Derms Gone Rogue: When We Go Off-Label

“Off-label” can sound like a red flag, but in dermatology it’s often the most practical way to treat real people with real problems. Dr. Trotter sits down with board-certified dermatologist Dr. Victoria Farley to explain what FDA approval actually means, why many effective skin treatments never get a specific label, and how we talk through safety, side effects, and expectations – so patients feel confident rather than confused.

We walk through concrete examples you may recognize from your own care: spironolactone for hormonal acne and androgen-related conditions, finasteride and dutasteride considerations for women, and why low-dose oral minoxidil can be a game-changer when topical routines are hard to keep up with. We also cover a classic “wait, why does my prescription mention cancer?” moment with topical 5-FU, and how that same medication can be used off label for stubborn plantar warts with thoughtful counseling and monitoring.

From there, we zoom out to what’s next in medical dermatology: GLP-1 drugs and their emerging connection to inflammatory skin disease like psoriasis and hidradenitis suppurativa, plus the rapidly expanding world of JAK inhibitors for immune-mediated conditions including lichen planus, lichen sclerosus, granuloma annulare, and more. We also dig into chronic itch, especially in older adults, and why antihistamines are not always the best long-term answer, with off-label options like naltrexone and gabapentin entering the conversation.

If you’ve ever wondered whether off-label prescribing is legal, ethical, or worth it, this conversation gives you a clear framework: evidence, experience, and a patient-specific risk-benefit plan, plus the reality of insurance coverage and prior authorizations. Subscribe for more practical dermatology education, share this with a friend who’s navigating a confusing prescription, and leave a review with the off-label question you want answered next.

DISCLAIMER: The views and opinions expressed in the Derm-it Trotter! podcast are those of the host and guests and do not necessarily reflect the views or positions of the guests’ or host’s institution or employers. The Derm-it Trotter! Podcast is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this podcast or materials linked from this podcast is at the user’s own risk. The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they may have and should seek the assistance of their health care professionals for any such conditions.

Transcript

Welcome And Guest Introduction

SPEAKER_00 0:05

Welcome to the Dermotrotter Don't Swear About Skin Care podcast. On today's show, we've got Dr. Victoria Farley. She's a board-certified dermatologist with Vivita Dermatology in Las Vegas, Nevada. She's dedicated to providing compassionate, high-quality care for her patients. And just like myself, she loves patient education. Welcome to the podcast, Victoria. It's great to have you here.

SPEAKER_01 0:27

Thank you. Glad to be here.

SPEAKER_00 0:28

We're going to tackle a topic that's near and dear to both of our hearts as dermatologists, going off-label or using medications, what we call off-label, because in dermatology, we have so many skin conditions that we don't have the luxury of having an FDA-approved medication for everything that we treat. But a lot of our patients may not even know what that means and why we even go that route.

What Off-Label Really Means

SPEAKER_00 0:48

So what do we even describe off-label? What does that mean when we're doing that in practice?

SPEAKER_01 0:53

Sure. So you brought up a great point when you're saying about being something being FDA approved. And what that means is that when a company is looking to get FDA approval for their medication for a given disease or condition, they actually have to do studies or what are called clinical trials where they test the medication out. And then assuming it meets what it's supposed to uh uh clear on the condition, then the FDA will uh approve it and say FDA approved. Um, but sometimes over time we find that given medications can also work for other things as well. But um it's it doesn't always have all the clinical trials that are done to it. It's just more clinical practice that sometimes it's thousands and thousands of patients worth. So it's even bigger than what you would do in a clinical trial. But since you don't have that exact clinical trial, then you can't put that FDA approved label on it. And so that's what off label is.

SPEAKER_00 1:43

So I think a lot of people might think that's a little scary, right? If the FDA hasn't approved it, would this mean that it's actually safe or would it work for my condition? And I think that's something that we have to talk about with our patients because this is pretty common practice, wouldn't you say, especially in our field?

