In episode 67 of Derms and Conditions, our host, Dr James Q. Del Rosso, sits down again with Dr Jeff Donovan, a board-certified dermatologist who practices in Whistler, Canada, with his dermatology clinic dedicated solely to the management of hair disorders, for part two of their discussion on alopecia areata and other hair loss conditions.

Dr Donovan begins the discussion by addressing autoimmune thyroid disease associated with alopecia areata and the appropriate laboratory interpretation and monitoring for these patients. He discusses the comprehensive baseline laboratory tests he collects before initiating JAK inhibitor treatment as well as how he approaches laboratory monitoring during the course of therapy.

Next, the pair addresses how to tackle low laboratory values, such as vitamin D and ferritin, that are associated with more severe alopecia areata. Dr Donovan emphasizes that when treating iron deficiency, patient comfort and adherence are paramount. The pair notes that patients genuinely appreciate a thorough and concerned clinician and how important it is to set appropriate patient expectations with treatment.

They then transition to the use of dupilumab in atopic children with alopecia areata who experience hair regrowth and how to determine which patients are more likely to respond to this treatment.

Next, Dr Del Rosso describes a difficult case of lichen planopilaris, and Dr Donovan shares key clinical and dermatoscopic findings and encourages clinicians to have a low threshold for biopsy when suspecting lichen planoplilaris or another disorder other than alopecia areata, some which may cause scarring. He discusses treatment with topical corticosteroids, intralesional triamcinolone injections, doxycycline, hydroxychloroquine, methotrexate, and cyclosporine in isolation and in combinations and what would constitute an appropriate trial on these therapies.

More data are needed on the use of JAK inhibitors for causes of inflammatory alopecia other than alopecia areata.

Dr Donovan concludes by mentioning education opportunities available in hair loss and his final words of wisdom regarding alopecia.

Tune in to this episode to learn all the details from a true hair expert!

In episode 66 of Derms and Conditions, our host, Dr James Q. Del Rosso, sits down with Dr Jeff Donovan, a board-certified dermatologist who practices in Whistler, Canada, with his dermatology clinic dedicated only to management of hair disorders. In part one of this series, they discuss how to approach patients with alopecia areata.

Dr Donovan starts by discussing conditions that can mimic alopecia areata and when a biopsy may be needed to confirm the diagnosis, prompting him to share his suggestions on biopsy caliber, appropriate sites for biopsy, and utilizing the right pathologist to review the sample.

Next, the pair discusses topical treatments for patchy alopecia areata, including topical clobetasol and topical minoxidil, and the important role of intralesional corticosteroid injections. They then discuss available study data and experience with the use of oral baricitinib (a JAK inhibitor) and oral ritlecitinib (a JAK-3 and TEC kinase inhibitor) in patients with severe alopecia areata. Specific recommendations were reviewed including important efficacy and safety findings, clinical and laboratory monitoring, and certain limitations with currently available studies. Both look forward to promising developments that are anticipated with longer-term data for both baricitinib and ritlecitinib.

They conclude by discussing the use of minoxidil in alopecia areata, including anecdotal evidence. Dr Donovan notes that more studies examining the effects of minoxidil in alopecia areata are needed.

Tune in to the episode to find out more from a dermatologist who treats patients with hair disorders throughout his entire workday whenever he is in clinic!

In episode 65 of Derms and Conditions, our host, James Q Del Rosso, DO, chats with Ted Rosen, MD, Professor of Dermatology at Baylor College of Medicine and Chief of Dermatology Service at Michael E. DeBakey Veterans Affairs Medical Center, to discuss new developments in psoriasis treatment.

They begin by discussing the current psoriasis treatment landscape and the perception that with effective biologics now on the market, there are no longer any unmet needs in psoriasis treatment. They reflect on the importance of having a variety of treatment options with differing mechanisms of action, which can address variability in patient response. They highlight the novel mechanism of action of bimekizumab, which provides dual inhibition of both IL-17A and IL-17F.

The pair then discuss the relationship between IL-17s and candidiasis, noting that while there is a broad spectrum of risk, it is usually minimal and manageable, typically presenting as oral thrush rather than serious systemic infections. Dr Rosen discusses how he counsels his patients about the increased risk of candidiasis when on an IL-17A-F blocker and the importance of balancing risk with the potential benefits.

