← Derms on Drugs
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- [00:02]
A
Welcome to season three of Terms on Drugs, a video podcast brought to you by Scholars in Medicine, the best educational platform in dermatology and provided at no cost. Medical providers Terms on Drugs is for cutting edge dermies, hit or miss comedy. I'm Dr. Matt Zyrus from Docs Dermatology and each week I'm joined by my residency buddies, Dr. Laura Faris from the University of North Carolina and Dr. Tim Patton from the University of Pittsburgh. And we use our 70 years of combined derm experience to discuss, debate and dissect the hottest topics in dermatology. It is everything you need to know to be on the king edge of derm and you'll like, say by listening. New episodes drop every Friday on Scholars in Medicine, Apple Podcast, Spotify and other major podcast platforms. And I highly recommend that you download the Scholars of Medicine app. We've got the full video archive of all the episodes. You can see all of the cool places Patton this week is recording out of a basement in somewhere near the beach. You know, it's crazy all right, but all the best. It's not just Scholars in Medicine, it's all the best. Durham Educational Content Pharma, independent coverage of the whole deal, supported by an amazing AI clinical consultant named Asked Simon. So this week we've got another one of our patented six pack episodes and let's go ahead and get kicked off. Dr. Faris, what do you got?
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B
All right, so I am excited about this paper. This just came out.
- [01:23]
A
You sound excited.
- [01:24]
B
I know I don't let the enthusiasm, you know, bully you over too much. But population skin cancer screening and melanoma mortality rates, which I know probably has everybody like tingling right now, but anybody who knows what I like to do is I'm very interested in population based skin cancer, particularly melanoma screening. And so my initial like enthusiasm for this began when, when there was a paper published, there was a study or an intervention done in schwick, Holstein, Germany 2003-2004. Basically what happened was that Schleswig Holstein they told they, they got all the primary care docs and said, they said we want to test if melanoma screening works. And they got together, primary care docs, dermatologist, they got an eight hour training, they to how do I detect scientific skin cancer? They then you know, advertised to the whole Schleswig Holstein state and said if you're 20 or older, come in for a one time skin cancer screening. It was like, you know, all this fanfare. They did the screenings and then they followed out and five years later they were like look, melanoma mortality went down in Schleswig Holstein. Isn't this great? We're like, yes, we should do this. And then they turned it loose. All of Germany, they said, we're going to offer skin cancer screening every two years to everybody 35 and older. Basically what has happened and this is just all background since then has been like, when they relooked at the Schleswig Holstein data and follow them over time, they're like, never mind. They did not really have a reduction in mortality at all. And they haven't really liked, you know, but they kept doing this and then like they tended to see that there wasn't a huge difference in Germany. But what they did in this study is now they're looking at Germany and not just Leslie Holstein, they're really looking at Germany and actually in most of it, minus Schleswig Holstein, since it had a different intervention versus like the surrounding nine neighboring countries. And they looked at train trends in age, standardized melanoma mortality rate from 2009 to 2022. So 2008 is when the screening began. Okay. And then if you said, well, is everybody getting screened? It looks like about 32% of the population. The two year participation rate is about 32% of the population. So not like huge, but I mean, pretty good, right? Like a lot of times when you have things like that, people don't do it. Do you have a comment on that, Matt? Was that.
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A
No, I was gonna say in. So in america that'd be 100 million people.
- [04:19]
B
Yeah, that's a lot of skin cancer,
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C
a lot of people.
- [04:22]
B
So then what they wanted to do was then they just said, okay, let's look at trans immortality and melanoma mortality in Germany, but then also the surrounding, you know, nine countries. And then, okay, so they did also break the data down to two sub periods, so 2009 to 13 and then 2013 to 22. Now why did they do that? Basically because after 2013, that's when we got, you know, all these great, you know, therapies that are definitely going to impact melanoma mortality, like checkpoint inhibitors, BRAF and MEK inhibitors. Okay, so what did they do? They looked at the data from 15 German federal states with a population of 79 million inhabitants. And then the data from the, the nine neighboring companies, that was 164 million inhabitants. This is pretty big populations. And so they looked at, you know, annual percent change in melanoma mortality. So from 2009 to 2022. So when they looked in Germany, they, you know, they looked state by state by state, but Basically they saw a 3.8% reduction in melanoma mortality and then in the control surrounding areas, also a 3.8% reduction. So exactly the same. And the pooled estimates were negative 1.8 for Germany, negative 2.2 for non German control regions. And that difference was not statistically significant. So essentially that is the top line result. You look at Germany, you look at the surrounding nine countries, there was not a difference. And if you're like, well, what were the countries? Interestingly they were sort of a mixture of, you know, I would say high, so more high socioeconomic, but also low. So you know, you've got Austria, you've got Belgium, Denmark, France, but then Netherlands, but then Switzerland, which is very wealthy country. But you also have like Poland in there, you've got the Czech Republic in there. And really there was no difference between the different countries in terms of mortality. So, you know, so what's the, what's
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A
the take, what's the takeaway here? Dr. Fares? We should, we should stop doing full body skin exams for melanoma. I mean, obviously that's not the takeaway, but it's got to be some, like we should stop doing them on just random. Anybody's. It should be.
