is actually really interesting, and it's just so great for dermatology that we found a genetic defect in basal cell carcinoma, which in the large proportion of them is a defect in a gene called patched. And then we found a molecule, an extra series of molecules that interact with that pathway and can basically turn it off. So we have this defective, what's called the sonic hedgehog pathway, and we have found molecules, hedgehog inhibitors, that turn that pathway off and really can be very valuable in basal cell carcinoma. And so thinking about the non surgical therapy of basal cell carcinoma, I mean, when I was a resident, it's when people first started toying around with using amiquamod as a topical therapy for basal succarcinom, and it just seemed so revolutionary at the time. And now we have really this oral therapy which really can help the dermatologist and moe surgeon. I think having access to these non surgical therapies makes me a better surgeon now, which was the first hedgehog inhibitor that became available. So the first FDA approved hedgehog inhibitor was bismodog. The trade name is Araveg. Okay. And now I believe there's more than one that's available now. I think there's two on the market. There are two FDA approved. So the one I mentioned, the vismodojib and then sonedegib, which goes by the trade name odomzo. Okay. So I've had. Most of what I've encountered is the. And the questions that I have about it. We obviously know for metastatic lesions or inoperable lesions, but I was wondering, how do you select patients that you feel are candidates, whether it be an on label use or times when you just find this to be helpful to you, even if you're anticipating doing surgery? Because we don't see a lot of metastatic lesions. Correct. If we do, obviously this would come into play. Yeah. Fortunately, metastatic basal carcinoma is very rare, so it's not something we're going to encounter with any frequency. When I think about non surgical options, when I think about using a hedgehog inhibitor, the patients fall into several categories. There's the category of just a really big cancer. It's just big. And surgery would be deforming or it would be technically challenging. So just really big ones. And then I sort of go back to. It's like real estate. Location, location, location. So it's really easy to take a fairly large piece of someone's cheek or their back or their arm. It's not easy to take a big piece of someone's eyelid, lip, nose, or ear. So I'm more likely to use a hedgehog inhibitor if I think surgery is going to be really difficult in one of those high risk anatomic locations. And then it just comes to the multiples we all unfortunately have. These patients who have, they come in and they've got four 5610 plus basal cell carcinomas. And in that case, any sort of therapy other than systemic therapy gets really challenging. It's hard to do surgery on six or seven or eight basal cells. It's hard to do radiation on six or seven or eight basal cells. So one of the primary indications in my practice is patients with multiple cancers. And I've been very happy with the results I've gotten with that. I think we also need to mention Gorlin syndrome patients. I operate on those patients very infrequently now. I used to operate on them all the time. When I'm talking to my colleagues or lecturing with residents, I tell them, you cannot cure a basal cell carcinoma nevis syndrome patient with surgery. You can remove a cancer, but you can't cure that patient with surgery. So all of those patients in my practice get hedgehog inhibitors. And then finally the last group, patients with multiple, there's not good surgical candidates. They got blood thinners and artificial heart valves and defibrillators, and they're on a walk. They got a walker and they're wearing oxygen. They're just not a great surgical candidate. And the drugs can be used palliatively in those patients. So I'm going to ask you to hold for a second because we want to take a break and get a message from our sponsor. This episode is sponsored by Genentech, who has been studying skin cancer treatments for nearly 20 years. To learn more about our therapies, visit abcctreatment.com. So now, Brent, I'm back, and I have another question. Now that you're talking about, you've made a decision that you're going to utilize a hedgehog inhibitor for a patient. And so what do you think about in terms of how you start the therapy and circumventing? What are some of the common side effects and things that we hear about, like aches and things of that nature, aching, muscle aching and things that patients experience. Are there tips to get around some of these side effects and how often do they occur? Yeah, absolutely. I think you've hit on really one of the key questions with using hedgehog inhibitors. After we've made that important decision to treat a patient with a hedgehog inhibitor, how are we going to make the course of therapy more tolerable for the patient? There's well described side effects that occur with all the hedgehog inhibitors, and the main things that people complain about are muscle spasms. They can have taste alteration. You can have some hair loss, fatigue, weight loss. These are all pretty well known. The way I have fixed these problems, as it were, in my practice, is through using some dosing schedules that have been really successful. I'm a firm believer in taking treatment breaks, and there's two ways to look at treatment breaks. You can say, well, I'm going to take a break when the patient needs it, when the patient complains of, gosh, I'm having these side effects. I just don't want to take the medicine anymore. I prefer to have built in treatment breaks. I don't wait for the patient to get to the point where they want to ask for one. So my standard formula for the vast majority of patients I treat with hedgehog inhibitors is they have two months of drug therapy, followed by a two month break, followed by two months of drug therapy, followed by a two month break, followed by two months of drug therapy. So my target for the vast majority of patients is six months of drug exposure spread out over ten months. My general experience is the side effects start kicking in around that five, six week time frame. But the patients know I've got two more weeks to go, and then I get a break. So they just continue. They march on, continue, and then they get the break, and then the side effects wash out during the break period. I've been really pleased with the patient response to this, and it's been well received in my patient population. So do you feel that it's helped not having patients choose to discontinue the therapy because the side effects got to the point that I don't want to continue doing this, or especially with an older patient where they have a caretaker, a family member who's a caretaker sometimes. I found that they're real cautious about some of these things because they have a hard time watching mom or dad go through it. Have you seen that? Absolutely. Taking a break is, I think, the most important thing we can do prior to figuring out this break business. And I kind of started toying around with it when trial, the Mikey trial was published several years ago, where they showed that taking the break really does not decrease efficacy. And that's when I really started toying around with it and came up with this sort of my recipe, as it were. Other things that I do for every patient, and this has been described in the literature, is using lcarnitine helps tremendously with the muscle spasms, decreases the amount of spasms, decreases the severity of the spasms. And that's something that patients get at the health food store or the supplement store. I give my patients 500 milligrams of lcarnitine twice a day. Has made a big difference with the muscle cramps. Yeah, I was going to ask you, is that something you give them right from the outset? Because I've heard about that just from the beginning. Every patient gets it correct, so I don't wait for them to develop muscle spasms. I think it's more effective to start it prophylactically. So when a patient sees me and we've made that decision in the office, you're going to start vismodjib. Just for an example, I say, hey, I want you to go start the lcarnitine today. Just logistically, by the time you do the paperwork and deal with the specialty pharmacy, it's going to be seven to 14 days before that patient gets their medicine. So they load up before they start the medicine, before they start the hedgehog inhibitor. So the last question I want to ask you, are there any situations where the patient may be on certain medications or have certain medical conditions where you wouldn't want to use a hedgehog inhibitor, or are there differences between the different agents that are available in terms of selection, one versus the other? So the short answer is not too many. There aren't many with vismogedib, particularly. There aren't many clinically significant drug interactions. So I've not had any issues there. The agents are similar. There's a fasting requirement with sonodejib that is not present with vismodejib. There's some blood work requirements with Sanadejib that's not there with vismodejib, but I've used both drugs, and they're more similar than they are different. I'll just be honest. I've got more experience with vismodigib. It's been out longer, so I tend to go with that one just out of familiarity, like I said, that was approved in, I think, in January of 2012, and I treated my first patient in March of 2012, so I've just got more experience with that one. You're coming up on your ten year anniversary of using that particular therapy not too far away. Well, thanks a lot, because I've had some experience and some knowledge, but you've helped me expand on that with having done a lot of it. So the practicality is really important. So have a great day, and I'm sure you have some other patients lined up, and I don't want to keep you from that. Thanks a lot. Appreciate it. Jim thank you for listening to this episode of Derms and Conditions. If you have any questions or comments, please email us at. Podcasts at Fred Health and most importantly, if you like this episode, subscribe to the Derms and conditions podcasts on Apple Podcasts or wherever you get your favorite. To learn more about Genentech, visit www.ge.com.

