Episode Summary: "Are You Serious? Tattoos Prevent Melanoma and More Curiosities from the Literature"

Podcast: Derms on Drugs
Hosts: Dr. Matt Zirwas (A), Dr. Laura Ferris (B), Dr. Tim Patton (C)
Date: October 31, 2025

Episode Overview

In this "six-pack" episode, the Derms on Drugs trio each present and dissect two recent articles or curiosities from the dermatology literature. The theme: surprising findings, practical pearls, and controversial headlines—like whether tattoos might actually lower melanoma risk. The hosts maintain their trademark mix of clinical expertise and comedic banter while giving practical advice for dermatology providers. Each segment includes discussion of real-world implications, study methodology, and take-home messages.

Highlights & Key Discussion Points

1. Switching JAK Inhibitors in Alopecia Areata

[01:14–09:31 | Laura Ferris]

• Study Brief: Yale case series (Khalil et al, JAMA Derm): 13 patients with severe alopecia areata who failed at least one JAK inhibitor, then responded to another.
• Key Finding: Some patients had dramatic responses after switching, even after multiple prior JAKs.
  • “One person actually went through four rounds. They went to four JAK inhibitors before they had hair regrowth.” – Laura Ferris [05:20]
• Clinical Nuances:
  • Not all JAKs are interchangeable; different subtypes may matter.
  • Real-world cases included adjunct therapies (oral minoxidil, intralesional steroids).
  • Weaknesses: small sample, retrospective, variable protocols.
• Pearl: Give at least 9 months on initial JAK and consider adjuncts before switching; oral minoxidil is safe and should be considered early.
  • “I think you add the oral minoxidil early and continue it on.” – Laura Ferris [07:52]
• Philosophy: Some prefer monotherapy, others combination—no consensus among the hosts.

2. Intralesional Therapies for Keloids & Hypertrophic Scars

[09:36–15:58 | Tim Patton]

• Meta-Analysis (Li et al): 24 RCTs comparing IL (only) therapies.
  • IL Botox and triamcinolone + 5-FU (TAC+5FU) performed best for efficacy and recurrence over triamcinolone alone.
  • Odds ratios: ~5 for Botox, ~4 for TAC+5FU.
• Practical Barriers: Logistics of compounding/administering 5FU are significant.
  • “There are a lot of logistics to it and I think a fair number of providers are like, I’m not dealing with any of that…” – Tim Patton [11:40]
• Protocols: Most use TAC (various strengths) and sometimes cryo; electron beam radiation for recurrent cases, but coverage varies.
• Memorable Moment: Banter about the “satellite dish” filter for drawing up 5FU and intra-institutional differences in practice.

3. Tattooing and Risk of Melanoma

[16:07–19:12 | Matt Zirwas]

• Utah Case-Control Study: Individuals with ≥4 tattoos had >50% lower melanoma risk; those with ≥3 large tattoos had 75% lower risk.
  • “Maybe you're priming people's immune system so that when they get a melanoma they already have some reactivity.” – Matt Zirwas [17:36]
• Host Skepticism:
  • Laura Ferris: “I’m glad it’s a video podcast so people can see me rolling my eyes...” [17:53]
  • Patton notes age confounding; Ferris posits detection bias (tattoos hide lesions).
• Takeaway: While fun to discuss and possibly a party fact, hosts don't change clinical practice based on this.

4. Tinted vs. Untinted Sunscreen for Melasma

[19:12–22:43 | Matt Zirwas with group discussion]

• Study: Randomized trial, tinted sunscreen (with iron oxide) vs. untinted, in melasma patients—the tinted group improved markedly over summer while the untinted group did not.
  • “The people who got the tinted sunscreen, their melasma got a heck of a lot better over the course of the summer, like impressively better as monotherapy.” – Matt Zirwas [20:40]
• Mechanism: Visible light appears to be a major trigger for melasma, especially in darker skin types.
• Practice Pearl: Strongly recommend tinted sunscreen, particularly in phototype III/IV.
• Open Question: Less clear if effect translates to very light-skinned individuals with melasma.

5. Dupilumab Exposure During Pregnancy

[23:11–32:23 | Laura Ferris with group discussion]

• Cohort Study (JAD): ~293 dupilumab-exposed pregnancies vs. matched controls—no elevated maternal risks; possible reduced risk in some adverse outcomes for women with type 2 inflammation.
  • “There was actually a reduction in… preterm labor… hazard ratio 0.11, which is pretty significant.” – Laura Ferris [28:38]
• Limitations: Could not assess neonatal/child outcomes, only maternal; timing/duration on drug varied.
• Practice Implication: Reasonable to continue dupilumab when trying to conceive; consider pausing during pregnancy unless significant disease flare.
  • “What I would probably do is hold your dupixent and then if your eczema starts to come back... restart.” – Matt Zirwas [30:08]
• Broader Point: Risks of stopping therapy (uncontrolled disease) also matter; treat type 2 inflammation during pregnancy.