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B
I mean the, you know, yes, I mean the, the takeaway points that you know, they made here are, you know, we do not have evidence even from having a long term, you know, every two year screening program in Germany are not seeing a reduction in melanoma mortality. And they, you know, interesting things that, that came up with this were that they talked about, you know, like why did we see this with the screen, that initial German, the, the Schw C1 and not this. So they said, well maybe it's because we started it at 20 instead of 35, but that's probably not it because you know, we know that 20 to 35 is a pretty low melanoma mortality period. Interestingly, when they looked at the data from screen in Schleswig Holstein, what they did see, while they saw a reduction in deaths attributed to melanoma, they actually saw an increase in deaths attributed to like non specific, you know, malignancy of unknown origin. So basically these like non specific cancer deaths. So there's probably a little bit of, you know, of coding error. They also said, you know, maybe part of the problem is that we're not, this really is not risk stratified screening other than age of 35, which is a mild risk factor. They weren't like, you know, what we need to do is like, you know, only do people who Are fair skinned only do people who have had sun damage focus on people with previous skin cancer. So they did not do that. You know, other things that they did say is that, you know, there has been a lot more publicity around skin cancer awareness and screening. There's been this pan European Euro melanoma campaign to sort of raise awareness about skin cancer. And they're like, it's sort of like our melanoma Mondays, our melanoma may, you know, awareness months. They also do may. So, you know, maybe there is more skin cancer screening going on throughout Europe, not, you know, outside of Germany. So. So that may have sort of evened out the trends. But you know, I think in general routine screening, unselected general population, we have just tried and tried to find a benefit. We cannot. You know, I think the thought is we probably need to find ways to truly risk stratify and only be screening high risk patients. But this is sort of another nail in the coffin for population based asymptomatic screening.
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A
Patton, any thoughts?
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C
No. I mean, right. I think that's why the U.S. preventative Task Force said, you know, we just don't have evidence that population based screening for skin cancer saves lives. And that's kind of what I tell patients. And you know, I would say a 50% say, okay, cool, I'll see you when I see you. And the other ones are like, well, my cousin died from melanoma, so I'd like to come back in a year and I'll see him back in a year because it's money and it's easy
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B
and you don't have to order any labs for it.
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C
Oh yeah, lots of labs. Cdc, lft, ldh, LDH in particular.
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A
Ferris, didn't you do a study on something like this a long time ago of like people with no specific skin complaint came in for. And like how often do we find something or am I thinking of something else?
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B
No, I've done a bunch of studies like that, but yes it is. So I've done that with like people without skin complaints. And you know, there it would argue for risk stratification because if you have, you know, patients who have had a previous skin cancer, particularly if they're male, they're over 60, the number goes up in terms of like how many you need to screen to find one melanoma or one skin cancer. So, you know, there, there is a difference there. We also did kind of a similar intervention at the University of Pittsburgh when I was there, where we trained patients, primary care docs to screen for and Identify skin cancer. We, you know, all I could do was control people who got screened versus people who did not get screened. And what we did show was that there was not a, there was an increase in the incidence of thin melanoma in the screen population, but there was no difference in the incidence of thick melanoma. So that was sort of another one, you know, other, you know, other things to think about. Like this wasn't the most rigorous. Like everybody didn't do a dermatology residency and then screen. So you could argue, well, this isn't like our level of derm screening. You know, they have shown in surveys of, you know, patients who were screened for this program that most of them did not, you know, get a super full quality, high quality, full exam. Like oftentimes the all the skin wasn't examined, genital skin wasn't examined. I'd argue that's still not enough to, you know, to explain it. They said, well, maybe it's because only 32% of the population was screened, but you know, they sort of did. They estimated that we should have still, if even with that you should have seen, you know, like a 10% or should have less, it should have resulted in a 13% reduction in melanoma mortality over, you know, 10 years. If you were actually, you know, has, has it.
