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- [00:11]
A
Welcome to season two of derms on drugs a video podcast brought to you by scholars in medicine the best educational platform in dermatology and provided at no cost to medical providers derms on drugs is where cutting edge derm meets hit or miss comedy i'm matt ziris from docs dermatology and each week i'm joined by my residency buddies doctor laura faris from the university of north carolina and doctor tim patton from the university of pittsburgh where we use our sixty years of combined derm experience to discuss debate and dissect the hottest topics in dermatology it's everything you need to know to be on the cutting edge of derm and you'll probably have fun listening new episodes drop every friday on scholars of medicine apple podcasts spotify and other major podcast platforms and as a reminder there is a video component that has the key figures and tables from most of the articles that we talk about this week we've got one of our patented six pack episodes where we are going to go through the stuff that has grabbed our attention in the literature over the last few weeks and we are joined by our special guest doctor scott drew a derm in practice for decades about an hour north of me also a member of docs dermatology so scott as our special guest this week we're thrilled to have you and let's throw it over to doctor faris for our.
- [01:22]
B
First article okay i am going to start with an article from jama dermatology which was amalians to prevent pediatric eczema so this was i think one that seemed like it got a lot of press so this was the cascade trial and so this is does moisturizing your baby prevent them from getting eczema so this was a large us study so randomized trial twelve forty seven infants twenty five clinics and they started they started basically moisturizing babies with emollient every day before the age of nine weeks and then they looked and said how many of them got atopic dermatitis by age two so the answer was the moisturizer group babies they had an incidence of thirty six percent of them versus forty three percent in the control group so that's a risk reduction of six point nine percent relative risk of zero point eight four so what does that mean you got to moisturize like fifteen babies to prevent one from getting atopic dermatitis so interesting things if you would think like oh okay what should really matter is like the kids who are at high risk they've got a high family history of atopic dermatitis they're going to benefit more but that is not true the babies who did the best were the ones who did not have a family history of eczema and also the ones who had a dog at home so as a dog lover i think that's good so i think i could do pediatric dermatology now i could just give out moisturizers and puppies to everybody it would be a lot more fun i wouldn't have to pry her off.
- [03:02]
A
Dupixent you would be the most popular pediatric dermatologist with the kids and the least popular with the parents all right so i'm gonna i'm gonna give my quick what i would call criticisms of this article so this is an area i've got a lot of interest been multiple studies have looked at this over the years most of them have showed no benefit of early moisturization this one here are the sort of concerns with it number one the prevalence of atop or the incidence of atopic dermatitis by the age of two was obscene so right there's not a study in the world that has ever shown a prevalence of atopic derm of forty percent so basically at least double the generally accepted prevalence and that kind of calls into question the diagnostic criteria they were using second thing because the diagnostic criteria were either parent report of health care person diagnosing them the children's eczema questionnaire or that they've got a diagnosis of ad and a prescription or that they got a or that they got a diagnosis of ad with an over the counter or a prescription or they met a modified uk working party and there was stunningly different so whenever we look at parent report of a diagnosis it was about thirty percent when we look at uk working party it was twelve percent so when we look at uk working party which is probably the most stringent there wasn't a meaningful difference there also an interesting thing that the people who had a first degree relative with ad there was no benefit it was only the kids who were with a from a family who had no first degree relatives with a diagnosis of ad so first study though that has shown a difference with moisturizing my take on this whole area is that there are a lot of derms out there who are researchers who really really really really really really really really really really really really really want it to be the case that moisturizing babies prevents eczema so far the data has and they've done really big studies that have all shown that it didn't this was the first one that showed that it did you know if you do enough studies eventually one's going to randomly like show benefit and even this one showed if there is benefit it's pretty small seems to seems to me like we're barking up the wrong tree thinking that moisturizing is going to prevent atopic derm but this study you know did show a difference so.
- [05:35]
B
That'S but maybe we're barking up the right tree with getting everybody a dog.
- [05:39]
C
A dog yes.
- [05:42]
A
That'S pretty good ferris but no harm in moisturizing babies at least we don't think so yeah i.
- [05:48]
C
Know but you know our patient our parents gonna be like i'm definitely gonna do this once a day every single day because this study showed that it prevents this disease that my kid's probably not going to get i don't see.
- [06:02]
A
Them motivated to do that and the other takeaway is for the parent who's like i have eczema i'm worried about my baby getting eczema willing them help this study says no right there was.