In episode 11 of Derms and Conditions, our host James Q. Del Rosso, DO speaks with Seemal R. Desai, MD regarding important points with chemical peels and other procedures performed on patients with skin of color.

In episode 11 of Derms and Conditions, our host James Q. Del Rosso, DO speaks with Seemal R. Desai, MD regarding important points with chemical peels and other procedures performed on patients with skin of color. Dr. Desai discusses tips and methods for using chemical peels on patients with skin of color including advantages of certain chemical compounds, the use of chemical peels with topical acne medications and how to counsel patients about expectations and downtime. He further discusses best practices for performing a chemical peel in different Fitzpatrick skin types and which conditions respond best. The episode concludes with Dr. Desai discussing a few new updates on the treatment of Vitiligo. Financial Disclosures James Del Rosso, DO CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Seemal R. Desai, MD 
Advisory Board:
Foundation for Research &amp; Education of Dermatology Dermavant Sciences
Investigator: AbbVie Incyte Corporation Dermavant Sciences AOBiome, LLC
Consultant: Galderma Laboratories, LP Almirall Ferndale Laboratories, Inc. Gore Range Capital Bristol-Myers Squibb AbbVie Verrica Pharmaceuticals Inc UCB Ortho Dermatologics Scientis EPI Health Avita Eli Lilly and Company Leo Pharma Inc. Pfizer Inc. Incyte Corporation L'Oreal USA Inc. Beiersdorf, Inc. Johnson and Johnson
Speaker: Galderma Laboratories, LP Pfizer Inc.
Stockholder: Gore Range Capital
Board of Directors: Womens Derm Society
Other: National Psoriasis Foundation

The Real Peel Deal

James Del Rosso, DO discusses topical management for psoriasis and a new formulation including vehicle differentiation, efficacy, and safety.

James Del Rosso, DO discusses topical management for psoriasis and a new formulation including vehicle differentiation, efficacy, and safety. Financial Disclosure James Del Rosso, DO CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo).

