Derm Literature Lightning Round: New Insights, Big Impact

[music] Welcome to season 2 of Derms on Drugs and Video Podcast brought to you by scholars in medicine, the best educational platform at dermatology and provided at NOVA's Dometical Providers. Derms on Drugs is where cutting edge dermis, intermiss comedy, a mad sirens from docs dermatology in each week. My residency buddies, Dr. War of Ferris from the University of North Carolina and Dr. Jim Batten from the University of Pittsburgh where we use our 60 years of combined derm experience to discuss debate and dissect the hottest topics in dermatology. Everything you need to know to be on the cutting edge of derm and you'll probably have fun listening. New episodes drop every Friday on scholarship medicine, apoptas, potify, and other major podcast platforms. And as a reminder, there is a video component that has the key figures and tables from most of the articles that we talk about. This week we've got one of our patented six pack episodes where we are going to go through the stuff that has grabbed our attention in the literature over the last few weeks. And we are joined by our special guest, Dr. Scott Drew, a derm in practice for decades about an hour north of me, also a member of docs dermatology. So Scott, as our special guest this week, we're thrilled to have you and let's throw it over to Dr. Ferris for our first article. Okay, I am going to start with an article from JAMA Dermatology, which was Amolions to prevent pediatric eczema. So this was, I think, one that seemed like it got a lot of press. So this was the cascade trial. And so this is, does moisturizing your baby prevent them from getting eczema? So this was a large US study. The randomized trial, 1247 infants, 25 clinics, and they started, they started basically moisturizing babies with amoliant every day before the age of nine weeks. And then they looked and said, how many of them got atopic dermatitis by age two? So the answer was the moisturizer group babies, they had an incidence of 36% of them versus 43% in the control group. So that's a risk reduction of 6.9% relative risk of 0.84. So what does that mean? You got to moisturize like 15 babies to prevent one from getting atopic dermatitis. So interesting things, if you would think like, okay, what should really matter is like the kids who are at high risk, they've got a high family history of atopic dermatitis, they're going to benefit more, but that is not true. But babies who did the best were the ones who did not have a family history of eczema and also the ones who had a dog at home. So as a dog lover, I think that's good. So I think I could do pediatric dermatology now. I could just give out moisturizers and puppies to everybody. It would be a lot more fun. I wouldn't have to prior off do picks them. You would be the most popular pediatric dermatologist with the kids and the least popular with the parents. All right. I'm going to give my quick what I would call criticisms of this article as an area I've got a lot of interest. I've been multiple studies have looked at this over the years. Most of them showed no benefit of early moisturization. This one here, the sort of concerns with it. Number one, the prevalence of a, or the incidence of atopic dermatitis by the age of two was obscene. So right, there's not a study in the world that has ever shown a prevalence of atopic dermat 40%. So basically at least double the generally accepted prevalence and that kind of calls into question the diagnostic criteria they were using. Second thing, because the diagnostic criteria were either parent report of a healthcare person diagnosing them. The children's exome questionnaire or that they've got a diagnosis of AD and a prescription or that they got a, say, or that they got a diagnosis of AD with a, an over the counter or a prescription or they met a modified UK working party and there was stunningly different. So whenever we look at parent report of a diagnosis, it was about 30% when we look at UK working party, it was 12%. So it, and when we look at UK working party, which was probably the most stringent, there there wasn't a meaningful difference there. Also an interesting thing that the people had a first degree relative with AD, there was no benefit, it was only the kids who were from a family who had no first degree relatives with a diagnosis of AD. So first study though that has shown a difference with moisturizing. My take on this whole area is that there are a lot of germs out there who are researchers who really, really, really, really, really, really, really, really, really, really, really, really want it to be the case that moisturizing babies prevents eczema. So far the data has, and they've done really big studies that have all shown that it didn't. This was the first one that showed that it did. You know, if you do enough studies, eventually one's going to randomly like show benefit. And even this one showed if there is benefit, it's pretty small. Those who seems to me like were barking up the wrong tree thinking that moisturizing is going to prevent a topic, derm, but this study did show a difference. So that's why we had to do it. But maybe we're barking up the right tree with getting everybody a dog. A dog has. A dog has a dog. A dog has a dog. It's pretty good for a dog. But no harm in moisturizing babies at least we don't think so. Yeah, I know. But our patients, our parents going to be like, I'm