- [06:11]
B
No harm other studies have shown increased risks of skin infection in the moisturizing arm this one did not i just.
- [06:17]
C
Worry about the the parent that brings in the kid that develops eczema at one years of age and then says yeah we could have stopped this why didn't you tell me that's true all.
- [06:28]
A
Right scott any comment yeah i think.
- [06:31]
D
This reflects maybe the motivation of this study was the frustration that patients and their parents have with this disease state because there's so much myth busting that's needed in the management of atopic dermatitis in children the one that's so frustrating for me is somehow the idea that you shouldn't bathe your baby if they've got eczema and you know i think the whole soak and seal thing is the key to not so much prevent the disease from happening but getting parents to buy into this is a life condition that's going to need some family wide engagement until they grow out of it if they're lucky enough to grow out of it that you moisturize that you use the right detergent that you have the right diet that you manage the asthma and the otitis and it's not just skin it is and matt you probably are more responsible than anybody for creating the idea that this is an atopic syndrome not a single disease skin problem yep so whether it's moisturizing the day you're born or or whatever regimen we're doing is to let parents know that the skin person the four of us and all of our colleagues are the people that should be the the home of this disease management and and that this is not going to be here take a pill or use this or suck flaxseed oil every day whatever the current myth is that this is this is a science based disease.
- [08:06]
A
All right pat all right let's move on pat what do you got yeah.
- [08:09]
C
So my first six pack was modernizing u s sunscreen regulations how newer filters can improve public health by turner et al in the june twenty twenty five.
- [08:20]
A
Edition sorry i fell asleep for a.
- [08:22]
C
Second of photodermatology photo immunology and photo medicine we recorded a recent episode yet to be released where we discuss gunshins in depth with doctor woolery lloyd so i don't want to go too too much what we already discussed one of the things we didn't talk about was some of the newer agents that are available in europe and they may be available in the us soon so before discussing the agents the papers a section about how sunscreens are regulated in the us versus europe and asia and the us sunscreens are reg over the counter drugs europe and asia regulated as cosmetics there's a section that reviews the sunscreens approved for the us and goes to the generally recognized as safe and effective categories then there's a section comparing the regulatory processes for approval in the us and europe and south korea section touches a little bit about how uva protection is marketed differently in the us compared to europe and asia and it focuses on the specific sunscreens not yet available in the us first there's bimit bemotrizenol and bezoctrazole organic broad spectrum sunscreens they have high molecular weight structurally large so absorption is very low i think that's that's going to be helpful some of the medications that get that got kicked over to the generally recognized as safe and effective category three meaning the fda needs more data the absorption was one of the bigger problems there apparently absorption is zero point zero one percent in some studies endocrine disruption is also not a concern based on certain testing that was done other two ingredients reviewed were terephthalidine i screwed that up dicamfor sulfonic acid tdsa and drometrizole trisiloxane also broad spectrum organic filters have shown little absorption after topical use these all have trade names so bemotrismal is tinosorb s so.
- [10:19]
A
Patton here what's so for for anybody who doesn't quite get this what's the benefit of an organic sunscreen which just means it's a chemical not a physical vers why would it be better if.
- [10:30]
C
These came out patient compliance and use right the the mineral sunscreens go on very pasty these go on very very nicely something that is cosmetically acceptable is going to be used by the patients these are being used all over canada europe asia and they're the ingredients that are in some of the more popular sunscreens because it has that broad spectrum activity that also adds in a lot you know the uva pigment darkening anti aging effects so kind of crazy that the united states has the system that it has to get these medications approved i just thought it was a something we had just talked about and it just came out and you know we may see especially bimo trisol is tinosorb s is the the brand name we may see that within a year being approved it'd be the first new sunscreen approved since like the nineties that'd be.
- [11:32]
A
Sweet okay so it would be good.
- [11:35]
B
But i'm like is this our hill to die on as dermatologists like we've made the point i don't know sometimes i feel like we just like we have such bigger fish to fry than what new suns when the fda will approve the next sunscreen like we have sunscreens we have sunscreens that work yes it would be nice to have other ones but like how much of our.
- [11:56]
C
Maybe delves into the deeper thing of the difficulty that the fda makes bringing new drugs to market in america sometimes they're just working against us and they're working against patients doing the same thing.
