Derms on Drugs – Hidden Gems, Part 2: How Generic Systemics Still Shine in Dermatology

Date: September 5, 2025
Hosts: Dr. Matt Zirwas, Dr. Laura Ferris, Dr. Tim Patton
Special Guest: Dr. Scott Drew

Episode Overview

In this episode, the Derms on Drugs crew reunites with veteran dermatologist Dr. Scott Drew for the second installment of “Hidden Gems,” zeroing in on time-tested generic systemic medications still central to dermatology. The discussion drills into the practical use, monitoring, and pearls for dapsone, roflumilast, acetretin, and touches on evolving cost/access considerations as newer agents go generic. The hosts share candid experiences, clinical mnemonics, and plenty of wry humor as they dissect when and how these “oldies but goodies” maintain a crucial role alongside expensive modern therapies.

Key Discussion Points & Insights

1. Dapsone: Uses, Monitoring, and Side Effects

[Starting 02:10]

• Indications & Regional Patterns

  • Dr. Drew highlights dapsone’s phenomenal utility in dermatitis herpetiformis (DH), noting regional trends in central Ohio due to local diets high in gluten.
  • “Some people want, you know, gluten free, I want gluten filled. But we definitely have a cohort...” (B, 02:34)

• Essential Pre-Treatment Labs and Safety

  • Never start dapsone without first checking G6PD status: “You cannot get this prescription until I see the blood results because...one dose of Dapsone in a G6PD deficient person and they're in the ER and they're the color of your scrub top...” (B, 03:40)
  • “My quote unquote pimp question...how do you take care of methemoglobinemia?” – answer: methylene blue, IV in ER (B, 03:27–03:40)

• Dosing & Monitoring

  • Titrate from 50mg with increases every 2–3 weeks if insufficient response, up to ~200mg over 3 months.
  • Warn patients of a ~1g hemoglobin drop (“you have to let them know” —B, 04:18), but reassure partial recovery.
  • Serial CBCs: baseline, 2 weeks, 1 month, then monthly during titration; once stable, switch to 6–12 month intervals. “G6PD is only a one time thing.” (B, 07:20)

• Other Indications

  • “I use it for a fair number of the mucous membrane pemphigoid patients...” (D, 10:39)
  • Utility in linear IgA, neutrophilic dermatoses, and “the flames” (mnemonic for eosinophilic conditions) (B, 12:11)
  • Anecdotes on side effects, e.g., neuropathy, and rare uses in Grover’s disease, eosinophilic dermatoses.

• Clinical Pearls

  • Dapsone can be highly effective at low doses; some patients remain well-controlled with 50mg/day (A, 12:11).
  • “Dapsone clears the flames” —board prep mnemonic (B, 12:11).
  • Rare but real risk of neurotoxicity (as with lindane/Quell, ivermectin—A, 13:43).

2. Roflumilast: The “Generic Otezla” with Emerging Utility

[14:41]

• Potency and Place in Therapy

  • “I think of Roflumilast as my methotrexate. I’ll almost always jump to roflumilast before methotrexate because you don’t have to do the blood work.” (D, 14:41)
  • Substantially more effective than apremilast based on trial data and clinical experience. Used broadly: psoriasis, GA, lichen planus (LP & LPP), oral LP, HS, hand eczema, subdermatitis. (A, 16:46)

• Side Effect Profile & Counseling

  • Similar GI/psychiatric adverse events as apremilast: “You might lose stools, nausea, if your mood changes, let me know...” (A, 17:56)
  • Dose ramping strategies to minimize GI upset:
    • Monday/Wednesday/Friday for 2 weeks, then increase frequency (D, 18:37)
    • Or flexible “try daily, then back down if needed” (C, 20:08)
  • “My experience is...the people who get like meaningful GI get it at the low dose and then it doesn't ever go away.” (A, 20:17)

• Cost and Access

  • Mark Cuban Cost Plus Pharmacy: “$6 a month for the 500 microgram dose. Cash.” (A, 22:36)
  • “It really is first line for anything that doesn’t have a spectacularly effective drug.” (A, 22:43)
  • No TB testing required; not immunosuppressive (A, 23:06–23:10).

• Notable Clinical Nuance

  • Can be used as a bridge or adjunct while awaiting biologic approval.
  • Speculation about future generic use for tofacitinib.

• Prolonged Health Benefits

  • “There’s actually data that people on roflumilast live longer, have better cardiovascular outcomes...neuroprotective effects...if you don’t get the GI, it’s so safe.” (A, 21:03)

3. Acitretin (Soriatane): Pros, Cons, and Practical Issues

[25:01]

• Indications & Patient Selection

  • Palmoplantar psoriasis, keratoderma, ichthyosiform disorders, adjunct for older psoriasis patients, solid organ transplant squamous CA prophylaxis (B, 27:05).
  • “I like acitretin for palmoplantar disease...keratodermas,” especially those with extensive sun exposure or phototherapy (C, 25:01).