definitely going to do this one today, every single day because this study show that it prevents this disease that my kids probably not going to get. I don't see them motivated to do that. And the other takeaway is for the parent who's like, I have Xima. I'm worried about my baby getting Xima. We'll be showing them help. This study says no. Right. But there was no harm. Other studies have shown increased risks of skin infection and the moisturizing arm. This one did not. Yes. I just worried about the parent that brings in the kid that developed Xima at one years of age and then says, yeah, we could have stopped this. Why didn't you tell me? That's true. All right. Scott, any comment? Yeah, I think this reflects maybe the motivation of the study was the frustration that patients and their parents have with this disease state because there's so much myth-busting that's needed in the management of atopic dermatitis and children. The one that's so frustrating for me is somehow the idea that you shouldn't bathe your baby if they've got Xima. And I think the whole socon seal thing is the key to not so much prevent the disease from happening, but getting parents to buy into this is a life condition that's going to need some amy wide engagement until they're very grow out of it if they're lucky enough to grow out of it. You moisturize, that you use the right detergent, that you have the right diet, that you manage the Xima and the otitis and it's not just skin. It is, and that you probably are more responsible than anybody for creating the idea that this is an atopic syndrome, not. That's a good disease. Skin problem. Yep. So whether it's moisturized from the day you're born or whatever regimen we're doing is to let parents know that the skin person, the four of us and all of our colleagues are the people that should be the home of this disease management. This is not going to be here, take a pill or use this or suck flaxseed oil every day. Whatever the current myth is, that this is a science-based disease. All right. All right. Let's move on. Pad, what do you got? My first six pack was modernizing US sunscreen regulations, how newer filters can improve public health by Turner et al. In the June 2025 edition. Sorry, I fell asleep for a second. Ha, of photo dermatology, photo immunology and photo medicine. We recorded a recent episode yet to be released where we discussed gun scenes in depth with Dr. Woolery Lloyd. So I don't want to go too much what we already discussed. One of the things we didn't talk about was some of the newer agents that are available in Europe and they may be available in the US soon. So before discussing the agents, the papers of the section about our sunscreens are regulated in the US versus Europe and Asia and the US sunscreens are regulated as over the counter drugs, Europe and Asia are regulated as cosmetics. There's a section that reviews the sunscreens approved for the US and goes to the generally recognized as safe and effective categories. Then there's a section comparing the regulatory processes for approval in the US and Europe and South Korea. Section touches a little bit about how UVA protection is marketed differently in the US compared to Europe and Asia. And it focuses on the specific sunscreens not yet available in the US. First, there's BIMO, TRIS and all and BESOCTRIS all. Organic broad spectrum sunscreens. They have high molecular weight structurally large. So absorption is very low. I think that's going to be helpful. Some of the medications that got kicked over to the generally recognized as safe and effective category 3, meaning the FDA needs more data. The absorption was one of the bigger problems there. Apparently absorption is 0.01 percent in some studies. Endocrine disruption is also not a concern based on certain testing that was done. We're two ingredients reviewed. We're a tariff. Thalidolididine, I screwed that up, dichampor, sulfonic acid, TDSA, and Drometrazol, trisiloxane. Also broad spectrum organic filters have shown little absorption after topical use. These all have trade names, so BEMO Tritonol is Tynosorb S. - So Pat, and here, what's, so for anybody who doesn't quite get this, what's the benefit of an organic sunscreen, which just means it's a chemical, not a physical, versus why would it be better if these came out? - Patient compliance and use, right? The mineral sunscreens go on very pasty. These go on very, very nicely. Something that is cosmetically acceptable is going to be used by the patients. These are being used all over Canada, Europe, Asia, and they're the ingredients that are in some of the more popular sunscreens, because it has that broad spectrum activity. That also adds in a lot, the UVA pigment darkening, anti-aging effects. So kind of crazy that the United States has the system that it has to get these medications approved. I just thought it was something we had just talked about, and it just came out. And we may see, especially BEMO Tritonol is Tynosorb S as the brand name. We may see that within a year being approved, it'd be the first new sunscreen approved since like the 90s. - That'd be sweet, okay? So-- - It would be good, but I'm like, is this our hill to die on as dermatologist? Like we've made the point, I don't know. Sometimes I feel like we just, like we have such bigger fish to fry than what new suns, when the FDA will approve the next sunscreen. Like we have sunscreens, we have sunscreens that work. Yes, it