Podcast Summary: Derms on Drugs

Episode: Dermatology Fact or Fiction – The Derms on Drugs Find Some Serious Fiction in the Latest Articles
Date: March 21, 2025
Hosts: Dr. Matt Zirwas, Dr. Laura Ferris, Dr. Tim Patton
Produced by: Scholars in Medicine

Episode Overview

This “six-pack” episode brings together dermatologists Matt Zirwas, Laura Ferris, and Tim Patton to dissect six of the most intriguing, controversial, or downright odd recent articles from the dermatology literature. Delivered in their signature blend of sharp expertise and self-aware, lighthearted banter, the trio weighs the evidence, calls out questionable conclusions, and offers practical pearls — and some laughs — for dermatology practitioners.

Key Discussion Points and Insights

1. Immune Checkpoint Inhibitors for AKs and Keratinocyte Carcinoma Prevention

[01:24-07:22] | Presenter: Dr. Laura Ferris

• Paper Discussed: Cox et al., JAMA Dermatology – Clinical trial of PD-1/PD-L1 inhibitors in patients with AKs (actinic keratoses) and cancer.
• Study Summary:
  • 23 immunocompetent adults, already on PD-1 or PD-L1 inhibitors for non-cutaneous cancers, monitored for changes in AK count at baseline, and after 3, 6, and 12 months.
  • Mean AK count went from 47 at baseline → 14 at 12 months (statistically significant).
  • For keratinocyte carcinoma (esp. SCC): Numbers dropped from 42 (pre-inhibitor) to 17 (post-inhibitor) but not statistically significant due to small sample.
  • No significant reduction for BCCs.
  • Adverse events: 30% maculopapular rash, one case of bullous pemphigoid, no clear correlation between adverse events and AK clearance.
• Panel Insights:
  • Dr. Zirwas jokes about future topical PD-1 inhibitors:
    “Topical PD1 inhibitor—could have a tube of that stuff for $24,000.” ([06:56])
  • Dr. Patton: Main adverse effect is not worth it for AKs:
    “Big drawback to treating AKs: now you have diabetes and adrenal insufficiency and hypothyroidism, and you may have died.” ([05:50])
  • Conclusion: Interesting mechanistic data, but not practical for AKs outside extraordinary circumstances due to cost and adverse effects.

2. Intradermal Botulinum Toxin (Botox) for Melasma

[07:29-11:56] | Presenter: Dr. Tim Patton

• Paper Discussed: Thanansarn, Nexorn et al., Derm Therapy, Jan 2022 – Split-faced trial with Dysport (botulinum toxin A) for refractory melasma.
• Study Summary:
  • In vitro: Dysport reduced UVA-induced melanin and tyrosinase activity, not cytotoxic.
  • Clinical: 12 women had Dysport on one side, saline on the other; melasma indices improved statistically for treated side.
• Panel Insights:
  • Mechanism of action unclear; speculation around acetylcholine’s effects on melanocytes.
  • Dr. Patton: “Given that we have 37 other things to lighten the skin, I think Botox is way down on the list for me.”
  • Dr. Ferris: Cites personal (comedic) experience of unwanted prolonged hemiparesis after Botox for rosacea:
    “I did have facial hemiparesis. The longest acting Botox I've ever had.” ([11:25])
  • General agreement: Not impressive in imagery, unlikely to change standard care for melasma.

3. Target Derm AD Registry – “Dupixent Doesn’t Work”?

[12:04-17:17] | Presenter: Dr. Matt Zirwas

• Paper Discussed: Target Derm AD Registry – Real-world effectiveness of advanced systemic (mainly Dupixent) for moderate/severe atopic dermatitis (AD).
• Study Summary:
  • Reported that two-thirds of patients failed to improve with Dupixent; similar poor numbers for itch, mood, and sleep.
• Panel Insights:
  • Dr. Zirwas suspicious enough to contact the authors; told “Derms are just satisfied with people not having very good results.”
  • “It's just, it's so unbelievable... that 80% of people, doopie doesn't help their itch or sleep, that's just ridiculous.” ([15:13])
  • General consensus: Registry data does not reflect clinical or trial reality; agreement to disregard further publications from this dataset.

4. Androgenic Cutaneous Adverse Events with Levonorgestrel IUDs

[17:26-22:27] | Presenter: Dr. Laura Ferris

• Paper Discussed: Cassard et al. – Analysis of FDA reporting for androgenic side effects from hormonal (levonorgestrel) and non-hormonal (copper) IUDs.
• Study Summary:
  • Levonorgestrel IUDs (Mirena, Kyleena, Skyla) linked to higher odds of acne (~3x), alopecia (~6x), hirsutism (~15x) vs. copper.
  • Oddly, Liletta (also 52 mg levonorgestrel) showed no such association — unexplained.
• Panel Insights:
  • Panel questions potential reporting bias, but agrees the association fits clinical anecdote.
  • Dr. Patton: “I thought I was so clever. I'm like, it's not the Mirena, it's that you're not on OCPs anymore... now I can't say that anymore.” ([20:21])
  • Limitations: Reporting bias likely; IUD choice may matter for dermatologic side effects.

