Loading summary
Transcript246 lines
- [00:02]
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 serum is comedy. I'm Matt Cyrus from Docs Dermatology, and each week I'm joined by my residency buddies, Dr. Laura Fares from the University of North Carolina 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 is everything you need to know to be on the 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 the video component, to remind everybody, has some of the key figures and tables from the article we talk about. And this week's episode is sponsored by Johnson and Johnson. Well, let's go ahead and get into it. We are have a very special guest this week, Dr. Doug Kress, also from the University of Pittsburgh, who happen to be deeply involved in training doctors Pat and Farris and I. And we are going to be talking about pediatric psoriasis, which should be a very interesting discussion with Dr. Kress. So before I get into the first slide here, Pat and Ferris, you guys have anything good happen over the weekend?
- [01:23]
B
Traveling home from Las Vegas from meeting.
- [01:27]
A
Fall clinical for Fair Clinical.
- [01:29]
B
Just happy I made it.
- [01:31]
A
What was the best. What was the most interesting thing at fall clinical? Any new data come out that was particularly.
- [01:36]
B
Ooh, you know, I didn't get to see it, but Castle Biosciences has a new test for predicting, you know, responses to atopic dermatitis therapy. That was the launch. I didn't get to get all the details, but I'm excited to learn about that.
- [01:51]
A
I heard that the new Novartis drug had a big presence. The Rapido. Rapsido.
- [01:59]
B
Yes.
- [02:00]
A
Not Rapsido. It's not Rapido. I know you said it correctly, but they want to be very clear. Everybody knows it's not Rapsido. It's Rapsodo.
- [02:08]
B
It's Rapsodo. They actually. The sphere in Las Vegas, they actually had an ad on the sphere. You know, you're big when you make it on the sphere. You two Eagles and Rap.
- [02:19]
C
You guys know how much that costs?
- [02:21]
B
I don't know. How much of it more than an academic chair salary?
- [02:25]
C
It's half a million dollars.
- [02:27]
A
Okay, Half a million dollars. Wow. That's a Lot of money. All right, well, let's, let's get into it here. So I'm going to get us started because you know what, for me personally, even I don't even really know what the current pediatric psoriasis drugs approved are. I have always kind of hated seeing kids. It's not that I mind the kids, I just don't like the parents. So I don't have a whole lot of experience with this. So I went into the literature and there was a Recent review in JAD Reviews, March 2025. Pediatric psoriasis Biologics and oral small molecule inhibitors and modern therapy. They didn't go into sort of comparative efficacy, but fortunately we've got another article about that that Dr. Patton's gonna talk about. But just to give everybody the reminder of what's approved and to what ages. So first we've got Etanercept, which was approved by the FDA roughly in 2016. That is given weekly and kids go through that. Right. Adalimumab, not approved for pediatric psoriasis in the US it is approved in Europe though. Then we've got Ustekinumab. That's a. So Etanercept is approved down to age 4, ustekinumab and the rest of the drugs I'm going to mention are approved down to H6 ustekinumab or steroid ustakinumab. I think we should take Ustekinumab.
- [03:56]
B
Who says Ustekinumab?
- [03:57]
C
Me.
- [03:59]
B
How about who says Ustekinumab?
- [04:03]
D
I probably switch it up.
- [04:05]
B
You do. You switch it up. Okay.
- [04:08]
A
I probably know how to pronounce in it for years. He called it Pruitus.
- [04:15]
D
Working on that.
- [04:18]
A
All right, so then we, so we got Stelara. We'll just say that that's easier. That's approved down to age six and it's given at week zero, week four and then every 12 weeks. So nice spacing outness compared to the weekly of Etanercept. Then we've got Ixekizumab, AKA Taults, also approved down to age six. It is week zero, week four, and then every four weeks going forward. It is based weight based dosing, as is Stelara. Second, Kitamab, also approved down to age six. It is weekly for the first month and then it goes to every four weeks. Also weight based dosing and then a premolast or Tesla, also approved down to age six and that's 20 milligrams twice a day. And then if they get there above 50 kilos, it goes to the normal adult dosing of 30 milligrams twice a day. So just a level set. Those are the agents that were approved as of the time of this review. However, we got a new agent approved that we are going to be talking about today. Gusalcomab or Tremphya. But before we get to that data, let's go on to Dr. Patton and Dr. Patton. What do you got?
- [05:35]
D
Yeah, so my deep dive paper was Biologics for the treatment of Pediatric Plaque Psoriasis. A Systematic review network meta analysis by Aliafon et al. And it was October 2025. JEADV NMA looked at over a thousand patients, seven randomized controlled trials, different efficacy safety measures. They did all the things that good NMA studies do. My favorite line on this NMA was the inconsistency was assessed via the inconsistency model. That was a good idea. Yeah, that's the best way to do it.
- [06:10]
A
So they consistently assessed the inconsistencies?
- [06:13]
D
I think so, yeah. The studied were etanercept, USTEC or ustecinumab, secumab, ixakizumab, Adalimumab, because this was in the eadd. And they also included methotrexate and fumaric acid exters, which really aren't biologics. But I guess they just wanted to make it a complete nma. As Matt said, Adalimumab, not FDA approved to treat pediatric plaque psoriasis, but it is approved by the ema. So if you spell pediatric with two A's, like a weirdo, you're allowed to treat kids with Adalim. Also, he was not included in the analysis, not yet approved in the EMA for kids. And it just got approved like last month, like about a month ago. It's a fresh, fresh approval. You can still smell it. So results, lots of tables and graphs and if you were after some sort of ranking, you could go to Table 2. One of the columns was probability of being the best, which I think Aaron drucker, like our DoD NMA expert would say is a little bit simplistic. But I am a simple man with simple tastes and a simple mind. So that was a table that worked for me. What did that table say this is again? Probability of being the best. I love.
