← Derms on Drugs
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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, Dr. Laura Faris from the University of North Carolina and and Dr. Tim Patton from the University of Pittsburgh. And we use our 60 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 a cutting edge of derm, and you'll actually have some fun listening. New episodes drop every Friday on Scholars in Medicine, Apple Podcasts, Spotify and other major podcast platforms. And if you want to tune into the video component, we have some of the key figures and tables from the articles that we talk about. We are so excited to continue our discussion about drugs that are oldies but goodies with an oldie But Goodie himself, Dr. Scott Drew, dermatologist practicing about an hour north of me here in Ohio, who's been at it in a big practice for decades. We are really going into. When I say an oldie but goodie, I mean a drug that is generic. So you're not supposed to have to do things like prioros for these drugs. But unlike some of our modern drugs, they do require some monitoring and have some real toxicities. Last week we did a really deep dive into methotrexate and talked about a couple of other drugs. This week we're going to continue the discussion with some of our other favorite drugs that we use on the regular. So, Scott, talk to us about Dapsone drug. We've all used drug we. You know, I don't write a whole lot of Dapsone anymore, but you know, back when I was a resident, we were using it to treat pydermic angrenosum and, and, you know, dermatitis or petiformis and some other things as well. Tell us about first, what, what diseases are you using Dapsone for the most?
- [02:10]
B
So I think dapsone has a great place primarily in my practice. It's for dermatitizer, pediformis and, and I don't know what's unusual about central Ohio, but, you know, there's this plan of the cave bear world of DH up here. Maybe it's the Amish pound cake and the bread and the icing and the beer.
- [02:31]
A
I don't know people are eating a gluten full diet.
- [02:35]
B
Yes. You know, some people want, you know, gluten free, I want gluten filled. But we definitely have a cohort and trying to, trying to eat a gluten free diet is, you know, very, very, very difficult. And, and so, you know, there's family trends of it and we definitely have a cohort. And I really think that's probably the drug I have had the most success with using. Sure. And of course it's, it's my quote unquote pimp question. I know pimping is not appropriate anymore, but the one question I pimp people on is how do you take care of methemel anemia? When I have a medical student, if you give them dapsone inappropriately without a, without a negative G6PD and that you get this doe eyed when I thought you were just skin doctors. So I like it. It brings to remembrance that we are physicians first and dermatologists.
- [03:28]
A
Let's pimp. Patton and Ferris. I think I know the answer.
- [03:31]
C
Methylene blue.
- [03:32]
A
Oh dear, you looked it up.
- [03:34]
B
Look at you.
- [03:35]
A
How do you give methylene blue? Do you, can you write?
- [03:38]
C
I have no idea. I just know the, I can answer it on the boards.
- [03:41]
B
You get IV er and when you, you know, you never get a call from ER ever. Right. Especially if it's something that you provoked. So it's one of the few drugs that's like a deal breaker. You have to, you, you cannot get this prescription until I see the blood results because, you know, one dose of Dapsone in a G6P deficient person and they're in the ER and they're the color of your scrub top and that's not a good look. However, at the same time, after about 10 days of, of Dapsone, I usually start around 50 and titrate my way up to 200.
- [04:14]
A
Wait, wait, how do you titrate up like 50 the first day or 50 for two weeks. How you doing?
- [04:19]
B
First two weeks. And then you have to tell people they're going to drop a gram of hemoglobin because what ends up happening is they go to their ob GYN or their orthopedic surgeon or whatever for their next health care journey. And, and they see a serial CBC and they're, they've dropped a glam. He dropped a gram of hemoglobin. And the next thing you know they're getting a bone marrow biopsy and blah, blah, blah, blah, blah. So after about three or four months that you'll recover About a half of that loss. So that's just a warning. You have to have to let them know. But the result that they get is tremendous and the itch relief that they get is comparable to someone's rinvoak for ad. It's like miraculous. So only short lived because one piece of pound cake or one beer and boom, you know, it's back. Perhaps not as severe if they're on 200 milligrams of Dapsone, but they're, you know, a gluten free holiday.