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A
Has anybody ever done the study where we teach people, okay, once a month, take 15 seconds and like spin around in front of a mirror and see if there's anything that you're just like, whoa. I do not. That looks bad. Like it, it seems like that would be the way to try and pick
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B
up the people have tried to look at skin self examination. There's some data that if you do it too often, you lose sensitivity. But we don't have anything that looks at like mortality. You can look at detection rates but not mortality. So.
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A
Okay, all right, all right, let's, let's move along. Patton, Pat, what do you got? Patton?
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C
My first six pack is from the journal Skin All Caps, May 2026. It was titled when to reapply Moisturizers, Evidence Based intervals from a 24 hour hydration study by Aoki et al. So I mean, this is very relevant, right? Counseling patients on moisturizing the skin. They say, what moistures would I recommend, how often they should be doing it, Standard line. I would say at least twice a day. I have no idea if that's based on anything. I usually give standard recommendations. Cerave, Cetaphil, Vanicream, Aveeno, Usrin. I mean that's Like a good, good list. And I kind of assume that there's probably not a huge difference between any of those. And it's more about personal preference. Well, anyhow, this paper, there were 30 volunteers. They had five spots marked on each forearm, so 10 spots total. They applied nothing. Then they did cave cataphil, Usrin and something called Skin Medica HA5 serum. So the authors used a device that measured tissue dielectric constant, apparently a measure of skin hydration. They recorded baseline 1, 4 and 24 hours. They report the data in the table and I, it doesn't like for me it's like a series of. But like that TDC was probably a number when your skin's not moisturized it's low and then it should be high. So like just do like bar graphs. They did this. Coefficients and significance for each product. It's very hard to understand intuitively but it's calculated over 24 hour period. So over a 24 hour period there wasn't that big of a difference between the inexpensive moisturizing creams and only Skin Medica product was statistically significantly better over a 24 hour period than applying nothing. Figure 2 is a line graph showing when the moisturized sites intersect with the non moisturized site. Again, this was a figure that was very confusing. Like if you looked at it, it looked like non moisturized skin over time became more moisturized. And they're like well no, that was this polynomial equation that we did to fit the curves. And that's just what we see in variations. Blah, blah, blah. What they said if you actually read the graph that is supposedly like the right way to read it. Here's when the moisturized sites got back to the same level of skin hydration when nothing is applied. And so it was about three hours for the inexpensive creams and almost five hours for the serum. So they're like okay, well that the serum is a more effective moisturizer. But like the moisturizing creams were run, run about 15 bucks. And the Skin Medica HH5 serum, it's like five proprietary forms of HA and it's like really, really expensive. It's like over 100 bucks. And like this little tiny amount. It was also controlled not patients with
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B
eczema face or the whole body or what were they looking at?
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C
It was, it was like little dots, little little circles on the arm and they just put a little bit here.
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B
A little jar of serum isn't.
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C
Oh, it's, it's like it's one ounce. Right. All the, all the moisturizers typically come in what I would say is like the 454 gram big jar. And this, this ha. I don't need. I don't think you could apply it
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B
over the whole body unless you're Elon Musk. Yeah.
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A
Yes.
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C
Yeah. So I, I cannot see patients applying a moisturizer every three hours. Who knows, maybe they will. I don't, I just don't know if this paper like. Okay, yeah, it seems like after three hours the effect of the moisturizers wear off. That's not terribly surprising to me. There have been other studies like, you know, do you do the moisturizer right after bathing or do you wait 30 minutes before you. And it just seems in those studies that it does kind of wear off over time. I think I'm just going to still tell people like twice a day. Try it. I don't know that this is going to change. I mean I could, I could say, well, there was a study that said every three hours. I know that's not terribly practical. Moisturize the skin as often as you can. If you can do it twice a day, that probably helps.
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B
Did any of the other moisturizers have hyaluronic acid in them?
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C
Yes, the cerave, I believe, had the ceramides and hyaluronic acid. There were, they had the. I, I wrote this down. I, I think that I wrote it down and yet I'm saying I don't know the answer, but I did write it down, but it's something that I don't have with me right now. Okay, I want to say the cerave had hyaluronic acid in the ceramides. I think the eucerin product had urea in it. And I believe that the cetaphil product had glycerin, like, like a maybe 3 to 5% glycerin. So it was almost like a comparison of, you know, humectants, things that hold water into the skin. And it just seems like this proprietary form of five different is a more effective humectant, which for over a hundred bucks you would expect that. I don't think it's terribly practical. And again, like when patients say, well, what's studies ever looked at? When does it wear off? I think you could say, yeah, there was one study, three hours. If you can do that, maybe that's when you would want to do it. But I don't think anyone's really going to do that.
