Podcast Summary: Derms on Drugs

Episode: Compliance, Adherence – Whatever, Just Put the D*mn Cream On...

Date: March 7, 2025
Hosts: Dr. Matt Zirwas, Dr. Laura Ferris, Dr. Tim Patton
Special Guest: Dr. Steve Feldman (Wake Forest University)

Episode Overview

This episode explores the perennial dermatology challenge of patient adherence (a.k.a. compliance) to treatment regimens—particularly with topical medications. Through expert discussions, humor, and a special appearance from Dr. Steve Feldman—a leading voice in adherence research—the hosts dissect recent clinical trial data, illuminate the real-world difficulties of getting patients to “just put the cream on,” and sift through what really matters for dermatology outcomes. The panel also tackles recent advances in oral and topical drugs and closes with their signature light-hearted biosimilar trivia.

Major Discussion Points & Insights

1. New Therapies for Psoriasis and Atopic Dermatitis

• Icotra Kinra (J&J2113 oral peptide, IL-23 inhibitor)

  • [01:38 - 08:33]
  • Dr. Ferris (First author on the study) introduces the 52-week extension data from the FRONTIER 2 study.
  • Oral peptide, small systemic absorption, blocks IL-23 receptor. Not unique to J&J; other oral peptides exist.
  • Main outcomes at 52 weeks:
    • PASI 75: 76.2%
    • PASI 90: 64.3%
    • PASI 100: 40.5%
  • Key Quote:
    "I do think that there are probably patients who prefer an oral medication and that is why I'm so excited to talk about this with our guest." — Dr. Ferris [06:43]
  • Discussion of efficacy compared to existing biologics (e.g., Cosentyx, Illumia, Skyrizi):
    • Similar to mid-tier biologics, below the most effective injectables.
    • Safety clean, some dosing drawbacks (needs to be taken fasting, BID in the trial).
  • Adherence tie-in: Oral administration may improve preference but fasting/BID might limit adherence.

• Tapinarof (VTAMA cream) in Atopic Dermatitis

  • [08:33 - 15:57]
  • First non-steroidal, non-TCI topical for kids as young as age 2.
  • Derived from “worm poop”, minimal systemic absorption, no boxed warnings, minimal baggage, works quickly.
  • Dr. Zirwas: “...It’s effective, it’s fast and there’s no baggage. It’s an interesting thing to see if this is going to change pediatric AD the same way that Opzelura changed adult AD.” [10:41]
  • Folliculitis is a drawback (~10%), but otherwise well-tolerated.
  • Comparison to Zoryve (roflumilast): efficacy likely a bit higher for VTAMA, but Zoryve has known MOA, preferred by peds derms.

• Cabtreo (Clindamycin, Benzoyl Peroxide, Adapalene gel) for Acne

  • [16:19 - 22:52]
  • First triple combination topical.
  • Study showed modest improvements in inflammatory/non-inflammatory lesions.
  • Quality of life metrics not superior to dual-combination products.
  • Industry-sponsored design discussed with skepticism.
  • Dr. Patton: “Like, why is it being sold to us this way?...They sell it to you in the most...it's deceptive, right?” [20:39]

2. Patient Adherence vs. Drug Efficacy – Real World Practice

• Patient Non-Adherence is Rampant

  • [23:55 - 26:45]
  • Dr. Feldman recounts studies (including one with electronic medication caps) showing no patients using topical regimens as prescribed (e.g., 80% adherence was achieved by zero participants).
  • Key Quote:
    "Not a single person used it 80% of the time. Not one." — Dr. Zirwas on Feldman's study [25:06]
  • Efficacy gaps between oral and injectable drugs may reflect adherence issues, not pharmacology.

• Trial Setting vs. Real World

  • In trials, blister packaging and frequent follow-ups improve adherence.
  • Blister packs and colorful packaging could help in real life—“Nothing should be packaged in a bottle, especially a beige bottle that's designed to blend into…” — Dr. Feldman [27:01]
  • Frequent follow-up is analogous to piano lessons:

    “If a piano teacher said, here's your sheet music, practice every day, I'll just see you at the recital in three months...that recital is going to sound abysmal.” — Dr. Feldman [28:13]

• Does Motivation Matter?

  • Desire for clear skin (e.g., severe acne, eczema, even painful diseases) does not guarantee adherence.
  • Even for conditions like gonorrhea, patients struggle to complete a mere 7-day course.