SPEAKER_01 1:59

100%. Yes. And yes, you do definitely talk to your patients about it. Uh the thing is, like you said, since we do it so often, we can speak to not only the evidence that we have in uh journals and articles, but also to our own clinical experience. Um, you know, I think a lot of things, common things being common, for instance, like spronolactone for acne. You know, uh uh over the 17 years I've been out of residency now, it's probably been hundreds, if not thousands, of patients with acne that I've treated with spronolactone. So, but we we also know what other things it's used for. So for instance, that medication is a diuretic. So I'll talk to patients about they feel like they might have to urinate or go to the bathroom a little more. They might feel a little bit more thirsty. There are other questions you ask depending on their exact uh past medical history and other uh medications they may be on. But yeah, you just kind of go through it the way honestly you'd go through an on-label medication.

SPEAKER_00 2:51

Yeah, and I think probably a lot of people, you know, myself included, and when we think about it, we do it such as a common practice every day that sometimes we might even forget or neglect to say, hey, this is an off-label use of this medication. And on label is something that, you know, I think patients might assume, well, if we're prescribing it, it must be something that's been FDA approved and actually gone through all that rigorous testing. But that costs a lot of money, right? And time. And sometimes, too, for our generic medications, it makes sense that maybe there isn't always that investment because it's actually a business piece or the payoff. But we can sort of pull out from other studies, okay, we kind of get an idea of what the safety of this medication would be. And based on how certain skin conditions behave, what we call that pathophysiology, we can probably figure out that this medicine might be potentially a good fit. But I do think, you know, for patients, they might be a little gas sometimes, or if we said off-label, I think just that term has a little bit of a negative connotation where they might say, hmm, what does that really mean? And is that even okay? Can a doctor or prescriber do off-label? Because they might think, is that illegal? Is it an unethical practice? And I want you to kind of clear that up too, because I think that might give people some pause.

5-FU Cream For Stubborn Warts

SPEAKER_01 4:01

Yeah. So for instance, uh another medication that I think of that I'll use uh off-label is uh there's a topical cream called 5FU for short or 5 fluoril. But there have also been multiple papers showing that it can help with warts, specifically planner warts. So when I'm talking to the patient about their different treatment options uh uh for their warts, and it'll say they decide that's the one they want to do, because although the creams can be slower, some patients like it because it doesn't quite have some of the pain that you can experience either with freezing with liquid nitrogen or doing something a little more invasive where either you're physically cutting out the wart or maybe you're uh cutting, scraping and burning it, or something we called an ED and C. And so they want to go a little bit milder route. So then at that point, then I'll talk to them about okay, so this medication was we use it in dermatology a lot for uh superficial skin cancers or for actinokeratosis. So if you, if you're the type of person that likes to read a package insert, you're gonna find in there it's gonna talk a lot about cancer. Don't worry, it doesn't mean you have cancer, but over time we have found that it actually helps with warts. And there's multiple papers on. So that's kind of how I explain it to them is what they'll see when they look in the package insert, but what I'm using it for and kind of the data behind it.

SPEAKER_00 5:15

Yeah, that makes sense because I I think it's good for the know that's kind of common practice. And even though, yes, it may not have gone through rigged testing with the FDA to get approval, there is evidence to suggest this can be effective. And even in those, you know, if they're case reports, just small groups of patients looking at how it was effective, or even if it was maybe a smaller type study, it's also going to comment on potentially, you know, the safety of it too, which is of course something we're always concerned with when we're doing a medication, whether it's on or off label. And I think to highlight, like you mentioned too, you know, a little bit here, that this is common, it's not illegal. It's actually a practice that we have to do on a regular basis. But I think one of the challenges with that practice, and especially what we can face in dermatology then, is sometimes insurance companies or payers saying, well, if something's not approved by the FDA, we're not going to cover it, we're not going to pay for it.

Insurance Denials And Workarounds

SPEAKER_00 6:02

So I want to get your thoughts on what you really think about that and how often you might even encounter that. And how do we get around that to get the right medication for our patient, even if it's not technically FDA approved?

