Why Good Dermatologists Don’t Always Give You What You Ask For

You can feel the tension the moment a patient says, “I want that medication.” From SkinTok trends to viral skincare advice, dermatologist Dr. Jim Del Rosso joins us from the AOCD meeting to break down how dermatologists navigate treatment requests while still building trust. We talk about acne, rosacea, topical steroid fears, antibiotic resistance, and why the right diagnosis matters more than chasing internet trends.

We also unpack the communication skills that actually improve outcomes, from setting realistic skincare timelines to explaining systemic treatments for eczema in a less intimidating way. If you’ve ever felt overwhelmed by conflicting skincare advice or frustrated that products are not working fast enough, this episode brings the focus back to evidence-based care that actually works.

Transcript

Cold Open On Risks And Reality

SPEAKER_02 0:00

I don't think that we have people dropping like flies from topical corticosteroid withdrawal syndrome. You know, some of the antibacterial cleansers can can trigger antibiotic resistance. It's something that it's very, very hard to avoid. Even patients that had been acne patients for many years, many of them were patients in their 20s and 30s, and they had some teenagers, that they asked them, how soon do you think it is that you expect to see a big difference in your acne?

SPEAKER_01 0:32

Welcome to Dermitrotter, Don't Swear About Skin Care, where host Dr. Shannon C. Trotter, a board-certified dermatologist, sits down with fellow dermatologists and skincare experts to separate fact from fiction and simplify skincare. Let's get started.

Welcome From The AOCD Meeting

SPEAKER_00 0:50

Welcome to the Dermotrotter Don't Swear About Skin Care podcast. We've got a great show here for you today. We're coming live from the AOCD meeting, the American Osteopathic College of Dermatology with Dr. Jim Del Rosso, who needs very little introduction. Worldly in dermatology, internationally renowned, expert in all things skin and derms. So it is a pleasure to have you on the podcast. Who am I again? Could you remind me again? Yes, I'll remind you quite often.

SPEAKER_02 1:17

Dr. Jim, actually, uh my first year with the AOCD was when in my residency, the first meeting was in 1983. Because I was 1983 to 1986. So it's been a while. I think I was president in the early 90s. That's how long ago it is. But it's a very important organization. I look at it as if it wasn't for this organization, that I wouldn't have had the opportunity to become a dermatologist. So regardless of what else is going on, it's really very important to be supportive of this group, of this group. That's how I feel about it.

SPEAKER_00 1:50

Well, and they've been great to have us here and do the podcast. You know, today for our listeners out there, we wanted to talk about, you know, the patients that come in that really want us to give them certain medications or treatments, but you stop them in their tracks and say, I'm not gonna do that. I'd rather do something else. And I thought, who else to ask but someone like yourself who's been practiced for a while and have to deal with that type of situation? So you we're gonna go through some examples. What are some common scenarios where you see this happen a lot now?

SPEAKER_02 2:17

So the first thing I want to say is I'm so excited to actually be on the first real podcast. I mean, this is the real deal. You get a card and you have all these different places where you can find it. And what's this? Is this some scan me code? It is. I'm gonna get sounds exciting to get scanned, but but it's interesting you say that because at different points in my career, you know, back in the day when people would come in and you say stop them in your tracks, I would stop them in their tracks because I'm the physician and uh you're here to find out what I think you should do, and I'm telling you what to do, right? That was okay for a while. And it really was agreed

Saying No While Keeping Rapport

SPEAKER_02 3:00

upon by the patients because they were in that mindset that, oh, that's why I go to the doctor, right? But it's changed now, right? To me, I'm not gonna go in and if they come in with an ad or they want a certain medicine because of what they heard or what they read. Um, and I'm I'm looking at their entire situation and figuring out what I think is best for them, and then I'll go through the different options with them. The mindset is not to say, no, no, no, I'm not gonna give you that medicine. So, well, let me take an opportunity to first of all make sure I'm giving you a diagnosis that I think is correct, or if we don't have one, what we need to do to get to the right diagnosis, because everything else is gonna be downhill if we're not treating the right condition. And then talk to them about, you know, different options and get an idea of I'll ask them, why is it that you're asking for this particular medication? It's for such and such a reason. And I said, but you know, it might be a situation where, well, based on your history, that's a general recommendation, but there's maybe some issues why we would not want to use those medications. So let's go through the different options and and work it from there. So a couple of things that um well, first let me stop there, because if I keep blabbering, you know, it's not really going to be a conversation. So what's your what do you have a question from what I'm saying?

