Derms on Drugs – Episode Summary

Episode Title: Boosting Isotretinoin, Outsmarting Botox Resistance & Other Plot Twists
Date: December 5, 2025
Hosts: Dr. Matt Zirwas, Dr. Laura Ferris, Dr. Tim Patton

Episode Overview

In this lively "six-pack" episode, Drs. Zirwas, Ferris, and Patton break down six of the hottest new dermatology articles and clinical trends, ranging from herbal triggers in dermatomyositis to outsmarting Botox resistance and new frontiers in oral psoriasis treatment. The tone is energetic, playful, and practical, with each host offering up pearls, debate, and context for real-world dermatology practice.

Key Discussion Points and Insights

1. Immunostimulatory Herbs and Dermatomyositis

• Article: JAMA Dermatology (Yang, Wirth et al.)
• Key Point: Immunostimulatory herbal supplements, particularly spirulina, can trigger dermatomyositis and are associated with antibody-negative presentations.
• Study Details: 286 dermatomyositis patients, 13% had used immune-boosting herbs (spirulina, elderberry, ashwagandha) before onset, median window ~1 year between first use and disease onset.
• Clinical Relevance:
  • Always ask about supplements; these don’t show up on med lists (04:32).
  • Patients may have classic disease without classic autoantibodies if herbally triggered.
  • Quote [03:09], Dr. Zirwas: “I almost started recommending spirulina ... forget that. I'm gonna get rid of their acne and give them dermato.”
  • Quote [07:32], Dr. Zirwas: “Spirulina. Got to ask about stuff that's cheap, that's easy. And I'm a big fan of cheap and easy.”
• Mechanisms Discussed: Spirulina increases toll-like receptor 4 activation; alfalfa-based products can elevate TNF/IFN levels.

Timestamps:

• 00:58–07:32 — Main discussion

2. Biologics Reduce Clot Risk in Hidradenitis Suppurativa (HS)

• Article: Alam et al., International Journal of Dermatology (Nov 2025)
• Key Point: Large TrinetX database study suggests biologics halve risk of venous thromboembolism (VTE) and pulmonary embolism (PE) in HS patients compared to non-biologic treatment.
  • Odds Ratio: 0.56 (VTE), 0.61 (PE)
• Caveats:
  • Potential confounding: Biologic patients are “better healthcare consumers” and may have lower baseline risk (13:25).
  • Differences in comorbidities (lower diabetes, CKD, tobacco use).
• Clinical Takeaway:
  • While interesting, not yet practice-changing: don’t pitch biologics for HS as VTE-preventers.
  • Quote [13:41], Dr. Patton: “Those patients are coming into your office, you're monitoring them much closer... it's not just the biologics.”

Timestamps:

• 07:45–14:03 — Main discussion

3. Boosting Isotretinoin Efficacy and Minimizing Side Effects

• Article: Systematic Review and Meta-analysis
• Key Point: Adding loratadine (or desloratadine/levocetirizine) to oral isotretinoin for acne:
  • Reduces inflammatory lesions (by ~8 at 12 weeks)
  • Halves the risk of cheilitis (16:03)
• Usability: Loratadine is cheap, safe, easily added.
  • Quote [14:23], Dr. Zirwas: “We probably ought to be like, hey, and by the way, get some generic loratadine... It's completely safe and extremely cheap.”
  • Suggests adding to standard patient counseling.
• Bonus Pearl: Omega-3 fish oil also helps reduce cheilitis/nosebleeds.

Timestamps:

• 14:13–17:14 — Main discussion

4. Drug-Induced Rosacea and Demodex in Immunomodulation

• Article: "TICKED Off by Rosacea"—Australian case series (Ducravacitinib)
• Key Point: Tyk2 inhibitor ducravacitinib and JAK inhibitors can trigger papulopustular rosacea, often Demodex-driven (18:51).
• Pearl:
  • Quote [21:32], Dr. Ferris: “If all of a sudden they've got papulopustularization, just look for Demodex... you might be able to treat through it.”
• Favorite Therapy:
  • Combo oral ivermectin + oral metronidazole, followed by a triple topical cream (ivermectin, metronidazole, azelaic acid) applied at night (22:32).
  • For resistant cases: topical 5-FU (off-label), based on corneal literature and anecdotal success.
  • Quote [23:48], Dr. Zirwas: “That's my favorite thing ever—5FU for Demodex right there.”
• Takeaway: Suspect Demodex when new follicular eruptions emerge on immunomodulators.