- [07:32]
A
That. Might be my new favorite metric.
- [07:36]
D
It makes it so easy.
- [07:37]
B
I think we should rank residents like that too. Should do an nma. Probability of being the best resident. I'm going to think about that.
- [07:45]
C
Can we do probability of being the worst resident as well?
- [07:47]
B
Yeah, we'll have to do that.
- [07:49]
D
One's often easier.
- [07:50]
B
Yes. We won't ask Dr. Which one of us was the best resident, but you know who you're.
- [07:57]
C
You guys were all super strong.
- [08:01]
D
That's right. Super. Very political way of saying it. All right, so pazi 90. Secinomab, the high dose. There were. There were two. There was like a low dose and a high dose trial. Basically, the high dose was like 15300 as the weight doses. The other one was like 75, 150 and 300 or something along those lines. Best Pazi 100 with ixakizumab, best Pazi 75, ustic enumab, and the Children's Dermatology Life Quality Index of 0 to 1. The best or best most likely to be the best was you stick in your map. So if you look at the fours plots for, like, Pazi 90, they have four plots. For a lot of these measures, you would say that for the biologic medications, none is really statistically significantly better than any other based on the forest plots that this NMA generated. But, like, that doesn't make sense to me. You know, like, how could I be the best at getting pediatric patients to PASI 100 but not the best at getting them to 90? Um, and in adults, the Ixora S trial from, like 2019, it compared ICSI to usticumab head to head. And the percentages of patients that reach Pazi 75 at week 12 were 88 for ICSI and 68.7 for USTEC Enumab. Like, do we think that those results would be that different in pediatric patients? I just went to AI and I'm like, Pasi 90 for the trials for pediatric psoriasis, I think I said, like, week 12 or 16, and they just basically spit back. Like, ICSI had the best, followed by Secukinumab, which was pretty close. Then you stick any map, then Adalimumab, then any tanercept. And that was just taking, like, PASI 90 scores from the clinical trials. So, you know, NMAs continue to confuse me. It's supposed to be the most powerful tool that you use to analyze data and tell us, you know, how can we think about these drugs? And I just want to say, in this case, the nma, like, it just wasn't right. But what did you guys think?
- [10:01]
A
I can't wait to hear it.
- [10:02]
B
Yeah, like, pediatric psoriasis studies, I think, are tough because the N is so small. Right. So it's hard to get the power to see, you know, robust differences. That's my take on it.
- [10:18]
A
I can't wait to hear what Dr. Kress has to say as somebody who has probably treated 157,000 patients with each of these drugs.
- [10:29]
C
So, yeah, I did look over the articles you sent me, and I agree with Tim. It's hard to figure out how, you know, Ustakin can get more to pass the 75, but then, you know, it can get more to, you know, past the 100. I think what happens is, you know, the IL12, IL23 agent gets a lot of patience, pretty much better. It's almost like the dupy of psoriasis. Right. It gets a lot of patience to 75, but it kind of stalls there. Whereas if itzy or, you know, psychokinmab, it may get fewer people to 75, but if it gets them to 75, it can get them to 90 or 100.
- [11:02]
D
Okay.
- [11:03]
C
Right. Okay. I think in clinical practice, I have not seen a huge difference, to be honest.
- [11:09]
D
Okay.
- [11:10]
C
But I use them all. You know, it's the psychic. Kinnamab and Ustekinumab are all fda and you can.
- [11:16]
A
You can use brand names on here. We're not seeing.
- [11:18]
C
I wasn't sure. Okay. So, you know, stellaricosynthes and Tuls. You know, it kind of depends on what you get.
- [11:24]
A
When was the last.
- [11:26]
C
Yeah, go ahead.
- [11:27]
A
Well, wait, let's go. Farris, tell us about the new data. Tell us about the Guselkumab study and then we'll get into more of a general discussion about all of this.
- [11:37]
B
Okay. Guselkumab for the treatment of moderate to severe plaque psoriasis. And pediatric also spelled with an A patients results of a phase 3 randomized placebo controlled protostar study. And this is Prajapati et Al in BJD, also across the pond. Okay. This is a phase three study. Kids 6 to 17 years old, they were randomized to geselcumab or placebo. But then they could also go on to. There was an arm that was open label etanercept as a comparator. I never quite. I mean, I kind of get it, but basically, what does that mean? You cannot draw statistical conclusions between the etanercept arm and the gelcumab arm. But you're like. It's like a sniff test. Like, does that look good? Yeah. Okay, that seems like what I would expect.
- [12:27]
A
So inclusion worried that the.
- [12:29]
B
What's that?
- [12:30]
A
They worried the a Tanner sep was going to beat him. Like, what the heck you mean?
