Podcast Summary: Derms on Drugs

Episode: "Rashes, Pre-cancers, and Cancers – we've got the answers!"

Date: October 3, 2025
Hosts: Dr. Matt Zirwas (A), Dr. Laura Ferris (B), Dr. Tim Patton (C)

Overview

This energetic episode features the dermatology trio—Drs. Matt Zirwas, Laura Ferris, and Tim Patton—discussing noteworthy recent studies and clinical pearls on rare skin cancers, supplements, eczema therapies, seborrheic dermatitis, actinic cheilitis, and the evolving science on the skin microbiome in atopic dermatitis. True to the podcast’s promise, the group injects banter and candid opinions, making for an informative yet entertaining session.

Key Discussion Points and Insights

1. Merkel Cell Carcinoma Surveillance with Antibody Titers

[01:10 - 12:35]

• Study: Gunnell et al., JAMA Dermatology (Paul Nghiem’s Seattle group): Long-term surveillance data using Merkel cell polyomavirus (MCPyV) oncoprotein antibody titers (AMERK test).
• Core findings:
  • About 80% of Merkel cell carcinoma (MCC) patients harbor the polyomavirus.
  • Antibody presence = better recurrence-free survival at baseline ([05:52]); ideal is to have a positive but low titer.
  • Falling or negative titers: Strongly predictive (>99% NPV at 3 months) of recurrence-free status ([06:22]).
  • Rising titers: Signal substantially increased recurrence risk (up to 68% in 2 years, HR ≈50:1) and predate clinical/imaging recurrence by ~4 months ([06:22, 09:04]).
  • Circulating tumor DNA (ctDNA): Even more ominous if detectable—27-fold increased recurrence risk ([08:46]).
• Clinical Takeaways:
  • Monitoring titers can spare patients unnecessary scans if falling/negative; crucial to draw baseline within 3 months of diagnosis ([11:10]).
  • Sentinel lymph node biopsy is essential ("If you remember nothing else, remember that" – Ferris, [12:05]).
  • MOHS not first-line unless multidisciplinary; always consider surgical oncology.
• Quote:
  • “If your titer is falling and you go to a negative titer, you could potentially avoid getting…CT or PET/CT scans.” (Ferris, [06:22])

2. Does Collagen Supplementation Work?

[12:36 - 19:47]

• Meta-analysis: Myung & Park, Am J Med, Sept 2025—RCTs of collagen supplements for aging skin.
• Findings:
  • Collagen improves hydration, elasticity, and wrinkles—but only in industry-sponsored and low-quality studies ([15:04, 15:47]).
  • Fish collagen in drinks best (not pills/powders), per sub-analysis ([15:09]).
  • Non-industry, high-quality studies: No benefit ([15:47]).
• Hosts’ reactions:
  • Widespread skepticism (“I am telling my patients collagen supplements are very likely a waste of money.” – Patton, [15:47]).
  • Still, minimal downside if patients insist, and price is key; suggest cheapest options ([19:18]).
• Quotes:
  • “If the study was a high quality study, it did not show any benefits.” (Patton, [15:47])
  • “Go with the cheapest.” (Patton, [19:42])

3. New Therapies for Chronic Hand Eczema: Ruxolitinib and Delgocitinib

[19:48 - 30:57]

• Study: Ruxolitinib cream (Opzelura) vs. placebo for moderate-severe chronic hand eczema—excluded classic atopic dermatitis ([21:01]).
  • 53% IGA success rate vs. 11% placebo ([24:44]).
• Delgocitinib (Zupco/Enzupgo): Lower raw % in its trial, but strict endpoint and different population—“truly can’t compare” ([27:57]).
• Key insights:
  • “Chronic hand eczema” = often AD + irritant contact component ([22:24]).
  • Steroids can worsen barrier—JAK inhibitors likely avoid this ([24:57]).
  • No reason to chase multiple indications for drugs with overlapping domains; treat by best access ([26:54, 28:06]).
• Quotes:
  • “Topical steroids make irritant contact derm worse…Opzelura and Zupco don’t have that adverse effect on the barrier.” (Zirwas, [24:57])
  • “Both work…It ought to be which one’s easier to get.” (Zirwas, [27:57])

4. Oral Isotretinoin for Seborrheic Dermatitis

[31:24 - 36:19]

• Study: Demirbas et al., JAD (Turkey)—retrospective, 10 vs. 20mg daily dosing, 3–4.5 months.
• Findings:
  • 20mg dose = better control, higher patient satisfaction, less recurrence at 1 year ([33:31]).
  • More adverse effects with 20mg (notably myalgia, nosebleeds), though dry lips/skin higher in 10mg ([34:00]).
  • Benefits largely while on drug; recurrence is common after stopping ([35:06]).
• Bonus Clinical Pearl: Isotretinoin effective for sebaceous hyperplasia—higher dose, short course yields long-term benefit ([36:04]).

