Derms on Drugs Take on Big Questions

Podcast: Derms on Drugs
Host: Scholars in Medicine
Date: February 28, 2025

Episode Overview

In this lively and educational special episode, three dermatologists—Dr. Matt Zirwas, Dr. Laura Ferris, and Dr. Tim Patton—review and debate six of the most interesting recent articles in clinical dermatology. With their signature mix of clinical depth, practical insights, and “mediocre comedy,” the panel breaks down new evidence on treatments for basal cell carcinoma, autoimmune disease risk with COVID infection and vaccination, dietary risk factors for melasma, antibiotic use in psoriasis, biologics in pediatric scleroderma, and cost-effective prescribing for inflammatory skin disease.
The tone is friendly and humorous, with the hosts interjecting personal anecdotes and quick-witted banter throughout.

Key Discussion Points & Insights

1. Surgical Debulking Before Vismodegib for Large Basal Cell Carcinoma

• Article Discussed: Surgical debulking modifies notch signaling and may improve vismodegib effectiveness for locally advanced basal cell carcinoma ([JID Innovations], Maglakitis et al.)
• Summary:
  • Small proof-of-concept study (n=4) treating sizable locally advanced BCCs (basal cell carcinomas of 5-9 cm).
  • Approach: Surgical debulking performed prior to vismodegib; punch biopsy one week post-op to assess gene expression.
  • Findings:
    • Debulking alone upregulates Notch and Wnt-signaling genes, potentially sensitizing tumors to subsequent vismodegib.
    • Clinical responses were “way better than you would think” with significant tumor regression in three out of four patients ([03:53]).
    • Traditional paradigm reversed: Instead of shrinking tumors with vismodegib first, then surgery, it may be effective to debulk first, then medicate.
  • Clinical Pearls:
    • “It might make sense to debulk it, then put them on medication and then bring them back and think about doing surgery.” (Dr. Laura Ferris, [03:01])
    • The trauma of surgery appears to make residual tumor more responsive to vismodegib.
  • Caveats:
    • Study was very small; more research needed before changing standard of care.
    • “Provisionally approved…awaiting a study of greater than four patients.” (Dr. Matt Zirwas, [05:42])
  • Humorous Note:
    • “The patients all have Alzheimer’s now, but it’s okay. Their BCC’s are better.” (Dr. Matt Zirwas, [05:00])

2. COVID-19 Infection, Vaccination, and Autoimmune Blistering Disease Risk

• Article Discussed: COVID 19 infection is associated with an elevated risk for autoimmune blistering diseases while COVID 19 vaccination decreases the risk (Kerman et al., JAD Nov 2024)
• Key Points:
  • Retrospective cohort of 112 million US patients, comparing risk of autoimmune blistering diseases (AIBD) after COVID infection, vaccination, or neither.
  • Findings:
    • COVID-19 infection increased risk of AIBDs by 50% compared to controls ([07:59]), especially pemphigus (hazard ratio 5.5).
    • Surprisingly, COVID-19 vaccination reduced risk of developing AIBD compared to controls (risk halved, largely due to decreased pemphigus; [08:57]).
    • “If patients are asking about COVID vaccine, will it increase my risk? … that with a particular condition, vaccination actually appeared to be protective.” (Dr. Tim Patton, [09:19])
  • Discussion:
    • Reverse causality and study limitations acknowledged—control group may not have captured all true COVID cases ([10:10]).
    • “This confirms for us we can just continue to use the virus excuse for everything.” (Dr. Matt Zirwas, [11:30])
  • Clinical Takeaway:
    • COVID-19 infection is associated with increased risk of AIBD; vaccination does not—and may even be protective.
    • Useful to reassure and counsel concerned patients ([09:19]).

3. Dietary and Environmental Risk Factors in Melasma

• Article Discussed: Diet and living environment as novel etiological factors for melasma: Case-control of 150 Chinese patients (Xi et al.)
• Key Results:
  • Risk factors for melasma:
    • Abnormal menstrual cycles, history of sunburn/sun exposure.
    • Regular sunscreen use higher among melasma patients (likely reverse causation).
    • Cystic breast hyperplasia (marker of increased estrogen).
    • Alcohol intake: Strong association—meaningful drinkers had a 20-fold increased risk.
      • “Now, whenever I see a patient who’s got melasma, I am going to…recommend to them that they cut that [alcohol] out as much as possible.” (Dr. Matt Zirwas, [14:31])
  • Protective associations:
    • Seborrheic dermatitis, drinking soft drinks (possible vitamin C effect), and—most notably—coffee intake.
    • “Coffee intake also reduced your risk of melasma.” (Dr. Matt Zirwas, [15:25])
  • Discussion:
    • Mechanistic explanations hypothesized, but multiple confounders exist (e.g., alcohol consumed outdoors, during house renovations).
    • Panel plans to mention alcohol intake reduction in practice, but remains skeptical about causality for some findings.

4. Antibiotic Therapy in Psoriasis with Streptococcal Infection

• Article Discussed: Impact of antibiotic therapy in psoriasis patients with active streptococcal infection: A prospective study (Bonciani et al., Journal of Dermatology)
• Summary:
  • 155 psoriasis patients and controls; throat cultures and ASO titers checked for strep.
  • Those with evidence of strep received antibiotics (+ topical betamethasone/calcipotriol); those without, just topical treatment.
  • Key Insight:
    • Strep infection/antibodies were more common in psoriasis patients (25% vs 13%).
    • Antibiotics did not yield statistically significant improvement in skin scores.
    • “They really did not see any more improvement with antibiotics…Didn’t give me a whole lot of answers, but interesting.” (Dr. Laura Ferris, [19:47])
  • Practice Implication:
    • Panelists don’t routinely give empiric antibiotics in guttate psoriasis.
    • Anecdotes about tonsillectomy helping psoriasis, but data remains inconclusive.