- [12:33]
B
Yeah, I don't know. I think powering it to be able to com to compare three different groups would have been hard, but they wanted to have sort of like I guess the most commonly used biologic in there. So, you know, I think when you have these smaller studies, you got to do kind of creative things versus a phase three adult study. Okay, inclusion criteria, it's what we think. BSA 10% PASI 12, IGA 3 plus. But because they're kids, they had to do something different. So they also had to have one or more of the following very thick lesions, clinically relevant facial, genital or and or hand, foot involvement, a PASI greater than or equal to 20, greater than 20% BSA or an IGA of 4. So basically what they were saying is moderate. Like they really wanted them to have a criteria that really kind of pushed you more toward the severe end of moderate to severe. Okay, double blinded. As I mentioned, weight based, so less than 70 kg, 1.3 mgs per kg greater than or equal to 70 kg. The adult dosing 100 mg on label etanercept was given. No comparisons made. Pazi of the group was around 18 at baseline. Very few of them had PSA. Their kids, I guess most had had previous systemic therapy or phototherapy. And they all had to be, you know, candidates for photo or systemic.
- [14:01]
A
And it was down to age six.
- [14:02]
B
Yep, down to age six. Okay, so primary endpoint was the 16 week data. So they were, there were, you know, smaller arms. Basically they were either in, they randomized either GE or 41 patients got cab 40, I'm sorry, 25 got placebo and then 26 got randomized to that open label reference arm of Etanercept. And you know, now that I think about it, maybe it also had something to do with like not being able to get blinded. Etanercept. I don't know. I'm making that up. I don't know. It's. I think it's the, that it. We powered it just to compare two groups. Okay, so what happened was aster 16 after week 16, everybody got sort of in, they got moved over. There was a decision point. So if they had a Pazi 90 then they were, you know, if, then the Gselkamab arm, then they would, they were withdrawal, they were taken off and then it was like a withdrawal retreat arm. Once they lost 50% of response, then they went back on selkimab. If you weren't at Pasi 90, stayed on casalkumab placebo. If you did not respond, if you didn't have a Pasi 90, then you got on Guselcumab if you did have a Pasi 90, then you got on gelcumab until you lost at least 50% of your initial response, which is kind of a weird way to look at it. And then etanercept patients could either decide to roll over and go on gelcumab or stop the study. There was also then a part two open label extension. 28 patients that just went on to open label gelcumab. Okay, so what did they see? At week 16, patients on Guselcumab did better than patients on placebo. So IGA 01, 66%, 16% in placebo, Pazi 75 rate, 76%. Pasi 90 rate was 56%. Pasi 100 was 34%. So you can kind of put that into context of your other NMAs. Right.
- [16:09]
A
So interesting that the IGA 0 and the Passy 100 are almost never the same number.
- [16:14]
B
Yes.
- [16:16]
A
Seems like they should be.
- [16:17]
B
Yeah, I know. I would like to meet the person who's like, that is an IGA 0 but a Pazi 99 or, you know, I don't know who does that, but to me they're the same. Okay. Patients who got open label etanercept actually had pretty high response rates. Their IGA 01 was 69%. I mean, it was sort of like the same as the, as the trumpaya group has. The 75 was 69%, a little bit lower. Pazi 90 was 54%. Pretty equivalent. They were actually better in adolescents than in children. Probably a little bit of the weight things, but so that they did note that's like higher than what they've seen in previous studies. So take that for what it's worth. Sometimes that happens. You're like, if you want your drug to look good, have another company do the trial with your drug. You know, so that was so 85% of patients randomized to open label etanercept. When given that choice of go off study or crossover, they did cross over and go on goselcumab. And then it when we look by week 20, they did have like slightly higher rates. So IGA 01 was then 6. Oh, no, it's about the same. 64%. P75 was 55% and P90 was 36%. So it actually went down to stayed the same.
- [17:43]
A
Sorry about that.
- [17:44]
B
Sorry about that. I. I said that wrong of that was the kids who crossed over. Those who did cross over, they did get better. They went up to like P90 of 91%, P75, 96% so far.
- [17:58]
A
I don't know the data at all for adult psoriasis drugs. Is this similar to the, you know, Gusulcomab in adults? Is it not as good? Is it better? Like, do you know, this is.
- [18:14]
B
I'd have to. This is actually slight. Well, no, this is about what I would expect. So Pazi1 it's not quite where. It depends what you look at. They're a little bit all over the board. So Pazi 100 rates for Geselcumab for Trumpya are a little better than 34%. For the oral IL23 inhibitor, it's about 40 pazi 100 about 60 pazi 90 and about 80 pazi 75. So these are kind of similar ish to maybe a little bit lower. But also realize the responses to Tremphaya are slightly higher than what you saw. I, you know, on the average Trump via patient than with the oral peptide. So they're, they're all in the same. Given the number, given the N, I would call it kind of similar. Okay, is that a confusing enough answer?
- [19:10]
A
Yes.
- [19:10]
B
Open label extension.
- [19:11]
A
Very good. Chair speak.
- [19:13]
B
Yes, exactly, exactly.
- [19:16]
C
The Enbrel, the Enbrel data in that trial is very generous. Those are the highest numbers I've ever seen. Forever.
- [19:25]
B
Yeah. Like, I remember when we were training with you, Dr. Kress, you were like a big Enbrel user, but like, so you've got lots of experience with it.
- [19:33]
C
That's all we have.
- [19:34]
B
That's all we had. Yeah.