- [12:11]
D
Yeah yep i think there's a a a lack of education among certainly me about what agents are in what sunscreens and i'll tell you my my little experience there is in southern africa and even in the horn of africa people want to be in all over the world perhaps they want to be one color and sunscreens in the third world are not very common because there's this myth that they don't get skin cancer and so when women particularly are enticed to use these products the best actor that's added to it to achieve a homogenous colorization unfortunately are laced with heavy metals so these women who are trying to achieve dyschromia relief are putting lead and arsenic on their skin and this is epidemic i mean this happens from from namibia all the way to sierra leone across the congo to somalia and the amount of arsenic and lead that's used actually leads to cns degradation so not that this issue is particularly germane to that however over the counter medications in you know in non regulated countries like we have are really problematic and i can tell you stories and show you pictures of patients that really have been injured by what we would consider cosmetical cosmetic usage all right i'm going.
- [13:48]
A
To jump on so i'm i'm taking a different tack on six packs and i'm presenting six quick hit one liners that i'll give you guys just a chance to comment on very briefly number one type two immunity links eczematous and lichenoid eruptions caused by immune checkpoint inhibitors basically what they did here was look at people who got eczematous eruption or lichenoid eruption from an immune checkpoint inhibitor compared the immune profile to normal eczematous dermatitis and normal lichenoid eruptions like lichen planus and what they found was that the lichenoid eruptions with immune checkpoint inhibitors are th two driven and what which makes sense since we think you know dupy works for them but what was interesting to me there is that i generally put a histologic reaction pattern together with a type of immunity and i've always thought of if it's like an oid it's th one and what this tells me is that lichenoid does not tell you the immune pattern so i now think that if i get somebody with lichenoid and spongiotic combination on a biopsy i'm going to assume that that is a th two type reaction that the spongiotic is primary and i'm going to treat it as an exematous disorder so that was kind of the interesting takeaway there any quick comments on that.
- [15:06]
B
One it fits it works dupy works well for lichenoid drug reactions to immunotherapy.
- [15:13]
C
So okay all right nick yeah i i would think like anoid i'm going to try with flumelast first but now this paper has me thinking maybe maybe the lichenoid in those patients is th two and try dupy yeah so i.
- [15:25]
A
Think if you get lichenoid and a hint of spongiosis go with the spongiosis.
- [15:30]
D
I think the message there matt is people who are on these drugs don't need to stop them because they develop a cutaneous side effect that we can manage them and let them stand their drug and give them hope that they otherwise would not have yep all right.
- [15:45]
A
Next alopecia areata whenever the jack doesn't work well enough two good options came out number one mini pulses so there was one it was a randomized controlled trial of they use beta methazone on weekends main takeaway for me here because rather than betamethasone i think we ought to be using dexamethasone if we're going to try and do this the type of regimen that you would use here and you could consider doing this as monotherapy or combining it with a jack it would be something like dexamethasone let me see here what did i think that the something like dexa two point five milligrams monday and friday or saturday and sunday in a kid or five milligrams saturday and sunday in an adult using a regimen like that they got salt scores went from an average of fifty to an average of twenty five that was monotherapy not combined with a jack the one that was even more interesting was a case report looking at they put somebody on a jack they didn't really regrow for a long time then they had them do high potency steroid under occlusion so put the high potency steroid under occlusion on one half of their head wear shower cap overnight that half of their head regrew hair the other half did not then so then they did it to their whole head and they regrew hair and they maintain the hair with just the jak inhibitor main takeaway is put somebody on a jack and it takes and they don't get better after three to six months do clobatazole under a swim cap at night until they start to regrow once they've got decent regrowth stop the clobazole under occlusion and the jack should maintain it i don't think we need any true real comment on those two other than it'd be reasonable to do the clobatazole under a swim cap at at baseline like to start doing that whenever you first start the jack wouldn't be unreasonable then once they've got the regrowth you stop the clobazole just keep doing the jak next one good studies showing that it was cerave versus regular moisturizer it was a two arm study literally meaning they put cerave on one arm regular moisturizer on the other so two arms involved and they showed that transepidermal water loss changed the same in both but the arm that got cerave whenever you did tape stripping it was more resistant to it when you did sodium lauryl sulfate irritation it was more resistant to it and it was more it was harder to basically interrupt the stratum corneum so we're starting to see more studies showing that cerave truly is different from other moisturizers kind