- [05:17]
A
So Scott, let's, let's talk a little bit more about what you say. So you see somebody that you think's got dh, right? So you do a biopsy and a dif, maybe you order tissue transglutaminase and anti gladin antibodies, whatever. But along with ordering that stuff, which those things looking more for celiac screening, kind of for celiac but you know, they've probably got celiac if they've got Dh. But so you order a G6PD level glucose 6 phosphate dehydrogenase, you don't start the dapsone till, till that lab comes back. Sounds like you start people on 50 once a day. Do you tell them, okay, you're going to do 50 once a day for two weeks and if your itch is completely better, stay at that dose, but if it's not, you know, then start taking two pills a day or what do you do?
- [06:07]
B
So like with all things, the patient's perception of better, not better, may not be the same as ours. So I like to see them and at least call. And in the, in the world of post Covid you can always do this virtually if you have to like to see them. And part of the whole DH phenomenon is not only the itch but then the secondary compulsive excoriation. So now are they itching because the DH is uncontrolled or because they have a tick? They're just in this habit and I think you can help, you can help discern that with, you know, with some eyes on and I'll push it to 200 and I've had very good success. I, I, I'm trying to remember if.
- [06:48]
A
I wait, so you do 50, have you see them back in two weeks or they call in two weeks if they're not dramatically better. Do you go to 100 and then give it two weeks and then go to 150 and give it two weeks and then go To 200 and give it two weeks? You go right from 50 to 2. Like what do you, do I say.
- [07:04]
B
To get to 50 to 200 probably would take three months.
- [07:07]
A
Okay, so like every, every couple of weeks. Two, three weeks or so. You'll check in and bump it up by another 50 if you need to.
- [07:16]
B
Yes.
- [07:16]
A
What are your, what are you doing for laps? How. How are you monitoring labs for these?
- [07:21]
B
Just cbc. I'm not back at the beginning. We do a whole metabolic profile, liver enzymes, all of that. I, I don't do HIV and hep C and all of that immunosuppressant. Right. And just then follow the CBC. Now, the G6PD is only a one time thing. Either you have it or you don't. It's not something that wears out or you lose it or you somehow get it. It's one and done.
- [07:47]
A
Yep. So you'll do. How often do you do the CBCs while you're taking.
- [07:53]
B
After the, after the. We get to 200, maybe every six months. Because the, the effect on the, on the, on the anemic profile really doesn't have a additive dose related effect.
- [08:07]
A
Yep. And from what I remember as a resident, for the first 12 weeks, there's a risk of agranulocytosis. And so for the first few months, do you monitor like every couple of weeks? Do you do. Once a month? For the first few months.
- [08:22]
B
What do you do once a month? Oh, well, I'm sorry. Baseline, two weeks, one month, and then monthly after that.
- [08:27]
A
Okay. And then once you get to a stable dose, you go to monitoring hemoglobin, hematocrit, say every six months or something like that.
- [08:36]
B
And even after that, because DH is forever. This is not like you're gonna disease modify and then at that once a year.
- [08:43]
A
Okay. Do you. Are there other. So right as off my head, the other diseases. I think of dapsone as having people talking about using it, neutrophilic dermatoses and maybe urticaria, especially if you buy ups. Urticaria. And there are a lot of neutrophils in it. I don't think I've ever seen literature that supports doing that. But I know people talk about it. People have talked about using it in dermal hypersensitivity reaction. I, I haven't used it in that setting. Are there other diseases that you, Anything else you use it for?
- [09:14]
B
Before I had gray hair. Thank you. I used it in Grover's disease. But I think there are better choices now that I would go to first.
- [09:21]
A
Such as?
- [09:23]
B
Oh, I would, I, I would use dupixent for Grover.
- [09:26]
A
What if you can't get the dupixent long. Right. You call the DUPY acanthalytic atopic dermatitis, something like that.
- [09:33]
B
If you look hard enough, you can probably find some ad, I think in those patients.