- [19:35]
C
I mean, prior to the study, Laura just gave the best number I ever saw. Passy 75 for Enbrel was 59. At 16 weeks, this is a full 10 points better. So now whether they do trials a little bit differently in Europe and you know, you had already commented, you know, why is IGA0 not all PASCI 100? But yeah, I think that data is a little generous for.
- [19:59]
B
Yeah. So that now, you know, I don't.
- [20:02]
C
Use a tenorcept anymore in kids unless I have to.
- [20:05]
B
Right. So yeah. And then if you look at the open label extension of the 28 kids who went on at week 52, IGA 01 was 86% Pazi 90 of 82%. So that's kind of up there. That's like around where I would see adult numbers too. So, you know, so, you know, good safety data, nothing to like, talk about. Basically nasopharyngitis, uris, headaches, like every other study. And they did look for anti drug antibodies and 18% were positive for them, but they were low titers, of course, spelled a very British way.
- [20:43]
D
No.
- [20:43]
B
Anti drug antibody positive patients had neutralizing antibodies, and they didn't, like, correlate with the pharmacokinetics or clinical response or injection site reactions or anything. So not like a. No. Like kind of immunology signal or immune, you know, that would make you worry. So. Yes. Tremphya now approved in adults and children 6 years old and older who also weigh at least 40 kg, and it is approved for psoriasis and psoriatic arthritis.
- [21:16]
C
I.
- [21:16]
A
The thing I've got to say, from the whatchamacallit, the safety data, it was fat. So there were fewer people. There were fewer nasopharyngitis cases in the gselkumab group compared to the placebo group.
- [21:30]
B
Yeah.
- [21:30]
A
That's crazy. The drugs always cause nasopharyngitis.
- [21:34]
C
Come on, Matt, you had kids. Kids are snobby. They get stuff all the time. Like, Eric, when I see those numbers in pediatric trials, I'm like, okay, they had colds.
- [21:41]
D
Right?
- [21:41]
C
Like, let's move on.
- [21:43]
A
It's shocking that it wasn't 100. 100%. Maybe that was really how many? They weren't looking very hard.
- [21:50]
C
Yes.
- [21:50]
B
Right.
- [21:51]
A
All right, so we've been through the data now. So for any. For those of you who do not know Dr. Doug Kress, he is. When Patton Faris and I were residents, he was the primary dermatologist at the University of Pittsburgh. So take care of all the kids, all the adults, and all the inpatient consults, but he's primarily a pediatric dermatologist and has been taking care of pretty much nothing but kids for the last 20 years. Extremely busy, so sees an insane number of patients. You know, works closely with apps in order to get that done. Takes amazing care, but his breadth of clinical experience would be hard to. Hard to match. And, you know, he was at ground zero whenever Enbrail came out as the first biologic. So that's kind of the intro for Dr. Kress I'm going to put in.
- [22:48]
B
There now that I'm like, a chair. I appreciate this. He was also program director of our residency program. Like, you were like, the guy seeing every consult, every patient. You were also the program director. I mean. Yeah, now that I get, like, how much time that takes. Kudos to you. I can't believe you didn't kill us all. So thank you.
- [23:11]
C
I did, but. But I did get divorced one of those years.
- [23:16]
B
Other than that, it was great.
- [23:18]
C
And so, Matt, I appreciate the backhanded way of you telling everybody how old I am. Yeah, I was around when enbrel was launched in 1999, which is hard to believe. That drug's been out 26 years. Wow.
- [23:31]
A
All right.
- [23:32]
C
So crazy.
- [23:33]
A
Yes. So, Doug, let's. Let's start. So, you know, I'm sure that all of our listeners are very, you know, treat a lot of adult psoriasis. I'm sure a lot of them treat some pediatric psoriasis because it's, you know, it's not always easy to access a pediatric dermatologist, but so in your thumbnail sketch, what's the difference in a kid and an adult? Walk in, you go from room A to room B, they've got similar psoriasis, 15% BSA, whatever. How do you think about kids differently? Are you less likely to go to a systemic. In a kid, are you more likely? How's it work?
- [24:16]
C
A couple differences. First, for those who don't know me on the podcast, I'm pretty aggressive as pediatric dermatologists go, so I'm not less likely to go to a biologic if the kid needs it. I think just like our adult patients, you know, we want to maximize topical therapy that's reasonable. And we have some new options and peeds that I'll touch on. But, you know, I think once you have more than 10, 15% body surface area, you have to consider systemic therapy. Couple differences between kids and adults. One, we see a lot of facial psoriasis. Very common in kids. You know, we all see the scalp, but in kids, we often see it on the face, eyelids. So one of the things I'll do there, it's one of the new options we have is Zarif. Okay, Right. You know, we have Zaria approved now down to age 6. So I love that topically for the face.
- [25:00]
D
Okay.
- [25:00]
C
Remember, kids get a lot more inverse psoriasis. So we see armpits, we see kind of private area even when they're not in diapers. See less scale. You know, a lot of people think it's inner trigo, but, you know, don't be fooled again. You know, Zarev is a nice thing there, just because it's a sensitive area. And then we see a lot of gutate psoriasis in kids. Right. So you have to make sure they haven't had a strep throat. You want to kind of COVID for that. Otherwise, wait, go ahead.
