DERM on RheumNow PODCAST (September 2026) Save

Welcome to the September 2026 edition of the DermNow RheumNow podcast. You're the experts on rashes, right? We rheumatologists, we got the joints, but you know, we both deal with a lot of overlap. We both deal with inflammation and autoimmunity. Our patients overlap, so should our knowledge. I'm Jack Cush, executive editor of RheumNow.com. The DermNow RheumNow podcast is for you and it's for you to know our take on what happened in dermatology this past month that we covered on RheumNow.com. So, let's get to the news.

This past month the FDA granted a priority review for zasocitanib, a new investigational TYK2 inhibitor like deucravacitinib, and this priority review is for the indication of plaque psoriasis. There's an expectation that this drug could be approved in the first quarter of 2027. The data supports its use. There's at least three randomized control trials over 3,000 patients in what's called the LATITUDE PSO 3001 and 3002 trials. This is the basis for future approval. It's up in front of the FDA. It's also been submitted to the EMA for potential approval in Europe.

A study this week looked at pregnancy in psoriasis patients. 290 pregnancies and 211 of those ended up in live births. That's a 73% rate. And the interesting thing about all these pregnancies is that there was biologic exposure. Interestingly, the most commonly used biologic at the time of conception was ixekizumab in 241 of those 290 cases, and in 42, TNF inhibitors. And the interesting thing about this data is that one, there were favorable outcomes, meaning expected rates of live births, good fetal outcomes, low birth weight, miscarriages, very few congenital anomalies. But the other surprising thing about this data set was that only 24 of those exposed patients carried the pregnancy while on a biologic, and they stayed on a biologic split between certolizumab and adalimumab, and that did not affect the outcomes. The point here is that it seems that dermatologists are not likely to continue the biologic. Maybe it's the dermatologist, maybe it's the patients.

I want to put that in contrast to GI gastroenterology with IBD. Everybody continues biologic and thiopurine, either 6-MP or azathioprine therapy. In rheumatology, it's about 70% of RA, PsA, and ankylosing spondylitis patients who continue their biologic therapy, with certolizumab leading the way. Less is known about newer drugs like IL-17, IL-23, and JAK inhibitors, where their use would be speculative at best. So what's the deal there? Maybe you can tell me.

An analysis of the SELECT-PsA 2 study — SELECT means it's an upadacitinib study, right — 195 PsA patients not responding to a TNF inhibitor were either switched to a JAK inhibitor or placebo, and guess what: upadacitinib was significantly better, 58% versus 22% with an arthritis outcome, MDA minimal disease activity 24% versus 3%. The point here is that after you fail a TNF inhibitor in psoriatic arthritis, looking at mainly arthritis outcomes, it's far better to switch drug classes than to keep playing the TNF inhibitors, where some will respond but you're going to lose response rates. Switching classes is currently the norm in rheumatology management and is endorsed by EULAR, the European League Against Rheumatism, in their guidelines for rheumatoid arthritis and other diseases. So switching MOAs is the way to go.

A number of studies we've talked about in the past have examined whether taking a biologic for psoriasis lowers the risk of future psoriatic arthritis. Patients with psoriasis have a 30% risk of future psoriatic arthritis. In rheumatology terms, we think of this as a preclinical psoriatic arthritis condition — it's not yet psoriatic arthritis, it might be. Maybe if you gave them more aggressive treatment, they wouldn't get psoriatic arthritis. We do know that patients with more aggressive psoriasis are at higher risk to develop psoriatic arthritis. Anyway, a meta-analysis of 15 studies, 124,000 PsA patients, and 780,000 patient years of follow-up show that biologic use lowers the risk of PsA by 46%. And that's significant. The best data was seen with IL-17 inhibitors, a 35% lowering, and IL-23 or IL-12/23 inhibitors, a 54% lowering, when compared to those who were treated with a TNF inhibitor. Looks like head-to-head, IL-23 may be superior to IL-17 in preventing future psoriatic arthritis — the lowering was 33% in favor of the IL-23 inhibitor. Again, these studies are always retrospective large cohort analyses. There is no prospective study here, but I think there's a consistency of messaging that says that yeah, when you guys are aggressive, we rheumatologists benefit. Please be aggressive.

Juvenile dermatomyositis can be a big problem, especially in the management of calcinosis cutis. I have here a 20-patient small study, open-label study of tofacitinib in JDM, average age 10 years. They had on average calcinosis cutis for 31 months. They measured
calcinosis using calcium scores by CT, the Agatston scores, and showed the calcium content went down on these topically treated JDM kids from a score of 6,349 — that's kind of high — to 4,000. No serious adverse events with tofacitinib. Obviously this is a setup for what should be a prospective randomized either active control or placebo control trial going forward. Except it's not going to happen with tofacitinib because tofacitinib just went generic this year.

