DERM on RheumNow Podcast (December 2025) Save
Features Dr. Jack Cush
Transcription
This is the Derm on Room Now podcast. Hi, I'm Doctor. Jack Cush, executive editor of roomnow.com. Derm on Room Now is a monthly podcast for dermatologists and skin focused healthcare professionals, where we discuss the intersection of dermatology and rheumatology. At RheumNow, we cover the news and curate all the sources to find that which is important to you as far as news info research on topics that Rheum's and Derm's are both concerned with: Psoriasis, psoriatic arthritis, cutaneous lupus, vasculitis, hidradenitis, and a bunch of other connective tissue diseases.
We also cover the efficacy, safety, and regulatory decisions regarding biologics, JAK inhibitors and dermatology therapeutics. Our focus is practical use, real world efficacy and drug safety. We hope that you'll sign up for this podcast and tell your friends about it. You can also register at roomnow.com to receive either our daily newsletter or and it can also be received as a weekly email or a topic specific email. In this week's podcast we'll be talking hydroxychloroquine monitoring, we'll be talking about the role of diet in psoriasis, and defining difficult to treat psoriatic arthritis.
Let's begin with a report from Lancet Rheumatology where the title is Should we be screening skin screening all of our rheumatoid arthritis patients? They basically review the skin cancer risk in patients with rheumatoid arthritis and other inflammatory arthritities, especially noting that both melanoma and non melanoma skin cancers are increased in RA and any condition that has chronic inflammation. They also note that the package insert really instructs you, for at least the TNF inhibitors, that patients taking TNF inhibitors should all have complete skin exams periodically. At one point, I think it was defined as annually, but it's at least periodically. And I know the rheumatologists aren't really doing that and they should be partnering with you to make sure that that's being done.
The bottom line is that this piece, provided the evidence that said skin cancer screening is highly advised. It's interesting that not all biologics mandate, at least per the package insert, skin cancer monitoring. For instance, the IL-seventeen and IL-twenty three inhibitors, it's not part of the package insert. So I thought that you should know at least what I've told my rheumatology colleagues about this issue. You know, we both manage cutaneous lupus and problematic lupus, and there's been a move afoot in the last five years for everyone to be doing hydroxychloroquine blood level monitoring in lupus.
It's been shown to: a) prove compliance with therapy. It's been correlated with efficacy. It's also been correlated with hazardous outcomes. This report that I've cited is a large international observational cohort that took almost 2,000 patients from the SLIC study and looked at hydroxychloroquine blood levels, looked at toxicity, and looked at clinical outcomes. So amongst eighteen forty two lupus patients, four point nine percent had hydroxychloroquine related ocular toxicity.
And they showed that ocular toxicity was clearly correlated with blood levels, and that basically if you had a blood level in the supratherapeutic range, which is defined as greater than eleven fifty ngmL, the risk of ocular toxicity was twofold higher. Also, twofold higher if the cumulative dose of hydroxychloroquine was more than a thousand grams total. So the bottom line is that this is probably advisable most rheumatologists are kind of going this way. This test is available through the commercial labs, LabCorp, Quest, and most universities are now doing this. They also showed in this report that it was particularly useful in high risk people patients with chronic kidney disease, CKD stage three or higher they had an even higher rate of ocular toxicity.
So, again, it probably is advisable that if you have patients on chronic hydroxychloroquine that you don't usually need blood monitoring for that, leave that up to the rheumatologist, and we do it like once a year, once every six months, and that's really to find out if something else is going on unrelated to hydroxychloroquine, but now we probably should be looking at hydroxychloroquine blood levels. Scleroderma we both manage, and scleroderma ILD is a really bad subset for any patient who experiences that, whether they're under your care or under my care. A study of one hundred and seventy seven systemic sclerosis patients, about two thirds of them with systemic ILD, and one third without ILD, they showed that those who had ILD were more likely to have diffuse systemic sclerosis. They were also more likely to have problematic Raynaud's and GI disease. In this study they showed that you could sort of predict the risk of SSC ILD by the triad of laboratory tests which included the neutrophil to lymphocyte ratio, the prothrombin time, and the presence of an SCL70 autoantibody.