of goes back to the paper fares talked about suggesting that we shouldn't just be asking does moisturizing help there probably is a component of you know maybe if you did cerave from birth on it would work better right i'm not saying it does we don't have any data for that but next one that was interesting first study and this one i was so bummed to see this this was a trinetic study where they looked at cardiovascular and thromboembolic risk in patients on jaks compared to dupy methotrexate or cyclosporine and they did show a higher risk of dvt and pe about a thousand patients in the jak inhibitor group a thousand patients in the dupy group higher rate of dvt and pe in the jak inhibitor group multiple other studies have shown the opposite but the big thing is this is the first study i've seen that showed a difference so i now cannot say there is no evidence anywhere not a single study anywhere that shows an increased risk with jaks now we do have one study that shows it we have multiple studies that show the opposite but just we can't say there are no studies that show an increase with jaks and then the last one trelo as an alternative for trilokinumab or adbri as an alternative for people with dupy induced arthralgia's case series of fifteen patients lead author was chris bunick really smart guy out of yale and his explanation for this was published in jid which basically using thermodynamics to talk about the difference between trelobri and dupy and the main takeaway was that lebri may have some indirect il four blockade so because of the way it binds to the il thirteen not that it binds the way that it allows the il thirteen to bind to the il thirteen receptor type alpha might reduce il four signaling as well because il four signaling for the type two receptors one half il four receptor one half il thirteen receptor so if you take away the il thirteen receptor now the il four receptor doesn't have anything to pair with so lebri may have some il four blockade associated with it it's iffy and questionable because in that case series of fifteen patients they did have one dupy arthralgia patient two who got it on lebri but all of the patients they switched to trelo did not have arthralgias and so that was kind of just again an interesting takeaway maybe lebri has more arthralgia risk than trelo but hard to say but those ton of.
- [21:02]
C
Patients from the clinical trials and even post marketing where we'd see that signal.
- [21:07]
A
With lebri you would think you would think but the the the people who get our throw just that are bad enough to like really matter are probably one in two hundred and so it didn't show up in the lebry trials it didn't show up in the trelo trials so i i remain unconvinced right the the main thing that i take away is though that i i now have a reason to say if you're the the one in two hundred people who get significant dupy or throuches and i want to keep you on an il a drug that's targeting il thirteen i'm probably going to choose trelo instead of lebri i now have something in the literature that gives me a reason to pick one over the other because i'm always looking for like subtle differences in these drugs and right that's and.
- [21:50]
B
It'S helpful to say you could safely this is a very reasonable thing to go to trelo next like because i think patients i've had patients get that and they fear going on another biologic.
- [21:59]
A
Yeah so yep all right that was it for for my six quick one hitters farris what do you got next.
- [22:06]
B
All right so we're done with you huh we're not going to hear from you i find that hard to believe okay i thought this was interesting this was this was a paper from the jad which was you know a multi i won't read the whole long title but basically this multi center study for autologous autologous cell harvesting device to treat vitiligo so this is a device called resell and so this was how do.
- [22:36]
A
You spell that how do you spell.
- [22:37]
B
It r e c e l l.
- [22:40]
A
Okay so if anybody wants to look it up r e c e l.
- [22:43]
B
L yes and so they had one hundred seven adults with with stable vitiligo they had every skin type represented and basically what they did it's it's basically a device that makes it easier for you know the average dermatologist who's not like a person who does melanocyte harvesting to to be able to treat vitiligo you know sort of surgically so basically patients had vitiligo they got like laser treatment like co two or the ktp laser that treated the base and then they harvest like a shave biopsy basically and then this device makes a cell suspension and they can basically harvest like five percent of the area that is involved they make this melanocyte you know like basically smoothie and then you put that on and then you can and then you basically let the area it's like a little melanocyte transplant so about two thirds of patients had a fifty percent or greater improvement and forty two percent of them had an eighty percent or greater improvement or repigmented only eight percent had full rigment full repigmentation and the satisfaction rates were like seventy two percent among patients eighty four percent among clinicians and so people started to see pretty you know early did they do.
- [24:24]
A
Anything together was like did they do anything together with it they did do.
- [24:31]
B
Uvb narrowband uvb with it as well.
- [24:34]
A
So for so it sounds like for normal patients if you could find a place that does this and get it covered get this done wait for it to heal and then do either narrowband or abzelura over it to try and protect those melanocytes that you just transplanted.