By the way, if you're not using tofacitinib, you should be. 5 milligrams BID is 25 bucks a month using Cost Plus Pharmacy — that's Mark Cuban's pharmacy. If you use GoodRx, it's 140 bucks a month. If there are some other sources selling generic tofacitinib, it's like $1,400 a month. That's a ripoff. But again, Cost Plus Pharmacy — people who need drugs, and again boy, you have a lot of indications for JAK inhibition use in your patients. They got to use the 5 milligram BID dose. There is no two 5 milligram pills once a day — that's not equivalent to the 11 milligrams once a day. But still, it's dirt cheap. Why not know about it? Why not use it?

A lupus analysis looked at metabolic syndrome. This was a meta-analysis, 65 articles, 11,000 patients, and you're used to this with psoriatic arthritis and we're trying to grapple with comorbidities in rheumatology, especially in psoriasis and lupus and RA. Anyway, the metabolic syndrome is 27% elevated in lupus patients, higher in males than females — 36% in males. But the interesting thing in this study was that those patients who were treated for lupus who are treated with hydroxychloroquine had a significant 33% lower risk of metabolic syndrome. In contrast, patients treated with Cytoxan had a significantly higher 39%. Azathioprine 25%, and mycophenolate — and this reflects the severity of disease, that they're getting these aggressive therapies, and the severity of disease brings with it metabolic syndrome, maybe because of steroid use and whatnot in lupus. But it turns out that steroids and methotrexate don't change the metabolic syndrome risk. And as expected, these patients with lupus who have metabolic syndrome were older, obese, high cholesterol, high LDL.

You guys are dealing with the JAK inhibitor story — oral surveillance, you know, the worries about venous thromboembolic events, malignancy risk, cardiovascular risk. You've got to use a TNF inhibitor before a JAK inhibitor. I want to point out for you two bits of data that came out recently that you should know about.

There's a TriNetX study, which is a massive few-million-patient retrospective EHR review of venous thromboembolic events in RA patients taking a JAK inhibitor, and they did not show an increased risk of VTE events. These were RA patients undergoing joint replacement surgery. The risk was higher, but it wasn't significant. The relative risk was 1.57 — 6% versus 3.8%. But I don't know if I can believe this because it's retrospective. It's an EHR review. TriNetX gives you some funny data. The propensity matching isn't as good as it should be unless it's done by real epidemiologic professionals.

I want to contrast this data with something that was just presented at the EULAR meeting in London in June. It's called the RA-BRANCH study. This was a study of baricitinib. When baricitinib was approved, they had in the label a risk of VTE. They made them do a post-regulatory commitment to do a large-scale study looking at the VTE risk. That completed and was reported at EULAR. It's going to be reported in November at the ACR meeting. 3,600 patients randomized to receive either a TNF inhibitor — etanercept or adalimumab — or baricitinib 2 milligrams a day or 4 milligrams a day. They followed them out three or four years and they showed a very clear increase in VTE events with either the 2 or the 4 milligram baricitinib dose compared to TNF inhibitors. That was significant. By the way, what was not significant was the MACE or cancer risk in that study.

So the bottom line here is I believe JAK inhibitors do carry a VTE risk. If your patients have had a prior pulmonary embolism or DVT that was serious, they probably should not be put on a JAK inhibitor. I think the risk for cardiovascular events and cancer is highest in those who are older than 65, with a cardiac history and with a smoking history, and that's how I guide my use of JAK inhibitors.

This month, September, on RheumNow, we committed to a large campaign on obesity and rheumatic disease. You guys deal with this. It's a big problem. I want to give you a few reports on obesity that will keep you up to date with what the rheumatologists were presented with. An analysis of the Swiss data on PsA showed that the risk of being overweight or obese was 66% in Switzerland versus a general population risk of 43%. In the United States — this is not part of this study, but I know the recent data — 72% of US patients are either overweight or obese if they
have psoriatic disease, psoriatic arthritis. Um it's 10, it's 10 points lower if they don't have psoriatic disease. Not good. So again, this is a big problem. Um, obesity was also associated with higher CRP, higher patient global, MD global and functional scores as well. Obesity is a bad player as you know. The question is when your patients go on these new GLP-1 drugs, what happens?