• Dosing & Side Effects

  • Most tolerate 10–25mg daily; “never gone over 50.” (C, 26:22)
  • Responses and tolerability idiosyncratic; some experience hair loss or “baby soft” skin, others not. “It’s just, you can't predict it. But I'm not like, really afraid of it.” (C, 26:22)
  • Avoid in women of childbearing potential; monitor triglycerides, AST/ALT (C, 26:56).

• Historical Use & Changing Trends

  • Used to be common for “RePUVA” (Retinoids + PUVA) regimens.
  • Still essential for severe ichthyosis, lamellar ichthyosis, Darier’s, Hailey-Hailey (“life-saving for them” —C, 31:10).

• Access & Cost

  • Not cheap: “The 25mg is...about 140 bucks a month” on GoodRx (A, 29:50).
  • Sometimes patients use Canadian pharmacies, but “I would never ever do anything illegal.” (C, 29:50)
  • Insurance denials are common—even as high-cost biologics are sometimes approved more readily (C, 31:10).

• Adjunctive/Polypharmacy Role

  • Used as add-on to biologics for refractory cases.
  • “We as a profession are adders and joiners. Polypharmacy is in our DNA.” (B, 31:45)

4. Highlights on Cost, Genericization, and Practice Philosophy

• Shifting Landscape
  • As tofacitinib, methotrexate, and other older drugs go generic, expect expanded use—potentially as replacement for prednisone or as cost-effective adjuncts (A, 23:30).
• Important Monitoring Pearls
  • Each systemic agent has unique monitoring, but older agents often require more vigilance than newer biologics—especially early on or during titration.
• Combining Therapies
  • “This conversation is about what can we add on to a biologic that is going to help us not switch.” (B, 31:45)
• Residency/Fellowship Culture
  • Cases where “n of 1” negative side effects shape future clinical hesitation (C, 10:24 and 12:18).

Notable Quotes & Memorable Moments

• On Dapsone & G6PD:
  “You cannot get this prescription until I see the blood results because...one dose of Dapsone in a G6PD deficient person and they're in the ER and they're the color of your scrub top and that's not a good look.” —Dr. Scott Drew (03:40)

• On Dapsone’s Efficacy:
  “The itch relief that they get is comparable to someone’s Rinvoq for AD. It’s like miraculous.” —Dr. Drew (04:13)

• On Polypharmacy:
  “We as a profession are adders and joiners. Polypharmacy is in our DNA. No one writes monotherapy for acne unless it's Accutane.” —Dr. Drew (31:45)

• On Roflumilast’s Cost:
  “Mark Cuban's Cost Plus Pharmacy. It's $6 a month for the 500 microgram dose. Cash.” —Dr. Zirwas (22:36)

• Clinical Humor:
  “So it sounds like the first one is an erectile dysfunction drug. Inflatum.” —Dr. Zirwas riffing on trivia (34:34)

Timestamps for Important Segments

| Timestamp | Segment | |-----------|-----------------------------------------------------------------------------------------| | 02:10 | Dapsone: Key uses, safety, dosing, and monitoring (Dr. Scott Drew) | | 06:06 | Approach to titrating dapsone and managing expectations | | 10:39 | Dapsone: Use in mucous membrane pemphigoid, neutrophilic dermatoses, and more | | 13:43 | Anecdotes on rare side effects with dapsone, lindane, ivermectin | | 14:41 | Roflumilast: Potency, practical use, comparison to methotrexate/apremilast, ramping | | 18:58 | Countering GI side effects with different dosing regimens (Monday/Wed/Fri strategies) | | 20:08 | Dr. Ferris’ flexible approach to roflumilast dosing | | 22:36 | Roflumilast cost and access through Mark Cuban’s Cost Plus Pharmacy | | 25:01 | Acitretin: Indications, dosing, tolerability, monitoring, and cost/access issues | | 27:05 | Acitretin’s special place in transplant, ichthyosis, and challenging keratodermas | | 29:50 | Navigating acitretin access, Canadian pharmacies for cost savings | | 31:45 | Add-on/adjunctive therapy culture in Dermatology | | 33:29 | Recap/synthesis of systemic agents discussed | | 33:50 | Patton's Trivia: Trivia on systemic medication manufacturing and history |

In Summary

The episode delivers an expert roundtable on the enduring value of generic systemic medications in dermatology. Despite the biologics boom, drugs like dapsone, roflumilast, and acitretin remain vital—either as first-line therapies in certain conditions, cost-effective bridges, or adjuncts to newer agents. The hosts share practical nuances, monitoring algorithms, regional quirks, safety pearls, and lived experience, all wrapped in their signature wit.

Takeaways:

• Don’t overlook older generics, especially as access and cost barriers persist for new agents.
• Know your monitoring—tailor labs to the drug and patient risk.
• Real-world dosing and side effect management evolve with experience and patient context.
• Combining therapies is common, and strategic add-ons can save patients from unnecessary biologic switches.
• The generic pipeline (including tofacitinib) could shift practice patterns further in coming years.

Memorable moment:
“We as a profession are adders and joiners. Polypharmacy is in our DNA.” —Dr. Scott Drew (31:45)