5. Dupilumab for Treatment-Resistant Grover’s Disease

[22:29-26:27] | Presenter: Dr. Tim Patton

• Paper Discussed: Amara et al., Br J Derm, Jan 2025 – Retrospective review of 10 Grover’s disease patients given Dupilumab.
• Study Summary:
  • Itch resolved in 6/10; improved in 2 more. Grover’s fully cleared in 7, improved in the rest.
  • All patients with an atopic diathesis responded.
  • BSA calculation for Grover’s questioned as odd by panel.
• Panel Insights:
  • Mechanistic link unclear, but practically, Dupilumab could have a role in itchy, recalcitrant Grover’s — especially in atopic individuals.
  • Mini-deep dive: Potential genetic associations and UV link for Grover's per Ferris.
  • Dr. Patton:
    “Will I use doopie for Grovers? Of course. Why not?” ([26:24])

6. Patch Testing Outcomes in Pediatric Allergic Contact Dermatitis

[27:26-38:06] | Presenter: Dr. Matt Zirwas

• Paper Discussed: Sandler et al. (senior author Jeff Yu) — Outcomes and timing from pediatric allergic contact dermatitis registry.
• Study Summary:
  • 459 children w/ positive patch tests — skin of color kids waited longer for testing.
  • Outcomes: One-third had no improvement, half partial, ~20% cleared after allergen avoidance.
  • In children with atopic dermatitis, relevant positive patch tests predicted improvement less frequently (e.g., only 17% fully cleared).
  • Odds of improvement for various allergens (e.g., fragrance, metals) were dramatically lower for atopic vs. non-atopic dermatitis.
• Panel Insights:
  • Ferris: “Is that really a false positive, or is it just not the whole story?” ([33:24])
  • Zirwas: Patch test positivity ≠ causality in many AD cases; avoid endless trials of avoidance if no improvement.
  • Consensus: Positive patch tests (esp. in AD kids) should be weighed cautiously; improvement with avoidance is the real standard for diagnosis.
  • Zirwas:
    “It just drives me nuts when I hear people say that a positive patch test is the gold standard... Every time somebody says that, I want to be like, you're a moron.” ([37:46])

7. Emerging Therapy: Respegilidusilukin, a Treg Cell Activator

[38:11-39:56] | Brief Mention

• Drug from Nectar Therapeutics granted FDA fast-track for atopic dermatitis.
• Mechanism: Activates T-reg cells (rather than blocking cytokines), offering potential for true remission.
• The trio good-naturedly stumble over the drug’s name and designation:
  “Maybe we should have looked this up before going on the air and just making up.” ([39:25])

Notable Quotes & Memorable Moments

• On PD-1 inhibitors for AKs:
  “Topical PD1 inhibitor—could have a tube of that stuff for $24,000.”
  – Dr. Zirwas [06:56]

• On side effects of systemic immunotherapy:
  “Big drawback to treating AKs. Now you have diabetes and adrenal insufficiency and hypothyroidism, and you may have died.”
  – Dr. Patton [05:50]

• On patch testing in peds/AD patients:
  “If you're diagnosing contact dermatitis based on a positive patch test, you are misdiagnosing half of your patients; only partially correctly diagnosing 90%.”
  – Dr. Zirwas [31:40]

• On ‘registry reality’:
  “80% of people, doopie doesn't help their itch or sleep, that's just ridiculous.”
  – Dr. Zirwas [15:13]

• On self-inflicted Botox mishaps:
  “I did have facial hemiparesis. The longest acting Botox I've ever had in my life.”
  – Dr. Ferris [11:25]

• When the paper doesn’t match clinical reality:
  “I'm never reading another paper coming from this registry because this is clearly not accurate.”
  – Dr. Patton [15:31]

Timestamps for Important Segments

• [01:24] Immune checkpoint inhibitors for AKs and SCCs
• [07:29] Intradermal Botox for melasma
• [12:04] Target Derm AD Registry and the "Dupixent doesn’t work" claim
• [17:26] Levonorgestrel IUDs and androgenic side effects
• [22:29] Dupilumab for Grover’s disease
• [27:26] Patch test outcomes in pediatric allergic contact dermatitis
• [38:11] Brief on Respegilidusilukin (Treg cell activator)

Tone and Takeaways

The panel offers deep dermatology insights with a healthy dose of skepticism and a dash of self-deprecating humor. Their conversations emphasize the importance of clinical judgment over headline-grabbing data, caution against over-reliance on registry or lab-based findings, and celebrate the quirky, incremental nature of dermatologic progress.

For more, visit scholarsinmedicine.com or email questions@dermsondrugs.com