Derms on Drugs – "Melasma, and Vitiligo, and Warts, Oh My!"

Podcast: Derms on Drugs
Hosts: Dr. Matt Zirwas, Dr. Laura Ferris, Dr. Tim Patton
Date: February 13, 2026
Episode Focus: The hottest fresh dermatology literature – from low-dose naltrexone to new melasma findings, treatments for urticaria, warts, vitiligo, and more, infused with friendly debate and classic derm humor.

Episode Overview

This "six-pack" format episode features the three host dermatologists each sharing two recent or notable dermatology papers, discussing practical pearls as well as methodological quirks, and adding their real-life prescribing experience—plus classic banter. Topics include low-dose naltrexone for skin conditions, metformin in hidradenitis suppurativa, dietary interventions for urticaria, hyperthermia for warts, aggressive dosing in psoriasis, tranexamic acid for melasma, and long-term follow-up in pityriasis lichenoides and vitiligo.

Discussion Highlights

1. Low-Dose Naltrexone (LDN) for Dermatologic Conditions

Presented by Dr. Laura Ferris
Reference: Ju et al., Clinical Review in JAMA Dermatology

Key Points

• Mechanism:
  • Low dose (1–6 mg) naltrexone briefly blocks opioid receptors, paradoxically upregulating endogenous opioids and reducing neurogenic inflammation and pruritus.
  • Also blocks TLR4, reducing pro-inflammatory cytokines (IL-1, IL-6, TNF).
• Efficacy:
  • Haley-Haley disease has most promising (if modest) data. (03:53)
  • Some benefit seen in Darier's, epidermolysis bullosa pruriginosa, lichen planus (especially nail involvement), and pruritic disorders.
  • For lichen planopilaris, a randomized trial found no difference vs. placebo when both groups used clobetasol.
  • May help with body-focused repetitive behaviors (excoriation, onychophagia, trichotillomania) via modulation of the mesolimbic reward system.
• Dose/Practical Tips:
  • Start at 1 mg daily, titrate by 1 mg every 1–2 weeks up to 5 mg.
  • Main side effect: vivid dreams (“number one side effect” - 01:47), plus insomnia, headache, dry mouth, vertigo.
  • Not for patients on opioids/liver failure.
  • Compounding is needed; hack: crush 5x50mg tabs in 8 oz orange juice for suspension ($2.50/month vs. $35–50).
• Host Experience: Mild efficacy, mainly used in hard-to-treat, pruritis-driven cases or nail lichen planus. (09:42, 10:47)
• Relevant Quote:
  “Vivid dreams is the number one side effect of low dose naltrexone. So you have to tell patients that might happen. I don’t know if anybody’s ever died of a vivid dream, but you know, scary dreams are scary.” – Dr. Ferris [01:47]

2. Metformin for Hidradenitis Suppurativa (HS)

Presented by Dr. Tim Patton
Reference: Arts et al., Br J Dermatol, Nov 2025

Key Points

• Design: Phase 3 RCT – Doxycycline 100mg + metformin (500–1500mg/d) vs. doxycycline + placebo.
• Findings:
  • No significant difference in HS outcomes (IHS4 score, flares, pain) between the two groups after 6 months.
  • Metformin improved BMI, waist circumference, and glucose.
  • Conclusion: Metformin may benefit comorbidities in HS patients, not the skin disease per se. (14:51)
• Clinical Pearls:
  • “So am I going to start it in all my HS patients? I don’t think so.” – Dr. Patton [15:45]
• Host Consensus: Use as adjunct if comorbidities present; not as a primary HS therapy.

3. Low-Salicylate Diet in Chronic Urticaria

Presented by Dr. Matt Zirwas
Reference: Korean Open-Label Study

Key Points

• Rationale: Up to one third of chronic urticaria is worsened by salicylates (aspirin, NSAIDs, certain foods).
• Findings:
  • 4-week low-salicylate diet → significant improvement in UAS4 scores (~50% decrease), 30% QOL improvement.
  • Greatest benefit in patients with partial, not complete, response to antihistamines/omalizumab.
• Host Tips & Pearls:
  • Remind to check for aspirin use in urticaria patients. [22:40]
  • “I will outright say I forget to ask people.” – Dr. Zirwas [23:03]
• Diet Notes: High salicylate foods include almonds, tomatoes, dried fruits.

4. Hyperthermia and Hydrogen Peroxide for Warts

Presented by Dr. Matt Zirwas
Reference: Unspecified RCT

Key Points

• Method: Heating pad (44°C, ~110–120°F) to warts 30 min/day, on 3 consecutive days per week, plus daily peroxide (3%) under Band-Aid.
• Results:
  • Hyperthermia: ~33% clearance
  • Hyperthermia + peroxide: ~50% clearance (26:15)
• Practicality:
  • Peroxide rapidly degrades to water; effect mechanism unclear; provides a safe low-cost at-home option.
  • “Anything that’s about warts and is something non-invasive you can give parents to do at home is worth thinking about.” [24:58–25:00]
• Other discussion: Use of curettes at home—possibly safe if bought online; “they probably all have knives at their house, so…” – Dr. Ferris [27:42]

5. High Induction Dosing of Risankizumab (“Knockout” Study) for Psoriasis

Presented by Dr. Laura Ferris
Reference: Blauvelt et al., Randomized Phase 2, 100-week Trial

Key Points

• Design: Risankizumab (Skyrizi) at 300mg or 600mg (vs. standard 150mg); dosed at weeks 0, 4, and 16; then stopped.
• Endpoints: Reduction of skin resident memory T cells (Trms), PASI response.
• Findings:
  • After 2 doses: PASI75 100%, PASI90 94%, PASI100 66%
  • @28 weeks, high rates maintained; by 1 year post-treatment, PASI75 78%, PASI100 44%.
  • At 2 years, only 6 remained, 2 with PASI100.
  • No clear benefit of 600mg over 300mg dosing.
• Host Perspective:
  • Does not “knock out” psoriasis in most, but remission lasts longer than with conventional induction.
  • “I was expecting it to work, like, based on the way I'd heard people talk about it...this did not show that at all.” – Dr. Zirwas [34:24]
• Takeaway: High-dose IL-23 blockers reduce Trms and may lengthen remission, but are not a cure.