- [09:37]
A
Okay. Yeah.
- [09:38]
B
With the, with the, with the approval of pemphigoid, there are plenty of people who argue that, that, that Grovers is a pre bullis pemphigoid cousin. So I think you're okay with that. I have never, I think my whole career I've only seen like a handful of piasum patients. So I really can't speak to how that is, was or is used in that disease state. But I, I know in the literature that's described as.
- [10:09]
C
Well, person I ever put on dapsone was a young man who had PG and he got pure motor neuropathy, which is like one of those things that you read about as a side effect and you're like, oh, that's just on the boards. But that was like my n of 1 experience.
- [10:24]
A
So did it go away when you stopped the dapsone?
- [10:27]
C
Yeah.
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A
Okay. Yeah.
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C
Now I have like this little fear. You know, you're, you're first experiences with a drug kind of shape you. But yes.
- [10:36]
A
Pat, do you use much dapatone for pg?
- [10:40]
D
Yeah, I, I usually add it on just because it's an easy one. I think it has some effects against the neutrophils as monotherapy. It's a little unusual, Sweets. I use it for a fair number of the mucous membrane pemphigoid patients that, you know, scarring or not, I mean, I, I would strongly discourage using it as monotherapy. And scarring, it's not an aggressive enough drug. But the patients who have the sort of the erosive gingival mmp, I think dapsone's a good anti inflammatory option. And obviously linear iga, the same thing just because of the effects it seems to have with IgA specific diseases like DH. I think you can see a similar effect in linear IGA or IG mmp.
- [11:30]
A
I also think there's some role in eosinophilic diseases. So you know, eosinophilic folliculitis, probably not hyper eosinophilic syndrome per se, but Wells.
- [11:42]
D
Have seen amazing death.
- [11:45]
A
Yeah, the couple cases of Wells I've ever seen, which there's also this one that's like annular eosinophilic dermatosis, which I kind of think of as like a weird Wells ish thing that's in circles. I've had Dapsone work well in that at very. And I often find the Dapsone will work really well at very, very low doses. Like you know, once people are doing okay, like 50 once a day long term, I often find that it would work okay.
- [12:11]
B
And that was my board mnemonic. Dapsone clears the flames. That was how we remembered that.
- [12:18]
A
Okay. All right.
- [12:20]
B
I want to. Laura Mates made a comment that I think we all suffer this n of 1 fear. And my n of 1 fear is also a rare drug. When I was resident, I had a neurotoxic patient on Quell, which I don't think anyone uses anymore. And they were using. It was a nursing home patient that used Quell bid for like 10 days and ended up in the, in the. What was then called the, the like the memory unit. We didn't. Wasn't called that then. But the stopping of the Quell return them to normaly.
- [12:52]
A
What is Quell?
- [12:53]
D
Scabies.
- [12:54]
B
Was that a Scabies? Yep, Scabies. Quell is the pre. The precursor of elamite. But it was the. It's a neurotoxic anti escape. And thank you for reminding me that your, your, your, your intro of your six years of experience. I think when you add me, it's now, it's now a century of.
- [13:12]
A
We had a century of experience whenever we add.
- [13:15]
B
I haven't written Quell. Same thing when I, when someone mentions that, it like just gives me.
- [13:21]
A
Yeah.
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B
Shutters.
- [13:22]
A
Yeah. Yeah. Okay.
- [13:23]
B
I'll look up the name of what the real dame of Quell is.
- [13:26]
D
So that was Lynn. Linda.
- [13:29]
B
Lindain.
- [13:30]
C
Yeah.
- [13:31]
A
Ah, nice patent.
- [13:32]
C
So remember they tried to bring that back for head lice.
- [13:36]
D
Yeah.
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C
Like in the past 10 or 20 years, they've tried to bring back Lindane for head lice. I'm like, I don't think so.
- [13:44]
B
And the rationale was because if you had it, you would just keep using it all the time. And, and if you use it more than once a week, you get neurotoxic.
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C
Yeah.
