DERM on RheumNow PODCAST (August 2026) Save

Welcome to the August 2026 edition of the Derm on RheumNow podcast. Hi, I'm doctor Jack Cush, executive editor of roomnow.com. This podcast is for you. It's about what dermatologists should know, want to know. We discuss and manage the same kinds of patients, use the same kinds of drugs, and hence the reason for my doing this podcast, which I do for rheumatologists as well.

Please tell your colleagues about this podcast, you can sign up to receive our daily email at roomnow.com. Better yet, you can sign up just to get a once a week report on psoriasis or on lupus or once a week email, however you want to do it. This week, we're going to start by talking about autoimmune disease, you know, they're rare conditions, right? Well, we see them, the generalist doesn't, you know, and numbers of autoimmune patients, out there are estimates better done by worldwide estimates, but this month there was an interesting report, for a US estimate. This estimate was based on six large US medical systems and their EHR data, and they were looking for the prevalence of autoimmune disease in The United States and it's felt to be over fifteen million, and that includes many different kinds of autoimmune disease, not just lupus and dermatomyositis, but I think up to 20 something different kinds of forms of autoimmune disease.

An overall population risk of four point six percent, twice as high in women, as in men, and a third of people with autoimmune disease are likely to have two or more autoimmune diseases. That's worth knowing. You may be familiar with the POET TK trials in psoriasis, there's a POET TK PSA1 trial we've been talking about for over a year now, it finally got published. This is ducravacitinib in biologic naive PSA patients, and it tested whether the TYK2 inhibitor primary endpoint, secondary endpoint, joint scan point. It's a drug we're using in rheumatology just as you're using it in psoriasis.

You have the job on it. We had a later FDA approval than you, but this is the evidence upon which our use and FDA approval is based. Moon Lake announced, new positive phase three data, from the ISAR-one control trial. That's using its dual inhibitor, sonolizumab. This is then, I think it's the nanobody, that, looked very good in this trial.

At week 16, patients were either treated with sonolizumab, or placebo. The, rates were very good for ACR 20 joint responses, sixty six percent, ACR, fifty, forty two percent, minimal disease activity, forty one percent, sixty one had a PASI 90 at week sixteen, and there is in process right now another, phase three trial I believe this is going to be. It's going be the ISAR-two trial that will ultimately be used for, approval in psoriasis and psoriatic arthritis. I think it's already approved in psoriasis, is it not? An interesting study comes from the British Dermatology Biologics Registry, the bad beer, it's not something you order when you go out on Friday night, almost nineteen thousand psoriasis patients and they looked at the incidence of serious infections.

Overall, the rate was twenty eight per 1,000 patient years, that's two point eight per 100 patient years. Let me give you a perspective on that. In the pre biologic era, in rheumatoid arthritis, where the rates of serious infections are higher than psoriasis, the rate is about nine per 100 patient years. With the development of all the biologics, especially the TNF inhibitors and whatnot, the rate that was reported in, from like 2000 to twenty twenty something is like three to six per one hundred patient years, suggesting that biologic, biospecific interventions might lower the risk of serious infectious events, maybe by control of inflammation. Overall, SIE rates in dermatology and psoriasis are less than in RA and Crohn's disease.

So, this rate of two point eight per 100 patient years is about what you see with biologics individual trials in psoriasis and also, I must say, also for psoriatic arthritis. The big teaching point of this study was that that rate of serious infection went up threefold to seven point nine per one hundred patient years if the patient had a prior SIE event. If the patient was previously hospitalized with sepsis or septic arthritis or meningitis or, urosepsis, They're more likely to get it again and more likely to get it especially if you're using a biologic. So, that might be someone who you have some degree of hesitancy for. They compared a lot of the drugs and it looked like the lowest risk of a serious infectious event SIE was seen with the IL-twenty three inhibitor, Rizenkizumab, where there was basically a twenty six to twenty percent drop compared to other drugs, and that includes bredalumab, etanercept, and other standards of care.

The good news also in your psoriasis patients is that there's a very low risk of death, less than two cases per one thousand years. That means a thousand patients treated with a biologic followed for a year, only two are going to die related to the drug. I think that's encouraging data. A comparative study looked at which is worse, juvenile systemic sclerosis or adult systemic sclerosis? Meta analysis of 39 studies, nine thirty five juvenile patients, fifteen thousand adult systemic sclerosis, and guess what?

