Derms and Conditions

• Teabag with Dr. D #1: Answers to Questions After FC2025

  In this “Teabag” episode of Tea with Dr. D, host James Q. Del Rosso, DO, tackles questions submitted by dermatology clinicians across the country, offering evidence-based insights across several challenging clinical topics. Dr Del Rosso begins with hidradenitis suppurativa (HS), highlighting the importance of recognizing comorbidities and lifestyle factors that contribute to disease onset and progression, including smoking and elevated body mass index. He advises a phased management approach: prioritizing symptom control and patient comfort before introducing discussions about weight loss or smoking cessation. Depression, diabetes, metabolic syndrome, and cardiovascular disease are also important comorbidities to address over time. On initiating biologic therapy for HS, he explains the 3 pathologic phases, inflammatory, destructive, and burnout, and emphasizes that biologics such as adalimumab, secukinumab, or bimekizumab should be started early, in the inflammatory phase, to prevent irreversible scarring and sinus tract formation. He also shares procedural pearls, including the use of high-dose intralesional triamcinolone, incision and drainage, and deroofing for focal or persistent lesions. The discussion then shifts to photodynamic therapy (PDT) for nonmelanoma skin cancers. Referencing a study by Schlesinger et al, Dr Del Rosso reviews the efficacy of red-light PDT with 10% aminolevulinic acid gel for superficial BCC, highlighting improved clearance rates and favorable cosmetic outcomes over vehicle. Finally, Dr Del Rosso reviews new insights into topical nonsteroidal options for lichen planus, including off-label use of roflumilast and ruxolitinib creams. Both agents, with mechanisms targeting PDE4 and JAK pathways, respectively, have demonstrated reductions in inflammation and pruritus in some reports. Tune in for a concise, high-yield discussion featuring Dr Del Rosso’s practical guidance and clinical pearls for today’s dermatology practice.

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• Two Valuable Perspectives from Two Brilliant Dermatologists: Expanding the Value of Topical PDE4 Inhibition

  In this episode of Tea with Dr D, host James Q. Del Rosso, DO, is joined by Christopher Bunick, MD, PhD, and later Lisa Swanson, MD, for a deep look at phosphodiesterase-4 (PDE4) inhibition in dermatology, with a special focus on topical roflumilast.  Dr Bunick opens with a primer on the science of PDE4, an enzyme that degrades cyclic AMP (cAMP), an intracellular messenger that regulates anti-inflammatory pathways. In conditions such as atopic dermatitis (AD) and psoriasis, overactive PDE4 leads to reduced cAMP and amplified inflammation. By “gumming up” PDE4, roflumilast restores a more balanced, anti-inflammatory state.  He explains why PDE4 inhibition is relevant across multiple inflammatory pathways, including Th1, Th2, and Th17, and why roflumilast has demonstrated stronger efficacy than earlier inhibitors like crisaborole. Molecularly, roflumilast mimics cyclic AMP’s binding to PDE4 across 3 key sites, producing far tighter binding than apremilast and crisaborole, which translates to superior clinical potency.  Dr Bunick illustrates this with a case of palmoplantar pustular psoriasis that cleared dramatically within 8 weeks on topical roflumilast after multiple biologic and corticosteroid failures, highlighting its durability and barrier-restoring properties. He and Dr Del Rosso contrast this with the limitations of chronic steroid use, noting that roflumilast supports long-term control without barrier compromise.  The discussion also touches on vitiligo, where Dr Bunick shares an early case of repigmentation following roflumilast treatment, suggesting possible cAMP-mediated stimulation of melanogenesis. They highlight the molecule’s innovative aqueous-based formulation, optimized for skin-compatible pH and excellent tolerability.  In Part 2, Dr Swanson joins to discuss pediatric use. She reviews the 0.15% cream for AD in patients ≥6 years and the 0.05% cream for ages 2–5, both once-daily, steroid-free options that minimize burning and stinging compared with earlier PDE4 inhibitors. They review clinical data that demonstrate rapid itch relief, strong efficacy across IGA and EASI end points, and sustained control with twice-weekly maintenance.  Tune in to hear how PDE4 inhibition, and particularly topical roflumilast, is redefining nonsteroidal therapy across age groups and disease states in dermatology.

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• Greatest Hits: Live from Fall Clinical Dermatology 2025