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A
That can very rarely, by the way happen with Ivermectin as well. So Ivermectin, about one person in a thousand. We have some kind of a genetic abnormality where they can get some neurotoxicity. Not, not dangerous or anything like that. But it does happen with ivermectin. I've had that happen once in one of my scabies patients. So let's see, let's see if. What other drugs do we want to jump on here? Let's, let's Talk some about reflumelast. We've mentioned it a number of times here on the show. Let's, let's get into reflumelast a little bit more. Dr. Patton, I know you're a big reflumelast user. I'm going to let you kind of start us off with, you know, what do you, what diseases do you use Reflumelast for? What's your, you know, spiel with patients, how do you use it, blah, blah, blah.
- [14:41]
D
I think of Reflumelast as my methotrexate. I'll, I'll almost always jump to roflumilast before I go to methotrexate because it's, you don't have to do the blood work. It gets a little bit tricky counseling the patients on how to get it.
- [14:57]
A
So wait, wait, let me, I'm going to back up just a second here just for our listeners. So Reflumelast is an oral so you've probably heard of it as it's the active ingredient in Zoriv topically but it is a, it's an oral PDE4 inhibitor, same class of drugs as a premolast. Just signif much, much more potent than a premolast in terms of how tightly it binds PDE4. The data on it, it's much more effective than a premolast. There's no head to head trial but just there is a head to head trial versus methotrexate and about 50% of patients got to pass C90s, almost 2/3 to 70% got to pass C75. So a very effective drug for psoriasis. So substantially more effective than a premolast and has the same side effect profile as a premolast. GI issues very significant headache and theoretical risk of depression. But so think of it as generic opremolast. Generic otesla that is more effective probably we don't have a head to head so I don't want to say more effective, probably more effective than Otesla based on the data we have. So we'll, we'll level set there and pat. So just be what diseases do you use it in most frequently?
- [16:14]
D
I use it in ga. It's kind of my first line. I like it for lichenoid lp. Yeah, both cutaneous and oral lp. We talked about psoriasis hs. I think it's a reasonable thing to try. There's some data in HS and Roflumelastic. I think we did a paper with hand eczema and Riflumilab.
- [16:37]
A
So let me show You, I mean.
- [16:38]
D
It'S just like, it's like methotrexate. It really can work across a pretty broad spectrum of inflammatory disease.
- [16:46]
A
I think it should be first line for literally every inflammatory. Unless somebody has like some disease where you're like I need to like pemphigus, you're not going to use it first line. But everything else, connective tissue disease, eczematous dermatoses, psoriasis, hand eczema, hs, pg, like ga, lichenoid dermatoses, lichen, plano, pylon, like everything. It is the same benefits as zotesla. Right? Non immunosuppressive, no labs, really easy drug to use. Cheap, right? And cheap.
- [17:24]
C
So I will also say I use it for the patients who have like really bad sibo psoriasis. Like, like they're really bad. Like their scalp's bad, their ears are bad. You know, particularly my patients who may have a hair type that they cannot wash their hair every day and it just keeps compounding. I like it for that too.
- [17:42]
A
Yeah. Subderms.
- [17:46]
B
Does it work for bichettes?
- [17:48]
A
I would expect expect it to.
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C
It's a great question.
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D
Is FDA approved, right? Yeah, the 500 microgram is.
- [17:57]
A
Well, so yeah. Yeah. What do you talk to patients about? Get so right you're given this, your spiel with a for same show as a Tesla. You might lose stools, nausea, you know, if your mood changes, let me know. But then what. What else about getting the drug? How do you talk to them?
- [18:14]
D
Yeah. So either online through Mark Cuban or use Goodrx Cubans. Significantly cheaper.
- [18:19]
A
Yeah.
- [18:20]
D
So I really do say sign up. It's easy like to sign up for that online Mark Cuban cost plus drugs.
- [18:28]
A
Which is it for our listeners who are on modernizing medicine. Emma that is in Emma as a pharmacy you can send to.