- [24:51]
C
Resell'S primary target is wound like grafting right so instead of taking this huge graft to cover up a defect you take a little tiny piece and it like dissolves it and puts it in a liquid and you just spray it on the wound yes so that's where resell works and so they're like well could we do this for vitiligo instead of punch grafting or whatever sort of melanocyte transfer surgical that you know nobody.
- [25:18]
B
Does right or very few sites like you don't get like you know when i've seen the punch graphs they get like little polka dots of repigmentation that kind of looks unnatural so this is like a smooth cell suspension right and so i think it is it makes it technically more easy for you know the average dermatologist to do so i.
- [25:41]
A
Thought it was interesting and i'm on their website right now looking to see if there's a like find a provider there's at least a contact us so we could tell patients to email the company to try and find somebody in their area that does it yeah i.
- [26:00]
B
Don'T know that it's actually like fda approved this is the clinical trial oh i thought it wasn't it's fda approved for this actual indication okay got it yeah but i thought it's interesting you know i would never do like punch grafts and the more surgical stuff but you know maybe if we had this.
- [26:18]
A
In our toolbox okay all right patton.
- [26:21]
C
What do you got all right my second may twenty two may twenty twenty five journal of dermatological treatment intralesional triamcinolone for inflammatory acne a comparative study of dose efficacy and investigation of a novel injection assistant device to enable self administration so basically it's this little plastic thing and you put a syringe in it and patients can at home inject their acne lesions and it's just as good as going to the doctor's office i just logistically have no idea how how you get them the medicate like they buy the plastic thing and then you just write for the syringe and they go to the pharmacy and get the syringe i i mean it's a neat device i i i don't see the like how it is eventually going to be implemented if it's going to be.
- [27:14]
A
Implemented well by the way i got to jump in and say i just asked ai so first resell is fda approved for vitiligo oh it is fda approved already and i asked where can i find a provider who does it and it said that i do it and i do not so ai certainly got that one wrong so maybe it's.
- [27:33]
C
Not fda approved maybe it's not fda.
- [27:35]
A
Who knows yeah who knows okay so pat and you're going to start giving this to your patients well it's not.
- [27:40]
C
Out yet again it's it was written by a company but you know fair like mo mostagani he he was an author on it a guy from stanford so they're working with the company to get this i i've had i've had.
- [27:56]
A
Friends i do very little intralesional tack for acne because i've had like friends like people i know in my community come in and done like you know one mig per per one mig per milliliter or two migs per milliliter and it gave them a dentist that it they always fill back in but for like a year they had a dent and i was like oh my god they'd be like it's still not better.
- [28:19]
B
I agree i can't imagine putting this in the hands of patients i i couldn't either but i guess the pearl when you have that happen and some people probably know this but worth mentioning is flooding with normal saline so if you do have somebody get fat atrophy from an injecting a lesion flood it with normal saline that does help to.
- [28:39]
A
Reverse it okay all right i've got six more quick ones what you were allowed six total i'm doing six more all right they'll be quick all right so first you have somebody do a they go get a center lymph node biopsy and they get anaphylaxis or a drug reaction afterwards most likely it could be the patent blue v dye or there's also this isosulfan blue that is the dye that they use so if that person came back and they were like what do you think they was allergic to whatever you can have them use methylene blue if for some reason they needed another sentinel lymph node biopsy that was number one i didn't even know that allergy to the dye was.
- [29:21]
B
A thing even and then if they had dapsone toxicity and a sentinel node.
- [29:25]
A
Biopsy we would kill you're good for.
- [29:27]
B
All be two birds with one methylene blue cell scone it'd be great all.
- [29:31]
A
Right burning mouth syndrome turned out that if you patch test people and they're allergic to a dental metal removing it did not help but if they were allergic to balsam of peru a balsam of peru diet may help so what i recommend there for a balsam approved free diet ai it just ask ai how would you follow a balsam approved free diet the main things though are tomatoes spices and so that includes vanilla and chocolate those are the big things and citrus so tomatoes citrus and spices are the three big things in balsam pru might be worth trying in burning mouse syndrome patients but difficult patients next one chronic idiopathic enidosum did great on off label of premolast so another thing to add to our rofluma last list of stuff so now reflumelast would be now my first line go to for enidosum frontal fibrosing alopecia case report of it stabilizing and maybe improving with topical latanoprost so this is generic latisse you get the little eye drops but instead of using an eye drop you put a drop in your hand rub it around your frontal fibrosing alopecia i would.
- [30:50]
C
At least those pictures were the least convincing pictures i've ever seen for any drug being effective ever they said it.