would be nice to have other ones, but like how much of-- - Maybe it maybe delves into the deeper thing of the difficulty that the FDA makes bringing new drugs to market in America. Sometimes they're just working against us and they're working against patients doing the same thing. - Yeah. - Yep. - I think you're saying a lack of education among, certainly me about what agents are in what sunscreens, and I'll tell you my little experience there is in Southern Africa and even in the horn of Africa, people want to be, and all of the world perhaps, they want to be one color, and sunscreens in the third world are not very common because there's a myth that it gets skin cancer. And so when women particularly are in taste to use these products, the best actor that's added to achieve a homogenous colorization, unfortunately are late with heavy metals. So these women who are trying to achieve discromy relief are putting lead and arsenic on their skin. Then this is epidemic. I mean, this happens from Namibia all the way to Sierra Leone across the Congo to Somalia, and the amount of arsenic and lead that's used actually leads to CNS degradation. So not that this issue is particularly germane to that, however, over the counter medications in non-regular the countries like we have are really problematic. And I can tell you stories and show you pictures of patients that really have been injured by what we would consider cosmetic usage. - All right, I'm gonna jump over. So I'm taking a different tack on six packs and I'm presenting six quick hit one liners that I'll give you guys just a chance to comment on very briefly. Number one, type two immunity links, extremitis and like annoyed eruptions caused by immune checkpoint inhibitors. Basically what they did here was look at people who got extremitis eruption or like annoyed eruption from an immune checkpoint inhibitor, compared the immune profile to normal extremitis dermatitis and normal like annoyed eruptions like LycanPlanis. And what they found was that the Lycanoid eruptions with immune checkpoint inhibitors are TH2 driven. And what makes sense since we think, Dupy works for them, but what was interesting to me there is that I generally put a histologic reaction pattern together with a type of immunity. And I've always thought of if it's Lycanoid, it's TH1. And what this tells me is that Lycanoid does not tell you the immune pattern. So I now think that if I get somebody with Lycanoid and spungiotic combination on a biopsy, I'm going to assume that that is a TH2 type reaction that the spungiotic is primary. And I'm going to treat it as an extremitis disorder. So that was kind of the interesting takeaway there. Any quick comments on that one? It works. Dupy works well for Lycanoid drug reactions to immunotherapy. So-- OK. All right. I would think Lycanoid, I'm going to try with flume alas first, but now this paper has me think. And maybe the Lycanoid in those patients is TH2 and try Dupy. Yeah. So I think if you get Lycanoid in a hint of spungiosis, go with the spungiosis. I think the message there, Matt, is people who are on these drugs don't need to stop them because they develop a cutaneous side effect that we can manage them and let them stand their drug and give them hope that they otherwise would not have. Yep. All right. Next, alopecia areata whenever the jack doesn't work well enough. Two good options came out. Number one, mini pulses. So there was one. It was a randomized controlled trial. They used beta methasone on weekends. Main takeaway for me here, because rather than beta methasone, I think we ought to be using dexamethasone if we're going to try and do this. The type of regimen that you would use here and you could consider doing this as monothera if you're combining it with a jack. It would be something like dexamethasone. Let me see here. What did I think that the-- something like Dexa 2.5 milligrams, mundane Friday, and a Saturday and Sunday, and a kid, or 5 milligrams Saturday and Sunday, and an adult, using a regimen like that. They got salt scores went from an average of 50 and an average of 25. That was monotherapy, not combined with a jack. The one that was even more interesting was a case report looking at-- they put somebody on a jack. They didn't really regrow for a long time. Then they had them do high-potency steroid under occlusion. So put the high-potency steroid under occlusion on one half of their head, where shower cap overnight, that half of their head re-grue hair. The other half did not. So then they did it to their whole head, and they re-grue hair, and they maintain the hair with just a jack inhibitor. Main takeaway is, if you put somebody on a jack and they don't get better after three to six months, do clubedazole under a swim cap at night until they start to regrow. Once they've got decent regrow, stop the clubedazole under occlusion, and the jack should maintain it. I don't think we need any true real comment on those two, other than it'd be reasonable to do the clubedazole under a swim cap at baseline. Like to start doing that whenever you first start the jack wouldn't be unreasonable. Then once they've got the regrowth, you stop the clubedazole, just keep doing the jack. Next one, good study showing that it was Saravie versus regular moisturizer. It was a two arm study, literally meaning they put Saravie in one arm, regular moisturizer on the other. So two arms involved, and they showed that transmitter