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.

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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;

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

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