Timestamps:

• 17:14–24:00 — Main discussion

5. Oral Icotral Kinra for Psoriasis — New Data

• Article: New England Journal of Medicine (Bisson et al.)
• Drug: Icotral Kinra—oral, daily, IL-23 receptor blocker (peptide)
• Results (16 weeks):
  • IGA 0/1: 65% vs 8% placebo
  • PASI 90: 50% vs 4% placebo
  • PASI 100: 27% vs <1% placebo
  • Well-tolerated, including in adolescents.
  • Extra Note: ~10% of patients had latent TB at baseline and were not treated, none developed TB reactivation—a potential advantage over biologic protocols (29:58).
  • Quote [30:50], Dr. Zirwas: “This may be a drug that we don’t actually have to do TB testing for.”
• Clinical Place: Likely to sit between Stelara and Tremfya in efficacy, but oral and potentially without labs.
  • Quote [31:15], Dr. Ferris: “It’s going to be better than a premolast, ... around the Stelara-ish efficacy... not quite Tremfya.”
• Dosing Note: Once daily, on empty stomach.

Timestamps:

• 24:05–33:36 — Main discussion

6. A Premelast for Oral Mucosal-Predominant Resistant Pemphigus Vulgaris

• Article: Zang et al., Oral Diseases (Nov 2025)
• Key Point: Small prospective study (n=5) suggests a premelast (PDE-4 inhibitor) as an adjunct for stubborn oral PV lesions.
• Discussion: Modest impact on disease activity/desmoglein antibodies; possibly strengthens the cytoskeleton, reducing erosions without eliminating antibodies.
• Clinical Use: Worth trying in misery-inducing, chronic oral pemphigus after steroids/rituximab.
  • Quote [39:24], Dr. Patton: “Oral erosions and ulcers—that’s just miserable, right? ... I’m gonna try it.”

Timestamps:

• 33:43–39:42 — Main discussion

7. Reversing Partial Botulinum Toxin Resistance with JAK Inhibition

• Article: Case series from Lebanon
• Key Point: Tofacitinib (JAK inhibitor) temporarily reversed partial resistance to Botox-A in two patients.
• Mechanistic Skepticism: Effect is puzzling/improbable; mechanistically, short-term JAKi shouldn't reduce antibody titers this quickly (40:39).
  • Quote [40:39], Dr. Zirwas: “Are we gonna give somebody a potentially toxic drug so that their Botox will last longer?”
• Practical Note: Not advisable, but patients may start asking.

Timestamps:

• 39:49–42:23 — Main discussion

8. Scalp Cooling for Chemotherapy-Induced Alopecia

• Discussion: Cold-cap therapy can markedly reduce hair loss for breast cancer chemo patients, particularly with taxanes.
  • For taxanes: 30 min before, 30–45 min after = best protocol.
  • With anthracyclines: less effective, may prevent complete baldness but patients often still require head covering.
  • Insurance coverage and availability varies by site (46:08–47:44).
  • Quote [44:07], Dr. Zirwas: “About 90% of them will protect the majority of their hair... it really did make a very big difference for them in their quality of life.”
  • Clinical Takeaway: An important quality-of-life intervention; derms should be aware so they can educate/support patients.

Timestamps:

• 42:36–47:44 — Main discussion

Notable Quotes & Memorable Moments

• Dr. Matt Zirwas [03:09]:
  “I almost started recommending spirulina ... forget that. I'm gonna get rid of their acne and give them dermato.”

• Dr. Tim Patton [13:41]:
  “Those patients are coming into your office, you're monitoring them much closer... it's not just the biologics.”

• Dr. Laura Ferris [21:32]:
  “If all of a sudden they've got papulopustularization, just look for Demodex... you might be able to treat through it.”

• Dr. Matt Zirwas [23:48]:
  “That's my favorite thing ever—5FU for Demodex right there.”

• Dr. Matt Zirwas [30:50]:
  “This may be a drug that we don’t actually have to do TB testing for.”

• Dr. Laura Ferris [31:15]:
  “It’s going to be better than a premolast, ... around the Stelara-ish efficacy... not quite Tremfya.”

• Dr. Tim Patton [39:24]:
  “Oral erosions and ulcers—that’s just miserable, right? ... I’m gonna try it.”

Engaging Takeaways

• Herbal supplements can have serious autoimmune consequences—ask specifically about them.
• Biologic patients may seem to have fewer clots, but data is complicated by who gets access to these drugs.
• Rotating in cheap, over-the-counter meds like loratadine may enhance acne regimens and reduce side-effect burden.
• Watch for emerging immunomodulator side effects—Demodex rosacea is a sneaky one, and creative therapies abound.
• Oral IL-23 receptor blockers are poised to shake up the psoriasis landscape, especially for needle-averse or kid patients—watch for them!
• Good science sometimes throws a curveball: Botox resistance and JAK inhibition anyone?
• Hair preservation during chemo is a critical quality-of-life issue—derms can advocate for their patients.

For Listeners:

This episode offers a mix of actionable clinical pearls, skeptical scrutiny of new data, and witty banter. Ideal for dermatology providers wanting both evidence-based updates and memorable practice-changing tips.