Taking it from the "Top" &ndash; Topical Management for Psoriasis

This episode is sponsored by Winsora, a new first in class water based cream formulation of calcipotrine and betamethasone dipropionate. Winsora is non greasy, is rapidly absorbed, and designed to be easy for your patients to use. Learn more about what makes Winsora unique by visiting winsora.com. You're listening to the Derms and Conditions podcast. Welcome to Derms and conditions. I'm Dr. Jim Dorasso here in Las Vegas, Nevada. And today I'm flying solo, which is not so bad because I'm okay with hanging around with myself to discuss a topic that I think is important to all of us. We're going to be talking about plaque psoriasis and specifically looking at topical therapy and to discuss a new product formulation and why it might be clinically relevant to you in practice. So when we look at psoriasis, plaque psoriasis, we obviously have a lot of new advances in plaque psoriasis with biologic agents and even a systemic agent, an oral pd four inhibitor, a premolast. And so we see patients that we face that we often will utilize those agents. But many of the patients that we see have localized involvement with psoriasis, a limited body surface area of involvement, where we're treating them initially with only topical therapy, and even those patients that have more extensive disease. Topical therapy comes into play because even with the best agents we have, patients will carry some persistent plaques that we treat with topical therapy. So when we look at the topical management of plaque psoriasis, many of the patients that we treat, and the majority of them are going to utilize a topical therapy because they have some persistent plaques, either because they have treatment for widespread disease with some systemic therapy, but they still don't have complete clearance, or they're patients that have limited disease from the outset, and they stay that way, which is, quite frankly, the majority of the patients that we see. So topical therapy, we all know this is the mainstay of treatment. So when we look at the agents that we have in our toolbox, we have a broad selection of topical corticosteroids, and we're often using from higher up on the ladder, where it's a higher potency of corticosteroid that we use to get the kind of effect that we typically need on plaque psoriasis, except in certain body locations where we may be utilizing a lower potency topical corticosteroid. And we have a limited selection of non steroidal agents. We have calcipitrine and tazaritine. I'm going to focus some on calcipitrine today, because we will be talking about a new product formulation that I want to go over with you that was recently FDA approved. So when we look at calcipitrine as a standalone, what is it actually bringing to the table? In psoriasis, we have to recognize what it's contributing, which is different in many ways in terms of its mechanism of action and what it brings to the table as compared to a topical corticosteroid. So calcibutrine, as I'm sure most of you are aware, if not all of you, it's a vitamin D analog, and it does many things. It interferes with proliferation of keratinocytes and differentiation of the epidermis. And mechanistically, part of that has to do with trying to improve or sustain the integrity of the stratum corneum by promoting the formation of the cornified envelope around the keratinocytes and promoting the increased expression of different proteins. Invalucrine, which has to do with the structure and transclutaminase, which has to do with the structural and functional integrity of the stratum corneum. And those corrections are important in the management of psoriasis. There are also antiinflammatory effects, inhibiting interleukin two and interleukin six, interferon gamma, and also inhibiting some t cell activity with cytotoxic t cells and natural killer cells. Also, when we utilize calcibatrine with a topical corticosteroid, we combat some of the epidermal atrophy that topical corticosteroids can cause. And we all recognize that we're limited in the duration of how long we can use topical corticosteroids because of different side effects that we get, such as atrophy. That doesn't typically happen in the short term, but with repeated use and prolonged use, especially continuous use, we certainly see atrophy in some cases, and we don't want to get that in our patients. One of the things that's important about calcipatrine is it's unstable in an acid ph. So if you're applying something else, like salicylic acid, or even if you're applying some topical corticosteroids that require an acid ph for their stability in their vehicle, you can get degradation of calcipitrine. So that's an important thing to consider. This episode is sponsored by Winsora. One of the best things about Winsora is how easy it is for your patients to access. $35 for all commercially insured patients. Learn more about what makes Winsora unique by visiting winsora.com. So that brings us to the next subject at hand when we look at combinations of agents, and the one that has been most commonly used over the years has been betamethasone dipropynate in combination with calcipitrine in the same formulation. We've had that for quite some time in both branded and generic formulations, ointment. There's also a branded suspension formulation, and that has gone under the name of taquinex. So those have been available for quite some time. So what I want to bring to the table today is to talk about a new formulation, which is actually a cream formulation of calcipitrine in combination with betamethasone metabethasone dipropynate in the same concentrations as were available in those other formulations. There's zero five doesn't take a lot of the calcipitrine, zero 5% calcipitrine, and zero 64% of the betamethasone dipropionate. And we've had these for the topical treatment of plaque psoriasis for some time. They're applied once a day, and they're typically used to get the patient under control, hopefully, and certainly more quickly than what we see with a non steroidal agent alone, at least with calcifitrine, which we're talking about today. So what's different now? Well, if we think about the formulations that we've had with calcipitrine, when we had calcipitrine as a standalone, which was under the brand name of Dovonex in an ointment vehicle, we saw the efficacy of that and the utility of that based on some of the factors I mentioned with calcipitrine earlier. But when there was a cream formulation that became available even as a brand, anecdotally, and we saw out there that clinicians, many clinicians, and I saw this myself, didn't feel that it had the same efficacy as the ointment. So it fell somewhat by the wayside in terms of the efficacy consideration. But patients, many of them, like a cream formulation better than an ointment formulation. And sometimes these formulations had some irritation associated with them. So why is there a discussion about the new cream formulation of calcibatrine betamethasone dipropynate? And that was recently approved as Winsoro cream? It is FDA approved for the topical treatment of plaque psoriasis in adults that's 18 years of age and older. And the labeling states you use it once a day to the affected areas with the plaque psoriasis for up to eight weeks, and at your discretion, you discontinue it when achievement is controlled, if it's earlier than the eight weeks, and then at that point, it's expected with these agents that you're going to give them some degree of a break before you might reinstitute therapy if patients have some persistence of lesions. A standard labeling with many of these agents and with the new cream formulation is to avoid use on the face, groin and exila, because it wasn't studied in those particular areas. And it does contain that higher potency, topical corticosteroid, the betamethasone dipropionate, and not to exceed 100 grams a week. So that's standard with that particular class of topical corticosteroid. There are no contraindications in the labeling, and I think that's important to recognize. But there are some warnings that a class labeling with calcipitrine that we often don't think much about, because we don't typically see problems in clinical practice, and that's hypercalcemia and hypercalceria. But that does appear in the labeling. What is different about this particular formulation? Because she could be saying, hey, Jim, we've had betamethasone dipropynate with calcipitrine in combination formulations for some time, and we've had also standalone calcipitrine. So why are you even talking about this? Well, there are some differences with this new cream formulation, which is under the brand name of Winsora. And I think a very important part of the discussion is how it's formulated. Calcipitrine is not an easy compound to formulate, and it's even more difficult when you put it in combination with a topical corticosteroid. And this particular branded cream formulation utilizes what's called pad technology, which stands for polyafron dispersion. And what's unique about this? Well, what they have to do to get these two individual active ingredients into a stable oil and water formulation, because, remember, a cream is oil droplets in water. You can have water droplets in oil. That's often going to be used, let's say, in a lotion formulation. But you have the difficulty that the outer phase is oil, and it tends to be more greasy and more sticky and not as patient friendly, where the patient's going to like the formulation. Some of them do, but creams are preferred by more patients. So what they do in this particular formulation is they take the calcipatrine, which requires an alkaline ph, and they take the betamethasone dipropinate, which requires an acid ph, and they compartmentalize them in what are called micelles. And what these micelles do is they're a surfactant that is added, that then compartmentalize each of those active ingredients so they're separated from each other, and then they're dispersed in a colloidal suspension, which is the entire product formulation. And the way they formulate this, that's different. And to some degree, this is the secret sauce of the formulation that the company is not going to necessarily tell you about, because they have this patented formulation that is unique, that allows for a greater delivery of those active ingredients into the skin, that actually leads to greater efficacy, which I'll get to in a moment, but also creates the stability. So the product remains stable in its packaging. And what that does is it incorporates this outer robust shell around the micelle that is unique to this pad technology. And within that, in order to have that active ingredient be consistent with a water phase, because this is a water phase. It's a cream. It's in the water phase predominantly. The outer tail is hydrophilic and the inner head is hydrophobic. And then within that, you have the active ingredients. So, to make a long story short, they have these individual, compartmentalized, kind of circular micelles that sit within the formulation that separately housed the calcipitrine and the betamethasone dipropionate. And this is the first time with this particular technology, they've been able to get betamethasone diproprinate and calcipitrine into a cream. What that correlated with in the clinical studies, and I don't want to data brow anyone with all the data from the clinical trials, but the patient acceptance was higher with a comparator, which happened to be the branded betamethasone dipropionate calcipitrine suspension. So that was also used in the eight week trials. And there was greater patient acceptability and greater response of the DLQI, the dermatology live quality index, in the patients that used the branded cream formulation, the Menzora cream, then the branded suspension formulation, which was the Taclinex suspension. And we believe it's this cream formulation and this technology that allows for the use of less surfactants. So in order to get those micelles, which you need surfactants, which are detergents, that basically allow the compartmentalization of those active ingredients in those micelles, lesser surfactants leads to greater tolerability, because surfactants can lead to irritation, they're detergents so they can help the formulation being developed, but they create more irritation on the skin. But this technology also allowed for greater delivery of the active ingredients. And actually, with pad technology, it's not only been looked at with this particular combination of active ingredients, but it's been looked at also with cyclosporin in eyedrops. It's been looked at with tecrolomus compared to the standard formulations, and there was a greater delivery of the active ingredient, and the formulators with that technology have the capability of doing that. So it's bringing two things to the table. It's allowing the stability with more favorable tolerability, or excellent tolerability with the formulation, but it's also allowing excellent penetration of the active ingredients in the skin. So let's sum up with what was actually the results in the clinical studies. And once again, I recognize that betamethasone, dipropynate and calcipitrine as combination formulation is something you're very familiar with. So what is different, based on the clinical trials with this cream formulation, this branded cream formulation, which is under the brand name of Winsora, is when you look at the physician, global assessment success. And the studies were done over eight weeks, where the patients were seen at baseline, they had to meet all the inclusion criteria, they had to be at least 18 years of age, they had to have psoriasis for at least six months. The mean duration was 15 to 17 years. 80% of them were rated as moderate. The mean BSA was about seven to 8%. So you can get an image of what the psoriasis patient was that was entering into the study. So it's pretty standard as a topical therapy study. But what was a little bit different is they included the active comparator, the taclinex suspension compared to the Windsor cream, and certainly compared to the vehicle. And so there were over 300 patients in both the actives and a little over 115 patients with the vehicle cream. And they were treated daily for eight weeks actively, and then two weeks after, they stopped. So all the subjects got eight weeks of active treatment once a day with whatever group they were in. And everybody was blinded. Right. The investigators were certainly blinded because they didn't know what they were getting, whether they were getting a cream or that suspension formulation. So to make a long story short, to reach success in the study, the primary endpoint was they had to get to clearer, almost clear, with at least a two great improvement from baseline to week eight. And by week four, there was a twofold greater separation of that success in the Windsor cream group as compared to the Taclink suspension group. And by the end of the study, it was just shy of 40% reaching that primary endpoint with the Windsor cream and just shy of 25%, 22.8% with the Taclinex suspension. So there was greater achievement of treatment success or endpoint success with that branded cream formulation as compared to that active comparator. So that is a differentiation that they were able to show in a pivotal trial. Also reaching, Pazi 75 did the same. By week four, there was a significant separation in the cream as compared to the suspension and certainly significantly better than the vehicle. Now, in this study, they also evaluated two other things. Itch reduction was evaluated and is included in the labeling. And that was based on utilizing the standard numeric rating scale, where to be considered clinically meaningful. They had to have at least a four point improvement. And at every time point, at two weeks, four weeks and eight weeks, the branded cream formulation, once a day, outperformed the branded suspension formulation. As early as week two. It was more than twofold greater in the percentage of patients that achieved that meaningful itch reduction. It was 44%, which is close to one out of two, and about 20.7, or about 21%, which is about one out of five with the suspension. So the cream outperformed as early as week two and throughout the study achieved that separation. By week eight, it was about two thirds of the patients getting the active cream had at least a four point itch reduction versus about one out of five with the suspension formulation at week eight, which was the study endpoint for active application. So that was another distinction. So what we're looking at is this formulation, at least based on these studies, brings to the table a cream formulation that, based on the patient outcomes, was very favorable. The patients evaluated this formulation and it was superior in terms of acceptance over the suspension in the parameters that were looked at, convenience scores, ease of application, et cetera. I don't want to belabor that, but the patients liked it better. And also, the itch reduction is something that we don't typically see in the pivotal trials, and we see a differentiation in terms of efficacy. So I think that summarizes what is different about this particular branded formulation of the betamethasone diproprinate calcipitrine cream as compared to previously, what we had. And it may be something that you find is helpful in your toolbox because of these features that I mentioned. So I do want to thank everyone for participating. I realize listening to Jim del Rosso alone, I know I'm tired of listening to myself right now, so I'll sign off so I can spare you listening to me any further. But hopefully I did bring something meaningful to the table. I was remiss in mentioning that the safety profile was highly favorable. There weren't any significant safety signals, and 1% of the patients with that cream formulation did develop application site reactions. So it's not zero, but it is very low. Thank you for listening to this episode of derms and conditions. If you have any questions or comments, please email us at. Podcasts at Fred Health and most importantly, if you like this episode, subscribe to the Derms and conditions podcast on Apple Podcasts or wherever you get your favorite shows. Thanks for joining us. Winsora and Epi Health thank you for joining this week's episode. To learn more about Winsora, visit www.winsora.com for important safety information and learn more about what makes Winsora unique.

