New drugs for Psoriasis looking GREAT!

TYK2 inhibitor is being developed by Bristol-Myers Squibb and the early Phase II trial results have been great. Why? Here is the scientific talk: the TYK2 inhibitor has been shown to be 100 times more selective in inhibiting IL-23 , IL-12, and interferon-alpha than JAK 1/3 inhibitors and 3,000 times more selective than JAK 2 inhibitors. What do you have to know: IL-23 is the primary cytokine responsible for developing psoriatic lesions and this new mediation works very well and blocking it.

It will be a while before this medication will be available as further studies are needed for both efficacy and, more importantly, safety. At least there will be another medication that may be the answer for patients with moderate to severe psoriasis. Oh, and of course what will the price tag be for this new drug? Who knows, but as history as shown us with the other new psoriasis drugs, we expect that it will be a lot.

Risankizumab also known as BI-655066 is a humanized monoclonal antibody targeting interleukin 23A (IL-23A). This drug is also in Phase II trials and has had great success.

It is exciting to see even more effective treatments for psoriasis on the horizon.


Hydrochlorothiazide (HCTZ) use is associated with increased risk of Basal Cell and Squamous Cell Carcinoma

A recent study published in the Journal of the American Academy of Dermatology has shown that taking hydrochlorothiazide (HCTZ) is associated with an increased risk of basal cell carcinoma and an even higher risk of squamous cell carcinoma. The risk was dose dependent (the higher the cumulative dose, the higher the risk).

An increased risk was not seen with other anti-hypertensive agents or diuretics.

High costs cited as major reason patients do not adhere to their treatments

Has anybody seen the changes in the cost of medications lately? In case you have not noticed, they have soared completely out of control. For example, a bottle of 100 doxycycline capsules used to cost about $4. Today that same bottle is well over $100.  Patients are faced with high copayments for their medications, which is leading to problems of affordability.

Physicians need to play their part too. All to often I see physicians prescribing expensive medications when a suitable generic alternative is available at a fraction of the cost.

Here are my simple recommendations:

Over-the-counter topical medications:

  • Differin Gel 1% — In 2017 this went over the counter. It is great for unclogging pores. There is no reason to get tretinoin (Retin A) or any other topical retinoid before using this for several months. The average cost is $18
  • Benzoyl Peroxide 2.5% – 5% gel–this is great at killing the bacteria that causes acne. in fact, there is nothing better.  This medication will bleach clothes and sheets so be careful. The average cost is about $5-10.
  • Benzoyl Peroxide 10% wash–this works well for acne on the back, chest, and shoulders. Use this once or twice day to these areas in the shower. Use towels that you do not like as they will get discolored.
  • Salicylic Acid–there are many preparations for this which helps to unclog the pores. It does not work nearly as well as Differin, but it can be used in addition to it.
  • Glycolic Acid–there are many preparation for this which also helps to unclog the pores. Some preparation combine this with salicylic acid. The two together work very well, but still not as well as Differin gel.

Always ask  your doctor if one of these above options will be suitable, as they will be FAR cheaper than prescription medications.

Those with deep seated cysts will require oral medications, which are available by prescription only.

Always request generic medications. You can always price them out on and get coupons with that site. For medications that are not covered, try to find one that is covered. In most cases, this insurance carrier is telling you that there is a cheaper alternative that can be prescribed. If you are paying for the medication or have a high copay for it, shop around.

I have a skin problem: Who should I see?

Without question, it is ALWAYS best to see a well-trained, board-certified Dermatologist if one has any skin problems (rashes or growths).  Although many PCPs and Urgent care centers can handle COMMON problems (i.e. Shingles, poison ivy and minor burns), but what happens when both you and the doctor does not know what is the diagnosis? In many of these cases, patients are treated with Lotrisone (clotrimazole/betamethasone cream), which I call the “I have no idea what you have so I will give you this” medication.