SPEAKER_00 4:30

Well, what I like is your take on what you just said, because you know, everyone talks about what we say in medicine, shared decision making, right? It's a partnership more with the patient on their ideas of what they think might be going on, potentially their diagnosis, and also their treatment. And I think that's very important now in the age of social media because people go there first, right? They go to TikTok to get a diagnosis or find out how they should treat their skin condition, whether it's acne or rosacea, they'll go there first with already a plan in place to talk to you about. And what I like about what you said is that you validate, you know, that they've done the research, they may have an idea of what's going on. And even if you disagree with them, the validation is so important because you get that trust, right, from the patient that you're gonna build that rapport. So even if you don't agree on maybe the next appropriate step, they're going to actually listen to you. And I think that's so essential nowadays.

SPEAKER_02 5:18

It is, and I'm not gonna say, oh, I disagree. Um so well, let's go through, you know, pros and cons and really come to the decision together. So shared decision making is sort of like unmet need and patient journey, these buzz phrases. Yeah, you have about seven hours because I can tell you all my unmet needs if you want to get down to it. I'm sure you have your list too. But but that term does have a meaning of making sure that they feel comfortable because they do have a lot of information that you don't know all the information they're getting or who they're speaking to. And even after there was a great article in the Journal of Clinical and Aesthetic Dermatology of the edit of the journal, and I I saw it, that a particular medication and where patients go after you've seen them, and they're still not necessarily calling you. They're going to all these other sources to find out well, how do I put this on? What do I use with it? What moisturizer can I use? Instead of calling your officer asking you, they're going to all these other social media sources. Some of them are medical sources, but it just shows you that it's totally different. And when I was growing up, we had the Merck Manual. That was the only physical thing you had in your house, or maybe the Encyclopedia Britannica, those big heavy books, and you went to the doctor's office. That was the only source of medication of information on medicine or whatever. So it is, it is totally different. So I do want them to realize that you can teach an old dog new tricks. And I do want to hear what they have to say within the confines of you can't be there for 45 minutes, but you develop a style of being able to get certain questions answered. I think it's extremely important.

Antibiotics And Steroid Fear Explained

SPEAKER_00 7:10

So I think one of the medications or things people want to take and use all the time. We talked a little bit about this, you know, just kind of in our prep, is antibiotics, right? People want antibiotics all the time or they want to stay on them, you know, for long periods of time. Can you walk me through how do you talk with patients about, you know, the pluses and minuses, or hey, we don't give antibiotics necessarily for everything? Or there are other medications or treatments you feel like that fit the bill that you feel like you need to kind of talk patients through that it's not maybe the best plan of action?