The area of the curve here is 88%, sensitivity 83%, specificity 85%. You know, I think it's probably worth doing if you're following these people, but of course what you want to know is: do the patients who have bad skin disease, are they the ones who are likely to progress there? And the answer is yes. Not the focus of this report, but shown in other reports, correlation between diffuse disease, and higher modified Rodden Skin scores, and the risk of ILD is about a point five correlation, so about a moderate correlation. But this is something that affects both of us.
A real fascinoma to me was this report coming out of Israel, where they have a high population, you know, a large volume of patients who have familial Mediterranean fever. In this retrospective study of nine thousand seven hundred patients with FMF who were taking colchicine, they matched that nine thousand seven hundred FMF patients one to ten to ninety seven thousand controls without FMF. And they showed that psoriatic arthritis was more prevalent in FMF patients compared to the non FMF, with a hazard ratio of 3.52, and that was significantly higher. Those at risk included people who were older, people who were smokers, and people who were socioeconomically disadvantaged. Those are kind of risk factors for a lot of inflammatory diseases, but what they did show was that the thing that, you know, we correlate with, that we associate with psoriasis and psoriatic arthritis is this high risk of comorbidities: obesity, diabetes, you know, hyperlipidemia.
And that was not a risk factor. So, whereas older age smoking and socioeconomic status was, But this association between FMF and PSA, this is sort of a novel first time association, if you ask me. This comes from JAMA Dermatology. Another study actually, no, this one's from JAMA Dermatology. It's the Medispo study, M E D I S P O.
It's a small study, thirty eight patients with psoriasis that's mild to moderate, and the intervention here was a Mediterranean diet versus a low fat diet. At the end of sixteen weeks, those on the Mediterranean diet did much better: they had significant drops in their Posse scores of -3.4 versus on the low fat diet, and the number of people achieving a Posse 75 reduction again they had mild to moderate disease was forty seven percent versus zero, favoring again the Mediterranean diet. Now, we know that diet, you know, obesity is really a big issue, and that weight loss gives you tremendous benefits in both psoriasis and in psoriatic arthritis. Here they're showing you a specific dietary intervention proving the point that's been made by others. A large study from Taiwan, about a twenty year study, looked at two thousand four hundred psoriatic arthritis patients who were treated with one or more DMARDs, and then compared those who were treated with biologic DMARDs, about 1,200 versus conventional DMARDs.
So we're talking conventional DMARTs, sulfasalazine, hydroxychloroquine, methotrexate versus biologics. And being on a biologic was associated with significantly lower risk of major adverse cardiac events or MACE events, a thirty five percent reduction. It was also associated with a fifty six percent reduction in all cause mortality, and a forty six percent reduction in cardiovascular mortality. But, if you're on a biologic, you had a forty five percent higher risk of infection that led to hospitalization. How do I read that?
Control of inflammation is really good as far as controlling cardiovascular and mortality risks. But if you are so inflamed that you're going to get on a biologic, you're probably carrying over an infectious risk. I don't know that that infection related hospitalizations I can't prove that it's related to the drug or is related to the underlying inflammation because I didn't really look at that. But that's what I teach and what I strongly believe based on a lot of research. So, I would be aggressive about using biologic in those that deserve it, and it's obviously you're already looking at or worried about serious infections, are you not?
Two more reports. One, there's been a GRAPA is a group of investigators who study psoriatic arthritis. They have come together and come up with a consensus definition for difficult to treat psoriatic arthritis. We know that this is a substantial number of patients that we see, that you see as well. It's at least probably five to ten percent of people who are difficult, persistent, hard to treat, and they really came up with two different definitions.
