Podcast Summary: Derms on Drugs

Episode: BCC Treatment Goes Viral: Find out what happens when you unleash a genetically modified herpes virus on difficult BCCs
Date: February 7, 2025
Hosts: Dr. Matt Zirwas, Dr. Laura Ferris, Dr. Tim Patton
Guest: Dr. Jakob Thyssen (University of Copenhagen)

Overview

This episode dives into cutting-edge topics in dermatology, with particular focus on:

• The use of genetically modified herpes simplex virus (TVEC) for difficult-to-treat basal cell carcinomas (BCCs)
• Current evidence and strategies for switching JAK inhibitors in alopecia areata
• Epidemiology and management pearls for hand eczema, featuring expert insights from Dr. Jakob Thyssen
• Noteworthy new studies in dermatology, covering BP therapy, actinic keratosis risks and treatments, advances in hyperhidrosis management, and more.

As always, the trio delivers their evidence-based analyses with their signature blend of humor and practical clinical wisdom.

Key Discussion Points & Insights

1. Genetically Modified Herpes Virus (TVEC) for BCC

[01:29]–[06:43]

• Study Recap:
  Dr. Ferris summarizes a new Nature Cancer paper on neoadjuvant TVEC (talimogene laherparepvec) for locally advanced BCC (NEO BCC Phase II trial, 18 patients).

  • TVEC is an intratumoral, genetically engineered HSV-1 virus expressing GM-CSF.
  • Key endpoint: conversion to resectable disease without needing plastic surgery reconstruction.

• Efficacy:

  • Study terminated early after meeting primary endpoint.
  • Quotable:
    "50% of patients did not need a flap or a graft... Pathologic complete response was a third of patients here." — Dr. Ferris [02:24]

• Mechanisms and Responses:

  • Good responders showed increased CD8+ T cells and B cells, decreased Tregs.
  • Lower than expected new BCCs suggest possible preventative effect.

• Side Effects/Clinical Pearls:

  • Patient without prior HSV antibodies developed symptoms similar to primary HSV infection; treatable with acyclovir if needed.
  • HSV-based therapy may be an emerging strategy for cutaneous tumors due to accessibility.

• Comparative Approaches:

  • Discussion of ongoing trials for intratumoral immune checkpoint inhibition.

• Memorable Moment:

  • "Be super cool if we ended up doing it for warts — like one virus and another virus and see if it worked." — Dr. Zirwas [05:55]

2. Switching JAK Inhibitors in Alopecia Areata

[06:46]–[11:34]

• Study Recap:
  Dr. Patton reviews a December 2024 case series (Clinical & Experimental Dermatology) on switching from baricitinib to ritlecitinib in severe alopecia areata.

  • 15 patients who stopped baricitinib (at least 3 months off) were started on ritlecitinib.

• Efficacy:

  • 60% responded; those with no response to baricitinib were much less likely to respond to ritlecitinib.

  • Quotable:
    "If a patient has absolutely no response to baricitinib, it's not like there's a chance it really isn't going to work, but it's not looking good." — Dr. Patton [09:33]

• Practical Takeaway:

  • If partial response to first JAK, reasonable to switch.

  • If zero response after six months, switching likely futile.

  • Summary Statement:
    "People have now learned everything they need to know about JAK inhibitors for alopecia areata from Derms on Drugs... If they haven't gotten better, they're not going to get better." — Dr. Zirwas [10:51]

• Patient Story:

  • Dr. Patton relays a “cute Hallmark movie” story of a patient trialing therapy to potentially help their child.

3. Chronic Hand Eczema Epidemiology

[12:24]–[16:42]

• Large Cross-Sectional Study:
  Dr. Zirwas presents the CHECK study (60,000 subjects, Europe/Canada), confirming known risk factors:

  • Physician-diagnosed hand eczema in last 12 months: 4.7%
  • Higher in women, employed, urban, and peak in ages 30–39

• Clinical Pearls:

  • Neither type of soap nor moisturizer use made much difference; only cold-water hand washing showed benefit.
  • Quotable:
    "What does help is washing your hands in cold water... It melts your intercellular lipid — lets it get rinsed away. Same thing in hand eczema." — Dr. Zirwas [14:53]

4. Feature Interview: Dr. Jakob Thyssen on Hand Eczema

[17:51]–[38:53]

Seasonality, Etiology, and Practice Pearls

• Role of Weather/Season:

  • Danish national data confirm increased topical steroid use in winter.
  • Quotable:
    "Cold is very, very important for skin barrier function. We have very big nationwide registry..." — Dr. Thyssen [18:30]

• Irritant and Allergic Factors in Hand Eczema:

  • Irritant exposure is primary; allergic contact (esp. nickel, fragrance) now accounts for ~10–15% in Denmark.
  • Emphasis on thorough history and patch testing when needed.

• Steroid Use & Systemic Effects:

  • Long-term, potent topical steroids may increase systemic risk (e.g., osteoporosis, diabetes) when used over large BSA—but rarely discussed with patients for hand eczema specifically.