- [30:57]
A
Stabilized so really the pictures just showed that it didn't get any worse okay but there are a couple of other reports for that as well you know for me first line for ffa you know intralesional tack topical jak inhibitor probably topical tofacitinib which you can get ten grams for about thirty five bucks from compounding pharmacies and oral reflumelast then the next one after that cheilitis granulomatosa my go to over the years has been injecting tack into their lips and giving them azithromycin or doxycycline so it was a case report that failed and they gave them oral metronidazole in addition to a shot of kenalog and the oral metronidazole worked great my first line for colitis granulomatosa now would probably be intralesional plus reflumelast although that's not been reported in the literature but this was just if you do intralesional and usually what you do is zero point one cc of k ten in four shots along.
- [32:05]
B
Each lip do you do humira you ever do humira for us only in.
- [32:09]
A
Patients who also so i had one girl who had it and it was the manifesting sign of crohn's and the humira helped but i've never used humira in someone who didn't also have inflammatory bowel disease and then the very last one that metformin or sgl two inhibitors either one of those when people with hs went on them cut their risk of death in half and so there was some data that hs people have a reduction in life expectancy of twenty years because of the severe systemic inflammation with their hs and so this data was like a you know it was a trinetics or database or something like that showed that either metformin or a sglt two inhibitor reduced the risk of death by about fifty percent crazy numbers crazy numbers and so now i actually think that most people with hs if they have any active disease should probably be on metformin additionally which is an unbelievably safe drug like unbelievably safe drug i often hear people go well i would never prescribe it but i'll tell them to talk to their primary care doctor if you prescribe doxycycline metformin is a much safer drug than doxycycline like much safer drug and it also upsets.
- [33:30]
B
Their stomach so it is just like.
- [33:33]
A
It is just like although with the doses that we talk about here so either a thousand extended release once a day or five hundred bid would be the typical doses we would use for like hs really unlikely to see much gi upset with it right and they.
- [33:46]
B
Will not be like you don't risk hypoglycemia i think that's the other like there's not like a true real risk of hypoglycemia i think that's what scares.
- [33:53]
C
Me yes the risk i've used metformin for hs and haven't been impressed with the results that it has in hs did they tie in what nobody's died.
- [34:04]
B
So you might be onto something no.
- [34:06]
C
But they didn't tie it into how their hs responded right this is just so that may be the difficult part like i'm giving you this because it's going to save your life yes now.
- [34:17]
A
I would never use it as i can't see using it as monotherapy for hs i could see like reflumelast plus this most likely either humira or bimzelics or cosentyx plus this plus reflumelast something.
- [34:31]
D
Like that i don't see any hs patient rejecting that those patients are so desperate and they have been misinformed for so long and the newer agents that benzelics et cetera and the jacks that are coming out are really offering hope to a population that's been so disenfranchised i think this would be a well.
- [34:53]
A
Received agent i think it's an easier drug to use even than spironolactone you're not worried about potassium right it's it's a really really easy drug to use the other place that it's got some reasonable data is an acne in a few other places as well yeah the.
- [35:10]
C
Results were so impressive it's like it's hard to argue that they shouldn't go.
- [35:15]
A
On it yeah i mean a fifty percent reduction and it was a substantial number of patients that were in this.
- [35:26]
C
And i think they did propensity score matching pretty well yeah they did it.
- [35:30]
A
With and without propensity score matching and it was a big reduction in heart attacks strokes heart failure peripheral vascular diseases and death and we're talking like five thousand hs patients versus seventy thousand people with hs without metformin or so we're talking like big numbers it works better.
- [35:57]
D
If it's given with a dog exactly.
- [36:00]
C
And moisturize every day and moisturize you went through those so quickly people are going to give their hs patients pulse dexamethasone shower caps with clobetazole reflumelast and.
- [36:12]
D
Iv methylene blue so they can re.
- [36:15]
A
Listen as many times as they want that's that's part of the idea here.
- [36:19]
C
They can that's great all right all.
- [36:22]
A
Right so i want to thank everybody for joining us scott i really want to thank you for sticking it out with us for three episodes it's fantastic you know i hope that everybody that listened hope you feel like you learned a few things i hope you laughed once or twice and mostly i'm hoping you're planning to join us next week until then i'm matt cyrus i'm tim.
- [36:43]
B
Patton and i'm laura faris and we are derm on drugs.