SPEAKER_01 6:12

I think you bring up a great point. And on that one, uh uh, we could go into a whole nother topic on frustrations that we as clinicians face with uh insurance companies. But on that one, actually, insurance companies talk a little bit out of both sides of their mouth because when you want to try to get on-label things, which of course, now going back to the cost, uh biologics or jack inhibitors, sometimes they'll want you to use medications that are cheaper, but they are not FDA approved. Uh uh, you know, depending on if you're talking about things like psoriasis or atopic dermatitis, they may want you to use methotrexate or azothioprin or cyclosporin. Like those are not FDA approved medications for those conditions. But historically, before we had biologics, those are what we had to use because that's all we had available. Now, like you said, they also like to go on the flip side though, like, oh, well, and again, usually it's for these more expensive medications, the generic medications, I very rarely find that they um will deny it. And honestly, even if they do, usually through things like good RX or sometimes even without it, the medications are just that cheap. It's still only five, $10 at the pharmacy. Um, where I find it's more of a challenge is certainly if you're trying to get a more expensive medication for an off-label use, that's where they're gonna right away be like, no. And so, really, the only way you can really get around it is sometimes you're if the patient actually has what the condition is FDA approved for, in addition to potentially this off-label use that it may help them with. Sometimes that's home, we can get a two-for effect of it if you want to try it and you know, we'll use it for both.

SPEAKER_00 7:45

Yeah, that's interesting that you mentioned that because I can recall getting denials actually for FDA approved medications to start a patient on. And surely because you can look at the cost factor, because it is a branded drug, yet they wanted me to use a generic medication that is off-label. So I do think, you know, unfortunately, cost does drive a lot of this, which we do have to pay attention to. But honestly, sometimes the off-label medication, as you and I know, is going to give the best result to the patient. And so we're looking at cost, but also what's going to have the best outcome, because that could be that off-label medication use. So I wanted to talk more though about you mentioned already a few examples because, you know, I think and I sit back, gosh, you know, I just, you know, saw, you know, patients all day. How many patients that I prescribe something was off-label? And I think it's shocking when you literally sit down and calculate it and look at it. I think we do it because it's such everyday practice with ease that I don't think I realize how often that's happening. But I wanted to talk more about some of those medications that we use, a little bit about how they're approved for FDA or approval, what they're approved for indication-wise, and then sort of what they've translated into dermatology, sort of just to educate, you know, obviously our patient listeners and some of our provider listeners might be looking for some creative ideas to treat some conditions that they've never even thought about going off label for.

Spironolactone For Hormonal Acne

SPEAKER_00 9:03

So we talked about spiralactone, you know, and use for acne. So I'm gonna have you kind of dive into that one a little bit deeper.

SPEAKER_01 9:10

Yeah, so spironolactone, what it originally got FDA approved for, uh, was for certain types of high blood pressure or even uh uh heart failure. And um, but the one of the properties of it is that it blocks androgens or the the testosterone, the male family of hormones. But even as women, we still have it as well. And so specifically for acne or anything that is hormone related, uh uh, even if the hormone levels are not abnormal, because I think that's important to know too. I feel like a lot of women, they hear if they have a hormonal condition, it means their hormones are abnormal. Don't get me wrong, sometimes they can be, but I would say in the vast majority of my patients, their hormone levels are normal. Just unfortunately, that given patient is a little more susceptible to the effects of the androgens in their body. Uh anyway, so along the way, we found that sporonolactone with its anti-androgen properties was helpful in conditions where androgens played a role. So, again, for things like acne, uh hydratinitis separativa, which a lot of those patients, because it's kind of in the acne family, will get flares around their periods as well. Or um in things like uh androgenic uh alopecia, or again, where uh androgens play a role uh acting on the scalp, uh that it's all been helpful for for all of those conditions, even though that's not what it was FDA approved for. But one of the things that it does being an anti-androgen explains why it could be helpful for those conditions.