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A
I gotta say I'm trying to. Maybe I missed it, but I looked. Somebody had to pay for this. This Was not like a cheap study to do in any way, shape or form. But I can't find any funding source. It says, literally says in the paper that there were no. No conflicts of interest.
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C
Literally says that, yeah.
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A
Conflict of interest disclosures, none. Funding, none. Who? Somebody.
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B
They took AAD samples and then had a med student measure it. Yeah.
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C
You could probably get enough at the AED to do this.
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B
You spent all your time in the exhibit hall.
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A
I mean, this is crazy. I mean, somebody paid for this. I want to know who paid for it. Like, it's. Because whoever paid for it, they're hiding it. Like, that's what makes it, like, disturbing to me. Not that somebody paid for it, but that they're hiding it. Whoever the authors of this are, if you're listening to this, please email me and tell me, confirm for me that nobody paid for this.
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B
You can email them, Matt, that'll be your homework this week.
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A
I'm going to email them. Are their email addresses in here? Oh, yeah, there is when I see it. Right?
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C
Yeah, there's probably a contact person.
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A
Oh, there is. Oh, I'm gonna find out. What the hell.
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B
All right.
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C
This is exciting. Something.
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A
Like this. Okay. Maybe a medical student did it all for free. Who knows? We'll see. Okay. All right, we're moving. Moving on to my patent. Patton, is that even a peer review journal?
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C
Skin? I don't know.
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A
Okay. All right.
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C
Yes, it is peer reviewed.
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B
It's pure review. It's not PubMed listed, but it is peer reviewed.
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A
Okay, so it's not indexed. Yeah, but it is peer reviewed. Okay, okay. All right, Fair. All right, so I'm gonna. We're gonna jump over to my first one. And this was really just useful. And it's really quick. Right. There's a lot of controversy about this dupilumab effect patch test reactions. I say the evidence says, no, it does not. There have been several studies looking at. We patch tested people before they run dupuy, patch tested again after they were on dupy. No big difference. Some people are like, well, but some halogen skew 2H2. I think it's all baloney. But so this one, they. They did JAK inhibitors. And this is what it looks like whenever you use a drug that actually does affect patch test reactions. So they did. 20 people patch tested them before they went on a jack and then patch tested them again after they were on a jack. And Jacks were extremely good at suppressing patch test reactions. So there were in the. So they did abro and oopa. So they did Rinvoak and SABINKO. And so 29 strong positive reactions in the ABRO group. After three months of treatment, roughly 2/3 of them were totally negative. Upadacitinib, same thing, 23 strong positive reactions, 2/3 of them were completely negative at the end. Whenever you looked at it on a broader study, 80% of them, almost 85%, got weaker or went away. Only 15% maintained. So it confirms what we already thought, that JAK inhibitors strongly inhibit patch testing. And. But it gave us a good, like, baseline of, okay, well, if you want to do a DUPY study and say it does it patch testing or not, like, this is what it looks like whenever something really affects patch testing. The question that actually comes from this, if somebody's on a jack and you want to patch test them, how long should they be off of it? Nobody has any idea. My gestalt would be that a week would be enough. Two weeks seems like it would certainly be enough. But we don't have any data to back that up on kind of making it up. So that was the takeaway. Any thoughts from you two?
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B
No. I think that maybe JAK inhibitors are the best treatment of contact dermatitis.
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A
Then I think that could be very true. I guess the other thing that I found was interesting in this was that I think there's a perception out there that upadacitinib is a more potent drug than Abrasit Nib. This is actually a pretty good way to try and measure that. And they came out the same. 15 of UPA and 100 of Abro looked pretty much exactly the same. That's my clinical experience as well. I don't, I don't think that one is better than the other, but that probably the other, if you're trying to dig something else kind of interesting and useful out of this, that's where I would put it.
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B
So, yeah.
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A
All right, let's move along. Ferris, what do you got next?
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B
Okay, I'm switching gears to a little bit of wellness and burnout, even though I know this with Lisa Swanson, but two papers that came out, and I'll be pretty brief about them because there's, you know.
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But yeah, I believe. I believe it when I hear it.