They also delve into the data on bimekizumab, highlighting the favorable PASI 75 results seen at 4 weeks and how it compared to adalimumab, ustekinumab, and secukinumab in pivotal studies. Dr Rosen also discusses how the patient conversation can differ when counseling a patient on an IL-23 blocker compared to a drug with a simplified dosing regimen with an early onset of action.

The pair concludes by discussing the dosing regimen for bimekizumab, noting that it’s possible to reduce injection frequency after the initial 16 weeks of treatment and still sustain the same level of efficacy.

They also discuss evidence that may suggest adjustments to the bimekizumab dosing regimen may lower the risk of candidiasis.

Tune in to this episode to learn more about bimekizumab and its impact on the psoriasis treatment landscape!

In Episode 64 of Derms and Conditions, our host, Dr James Q. Del Rosso sits down with Dr

Shane Chapman, Chair of the Department of Dermatology at Dartmouth Hitchcock Medical

Center, to discuss nonsurgical approaches to treating nonmelanoma skin cancer. 

Dr. Chapman begins by discussing topical treatment options for nonmelanoma skin cancer for

patients who are not candidates for surgery. He comments on the use of intralesional

chemotherapy for keratoacanthomas or squamous cell carcinomas in poorly healing areas or

when multiple lesions are present, compares the benefits of 5-fluorouracil and intralesional

methotrexate, and explains the benefits of using oral acitretin with intralesional therapy.

The pair then discuss intralesional methotrexate in more detail, explaining how methotrexate

and 5-fluorouracil can be interchanged or used in combination with PDT to treat

keratoacanthomas/squamous cell carcinomas. They also discuss how to approach a case of a

patient with a nodular basal cell carcinoma on her nasal tip who refuses treatment with surgery

or radiation.

Next, they discuss treatment of broader skin lesions, such as superficial or multifocal basal cell

carcinomas and detail imiquimod, 5-fluorouracil, and both red and blue light PDT as potential

treatment options.

To conclude, they discuss how to manage brisk imiquimod responses and the impact on

treatment duration. Tune into this episode to hear the full details and learn more!

In Episode 63 of Derms and Conditions, our host, James Q. Del Rosso, DO, sits down with Adam Friedman, MD, to discuss some important topics in dermatology, including a comprehensive resource for portraying skin conditions and his research findings relating to sensitive skin.

Dr Friedman begins by describing his atlas project, created to address a gap in dermatology in the limited way textbooks and atlases portray skin conditions. The Full Spectrum of Dermatology: A Diverse and Inclusive Atlas is a comprehensive resource that depicts dermatologic conditions across the full spectrum of skin tones to help dermatology professionals visualize the nuances in skin conditions.

Next, Dr Friedman discusses his research on sensitive skin and how he puts his findings into practice with his patients. He details his global study that looked in-depth at sensitive skin and what factors trigger and exacerbate it, highlighting the importance of dermatologists having tools to assess the condition and provide management strategies. The pair also touch on guiding patients on the use of products for sensitive skin and utilizing samples.

They conclude by discussing the importance of early intervention to prevent disease progression and the benefits of initiating more advanced therapies in earlier disease.

Tune into this episode to hear more about what’s on Dr Adam Friedman’s mind!

In this episode of Derms and Conditions, Dr. Jim Del Rosso and Dr. Gary Goldenberg discuss some of the highlights from the meeting. These include recent FDA approvals such as bimekizumab for psoriasis and the triple topical combination for acne vulgaris, the newer nonsteroidal topical agents, tapinarof and roflumilast, and their relevant clinical use, the significance of narrow-spectrum oral antibiotic therapy with sarecycline as compared to other oral tetracycline with regard to antibiotic resistance, and physical devices such as laser systems used to treat acne vulgaris. 

In episode 61 of Derms and Conditions, our host, James Q. Del Rosso, DO, presents a self-made episode where he clarifies key points on many therapies relevant to every-day clinical

practice. First, he discusses topical alpha-agonist therapy for persistent facial erythema (PFE) of rosacea. Long-term data shows that daily use of either topical oxymetazoline or

brimonidine appears to “reset” (lower) the baseline level of PFE in patients with rosacea. 