5. Biologics for Linear Scleroderma in Children

• Article Discussed: Use of biologic drugs in the treatment of local scleroderma and systemic sclerosis in children: A scoping review (Seminars in Arthritis & Rheumatism, Center et al.)
• Highlights:
  • 29-article review, focus on linear scleroderma.
  • Most patients already on corticosteroids and methotrexate; some also tried mycophenolate.
  • Biologics Used:
    • Abatacept (Orencia): 55% of those on biologics; blocks T-cell costimulation ([23:23]).
    • Tocilizumab (anti-IL6): 48%.
    • Reported “92.9% improvement rate” with abatacept, but this was based on incomplete data (33% had outcomes reported, [24:00]); tocilizumab rate may be more reliable.
  • Bottom Line:
    • No strong evidence to replace traditional first-line agents (steroids, methotrexate).
    • “Reassured me—steroids and methotrexate probably still the way to go. Consider biologics if refractory.” (Dr. Tim Patton, [25:13])
    • Neither abatacept nor tocilizumab had met primary endpoints in prior controlled trials.
  • Humor:
    • “I want to get that [cord diagram] on a T-shirt. And then I would wear it and people would come up to me and ask about my cool T-shirt.” (Dr. Tim Patton, [26:15])

6. Oral Roflumilast: A Cheap and Effective Option in Psoriasis and Beyond

• Article Discussed: Oral roflumilast: Real world 24-week prospective cohort study (unnamed author)
• Main Points:
  • Roflumilast is similar to apremilast (Otezla)—a PDE-4 inhibitor—but more potent, with more GI side effects, and now generic ($6/month via Mark Cuban Cost Plus Pharmacy).
  • Effectiveness:
    • PASI 75 achieved in 50–66%, PASI 90 in 33–50% depending on analysis approach.
    • Useful for patients where biologics are inaccessible or as an add-on.
    • No routine lab monitoring, minimal immunosuppression burden.
    • “We use methotrexate for a bunch of stuff…[but] you do have to do monitoring…Roflumilast—it’s just, I love it. It’s my methotrexate.” (Dr. Tim Patton, [30:51])
  • Patient Experience:
    • Substantial GI side effects are possible (nausea, diarrhea, weight loss).
    • Interesting anecdote: Dr. Zirwas described dramatic improvement in a rare case of gingival plasmacytosis, but the patient “lost 40 pounds…miserable from the GI side effects.” ([32:12])
  • Other notes:
    • Some evidence for improved cognition and cardiovascular outcomes (mentioned anecdotally).
    • "Think Otezla, but free and more effective." (Dr. Matt Zirwas, [29:53])

Notable Quotes & Memorable Moments

• On modifying standard debulking protocols:
  • “It might make sense to debulk it, then put them on medication and then bring them back and think about doing surgery.”
    — Dr. Laura Ferris ([03:01])
• Comedy on debulking side effects:
  • “The patients all have Alzheimer’s now, but it’s okay. Their BCC's are better.”
    — Dr. Matt Zirwas ([05:00])
• Practical vaccine guidance:
  • “If patients are asking about COVID vaccine, will it increase my risk? … We have one study, and it showed vaccination actually appeared to be protective.”
    — Dr. Tim Patton ([09:19])
• On unexpected risk factors for melasma:
  • “The number of people who were significant alcohol consumers was relatively low...but the relative risk of melasma...was 20-fold higher.”
    — Dr. Matt Zirwas ([14:31])
• On the problem with incomplete data in reviews:
  • “92.9% improvement rate! But…they didn't have data on 70% of the patients.”
    — Dr. Tim Patton ([24:11])
• Panel camaraderie and lightness:
  • “I want to get that [cord diagram] on a T-shirt.”
    — Dr. Tim Patton ([26:15])
  • “Think Otezla, but free and more effective.”
    — Dr. Matt Zirwas ([29:53])
  • “If you were smart enough, you would remember that you told us that.”
    — Dr. Tim Patton ([31:29])

Timestamps for Key Segments

• [01:18] - Introduction to the article round-up “six pack”
• [01:55] - Basal cell carcinoma debulking and vismodegib
• [05:57] - COVID-19, vaccination, and autoimmune blistering disease
• [12:23] - Melasma, diet, environment, and surprising risk factors
• [16:59] - Antibiotics for streptococcal infection in psoriasis
• [21:41] - Biologics for pediatric scleroderma
• [29:53] - Oral roflumilast for psoriasis and other inflammatory dermatoses

Panel’s Bottom Line Takeaways

• Basal cell carcinoma: Early debulking may enhance vismodegib response; more data needed.
• COVID-19 & AIBDs: Infection increases risk, but vaccination decreases or does not increase risk.
• Melasma: Alcohol may be a strong, under-recognized risk factor; consider advising reduction.
• Psoriasis & Strep: Antibiotic treatment of asymptomatic strep in psoriasis does not clearly improve outcomes.
• Pediatric linear scleroderma: Steroids and methotrexate remain first-line; biologics considered for refractory cases, but supporting data limited.
• Oral roflumilast: An affordable, effective non-immunosuppressive option for various inflammatory skin conditions; GI side effects may limit use.

For questions, suggestions, or to access supplemental dermatology education, the panel suggests visiting Scholars in Medicine.