Derms on Drugs: "More Answers for Tough Questions"

Date: January 16, 2026
Hosts: Dr. Matt Zirwas, Dr. Laura Ferris, Dr. Tim Patton
Produced by: Scholars in Medicine

Episode Overview

In this lively “six pack” episode, the three dermatologists tackle a range of challenging and intriguing recent studies in dermatology. They blend sharp clinical insights with an easygoing, comedic flow, each bringing two articles to dissect and discuss. Topics range from demodicosis in immunocompromised patients and evolving therapies for prurigo nodularis to new methods of managing cheilitis and considerations for radiation vs. Mohs surgery. As always, the team zeroes in on clinical pearls, therapeutic tricks, and a few playful debates.

Key Discussion Points and Insights

1. Demodicosis & Mazzotti-like Reaction in Stem Cell Transplant Patients

Source: Research letter from JAMA Dermatology
[01:12–06:31]

• Summary:

  • NIH study observed 307 allogeneic hematopoietic stem cell transplant patients within 100 days of transplant; 5.5% diagnosed with Demodex infestation.
  • Typical description: pruritic, folliculocentric papules and pustules, mainly face, neck, trunk; periocular skin and scalp usually spared.
  • Key confusion is between acute GVHD (graft versus host disease) and Demodex eruptions.
  • Treatment with ivermectin occasionally led to an acute inflammatory “Mazzotti-like reaction” in profoundly immunocompromised patients—sometimes requiring systemic steroids.

• Clinical Takeaways:

  • Think Demodex: When seeing facial papules after stem cell transplant, always consider Demodex before diagnosing acute GVHD.
  • Be aware of Mazzotti-like (MATI) reactions with ivermectin, not previously well-recognized for Demodex.

• Notable Quote:

  “If you're thinking acute GVHD and it's mostly facial, look for Demodex. And then if you treat them and they get this [reaction], remember that that might be what's going on.”
  – Dr. Laura Ferris [05:01]

  “This article gives support to what I have been making up for years…but it is my clinical experience. So this helps explain something that I see not infrequently in regular people.”
  – Dr. Matt Zirwas [05:25]

2. JAK Inhibitors vs. Dupilumab in Prurigo Nodularis

Source: Clinical and Experimental Dermatology, November 2025
[06:54–13:47]

• Summary:

  • Retrospective multicohort study comparing dupilumab, abrocitinib, and upadacitinib in treatment-resistant PN (patients had to fail 2 systemic therapies, no AD/atopic diathesis).
  • All drugs improved pruritus and nodule counts, but JAKs (Abro, UPA) acted faster and appeared somewhat more effective, though baseline population differences complicate interpretation.
  • Discussion on whether PN is simply a subtype of atopic dermatitis (AD).

• Clinical Controversy:

  • Dr. Patton and Dr. Zirwas favor lumping PN with AD for expanded therapeutic options.
  • Dr. Ferris feels they're mechanistically distinct—AD T-cell initiated, PN nerve initiated—but similar downstream.

• Notable Quotes:

  “Diagnosing Prurigo nodularis, you're kind of taking away a lot of potential medications... for me, paragon is atopic derm.”
  – Dr. Tim Patton [09:40]

  “We are doing our patients a disservice if we say this might be... I'm going to call it PN, no AD, so that I limit your therapeutic options.”
  – Dr. Matt Zirwas [11:09]

  “I think it's all a spectrum and I am definitely like a lumper, not a splitter.”
  – Dr. Laura Ferris [13:47]

3. Apremilast for Palmarplantar Pustulosis

Source: Phase 3 trial in Japanese patients
[14:03–15:13]

• Apremilast found effective.
• Zirwas suggests this points to roflumilast as a possibly better, cheaper oral alternative for the disease.
• Topical roflumilast may also be beneficial, but requires future study.

4. Intranasal Steroids for Chronic Idiopathic Urticaria (CIU)

Source: RCT from Iran
[15:15–19:49]

• Intranasal budesonide reduced urticaria activity scores slightly but significantly, despite modest systemic absorption.

• Mechanistic speculation: dampening nasal mast cell activation blunts systemic urticarial responses.

• Practical pearl: For CIU patients not fully controlled on antihistamines and biologics, adding OTC nasal steroid spray is a cheap, low-risk adjunct to try.

• Notable Quote:

  “It's just a something to have in your therapeutic toolbox of tricks for people who have an inadequate response to systemic drugs for CIU.”
  – Dr. Matt Zirwas [17:54]

5. Infection Risk: Biologics vs. JAK Inhibitors in Atopic Dermatitis (BioDay Registry)

Source: JEADV, Dutch multicenter registry
[20:11–28:00]

• JAK inhibitors (JAKs) carried a much higher infectious risk (esp. for herpes viruses and bacterial SSTIs) than biologics over 4,000 patient years.