In episode 9 of&nbsp;Derms and Conditions, James Del Rosso, DO speaks with Emmy Graber, MD, MBA regarding acne and rosacea. Dr. Graber provides tips on how to manage persistent erythema associated with acne using a pulsed-dye laser.

In episode 9 of&nbsp;Derms and Conditions, James Del Rosso, DO speaks with Emmy Graber, MD, MBA regarding acne and rosacea. Dr. Graber provides tips on how to manage persistent erythema associated with acne using a pulsed-dye laser.
Treatment for acne scarring is also discussed and Dr. Graber shares some tips and tricks for treating sequelae of acne. Dr. Del Rosso asks Dr. Graber how she integrates physical and medical treatments for rosacea and residual erythema associated with rosacea. Finally, Dr. Graber shares an in office pearl which involves the use of a hair dryer and a pulsed dye laser. Financial Disclosures James Del Rosso, DO CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Emmy Graber, MD, MBA CONSULTANT/ADVISOR Digital Diagnostics, Almirall, Hovione, Keratin Biosciences, Sebacia, SolGel, Verrica, WebMD RESEARCH INVESTIGATOR Hovione, Ortho Dermatologics, Sebacia SPEAKER Almirall ROYALTIES WoltersKluwer Health

How to Avoid "Getting Red in the Face" When Treating Persistent Erythema Associated with Acne and Rosacea

In episode 8 of&nbsp;Derms and Conditions, our host James Del Rosso, DO speaks with Neal Bhatia, MD regarding barriers to sunscreen use and offers tips on how to counsel patients on sunscreen use and photoprotection.

In episode 8 of Derms and Conditions, our host James Del Rosso, DO speaks with Neal Bhatia, MD regarding barriers to sunscreen use and offers tips on how to counsel patients on sunscreen use and photoprotection.
Dr. Del Rosso and Dr. Bhatia also discuss the optimal use of photodynamic therapy for actinic keratoses, both pre-procedural and post-procedure. Finally, Dr. Del Rosso poses an intriguing question and Dr. Bhatia shares a very important clinical pearl for management of dermatological issues in the Emergency Room. Financial Disclosures James Del Rosso, DO CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Neal Bhatia, MD Advisory Board: Abbvie, Almirall, Biofrontera, BMS, BI, EPI Health, Ferndale, Foamix, Galderma, InCyte, ISDIN, J&amp;J, LaRoche-Posay, Leo, Lilly, Ortho, Pfizer, P&amp;G, Regeneron, Sanofi, SunPharma, Vyne, and Vyome Research: Abbvie, Almirall, Biofrontera, BMS, BI, EPI Health, Ferndale, Foamix, Galderma, InCyte, ISDIN, J&amp;J, LaRoche-Posay, Leo, Lilly, Ortho, Pfizer, P&amp;G, Regeneron, Sanofi, SunPharma, Vyne, and Vyome Speakers' Bureau: Abbvie, Almirall, Biofrontera, BMS, BI, EPI Health, Ferndale, Foamix, Galderma, InCyte, ISDIN, J&amp;J, LaRoche-Posay, Leo, Lilly, Ortho, Pfizer, P&amp;G, Regeneron, Sanofi, SunPharma, Vyne, and Vyome

Fun in the Sun: Tips for Counseling Patients on Sunscreen and Treatment Tips for Photodynamic Therapy

In a conversion with Dr. Jim Del Rosso, Dr. Adam Friedman brings us up to date on what we know and what we&nbsp;don't know&nbsp;about CBD use in dermatology and newer information on breast cancer risk in women treated with oral spironolactone.

In Episode 7 of Derms and Conditions, our host James Del Rosso, DO talks with Adam Friedman, MD, Professor and Chair of Dermatology at The George Washington University School of Medicine &amp; Health Sciences on the use of topical CBD in dermatology and the use of oral spironolactone in breast cancer patients. Dr. Del Rosso and Dr. Friedman discuss many diverse topics on CBD including FDA regulations, counseling patients, and clinical studies on topical CBD gel in the treatment of xerosis and atopic dermatitis. They further discuss evidence regarding the risk of oral spironolactone in breast cancer recurrence along with effective ways to manage and counsel patients who have a personal or family history of breast cancer. Financial Disclosures James Del Rosso, DO CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Adam Friedman, MD Consulting/Ad board: Loreal, La Roche Posay, Galderma, Aveeno, Microcures, Pfizer, Novartis, Lilly, Aclaris, Dermira, Brickell Biotech, Incyte, Trevi, Zylo Therapeutics, Hoth therapeutics, Corbus, Greenway Therapeutics, TruPotency, Bristol Myer Squibb, UCB, Janssen. Speaker: Regeneron/Sanofi, Abbvie, Janssen, Dermira, Brickell Biotech. Grants: Pfizer, Dermatology Foundation, Incyte.