- [25:25]
A
Question for you here. So I remember when I. Dr. J. So Patton and Ferris, I don't know if they ever even met Dr. J. He was the chair whenever I was a medical student at the University of Pittsburgh. He passed away Before I started residency. But I remember as a medical student, him talking about type 1 psoriasis and type 2 psoriasis. And it was like one of them started in childhood and had a positive family history and was much more recalcitrant to therapy. Is that, or do you, you know, if you get psoriasis as a kid, is, is it an indicator it's harder to treat?
- [25:58]
C
No, I think that may have passed with him. I think that was kind of his thing. You know, look, we see if you think about psoriasis patients, you know, what do you think is the incidence in the adult patient population? 2 to 3% in the US we live with that.
- [26:12]
D
Right.
- [26:12]
C
So there's some data different than what was in the articles you guys read today. But that suggests about 10% of that 2 to 3% present before the age of 10. Only 2% of that 2 to 3% before the age of 2.
- [26:26]
A
Okay, wow.
- [26:27]
C
Pretty uncommon under 10. So you know, as far as, you know, their progression, I mean, I think they do the same. And I heard you mention, you know, their kids, they don't have psoriatic arthritis. They do, actually. If you look at the data, they have the same incident of psoriatic arthritis that adults do. People just don't ask. You know, you all have kids. Were any of your kids ever told they had growing pains? I still told them. I always thought it was crap. Right. But you know, if you see somebody, a kid with psoriasis and growing pains, they probably have early psoriatic arthritis. And again, the rheumatologists are never going to call it that. I call it psoriatic arthropathy. But you know, we should get them on a biologic at that point. So.
- [27:07]
B
Yeah, and that was I switch over to study. They, it was a very low percent. But you're right, like how carefully were they screening them? Right, for the kids. Yeah.
- [27:18]
C
Right. You know, especially in the same adults, if you see a lot of nail pitting, you know, you really got to look for psoriatic arthropathy. Not going to find that on an X ray. But I do think you can alter these kids progression if you get them on a biologic early. Go ahead, Matt.
- [27:30]
A
So Doug, how many, by how many topicals will you try in a kid? So right there, there's, there's the kid who's, you know, 20, 30% BSA, who you're sort of going to go to a systemic kind of right away, but the kid who's, you know, 10, 15, 20%, who you couldn't treat adult who was 20% topically. But you could. A kid.
- [27:50]
C
Right.
- [27:51]
A
How. How many agents do you try before you.
- [27:54]
C
I mean, I'll probably do two or three. I might give them Triumph center alone and Davinex, you know, the first time I see them. And if they're not better, you know, I might go to Clobatasol, but, you know, I'm not going to keep screwing around at that point.
- [28:04]
D
Okay.
- [28:05]
C
And then I'll try to go to a biologic if I can. You know, until Trump Fire came out, I did prefer Stellar. Just because it was the fewer shots.
- [28:12]
A
Yeah.
- [28:12]
C
For kids. Even though just like an adult, Stellar loses some efficacy. About 10 weeks.
- [28:17]
D
Okay.
- [28:17]
C
But, you know, in our market, which Tim knows. Well, you know, you guys abandoned us here in Pittsburgh, but, you know, we have such mean managed care. I often don't get to choose what agent I want to give.
- [28:27]
D
Yeah, I was going to say there are. So I think you stuck in your map. It's up to like six, maybe five biosimilars. Do you see that as pretty much driving what they're going to let you do?
- [28:40]
C
Because, in fact, that just happened today. I had a kid in that I've had on Stellar for years, doing great, and they said we had to switch. But I have to tell you, I have had many fewer issues with Stellara biosimilars. Although it's newer, I've had terrible issues with Remicade biosimilars and Humira biosimilars in my Crohn's psoriasis overlap patient population. I don't know if you guys want to go there, but I have had a lot of issues with Humira and Remicade biosimilars, but not yet. Stellar, huh?
- [29:09]
B
Interesting.
- [29:10]
A
That's interesting.
- [29:11]
B
Yeah. The Humira world is tough because there's so many of them, Right?
- [29:18]
C
Yeah, they're.
- [29:18]
B
Yeah. Okay.
- [29:20]
C
It's nuts. And then now we're hearing that, you know, certain insurances only cover certain biosimilars.
- [29:27]
B
Yes, we've had that happen.
- [29:28]
C
I'm getting that a lot. Yeah.
- [29:29]
B
And then they'll say, you have to use this one, and then you'll prescribe it. And they're like, that's not available anymore. I'm like, okay, well, I guess you're stuck because that's what you got to use, and if you don't, we're not going to approve it. Yeah, this is.
- [29:43]
C
But I mean, I'm super excited about the data. You know, it's new. I don't know if we can get it, but I love the idea of the 23 in kids. And, you know, did the pill get approved to 12? It did, right? The 23.
- [29:56]
B
It's not approved yet. It is in trials. In pediatric trials. Yeah. So that'll be, that'll be even. So I'm curious your question. So every time I talk to. Or your answer, I talk to industry, they're like, what do you think? What are you going to do when you got a pill and you've got a shot that's both, you know, inhibit the aisle 23 pathway? And I'm like, I don't know, like, people can choose. And I was, I mean, you know, I'm like, some people would be like, I would way rather take a shot every three months than take a pill every day. You know, some kids aren't good at swat. Like, what do you think parents and kids want? Do you think they want a pill more than.
- [30:32]
C
So look, the. The counter to that theory is a Tesla. Yeah, right. I mean, o. Tesla's not the best drug we have for psoriasis, and it does $3 billion a year.
