Podcast Summary: Derms on Drugs – Episode: Melanoma Meltdowns, Biosimilar Betrayals, and the Eczema Enigma Exposed!

Date: January 31, 2025
Hosts: Dr. Matt Zirwas, Dr. Laura Ferris, Dr. Tim Patton
Special Guest: Dr. Ian Miles (NIH allergist, air pollution & atopic dermatitis researcher)

Episode Overview

This episode dives deeply into some of the most intriguing recent topics in dermatology:

• The psychological impact of melanoma
• The debate over biosimilar use in psoriasis
• Groundbreaking environmental research clarifying the surge in atopic dermatitis
• Practical pearls and a rapid-fire roundup of impactful recent derm papers

The hosts blend serious clinical insights with lighthearted banter, and welcome Dr. Ian Miles to illuminate the environmental causes behind the “eczema epidemic”.

Main Discussion Segments

1. Melanoma and Mental Health: More Than Just a Skin Deep Diagnosis

[01:43–06:48] Laura Ferris leads discussion

• Journal Club Article: UK/European meta-analysis on anxiety & depression prevalence in melanoma patients
• Key Findings:
  • Highest anxiety and depression in women, younger patients, and those with less education
  • Patients on older treatments (chemo, interferon) had more distress than those on targeted/modern therapies
  • Stage of disease did not map directly to psychological distress (“You’d think it’s stage 4ers, but that really wasn't the case.” – Ferris, 03:32)
• Practical Insight:
  • Many patients with early-stage or even in situ melanomas develop disproportionate anxiety—often “screening more than recommended”.
  • Importance of nuanced communication: “Maybe we need to think about the words that we use to describe melanoma in situ.” (Ferris, 03:34)
• Discussion Points:
  • Time since diagnosis: Anxiety highest in year 1, but persists.
  • Patient, not physician-driven anxiety may dominate (“I think this is the patients... I don’t think we’re better at it than they are in Europe.” – Ferris, 04:54)
  • Real-world challenge: Conveying “true recurrence risk” to low-risk patients

2. Biosimilars vs. Original Biologics: Do They Measure Up in Practice?

[06:57–13:29] Tim Patton leads discussion

• Journal Club Article: Multinational database study on adalimumab biosimilars in psoriasis
• Key Points:
  • No major difference in adverse events or discontinuation among naïve (new start) users between biosimilars and originator (Humira)
  • But: Patients switched from Humira to a biosimilar DC’d more often, with some brands (Amjevita, Emraldi) linked to lower perceived efficacy
    • “A 1.35 hazard ratio of discontinuation in switchers.” (Patton, 09:15)
  • Likely contributors: "Nocebo effect", negative perceptions (“They were like, oh, this drug sucks, it’s cheap… I want something else.” – Zirwas, 10:30)
  • Head-to-head studies where patients were blinded to what they were receiving: “...curves just overlap. It does look like they really work the same.” (Ferris, 11:02)
• Panel Wisdom:
  • Experience with payer-mandated switches is growing, especially in hidradenitis suppurativa.
  • Clinical anecdotes: Many still hesitate to appeal for brand preference; notable exceptions in off-label Remicade and rituximab.

3. The Eczema Enigma: Air Pollution, Fabrics, and the Surprising Urban Surge

[13:30–36:28] Matt Zirwas introduces & interviews Dr. Ian Miles

The New Theory—Solving the Atopic Dermatitis Boom:

• Researcher: Dr. Ian Miles, NIH
• Pivotal Chemicals:
  • Toluene diisocyanate (TDI): From car exhaust (catalytic converters post-1975), also found in nylon, polyester, furniture, memory foam, wallpaper glue, polyurethane
  • Xylene and others: Also implicated
  • “Catalytic converters getting implemented in the 70s and nylon and polyester in the 70s turns out are what has driven the atopic epidemic” (Zirwas, 16:12)
• Data & Mechanism:
  • Massive environmental/urban exposure inexplainable by genetics
  • Advanced geospatial analysis cross-linking chemical concentration (EPA zip-code data) and atopic visits: “All of them say the same thing.” – Miles, 21:10
  • TDI is used to induce atopic derm in mouse models—making the human link all the more plausible

Memorable Quotes:

• “Famous science words: ‘That’s weird.’” – Zirwas & Miles, 21:07–21:12
• “Before 1970, no cars produced diisocyanate. After 1975, it was mandatory.” (Miles, 21:58)
• “If you want to make a healthy commensal act like it came off someone with atopic derm, expose it to diisocyanate.” (Miles, 24:01)
• “Now, when I explain to patients it’s chemicals over 30 years, they really get it.” (Zirwas, 18:16)

Topical Probiotics—A Solution?