5. Best Treatments for Actinic Cheilitis

[36:22 - 43:04]

• Meta-analysis: Al Fartsi et al., Biomedicines, Aug 2025.
• High-efficacy options: CO₂ laser & imiquimod show best clearance and recurrence rates ([38:12]).
• Practical challenges: CO₂ laser rarely available; imiquimod regimens often too harsh, causing severe reactions ([39:26, 40:07]).
• Host practical approach: Use cautious, slow-start regimens if needed; cryotherapy for tolerability (Patton's real-world experience, [41:11]).
• Quotes:
  • “If you use field therapy on the lip, it is an absolute disaster…absolute disaster.” (Patton, [39:26])
  • On practical management: “It’s so tailored and individual with actinic cheilitis.” (Ferris, [42:35])

6. Imiquimod for Lentigo Maligna & Other Quick Studies

[43:10 - 47:43]

• Imiquimod vs. Radiation for Lentigo Maligna: Imiquimod 5% (up to 5 days/week for 12 weeks) gives ~92% success, especially for nonsurgical candidates—frequency titrated by patient tolerance ([43:10]).
• Discussion: Options must be individualized, balancing surgery, radiation, or topical approaches based on patient health/goals ([44:28]).
• Other brief updates:
  • Apremilast showed modest benefit for central centrifugal cicatricial alopecia ([47:07]).
  • Ongoing advocacy for oral roflumilast: “$6 a month on Mark Cuban’s Cost Plus Pharmacy...works just as well as apremilast” (Zirwas, [47:43]).

7. Skin Microbiome & Atopic Dermatitis Targeted Therapies

[48:18 - 53:39]

• Study: JID commentary—comparison of JAK inhibitors, IL-13 pathway biologics, cyclosporine, and steroids on skin flora ([48:18]).
  • Dupilumab (Doopie) and JAK inhibitors improved skin microbiome (esp. staph reduction); cyclosporine & steroids did not ([48:18]).
• Quorum sensing: Once staph density is high, bacteria coordinate and trigger more aggressive pathogenicity ([50:27]).
• Clinical recommendation: For AD patients with recurrent infections, IL-13 pathway agents might offer special advantage ([50:41]).
• Quotes:
  • “Getting rid of the staph isn’t just because the disease got better—the drug does matter.” (Zirwas, [50:41])
  • “IL-13 inhibition...helps to get rid of staph.” (Zirwas, [50:41])

Notable Quotes & Memorable Moments

• Merkel cell antibody test:
  “If you remember nothing else, remember that [sentinel lymph node biopsy]” (Ferris, [12:05])
• Collagen supplements skepticism:
  “Pills and powders, not effective. You need to take collagen drinks...like fish collagen soda...disgusting.” (Patton, [15:09])
• Hand eczema drug choice:
  “Both [JAK inhibitors] work...should be which one’s easier to get...” (Zirwas, [27:57])
• Actinic cheilitis field therapy:
  “If you use field therapy on the lip, it is an absolute disaster.” (Patton, [39:26])
• Microbiome insight:
  “Quorum sensing: Once there’s enough of us, let’s go wild.” (Zirwas, [50:27])
• Podcast culture:
  “There’s a History of Rome podcast....I listened to the whole thing and then started it over.” (Patton, [51:17])

Timestamps for Key Segments

• [01:10] Merkel cell carcinoma antibody titers and surveillance
• [12:36] Collagen supplementation and industry bias
• [19:48] New hand eczema therapies: Ruxolitinib & Delgocitinib
• [31:24] Oral isotretinoin for seborrheic dermatitis
• [36:22] Actinic cheilitis best treatments
• [43:10] Imiquimod for lentigo maligna; minor studies round-up
• [48:18] Microbiome and atopic dermatitis targeted therapies
• [52:54] Clinical “itch” pathways and effect of different agents

Tone and Conclusion

The hosts deliver a fast-paced, insightful review of “six pack” new studies in dermatology, blending clinical pearls with dry humor and friendly jabs. Key takeaways: evidence must always be scrutinized for bias, the best drugs are often the easiest to access, and practical management beats perfection in complex real-world patients.

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Next episode drops Friday!