Podcast Summary: Derms on Drugs

Episode: "Dermatology Update: The New, The Old, The Common and The Rare"

Date: October 17, 2025
Hosts: Dr. Matt Zirwas, Dr. Laura Ferris, Dr. Tim Patton
Podcast Description:
Derms on Drugs serves up cutting-edge dermatology mixed with candid camaraderie and comedic banter between three experienced dermatologists. In this "six pack" episode, each host presents and discusses standout articles and news from recent dermatology literature, sharing clinical pearls, practical insights, and some much-needed comic relief.

Episode Overview

This episode spotlights major developments in dermatology: from new large-scale evidence for nicotinamide in skin cancer prevention, to the ranking of the newest pruritus therapies, to updates on oral minoxidil for hair loss, psoriasis therapeutics, and advances in pediatric atopic dermatitis treatment. The conversation is lively, irreverent, and peppered with clinical takeaways.

Key Discussion Points & Insights

1. Nicotinamide (Vitamin B3) for Skin Cancer Prevention

Segment: [01:08–08:49]
Presenter: Dr. Laura Ferris

• Study Highlight:
  Massive VA database analysis (33,000+ patients) examined nicotinamide 500 mg BID vs. control for skin cancer prevention in those with prior skin cancer.
• Topline Results:
  • 14% reduction in overall skin cancer risk in treated group.
  • Biggest effect: 22% reduction in cutaneous squamous cell carcinoma, especially if started after first skin cancer (up to 50% reduction among early adopters).
  • Little impact for solid organ transplant patients unless started early.
• Clinical Pearls:
  • Ferris: "The take home point is: if you're going to do it, start early. You get more bang for your buck if you start after that first skin cancer." [05:38]
  • Nicotinamide is safe, OTC, and well documented in VA records.
• Practice Discussion:
  • Concerns about giving nicotinamide to higher-risk patients only after multiple cancers ("the wrong approach").
  • New resolve to recommend it universally to skin cancer patients.
• Limitation: Study population mostly older, white males (VA). Possible confounding if some "control" patients took OTC nicotinamide—but would bias toward null.
• Practical Tips:
  • Also check patients' medication list for hydrochlorothiazide, which is independently linked to increased skin cancer risk.

Notable Quote:

• Ferris: "This is a vitamin. It's pretty safe. Why don't you do this?" [06:45]
• Zirwas: "Why are all the studies 500 BID? ...People are much more likely to take 1,000 once a day." [08:12]
• Ferris, on confusing niacin vs. nicotinamide: "If you get somebody who's flushing, definitely...if they say they're on niacinamide, definitely make sure of that." [08:49]

2. New Pharmacotherapies for Pruritus: Network Meta-Analysis

Segment: [09:19–17:49]
Presenter: Dr. Tim Patton

• Study Highlight:
  Network meta-analysis compared pruritus reduction across multiple diseases (atopic dermatitis, psoriasis, prurigo nodularis) using the four-point reduction in the peak pruritus NRS as primary metric.
• Key Findings:
  • Atopic Dermatitis: Upadacitinib (UPA) most effective, followed by abrocitinib, dupilumab, lebrikizumab, tralokinumab.
  • Psoriasis: Ixekizumab and ustekinumab led the pack, but limited by non-inclusion of some newer powerful drugs.
  • Prurigo Nodularis: Nemolizumab was top performer; followed by dupilumab, serlopitant (trial halted), vixarelimab (trial halted).
• Real-World Application & Critique:
  • Hosts poke fun at how confusing "pruritus" is to pronounce—and how patient anchoring affects itch scales.
  • Zirwas: Critiques 10-point scales for itch/pain as "crazy talk," noting that perception is relative to personal history and experience.
  • Zirwas: "For both itch and pain, they should be functional questions...is it making you scratch all the time, is it disrupting your sleep?" [15:23]
• Consensus: Study findings align with clinical experience. JAK inhibitors edge out others for itch. Nemolizumab likely best biologic for itch in prurigo nodularis.

