Podcast Summary: Derms on Drugs – Busting Dermatology Myths & Making Life Easier for Derms

Episode Title: The Derms on Drugs Bust Myths and Make Life Easier for Derms This Week
Date: February 20, 2026
Hosts: Dr. Matt Zirwas (A), Dr. Laura Ferris (B), Dr. Tim Patton (C)

Episode Overview

This "six-pack" episode features Drs. Zirwas, Ferris, and Patton diving into recent dermatology literature and guidelines, notably challenging common myths and outdated practices in biologic monitoring, chemo-prevention for skin cancer, new data on medication side effects, and cutting-edge treatments in chronic urticaria and atopic dermatitis. Throughout, the trio maintains their trademark blend of clinical acumen, skepticism, and banter—making complicated topics both accessible and engaging.

Key Discussion Points & Insights

1. Rethinking TB Testing for IL-17 & IL-23 Inhibitors

[01:07–16:42]

• Papers Discussed:
  • IPC & NPF Joint Position Statement (JAD): Routine TB testing not required for psoriasis patients on IL-17 or IL-23 inhibitors.
  • Feldman et al. Guideline Paper: Echoes de-escalation of routine lab monitoring.
• Key Takeaways:
  • TNF inhibitors disrupt granulomas, hence the original rationale for TB screening (B, 02:01–02:41).
  • "All biologics are not the same"—preclinical, clinical, and real-world data suggest virtually no TB reactivation risk with IL-17/23s (B, 04:19–10:18).
  • FARES database: 0 disseminated TB cases in ~96,000 IL-17/23 safety reports vs. 26 (8 disseminated) in ~140,000 TNF reports (B, 09:00).
  • False positives for TB carry risk: unnecessary treatment, hepatotoxicity, and misdiagnosis (B, 09:52).
  • Practical impact: Routine TB screening for these newer agents should be reconsidered, except in endemic regions or with co-immunosuppression (B, 09:49).
  • European consensus is aligned—screen if high risk, otherwise stop habitual annual TB testing for these agents (B, 13:46).
• Memorable Quote:
  • "Routine testing for latent TB infection is not required prior to or during treatment of psoriasis patients with IL-17 or IL-23 inhibitors, period." —Laura Ferris, summarizing consensus statement [09:33]
• Insurance Headaches:
  • Insurance often mandates unnecessary labs, likely as a tactic to delay costly prescriptions (A/B/C, 12:20–13:33).

2. Nicotinamide for Skin Cancer Prevention: Jury Still Out

[17:00–23:19]

• Paper:
  • Tan et al., Am J Clin Derm (2026): Challenges the presumed benefit of nicotinamide.
• Key Insights:
  • The large VA study was observational; unmeasured confounders and outcome mismeasurement undermine reliability (C, 19:04–21:14).
  • Previous skepticism is echoed; no move to make nicotinamide standard of care just yet (C, 21:14).
  • Most panelists recommend presenting it as an option, not a mandate (C, 22:49).
• Memorable Exchange:
  • "Nicotinamide prevents skin cancer. Like, seems too good to be true. It's cheap. It's...right?" —Tim Patton [17:46]
  • "It's easy to just be like, here you go...but I don't think I've seen a randomized trial that counseling people about sun exposure reduces mortality from skin cancer." —Matt Zirwas [21:39]

3. Topical Steroids: New Data on GI Side Effects

[23:22–29:38]

• Study:
  • Taiwanese national database: Topical corticosteroid use may increase GI ulcer risk.
• Key Points:
  • Odds ratio 1.78 (70% increased relative risk), but absolute risk modest: from 1/1000 to 1/600 annually (A, 24:31).
  • Risk rises synergistically with NSAIDs and aspirin (A, 25:25).
  • Observational/association only, not causality (B, 26:30).
  • Overuse signals more about uncontrolled disease than ulcer risk (C, 28:55).
• Notable Quote:
  • "We now have data that topical steroid use is...associated with increased risk of stomach ulcers, but is this going to change my practice? Not really." —Matt Zirwas [25:14]

4. Switching Dupilumab to Upadacitinib in Atopic Dermatitis

[29:44–31:43]