and water loss changed the same in both, but the arm that got Saravie, whenever you did tape stripping, it was more resistant to it. When you did sodium lural sulfate irritation, it was more resistant to it, and it was harder to basically interrupt the stratum corneum. So we're starting to see more studies showing that Saravie truly is different from other moisturizers. Kind of goes back to the paper fairs talked about suggesting that we shouldn't just be asking, does moisturizing help? They're probably as a component of, maybe if you did Saravie from birth on, it would work better. I'm not saying it does, I don't have any data for that, but next one that was interesting, first study, and this one, I was so bummed to see this, this was a trinetic study where they looked at cardiovascular and thrombomboembolic risk in patients on jacks, compared to Dupy, Methatrexate or Cyposporin, and they did show a higher risk of DVT and PE, about 1,000 patients in the Jack inhibitor group, 1,000 patients in the Dupy group, higher rate of DVT and PE in the Jack inhibitor group, multiple other studies have shown the opposite, but the big thing is this is the first study I've seen that showed a difference. So I now cannot say there is no evidence anywhere, not a single study anywhere that shows an increased risk with jacks. Now we do have one study that shows it, we have multiple studies that show the opposite, but just we can't say there are no studies that show an increased risk with jacks. And then the last one, Traylo as an alternative for Trailokinimab or Adbury as an alternative for people with Dupy, induced arthralges, case series of 15 patients. Lead author was Chris Buneck, really smart guy out of Yale, and his explanation for this was published in JID, which basically using thermodynamics to talk about the difference between Traylo, Lebrion, Dupy, And the main takeaway was that. So, because of the way it binds to the IL-13, the way that it allows the IL-13 to bind to the IL-13 receptor type alpha, might reduce IL-4 signaling as well. Because IL-4 signaling for the type 2 receptors, one half IL-4 receptor, one half IL-13 receptor. So, if you take away the IL-13 receptor, now the IL-4 receptor doesn't have anything to pair with. So, you, the library may have some IL-4 blockade associated with it. It's iffy and questionable. Because in that case series of 15 patients, they did have one duper-r-throucher patient who got it on library. But all of the patients they switched to trade-load did not have arthrouches. And so, that was kind of an interesting takeaway. Maybe, the library has more arthroucher risks than two. Maybe, the library has more arthroucher risks than trade-load. But, you know, hard to say. But those are sort of ton of patients from the clinical trials and even post-marketing where we'd see that signal with library. You would think, you would think, but the people who get arthrouches that are bad enough to really matter are probably one in 200. And so, it didn't show up in the library trials. It didn't show up in the trade-load trials. So, I remain unconvinced. The main thing that I take away is, though, that I now have a reason to say, if you're the one in 200 people who get significant duper-r-throuches, and I want to keep you on an drug that's targeting I-13, I'm probably going to choose trade-load instead of library. I now have something in the literature that gives me a reason to pick one over the other. Because I'm always looking for subtle differences in these drugs. And, right, that's that. And it's helpful to say you could safely, this is a very reasonable thing to go to trade-load next. Because I think patients, I've had patients get that, and they fear going on another biologic. Yeah. So, yep. Hopefully. That was it for my six quick one, hitters, Ferris, what do you got next? All right. So, we're done with you, huh? We're not going to hear from you. Oh, no, I have something more. I find that hard to believe. Okay. I thought this was interesting. This was a paper from the JAD, which was, you know, a multi, I won't read the whole long title, but basically this multi-center study for autologous, autologous cell harvesting device to treat Vidaligo. So, this is a device called resell. And so, this was a little bit. How do you spell that? How do you spell it? R-E-C-E-L-L. Okay. So, if anybody wants to look it up, R-E-C-E-L-L. Yes. And so, they had 107 adults with stable Vidaligo. They had every skin type represented. And basically, what they did, it's basically a device that makes it easier for, you know, the average dermatologist who's not like a person who does malanocytes harvesting to be able to treat Vidaligo, you know, sort of surgically. So, basically, patients had Vidaligo. They got like laser treatment like CO2 or the KTP laser that treated the base. And then they harvest like a shaved biopsy, basically. And then this device makes a cell suspension. And they can basically harvest like 5% of the area that is involved. They make this malanocytes, you know, like basically smoothie. And then you put that on and then you can, and then you basically let the area, it's like a little malanocytes transplant. So, about two thirds of patients had a 50% or greater improvement. And 42% of them had an 80% or greater improvement or repigmentation. Only 8% had full repigmentation. And the satisfaction rates were like 72% among patients, 84% among clinicians. And so people started to see