Notable Quote:

• Patton (on saying 'pruritus'): "You can't say pru or error. I just ignored the first R and went with 'puritus'. That was how I said it." [10:59]
• Zirwas (on subjective scales): "It's crazy talk that patients with psoriasis don't complain about itching like patients with atopic derm...it's very susceptible to anchoring." [13:13]

3. Oral Minoxidil for Androgenic Alopecia: 2.5 mg vs 5 mg

Segment: [18:07–21:48]
Presenter: Dr. Matt Zirwas

• Study Highlight:
  Double-blind RCT compared oral minoxidil 2.5mg vs 5mg in males. Dermatologist-assessed improvement showed no significant difference, but patients reported greater satisfaction with 5mg (72% vs 46%).
• Takeaways:
  • Patient assessment is sometimes more "optimistic" than physician grading.
  • Authors note more robust effects might be found in larger samples.
  • Usual practice: Start with 2.5mg for men, 1.25mg for women (bump to 2.5mg if tolerated).
• Safety notes:
  • Hypertrichosis (unwanted hair growth) is rare—but more commonly reported by female patients.
  • Ferris: "I gave one woman when I first started using it...went up to like 7.5mg or something and this poor woman...came in with horrible hypertrichosis." [21:10]

Notable Quote:

• Zirwas: "There was a significant difference...the people who got 5 milligrams it was 72%." [18:54]

4. Off-Label Case: Apremilast for Pityriasis Lichenoides

Segment: [22:01–23:09]
Presenter: Dr. Zirwas

• Case Summary:
  Reports rapid resolution of severe pityriasis lichenoides et varioliformis acuta with apremilast (after failed prednisone, azithromycin, acitretin).
• Takeaway:
  Consider systemic PDE4 inhibitors, including apremilast and roflumilast, for stubborn cases of PLEVA and PLC.
• Lively banter about making roflumilast the sponsor (despite its low cost).

Notable Quote:

• Patton (comically): "Podcast should be changed to Derms on Rofluma last." [22:58]

5. Icotra Kinra vs. Ducravacitinib for Moderate-Severe Plaque Psoriasis

Segment: [23:21–29:28]
Presenter: Dr. Laura Ferris

• Study Highlight:
  Phase 3, head-to-head trials (ICONIC 1 & 2) compared oral icotra kinra (IL-23 pathway peptide) to oral ducravacitinib.
• Results:
  • Icotra kinra: 70% achieved clear/almost clear skin at week 16. PASI 90 in 55–57%.
  • Icotra kinra outperformed ducravacitinib in PASI 100 (30% vs 12%).
• Context:
  • Ducravacitinib itself beats Otezla; thus, icotra kinra likely superior to both.
  • Safety profile: Fewer AEs with icotra kinra vs ducravacitinib (57% vs 65%).
• Debate:
  • With second-gen TYK2 inhibitors on the way, comparisons may soon be possible.
  • Oral peptide technology may allow broader use across diseases (e.g., IBD), possibly with better tissue penetration, though this remains speculative.
• Clinical Implications:
  • Will patients opt for daily oral meds or infrequent injections? Personalized based on patient preference.

Notable Quotes:

• Ferris: "It's an interesting technology...I'm really curious...does it penetrate into the skin differently?" [27:13]
• Patton: "It's not just like a shot. Right. It's like once every three months. You have to remember to take [a pill] every day. So it's going to be tough." [29:28]

6. Avapritinib for Systemic Mastocytosis with Cutaneous Involvement

Segment: [30:04–33:14]
Presenter: Dr. Tim Patton

• Study Highlight:
  Low-dose avapritinib (25mg daily) improved both systemic and cutaneous symptoms in two German patients with indolent systemic mastocytosis and prominent skin findings.
• Relevant Context:
  • Avapritinib is FDA-approved for systemic mastocytosis and GI stromal tumors.
  • For the first time, dramatic skin improvement reported for disease historically resistant to therapy.
• Practical Impact:
  • Collaboration with HEM-ONC may benefit these patients.
• Hosts’ Response:
  General surprise and interest, noting increasing marketing targeting dermatologists about mastocytosis, amusing comparison to GPP marketing campaigns.