SPEAKER_02 7:36

So there are a couple of different sides to that fence. I mean, we're obviously hearing so much about topical corticosteroids and don't be using topical corticosteroids. Well, you know, I don't believe that it's, oh, it's terrible that you're using topical corticosteroids, because I don't think that's true. But I think we know how to use them. It's and probably a lot of times you don't necessarily need them. And there are times that I won't necessarily do it, let's say, for atopic dermatitis, you know, that a patient has in different locations. But if I feel they need a short course, that's where they're, that's what they're for. So I'm not as hard fast about, I don't think that we have people dropping like flies from topical corticosteroid withdrawal syndrome. But we if they're not used properly, you're certainly going to run into that. And it is a big problem when it happens. So sometimes I might want to use a corticosteroid, and the patient pushes back, and I'll just basically have to say, I need a week from you in this situation. And it's probably going to be maybe 10% of the time, 90% of the time, I'm going to be using one of these better non-steroidals. But it's not, I don't want it to be an all or none, you know, that that clinicians are hearing from the from their peers. On the antibiotic side, it really depends on the situation. If it's an infection, and then I need to be using it for a short course and explain to them that this is very, very important as part of that. It's not going to be something that's long-term. And if they say, well, can I get antibiotic resistance from it? Yes, you can, but you can get antibiotic resistance from things that you're even using over the counter. You know, some of the antibacterial cleansers can can trigger antibiotic resistance. It's something that it's very, very hard to avoid. Now, for things like acne and rosacea, depending on the situation, there may be ways to get around it without the oral antibiotic, right? Acne, to me, is a perfect example. The topical regimen hasn't been controlling you. We're going to continue that. We're not necessarily going to get everybody on oral isotretinoin. Not every female is going to go on oral contraceptor's horactone. The males certainly can't be treated with those. So there's going to be a time times where, well, this is what it will offer you. And if you don't do it, this is the consequence of you saying no. Because every decision that they make, it's not as if I have a magic wand to come up with something else. There's a consequence to them saying no. And they have to under, they're part of that joint decision making. Yeah. And so I explain it to them in that way. And if we do it, we're going to do it for as short as we possibly can to get you better and then figure out how to move it along. And that's going to a lot of times depend on what they have access to. If they can afford a good laser system to use, we can get a lot further. But if they can't, then that option comes off the plate unless we want to be offering it to them and not charging them for it. So that's the way I handle it now. I'm a kinder, gentler Jim Del Rasso. I don't I don't kill two birds with one stone. In the words of Peter Leo, I feed two birds with one stone. It's much kinder. Much kinder.

SPEAKER_00 11:04

What flavor of scone?

SPEAKER_02 11:06

Well, you know, I'm not picky.

SPEAKER_00 11:08

Fair, fair. Kind of prone to blueberry, but I can take any of this.

SPEAKER_02 11:14

Dermatrotter, blueberry stones, right?

SPEAKER_00 11:17

So I think, you know, with talking with patients, I I find it challenging, you know, to figure out, okay, where they're at, right? Do are we on the same page with what's even happening or going on? And, you know, I think part of a skill is how do you talk with somebody to sometimes I would say persuade or convince them, you know, that, oh, they thought maybe they truly had acting. And you're like, no, you actually have rosacea, something that's different but can look similar in some respects. How do you help, you know, get somebody sort of on the same page with you, especially if you've encountered somebody who's resistant? I'm sure I I've had some patients

Resetting Your Mind Before The Room

SPEAKER_00 11:50

that, you know, it's ride or die, what they think they have is what they have. So I'm trying to help, you know, for our patient listeners out there like to be open to what you know physicians say, because I feel like there's a lot of mistrust in the healthcare system.

SPEAKER_02 12:01

I understandable. I get it. Yeah. So to me, it starts with, and I try to remain aware of this, but we're human. We're busy, we get interrupted in the hallway, we just left the room with a patient that has a melanoma that's advanced that they didn't know about. It's it's a conversation that we carry, we feel badly about. And then we're gonna go in the next room with the next person that doesn't have anything to do with what happened in the room before. They're there because they're there to get the best from you as the clinician. So, how I enter the room, I I try to always remember, and I'd always tell the residents when I had the residency program, stop yourself before you go in the room, reset yourself. When you go in, make sure you're making eye contact. Make sure your staff is making eye contact. Because in a lot of offices, they have to sit down and start typing. And after a while, the patients get to know who your staff is by what the back of their head looks like. And I don't want that. We got to make that eye contact, but they do have to get their work done. But I try to sit down, be at the same eye level or a little bit below, and talk to them, let them know. So what is the main reason that you're here today that I can do for you today that's bothering you the most? Right. And making sure that I'm addressing that, right? It, you know, if it's their acne, what about their acne? And then explain to them realistically what we can do and what the time course is going to be. What I need from them, right, over a period of time. So let's say we come up with a regimen, you know, I like to recommend specific cleansers and moisturizers to patients rather than try one of these three, whatever. I feel like they're coming for a recommendation, and I'll tell them this is what I think is going to be best for you, but it may not be. We can always adjust it. But I also try to find out what they have. Because if they spent a fortune on some things and it's okay for them to keep using that, yeah. But sometimes it's what you don't want them to be using. And I'll say, well, right now, instead of saying, Well, who gave you that? Right? That's terrible. Right now, I would put that aside. I don't think it's the best thing for you right now, and just let them know that the skincare is an extremely important part of it, not just medicine from column A, medicine from column B. And let's say there's a couple of different things they're going to be using,