SPEAKER_00 10:31

And I love that because I think that's where the art of medicine comes in, right? We're looking at the why behind so many of these skin conditions. And, you know, it's nearly impossible to have everything approved. So if you can find medications that target that why or that reason, you know, it makes sense that we're gonna pull those out and try those for our patients. And I think it is important for our patients to know, like you highlighted earlier, too, about the safety piece, that we have clinical trials for those FDA-approved indications. And there are some going on, you know, with acne as well to try to justify its use and give us even stronger data, more than what we even see clinically, on how well it can improve these conditions. So I think that's what's been valuable for our patients

Hair Loss Options Beyond Labels

SPEAKER_00 11:08

too. You know, you talked about hair loss, because I feel like for hair loss, we've got to go off label a little bit more often than we think of, especially for pattern hair loss or androgenetic alopecia. You mentioned spironolactone playing a role with that. What about, you know, drugs that patients might have maybe heard of, especially men? They might be familiar with phenasteride for them because an FDA approved label for male pattern hair loss, but what about phenasteride, especially for women as well?

SPEAKER_01 11:32

Yeah, and it's that same thing. It with that uh blockade of the androgens is how it helps with the hair. Now, the thing that I'm uh uh uh very verbal about and vocal about though, when I'm talking about either one finasteride or doutasteride for women, is just you cannot get pregnant on it. So uh uh uh so for those medications, I really try as much as possible to use it um either in my female patients that have had a hysterectomy or uh are post-menopausal. So like I always make some of my 70 and 80-year-old patients giggle and I'm like, all right, but you got to promise me you're not gonna get pregnant. And they're like, no, that's not gonna happen, you know. But because uh uh and then and I also explained to them why, you know, I'm like, it's just because since it blocks the androgens, even though us as women, that's not our main hormone. So if you block it, it's not as big a deal. But if we were pregnant with a baby boy, obviously we don't want to block his androgen. So it also helps them to understand like it's not that it's harming something inside our bodies or, you know, but it's just we wouldn't want to harm another potential person that could be growing in our body that would meet that testosterone.

SPEAKER_00 12:37

Yeah, and I think that's where people are sometimes, you know, surprised for, and and maybe not so much myself at times though, especially for women in hair loss, you know, the lack of that we don't have FDA-approved medications to even tackle this as an issue. You know, with finasterite, we were lucky to have at least one for men, but sometimes, again, it's not the right option. So we need to kind of look at what else could be out there that could still go after why it's happening in the first place, which is kind of a tie-in to another medication for hair loss. We use off label orally, monoxidol. A lot of people are familiar with monoxidol topically because they know ray gain, roguein. It has that household name, right? Just kind of like Botox. We're like, oh, rogain, seen it on TV. I've tried it, seen it in the stores. And it's funny, I think when patients come in, I'm like, yeah, but did you know we could potentially do this orally? So kind of wanted to see how you talk with patients about that and the value you think it adds potentially for hair loss as well.

SPEAKER_01 13:26

Yeah, no, I think uh oral monoxidal adds significantly for hair loss. And I use it for almost pretty much every kind of hair loss that uh uh uh uh I treat. Um, absolutely, it can work for androgenic, but even inflammatory or autoimmune types of hair loss. Now, by no means, unfortunately, minoxidil does not target the inflammation, but it does still help with getting that hair to grow in, especially in patients that have more stubborn uh or recalcitrant uh uh conditions. It just helps to give it that extra oomph to try to get it to grow in. But yeah, so it's the same thing. Uh I always just ask my patients uh about their blood pressure, because like sporonolactone at uh higher doses, it is used to treat certain types of high blood pressure. So if if a patient tells me that the systolic or the top number in their blood pressure tends to be on the low side, you know, then that may be something we need to discuss that it could cause some lightheadedness, um, uh uh, you know, get their cardiac history, things like that. But I always explain to them the dose that we use when we're treating your hair is teeny tiny compared to the dose that is used when it's used uh uh for blood pressure or for cardiac reasons.

