DERM on RheumNow PODCAST (January 2026) Save

Welcome to the Derm on RheumNow podcast. Hi, I'm Jack Cush, executive editor of roomnow.com. This podcast is a collection of citations and content that's curated for you, the dermatologist. We cover a lot of dermatology content on roomnow.com and we invite you to join us. This includes reports, advances, regulatory issues on psoriasis, psoriatic arthritis, cutaneous lupus, vasculitis, hidradenitis, a lot of connective tissue related stuff including the drugs that we both use, biologics, DMARDs, JAK inhibitors, both how they work, where their new uses, what are the concerns on toxicities.

So I hope you enjoy this podcast, I hope you'll, you know that we've been doing it since September I believe, every month. The podcast comes out at the end of the month. Please tell your colleagues, please sign up, please register at roomnow.com. This podcast is brought to you by not just RheumNow, but RheumNow Live. RheumNow has an annual meeting that's going to run February seventh and eighth in Dallas.

You can sign up and attend. We have a bunch of dermatologists who are lecturing at the meeting and also coming to the meeting. We have a whole pod, a session, a two hour session on psoriatic disease. Joe Marola talking about paradoxical skin reactions to the drugs that you use, that I use, Andre Ribero talking about choosing between IL-seventeen and IL-twenty three inhibition, Arti Kavanaugh saying why he doesn't do x rays in psoriatic arthritis. I think he's gone to Maui Derm too many times, and he's starting to think like a dermatologist rather than a rheumatologist, but we gotta go to lecture and see what he's gonna say.

Alright, so we have a number of things to review. I think it's important to note, those of you who do research, were in a panic last year with all these cuts, and research grants looked like they disappeared. Well, were a number of publications this week and announcements including the Lupus Accelerated Breakthroughs Consortium, published their recommendations about skin outcomes. It was a multi stakeholder meeting and ended up in a publication, included the FDA, and in this publication that's in Nature, they addressed best outcomes for cutaneous lupus and they endorsed, of course, the classy, the cutaneous lupus erythematosus disease activity, disease area and severity index developed by Victoria Worth, a dermatologist at UPenn. It is the primary endpoint, it should be the primary endpoint in lupus clinical trials on this basis.

We'll see more drugs being used and developed for lupus. Later on we'll talk about anifrolumab, the alpha interferon inhibitor, and although that's not specifically approved for cutaneous lupus, it looks good. Second report about just a review of the Papa syndrome. This is when, you know, sterile pyogenic arthritis meets sort of pustular disease, so pyogenic arthritis, pyoderma gangrenosum, and acne, cystic acne, it's a rare auto inflammatory syndrome that has a gain of function mutation and PSTPIP1, regulating an inflammasome and producing more pyrin. This leads to what is a classic monogenic auto inflammatory disease, usually with onset in children, but I've seen them later, you know, in adolescence and leading on into adulthood.

They often get attacks at infrequent we don't know why they get attacks or what they you know, there's no periodicity to it. You know, and that's sort of interesting. It's sometimes triggered by minor trauma. They have all the markers of inflammation, high saturate CRPs, but have normal cell counts, normal cultures. If you do genetic testing you can find a few of these variants, and this is an autosomal dominant condition.

A nice review for you online and in the speaker notes. The Turkish League Against Rheumatism, TLAR did a study looking at the association between periodontal disease, periodontitis and psoriatic disease. Now periodontal disease is a big issue in RA and the biology of periodontitis is the same as synovitis in RA. It's probably similar to what you see in psoriasis as well. And in this study of sixty six psoriatic arthritis and sixty two psoriasis only patients from Turkey.

They did an extensive assessment on them and found that periodontal disease was seen in thirty one percent of the psoriasis patients, but a higher number in PSA forty seven percent, almost significant zero point five eight. But periodontal disease was significantly correlated and seen in psoriasis patients with disease activity in psoriasis as measured by the CPDAI, I'm not familiar with that measure, but you are. Again, a very significant association, higher odds ratio one point three eight, and it was also associated with enthesitis significantly, about thirty nine percent higher, using a measure that's seen in patients who have enthesitis and psoriatic arthritis. So, again, problematic psoriatic disease, look at their teeth, send them to the dentist, it's not a bad idea. I, inferred earlier about the outcomes of the alpha interferon monoclonal antibody anifrolumab.

Sue Manzi from Pittsburgh published the report of subcutaneous anifrolumab is now available. It was previously a monthly infusion indicated for lupus, worked very very well. The sub analyses of those lupus trials showed that it worked really well in skin and joints. Really well in skin and joints. And there's a ton of reports of problematic skin lupus and or dermatomyositis responding really well to anifrolumab.

Now, with this report, which is called the TULIP SC study, it shows that sub q anifrolumab is as effective as the IV. Sub q anifrolumab is given as a weekly injection, easy to give, looks like it has a good safety profile, it's going to soon be available to you. So sub q therapy is something we use a lot of, I'm sure you use some of. I came across this issue this week in managing patients that I like to use rituximab, but I can't give an infusion for money reasons and a lot of administrative reasons can't do IV rituximab, but you know there's a subcutaneous rituximab that was approved in 2017. It's called Sahysella.

It basically is rituximab, but formulated with hyaluronidase to be given subcutaneously. And it's a faster injection, five to ten minutes, as opposed to hours. Unfortunately, it's only approved for two or three different lymphomas, and that's probably where its primary use is. And if you are going to use this, and you know there are certain conditions, that you manage, or that we co manage, where Rituximab is a drug of choice. If you are going to use this, you have to give the first dose IV, and then subsequently subcutaneous weekly rituximab seems to be the way to go.