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B
Uhhuh. One of them was in JAMA Research letter Trends in Patient Portal Messages, Office Visits, and Telephone Encounters. So this looked at data from epic Cosmos, over 2,000 hospitals, 47,000 patient, 47,000 clinics. And they looked at active patients and looked at all patient portal messages, telephone telehealth encounters and office visits. Okay, so what did they find? You know, this was like over like 139 million patients. What percentage of them would were messengers had sent at least one message? 30% of patients have used the portal. So patients are messaging at a high rate. And then they looked at between 2020 and 2025, the number of, you know, patients went up, the number of visits went up. But the patient authored portal messages increased from basically 1 per patient per year to 2.5 per patient per year. So a 153% increase. Now office visits increased per patient per year. 17%. Clinic and staff authored messages increased by 24%. But there was also like this big Covid peak. So we can sort of take that out. But if you look at the graph, like basically kind of the take home message from here is yeah, yeah, there was this like weird spike in all of the COVID stuff. But man, what keeps going up and up and up is not telehealth. It's not, you know, office visits. It is patient portal messages. So patients are, you know, messaging. It's not really like oh, but it's, you know, the number of telephone encounters declined a little bit. So we're doing more messaging than telephone encounters. But it's not like replacing office visits. It is just patients are messaging more and more and more. So it is an expansion of between visit care and you know, one of the points that they made are like health systems need to take this into account. Right. So like we should either find a way to get reimbursed for this, think about how we might limit it, or at least make sure that people are adequately staffed to be able to, to deal with this. So it sort of confirmed what I had felt which is that patients are more and more finding ways to reach us outside of a typical visit.
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A
You know, the best, the best take I heard on this, it was that in 200070 year olds did not know how to message.
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C
Yes.
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B
But when we look at who's doing it, it's women. It is like people in the 40 to 60 year old range. And it is people who are basically like they use the social vulnerability index but wealthier, more. Well, so sadly I guess it is not like, oh, this is helping to you know, democratize care for our either like you know, very elderly or very poor patients.
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A
Nope, it's, there's a, I really think there's a big component of just that more of the population is now comfortable with electronic messaging. Right. Like go, go. If you go back to 2000, like I didn't have I would, didn't have a cell phone. I wasn't texting like I was. Right, right. It's now everybody's, everybody's used to texting and messaging now.
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B
Right.
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A
So it's, it, it may have plateaued is kind of what I'm hoping. But I didn't look at the graph. Is it, was there been any leveling off in the rate of increase?
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B
Nope. It is only going. Yeah. So it average patient messages per mess, you know, per year. So you know that, that average, that 150% increase is over time. But if you look at the average number in 2020, it was a little over 2 in 2026, it's now like 5.1. So it is, it's a big impri. It's a big, you know, and then if you look at who is doing it, it is sort of the, the biggest group is the 40 to 64. But to your point, Matt, 33%, like the 33% of people over 65 are messenger. Are messaging. Okay. And then just a real quick follow up to that. Was there was, there's this in the Kaiser. It was the Permanente Journal, which is sort of the Kaiser Permanente journal. It's called why have all the Doctors Gone? Insights into early Clinical departure among physicians in the U.S. a national survey. So what they were trying to do is like they just, they looked at the people. They took a sample of clinically inactive physicians drawn from the AMA's Physician Professional data. So survey completed May and June of 2024. So, you know, they talk about the fact that like there is a projected shortage of between basically 13,000 to 86,000 physicians in the US by year 2036. And so what they wanted, what they did was they looked at like there are patients who are like, oh, I'm not, I'm sorry. Physicians who, you know, note that they are not clinically active. And so the majority, so they may have never practiced, they're not currently practicing or they're currently practicing, but they're like less than 20 hours a week. So the majority of those are people who used to practice, but we're not practicing anymore. Okay. And then if you look at who are these people, it's mostly people in the internal medicine specialties. And the people who aren't practicing, more on their mean average, their mean practice length was about nine years. So this is pretty early, you know, retirement about what was interesting or, you
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A
know, I got to say they're lucky bastards.
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B
Lucky bastards only practice nine years now. They're not all, you know, they're doing other things sometimes they might be working outside of clinical medicine. But what I thought was interesting was like, what was the reason why you left? And the number one reason the top two were. Number one was hassle factor. And then number the other top one was too stressful. And then so that was like, you know, the percent who indicated this as a reason. And you could have multiple reasons. 45% hassle factor, 45% too stressful. 41% increasingly unrealistic patient demands. So, you know, I just thought that that kind of, you know, paired nicely with the previous paper that, you know, are patients more demanding? We are like, there is an expectation to be available all the time. Women more likely to leave for, you know, like, caring for family members than that.