Next, he talks about sub-antibiotic dosing of doxycycline and how its anti-inflammatory properties, including support of the dermal matrix, can be used for the treatment of

rosacea. He notes that studies have demonstrated reduced antibiotic selection pressure with decreased emergence of antibiotic-resistant bacterial strains with this therapeutic

approach. Additionally, monotherapy with sub-antibiotic dose doxycycline used as maintenance treatment has been shown to be effective in reducing relapse of papulopustular rosacea (PPR), an

approach that is appealing to those patients who do not prefer or are not compliant with topical therapy. Dr. Del Rosso then mentions sarecycline, a narrow-spectrum tetracycline FDA-approved for

the treatment of acne in patients > 9years of age, which has also been shown in a large pilot study to be effective for PPR.

Microbiological data demonstrates that the narrow antibiotic spectrum of sarecycline spares activity against many strains of bacteria, especially gram-negative organisms that

inhabit the GI tract.

He then transitions to hidradenitis suppurativa (HS) and the welcome emergence of IL-17 inhibitors for HS, which are very effective based on study results to date. Dr. Del Rosso

stresses the importance of early consideration of biologic therapies (such as anti-IL agents) for HS as this disease progresses below the skin surface with eventual development of sinus

tracts and scarring. If we wait until we “see” these consequences, it is too late as they have already occurred. FDA approvals and published guidelines typically depend on visibly

seeing the clinical manifestation before a specific therapy is recommended, which is not early enough in many cases.

He finishes with a discussion on dupilumab for the treatment of atopic dermatitis, which is often remarkably effective, but at times may be limited by partial efficacy or side effects

such as conjunctivitis and facial erythema. Dr. Del Rosso discusses practical use of JAK inhibitors, such as abrocitinib and upadacitinib for AD in dupilumab “non-responders”,

and also case reports with tralokinumab, a monoclonal antibody targeting IL-13. Tune in to this episode to learn more!

In episode 60 of Derms and Conditions, our host, James Q. Del Rosso, DO, sits down with Cheri Frye, MD, the residency program director of dermatology at Howard University. The 2 discuss how to address skin care with patients and key products that should be incorporated into a skin care routine for specific skin types and populations.

Dr Del Rosso begins by asking Dr Frye about her approach to advising the general patient on their skin care. She notes that interest in skin care has grown tremendously, and dermatologists are rightfully being increasingly viewed as the foremost skin care experts. She recommends that dermatologists embrace and directly incorporate skin care into management recommendations for patients and should also consider offering products to patients directly in the office for efficiency and convenience. She also stresses the importance of validating the patient’s concerns by confirming that their dermatologist is the appropriate person to consult.

Next, Dr Del Rosso delves deeper into Dr Frye’s more specific recommendations for skin care. She notes that while it is difficult to generalize, data supports typical concerns that are more prevalent in certain populations, such as hyperpigmentation with darker skin tones. She recommends incorporating toners with salicylic acid and glycolic acid into acne treatment routines to tackle pigmentation. Additionally, she acknowledges that patients reluctant to discontinue using an unessential type of skin care product that may not be optimal for their skin should instead be switched to a better alternative to maintain the patient-physician relationship. 

They then switch topics to discuss skin care tips for dry skin. Dr Frye mentions that African American patients should use moisturizers rich in ceramides, as their skin is likely to be more deficient in this lipid based on current evidence. She emphasizes the need for open discussion and education about these skin care trends with patients. Dr Del Rosso finishes by asking about some common helpful ingredients. Dr Frye notes that ascorbic acid has beneficial antioxidant properties. She also favors niacinamide 3-5% for its antioxidant activity and recommends having glycolic acid in moisturizers specifically for concerns with dyschromia. Tune in to this episode to learn more!

In Episode 59 of Derms and Conditions, our host, James Q. Del Rosso, DO, continues his conversation with Christopher Bunick, MD, PhD, an associate professor of dermatology at Yale University School of Medicine who performs specialized research on novel treatments and therapies. After discussing sarecycline for acne in part 1, the two switch gears to monoclonal antibodies. 