Is that weekly? I think it is weekly. In Germany there's a registry of psoriasis patients called ProBest. This includes almost 600 patients treated with, Primalast, either as monotherapy, the vast majority, about eighty percent of them are on monotherapy, and the rest are on some combinations. And when they compared outcomes, they basically showed that patients in their registry who took Primalast tended to be a little older, tended to have more comorbidities, cardiovascular especially.

They had a few more non serious adverse events, URIs and things like that. And side the main one was ineffectiveness fourteen percent, diarrhea nine percent, nausea seven percent, headache six percent. So, certainly you are using a lot more Primalas than most rheumatologists are, but rheumatologists are using it as well, both for skin but also for joint, although they believe, wrongly so, that it's from mild joint disease. And actually that's not in the indication, and that's never been proven. So why do they give it for mild disease?

Well, A) it's easy to take, and it doesn't require monitoring. But it's got the label for mild because the response rates, which for other DMARDs is like, you know, fifty-sixty percent. With Epremelast for joint disease the response rates are like, you know, thirty eight-forty two percent. They're not that high. So, being less effective than, for instance, methotrexate or etanercept in clinical trials, it gets the mild label.

And can tell you, I've treated a lot of patients with arthritis with aprimilast, and I've seen bad disease melt away, except the response rates are low, right? So, don't necessarily believe that mild thing. I'd be interested in what you would say about what kind of responses you see when using Primalist just for the skin disease alone. An interesting report this week in, I think in JAMA Derm about the use of DMARDs in localized scleroderma. You know, we have Heidi Jacoby at UT Southwestern has taught all us rheumatologists about use of methotrexate in localized scleroderma, you know, morphia, linear, etc.

And but also other DMARDs in this study, it's basically looking to compare outcomes between methotrexate and mycophenolate. One hundred and fourteen patients with localized scleroderma, and they were equivalent in their responses. Again, it wasn't a randomized trial, I think it was an experiential observational retrospective thing, but the outcomes were the same, Okay? I mean, who can do a randomized trial on localized scleroderma? Who's got the number of patients?

Well, got one hundred and fourteen. That's commendable. As you might expect, side effects were the same except methotrexate had more fatigue, forty seven percent versus eleven percent, and Mycophenolate more nausea, sixty percent versus seven percent. So again, another option for you. I found this report also in JAMA Derm about advanced practice providers, or APCs, working in dermatology clinics and working on psoriasis.

This was an accounting of what they're doing and what they're prescribing. And basically showing that in outpatient care APCs are delivering a large amount of outpatient care accounting for about over a third of clinician visits or dermatology visits in general. Bottom line: all prescription cost written by APCs rose from $140,000,000 at the beginning of this study, which was $20.13, 2,007, 2,000 it's going to come to me, $20.13, 140,000,000 in 2013 to 952,000,000 in 2020. That that's all prescriptions written by the prior the APCs, physician assistants and nurse practitioners. But the use of the prescription the cost of or the writing of specialty drugs, you know, that they have to go to specialty pharmacy, we're largely talking about biologics and JAKs, increased from 24,000,000 in 2013 to 744,000,000 in 2022, a 46% increase per year.

And the number of specialty drugs by APCs increased from 10% to 31%. In this period of observation, I guess from 2013 to twenty twenty three-twenty two, the number of dermatologists being added to practices only grew about 1.2%. But the number of APCs went up much more, went from 21% to thirty eight percent, and during this period they're taking on a larger proportion of the expensive drugs. Interesting. I didn't know that that was happening, and I think it one says that you have great faith in your physician assistant and nurse practitioner as I do in rheumatology.

My nurse practitioners that work with me can do everything I can do: inject joints, write biologics, manage the most complex vasculitis and lupus patients. I don't give them the easy stuff or the stuff I don't want to see. I put them to work and they're highly productive. Lastly, I think this was the report of the month. And it came out mid month.

It was an announcement it was a press release, so there's not a lot of data here, actually there's no data. It's a press release from Lilly, who is, as you know, makes, ixekizumab, an IL-seventeen inhibitor, but they're also getting more famous for their tirzepatide, the weight loss drug Zepbound. And they are the first to go public with their combination clinical trial called the Together PSA trial. It's a phase 3B study showing that you can use either ixekizumab alone or ixekizumab plus tirzepatide in psoriatic arthritis patients who are obese. Now, I'm going to disappoint you and say I don't have a skin outcome here.

Their press release basically said that the combination was better than a single drug. Adding in the IL-seventeen inhibitor to adding in the GLP-one agonist to the IL-seventeen inhibitor was better than the IL-seventeen inhibitor alone. And that was with a primary endpoint of an ACR50, a very stringent joint outcome, plus greater than 10% weight loss. Oh my goodness! And then more importantly, then the question is what is tirzepatide, the GLP-one, adding to this?

Is it just weight loss making the arthritis better? Is it just weight loss making the skin better? And I don't have that data on skin. And so they looked at just ACR fifty responses and they saw the same thing. But again, they didn't give us a detailed analysis.

Maybe the paper, when it's presented at one of your meetings, or one of our meetings, will tell us whether this, the outcomes look like the addition of a GLP-one agonist provides more of an anti inflammatory effect, or is it all just weight loss? So anyway, I like this. Again, you look at just ACR 50 responses, when you took ixekizumab plus tirzepatide, a thirty three percent ACR 50, that's pretty healthy, compared to ixekizumab alone, only twenty percent, and that was significant at point o five, less than point zero five. Anyway, that's the end of this podcast. I hope you take care of yourself.

I hope to see you in Dallas or virtually online, roomnow. Live. Register for our meeting. I think you'll enjoy it. Take care.