Where are we now with CBD and other questions facing dermatology? Perspectives from Adam Friedman, MD

In Episode 6 of Derms and Conditions, host James Del Rosso, DO sits down with Matthew Zirwas, MD to talk facts and fiction in the world of allergic contact dermatitis.

In this episode, James Del Rosso, DO talks to Matthew Zirwas, MD about some very practical pearls for prevention, clinical diagnosis, and management of contact dermatitis, especially in the absence of patch testing. Drs. Del Rosso and Zirwas discuss the origins of latex allergies and clinical patterns to recognize in hand, scalp, and face dermatitis, as well as some of Dr. Zirwas' favorite products for sensitive skin, including gloves for patients and medical professionals, deodorants, antiperspirants, hair coloring, and soaps. JAMES DEL ROSSO, DO FINANCIAL DISCLOSURES: CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). MATTHEW ZIRWAS, MD FINANCIAL DISCLOSURES: Regeneron / Sanofi - Speaker, consultant, investigator Fit Bit - Consultant Genench / Novartis - Speaker L&rsquo;Oreal - Consultant Menlo - Consultant AsepticMD - Part Owner Leo - Investigator, Consultant Janssen - Investigator Incyte - Investigator Foamix - Investigator UCB - Investigator Pfizer - Investigator, consultant Lilly - Investigator, consultant Asana - Investigator Avillion - Investigator Ortho Derm - Consultant Abbvie - Investigator Edessa Biotech - Investigator Galderma - Investigator Dermavant - Investigator Arcutis - Investigator, Consultant Sol-Gel - Consultant Bausch Health - Consultant EPI Health - Consultant, Investigator

Practical Tips on Contact Dermatitis from the Heartland of America&nbsp;

James Del Rosso, DO talks with Zoe Diana Draelos, MD about topical management of common skin wounds encountered in office practice, formulation characteristics, some basic do&rsquo;s and don&rsquo;ts, and details about data with Aquaphor.

In this episode, James Del Rosso, DO talks with Zoe Diana Draelos, MD about topical management of common skin wounds encountered in office practice, formulation characteristics, some basic do&rsquo;s and don&rsquo;ts, and details about data with Aquaphor. &nbsp; Financial Disclosures: James Del Rosso, DO CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo)
RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo).
 Zoe Diana Draelos, MD Consultant and Research Activities I am or have been a consultant and researcher to the following companies: Aclaris, Aesthetics Biomedical, Aivita, Allergan, Almirall, Amderma, Amgen, AOBiome, Arcutis, Bausch, Bayer, Biopelle, Boehringer Ingelheim, Boots, Botanix, Brickell Biotech, Burt's Bees, Carpe, Chattem, Chlorox, Clark Pharmaceuticals, Clay-Parks Laboratories, Colgate-Palmolive, Coloplast, Combe, DelArrivo, Dermavant, Dermira, Dial, Dr. Reddy's, Estee Lauder, ET Browne, Evolus, Ferndale Laboratories, Foamix, Galderma, Genetech, General Mills, Glaxo, Glenmark, Helix Biomedix, Henkel, Hovione, International Specialty Products, Johnson &amp; Johnson, Kamedis, Kao, LaRoche Posay, Leo, Lilly, L&rsquo;Oreal, Lululemon, Maruho, Menlo, Merck, Milliken, NicePak, Novartis, Nu Skin, Perricone MD, Perrigo, Pfizer, Pharmanet, Proctor &amp; Gamble, Reckitt Benkiser, Regenerist, Revance, Rodan &amp; Fields, Roviant, Sanofi, Schick, SkinCeuticals, Symrise, TEVA Pharmaceuticals USA, Taro, Teoxane, Tolmar, Topix, Vanda, Verrica, Warner-Chilcott, WellSpring, Ya-Man, ZO Skin Health.

Keeping It Simple: Wound Healing Tips From A Voice of Experience

In this episode of&nbsp;Derms and Conditions, Gary Goldenberg, MD interviews Amy McMichael, MD, Professor and Chair of Dermatology at Wake Forest University School of Medicine,&nbsp;as she breaks down how to take personal and professional relationships to the next level to have a fulfilling career.

In this episode of Derms and Conditions, Gary Goldenberg, MD interviews Amy McMichael, MD, Professor and Chair of Dermatology at Wake Forest University School of Medicine and Co-Chair of the Skin of Color Society Scientific Committee. She breaks down how to take personal and professional relationships to the next level to have a fulfilling career, and provides some valuable clinical pearls as well. Dr. McMichael has found that dermatology is full of wonderful relationships, and that this camaraderie has been the foundation for her success in mentoring residents, students, and even patients. &ldquo;If you support people, and you make them know that you are confident in their ability [&hellip;] they do infinitely better.&rdquo; said Dr. McMichael. &ldquo;If you want to have a really invigorating career that&rsquo;s rewarding, you feed [them] and they feed you.&rdquo; Like this&nbsp;episode? Drop us an email at <a href="mailto:podcasts@fred.health" target="_blank">podcasts@fred.health</a>&nbsp;and let us know what you think. We welcome any feedback, topic suggestions, ideas, etc. Financial Disclosures: Gary Goldenberg, MD Consultant: AbbVie, Allergan, Amgen, ALMA, Almirall, Bayer, Castle Biosciences, Celgene, Dermira, Eclipse, Galderma, Genentech, GSK/Stiefel, Intraderm, ISDIN, Janssen, Leo, Menlo, Novartis, Pharaderm, Pfizer, Ranbaxy, Regeneron/Sanofi, Scibase, Suneva, TEVA, Valeant/Ortho Dermatologic, Verrica Speakers&rsquo; Bureau or Honoraria: AbbVie, ALMA, Bayer, Celgene, Dermira, LEO, Merz, Novartis, Pharmaderm, Pfizer, Regeneron/Sanofi Other Financial Benefit: BOD-Verrica Amy McMichael, MD 
<div>No conflicts for the podcast. </div>
<div>Other Disclosures:</div>
<div>&nbsp;</div>
<div>Grants: Incyte, Concert, Procter &amp; Gamble, Aclaris, Cassiopea, Arcutis</div>
<div>&nbsp;</div>
<div>Consultant: Aclaris, Allergan, Almirall, Bioniz, Cassiopea, Galderma, Pfizer, Lilly, Revian</div>
<div>&nbsp;</div>
<div>Royalties: Up to Date, Informa Healthcare</div>

Relationships in Dermatology: Elevating Your Career Through Mentorship, Diversity, and Leadership with Amy McMichael, MD

In this episode, James Del Rosso, DO and Dawn Sammons, DO discuss&nbsp;frequently&nbsp;encountered clinical challenges in everyday practice with patients including chronic hair loss in women, application of topical lovastatin and cholesterol for&nbsp;Porokeratosis, and more.