- [30:44]
A
Yeah, but that, that's because it's so safe. It's. Right, it's. It's poorly tolerated, but it's so you don't have to talk to people about immunosuppression or anything else.
- [30:53]
C
How safe is the oral aisle 23 going to be, Laura?
- [30:56]
B
I think it's going to be awfully safe. I mean, the data look very good.
- [31:00]
C
And yeah, I mean, if I could get a safe oral, I would so much rather. You know, you guys haven't been in my office in a long time. The most common sound you hear in my office is screaming of kids who are getting.
- [31:14]
B
So now it's the kill. Okay.
- [31:18]
C
The families aren't comfortable to do it. Right. Even if it's a couple times a year. You know, poor Dr. Patton shares an office with another pediatric dermatologist, and every now and then one of her patient comes in to get a shot and poor Dr. Patton has to hear the screaming.
- [31:33]
B
Yeah. Okay, so. So it really, it is real. And with kids, that is going to be a big deal to be able to have a pill. And especially if we get a pill with no labs, which is, I think, one of the most appealing things about otesla.
- [31:48]
C
I mean, I had two kids in today clear on dupy, and the parents are like, we need to stop because.
- [31:54]
B
They just don't want to do the shot anymore.
- [31:56]
C
The anxiety, it's so stressful. The kids were bawling when they Came into my office today thinking they were going to get a shot, even though they didn't because we stopped.
- [32:06]
D
Wow. Yeah.
- [32:07]
C
Wow. So I think for kids, I think a pill is always going to be better if you don't have to do labs.
- [32:13]
B
Right?
- [32:14]
C
So labs, what's the difference?
- [32:17]
A
You've been doing this long enough now that I'm sure you've got plenty of kids who started, you know, especially with the psoriasis drugs. You know, that's been five, ten years they've been on shots now. Do you think it scars any of them long term where they're like, medic, you know, medical anxiety for the rest of their life because of the, you know, terror of the shots?
- [32:40]
C
I don't. The ones that have true needle phobia. And true needle phobia, that's a thing. I mean, that is a real serious thing. And some adults have it too, right? Yeah. So, you know, the kids that truly have needle phobia can't stay on the biologics. We try and they just can't. And then we have to do topicals. And look, now we have a lot of new topical choices, Right. More for AD than psoriasis. But it's, you know, unbelievable what we can offer these kids now.
- [33:05]
A
So in, in recent years, since Tulce and Cosentyx got approved for psoriasis, if we take insurance out of the picture and just say you could pick, you know, Talts, Cosentics, Stelara, just. And I know it is going to. You're going to offer all of them to the patients and blah, blah, blah, blah, blah. What, you know, how did you. Or how do you kind of present them to patients? How do you differentiate?
- [33:37]
C
That's easy. So I tell them they're four, right? And Brell approved to age four. Been out the longest for sure. The safest, least effective shot once a week. And then cosentics and Talts, which I think are similar. I like tilts a little bit better because I think the dosing is a little bit easier now that they have the pediatric formulation. And I think it's a little quicker, just my personal experience, but I think they're similar. And then Stellara, which I think has good data. And, you know, basically after the two loads, you know, it's four shots a year. So I usually nudge people to do that just because I think it's the easiest and best for kids. And I do think the data is a little bit better than what you guys presented. I've seen some other data that I thought was A little better. But, you know, then I. I try to get what the parents and I decide on, but that's not always what we get. Yeah, right. I don't know if this happened to you guys. I routinely have had patients on Tulsa Cosentics and a year in the insurance tells me I have to switch to the other one. Yeah. Which I do. I mean, that's not a big deal. Yeah. But, you know, I think Trump fire is probably what I'll go to. I just have no idea if I'll be able to get it. First line.
- [34:46]
B
Yeah, I like the aisle 23 pathway state. You know, safety. So inconvenience.
- [34:52]
D
How. How much worried are you about the IBD signal that. Do they still. They have that signal with these 17s? Do you see parents saying, what about this IBD? How come these guys, this group has that and the other ones don't?
- [35:08]
C
Yeah, I thought that was interesting and I thought that percentage they quoted was higher than. Made me super happy, actually. And it was in one of the three articles. Look, I think that's probably one of the reasons that I pursue the stellar if I can get it. Okay. You know, I work pretty closely with the PGI group. As you can imagine, there's a tremendous amount of overlap between, you know, psoriasis and Crohn's and hs. You know, they don't seem hugely worried. You know, they don't tell me I can't put these kids on aisle seven teenagers if I need. And knock wood. I mean, I haven't seen a case that I can think that happened to me. And like Matt said, I see a lot of these patients, but, you know, it's in the back of my mind.
- [35:46]
B
Doug, I'm going to ask you a question that always comes up when I talk about biologics and this is more relevant to kids. What do you do about vaccines? Give your. Everyone's going to want to know what do you do about vaccines? Because kids need them.
- [35:59]
C
Right. So that is the one downside of Stelera. Right. Because it's in for a long time. So first thing you want to do is get everybody cut off on vaccines before you start a biologic, if you can. Right. And often you can do that. Like, you know, you're going to get ready to start a biologic. Non live vaccines. Right. Not an issue. And live vaccines are only a theoretic issue. Right. So what I do like, let's say you're going to give for Tulsa Cosette. Right. You're giving it monthly. So they take their Shot now they're due their next shot. You don't give it. Basically it's out of their system because they'd be due their next shot. You don't give it, you give them their vaccine. And if you think about immunoglobulin class switching from IgM to IgG, it generally takes about two weeks. So theoretically, you could start back up two weeks later. If not, you could start back up a month later. But for monthly drugs, I just skip one shot and get them vaccinated on that time the shot would be due.