- [18:38]
D
The 500 microgram is cheaper than the 250. It comes in both 250 and 500 micrograms. So I do go with the 500 micrograms and just like we do with Otesla, I slowly ramp it up. I do Monday, Wednesday, Friday for two weeks. I tell them if that's the dose that works, that's your dose. Then I go Monday through Friday and then I go daily.
- [18:58]
A
Okay, so Monday, so Monday, Wednesday, Friday for two weeks, then Monday through Friday, then every day. But if they get better on one of the lower doses. Yeah, I'm just stay on the lower dose. That's interesting. I've usually done it as a half a pill a day for the first time. Month, two weeks to a month and then go up to a full pill a day. I really wonder if There's a better GI profile doing you know, 500 every other 500 Monday, Wednesday, Friday instead of 250 every day. Have you tried both patent? Yeah. If you had to guess what percent of your patients get GI that is intolerable, I'd say that, yeah I'd say the same at the 250 once a day Ferris. You use it much?
- [19:48]
C
I do same you know kind of spectrum of disease. Lichen like lichen Planus mostly just psoriasis. It's one of my and yeah like lichenoid drug eruptions from PD1 inhibitors too.
- [20:02]
A
Okay. Do you do 500 Monday, Wednesday, Friday and then increase the days or you do 250?
- [20:08]
C
I say I'm writing it every day. It might upset your stomach. You might. You know if you can only take it every other day day particularly for the first couple months, that's totally fine. I'm a little less prescribed about it.
- [20:18]
A
That's actually really good because my experience has been that the people who get like meaningful GI like get it at the low dose and then it doesn't ever go away and the people who don't get GI never get it at all. So your, your way of doing it where try taking it every day. If your stomach starts to bother you just take it a few times a week. You know if it, if your stomach gets tolerable, try taking it more. That actually makes a lot of sense for this drug. I might, I, I'm Patton.
- [20:44]
C
What do you give it?
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A
Yeah. You going to try that patent?
- [20:48]
D
I'm sticking with my plan.
- [20:50]
A
It's obviously the okay Scott, I love this.
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B
This is like I, I, I'm ready to go for hour three now. So Tim, is this your go to for GA and LP and LPP before Rinvo?
- [21:03]
D
Oh yeah.
- [21:04]
A
So Scott. Yeah, number one, it is so safe, easy and cheap. And there's actually data that people in reflu molass live longer, they have better cardiovascular outcomes and people not over flumalast. There's data that it makes young healthy people because it has neuroprotective effects. Like it's, it's if you don't get the GI like it's so like I have a friend who had bad gingival hyperplasia that was idiopathic, you know seeing an oral pathologist and they're like oh if only I could get him on a premolast like and I was like oh well let me call your oral pathologist. Put him on reflumelast, cleared immediately, but he got bad GI and basically had to stop it because the gi. After six months, he was still getting bad GI effects.
- [21:47]
B
But Tim, how long do you keep them on refluvilast for ga, say, general adult generalized ga. How long do you keep them on before you make a dose adjustment or. Or switch?
- [21:57]
D
Yeah, if they got clear or if they didn't respond, like, I. Yeah, I'd give it three months. You know, three months. If they weren't seeing an improvement on the daily. Like if you could get them all the way to the daily dose and they were on it for three months and didn't respond, I'd move on.
- [22:13]
B
Okay.
- [22:14]
A
And if they do.
- [22:14]
B
Well, a bigger issue, Matt, about older drugs as newer drugs versus cost, because heretofore up until three minutes ago, my. My go to was Renvoak, which clears ga, generalizes Dolce ga like. Like a whiteboard. Yeah, but that's not cheap. And it sounds like reflumelast is on.
- [22:36]
A
Mark Cuban's Cost Plus Pharmacy. It's $6 a month for the 500 microgram dose. Cash.
- [22:42]
B
Okay.
- [22:43]
A
And it really is first line for anything that doesn't have a spectacularly effective drug. Right. And even if some does have a spectacularly effective drug, you can start the reflux while you're trying to get the spectacular effective drug covered and you can add reflux on to anything, like literally anything if they're doing okay.