Notable Quote:

• Patton: "For a disease that literally we had nothing for these patients… and now we have something." [31:37]

7. Psoriasis & Atopic Dermatitis Overlap—Pathogenesis & Therapeutics

Segment: [33:26–36:32]
Presenter: Dr. Matt Zirwas

• Article Highlight:
  Review by Peter Leo lays out management of true disease overlap (not eczematized psoriasis or vice versa).
• Clinical Takeaways:
  • First-line: JAK inhibitor for true overlap.
  • If JAK fails, go by dominant phenotype: IL-17 for psoriasis, IL-13 for AD.
  • Consider combinational therapies as needed.
• Ferris’ Pearls:
  • Methotrexate remains useful for these “spectrum” patients due to its breadth.
• Literature Note:
  Atopic reactions (eczema) induced by IL-17 inhibitors more common than vice versa.

Notable Quotes:

• Ferris: “I have seen patients where...the cytokine inhibitors are so targeted and polarizing that you can...make them flip back and forth, whereas a little bit more...non-targeted [like methotrexate] can be helpful.” [35:38]

8. Ruxolitinib Cream for Pediatric Atopic Dermatitis (Opzelura to Age 2+)

Segment: [37:26–40:03]
Presenter: Dr. Matt Zirwas

• Clinical Trial Highlight:
  Ruxolitinib cream, now approved down to age 2. In children, 56% achieved IGA success (vs. ~51% in adults). Best suited for mild-moderate disease and localized lesions.
• Safety & Counseling:
  Main challenge: managing parent concerns about boxed warning for systemic JAK inhibitors. Systemic absorption possible, but usually not at clinically meaningful levels.
• Use Case:
  • Dupliumab remains best for extensive, severe pediatric disease, but ruxolitinib cream offers non-injectable alternative for smaller/less severe cases, or injection-averse children.
• Hosts’ Reaction:
  Discuss experiences with kids in the clinic, realities of pediatric care, and challenges for parents.

Notable Quote:

• Zirwas: "There is a little bit of systemic absorption… Is it imaginable that if you use it over a big enough body surface area there'll be some kids who get a high enough level that it could do… imaginable, is unlikely, but it's imaginable." [38:21]

Notable Quotes & Banter Highlights

• Patton (about his persistent mispronunciation):
  "Well, I just wanted to explain why. I think maybe garner a little bit more sympathy." [12:00]
  Zirwas: "You didn't need to explain why. It's just that you're an idiot." [12:05]

• On Pruritus Scales:
  Zirwas: "Any kind of a scale like that is very susceptible to anchoring...The pain 10-point scale is the main bad guy in the world [that] caused the opioid epidemic. Forget Purdue Pharma. If somebody could sue the 10-point pain scale..." [13:13]

• On Methotrexate:
  Ferris: "These are the patients I like methotrexate for, sometimes cheap. And it can work for both." [35:38]

Timestamps for Important Segments

• [01:08] - Nicotinamide for skin cancer prevention (Ferris)
• [09:19] - Pruritus therapies—meta-analysis & critique (Patton)
• [18:07] - Oral minoxidil dosing for androgenic alopecia (Zirwas)
• [22:01] - Apremilast for PLEVA/PLC (Zirwas, case report)
• [23:21] - Icotra Kinra for psoriasis: results, context (Ferris)
• [30:04] - Avapritinib for systemic/cutaneous mastocytosis (Patton)
• [33:26] - Psoriasis-atopic dermatitis overlap: JAK-first approach (Zirwas/Ferris)
• [37:26] - Ruxolitinib cream in pediatric atopic dermatitis (Zirwas)

Episode Tone & Style

• Conversational, irreverent, informative.
• Banter and inside jokes abound: "six pack" format, mild self-mockery, and dry humor.
• Direct, unfiltered clinical opinions based on real-world experience.

Summary for New Listeners

This episode delivers rapid-fire, practical gems for dermatology clinicians—from choosing the right vitamin supplement, to picking the best itch drug, to the fine print on new oral and topical medications. The hosts’ expertise shines through in their lively debate, willingness to push guidelines, and the way they integrate new evidence into real-world practice—all while keeping the mood upbeat and relatable.

Whether you're a specialist, general practitioner, or derm enthusiast, the latest "six pack" of dermatology news is equal parts enlightening and entertaining.