pretty, you know, early results like before. Did they do anything together with it? They did do UVB, neuroband UVB with it as well. So for, so it sounds like for normal patients, if you could find a place that does this and get it covered, get this done, wait for it to heal, and then do either narrow band or obsular over it to try and protect those malanocytes that you just transplanted. Reselves primary target is, is like grafting, right? So instead of taking this huge graft to cover up a defect, you take a little tiny piece and it like dissolves it and puts it in a liquid and you just spray it on the wound. Yes. So that's where resell works. And so they're like, well, could we do this for vitiligo instead of punch grafting or whatever sort of malanocytes transfer surgical that, you know, nobody does. Right. Our very few sites we like, and you don't get like, you know, when I've seen the punch graphs, they get like little polka dots of repigmentation that kind of looks unnatural. So this is like a smooth cell suspension, right? And so I think it is, it makes it technically more easy for, you know, the average dermatologist to do. So I thought it was interesting. And I'm on their website right now looking to see if there's a like fine day provider. There's at least a contact us. So we could tell patients to email the company to try and find somebody in their area that doesn't. Yeah, I don't know that it's actually like FDA approved. This is the clinical trial. Oh, I thought it was. If it's FDA approved for this actual indication. Okay. Got it. Yeah. But I thought it's interesting. Yeah. I would never do like punch graphs and the more surgical stuff. But you know, maybe if we had this in our toolbox. Okay. All right, Pat, what do you got? All right. My second May 20, I may 2025 journal with dermatological treatment. Intrilitional triumsonolone for inflammatory acne, a comparative study of dose efficacy and investigation of a novel injection assistant device to enable self administration. So basically it's this little plastic thing. And you put a syringe in it and patients can at home inject their acne lesions. And it's just as good as going to the doctor's office. I just logistically have no idea how how you get them the Medicaid like they buy the plastic thing. And then you just write for the syringe and they go to the pharmacy and get the syringe. I mean, it's a neat device. I don't see the like how it is eventually going to be implemented if it's going to be. Well, by the way, I got to jump in and say I just asked AI. So first resell is FDA approved for Vidal I go. I would as FDA approved already. And I asked where can I find a provider who does it? And it said that I do it. And I do not. So AI certainly got that one wrong. So maybe it's not FDA. Maybe it's not. Who knows. Yeah. Who knows? Okay. So Pat, and you're going to start giving this to your patients. I'm not out yet. Again, it's it was written by a company, but you know, fair like most, most, most agonnie. He was an author on it. A guy from Stanford. So they're working with the company to get this. I've had, I've had friends. I do very little interleasional attack for acne because I've had like friends. Like people I know in my community come in and it's done like, you know, one mid per one big per ml or two mix per ml. And they gave them a dent that they always fill back in. But for like a year, they had a dent. And I was like, oh my god, I hope that they'd be like, it's not better. I agree. I can't imagine putting this in the hands of. I couldn't either. And I guess the pearl when you have that happen and some people probably know this, but worth mentioning is flooding with normal saline. So if you do have somebody get fat atrophy from an injecting. And then you can get an allusion flooded with normal saline that does help to reverse it. Okay. All right. I've got six more quick ones. What? You were last six total job doing six more. All right. Don't be quick. All right. So first you have somebody do a, they go get a centenial lift to a biopsy and they get to anaphylaxis or a drug reaction afterwards. Most likely it could be the paint to blue V die. And there's also this isosulfan blue that is the dye that they use. So if that person came back and they're like, what do you think there was allergic to whatever you can have them use methylene blue. If for some reason they needed another sentinel lymph node biopsy. That was number one. I didn't even know that allergy to the dye was a thing. Even and then if they adapt zone toxicity and sentinel node biopsy, you could kill two birds with one methylene blue scone. It'd be great. Right. Burning mouth syndrome turned out that if you pass as people and they're allergic to a dental metal removing it did not help. But if they were allergic to balsam of Peru, a balsam of Peru diet may help. So what I recommend there for a balsam of proof free diet, a diet, just ask AI, how would you follow a balsam of proof free diet. The main things though are tomatoes, spices. And so that includes vanilla and chocolate. Those are the big. things in citrus. So tomatoes, citrus and spices are the three big things in balsam True might be worth trying in burning mouse syndrome patients but difficult patients. Next one, chronic neuopathetic Inodosum did great on off label of premelast. So another thing to add to our roflumelast list of stuff. So now, roflumelast would be now my first line go to for Inodosum. Frontal