- [37:04]
A
So what I tell people with doopie, so let's go to a different drug.
- [37:08]
C
This is a different conversation. Go ahead.
- [37:11]
A
So I tell people with doopie to not skip any doses because I've seen enough kids who you skip one dose and their eczema flares and now they're at risk for a staph infection. You know, just because AD is so much faster of a, of a disease. Is that what. Do you skip doopie doses or do you.
- [37:32]
C
For doopie, I do it a little bit different. So again, if it's a non live vaccine, if it doesn't matter among friends, if it's a live vaccine, we have data that shows for Dupy it doesn't matter anyway. Right. But medical legally, Matt, the rest of us have to tell people they need to stop or shot. I know you don't, but medico legally the rest of us, but. So for doopie, if they're Q2 week doopie. Right. I skip one shot. Right. Then a month in, given the vaccine. So again, it's a month later and then two weeks later stop. So they're really only off, you know, about four to six weeks. And I would manage with topicals in the midst because the pediatricians that I work with, you know, they read package inserts. They're just not going to give the vaccine if the kid's on dupy, even if I talk to him. So I do take very short breaks from dupy if they're, you know, the younger kids are who get most vaccines obviously. And Doopie six and under is monthly anyway. So they just take their shot a month later, get their vaccine a month later, start back up. If you call the company, they tell you to stop dupy for three months, get the vaccine and then take a shot three months later. Which is absurd scientifically, but that's what the lawyers want on so. But again, there was a huge study in Brazil. Live vaccine, Doopy, everybody did fine.
- [38:46]
A
Yep. You know, yellow fever vaccine, you know.
- [38:51]
C
Even if we talk about, you know, Trumpy in six year olds. What immunologically does Trumpya do that's going to keep you from mounting an appropriate antibody response to a vaccine? Yeah, nothing. It's just class labeling.
- [39:04]
A
So yeah, it's frustrating that it is. In just the absence of data, the assumption is risk. When there is risk to stopping these drugs. Right. There's not.
- [39:14]
C
Not a ton then only skipping a shot. I haven't found any trouble really, either with DUPY or the biologics. Yeah, Stellar is trickier. That's tougher.
- [39:24]
A
How long will you give people off with Stellara if you do it, you.
- [39:27]
C
Know, if you think about Q, three months. You'd have to have them take a shot and then wait three months, get a vaccine and then take the next shot a month later.
- [39:35]
A
Yeah, yeah, yeah, yeah. All right, Pat and Ferris, you got anything else you want to ask Doug while we've got him on here?
- [39:44]
D
Oh, conventional therapies. Methotrexate. I mean, do you have to use those at all anymore? Is it easier in kids? Even in.
- [39:53]
C
There are still some insurance companies that require a three month failure of methotrexate. We have a few. I hope other areas of the country don't, but we still have a few. And look, it's not that methotrexate doesn't work. Yeah. You know, like I have kids that I have to put on methotrexate for alopecia areata before I can get them on litful O. It works, you know, not well. And nobody wants a kid on methotrexate. Right, Right. But yeah, I still have kids on methotrexate for both alopecia and psoriasis. I almost never have to do it anymore for eczema. I mean, it's because there's so many options of 12. Yeah, but I still have some Thor addicts on methotrex.
- [40:28]
A
Especially if they're kids like Patton who start drinking at age 9. You really got to worry about that liver toxicity at that age.
- [40:36]
D
Nine in the morning is what you.
- [40:40]
C
Since we've known each other a long time, I seem to remember I was somewhere where one of Matt's children was young enough that he was holding him like this and having him taste the beer. So I'd be careful, Matt. I got a long memory.
- [40:56]
B
Yeah.
- [40:56]
C
God knows how old that kid is now. Probably in college.
- [40:59]
A
Oh, yeah. Margaret is now a senior at the University of Virginia.
- [41:03]
C
Yeah, that's what I figured.
- [41:05]
A
Yeah. President of her sorority applying for a Fulbright scholarship.
- [41:08]
C
She's oh, my God.
- [41:10]
A
Yeah, she's doing good.
- [41:11]
B
Start them early. That's the lesson there.
- [41:15]
C
Yeah.
- [41:15]
A
All right, so let's move on to our everybody's favorite segment, our trivia segment. So. So Doug, here's how it works.
- [41:21]
C
Okay.
- [41:22]
A
Patton is going to read a question. You have to let him finish reading it, but then as soon as he finishes reading it, you shout out, you know, whatever your best guess is. Whoever shouts out the answer first is the way you know, gets it. We typically do three questions.
- [41:39]
C
Okay.
- [41:40]
D
All right, Pat. And it's all, all pediatric stuff, keeping with the. The theme. Okay. In 1948, Sophie Spitz described 13 cases of juvenile melanoma in patients that ranged in age from 18 months to 12 years. How many of these 13 patients died from their melanoma? One.
- [42:01]
C
70.
- [42:04]
D
Somebody said one. It was one.
- [42:07]
C
It was one.