In this episode, James Del Rosso, DO and Dawn Sammons, DO discuss&nbsp;frequently&nbsp;encountered clinical challenges in everyday practice with patients including chronic hair loss in women, application of topical lovastatin and cholesterol for&nbsp;Porokeratosis, and more. 
Financial Disclosures:
James Del Rosso, DO:
CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo)
SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo)
RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Dawn Sammons, DO:
CONSULTANT/ADVISOR Abbvie, Novartis Pfizer,&nbsp;Lilly, UCB.
SPEAKER BUREAU Abbvie, Novartis Pfizer,&nbsp;Lilly, OrthDermatologics, Sun, Amgen, Janssen.

Untangling Common Challenges in Clinical Practice: Tips You Can Use Right Now with Dawn Sammons, DO

In Part 2, James Del Rosso, DO and David Cohen, MD continue where they left off and talk more about currently available and new systemic therapies for Atopic Dermatitis and Psoriasis.

In Part 2 of our conversation, James Del Rosso, DO and David Cohen, MD discuss the use of currently available and new systemic therapies for Atopic Dermatitis and Psoriasis. All that and a lot more in this episode of Derms and Conditions. 
<div class="pl-3">
David Cohen, MD Vice Chair for Clinical Affairs and the Charles C. And Dorothea E. Harris Professor of Dermatology NYU Langone Health New York, NY
James Q. Del Rosso, DO Co-director Adjunct Clinical Professor (Dermatology) Touro University College of Osteopathic Medicine Henderson, NV Financial Disclosures:
James Del Rosso, DO:
CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo)
SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo)
RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo)
 David Cohen, MD:
<div class="">Consultant and Honorarium:&nbsp;</div>
<ul class="">
<li class="">Ferndale Laboratories,&nbsp;</li>
<li class="">Asana</li>
<li class="">Medimetriks [past]</li>
<li class="">Leo</li>
<li class="">UCB</li>
<li class="">Novartis</li>
<li class="">Dermavant</li>
<li class="">FSJ</li>
<li class="">FIDE. (FIDE receives industry sponsorship from AbbVie, Almirall, Amgen, Arcutis, Bausch and Lomb, Bristol-Myers Squibb, Celgene Dermavant, Dermira, Janssen, Kyowa Hakko Kirin, LEO, Lilly, Novartis, Ortho Dermatologics, Pfizer, Sanofi Genzyme, Regeneron, Sun Pharma, UCB, Valeant)</li>
<li class="">Cosmetic Ingredient Review (CIR)</li>
</ul>
<div class="">Stock or stock options: &nbsp;Dermira [past], Medimetriks [past], Brickell Biotech [past], Kadmon, Evommune, Timber</div>
<div class="">Board of&nbsp;Directors: &nbsp;Kadmon, Timber, Evommune, Dermira-[Past]</div>
</div>

Clinical Pearls in Dermatology in More than a New York Minute with David Cohen, MD (Part 2)

James Del Rosso, DO and David Cohen, MD discuss the use of COVID-19 vaccines in patients on systemic therapies and review in detail how to sort through the large volume of information on the use of currently available and new therapies for Atopic Dermatitis and Psoriasis.

In this episode, James Del Rosso, DO and David Cohen, MD discuss the use of COVID-19 vaccines in patients on systemic therapies and review in detail how to sort through the large volume of information on the use of currently available and new therapies for Atopic Dermatitis and Psoriasis. David Cohen, MD Vice Chair for Clinical Affairs and the Charles C. And Dorothea E. Harris Professor of Dermatology NYU Langone Health New York, NY
James Q. Del Rosso, DO Co-director Adjunct Clinical Professor (Dermatology) Touro University College of Osteopathic Medicine Henderson, NV Financial Disclosures:
James Del Rosso, DO:
CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo)
SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo)
RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo)
 David Cohen, MD:
<div class="">Consultant and Honorarium:&nbsp;</div>
<ul class="">
<li class="">Ferndale Laboratories,&nbsp;</li>
<li class="">Asana</li>
<li class="">Medimetriks [past]</li>
<li class="">Leo</li>
<li class="">UCB</li>
<li class="">Novartis</li>
<li class="">Dermavant</li>
<li class="">FSJ</li>
<li class="">FIDE. (FIDE receives industry sponsorship from AbbVie, Almirall, Amgen, Arcutis, Bausch and Lomb, Bristol-Myers Squibb, Celgene Dermavant, Dermira, Janssen, Kyowa Hakko Kirin, LEO, Lilly, Novartis, Ortho Dermatologics, Pfizer, Sanofi Genzyme, Regeneron, Sun Pharma, UCB, Valeant)</li>
<li class="">Cosmetic Ingredient Review (CIR)</li>
</ul>
<div class="">Stock or stock options: &nbsp;Dermira [past], Medimetriks [past], Brickell Biotech [past], Kadmon, Evommune, Timber</div>
<div class="">Board of&nbsp;Directors: &nbsp;Kadmon, Timber, Evommune, Dermira-[Past]</div>

Clinical Pearls in Dermatology in More than a New York Minute with David Cohen, MD (Part 1)

