Derm on RheumNow (Aug 2025) Save

This is the Derm on RheumNow podcast. Hi. I'm doctor Jack Cush, editor of roomnow.com, and this is the August 2025 edition. Derm on RheumNow is content curated for dermatologists and you skin deep health care providers who are interested in all things derm. We cover a lot of rheumatology on roomnow.com, but we also cover lupus vasculitis, psoriasis, hydradenitis, and derm drugs, their use, efficacy, safety, a lot that is of interest to dermatology.

So we're going to cover items that I put out there on social media and post up on our website, rheumnow.com. This includes feature articles and tweets. So let's get to it. Our first is a report on the cardiovascular risk associated with CLE, chronic cutaneous lupus erythematosus. This is a retrospective claims data analysis of a large number of patients.

Specifically they're comparing patients with CLE over eight thousand, with twenty four thousand systemic lupus patients, one hundred and ninety two thousand psoriasis patients, and eighty one thousand controls. After a lot of adjustments and multivariate analysis, when you look at the outcomes as far as atherosclerotic cardiovascular events over a three year period, the rate was lowest in controls at ten events per 1,000 patient years. That's a thousand patients followed one year, 10 events, etc. In psoriasis, it's up, it's forty percent higher at fourteen per one thousand. CLE is like psoriasis, it's at fifteen per one thousand person years, and lupus is the highest at twenty five thousand per 1,000 patient years.

So 1,000 patient years, convert that to 100 patient years, it goes from twenty five down to two point five for 100 patient years. That gives you a relative risk, as you might consider that for your patients with chronic lupus. So we're worried about comorbidity and cardiovascular comorbidities in chronic psoriasis patients. We should also be worried about it in other forms of chronic cutaneous inflammation, including lupus and CLE. Another interesting claims data study was published this past month coming from Joe Marola and colleagues at UT Southwestern.

This was looking at the safety of using what he called combination targeted therapies. So while you know there one of the big things going on in psoriasis right now is that there are these combination biologic studies that are in play. They the early story is that they look to be safe, but we're gonna see what they do. We need the results. So Marola and colleagues actually looked at a large number of PSA patients, eighty two thousand, and found that about one percent, or specifically five forty two, were on these CTTs, combination targeted therapies.

But it's not what you think. It's really a Primalas plus an IL-seventeen inhibitor or primalase plus a TNF inhibitor is the two biggest groups here, but other combos are also in play. And the question is, when you were taking two of these drugs, were you at higher risk than if you were taking just one of these drugs? And it turns out when it comes to serious infection, you're at no higher risk. The rate ratio is below one, it's point five three, so it's actually forty seven percent lower, but it crosses over one, so it's not inferior to taking one drug or not any more serious than taking one drug.

Opportunistic was exactly one, again, crossing over one. So it turns out, again, this report, since it's claims data, can't look at efficacy. But they are looking at safety, and that is one of the main concerns, is it not? We need more data on combination therapy in patients with difficult psoriatic disease. You need it in dermatology, I need it in rheumatology.

One thing that we rheumatologists have learned from the dermatologists is this term, Jackne. What? That's right, acne occurring with JAK inhibitors, and I've reported a lot on it in the last two years, three years, and my rheumatology colleagues say I never see it, and I had to admit that most of the reports were coming from the dermatology literature. But here I found a report that comes from patients with IBD. So this is almost two thousand two hundred IBD patients who are taking JAK inhibitors, and more than ten percent, two seventy two, developed acne, so that would be called JACNE, would it not?

Again, the actual, drugs that were implicated here, it happened in sixteen percent on upadacitinib, four percent on tofacitinib, two percent on filgotinib, and for upa and tofa, it was dose dependent. The more higher dose you use, the more the risk. Again, I don't know what this means, and maybe you do being in the field, but patients who had a prior history of acne vulgaris had a fivefold increased risk of getting jackknee if they went on a jack. Now is that recurrence of their acne, and it's being attributed to the jack? Is that the jack flaring the acne?

Does it even matter? What you'd have to know is what happens if you stop the jack? Does the acne flare go away? Anyway, the patients who are more likely to get this were between the ages of 30 and 50, had mild to moderate severity, and then they tended to get it in the first three months. Watch for the jackknee, it's coming to a clinic near you.