  • “But they won't take a pill. The stuff we ask them to do, the stuff you're asking your acne patient to do for three months, they're not.” — Dr. Feldman [38:50]

3. Strategies to Improve Adherence

• "Idiot Proof" Drugs vs. Behavioral Interventions
  • Once-every-few-months injectables may bypass the adherence issue.
  • On the other hand, adherence can be improved with effort: short intervals between visits, accountability mechanisms.
  • Ideas range from quick turnaround follow-ups (“see you in three days”) to future tech (deepfake AIs checking in as their doctor).
  • Key Quote:

    “It will cost nothing to create this sense of accountability that drives people's behavior, you know?” — Dr. Feldman [34:50]

  • Simple interventions:
    • Office-administered medications (lightbox as excuse for daily topical use).
    • Accountability check-ins dramatically increase usage.

4. Memorable Quotes & Moments

• On Study Designs:

  "This is an advertisement by the company that's masquerading itself as a, you know, like an independent scientific inquiry.” — Dr. Patton [19:41]

• On Doctor Influence:

  "You're reminding me of something...do you think maybe the reason you think CeraVe works so well is because you're telling your patients, oh my God, this is a miracle...?"
  — Dr. Feldman (paraphrased by Dr. Zirwas) [29:25]

• On Adherence as a Provider Problem:

  "If the lettuce is not growing, well, you don't blame the lettuce. All right?"
  — Dr. Feldman [36:07]

• On Accutane Success:

  "Maybe that's why Accutane works so well…you have to see those patients every month because of the whole iPLEDGE thing."
  — Dr. Patton [39:07]

5. Notable Fun Segment: Biosimilar or Science Fiction?

[40:28 - 45:26]

• A rapid-fire trivia game where the hosts and guest try to distinguish whether names are of new biosimilars or from science fiction.

  • Tie game among all four.
  • Lighter moment underscores how confusing drug names can be versus sci-fi!

  “The Humira ones are good. The ones that are coming out for Stelara…I mean, every single one sounds like a science fiction character. It's awesome.” — Dr. Patton [45:13]

Key Timestamps by Segment

| Timestamp | Segment/Discussion | |-----------|---------------------------------------------------| | 01:37 | Icotra Kinra oral peptide for psoriasis | | 03:38 | Phase 2b extension results and clinical use | | 04:50 | Efficacy comparisons and practical limitations | | 08:33 | Tapinarof (VTAMA) in pediatric atopic dermatitis | | 12:48 | Comparison with Zoryve and real-world perspectives| | 16:19 | Cabtreo triple combo for acne | | 19:26 | Critical take on clinical trial and outcomes | | 23:55 | Dr. Feldman on adherence: studies and insights | | 25:06 | Real rates of topical use | | 27:01 | Packaging and behavioral cues for adherence | | 28:13 | Piano lesson analogy for follow-up frequency | | 34:50 | Deepfake doctor accountability idea | | 36:07 | "Don't blame the lettuce"—responsibility for adherence| | 38:50 | Why even severe symptoms don’t guarantee adherence| | 40:28 | “Biosimilar or Science Fiction?” trivia game | | 45:26 | Wrap-up and closing remarks |

Actionable Clinical Pearls

• Adherence is the real limiting factor in dermatologic outcomes—not necessarily drug efficacy.
• Oral drugs may provide convenience but have their own adherence hurdles (fasting/BID requirements, etc.).
• Simple changes—colorful packaging, frequent short-interval follow-ups, explicit positive framing (“miracle cream!”)—can influence patient behaviors.
• Don’t assume patient motivation equals proper medication use; it almost never does.
• If a patient’s condition isn’t improving, suspect lack of regular use before changing/adding treatments.

Memorable Quotes – Quick Reference

• "Not a single person used it 80% of the time. Not one." — Dr. Zirwas, [25:06]
• "If the lettuce is not growing, well, you don't blame the lettuce." — Dr. Feldman, [36:07]
• "The stuff we ask them to do for three months, they're not." — Dr. Feldman, [38:50]
• "Nothing should be packaged in a bottle, especially a beige bottle..." — Dr. Feldman, [27:01]
• "It will cost nothing to create this sense of accountability..." — Dr. Feldman, [34:50]
• "This is an advertisement by the company that's masquerading itself as a, you know, like an independent scientific inquiry." — Dr. Patton, [19:41]

For those who haven’t listened:
This episode will confirm your suspicions, challenge your assumptions, and offer real, pragmatic advice about the biggest unsolved problem in dermatology: patient adherence. In between laughter and biosimilar-based word games, the hosts and Dr. Feldman remind clinicians that most of the therapies in dermatology work—if only we can convince our patients (and ourselves) to use them as intended!