  • Advocates for stepping down potency and intermittent use.

  • Quotable:
    "My experience is that clobetasol is just too much...steroids on the hands work great, but there is a price to pay, and it comes down the line because you will destroy the barrier." — Dr. Thyssen [25:07]

Topicals and the Future of Therapy

• JAK Inhibitors for Hand Eczema:

  • Both Drs. Zirwas and Thyssen express optimism for topical JAK inhibitors (e.g., Opzelura, delgocitinib).
  • JAKs may “reduce inflammation but not at the cost of barrier impairment.” [31:26–32:24]

• Dietary Nickel:

  • Once a significant driver of hand eczema in Europe; less so now due to successful regulation reducing both prevalence and severity of nickel allergy.

  • For severe nickel allergy (3+ patch), dietary avoidance may still be relevant. US rates much higher due to lack of regulation.

  • Quotable:
    “Low nickel diet is rock solid proof... This is the only truly anti-inflammatory diet.” — Dr. Zirwas [37:10]

Notable Moments

• Danish Medical Records:
  “Every Dane is basically recorded in the reg. If you pick up a topical corticosteroid... you will be recorded. And we had a PhD student…” — Dr. Thyssen [18:30]
  (“All Americans nervous about Denmark now!” — Dr. Zirwas)

• Steroid Barriers:
  “Three days of clobetasol and you stop making and releasing lamellar bodies... you can’t do barrier repair after three days of clobetasol” — Dr. Zirwas [26:06]

5. Article Roundup — “Six Pack”

[45:46]–[60:49]

a. Imiquimod + Curettage vs. Excision for Nodular BCC

[45:46]–[47:14]

• Excision remains superior (recurrence-free rates: excision 98%, imiquimod 77.8%).
• “Nothing terribly new, but confirms excision as best,” per Dr. Ferris.

b. Off-Label Tralokinumab for Bullous Pemphigoid

[47:43]–[49:51]

• Small case series; results similar to dupilumab. Some required ongoing prednisone.
• Potential for future IL-13 blockers for BP.

c. Blood Pressure Medications and Actinic Keratosis

[50:00]–[52:39]

• Hydrochlorothiazide increases AK/cancer risks (approx. 20%).
• Suggest switching if patients have heavy UV-related skin disease.

d. AI vs. Physicians in Patient Communication

[52:56]–[54:53]

• Patient satisfaction higher with AI-generated responses (Stanford AI GPT model); AI replies were longer, but length didn’t matter for satisfaction.
• Potential for AI scribing to reduce “pajama time” for clinicians.

e. New Treatments for Hyperhidrosis

[55:38]–[57:18]

• Sofpironium (topical glycopyrrolate, “Softra”) and Brella (sodium patch) highlighted.
• Many patients still managed with oral glycopyrrolate or oxybutynin; watch for side effects like dry mouth.

f. Suture Materials and Skin “Tear-Through”

[57:57]–[60:49]

• Tapered needles reduce risk of suture tearing through aged skin, compared to cutting/reverse cutting types.
• No notable price difference found.

6. Trivia Segment — International & Dermatologic Oddities

[39:44]–[44:51]

• A lighthearted quiz on patch testing, Danish trivia, and Nobel Prize-winning dermatologists—highlights humor and camaraderie.

Notable Quotes & Memorable Moments

• “You have a bunch of animal studies showing the same [effect of cold and humidity changes], but what's interesting is we have very big nationwide registry... and we had a PhD student from the US, Dayton, by the way…” — Dr. Thyssen [18:30]
• "Major take-home point for [alopecia areata] — after six months on one JAK inhibitor, if there's no response, switching probably isn't going to help." — Dr. Ferris [11:34]
• "Moisturizers don’t help a whole lot...wash your hands in cold water." — Dr. Zirwas [14:53]

Timestamps for Important Segments

• [01:29] — TVEC for BCC discussion
• [06:46] — Switching JAK inhibitors in AA
• [12:24] — Hand eczema epidemiology
• [17:51] — Dr. Thyssen feature interview
• [26:06] — Topical steroid barrier impairment
• [31:26] — JAK inhibitors and new topicals for hand eczema
• [37:10] — Dietary nickel deep dive
• [45:46] — Article roundup begins
• [52:56] — AI vs. doctors in patient messages
• [55:38] — New hyperhidrosis treatments
• [57:57] — Suture techniques for fragile skin
• [39:44/44:51] — Trivia segment

Final Thoughts

This episode delivers a rich blend of clinical updates and nuanced management pearls on basal cell carcinoma, alopecia areata, and hand eczema. The hosts provide actionable takeaways for practicing dermatologists—with many "aha" moments and generous doses of humor.
The guest interview with Dr. Thyssen is particularly enlightening around hand eczema epidemiology, therapy, and practical issues. The article roundup and trivia segment round out a lively, information-packed hour.

For more episodes and dermatology education:
Scholars in Medicine

“Hope you learned a few things. Hope you laughed once or twice. And mostly, I hope you're going to join us next week.” — Dr. Matt Zirwas [61:32]