A study of 119 rheumatic patients on GLP-1 therapy, 2/3 for diabetes, 1/3 for obesity, they had a mean BMI of 35. 12 months later, significant weight loss and 56% lowered themselves from one BMI category to the one lower — if they were obese category 1, 30 um they drop down to overweight meaning 25 to 30 etc. Significant decreases in these patients in A1C, uh blood sugars, lipids, LDL, triglycerides, LDLs, CRP. These drugs have tremendous cardiometabolic benefit.

A thing that our patients are often dealing with now is online pitches for getting on GLP-1. You know, Serena Williams, Charles Barkley, the company Ro, they're, you know, they're pushing these things. These are largely online compounding pharmacies that are manufacturing the drug. These are not coming directly from Lilly or other manufacturers. It's estimated that 7 million Americans are getting their GLP-1 drug online from a compounding source. The problem is these are not FDA approved. They're allowed because one or two years ago there was a shortage of these GLP-1 incretin therapies, incretin therapies, excuse me. Um, and because of the shortage, um, the drugs could be compounded by a pharmacy. Except there's no more shortage, and the government's about to shut down this what's called 503b loophole that will probably outlaw these copycat drugs.

The problem for you and I is, yeah, seems like a good idea. Go ahead, get it, especially if you can save some money. But their purity and consistency and safety is very, very suspect. I mean, just look it up. It's a lot of problems. I don't recommend that you recommend your patients take these from online sources. Um, look into the Medicare program for $50 a month for people to receive a GLP-1 drug. That's a great way to go. Uh, you're going to have to deal with, you know, prior authorizations and paperwork, but it does work well.

Um, data presented at a 2024 bariatric society meeting showed that weight loss surgeries dropped about 23% from 2022 to 2024. Um and you know it's not good — 230,000 in 2022 to 177,000. Um yet they say that despite this drop, very few people are getting weight loss surgery. Bariatric surgery — less than 1% who are actually eligible are getting it — and by the way bariatric surgery has proven to actually work better than the GLP-1 drugs, with greater durability and consistency over time. Don't take that off the table. Refer your patients to either weight loss centers who can discuss that with your patients or to bariatric surgeons.

An update of the SURMOUNT-PSA study and SURMOUNT-PSO study shows the 12-month benefits, uh the week 52 benefits. Um in the PSO study 274 patients um the primary endpoint was a PASI 100 plus 10% weight loss or more. Um the week 52 data was 31% for tirzepatide with Zepbound versus 4% tirzepatide alone, showing that there's a durability to this response. This is a major study for both of us.

Um, two more reports. The FDA approved uh last month brepocitinib for the treatment of dermatomyositis. Brepocitinib is a combination JAK1/TYK2 inhibitor uh approved for use in patients with dermatomyositis not responding to conventional therapy. It's estimated that there are about 40,000 or more patients with dermatomyositis in the United States. The approval was based on the VALOR study, a phase 3 241-patient study where they either got 30 or 15 milligrams of brepocitinib, also called now Lisen, and Lisen was shown to be significantly better at what's called the Total Improvement Score, the TIS score, which is an improvement of muscle function and CPK. But when they looked at skin outcomes they were also much, much better. Now we have two FDA approved drugs for dermatomyositis — one is IVIG and the second now is brepocitinib. There are other drugs that have been in development here and of course I'm sure you're using methotrexate. I use a lot of leflunomide I must say in my problematic or um actually in first line in my patients with either dermatomyositis or polymyositis — that's me, and there's anecdotal evidence of that.

Lastly, um, IgA vasculitis — we both see, we both deal with. There are maybe 10% of those patients who will have necrotizing arteritis on biopsy. That's a bad group. This review paper looked at 30 patients with necrotizing arteritis with IgA vasculitis, compared them to 200 adults with plain old IgA vasculitis and 196 PAN patients. Again, IgA vasculitis with necrotizing arteritis — more severe, more life-threatening disease, more morbidity, more mortality. When you see this, patients need to have vascular imaging, large vessel vascular imaging, small vessel vascular
imaging and have and need to be treated with intensive immunosuppression. When you looked at these patients they had more GI bleeds, more perforation, surgical abdomen, neuropathy, pancreatitis, libido, and multi-organ involvement, and yes, more mortality.

Um, I don't see many of those. I have seen a few in my career. I think you're going to see more than I see.

Anyway, that's it for this month on Derm on RheumNow. Please share this podcast with your colleague, especially the nurse practitioners and physician associates. You and they can sign up for the daily or weekly RheumNow report, or you can sign up for just either a lupus weekly report or a psoriasis weekly report at RheumNow.com. Until then, keep it up. We're going to continue to have this skin and joint cross talk thing going forward. Take care.