6. Kappa Opioid Receptor Agonists for Uremic Pruritus

[32:27–38:04 | Tim Patton]

• BMJ Study: IV kappa agonist (Anarikafon)—primary and secondary endpoints met for pruritus reduction in dialysis patients; side effects similar to placebo except for dizziness.
  • “37%…reached the primary endpoint…compared to 15% in placebo.” – Tim Patton [34:30]
• Clinical Context: Most use now falls to nephrology; dermatologists see fewer cases due to new renal treatments.
• Bonus: Butorphanol (intranasal, Kappa agonist/Mu antagonist) historically effective but hard to prescribe now.

7. Oral JAK Inhibitors for Vitiligo

[38:07–42:59 | Matt Zirwas with group]

• Retrospective review: JAK inhibitors show modest efficacy for vitiligo; most patients also on UVB/topicals. Results improve with longer duration (but drop-off and observer bias likely).
  • “About half…got 25% repigmentation only 10% got 75% repigmentation…” – Matt Zirwas [39:28]
• Key Insight: JAKs less transformative than expected; uncertainty about durability (does repigmentation persist after stopping?).
  • “You took a patient that had vitiligo and turned them into a patient that has vitiligo. It’s better…but…” – Tim Patton [41:57]

8. Topical Timolol for Chronic Wounds and Hand Eczema Fissures

[42:59–45:52 | Matt Zirwas, group]

• Case Report & Theoretical Discussion: Cheap, accessible topical timolol (ophthalmic solution) appears helpful for chronic wounds and recalcitrant fissures.
  • “Topical Timolol is cheap, easy to get, and you just put a drop on the fissure…” – Matt Zirwas [43:50]
• Mechanism: Beta-adrenergic effects on keratinocytes.
• Caveat: Rare risk of allergic contact dermatitis.

9. Mendelian Randomization Studies—Skepticism

[45:56–46:49 | Matt Zirwas]

• Hosts note the mass retraction of Mendelian randomization studies; agree these are rarely conclusive for clinical practice and best regarded with skepticism.

Notable Quotes

• “Switching jacks can help no matter how many jacks.” — Matt Zirwas [09:31]
• “Maybe you're priming people's immune system so that when they get a melanoma they already have some reactivity.” — Matt Zirwas [17:36]
• “There is pretty overwhelming evidence… that visible light is a big factor in melasma.” — Matt Zirwas [22:08]
• “There was actually a reduction…in preterm labor…if you had type 2 inflammatory disorders and you were on dupilumab…” — Laura Ferris [28:38]
• “You took a patient that had vitiligo and turned them into a patient that has vitiligo. It’s better…but…” — Tim Patton [41:57]
• “Topical Timolol is cheap, easy to get, and you just put a drop on the fissure…” — Matt Zirwas [43:50]
• “Maybe I’ll tell my patients to take nicotinamide and get three huge tattoos.” — Tim Patton [19:07]

Timestamps for Major Segments

| Segment | Host(s) | Timestamp | |---------------------------------------------------|------------------------|-------------| | Switching JAK inhibitors in alopecia areata | Laura, Matt, Tim | 01:14–09:31 | | Intralesional keloid therapies | Tim, Laura, Matt | 09:36–15:58 | | Tattoos and melanoma risk | Matt, Laura, Tim | 16:07–19:12 | | Tinted vs. untinted sunscreen for melasma | Matt, Laura, Tim | 19:12–22:43 | | Dupilumab in pregnancy | Laura, Matt, Tim | 23:11–32:23 | | Kappa agonists for uremic pruritus | Tim, Matt, Laura | 32:27–38:04 | | Oral JAKs for vitiligo | Matt, Laura, Tim | 38:07–42:59 | | Topical timolol for chronic wounds/fissures | Matt, Laura, Tim | 42:59–45:52 | | Mendelian randomization skepticism | Matt | 45:56–46:49 |

In the Hosts' Own Words (Memorable Banter)

• Laura Ferris [17:53]: “I’m glad it’s a video podcast so people can see me rolling my eyes and Patton smirking at this study.”
• Tim Patton [19:07]: “I know I’m gonna tell my patients to take nicotinamide and get three huge tattoos.”
• Matt Zirwas [22:08]: “Come on, Pat. There’s not some evidence. There is pretty overwhelming evidence to me at this point that visible light is a big factor in melasma.”

Practical Pearls

• For severe alopecia areata, be patient with JAK inhibitors and consider adjuncts—switching is reasonable if no/poor response after 9+ months.
• For keloids, consider TAC+5FU for better efficacy/recurrence, but administrative logistics may limit use.
• Melasma patients (esp. Fitzpatrick III/IV): Tinted sunscreen is likely superior to untinted—make it your go-to recommendation.
• Pregnancy and dupilumab: No signal of increased maternal risk; balance disease control and fetal exposure—stop if possible but restart for flare.
• Severe uremic pruritus: If renal team has not tried a kappa agonist, suggest they consider it; butorphanol is rarely used now due to script restrictions.
• Vitiligo: Oral JAKs may take many months and results are less robust than biologic use in psoriasis—set expectations.

Useful for Listeners Who Haven't Tuned In

If you missed this installment, you missed spirited, expert discussion on surprising dermatology findings. The hosts reviewed literature from practical pearls (tinted sunscreen, topical timolol) to quirky findings (tattoos vs. melanoma), all while offering plenty of clinical wisdom and real-world skepticism about overhyped results. The episode is a can’t-miss for anyone who likes their education mixed with laughter.