Acne Plans Need Time And Consistency

SPEAKER_02 14:40

making sure they know exactly what to use and when, right? Not just here's the medications, but to understand why they're doing it. And that they need to do use all of it. Because if they leave something out of it, the time course that I'm expecting to see a good response, and I describe that to them, what that will be by eight weeks or whatever. If they're not doing that, then all bets are off because each one of these things that we're recommending play a role in getting your acne better. Right. And sort of get that agreement unless they're having a problem. And then if we get to that at eight weeks and and you're not satisfied, you know, explain why. And if we have to adjust it, great. If not, you know, you're actually on track. Give me another four weeks. So basically, I ask them for 12 weeks, right, of following my instructions completely, unless there's a problem, and have that eye-to-eye verbal contract. If we keep chasing too early, two weeks you're not better. You're gonna keep changing and chasing those changes. You're never gonna get to the point that you're looking for because she didn't give it enough time with acne. Okay. So that there was a very interesting study on even patients that had been acne patients for many years, many of them were were patients in their 20s and 30s, and they had some teenagers that they asked them, how soon do you think it is that you expect to see a big difference in your acne? They kept saying two weeks. So even though you think they have experience and they would know, or you think they know not to spot apply, Steve Feldman, great study. Cameras watching patients put the medicine on, they're spot applying 40% of them still spot applying the medicine. You can't assume that they know what to do. Assume as you make an ass out of you and me if you spell the word, right? Quote my father and his father and his father, right? And so I I try to really be conscious about that. But years ago, you didn't have to go through a lot of this, right? You gave a handout, and somehow the people followed everything. It's different now. They leave, they're distracted by something somebody else is telling them. Right. So that's what I try to do. Now, if the different diagnosis, that was the question you asked, that they think they

When Patients Diagnose Themselves

SPEAKER_02 17:20

have acne or they have rosacea and they go, I have lupus.

SPEAKER_00 17:26

Yes, yes, that's a common.

SPEAKER_02 17:27

And you're trying to convince them that no, you don't have lupus, you just have it just have to be, you know, in my opinion, no, for the following reasons. This is why I don't think that's correct. And this is what I'm gonna suggest. If they're that adamant and they don't want to listen, then we can call it a day. It's okay. But that doesn't happen very much. I'm not gonna treat you for lupus if you don't have it. Yeah, now if they really push and they, you know, they say, can you can you test the ANA? Yes, I can do that. But I could I also have to warn them, depending on their age, they may have a false, a low false positive. So a positive, you know, then you're getting into but I'll but I'll I'll I'll give on that. Sure. But let's get get you started on your rosacea treatment.

unknown 18:17

Right.

SPEAKER_00 18:17

But but it's so important what you said because you're again you're listening to the patient, you know, if they've convinced us something and you say, you know, again, you're expressing your opinion of, you know, I don't think this is it. But if they're adamant, you know, we can do a workup within reason. And I think again, you're building that trust and rapport. Have you ever had a patient come in that you know really sticks out in your mind of someone that you maybe convinced to kind of go a different direction with treatment because maybe where they were headed wasn't working, or maybe they were resistant? You know, I know we have so many new medicines, right, that are out now for all the skin conditions that we treat. And, you know, I think a lot of us struggle to talk with patients in a way that makes them feel reassured that we understand that we safety, we think this is the best treatment choice, especially with you know, Jack inhibitors, biologics, all these medications at our disposal. Have you ever had to have that conversation to sort of, you know, kind of lead them in that direction, you know, where you feel comfortable with it, but you're

Biologics Versus JAK Options

SPEAKER_00 19:10

trying to get them to see the benefit of the medicine.