The juveniles had worse diffuse disease, seventy percent versus forty one percent. That's juvenile versus adult. More overlap myositis, thirty three versus five. More arthritis, thirty three versus eighteen, more digital ulcers, fifty one percent versus twenty percent, less renal crisis and less mortality. So, adults have more mortality and more renal crisis, meaning they probably need more comorbidities or more disease duration to develop those ugly, ugly outcomes.

There's a registry cohort study called Spring from Italy that looked at patients with systemic sclerosis, and I don't know about you, but when I get a systemic sclerosis patient, whether it's limited or diffused, I will do nail fold capillaroscopy. I use a cheap 10x child's microscope that I bought at The Container Store for $6 You can buy it online at Amazon for probably 10 or 12, but you probably have a dermatoscope or have a better microscope. So, the idea here is if they have that scleroderma pattern, you know, significant dropout, dilated loops, hemorrhages, that's bad news, that's a more aggressive disease. The question that they asked in this study of almost seventeen thousand patients in their cohort, how many of these people did not have the typical scleroderma pattern on nail fold video capillaroscopy, the best tool that you can use? And it turns out it was only five percent out of the sixteen eighty nine patients.

These people who didn't have the typical scleroderma pattern were going to have milder disease, less vascular complications, less pitting, thirty three percent versus forty eight percent, less telangiectasis, fifty two percent versus seventy four percent, less calcinosis, three percent versus twelve percent, and higher DLCOs at twelve, twenty four, and thirty six months, meaning they had better lung function if they didn't have that scleroderma pattern. Again, this is reason enough to do nail fold capillaroscopy in patients with systemic sclerosis. It only takes, a minute to do. You, are the expert at rashes. We struggle in rheumatology, we learn from you, we want to learn from you, and we've learned, I've learned that, the rashes of dermatomyositis and lupus don't look the same in patients of color.

So, posted for you in the show notes of publication that basically reviews this issue and I put it up for rheumatologists but I thought you may want to have it and use it, and refer your, colleagues that are not, seasoned dermatologists, you know, that red rashes can look brown or violaceous, that Gottrin's lesions and heliotrope lesions can look scaly and eczematous, and the problem is that, if it's not recognized, this will delay the diagnosis and this is a problem, especially in MDA-five positive, patients who have a skin involvement, rapidly progressive and deadly lung involvement. Again, early diagnosis is paramount. This month, upadacitinib was approved for adults and adolescents, in the EMA, that's the European Union, for use in non segmental vitiligo, based on positive results from the VITI up study, giddy up, viddy up, and yeah, upadacitinib works in vitiligo. The list of indications we're going to have for JAK inhibitors in dermatology is going to be large, which means that you need to understand the risks of JAK inhibitors and TIC inhibitors, and not be so freaked out by the oral surveillance study that put a big time warning on the labels of all the JAK inhibitors saying you got to use a TNF before you use a JAK, and that's good advice, but the real risk of cancer, MACE, serious infectious events and VTE was primarily noted in people 65, not 50.

People who had a cardiovascular history like MI and people who were smokers. Having two out of those three are people I definitely wouldn't use a JAK inhibitor in, The rest, I'm using it all the time, but I still think you need to be mindful of the recommendations, and I'm gonna guess that when it gets around to this being approved in The United States, it's gonna have those same warnings and you're gonna need to know how to navigate that. My last report is on a hidradenitis suppurativa. A lot of interesting stuff going on in HS these days. Is a, right now there are three drugs that are FDA approved for hidradenitis secukinumab, adalimumab, bimekizumab.

There's a new JAK1 inhibitor that I'm not familiar with called povoricitinib and they have two studies, the STOP HS1, STOP HS2 studies, two study names but three RCTs, I can't figure that out. Bottom line is combining the data, the povoracitinib or povocitinib had significant results at, week twelve and high SCR50 score of forty two percent with the JAK inhibitor versus twenty nine percent with the placebo. The adverse events with this new drug are like the other ones, Jack me and pharyngitis and nonsensical things. It's been an interesting month for Skin Stuff on roomnow.com. Tune in next month, we'll talk then.