6. Oral vs. Topical Tranexamic Acid for Melasma

Presented by Dr. Tim Patton
Reference: Hadari et al., J Cosmetic Dermatol, Sept 2025

Key Points

• Design: 50 patients, randomized: oral TXA (250mg daily) vs. topical TXA 5% BID for 12 weeks.
• Findings:
  • Both groups improved. Poor reporting of data: topical group appeared to have slightly greater MASI score reduction (49% vs. 41%).
  • Errors in manuscript calculation/interpretation.
  • Topical agents likely as or more effective, with fewer systemic risks.
  • Oral TXA group: 14% reported oligomenorrhea; 0 dropouts. One dropout in topical group due to irritation.
• Hosts’ Prescribing Habits:
  • Topical “magic mix” (TXA, niacinamide, tretinoin, kojic acid) is popular and well-tolerated.
  • “I’ve never used systemic ... I scare the bejesus out of patients by telling them the drug is used to clot blood.” – Dr. Patton [40:06]
• Extra Pearl:
  • Recent RCT showed topical TXA+niacinamide as effective as hydroquinone 4% but better tolerated. [41:01]

7. Ruxolitinib Cream Withdrawal in Vitiligo

Presented by Dr. Matt Zirwas

Key Points

• Design: Patients who responded to ruxolitinib (Opzelura) cream for facial vitiligo were randomized to stop (placebo cream) or continue.
• Finding:
  • Maintenance of response at 1 year: 75% if continued, 24% if stopped.
• Implication:
  • Continuous use is needed to maintain effect. “As you would expect…” [43:15]

8. Long-Term Follow-up of Pityriasis Lichenoides Spectrum Disorders

Presented by Dr. Matt Zirwas
Reference: Serbian Long-Term Cohort Study

Key Insights

• Case Mix:
  • Both PLC and PLEVA seen in both kids and adults (roughly 50/50).
  • Febrile ulceronecrotic Mucha-Habermann form more common in children.
• Duration:
  • PLC median: 4.5 months, but range up to 12 years.
  • PLEVA median: 3 months, max 3 years.
  • “The longest Pleva went in anybody was three years, whereas PLC lasted up to 12 years.” – Dr. Zirwas [44:46]
• Therapies Used:
  • Methotrexate, phototherapy, IM Kenalog, doxycycline, erythromycin (kids); possibility of apremilast in the future.
• Takeaway:
  • Most cases are shorter-lived than many textbooks suggest; some outliers persist years.
  • Useful for patient counseling on expected course.

Notable Quotes & Memorable Moments

• On LDN dreams:
  “I don’t know if anybody’s ever died of a vivid dream, but you know, scary dreams are scary.” — Dr. Ferris [01:47]
• DIY naltrexone:
  “Dirk Elston hack: take five 50 mg tablets, crush them up, put them into eight ounces of pure orange juice … stable for up to two months, about $2.50 a month.” — Dr. Ferris [07:22]
• Patient directions for at-home warts:
  “Put enough drops of hydrogen peroxide [3%] on the pad of a band aid to get it wet and then put it on, leave on until it falls off. Put it on every day.” – Dr. Zirwas [26:03]
• Real-life patient advice gaps:
  “I will outright say I forget to ask people [about aspirin use in urticaria patients].” – Dr. Zirwas [23:03]
• Clinical humility:
  “Is this how I’m going to start prescribing [high-dose Skyrizi]? Probably not.” – Dr. Patton [34:11]
• Melasma pearls:
  “The biggest takeaway for melasma is ... whatever we’re doing, we need to have them use iron oxide containing sunscreens.” – Dr. Zirwas [41:51]

Key Segment Timestamps

• LDN for skin diseases: 00:54 – 12:24
• Metformin vs. doxy for HS: 12:28 – 18:41
• Low-salicylate diet in urticaria: 18:41 – 23:14
• Hyperthermia/peroxide for warts: 23:18 – 27:39
• “Knockout” study (Skyrizi high-dose): 28:03 – 36:12
• Tranexamic acid (oral vs topical) for melasma: 36:14 – 43:15
• Ruxolitinib withdrawal in vitiligo: 43:15 – 44:33
• Pityriasis lichenoides follow-up: 44:33 – 51:38

Episode Tone and Takeaways

The episode is dynamic, conversational, and both evidence- and practically driven, with the hosts often challenging each other’s preconceptions, poking fun at themselves, and grounding research findings in patient realities.

Summary in a Nutshell:
You’ll leave with a handful of practice-changing pearls, a few new pathways to investigate for hard-to-treat patients, and a strong reminder that even in the era of AI, remembering to ask about aspirin, or having a hack for compounding naltrexone, can make a big difference.