You're listening to the Derms and Conditions podcast. Hello, I'm Dr. Jim Delrasso, and I'm very excited to kick off our podcast series, Derms and Conditions, with Dr. David Cohen, who is well known in dermatology. And Dr. Cohen is at NYU Langone Health, where he is the vice chairman of dermatology. And he is also a clinical professor at NYU Grossman School of Medicine in the department of dermatology. And one of the reasons why I want to converse with Dr. Cohen today is I always have questions for him because we think of him as an academician. But David sees a lot of patients in the trenches. He's treating a lot of patients beyond just contact dermatitis, which we often hear him talk about, and patch testing, he's treating a lot of patients with inflammatory skin diseases that are difficult cases, not all. He treats the garden variety cases like we do, but he sees a lot of challenging cases where he has to step up into utilizing some systemic therapies that many of us may not have used or don't use regularly. So I like to call David and get his perceptions because he's actually treating patients. He's just not reading literature and digesting literature based on what studies say. So I'd like to open up the discussion with Dr. Cohen because I get questions about this, but my understanding, David, from speaking to you, is you get anywhere from five to 20 queries a day, either through email or people calling you about COVID vaccine in patients that are on different systemic therapies that we use, let's say, for psoriasis or atopic dermatitis, like monoclonal antibody agents, biologics, Janus kinase inhibitors. So can you talk about how you handle that particular scenario? Thanks, Jim. And thanks so much for the opportunity to talk with you today. You're right on with that. The calls come in regularly about the COVID vaccines and not only how we deal with the medications patients are on, but they're also concerned about reactions to the vaccine and what they may need to look out for. So for most patients that are on stable immunomodulatory drugs, systemic ones, I'm having them getting vaccinated without any major change in their meds. For some patients who are on methotrexate, I'm asking them to hold the dose before their vaccine so you give them a little time to wash out. For cyclosporin, we could take a day or two off. It really depends on the labile nature of their eruption. If they're very stable and they're clear and they could sort of clinically afford to take their medicine down for a little while. Okay, we do that particularly with methotrexate, the jack inhibitors, they're very rapid on have short half lives. Just skipping a couple of doses is generally okay, but once you start going further and further out, I don't want an unstable inflammatory patient getting the vaccine either. So I'm tending to let it go through. Try to get the steroids, if they're oral steroids, down as low as you can get, or give them a few days methotrexate for a dose before, and most others. I'm continuing through for atopic derms. I'm not making much change in the way of dupilumab. It's really the small molecule orals I'm making a few minor changes to. So why is it with cyclosporin that it's a shorter time that you have to be stopping the drug as compared to methotrexate? What differentiates them? I would go with the half life of cyclosporin is about 8 hours. Right. So you could cycle it out pretty quickly and it's a pretty rapidly acting drug on and off. Now, methotrexate has a bit of a longer half life. It's a little under a day, but we know the clinical effects of methotrexate far outlive the half life of the drug, and we tend to be dosing it weekly, so it's very hard to time it any other way. It just gets a little complicated. I think these days in particular, the schedule of the vaccine dictates what we're going to do rather than the other way around. So with these messenger rna vaccines, like, people talk about the moderna and the Pfizer vaccine as compared to the newer one. I believe it's a J. Janssen vaccine that there's one dose that I think utilizes a different technology. How long does it take, on the average, for a patient to mount the response we're trying to get? And then after that point in time, it doesn't matter what therapies they're using. Right. We're usually telling patients about two weeks after the last dose, depending on the vaccine. Right. So the J J vaccine is an adenovirus vector, but it is a non replicating adenovirus, so we can use it in patients who are on immunosuppressive drugs. And I usually tell them, you're going to get there in about two weeks, maybe three weeks before you could feel comfortable, you've achieved, where you want to go with that. The other questions I'm getting from patients and from providers is reactivity or how they may safely proceed with the vaccine, particularly atopics that have a lot of allergic phenomena and they may have contact allergens. They don't know how to move forward. And there's a concern, fortunately, the COVID vaccines have very few contraindications. Right. And the contraindication, the absolute ones, are an immediate type hypersensitivity or anaphylactic reaction to the first dose. Right. So that one's pretty obvious to us. Those patients really don't proceed to the second dose or they have a history of anaphylaxis or immediate type hypersensitivity to components of the vaccine. Right. And we're largely talking about polyethylene glycol and polysorbate 80. So the two mrna vaccines have polyethylene glycol 2000, the J and J vaccine, which is an adenovirus vector, but it's a non replicating virus, so they're all safe to use in immunosuppressed patients. Polysorbate 80 is functionally like polyethylene glycol. It's an epoxylated sorbitan, so they look similar to our immune systems. So polyethylene glycol sounds an awful lot like propylene glycol, and they're not the same. Propylene glycol is very small molecule polyethylene glycol in these vaccines, very large molecules. So my patients with contact allergens to pg or other items, they're going ahead and getting vaccinated. Right. Polyethylene glycol is in a lot of products that we use. It's in oral preparations for colonoscopies. They're in constipation meds, so things like go lightly and miralax, they don't contain polyethylene glycol as an inactive ingredient. They are polyethylene glycol. Right. Many drugs have polyethylene glycol in them. So patients often already come to the office having exposures and generally tolerating them well. So most of your patients are going to be safe to proceed. Those that have some precautions, perhaps they've anaphylax from foods or drugs or other vaccines. Those are people who you want to spend a little more time with. But if you look back at the data on the patients that have had serious events like anaphylaxis within 4 hours. Right. They tend to occur almost always within the first 15 to 30 minutes. So my advice to the patients are, look, on average, the average patient is going to hang around about 15 minutes. If you're concerned or you're a person who has had some vaccination reactions or drug or food reactions, hang around 30. And I often tell them maybe loiter around another 15 minutes, maybe 45 minutes, because most of those cases are going to be captured and patients do well when they're treated immediately. Yeah, those loitering patients are the one that steal or take a lot of your brochures out of the racks because they try to do something with their time. Yeah, I think it's a good idea that if you've had anaphylaxis from something, you don't get that again. But that was extremely practical. I want to ask you, and I have a lot of these questions, and I know a fair amount about a lot of these therapies and have researched some of them and certainly pay a lot of attention to them. But I want to get your perspective, because we have a virtual barrage of information that as clinicians and think about people in the trenches that are not necessarily as academically involved. They're in their practices every day seeing patients. Fortunately, they're doing that. How are they going to digest, in their mind, all this information about these new therapies, the white noise versus what's relevant? So I want to walk through some of these things and start with atopic dermatitis, with the things that we have already, because new things are going to come along, but they're not necessarily everything we have before is going to be replaced, or is it going to be necessary to replace it? So if we could touch upon topical corticosteroids, we'll start in the topical arena first and talk about corticosteroids, calcinorin inhibitors like Decolamus and Pimacrolamus, and then the PDE four inhibitor that we have on the market. Chris Aboro, if we can touch on those, what your top line view is at this point in time, and then we'll get to some of the newer drugs and what you think about them in terms of how they might be integrated. So let's start with what we already know. We have a great deal of medications available to us to treat patients with inflammatory diseases. But, Jim, there is a tsunami of new things coming, and it is an amazing revolution. And no matter where you are practicing, no matter what type of practice you have, you will be positively impacted by the developments right now, because we have new topicals coming, we have new oral agents coming. We have biologic agents coming, and there's going to be something for everyone out there. Right. So I think it's an amazing time to be practicing dermatology. As far as corticosteroids, they're the mainstay of therapy. I don't see them anytime in the near future or midterm future that that's going to change. We have the flexibility of multiple potencies and multiple vehicles. So we can really practically treat anybody site with lots of topical cortical steroids, both branded and generic. We just have that ability right now. I think one area we run into I see as a problem for atopic dermatitis is the chronic long term use of mid and high potency topical steroids for those with moderate to severe disease. I think we're evolving out of that because we have good treatments now and good treatments coming to sort of prevent atrophy and sort of just fatigue. For patients having to place large amounts of this on their surface. For mild or intermittent disease, the low and mid potency steroids are here to stay and they're going to continue to be a mainstay. So for atopics, I still tend to try to use bland ointment vehicles whenever I can. Those that have petrolatum bases, sometimes creams solutions. Foams may sting open skin, but are very appropriate as that epidermal barrier improves. And they tend to be more cosmetically elegant. And what about, I think it's important that you mentioned barrier because obviously gentle cleansers and moisturizers are important for people to be using regularly, diffusely on their skin with atopic dermatitis. And I think even with psoriasis. Psoriasis has barrier impairment also. It's just not talked about as much. And it's different in some ways than atopic dermatitis. But with the medications we have, those different vehicles. What about calcino inhibitors and PDE four inhibitor, the agent crystal borol that we have right now, where does that stand with you? I like them and use them frequently. And I think you brought up a really important issue. We get so excited by the therapies that we have and those that are coming. You can't forget to just talk about basic moisturization as critical for maintaining a good effect. Right. To maintaining clearance. So as for the calcium inhibitors, tacrolimus, a very good performer. Right. And we have the zero three labeled down to h two. But our AAD guidelines of care that have been around for a long time allow us to use them under that. And the 0.1% for 14 year olds and above, I think that's indispensable. I like the ointment base. That one, I think is generally well tolerated on body. When you start putting it on face and eyelids, on really inflamed skin, burning and stinging is a real issue. Right. And so what I tend to do is introduce a corticosteroid of low potency on the face, the intotrigenous areas, and have them slowly start mixing in the tacrolimus ointment to that steroid until they're off at about a week later. And we really reduce burning and stinging. But that is the main headwind of using calcium inhibitors. Same with pimacrolomus burns a little bit less, may have a little bit, though, less potency than the tacrolimus, but very easy to use on face and intitrigenous areas based on the vehicle. Crystal borol, again, mainstay of long standing therapy in intitrigenous areas, face and well controlled areas on the body. Again, burning and stinging was, I think, a bit of a surprise for clinicians because I think we relied on the label a lot where we saw a lot less burning and stinging in the package insert. But when we practically started using it in patients who were putting it on raw, inflamed skin, we really got a lot of feedback that it was not so easily tolerated. So you got to use the same strategies that you use for the calcinorn inhibitors. Yeah. My patients that have used topical crystalbarol without experience of burning and stinging have done very well, but we did see more than what we expected based on the data. Let's go to some of these newer agents that are in development. The Aral hydrocarbon modulator, topical topinorov, these are all different. Each one has a unique mechanism of action. Rufumalas, which is a topical PD four inhibitor, being looked at for psoriasis, sebriat dermatitis, and also some data coming along on atopic dermatitis, which appears to have more favorable tolerability, even being a pd four inhibitor. And also ruxalitinib, which is a Janus kinase agent. Topical agent being looked at for psoriasis and atopic dermatitis. What's your feeling on these? Because these are non steroidal options, as you mentioned. Yeah. And I think these are really going to expand the capacity for us to treat mild and moderate patients. These are going to be an amazing addition to our armamentarium and I think really will change the way we practice. You mentioned three late stage development products when I'm thinking aD. The highest level of excitement right now for AD is topical ruxolidum, and that's a jack one two inhibitor. Right. And it's available orally. It's used by our hemonc colleagues mostly now, but as a topical agent. We saw phase two data for twice daily dosing in mild to moderate disease. Probably the best of any non corticosteroid product we've ever seen. Right. So by week four, about 45% of patients were clearer, almost clear. By week eight, about 50% of them were clearer, almost clear. And these are patients who entered the trial with about three to 20% body surface area. So they were bona fide mild to moderate. When you dove in a little deeper, the average was about nine to 10%. That's going to represent an awful lot of atopics that are walking into your. And it was predominantly moderate severity, even though they included mild. Yes, that's right. About three quarters of the patients had moderate disease. And you're getting a pretty impressive effect from this new topical. I guess the question out there will be, the adverse event profile looks pretty clean. Right. What will the label look like? Will we have a label that looks like Chrisoborol, or do we have a label that looks like the calcium inhibitors? Are there going to be warnings from, say, the parent molecule? That part's unclear, and I think that part will influence the regular uptake of it. If the label is clear, I think people will quickly take this up because they can pull some of those moderate patients back from the line of maybe having to go systemic. Right. And probably outperforming the other non steroidals out there. As far as I could tell, no head to heads. It's just a gestalt on looking at the data. When we look at the data on topical topinorov, and they have the long term data available now in their phase three data, and rafumalast has their data with psoriasis, and certainly we're seeing some come along with separate dermatitis. Those agents, we would anticipate, would also be helpful for atopic dermatitis. They're not as far along in the development, clinical development and research development, though they're being looked at for those other entities. They may also be big performers in the atopic dermatitis marketplace as non steroidals. Do you agree with that? That's been my sense. I think you hit the nail right on the head. Look to pin her off. For those who've heard of it before or just reading about it, it's an aryal hydrocarbon receptor agonist. Right. So it sounds kind of complex, but this process regulates important transcription factors of inflammation, and this generally functions as a sensor on the surface for environmental and microbiome stressors. So it's influencing the way your immune system is interpreting its environment. And being an agonist has anti inflammatory effects. Now, when I think topinarov today, I'm getting excited about psoriasis, although we did see encouraging ad data in their phase two, we got to see later stage data. And I think we're going to see topinora for psoriasis before we see it for atopic dermatitis. But again, that was looked at for plaque psoriasis, three to 20% bsA, and looking at over a third or 40% of the patients getting clearer, almost clear. I think that's pretty exciting. Right. And for daily application. Right. So being able to treat areas where we don't want to use steroids for long periods of time, like face intertrignous areas, I think I share your excitement about that. Yeah. I think with all three of these agents to Pinarov, Rafumalast, and ruxolitinib, these diseases, we see the phase three trials, they're shorter duration, they have to capture their data and submit for approval. But these are long term diseases. And I see these non steroidals as being very helpful in terms of the long term management, maybe even with intermittent use like is sometimes used with corticosteroids to reduce the side effects. Dr. David Cohen and I had such a great conversation that we decided to divide this podcast into two parts. In the next episode of derms and conditions, Dr. Cone and I discuss systemic therapies for atopic dermatitis and psoriasis, including monoclonal antibodies and Janus Kinase inhibitors. If you have any topics, concerns, or questions that you want to share with us, be sure to email us at podcasts at Fred Health that's podcasts with an s at the end at Fred Health. And be sure to subscribe to Derms and conditions on Apple Podcasts, Spotify or wherever you get your favorite shows. Thank you.

