DERM on RheumNow (October 2025) Save

Welcome to the Derm on RheumNow podcast. Hi. I'm doctor Jack Cush, executive editor of rheumnow.com. On this podcast, we discuss dermatology stuff that rooms are taking note of, derms should take note of too. It's important citations and content curated for you, the dermatologist.

It looks we look at psoriasis, psoriatic arthritis, lupus skin disease, CTD skin disease, vasculitis, hydradenitis, dermatology drugs, biologics, JAK inhibitors, their use safety and side effects, and regulatory decisions. This week on the podcast, we'll talk about skin biopsies and scleroderma. What's a surefire way to screw up your outcomes in psoriasis? New regulatory decision, for pediatric psoriasis, another seventeen AF inhibitor. Is it good news or bad news?

And then what happens when psoriasis occurs, and how long do you wait for the arthritis to happen? So at the top, let's start with let's start with our FDA approval. FDA approved, in October, guselkumab. It's an IL twenty three inhibitor for use in pediatric psoriasis and psoriatic arthritis. Again, this, guselkumab has been around for a while.

This drug is now approved for children six years of age and older and those weighing at least forty kilograms. The results of the pro ProtoSTAR study were what was used, for this approval, and that was a psoriasis pediatric psoriasis study. The extrapolation to pediatric psoriatic arthritis was based on pharmacokinetic extrapolation. In this study, the pro ProtoSTAR study, it was the results were impressive. The PASI ninety results were fifty six percent versus sixteen percent.

The same, results for inactive disease. So, that's good news, for both you in dermatology and us in rheumatology on how to best manage pediatric disease. Interesting report this week comes out of the hospital for special surgery in Weill Cornell Medicine, where they looked at skin biopsies of a hundred and five systemic sclerosis patients who were enrolled in about four or five different clinical trials. But part of the study was to look at biomarkers and fibroblast phenotypes in skin biopsies. And the bottom line is that they showed that a skin biopsy done at the start could define a fibroblast immunophenotype that could have important prognostic and early treatment decision impact.

Important because, honestly, do we know what the right drug for scleroderma is? No. Do we have any assurances? No. If you could get some clue by doing skin biopsies and looking at c d 34 and alpha smooth muscle actin staining and fibroblasts, you'll see things that would help maybe to predict it.

This is kind of where I think we need to go on difficult disorders like systemic sclerosis. A German study recently looked at fibromyalgia and matched six actually, this is not the German study. This is a retrospective cohort study of sixty one thousand psoriasis patients matched one to four with 244,000 controls to look at the influence of coexistent fibromyalgia. Now we diagnose this commonly in rheumatology. You may not, be familiar with it or see it as much.

Fibromyalgia is a pain amplification disorder. These patients always have a sleep disturbance. They have heightened pain responses. They see more doctors and have more drug failures. And in this matched cohort analysis, the prevalence of fibromyalgia was higher in psoriasis than in controls, about forty five percent higher.

And that's important because you're gonna see it, I'm gonna see it. In the psoriasis patients who also had psoriatic arthritis, it was shown that biologic use was really hampered. Decreased biologic survival. Six years if you had fibromyalgia, ten years if you didn't. And this is just in psoriasis.

There was an increase also in biologic switching, meaning that there was futility and frustration. So the presence of fibromyalgia, really can complicate outcomes. And the good news for you is, it'll be your psoriasis patients with a myriad of complaints, and you're not sure that you really see any swollen joints that would make you think psoriatic arthritis. Ask about a sleep disturb disturbance, send them to the rheumatologist, get that fixed, because it will undermine your therapy. Sonalicimab, a nanobody that is a dual inhibitor IL-17A and F.

So, this is falling on the heels of bimekizumab, another AF inhibitor, working great in skin, working pretty good in joints. They just published the results of a phase two ARGO trial, two zero seven patients with active psoriatic arthritis, who were given one of two different regimens with sonolikumab or placebo or adalimumab at week twelve. The really, really high end, almost like Posse 90 response for psoriatic arthritis, the ACR 50 at week twelve was forty six percent with one dose, forty six percent with another dosing regimen, and twenty percent with placebo. The PASI 90 responses was seventy seven percent with sixty milligrams, fifty nine percent with the other one hundred and twenty milligram dose versus fifteen percent in placebo. So this looks great in psoriatic arthritis.