fibrosin alopecia. Case report of it stabilizing and maybe improving with topical latana prost. So this is generic latisse. You get the little eye drops but instead of using an eye drop you put a drop in your hand, add a rub it around your frontal fibrosin alopecia. Those pictures were the least convincing pictures I've ever seen for any drug being effective ever. If they said it's stabilized. So really the pictures just show that it didn't get any worse. Okay. But there are a couple of other reports for that as well. You know, for me first line for FFA, you know, interleasional tack, topical jack inhibitor, probably topical tophacidinib, which you can get 10 grams for about 35 bucks from compounding pharmacies and oral roflumelast. Then the next one after that, Kylitis granulomatosa, my go to over the years has been injecting tack into their lips and giving them a zytheromycin or doxycycline. So it was a case report that failed and they gave them oral metronitis all in addition to a shot of catalogue and the oral metronitis all worked great. My first line for colitis granulomatosa now would probably be interleasional plus roflumelast, although that's not been reported in the literature. But this was just if you do interleasional and usually what you do is point one CC of K 10 in like four shots along each lip. Do you hear me? You ever do hear me? I only in patients who also had one girl who had it and it was the manifesting sign of Crohn's and the Humeera helped but I've never used Humeera and someone who didn't also have inflammatory bowel disease. And then the very last one that met foreman or SGL2 inhibitors, either one of those when people with HS went on them cut their risk of death in half. And so there was some data that HS people have a reduction in life expectancy of 20 years because of the severe systemic inflammation with their HS. And so this data is was like a, you know, it was a trinetics or database or something like that showed that either met foreman or at SGLT to inhibitor reduce the risk of death by about 50 percent crazy numbers. Crazy numbers. And so now I actually think that most people with HS if they have any active disease should probably be on met foreman additionally which is an unbelievably safe drug. Like unbelievably safe drug. People I often hear people go well I would never prescribe it but I'll tell them to talk to their primary care doctor or that if you prescribed doxycycline met foreman is a much safer drug than doxycycline like much safer drug. And it also upsets their stomach so it is just like it is just like. Although with the doses that we talk about here so either a thousand extended release once a day or 500 BID would be the typical doses we would use for like HS really unlikely to see much GI upset with. Right and they will not be cut like you don't risk hypoglycemia I think that's the other like it there's not like a true real risk of hypoglycemia I think that's what scares. I guess I've used met foreman for HS and haven't been impressed with the results that it has in HS. Did they tie in? Nobody's died so you might be on to something. No but they didn't tie it into how their HS responded right? This is just so that may be the difficult part like I'm giving you this because it's going to save your life. Yes now I would never use it as I can't see using this monotherapy for HS I could see like reflumalase plus this most likely either humera or bimzellics or chocentics plus this plus reflumalase something like that. I don't see any HS patient rejecting that those patients are so desperate and they have been misinformed for so long and the newer agents that have been Zellix etc and the the the the jacks that are coming out are really offering hope to a to a population that's been so disenfranchised I think this would be a well-received agent. I think it's an easier drug to use even than Spuronal Actone you're not worried about potassium right it's it's a really really easy drug to use the other place that it's got some reasonable data as an acne and a few other places as well. The results were so impressive it's like it's hard to argue that they shouldn't go on it. Yeah I mean a 50% reduction and it was a substantial number of patients that were in this I think they did propensity score matching pretty well. Yeah they did it with and with propensity score matching and it was a big reduction in heart attack strokes heart failure peripheral vascular diseases and death and we're talking like 5,000 HS patients versus 70,000 people with HS without metformin or so we're talking like big numbers. It works better if that's given it with a dog. Exactly. And moisturize every day. And moisturize. We went through those so quickly people are going to give their HS patients pulse dexamethasone shower caps with clubeidazole, reflumolast and ibimethylene blue. With this description they can read listen as many times as they want that's that's part of the idea here they can read. That's great. All right all right so I want to thank everybody for joining us Scott I really want to thank you for sticking it out with us for three episodes. Thank you for being with us. Fantastic. You know I hope that everybody that listened I hope you feel like you learned a few things. I hope you laugh once or twice and mostly I'm hoping you're planning to join us next week. Until then I'm Matt Zyrus. I'm Tim Patton. And I'm Laura Farrus and we are Derms on drugs. [BLANK_AUDIO]