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A
I think another part of that unrealistic expectation is, is pharma to blame? So I think it's the drug commercials make people think like, oh, I should go to the doctor, and then I'll be playing volleyball and dancing on the beach just like all those psoriasis patients I see in the tremphyle commercials. Like it. I really think that DTC advertising and all of the, you know, all of the viral news stories of breakthrough treatment and break through this and break through that. Like, if you were an alien and didn't know anything and just saw like, what's the media putting out about medicine? You would be like, they have everything's fixed. Everything's fixed, but somehow they still don't like the doctors. Those doctors must be awful people because everything have fixed everything, but the patients still aren't happy. Like, that's what it's. It's blah.
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B
Yeah. Yes, I agree. Like, I do think we're told, like, ask about quality of life. You got to address everybody's quality of life. And I think we need to treat disease and get people better and that the quality of life follows from. So, yeah, I thought that was interesting. But, you know, the other thing is, like, when you look at the, the, the predictions of our workforce, this is assuming people are, you know, going to. It's not assuming an increase in attrition. It is assuming if everybody, you know, keeps coming in at the same rate, works full time. So, like, this probably has some pretty. Like, we really need to think about this. Like, this has some really important, you know, consequences for, you know, our workforce.
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A
We're going to have a surplus of doctors. AI is going to replace us all.
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B
Well, we'll see.
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A
It's going to be no problem. Everybody, if you haven't done this Go check out Doctronic. I have no conflict of interest. D O C T R O N I C. It's free. You just go in there, pretend you're a patient, any random patient of yours and start being like, I have a headache. And it's, you'll, you'll see why I got to the point of if this is where it is now, in six months or a year, I don't know, we're not really going to get replaced. But it's, it's in the next like year.
- [32:30]
B
Yeah, there's, it's going to change things. But yeah, yeah. Just one stat that I thought was crazy. In the latest AMA or American Medical College Physician workforce projections, they said that a decrease increase in the average retirement age of two years. Right. These are, we're talking about like this survey is people quitting after nine years. So that's like a retirement a, you know, 20 years.
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A
Forty. Right.
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B
And a decrease of the projected physician supply in 2036, which is not that far away, by approximately 40,000 physicians. And that's just if the average retirement age went down two years. So when we're losing people completely, you know, 20 years early, it's a big deal. So I think between the portal messages, the, you know, patients are the main reason people leave is the hassle factor. Like gotta look out for physicians and we've gotta do what we can to keep people in the workforce and, you know, take good care of patients, but try to limit the hassles.
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A
I think our, our AI overlords will save us all.
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B
Right.
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C
I hope they do.
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B
Help me, Claude.
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A
Pat. I, I, I remember Patton saying something along those lines.
- [33:45]
C
It was, I stole, it was a line from the Simpsons. I was paraphrasing a Simpsons line. Okay, Ant overlords. You have to see the episode. It makes sense, trust me.
- [33:55]
A
Fair?
- [33:56]
B
Fair.
- [33:56]
A
All right, Deck fairy. Patton, what do you got?
- [33:58]
C
All Right, my second six packs from the journal Microbial Pathogenesis and PubMed. It's listed as being from the August 2026 edition. So it's from the future.
- [34:09]
B
Paper from the future.
- [34:10]
C
Yeah, it looks like it was available online May of 2026.
- [34:14]
A
We're tied on the cutting edge.
- [34:16]
C
Breaking the treatment barrier and Trichophyton, endotinia and related species A systematic review of case reports and case series by Rafa et al. This was a paper from Matt. Iran.
- [34:29]
A
Iran.
- [34:31]
C
Trichophyton indentinea infection is a dermatophyte infection. Around 2014, 2018, an explosion of Tinea infections in India were reported. They were More extensive, they were more inflammatory. So like itchy tinea, widespread and resistant to standard therapies, particularly systemic terbinafine in its standard dosing. Reports of resistance to azole also reported the resistance to terbinafine is mediated through mutations of the squalene epoxidase gene. I read where about. I mean it depends where you read but about 85% of these trichophyton endotinia infections harbor those sqle mutations. This paper was a systematic review of T Endotinia infections examining clinical and laboratory features, hoping to guide diagnosis treatment decisions. So they reported 132 infections. Most of the cases were from Germany. This was a like a literature search. Most of the cases were from Germany, although the paper acknowledged this was probably more a function of who's reporting the infection as opposed to where most cases are likely occurring. It's crazy. There was this report. Close to 80% of dermatified infections in India are t in dotinia Crazy. Yeah. The bulk of the paper consisted of two tables. Tables 1 is a clinical and demographic data. Table 2 microbial information. Tenia cruis and ta corporis were the predominant clinical presentations. 112 cases describe the use of terbenine as therapy and over half, like 62.5% did not respond. Itraconazole was used most frequently as alternative therapy, although apparently increasing the dose of terbinafine and the duration is also a reasonable option. I was going through this table. I have never heard of this drug. Have you guys ever heard of suba itraconazole?