They didn't want to use difficult to treat because the patients didn't want to be called difficult. I personally like being called difficult because I think I get, a little more attention. But then again, that's me. They did label these groups as complex to manage, C2M PSA, and treatment refractory PSA, or TR PSA. Complex to manage is the persistence of symptoms, and difficult disease having received at least two or more biologic or targeted synthetics, and that could be, you know, a lot of other factors could be in play there as well.
The other more stringent definition of treatment refractory disease, treatment refractory or TR PSA is a subset of C2M PSA, and those people have to be more difficult by having failed three or more targeted or biologic synthetics with different MOAs and at least two, and at least two of the the different MOA drugs have to be biologic or targeted synthetics. They have to have persistent, ongoing symptoms and evidence of inflammation on laboratory and exam. Why are they doing this? I don't know that, you're going to be labelling your patients as such, or whether dermatology is going to adopt similar definitions for complex to manage psoriasis and treatment refractory psoriasis, it probably wouldn't be a bad idea, because when these definitions are established, now you're fostering research on what to do with these subsets. How they can be approached.
Do they really need more aggressive therapy, or a specific therapy? Or are there other things in play, like comorbidities, that are leaving patients as refractory. So it's going to help research, it's going to help, us to further define management. Lastly, I'll point you to a publication, on a tremendous review of dermatomyositis in seminars in immuno pathology written by Victoria Worth from the University of Pennsylvania and her colleagues. It's a full read article, talks about etiology, pathogenesis, cytokines, genetics, environmental factors, specific treatments for specific scenarios.
As you know, Doctor. Wirth has led a lot of research in this. She's developed the skin score outcomes for both lupus and dermatomyositis. It's a really good reference that you probably should take note of. Anyway, that's it for the December issue of Derm on RheumNow.
We do hope that you had a wonderful holiday. I'll encourage you to sign up for this podcast, give us a good score. Go to rheumnow.com and register to receive the daily or weekly email. And you know what? RheumNow has a great meeting coming up at, in Dallas on February 2026.
It's called RheumNow Live. It's a day and a half meeting. We've got a few dermatologists lecturing, a bunch of dermatologists, nurse practitioners, physician assistants do attend. I think you'll find it interesting. Hope to see you there.
Take care.
We also cover the efficacy, safety, and regulatory decisions regarding biologics, JAK inhibitors and dermatology therapeutics. Our focus is practical use, real world efficacy and drug safety. We hope that you'll sign up for this podcast and tell your friends about it. You can also register at roomnow.com to receive either our daily newsletter or and it can also be received as a weekly email or a topic specific email. In this week's podcast we'll be talking hydroxychloroquine monitoring, we'll be talking about the role of diet in psoriasis, and defining difficult to treat psoriatic arthritis.
Let's begin with a report from Lancet Rheumatology where the title is Should we be screening skin screening all of our rheumatoid arthritis patients? They basically review the skin cancer risk in patients with rheumatoid arthritis and other inflammatory arthritities, especially noting that both melanoma and non melanoma skin cancers are increased in RA and any condition that has chronic inflammation. They also note that the package insert really instructs you, for at least the TNF inhibitors, that patients taking TNF inhibitors should all have complete skin exams periodically. At one point, I think it was defined as annually, but it's at least periodically. And I know the rheumatologists aren't really doing that and they should be partnering with you to make sure that that's being done.
The bottom line is that this piece, provided the evidence that said skin cancer screening is highly advised. It's interesting that not all biologics mandate, at least per the package insert, skin cancer monitoring. For instance, the IL-seventeen and IL-twenty three inhibitors, it's not part of the package insert. So I thought that you should know at least what I've told my rheumatology colleagues about this issue. You know, we both manage cutaneous lupus and problematic lupus, and there's been a move afoot in the last five years for everyone to be doing hydroxychloroquine blood level monitoring in lupus.