- [42:08]
D
Yeah. One of the patients died. 12 year old girl. She still brought up the fact that this was a very low percentage. It was like 7%. She compared it to a group of patients from like 13 to 18 and was like it was 70%. And so she's kind of like, there's something about these mel. These things that we call melanomas in very, very young kids where they're just not the same thing. But it was like a seminal landmark.
- [42:33]
B
That was back in the day. If you lost 1 out of 12 kids, you're like, that's, that's fine.
- [42:37]
A
Yes.
- [42:38]
C
Yeah, yeah. For the farm.
- [42:41]
A
What do you, what do you do with 48?
- [42:43]
D
Right? What's that?
- [42:45]
A
I was asking Doug, what do you do with Spitz Nevi these days? If full.
- [42:50]
C
I mean, if they're not doing anything, we just watch them. You know, we monitor photographically. If we cut them out and they're at all atypical, we re. Excise.
- [42:57]
D
Okay.
- [42:58]
C
But we see a lot of, you know, Spits and Evi that are stable.
- [43:01]
A
Yep.
- [43:02]
D
That would drive me crazy.
- [43:04]
B
All right.
- [43:05]
D
All right. Number two. Erythema infectiosum is also known as fifth disease. It was so named because it was listed as the fifth disease in a list of rash causing illnesses. What was first disease?
- [43:17]
B
Measles.
- [43:17]
A
Measles.
- [43:19]
C
Rosiola.
- [43:20]
D
It was measles. Rosiola.
- [43:23]
C
Was that fourth? Third.
- [43:26]
D
No. You know what fourth was? Dukes, which. They're like that. That was probably just the misclassification. I think Roliola is. Is six or six. Rubiola was third. Second was scarlet fever.
- [43:39]
C
I usually have residents with you to answer these questions.
- [43:43]
B
We're all grown up now.
- [43:45]
D
You gotta get on your own Last one. It's a little bit wordy. All right, so we talked about biologics for psoriasis. I think they've revolutionized the treatment for both pediatric and adults patients. But another revolutionary pediatric derm therapy, at least in our time, was using propranolol for the treatment of congenital hemangiomas. The widespread adoption of this treatment followed a case series published in the New England Journal of Medicine in what year?
- [44:15]
A
2006.
- [44:17]
B
I'm going to go with 2000.
- [44:22]
C
No, I'm gonna give us 2005.
- [44:25]
D
It was 2008.
- [44:27]
B
Wow.
- [44:28]
D
Yeah. It was like a letter to the editor of, hey, we treated 11 kids. I think this is like, the new treatment. And it.
- [44:36]
C
Yeah, it was out of the NICU in Paris.
- [44:39]
D
Yeah, right.
- [44:40]
B
I can remember starting to do that as a resident.
- [44:45]
D
Yeah, during. Right. When we started.
- [44:47]
B
That was during our residency. Okay.
- [44:51]
A
Doug, do you use my topical Timolol at this point?
- [44:54]
C
I do. I love topical Timolol. If you catch them early, especially on the face or under the diaper, do you use. It works fine.
- [45:00]
A
Do you use it for pygenic granulomas?
- [45:02]
C
I do.
- [45:03]
A
How else it works for those?
- [45:05]
C
I think it doesn't work as well, but it can save. You know, I see a lot of autistic kids, you know, who. Facial surgery is going to be really difficult. You know, I try the timolol. I think it works more often than it does.
- [45:18]
A
Okay. Okay.
- [45:19]
B
We just had a paper the other day about Timolol for hand fissures and for fissured skin and hand dermatitis. Right?
- [45:27]
C
Yep. Yeah, yeah.
- [45:29]
A
It was from, like, 2021. It was a single case report. Somebody's doing an actual study on it now. Doesn't work for, like, hand eczema in general, but for the fissures like you get on your fingertip or something, it actually can help accelerate the healing. They came up with this idea because there's some data showing that Timolol helps with poorly healing wounds. So lower extremity wounds, they'll use Timolol along the edges, and it does seem to help. And Doug, just. This is for our listeners. Next on next week's episode. I'll be covering this, but there was also just an article about using Timolol for spider angiomas in kids.
- [46:10]
C
Yeah.
- [46:10]
A
So it. It was not terror. It's not terribly effective, but it's something.
- [46:16]
C
That one, I haven't tried. Most of my patients don't seem terribly bothered by those.
- [46:21]
A
Yeah, yeah.
- [46:22]
C
I'm not surprised. It works for some.
- [46:24]
A
Yeah.
- [46:24]
C
Yep.
- [46:25]
A
Made some sense. What?
- [46:26]
D
Doug? It was.
- [46:28]
A
What's that? Yeah. Don't know.
- [46:29]
C
Why?
- [46:30]
A
Yes. No idea why.
- [46:31]
C
I mean, I think it's correcting an imbalance in the humors. You guys remember the humors?
- [46:35]
D
We do. Yeah.
- [46:37]
A
Well, Doug, thanks for coming on. It was great having you on and great having this conversation about pediatric psoriasis. For all of our listeners, thanks for joining us this week. I hope you learned a few things. Hope you laughed once or twice. And mostly, we're hoping you're planning to join us next week. Until then, I'm Matt Zyrus.
- [46:54]
D
I'm Tim Patton.
- [46:55]
B
And I'm Laura Farris. And we are Derms on Drug.