In short, this medication is RARELY ever used by Dermatologists for a couple of reasons. It is a combination of a VERY STRONG topical steroid with an old anti-fungal agent. If one really had a fungal infection, topical steroids actually stimulate the growth of fungi. For this reason, it is uncommon to use a very strong steroid with an anti-fungal drug. Additionally, the use of strong topical steroids can thin the skin if used for more than 2 weeks, especially if used in the armpits, groin, face, or neck. I see patients regularly who are prescribed this medication only to be left with thin skin or stretch marks that will not go away. Dermatologists do occasionally use topical steroids with anti-fungal creams, although usually they prescribe them both separately, which costs less and is safer.

In summary, if you have an acute problem, such as an infection, Shingles, a burn, or Poison Ivy, your PCP and/or local Urgent Care Center will likely be able to treat you effectively. For these acute problems, you do not want to delay treatment.

If you have a “rash” or “growth” and do not know the cause, your best bet is to find a good Dermatologist. In my experience, it is far less costly to pay more for a visit with a Specialist than to be ineffectively treated with medications that can be costly. For example, a 15g tube (tiny) of generic Lotrisone can cost $131 compared with a 85g tube of another steroid that costs $12.

Most importantly, Emergency Rooms are for just that–life threatening emergencies. Nearly all skin conditions are NOT life-threatening, and unless one has reason to suspect otherwise (many blisters, sheets of skin coming off, or suspected serious infection), one should not seek advice for skin conditions in an Emergency Room Setting. There are times when one might be prompted to go to the Emergency Room. An example of such would be a diabetic who thinks that he/she has cellulitis who calls his/her PCP for advice and is then directed to go to the Emergency Room for evaluation.

Infections after a Pedicure

Patients often ask about the risk of getting infections after a Pedicure. In most cases, they are asking about getting a toenail fungal infection, which is rare in this circumstance. Bacterial infections have occurred after getting a Pedicure, although is uncommon. Those who are immuno-compromised or have diabetes and/or poor circulation are more at risk to getting infections.

The American Academy of Dermatology recommends that people not shave their lower legs for at least 24 hours before receiving a pedicure, because cuts from shaving could put people at risk of infection.

High deductible: choose your Dermatologist wisely!

Nowadays it is common to have a very high deductible. This is a big problem as patients are bearing a significant cost. In this case, it is very important to choose your doctor wisely!!!  Let me give you a few examples and some critical information.

  1. Contracted Rates–some plans pay doctors very differently. In fact, one may get paid almost twice as much as another.  One way to check this is ask, “What is your reimbursement for a 99202 New patient visit”.  This will compare apples to apples.
  2. Get some good opinions on the doctor–when he/she takes biopsies are they almost always cancer? Are they often negative (non-cancerous). Does he/she prescribe inexpensive medications?

It is important to look at BOTH of these. I’ll give a couple of examples.

Doctor 1 gets paid $100 for a 99202. He is very conservative and only does biopsies that are necessary. He is uses inexpensive prescriptions when possible.

Doctor 2 gets paid $75 for a 99202. He is fairly conservative, but tends to take a biopsy at most visits. He uses some inexpensive medications and some that are expensive.

Who would cost less? How much?

In this case, Doctor 2 may cost a patient more than double of what Doctor 1 gets, even though Doctor 1 gets paid at a higher rate. With a biopsy you have the fee for the procedure and the pathology as well. The cost difference between a generic inexpensive prescription and a brand-name can be $50 or more to the patient if it is covered. If the medications are not covered, the cost difference can be over $300 difference for products that do the same thing.

In short, look at the reimbursement rate and get good recommendations. Even if you have to pay a little more for the doctor in terms of reimbursement, it will likely save you money in the long run if he/she is a good physician who practices ethical medicine.

Free skin cancer screenings are offered all of the country. These are usually offered around May and is a no-cost opportunity to get screened. Nothing else will be evaluated during these visits–no treatments, no prescriptions, no biopsies. This is a great option for those unable to afford their deductible.