- [36:18]
B
No, but it sounds like super itraconazole.
- [36:22]
C
Absolutely is. It's marketed as Tulsura in the US it stands for suba, stands for super bioavailable. I you not. It uses some sort of matrix technology to improve bioavailability.
- [36:39]
B
So it's available in the U. S?
- [36:42]
A
Yeah. How much is this?
- [36:44]
C
Thousands of dollars. It's very, very expensive for insurance.
- [36:48]
B
From the by the people who come here and, and get with tinia indo,
- [36:54]
A
doesn't it suggest you could just give people massive doses of regular itraconazole?
- [36:58]
C
You know what it not necessarily so I don't, I don't know if they addressed that in this paper, but I just did a little bit of reading on T Endotinia infection. There was a paper from 2024 they found that like the 100 milligrams a day is fine and, and they studied, there was a study that compared that to 200 to 400 and there was really no difference in percentage of patients. So this, this JAD paper, which is a really, really good paper too. I'm not going to talk about it. But the 2024, it goes through a lot of the stuff with T into tinea. The key the difference is like tinea corporis for me, whether it's terbinafine, whether it's itraconazole, whether it was fluconazole. Typically that was a two week treatment. They're saying for T and to 10A, it's like six weeks minimum. And for a lot of patients they take it out to eight weeks. So that's the big, that's the big difference that, that super duper, super duper itraconazole is like FDA approved to treat like certain forms of blast mycosis and histoplasmosis. So it's like more of the sort of invasive dimorphic fungal type things.
- [38:05]
A
Have you, have you guys seen any inditine cases?
- [38:09]
B
I have one right now that I am treating.
- [38:12]
C
Like, I have not.
- [38:13]
A
I've only seen it like one, a couple. And it was my like my partner like did all the work of it. It was so inflammatory.
- [38:19]
B
Yeah.
- [38:20]
A
And like it did not look like normal tinea. It was like, it looked like tinea, but it looked like tinea from hell.
- [38:26]
B
It's super itchy and miserable.
- [38:28]
C
Yeah, it looks like, it looks like eczema where the body surface area is like 60.
- [38:32]
A
Yeah, it was awful.
- [38:33]
B
Awful.
- [38:35]
C
So yeah, there were some cases reported in the US all the cases were reported in patients that had traveled to Bangladesh, Turkey, India. The Bangladeshi. It was like then it was passed from family member to family member. So you know, take away recalcitin churning infection, widespread, maybe more inflammatory. Get a travel history. Think about starting with itraconazole in these patients and sedentary. I do not know how widely available the testing is. There is this PCR on what's called an internal transcript spacer or its. So you do PCR on its and that'll say yes, this is T. Endotinia. It.
- [39:12]
A
It. Yeah.
- [39:13]
C
So that's it. So you know, doing cultures and, and calculating minimal inhibitory concentrations. I don't think that's a very practical thing that microbiology labs do. So the identification is really with that itc, but just by history, if it's widespread, maybe those are the patients where you think itraconazole first instead of terbenafine or, you know, itraconazole is tricky drug interactions and you know, if they have CHF or any heart stuff, you get a little bit nervous with itraconazole so if you want to do terbinafine, you would maybe start off with like the 250mg bid dose. And whether it's itraconazole, whether it's terbinafine, you treat those patients for like minimum of six weeks, maybe sometimes out to eight weeks.
- [40:02]
A
Okay, that's it. Okay. All right. That's. That's Indotini, man. That's one of the things I. I now hope I don't get. Yeah. All right.
- [40:14]
B
Travel history.