SPEAKER_02 19:12

In that situation, I have to feel comfortable with all the options. And if it's something I'm not gonna do and it's what they need, I'm gonna get them where they need to get it, right? So if I'm of the mindset that I don't use biologics or I don't use genus kinase inhibitors, I'm probably not the best person for them to see because that may be an option that that is gonna be the best for them. So all these drugs work, but they don't necessarily work the same in everybody because the people are not the same. And we're finding out more about their individual genetic patterns, but we can't test all we're just in the beginning of being able to do that, and that's not always going to be 100% perfect. So, what what what I would do in a situation like that is we we have a couple of options. So, a great example would be we we need a systemic therapy in your case for your atopic dermatitis. We can keep going with different topicals that you can use in breakthrough areas. We're not curing this disease. You still might need it here and there, and we go through that. But now I can use to put put you on, I could choose to put you on one of the biologics, whether it be uh dupilomab, leprachigiumab, a tralokiniumab, right? We have those three. And we have anemolisia mab, we have those four now, or I can go to a Janus kinase inhibitor, right? We do have a test now that can sort between the two of those. But the majority of those patients, a good seven to eight out of ten, are going to do just as well with either one, right? We don't have the tease out data on pneumolisia mab yet, but keeping them for the sake of conversation, either either a biologic or a janus kinase inhibitor, or I can put them all on Janus kinase inhibitors and very likely get them all better. But then you have another totally different discussion about that. So then you gotta weigh what the patients feel comfortable with in terms of do I want to go through those blood tests? Do I want to, you know, and most of the time they'll they'll be fine with that, but they may not need that. And they'll do just as well if they're on one of the genus, one of the biologics. So give them that particular option. I don't find a lot of trouble having people that say, Well, I don't know if I want to take an injection when I talk to them about what is actually involved with the injections. So let's say it's twice a month. So the injection is I'll give you 10 seconds. 20 seconds a month, and you're done.

SPEAKER_00 21:55

Put in perspective.

SPEAKER_02 21:56

Puts it in a different perspective than oh my god, it's an injection. I don't believe there's like needle phobia that people are gonna go jump off a bridge. I do believe that if you ask people, do they like to get injections, generally, no, I don't want to get, but if you put it in the context of you or your child, is this miserable? And you can get to a place where many days you're not even thinking about having it, right? That's that's the reality of the context. So I really don't have any trouble. Or having them go on an oral. Are you okay?

SPEAKER_00 22:30

Yeah, I may need some water. Okay, grab some.

SPEAKER_02 22:34

How am I doing? Am I talking too much? Oh great. Am I blabbing too much?

SPEAKER_00 22:37

No. Actually, I have one in my bag if it's right over there. Sorry. Thank you. I don't know what just happened.

SPEAKER_02 22:46

No, it it it does it happens to me in Vegas all the time. It's horrible. It's horrible in Las Vegas. It's horrible in Las Vegas.

SPEAKER_00 22:59

Are you okay if I

Keeping Treatment Decisions Adjustable

SPEAKER_00 23:00

just go back in? We're good. Okay. Okay. So I I think that's where, you know, when we started this conversation, part of it is, you know, how do we work with patients and you know, our provider listeners, our patient listeners? You know, what is your advice for I think just getting through that conversation? Maybe there's something out there that struggles that feels like, gosh, you know, I always feel like I'm trying to help my patient understand, but I get a lot of resistance or I'm not successful. Do you have tips and how you think that helps?