Dr Bunick begins by discussing dupilumab, an IL-4 and IL-13 blocker with significant clinical efficacy and a favorable safety profile in treating atopic dermatitis (AD). He states that in a network meta-analysis, upadacitinib and abrocitinib were shown to be more effective at treating AD than dupilumab, but dupilumab was shown to be more efficacious than tralokinumab and lebrikizumab. He and Dr Del Rosso agree that despite being part of a similar class, each IL-13 blocker should be applied and understood individually. They note several cases where patients who responded poorly to dupilumab had a beneficial response to tralokinumab, despite having similar mechanisms of action.

Next, they discuss IL-13 signaling, which is increased and more persistent in tissues compared to other cytokines. However, Dr Bunick explains that IL-4 has more potent signaling, so IL-13 isn’t necessarily more clinically relevant. He notes that more research is required to further understand the structure-function mechanisms of cytokines in the cell. He then mentions the non-canonical receptor, aka the “decoy receptor”, for IL-13, which could also explain a difference in drugs within the same class. Dr Del Rosso concludes that switching from one IL-13 blocker to another in a patient who was initially unresponsive to treatment may be more favorable than escalating to an alternative class of medication.

Dr Del Rosso then discusses Dr Bunick’s recent publication that compared the adverse effects of common immunosuppressive drugs to those of upadacitinib and abrocitinib in the treatment of AD. While the study population that used the common immunosuppressives did have comorbidities outside of AD, Dr Bunick notes that the risk of adverse events still exists for those treatments in AD and is not present only in JAK inhibitors. Dr Del Rosso states that many risk factors can contribute to adverse events, and not all responsibility should be shifted to JAK inhibitors. Tune in to this episode to learn the complete details about monoclonal antibodies and JAK inhibitors!

In episode 58 of Derms and Conditions, our host, Dr James Q. Del Rosso, presents a self-made episode where he discusses some clarifications regarding commonly misunderstood therapies in dermatology. Dr Del Rosso begins by discussing the use of benzoyl peroxide (BPO) for papulopustular rosacea and notes that many providers are hesitant to use this treatment given the perceived irritant effects. He notes that the microencapsulated BPO 5% cream (FDA approved EPSOLAY®), specifically formulated to allow for the slow release of the drug in the skin, is the only formulation proven to be efficacious, safe, and tolerable in rosacea. He summarizes a 12-week study of patients with moderate to severe papulopustular rosacea in which 25% of patients were clear or almost clear at 4 weeks with total inflammation reduced by 70% at 12 weeks. In addition, he notes that the tolerability was favorable with no differences noted between the active and vehicle groups.

Next, Dr Del Rosso discusses clascoterone 1% cream, FDA approved for twice daily use for acne in patients aged 12 years and older with no limitations on duration of use. He explains findings from a recently published study that show even with the maximum use of clascoterone, 4 to 6 times greater than the normal 1-gram dose, there were no clinically significant hyperkalemia readings, adverse events, or EKG changes in any participant in the control or experimental groups. Given its topical use, negligible systemic absorption especially when used as recommended, and the findings of this study, Dr Del Rosso agrees that clinicians should be reassured about the lack of risk of hyperkalemia with clascoterone use.

Lastly, Dr Del Rosso switches focus to Janus kinase (JAK) inhibitors and biologics. He discusses where the boxed warnings for JAK inhibitors originated and why they are not as concerning overall with oral JAK inhibitors used for dermatologic indications in younger populations who exhibit fewer comorbidities and/or concomitant therapies. In addition, he notes that the risk of several side effects of special interest, such as lymphopenia, malignancy, and thromboembolic events are quite low. He also emphasizes that not all monoclonal antibodies with similar modes of action exhibit the same pharmacologic and therapeutic profiles. In a selected case where a patient with AD has an inadequate response or adverse event such as persistent conjunctivitis caused by dupilumab (which inhibits IL-13 and IL-4), case reports have shown that changing to another monoclonal antibody that inhibits IL-13 (ie, tralokinumab) can exhibit relevant efficacy without associated conjunctivitis. Ultimately, it is good for clinicians to have options and as much data as possible to differentiate their use. He concludes that although certain drugs are part of the same category or class, they all have differences in pharmacokinetics, and the benefits and differences of each drug must be understood to optimize treatment selection for individual patients.

Tune in to this episode to learn all the valuable clinical pearls surrounding many commonly confused therapies!