Derms and Conditions is a new podcast from the team that brings you the Fall and Winter Clinical Dermatology Conferences. Each episode you'll hear from leading Dermatologists in the US as they talk about Dermatology's hottest and most relevant topics and conditions.

Derms and Conditions is a new podcast from the team that brings you the Fall and Winter Clinical Dermatology Conferences. Each episode you'll hear from leading Dermatologists in the US as they talk about Dermatology's hottest and most relevant topics and conditions.
Dermatologists all face a barrage of new information virtually every day that is difficult to keep up with and digest. In this podcast, you'll hear about clinical practice tips and treatment pearls that you can implement on a daily basis in your busy practice.
Subscribe to Derms and Conditions today to stay in-the-know with the country's leading experts. Thanks for listening!

Derms and Conditions Trailer

Hello. I'm Dr. Jim del Rosso, a dermatologist in Las Vegas, Nevada, and I'm really excited to bring to you derms and conditions, a new podcast series that we will bring to you regularly. You will hear from leading dermatologists about how you can best integrate latest developments in dermatology with your current practice. The main goal is to provide you with practice tips and treatment pearls that you can use on a daily basis. We all face a barrage of new information virtually every day that is difficult to keep up with and digest over time. With each derms and conditions episode, you will have the opportunity to listen to conversations between leading dermatologists from across the country on a variety of relevant topics in dermatology. So subscribe today to the Derms and Conditions podcast on Apple Podcasts or wherever you get your favorite shows. And my guess is that before too long, the Derms and Conditions podcast will definitely become your favorite show. Believe.

Season 1

Derms and Conditions is a podcast from the team that brings you the Fall and Winter Clinical Dermatology Conferences. Each episode you'll hear from leading Dermatologists in the US as they talk about Dermatology's hottest and most relevant topics and conditions. 

Derms and Conditions Podcast