And if you're following sonolizumab from Moon Lake as the manufacturer, they took it on the chin this last month because they came out with a report, the Vela report on sonolikumab, the IL seventeen AF inhibitor in hydradenitis suppurativa, and it didn't look so good. And everybody kind of flipped out about it. I think the primary endpoint responses were like 36% on sonolikumab and 20 or 25% on placebo. The point was they had a really high placebo response and everyone's losing their cool. Well, first off, you guys are the experts at hidradenitis suppurativa.

Not an easy disorder to treat. It could be like the fibromyalgia of rheumatology practices. So, a failure in hydradenitis suppurativa shouldn't discount the successes of this drug in psoriasis and psoriatic arthritis. More research I'm sure is coming. A study of almost 800 Turkish patients looked at the onset of psoriasis and then when psoriatic arthritis happened.

In thirty percent the onset was concurrent, and they had a kind of wide window if the arthritis occurred within 12 of the skin, they say that's concurrent. And many of them were really concurrent, but there are a few that were a little bit after. There are a few that actually arthritis is a little bit before, right? But seventy percent there was a long transition time with an average time to the diagnosis of PSA of being thirteen years. That prolonged interval was more likely if the patient had depression, fatigue, scalp psoriasis, nail psoriasis, a family history, and enthesitis ever.

Now if there was a family history of psoriatic arthritis, the transition time was a lot faster. Right? So, again, this has a lot to do with how we co manage these patients together. Two more reports. The Medispo study, the Mediterranean diet, in psoriasis study.

This was published in JAMA. It's a small study, but I think an important study. Thirty eight patients were randomized, and either given a Mediterranean diet with weekly counseling over sixteen weeks, I think it was, by a a nutritionist, and they were also given virgin olive oil. The other group was just had no counseling and was given a paper diet to follow low fat, something like that. The bottom line was at week sixteen, the posse changes were significant.

Minus three four point 3.4 Posse change in the Mediterranean diet versus no change in the control group. The Posse 75 change was achieved in forty seven percent on Mediterranean diet and zero on the control group. Also, the Mediterranean diet group had a significant lowering of their hemoglobin a one c, which you know correlates with the activity of psoriasis. So this is a strong and, I think, endorsement for the Mediterranean diet, which you know is a low gluten, a no gluten and low carbohydrate diet, basically. I'm a big believer of no gluten, in patients with psoriasis, psoriatic arthritis.

I had tremendous success in our practice without using biologics, just using diet. So think about it. Our last thing is a factor that we've learned from the dermatologist that there are gender differences in psoriasis and psoriatic arthritis on outcomes. This is that German study I started to talk about. 800 patients with PSA who are bio naive enrolled in this German rabbit spa registry, who were gonna start their first time biologic or first time targeted synthetic.

And what they found at baseline, women had more severe disease, more severe joint involvement, higher disease activity scores, higher pain, greater functional limitations than did men. This is very worrisome. Men had more skin involvement and a higher prevalence of nail psoriasis. When we looked at drug durability, females had the lowest drug durability numbers, and this didn't matter what therapy we're talking about. Whether it was biologic, targets like TNF inhibitor, IL 17, IL 23 didn't matter.

Again, when it came to retention on drug, higher in males at twelve months than females. Sixty eight percent versus fifty two percent when you looked at their initial durability of a biologic or targeted synthetic. And then discontinuations. Males more frequently discontinue drugs for lack of efficacy and remission. Females discontinued for adverse events.

Again, this is a big issue, is it not? We need gender specific treatment strategies for psoriasis and psoriatic arthritis. Follow us on rheumnow.com. Sign up on Twitter for RheumNow. We're gonna be at the ACR meeting with tons of reports on skin disease, psoriatic arthritis, and all things rheumatology.

That's coming up next week. We'll talk next month here on derm on RheumNow. Thanks.