  • Herpes infection rate for JAKs: 13.6–20/100 pt-yrs; biologics: ~3/100 pt-yrs.
  • Bacterial infection: impetigo rate for upadacitinib 60.9, vs. 7.7 per 1,000 pt-yrs for dupilumab.

• Key Practical Point: For AD patients with history of skin infection, prefer an IL-13 blocker biologic.

• Notable Quotes:

  “JAKs definitely increased the risk of herpes stuff. And they... do not decrease the risk of bacterial infections the way that biologics do.”
  – Dr. Matt Zirwas [25:29]

  “If they've got that history of skin infection, it is a reason to... go biologic first.”
  – Dr. Laura Ferris [27:35]

6. Superficial Radiation Therapy (SRT) vs. Mohs Surgery for NMSC

Source: Derm Surgery, November 2025, Systematic Review and Meta-Analysis
[28:05–34:59]

• Finding: Mohs surgery has significantly lower recurrence (1.9% vs 6.3% with SRT at ~50 months), based on large cohort review.

  • Study excluded "image-guided" superficial radiation therapy (IGSRT), which is often hyped but not clearly superior.
  • No definitive data that IGSRT is better than traditional SRT.

• Counseling Pearl:

  • Mohs remains the gold standard for most NMSC, but SRT may be an option for select difficult facial cases.
  • Avoiding Mohs may be justified in rare, highly specific anatomic scenarios (e.g., tiny nasal tip basal cell).

• Notable Quotes:

  “I think Mohs surgery is the gold standard. And if patients ask about radiation therapy... Mohs is better.”
  – Dr. Tim Patton [31:03]

7. Isotretinoin for Dermal Macular Hyperpigmentation

Source: Multi-institutional retrospective analysis
[34:25–43:27]

• Use: Oral isotretinoin improved facial hyperpigmentation in patients with Riehl’s melanosis and lichen planus pigmentosus, even though these are considered dermal pigmentary disorders (not epidermal).

• Practical pearl: In stubborn facial hyperpigmentation—especially when etiology uncertain—may be worth a therapeutic trial.

• Dosing: Lower than acne; mean 20 mg/day for 7–9 months.

• Discussion on Reihl's melanosis:

  • Some debate whether it is primarily pigmented contact dermatitis or a distinct entity.
  • In practice: If no itch/rash, patch test may be less relevant.

8. Wet Gauze for Atopic Cheilitis

[37:38–39:13]

• Study: Wet saline gauze dressing x20 min, then topical corticosteroid, twice daily—vs triamcinolone alone.
• Finding: Significantly better with wet dressing; fits with literature on "wet wrap" therapy elsewhere on atopic skin.
• Host pearls: For difficult cheilitis, have patient use normal saline-soaked gauze before topical therapy. Could also try mild acidification (salt + vinegar) for theoretical benefit.

Notable Quotes & Memorable Moments

• On clinical philosophy and diagnosis:

  “It's all a spectrum and I am definitely like a lumper, not a splitter.”
  – Dr. Laura Ferris [13:47]

• On cheap, practical therapeutics:

  “It's cheap and easy. That's what I'm always looking for. Cheap and easy. Kind of like whenever I'm dating.”
  – Dr. Matt Zirwas [19:49]

Timestamps for Major Segments

| MM:SS | Topic | |-------|---------------------------------------------------------------| | 01:12 | Demodicosis & Mazzotti-like reaction in stem cell patients | | 06:54 | JAK inhibitors vs. Dupilumab in prurigo nodularis | | 14:03 | Apremilast (& roflumilast) for palmarplantar pustulosis | | 15:15 | Intranasal steroids for chronic idiopathic urticaria (CIU) | | 20:11 | Infection risk: Biologics vs JAKs in atopic dermatitis | | 28:05 | SRT vs. Mohs surgery in NMSC | | 34:25 | Isotretinoin for dermal macular hyperpigmentation | | 37:38 | Wet gauze dressing for atopic cheilitis |

Conclusion

This episode delivers a high-yield, practical sweep through key new findings in dermatology, spiked with the hosts’ characteristic humor and debate. Listeners come away with actionable pearls for difficult clinical scenarios—from immunocompromised patients with facial eruptions to recalcitrant cheilitis or stubborn pigment changes—and a reminder that sometimes, the best therapy is the one you might have overlooked. As always, the ethos: make dermatology cutting-edge, accessible, and fun.