  In this special Derms and Conditions episode recorded live at Fall Clinical 2025, host James Q. Del Rosso, DO, is joined by April Armstrong, MD, MPH, and David Cohen, MD, to share highlights and clinical takeaways from this year’s meeting. Dr Armstrong kicks off with updates in hidradenitis suppurativa (HS), noting the field’s rapid progress with 3 FDA-approved therapies (adalimumab, secukinumab, and bimekizumab), emerging 3-year data for bimekizumab, and exciting new agents such as oral povorcitinib and topical ruxolitinib. She shares learnings on the importance of proactive flare management plans and setting realistic patient expectations, particularly regarding scarring and lymphedema. Dr Cohen and Dr Del Rosso echo the importance of reengaging patients with longstanding HS and highlight the promise of JAK inhibition in this complex disease. The discussion shifts to chronic spontaneous urticaria (CSU), where Dr Cohen spotlights remibrutinib, a twice-daily oral Bruton kinase inhibitor delivering rapid results sometimes within 1 to 2 weeks and potentially enabling dermatologists to manage CSU more directly. Dr Armstrong adds that dupilumab now offers another trusted option for CSU, with a head-to-head trial versus remibrutinib on the horizon. For chronic hand eczema (CHE), they discuss the paradigm-shifting approval of delgocitinib cream, a topical pan-JAK inhibitor effective across CHE subtypes and free of boxed warnings. They note strong data for pain and itch reduction and its potential to mitigate chronic steroid reliance. The episode closes with emerging oral psoriasis therapies, including 5-year deucravacitinib safety data and radiographic progression inhibition shown with guselkumab. Looking ahead, they predict major advances by 2026 in TYK2 inhibitors, OX40-targeted therapies, and personalized molecular profiling for atopic dermatitis. Tune in to the full episode for expert perspectives straight from the Fall Clinical stage!

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• A Topical Marriage Made in Heaven: The Right Active Ingredient Meets the Right Formulator

  In this episode of Derms and Conditions, host James Q. Del Rosso, DO, welcomes David Osborne, PhD, a formulation expert behind several dermatologic topicals, to explore what drives topical performance, using dapsone and roflumilast as case studies. They begin by challenging long-held vehicle dogma rooted in mid-20th-century corticosteroid training: the idea that ointments always outperform creams or lotions. They note that with newer solubilizers, stabilizers, and vehicles, those rules don’t consistently hold for products approved in the modern era. They next revisit propylene glycol (PG) as a classic double-edged tool: its ability to dissolve more drug helped create “super-potent” corticosteroid lotions, yet higher PG levels can irritate skin, induce contact allergy, and compromise barrier function. However, they clarify that small amounts may serve as a humectant and offer antimicrobial benefits. They then discuss topical roflumilast’s development to illustrate modern formulation problem-solving: the roflumilast molecule is difficult to dissolve in water and tends to precipitate when water is present. The formulation approach minimized supersaturation (allowing a small solid fraction), leveraged a high purity grade of diethylene glycol monoethyl ether (DEGEE), known under the commercial name Transcutol, to hold the active ingredient drug (roflumilast) in solution in the presence of water, and delivered a highly moisturizing, propylene glycol-free and ethanol-free cream. Use of a unique emulsification approach ensured physical stability even at elevated temperatures while avoiding lipid extraction and additional barrier damage. For topical dapsone, Osborne incorporated pharmaceutical-grade Transcutol (free of ethylene-glycol contaminants) to partition the drug, slow release, and reduce systemic exposure. He emphasizes “topical product metamorphosis”: as water evaporates on skin, the local Transcutol concentration rises, dissolving residual crystals and enhancing delivery, the opposite of older vehicles that left behind residual visible crystals and under-delivered active. They close by looking ahead towards preservative minimalism, microbiome-aware vehicles, and designing drugs intrinsically optimized for cutaneous delivery so the base can remain as inert as possible. Tune in to the full episode to hear the formulation backstories behind roflumilast and dapsone, why PG can both enhance delivery and damage skin barrier integrity and function, how Transcutol and robust emulsifiers can solve solubility and stability hurdles, and pearls you can use tomorrow when selecting vehicles and counseling on tolerability.

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• Shedding New Light on Phototherapy: Now in the Comfort of Your Own Home

  In this episode of Derms and Conditions, host James Q. Del Rosso, DO, sits down with E. James Song, MD, for a discussion on phototherapy and its place in modern dermatology. While phototherapy has long been a safe and effective treatment for various skin disorders, its use has declined due to limited access, inconsistent residency training, and clinician concerns about dosing. They review why these barriers are more logistical than clinical and how newer technologies are making treatment more accessible than ever. They begin by highlighting one of the most significant advances in phototherapy: home-based narrowband UVB devices. These units feature guided dosing modes that adjust treatments based on patient feedback, minimizing risks and removing guesswork. They review real-world evidence from the LITE study, which demonstrated home-based therapy to be at least as effective as in-office treatment, with strong adherence, particularly among patients of color, while maintaining a favorable safety profile. Dr Song then reviews appropriate patient selection, contraindications, and practical steps for prescribing at-home devices, from enrollment forms to choosing unit sizes for full-body or targeted treatment. He also shares pearls on using phototherapy as an adjunct in conditions like psoriasis with psoriatic arthritis, and highlights approved indications that extend beyond psoriasis, including atopic dermatitis, vitiligo, and cutaneous T-cell lymphoma. The conversation concludes with a look at broader implications: phototherapy’s favorable cost-effectiveness compared to biologics, evidence of improvements in systemic inflammatory markers, and emerging research suggesting potential benefits in autoimmune conditions outside dermatology. Tune in to the full episode for practical guidance on this mainstay of dermatologic practice and a renewed perspective on integrating phototherapy into modern care.

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