• Takeaway:
  • If Dupilumab is ineffective, switching to Upadacitinib yields response rates similar to Upadacitinib in biologic-naïve patients (~80% to EASI-75 by week 32).
  • Study fails to answer "Will I be worse off after switching?"—a critical patient question (A, 30:25).
• Quote:
  • "The question that Abbvie needed to answer, that they didn't: how many people did at least as well on Rinvoq as they did on Dupixent?" —Matt Zirwas [31:26]

5. Remibrutinib for Chronic Spontaneous Urticaria: 52-Week Data

[31:50–39:00]

• Findings:
  • Oral BTK inhibitor, Remibrutinib, maintains efficacy and safety to one year in CSU.
  • 63% achieved well-controlled disease; 45% were itch-and-hive free at week 52 (B, 36:19).
  • No new safety signals; petechiae (mild, cosmetic) in 4%—main AE (B, 37:55).
• Mechanistic Note:
  • Petechiae may reflect transient capillary/vascular stability due to mast cell silencing, not direct coagulation inhibition (A, 47:14).

6. A Premolast in BP Overlap with Psoriasis & Broader Implications

[39:48–46:50]

• Key Messages:
  • Overlap of BP & psoriasis is not rare; treatment options are limited by adverse reaction profiles (C, 40:13).
  • Case report of successful a premolast use for both conditions—raises prospect of using cheap oral PDE4 inhibitors (oral roflumilast) more broadly (C, 41:26+).
  • Access/cost: Mark Cuban's Cost Plus Pharmacy offers oral roflumilast for $5/month (A, 45:13).
  • Issues with insurance and pharmacists refusing cash/GoodRx to maximize reimbursement (B, 46:01).
• Funny Aside:
  • "Having 80-year-old patients figure out Mark Cuban, that I think is a legitimate challenge." —Tim Patton [45:29]

7. So TIK2 Efficacy in Atopic Dermatitis – Ignore the Skeptics

[48:30–51:29]

• Details:
  • TIK2 inhibition (ICPI-332) shows rapid, significant improvement in atopic dermatitis—contrary to earlier scientific beliefs (A, 48:30).
  • Lesson: Basic scientists can underestimate therapeutic potential; real-world drug trials are essential (A, 50:40).
• Quote:
  • "You don't know if a drug works in a disease until you have a drug that affects that pathway." —Matt Zirwas [50:29]

Timestamped Memorable Moments and Banter

• On TB Testing Myths Debunked:
  "The day I can teach you something is a happy day in my life." —Laura Ferris [04:11]
• On Study Evidence:
  "I find it so easy to just hand out supplements...Have I seen a randomized double blind, placebo-controlled trial that counseling people about sun exposure reduces mortality? I don't think I have." —Matt Zirwas [21:39]
• On Football Coaching:
  "You can only be as good as the material you were given to work with." —Laura Ferris, on Pittsburgh’s longtime coach departing [54:42]
• Unique Paper Critiques:
  "This is my kind of paper—just making it up. Speculation, I know." —Matt Zirwas on mechanistic hypotheses about Remibrutinib’s petechiae [48:26]
• On Mark Cuban’s Pharmacy and 80-Year-Olds:
  "Having 80-year-old patients figure out Mark Cuban, that I think is a legitimate challenge." —Tim Patton [45:29]

Segment Timestamps (Highlights Only)

• 0:00–01:07 – Show intro, setting up the episode
• 01:07–16:42 – Mythbusting TB testing for biologics
• 17:00–23:19 – Nicotinamide & skin cancer prevention skepticism
• 23:22–29:38 – Topical corticosteroids & GI ulcer risk
• 29:44–31:43 – Switching therapies in atopic dermatitis
• 31:50–39:00 – Remibrutinib’s lasting efficacy for chronic urticaria
• 39:48–46:50 – Managing BP and psoriasis overlap; oral PDE4 inhibitors as emerging options
• 47:13–51:29 – Mechanistic explanations for BTK inhibitor AEs; So TIK2 in atopic dermatitis
• 53:17–55:41 – Steelers and NFL coach talk; concluding banter

Conclusion

This episode offers dermatology providers practical updates for cutting unnecessary testing, critically assesses chemo-preventive dogma, explores side effects of commonly used meds, and spotlights promising therapies for chronic skin diseases—all delivered with humor and candor. The interplay between clinical experience, evidence appraisal, and real-world challenges makes "Derms on Drugs" both educational and entertaining.