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.

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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 dupilomab. 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 1223s or 23s. 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 apremalas 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 premalast. If it hasn't, switch to, let's say, a biologic. But also premalast can be useful as an adjunctive therapy. Add it 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 premalass, 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.&nbsp; 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’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 &nbsp;

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.&nbsp; 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’oreal, travel,&nbsp; DAR companies: Founder ASLMS: A Ward Memorial Research Grant Skin Cancer Foundation: Research Grant Regen: Research / Study Funding LeoPharma: Research / Study Funding&nbsp; Biofrontera: Research Study Funding&nbsp; 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. &nbsp;

The Scoop on Squamous Cell Carcinoma

You're listening to the Derms and Conditions podcast. Hello, Dr. Jim del Rasso, 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 histologically 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 sonometer 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 perinural 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 breadloaf 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 adnexal 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. Schmultz 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 carato 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 mose 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 on 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 submiplamab 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. So 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.&nbsp; 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.&nbsp; 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&nbsp; 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 ring 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 Lebow. 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 a 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 was 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 mo 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 buzwords. 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, too? 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 sonedejib, 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 Gorland 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 vismodigib. 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.

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.&nbsp; 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.&nbsp; 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 &nbsp;Advisory Board:Foundation for Research &amp; Education of Dermatology Dermavant SciencesInvestigator: AbbVie Incyte Corporation Dermavant Sciences AOBiome, LLCConsultant: 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 JohnsonSpeaker: Galderma Laboratories, LP Pfizer Inc.Stockholder: Gore Range CapitalBoard of Directors: Womens Derm SocietyOther: National Psoriasis Foundation &nbsp;

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" 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 in 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 in 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 taquanak. 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 Dovanex 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 exilla, 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 dipropionate 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 Winsora 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 Winsora cream group as compared to the Taclinex 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 dipropynate 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 Delrasso 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 &nbsp;

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

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, know, 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 dupillumab. 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 JNJ 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, calcium inhibitors like decolamus and pimacrolomus, 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 calcin 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 intotrigenous 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 ruxalidum, 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 rufumolast has their data with psoriasis, and certainly we're seeing some come along with sebric 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 intertrigenous areas, I think I share your excitement about that. Yeah. I think with all three of these agents to Pinarov, rafumalast, and ruxalitinib, 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 Dol 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.

Derms and Conditions Trailer

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