- [23:07]
B
If we're working on these granulomatous things, there's no TB warning on this.
- [23:10]
A
No, correct. It's a premolast. It is a premolast. Just more effective than $6 a month.
- [23:17]
B
Okay.
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D
And I think the Rinvo point is interesting, talking about generic drugs, because tofacitinib becoming generic. Is that going to be our. Our next.
- [23:29]
A
Right.
- [23:30]
D
We're just going to get them on.
- [23:32]
A
Oh, yeah.
- [23:34]
B
No, yeah.
- [23:35]
A
Because is this somebody off label? You're using reflumelast, You're. But I'm sorry, you're right. If you're. Sorry, if you're using Tofacitinib off label. But I think for people who have extremely recalcitrant diseases that have failed other stuff, who have been well counseled once Tofacitinib is generic, it. It'll be like having. I think it's good. I think it can replace prednisone. I think it can replace prednisone that we might use short term. Right. So for like two or three weeks of Tofacitinib is definitely going to Be safer than two or three weeks of prednisone, right. Or, you know, okay, we're going to put you on topacit and transition you over to something else. But even long term, rather than, you know, trying to use off label, you know, Rinvoak or Abro or Lumient, it might be an option for people who, you know, we can't get better with other stuff. That's going to be. When it goes generic, that's going to be really fascinating to see how we use it. Like, really fascinating. All right, let's jump over to another drug, Soriotane. So acetretin, right? I, I can probably career wise count the number of times I've written acetretin. Pat and Ferris, I think Scott probably writes a fair amount of it. Is the, is the. Or at least has over the years patent. Ferris, you guys use much of it for skin cancer, prophylaxis, psoriasis, anything.
- [25:01]
C
I like acetretin. Like, it's funny moving here. I feel like nobody, you know, you move to a new place and like, I think we use some in Pittsburgh. So I was used to it and then people here didn't do it. I like acetretin. I like it for like palm plantar disease that's, you know, like kind of like what we would call palma plantar psoriasis. But maybe they only have hand foot disease. I feel like that does well on acetratin. So like keratodermas. I like it for that. Older people for psoriasis, particularly if they're going to do a little phototherapy or they're just out in the sun a lot, I like it for that, you know, Do I use tons and tons of it? No, but it's been really like. I've had patients who have like palma plantar, either palma plantar pustulosis or palma plantar psoriasis or this like weird, like dyshidrotic hand eczema.
- [25:53]
A
And it works well, A, a different blanket on the name of it, but there's a retin. There's a systemic retinoid approved for chronic hand eczema in Europe and Canada. What's that? Target? No, it's not Targaryen and there's allotret. No. 1. So, yeah, for so far. What's your normal. Do you ever go above 25? And, and I think of it as a poorly tolerated drug, meaning like hair loss, fingernail problems.
- [26:23]
C
I think people tolerate it fine at 10 milligrams, often at 25. I have had people who do well on. I'VE never gone over 50 a day. I have some people who have done well on 50. It's, it's like kind of idiosyncratic how people respond. So some people lose hair. It's terrible. Some people get baby soft skin. Some people get like really dry skin. It's just, you can't predict it. But I'm not like, really afraid of it. Obviously, I'd never put a woman of any childbearing potential on it, but other.
- [26:53]
A
Than that and triglycerides, we got to remember, it's. It's triglycerides.
- [26:57]
C
You have to. I monitor triglycerides. I monitor AST and alt.
- [27:00]
A
So, Scott, how much acetretin have you used over the years?
- [27:06]
B
A lot, actually. So back in the day, we had, we used to go to the academy for puva club and there was this thing that Laura referenced, Repuva, which was retinoids and puva together, which obviously is no more. But I think acetran had a great place in the ichthyosiform disease states.
- [27:29]
A
Yeah, it's true. Darias. Haley. Haley. It can be useful in both of them.