It's been shown to: a) prove compliance with therapy. It's been correlated with efficacy. It's also been correlated with hazardous outcomes. This report that I've cited is a large international observational cohort that took almost 2,000 patients from the SLIC study and looked at hydroxychloroquine blood levels, looked at toxicity, and looked at clinical outcomes. So amongst eighteen forty two lupus patients, four point nine percent had hydroxychloroquine related ocular toxicity.
And they showed that ocular toxicity was clearly correlated with blood levels, and that basically if you had a blood level in the supratherapeutic range, which is defined as greater than eleven fifty ngmL, the risk of ocular toxicity was twofold higher. Also, twofold higher if the cumulative dose of hydroxychloroquine was more than a thousand grams total. So the bottom line is that this is probably advisable most rheumatologists are kind of going this way. This test is available through the commercial labs, LabCorp, Quest, and most universities are now doing this. They also showed in this report that it was particularly useful in high risk people patients with chronic kidney disease, CKD stage three or higher they had an even higher rate of ocular toxicity.
So, again, it probably is advisable that if you have patients on chronic hydroxychloroquine that you don't usually need blood monitoring for that, leave that up to the rheumatologist, and we do it like once a year, once every six months, and that's really to find out if something else is going on unrelated to hydroxychloroquine, but now we probably should be looking at hydroxychloroquine blood levels. Scleroderma we both manage, and scleroderma ILD is a really bad subset for any patient who experiences that, whether they're under your care or under my care. A study of one hundred and seventy seven systemic sclerosis patients, about two thirds of them with systemic ILD, and one third without ILD, they showed that those who had ILD were more likely to have diffuse systemic sclerosis. They were also more likely to have problematic Raynaud's and GI disease. In this study they showed that you could sort of predict the risk of SSC ILD by the triad of laboratory tests which included the neutrophil to lymphocyte ratio, the prothrombin time, and the presence of an SCL70 autoantibody.
The area of the curve here is 88%, sensitivity 83%, specificity 85%. You know, I think it's probably worth doing if you're following these people, but of course what you want to know is: do the patients who have bad skin disease, are they the ones who are likely to progress there? And the answer is yes. Not the focus of this report, but shown in other reports, correlation between diffuse disease, and higher modified Rodden Skin scores, and the risk of ILD is about a point five correlation, so about a moderate correlation. But this is something that affects both of us.
A real fascinoma to me was this report coming out of Israel, where they have a high population, you know, a large volume of patients who have familial Mediterranean fever. In this retrospective study of nine thousand seven hundred patients with FMF who were taking colchicine, they matched that nine thousand seven hundred FMF patients one to ten to ninety seven thousand controls without FMF. And they showed that psoriatic arthritis was more prevalent in FMF patients compared to the non FMF, with a hazard ratio of 3.52, and that was significantly higher. Those at risk included people who were older, people who were smokers, and people who were socioeconomically disadvantaged. Those are kind of risk factors for a lot of inflammatory diseases, but what they did show was that the thing that, you know, we correlate with, that we associate with psoriasis and psoriatic arthritis is this high risk of comorbidities: obesity, diabetes, you know, hyperlipidemia.
And that was not a risk factor. So, whereas older age smoking and socioeconomic status was, But this association between FMF and PSA, this is sort of a novel first time association, if you ask me. This comes from JAMA Dermatology. Another study actually, no, this one's from JAMA Dermatology. It's the Medispo study, M E D I S P O.
It's a small study, thirty eight patients with psoriasis that's mild to moderate, and the intervention here was a Mediterranean diet versus a low fat diet. At the end of sixteen weeks, those on the Mediterranean diet did much better: they had significant drops in their Posse scores of -3.4 versus on the low fat diet, and the number of people achieving a Posse 75 reduction again they had mild to moderate disease was forty seven percent versus zero, favoring again the Mediterranean diet. Now, we know that diet, you know, obesity is really a big issue, and that weight loss gives you tremendous benefits in both psoriasis and in psoriatic arthritis. Here they're showing you a specific dietary intervention proving the point that's been made by others. A large study from Taiwan, about a twenty year study, looked at two thousand four hundred psoriatic arthritis patients who were treated with one or more DMARDs, and then compared those who were treated with biologic DMARDs, about 1,200 versus conventional DMARDs.