SPEAKER_02 23:28

So we have that discussion, and then to somewhat I'm reading their facial expression, they're they're not totally convinced. And I'm not trying to convince them of one versus the other. But if they ask me, what do you would you think? I'd say, Well, this is what I think is the best for you. But if you don't want to do that right now, we don't have to.

SPEAKER_01 23:49

Okay.

SPEAKER_02 23:50

We're not we're not married indefinitely to any particular decision. And if you say, Well, I'm not exactly sure, but I but I trust you, I'm gonna go with you, we can stop it at any time and adjust and then deal with the realities of what direction we need to go. So it's it's always an adjustable situation. But if they decide on something that is likely going to be less optimal, when they come back, if it's doing well, then I'm pleasantly surprised. Hey, it worked out great for you. You know, that was great that you you took option number two, whatever, right? But if not, they've had time to think about it. They've developed a trust in me in talking with her, in uh talking with them, and then you're in a better position for them to say, okay, Dr. Trotter, let's give that a try. Well, what else can we do? Sometimes you're going back to the old treatments that get maligned. Right. I still I have some patients that are atopic that are on cyclospore and they're doing extremely well. They love it. That's what worked for them, and they don't want to move. But they have to understand the pros and cons of that. And usually they do just fine. They did for years before we had these new treatments. But I think the newer treatments are so much better than what we had in the past. So that's typically what I'm gonna go to.

SPEAKER_00 25:14

And what would you tell, you know, in the last few seconds we have here, you know, a patient with all the information overload out there, what would you tell them, like if they're gonna do that research before coming in

Handling Online Research And Misinformation

SPEAKER_00 25:25

to meet with you or another dermatology provider, like what would you tell them, you know, about the information that they're getting out there just to help them kind of prepare for that visit, you know, and balance the situation?

SPEAKER_02 25:35

So if, you know, if they're not a medical person that really understands it to that depth, I'll say I appreciate that. But all of that is some of it's written from good sources, some of it, the sources are somewhat questionable from the science side of it, and I'll point that out. But let's say they have some really good reputable sources, at least from my perception of what I'm looking at. Oh, but they they need to be in the context. There's a context of where they fit in that no offense, but you're a um an accountant, and I would never be able to touch the kind of things you do. There's things here that that's why you're here with me to try to help you understand it. And then if they're still not convinced, you know, I'm more than happy to, you know, talk to you at any time. But what what choice would you like to make right now? And then if they're making a choice to walk out with any treatment, then they're keeping their disease the way it is right now. I can't, I can't control that. But I I always want to let them know I'm willing to try to help them in some way.

SPEAKER_00 26:45

Well, and I feel like you helped them with just what you said. You gave the power back to them to make that choice, you know, in that decision-making process. So it's been a great time having you here on the podcast today, Dr. D. I really appreciate your insights on how to work through, you know, patients and medicines we're going to recommend and things that you know, I think providers find challenging, and then also for patients that are learning about everything out there and just trying to have a great relationship with their provider.

SPEAKER_02 27:09

But I explained to you the Nirvana, it's what I try to do.

SPEAKER_00 27:13

Uh-huh.

SPEAKER_02 27:13

But there's times I'm driving home and there was a patient, you know, I I didn't do the best job there. You know, I didn't do as good a job with one of those areas, whatever, right? Because we're human and we're busy. So you just try to get better and better each time. But I finally made it on a on a real, real podcast. Thank you so much. I really enjoyed talking with you. I love watching your show.

SPEAKER_00 27:36

Well, thank you. It's been an honor to have you, you know, on the podcast. And we'll have to have you back. We'll have a different topic. We'll do that. Lessons in life. I love it. We'll definitely get there.

Final Takeaways And How To Support

SPEAKER_00 27:45

We'll get there. Well, stay tuned for the next episode of Dermot Trotter. Don't swear about skincare.

SPEAKER_01 27:51

Thanks for listening to Dermotch Mutter. For more about skincare, visit dermitchmutter.com. Don't forget to subscribe, leave a review, and share this podcast with anyone who needs a little skincare sanity. Until next time, stay skin smart.