- [27:32]
B
And like lamella ichthyosis. Yep. It's really remarkable. And then I'm halfway between Cleveland and Columbus and so I get the, the referral, the germ referrals from the transplant teams at both places. And back when we had these aggressive anti rejection drugs for the solid organ transplant people, that was sort of the protocol back then for chemoprophylaxis against the development of squamous cell carcinoma. I think there are the drugs that we use that, that, that our transplant folks use have less risk than the ones that were.
- [28:11]
A
Yep. What, what's your normal. Would you echo what Laura said, that 10 milligrams a day, rare to see AES, 25 milligrams a day starts to get to be hit or miss. What would you say?
- [28:21]
B
What I tell people who are transplant patients who are still on the older drugs is the dose of efficacy is the same as the dose of intolerability. And so it was a, it was a difficult thing. And we were doing these crazy regimens. All right, every, you know, four days on one day off or five days on one day off. We really, you really had to play with that dosing, kind of like the way you play with Airvidge or Adamzo to manage these people to develop efficacy and, and still be tolerable.
- [28:54]
A
I, I've often wondered about something like acid tretin, 10 milligrams a day as an anti aging regimen. Like a full body, you know, rather than doing tretinoin, you know, once a day on your face, do acetretin 10 milligrams a day and you're retinoid in your whole body, right?
- [29:15]
C
I don't think so. It doesn't quite. I'm not seeing it from all that's.
- [29:20]
A
Just it would photo.
- [29:21]
D
You'd be photosensitized and losing hair. Yeah, you would look ten years older than.
- [29:27]
B
Alopecia is real. It's real.
- [29:29]
A
Do you ever see it at 10 or is it 10 a pretty safe dose.
- [29:34]
C
I feel like I see it more once I'm over 10. But there's also like once people get alopecia, they're free, freaked out and that's the end of it. I always say like if you got it, you could. It's not scarring alopecia, you stop, it'll grow back. But it freaks them out.
- [29:48]
A
Now I'm looking up, is it hard to get?
- [29:51]
C
So I. Yes, it is expensive. What in it is not cheap. It's not as cheap on cost plus drugs. There are Canadian pharmacies. Do I prescribe to Canadian pharmacies? No, because that would be illegal and I would never ever do anything illegal. So I don't. But I tell patients that they exist and then I give them a written script and they can fax their own script there and I have no idea. It's like I don't ask you did you go to Walgreens or cvs? I just write them a script and then they can send it to a Canadian pharmacy who can ship it to.
- [30:25]
B
Them at the risk of being pummeled. Here I am. I recall the days when I had both and Accutane samples in my closet. You can just come out like candy. It was before I pledged before the stickers. It just the Roche rep would come in and here you were and.
- [30:46]
A
And so far you can't getting it prior authors. So looking it up on Goodrx which I think of Goodrx is a reasonable proxy for the actual cost of a drug. 3025 milligram pills is if you go to the right place, about 140 bucks a month. So if you did 25 every other day, it's 75 bucks a month. Do you ever try and get a prior off?
- [31:10]
C
Yeah, I will, I will. But like if I get denied and denied. I mean I love it when I get denied for acetin and then I get like Skyrizi approved. Yes, but yeah, but yes, I, I will certainly try to get it Approved. I'd rather go through the normal, you know, ways, but there are patients who are like, this is just a pain. And I, you know, it works like Haley. Haley. I agree. I've got some of those patients and it's been life saving for them.
- [31:38]
A
Do you ever use it as add on therapy to a biologic?
- [31:40]
C
Yeah, definitely. For some my more challenging psoriasis patients.
- [31:46]
B
I think that is really where much of the utility on a day to day basis. This conversation is about what can we add on to a biologic that is going to help us not switch? And when I'm talking to residents or people who are like bio afraid, I remind them that we as a profession are adders and joiners. I mean, polypharmacies in our DNA. No one writes monotherapy for acne unless it's Accutane. No one writes monotherapy. In the old days for A.D. we all had, you know, this, our own little regimen. So. And there's no double blind controlled studies on tretinoin, doxycycline, bpo. Right. They're, you know, the additive effect of all these things together. So that's an important thing to point at the our younger colleagues.