- [40:15]
A
Good going on to. That's true. That's why I don't like to leave America. America don't like to leave it. All right, so my last two are both Nemo Lizumab papers. First one is nimulizumab. Let's see here in people who have cancer. So nimolizumab for treatment. Refractory cutaneous adverse events in patients with cancer. Retrospective multi institutional series, primarily from the HAVID program. And essentially they got a fair number of people with bad itching that they thought was either paraneoplastic or, or was related to therapy. About 15 people total. And Nimliv worked pretty darn well. So 6 out of 15 got a complete response. Searching, went away completely. 7 out of 15. So a total of 13 out of 15 improved substantially and two did not approve. And you know, there were. It was tolerated fine. So people did not. Didn't seem to make cancer progress at all. So just useful to have out there now if you've got itchy people who either you think it's paraneoplastic or related to cancer therapy. Obviously we have a lot of data on dupilumab in these people. It's nice to have now some data on nimolizumab that at least we can have a reference for. The other one was nemalizumab for pruritus control in ctcl. I actually thought this was even more kind of useful. Interesting, because at this point, you know, we're kind of all thinking like, man, if I got somebody who's super itchy with CTCL, I'm sure not putting them on DUPY, which is a good, you know, with the other IL13 inhibitors, we're not sure, but I still wouldn't want to put them on that, like Jax or a. Maybe when you talk to the CTCL people, you think that it'd be like, oh my God, no way. But they're like, maybe, but. So this was the first stuff I saw with Nema Lizbeth, and it was pretty stunningly effective. So they gave people their. So it was eight patients, they gave them a, the normal loading dose. Then most of them they gave another dose at about four weeks. And then from there on out it was kind of just like, oh, let's see how you do. And so everybody got at least partial control with their loading dose. And then a lot of these people were able to go. So then they, almost everybody got a second dose at four weeks. And then after that like a fair number of them were able to go 20 out, 20 weeks without a dose. Some of them went out to 30, 35 weeks without another dose. And in the people who did get itchy again, it was like as soon as they got itchy they gave them another dose and then they got better again. So just really interesting, these recessery patients and MF patients didn't seem to make the disease progress. Follow up time. You know, there were several of them that they had seven or eight, six or seven, eight months of follow up. Some of them follow up was fairly short, but did not seem to make the disease progress. And it suggests that in ctcl, you know, you give them their baseline dose, you give them another dose four weeks later and then you probably can just dose it on an as needed basis after that. So really useful to know. And you know, these were all people who were on other stuff. So some of them were on Mogamu, Lizumab. Close enough, close enough. Interferon photophoresis and like it, it really worked.
- [44:01]
B
So you are in dosing like, you know that's good.
- [44:05]
A
Yeah, yeah, there was, so there were, let's see, they did. Of the eight patients, one person got a PRN dose and then they went from completely controlled. So they got their baseline dose, no four week dose. Their second dose was at week 12 it looks like because they started to get itchy and then they are itching came back a little bit and they never got any more doses and it never got terrible again. But Everybody else like PRN dosing, where that was the only person in whom PRN dosing did not work. 7 out of 8. Good. So use useful information.
- [44:45]
B
I love this study because you know that they're like, oh God, they're itchy. Like do we have Nemo in the fridge like you do? Let's give them that. Like you totally know that is how this happened.
- [44:56]
C
But 100%, yeah, it is.
- [44:58]
A
That is how most new drug discoveries in derm are made. What do we have in the fridge? What's in the fridge?
- [45:05]
B
I look at the sample fridge in my.
- [45:07]
C
Yeah, I mean, it's a great drug, right? You don't have to worry about, like, nice to have things in cancer patients where you're like, yeah, don't worry about this.
- [45:15]
A
And now if that. If that didn't work, you can give them the generic tofacitinib. That's right. Right. That's. You probably want to check with your local CTCL specialist first. But that generic tofacitinib, it's a game changer to have it in your back pocket. Right?
- [45:30]
C
Cheap, cheap, cheap.
- [45:31]
B
How much is it on Cost plus. Mark Cuban, Cost plus drugs it is. How much a month to have a sitinib?
- [45:38]
C
5 milligrams, twice a day dose is 25 bucks. 10 milligrams, twice a day Dose is 28.
- [45:45]
B
Okay.
- [45:46]
A
A month. Wow.
- [45:47]
B
A month.
- [45:48]
A
Crazy. It's going to be so fascinating to see if that, like, brings the development of all these other jacks to a halt.
- [45:54]
C
It's. It'll be interesting. That's a huge cut into that. You would think. Although oral reflumelast is available, do you think more patients get reflumelast or a premolast?
- [46:04]
A
Yeah, yeah, yeah, yeah. No, that's because everybody needs to listen to derms on drugs. And we could fix that, probably save American medicine.
- [46:14]
C
We would make the world a better place.
- [46:16]
A
Make the world a better place. Right on. Right.
- [46:19]
B
I know. Before you start crying, I'm getting emotional.
- [46:25]
A
Right, America? All right, so I want to thank everybody for tuning in. We hope you learned a thing or two. We hope to laugh once or twice, but mostly we hope. When you're planning to join us next week. Until then, I'm Matt Zyrus.
- [46:36]
C
I'm Tim Patton.
- [46:37]
B
And I'm Laura Faris. And we are Derms on drug.