• Roseomonas bacteria, topical trial: benefit persisted after 8 months, but may be less effective in high pollution zones (“…your ambient pollution will rob it of its abilities.” – Miles, 25:41)
• “You can’t make a drug that people can use and be cured. Then the pharmaceutical companies won’t make any money!” (Zirwas, 25:43)
• Now licensed OTC as a probiotic—can't overtly market as eczema treatment (FDA constraints)

Practical Patient Advice:

• Mnemonic "HELPS AD":
  • Home decor (reduce synthetic fabrics/furnishings)
  • Emollients
  • Laundering practices
  • Probiotics (those with third-party validation)
  • Soaking/bathing
  • Social support
  • Air quality: Counterintuitively, indoor air quality (worse than outdoors except during disasters), so ventilation is key, and box fan plus filter is recommended. (Miles, 27:55; 29:50)
  • Diet: Processed foods likely play some role
• Filter types: HEPA & activated charcoal unclear benefits for VOCs/isocyanates, but keeping air moving + filtering pollen is useful (Miles, 30:02–30:51)
• Moving for eczema? “Rural parts of Africa”—but for most, living downwind (west coast with prevailing winds from ocean) or away from highways can help (Miles & Zirwas, 32:52–33:35)

Scope of the Problem:

• TDI, xylene may explain “75–80%” of modern atopic derm, possibly higher (Miles, 31:24)
• “One last thought”—same geospatial methodology might help explain other ‘new’ diseases (frontal fibrosing alopecia, neuroinflammatory disorders) (Ferris & Miles, 34:08–35:22)
• Policy implications and research resonate: “Concern about lack of long term safety evaluation for pharmaceuticals... yes.” (Miles, 35:58)

4. Dermatology Trivia Challenge

[37:12–39:24]

• Panel faces classic eponym/derm history/FDA trivia
• Denny-Morgan lines, Roman emperors, non-steroid AD topicals ("Who was Augustus?" – Miles, 38:07)
• Lighthearted, showcases breadth of derm lore, friendly competition

5. Six-Pack: Rapid Journal Club Roundup

[39:54–end] Each host presents an interesting new derm paper

Article 1: Acne Relapse & Isotretinoin Retreatment (JAMA Derm)

[39:54–44:17] Ferris

• MarketScan claims data: Higher cumulative dose isotretinoin → lower relapse
• Data is rough (all weights estimated), but directional finding still valuable
• Clinical pearl: High Omega-3 fish oil can decrease cheilitis/nosebleeds on Accutane (Zirwas, 43:54)

Article 2: Dupilumab & Malignancy Risk (J Allergy Clin Immunol Pract)

[44:17–48:19] Patton

• Big database: Dupilumab users had lower rates of skin & internal malignancies than mild AD or systemic immunosuppressive users
• “Does dupilumab cure cancer?” Playful, but epidemiology only—won't (yet) change practice
• Mechanism: Th2 blockade may unmask Th1/Th17 cancer immunosurveillance (Zirwas, 47:07)
• Awaiting COPD trial outcomes to confirm

Article 3: Tralokinumab after Dupilumab Failure (JACI: In Practice)

[48:19–50:56] Zirwas

• Patients who lost efficacy or had AE's on Dupilumab often did well on Tralokinumab
• Switching: Presence of conjunctivitis on DUPY modestly predicts recurrence on Trelo, but if not, unlikely to develop on Trelo (“If you did not get DUPY-induced conjunctivitis, not a single one got it on Trelo.” – 49:55)

Article 4: Ferulic Acid for Papulopustular Rosacea (J Cosmet Derm)

[51:03–53:36] Ferris

• Small RCT, all patients also on doxycycline
• Topical ferulic acid beat saline (vehicle non-ideal) in some endpoints, possible over-the-counter adjunct

Article 5: Systemine 5% Cream for Melasma (Arch Derm Res)

[53:41–56:17] Patton

• Meta-analysis: Systemine better than placebo, equal to hydroquinone but not less irritating
• Group admits: confusing profusion of skin lighteners—interested in data on real comparative efficacy

Article 6: Treatment of Digital Mucous Cysts (Arch Derm Res)

[56:57–60:34] Zirwas

• Intralesional Kenalog + drainage works ~44% of the time; surgery best (~86% success), but with meaningful complications (pain, infection, immobility)
• Panel practice: Most previously defaulted to hand surgeons, but this data supports a trial of in-clinic aspiration + ILK first

Notable Quotes & Moments

• “Melanoma is scary… even if it’s a low percentage, you could be in that percentage.” – Patton, 05:20
• “We’re definitely better at everything.” – Zirwas, 05:25
• "I haven’t put anybody on Humira in like 15 years.” – Zirwas, 12:06
• “Your ambient pollution will rob [topical probiotics] of its abilities.” – Miles, 25:41
• “Now, when I explain it to patients that way, they get it.” – Zirwas, 18:16
• “HEPA and activated charcoal: none are rated against these specific chemicals… You just want to flush the air out.” – Miles, 30:03
• “Does DUPY cure cancer?” – Patton, 47:07
• “Longevity! Zepp bound + Doopie: you'll be skinny and cancer-free forever!” – Zirwas, 48:18

Useful Timestamps

• 00:15 – Show intro
• 01:43 – Melanoma anxiety/depression meta-analysis [Ferris]
• 06:57 – Biosimilar adalimumab study [Patton]
• 13:30 – Environmental causes of atopic dermatitis; Dr. Ian Miles interview
• 27:52 – Practical environmental advice for patients, “HELPS AD” mnemonic
• 37:12 – Dermatology trivia
• 39:54 – Six-pack rapid journal club begins

Conclusion

This lively, info-packed episode delivers both the frontlines of clinical dermatology and an entertaining listening experience. Dr. Ian Miles’ research on environmental factors in atopic dermatitis is especially groundbreaking and actionable. For practicing derms, residents, and allied health, it’s a must-listen for both clinical pearls and broader perspective on where the specialty—and the environment—are headed.

For questions, feedback, or topic suggestions: questions@dermsondrugs.com