- [32:35]
A
All right, I'm going to give a quick summary and then we're going to go to Patton's trivia. So methotrexate, very safe, very, very safe. 10 milligrams once a week. Broad spectrum drug, mycophenolate, not a whole lot of use for it these days. Cyclosporine works for everything, but we try and keep the dose very low. And you really want to monitor creatinine and blood pressure. Then we get into talking about drugs like dapsone, very good for a few dermatoses, especially things that are neutrophil driven. We get into reflumelast, good drug, first line for literally everything. Inflammatory. Also very good option is add on therapy to anything. Then we talk about ceritane or acetretin. Drug that probably gets underused nowadays but can be a little bit difficult to get prior off.
- [33:29]
B
Still.
- [33:32]
A
We'Re gonna now let's jump into what is usually everybody's favorite thing on the entire show, Patton's trivia. So, Scott, here are the rules. We gotta let Patton finish reading the question. As soon as he finishes reading the question, you can shout out your answer. All right, that's it.
- [33:50]
D
Patton, are you ready?
- [33:51]
A
What do we got?
- [33:53]
D
All right, between cyclosporine, methotrexate and mycophenolate mofetil, which medication does not use fungal Fermentation as a step in its manufacturing process.
- [34:04]
A
Got to be cyclosporine Cellcept. Scott, you got to guess. Methotrexate.
- [34:11]
B
Methotrexate.
- [34:12]
D
Methotrexate is. Is synthesized. Cyclosporine and mycophenolate still use fungal fermentation as the initial step. Cyclosporine, they culture totally podium inflatum. And that's what still makes cyclosporine acid. It's penicillium brevicompactum.
- [34:34]
A
So it sounds like the first one is an erectile dysfunction drug. Inflatum.
- [34:40]
D
Inflatum.
- [34:41]
A
And the second one sounded like it was. Well, it.
- [34:46]
D
That's what you take to reverse. It says compact them.
- [34:48]
A
Revi compactum. All right, next.
- [34:55]
C
That'll be the next episode.
- [34:56]
B
Let's move on, please.
- [35:00]
D
All right, number two, between cyclosporine methotrexate and mycophenolate mofatil, which does not have an FDA indication for dermatologic disease. Methotrexate, Mycophenolate. I heard it from Zyrus first.
- [35:16]
A
Oh, I could.
- [35:17]
D
FDA approved to treat psoriasis in 72. And as Scott said earlier, cyclosporine was approved in 19 night.
- [35:26]
B
I actually knew that because it was approved in 72 for psoriasis. And that was the same year the then governor of Maryland, my home state, Spiro Agnew, came to my high school to, like, talk before he went to jail. So, yeah.
- [35:43]
C
Wow. And I was one. So there you go.
- [35:48]
D
All right, final one. Which was discovered first? Methotrex Cyclosporine or mycophenolic acid.
- [35:55]
A
Mycophenolic acid.
- [35:58]
D
That is true, yes.
- [36:00]
A
What you gotta.
- [36:01]
D
You got a. A date? You would guess for me within 20.
- [36:07]
A
Mycophenolic acid. I would say 1934.
- [36:10]
D
It's crazy. 1893, this Italian chemist isolated it, thought it would be an effective antibacterial. And it's just kind of. His experiment went on the shelf until it was rediscovered as an immunosuppressant medication.
- [36:26]
C
Cool.
- [36:27]
A
Okay. It's good stuff. All right. Well, Scott, I want to thank you for joining us. These have been a really fun two episodes. Really enjoyed having your wisdom to help us out this week. And so I also want to thank all of our listeners for joining us. I hope you learned a few things. Hope you laughed once or twice. Most I'm hoping you're planning to join us next week. And until then, I'm Matt Zyrus.
- [36:54]
C
Tim Patton, and I'm Laura Ferris and we are derms on drug.