So we're talking conventional DMARTs, sulfasalazine, hydroxychloroquine, methotrexate versus biologics. And being on a biologic was associated with significantly lower risk of major adverse cardiac events or MACE events, a thirty five percent reduction. It was also associated with a fifty six percent reduction in all cause mortality, and a forty six percent reduction in cardiovascular mortality. But, if you're on a biologic, you had a forty five percent higher risk of infection that led to hospitalization. How do I read that?
Control of inflammation is really good as far as controlling cardiovascular and mortality risks. But if you are so inflamed that you're going to get on a biologic, you're probably carrying over an infectious risk. I don't know that that infection related hospitalizations I can't prove that it's related to the drug or is related to the underlying inflammation because I didn't really look at that. But that's what I teach and what I strongly believe based on a lot of research. So, I would be aggressive about using biologic in those that deserve it, and it's obviously you're already looking at or worried about serious infections, are you not?
Two more reports. One, there's been a GRAPA is a group of investigators who study psoriatic arthritis. They have come together and come up with a consensus definition for difficult to treat psoriatic arthritis. We know that this is a substantial number of patients that we see, that you see as well. It's at least probably five to ten percent of people who are difficult, persistent, hard to treat, and they really came up with two different definitions.
They didn't want to use difficult to treat because the patients didn't want to be called difficult. I personally like being called difficult because I think I get, a little more attention. But then again, that's me. They did label these groups as complex to manage, C2M PSA, and treatment refractory PSA, or TR PSA. Complex to manage is the persistence of symptoms, and difficult disease having received at least two or more biologic or targeted synthetics, and that could be, you know, a lot of other factors could be in play there as well.
The other more stringent definition of treatment refractory disease, treatment refractory or TR PSA is a subset of C2M PSA, and those people have to be more difficult by having failed three or more targeted or biologic synthetics with different MOAs and at least two, and at least two of the the different MOA drugs have to be biologic or targeted synthetics. They have to have persistent, ongoing symptoms and evidence of inflammation on laboratory and exam. Why are they doing this? I don't know that, you're going to be labelling your patients as such, or whether dermatology is going to adopt similar definitions for complex to manage psoriasis and treatment refractory psoriasis, it probably wouldn't be a bad idea, because when these definitions are established, now you're fostering research on what to do with these subsets. How they can be approached.
Do they really need more aggressive therapy, or a specific therapy? Or are there other things in play, like comorbidities, that are leaving patients as refractory. So it's going to help research, it's going to help, us to further define management. Lastly, I'll point you to a publication, on a tremendous review of dermatomyositis in seminars in immuno pathology written by Victoria Worth from the University of Pennsylvania and her colleagues. It's a full read article, talks about etiology, pathogenesis, cytokines, genetics, environmental factors, specific treatments for specific scenarios.
As you know, Doctor. Wirth has led a lot of research in this. She's developed the skin score outcomes for both lupus and dermatomyositis. It's a really good reference that you probably should take note of. Anyway, that's it for the December issue of Derm on RheumNow.
We do hope that you had a wonderful holiday. I'll encourage you to sign up for this podcast, give us a good score. Go to rheumnow.com and register to receive the daily or weekly email. And you know what? RheumNow has a great meeting coming up at, in Dallas on February 2026.
It's called RheumNow Live. It's a day and a half meeting. We've got a few dermatologists lecturing, a bunch of dermatologists, nurse practitioners, physician assistants do attend. I think you'll find it interesting. Hope to see you there.
Take care.
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