Nailfold capilloscopy, we do it in rheumatology, I assume sometimes you do it too. A review of its use in two fifty eight patients with systemic sclerosis and controls found that the most specific finding on nail fold video capillaroscopy was giant capillaries, giant capillaries, these big dilated tortuous vessels, with a specificity of 98%, and then capillary density, aka dropout, that was best at defining a scleroderma pattern on nail foil testing. So dropout was defined as a density of eight or fewer capillaries per millimeter, that had an AUC of 91%. Again, having both these things, while found in thirty nine percent of patients who had scleroderma, ultimately, it had a ninety one percent accuracy when it was found. Interesting to note.

Something of concern to another thing of concern to both rheumatology dermatology is whether psoriasis patients are at a risk for developing psoriatic arthritis. A lot written about this, as you know. This is sort of a problematic area, and, you know, three percent of the population has psoriasis, up to thirty percent of psoriasis patients will get psoriatic arthritis or develop it. It tends to be more likely in patients who have more severe skin disease, and there's a number of tools that have been developed that you could use, and these are survey tools that you can use in your clinic to know who to refer and whatnot, and that includes the PEST and the passe and EARD and TOPA surveys. I'm going to tell you based on this report, just order an MRI and an ultrasound to figure out who you need to refer.

So this was a meta analysis of 12 studies, included sixteen hundred psoriasis patients, three twenty seven PSA patients, and six eighty six controls. It turns out when in amongst all these people that if subclinical synovitis was found, meaning these patients didn't have swollen joints or complain of swollen joints, but was found on either MRI or ultrasound, there was two and a half fold more likely to be found amongst people with psoriasis. So your patients with psoriasis are at risk. Detection was higher than with ultrasound. So ultrasound, gave a relative risk of six point four, I'm sorry, MRI relative risk of six point four, ultrasound two point five.

So again, to consider, as a screening tool. I think that this is valuable, and it could be done in lieu of or as a first step before you refer to rheumatology. Think about it. Two more reports, one about the efficiency of ANA testing, something you deal with, everyone in medicine deals with this. This is a large cohort study from a federal hospital system where they did chart reviews when ANAs were ordered, that's on 2,500 individuals.

Turns out that, ninety seven percent of the ANAs that were ordered did not lead to a rheumatic or autoimmune diagnosis. Again, lot of these were being done for a lot of reasons. Most of them were being done in primary care. Of those that were ANA positive, thirteen percent were diagnosed with a new autoimmune rheumatic disease, most often Sjogren's lupus and undifferentiated connective tissue disease. In the ANA negative group, only one percent, one point six percent, were diagnosed with a new autoimmune or rheumatic condition, and that was most most frequently RA or spondyloarthritis.

So the point is, and one of my teaching is, don't order an ANA for one reason. You need, like, three or four reasons. You need three or four good criteria or symptoms of lupus to make ordering the ANA have clinical utility. If you're ordering an ANA with someone with arthralgia, it has almost no predictive value. If you order an ANA in someone who's got arthralgia, Raynaud's, a malar rash, a family history, well, now it probably does mean more.

So, again, you're ratcheting closer and closer to the diagnosis once you find that positive result. The last report is about a TYK2 inhibitor. You have ducravacitinib currently approved for use in psoriasis. We don't have it approved for psoriatic arthritis, although that may happen later this year. Another TYK2 inhibitor in development is called Zazosidenib, TAK-two seventy nine, made by Takeda, and they reported their, phase two clinical trial results on almost three thousand psoriatic arthritis patients who were randomized to receive either placebo, thirty milligrams, fifteen milligrams, or five milligrams once a day.

The primary endpoint was twelve weeks, it was a one year study. The twelve week outcome, and this was an arthritis outcome, obviously showed efficacy for the thirty milligram and fifteen milligram dose, both having more than fifty three percent ACR20 responses, as I say ACR 20 is a composite arthritis response of seven variables, where you have to improve in each variable by more than 20% at least five out of seven times. It's actually hard to achieve, it's not 20% improvement, it's actually much more than that. The placebo response was twenty nine percent, so the delta over placebo, the treatment effect is twenty percent and that's pretty good. That's enough to get you into a new phase three, large phase three trial, so that's encouraging.

There might be more than one TIC inhibitor out there in the market, and the question is, how will you use it? And, you'll probably teach us in rheumatology how to best use, a TIC two, because we're certainly gonna need that advice coming up later in 2025. There were no new, safety signals in the study indicating, again, its safety going forward. So that's it for the first episode of Derm on RheumNow. Tell your friends we'll do this once a month look for us in September.

Bye