SPEAKER_00 14:32

Yeah, and I think too, with it, you know, available over the counter, sometimes I feel like, you know, and topically where patients can find a solution and foam, there might be a little bit of comfort with it. And then it sort of shocks them like, oh, I could do this orally. And I feel like that's one of the reasons sometimes we go off label because we know it's really tough to keep up with the topical. I mean, technically, you know, if you look at how it's studied, a twice-a-day application, you know, just the time it takes, the residue on hair, how it can affect different hair types if you have thinner or finer hair versus coarse hair. I mean, there's all these challenges with the topical that I think this is where the creativity comes in. Could we look at an oral option? And then maybe some data suggests will oral be potentially a little bit better? Does it actually deliver the medication, you know, a little bit better and get to, you know, the scene of the crime, if you will, or the action where sometimes for topicals, there could be rate limiting steps of how much we put on, does it get absorbed enough? And then other, you know, challenges with monoxyl, because not everyone is a responder. But I think this is a good example of where we're like, gosh, you know, maybe this is a a role for going off label for an oral medication that could actually work better. And sometimes it's a matter of compliance. Do you find that for your patients that sometimes they want to do the oral because it just seems to be easier or they can just be, you know, better at keeping up with it?

SPEAKER_01 15:43

100%. Um, I I find, you know, unless patients uh have very short hair, which stereotypically tends to lean towards uh uh men, but even my male patients that have, when I say longer hair, I'm saying like hair that's maybe this long as opposed to like my husband's hair that, you know, spikes. Um they don't necessarily, and women included, don't tend to wash their hair every day. Right. Uh uh uh I have some of my patients that wash their hair once a week, twice a week. And so the the thought of putting something in their hair, like you said, once or twice a day, every single day, it's gonna build up if you have any length to your hair. And and most people just don't like that. And so uh uh, and I do explain that to them when I'm giving because I always tell them, all right, I'm gonna talk a while. I apologize. Please feel free to interrupt. But here are their options. And I start with the topicals and then work my way up. I go, but what's with any of these medications, topicals included, what really tends to give you the biggest benefit is how consistent you can be with it. So unfortunately, even though if you're consistent with it once or twice a week, that that's not gonna quite cut it. We need to be consistent with it like once or twice a day. So if you don't think that that's gonna be realistic for you, but you are really wanting to aggressively treat your hair, then I think the oral will probably be your best bet.

SPEAKER_00 17:00

You know, and then as I was listening to you explaining that, one of the things that came to mind too is, you know, when we talk about what off-label means, a lot of times, you know, we just talk in terms of FDA indication, right? But it is also about how it's dosed, right? So, you know, we have topical monoxidal that is approved and we use it for hair loss, but the oral version, even though people are like, oh, it's the same medicine, right? So why wouldn't it be FDA approved? And I try to explain that, well, you'd have to have the study and go through the process of seeking that approval. So just the fact that we're changing how it's delivered, a topical versus an oral, that would be considered an off-label use. And then if we even change the frequency, right, or the dosage of something. So, and we do that a lot, I think, in medicine in general, because a lot of us are like, gosh, we would like to have you on the least amount of medicine possible, maybe to control your condition. So we might modify the dose or lower it. Or sometimes, as you know, we've got to up the dose a little bit too, because people actually need more of the medication to actually work or be efficacious for their skin condition. And maybe, yeah, the drug was studied that way, but ultimately that dosing wasn't chosen. So I I think I like what you kind of mentioned there too, just how we think about in terms of off-label, that that could be the medication itself has no indication yet we're using it for the condition, or it may already have FDA approval for the indication, but we're changing it up on how like frequent we give it to somebody, how much we actually give them as well. And again, it goes to the R of medicine because we're treating the individual. And when these get approved, it's kind of a blanket approach. And I think monoxil is kind of good way to highlight that as well.

GLP-1 Drugs For Psoriasis And HS

SPEAKER_00 18:26

And the hair loss we've been talking about, I think, is a great segue to to talk about GLP ones, because right, this is on everyone's mind. Um, some of our listeners, I'm sure, are on them. I have colleagues that are microdosing these for longevity medicine. They're all the rage, obviously, for diabetes, even prediabetic states, and of course, weight loss. And we're seeing them now in dermatology playing a role in inflammatory disease for us too. So I wanted to talk about this because I think some people might be surprised if, especially some of our patients, if they haven't really heard of this, some of our colleagues are already using them and wanted to see if you had some experience with this as well.

SPEAKER_01 18:59

Yeah, no, there's actually so data so far. I mean, obviously, like you said, we still need trials to look at GLP1s, specifically for uh psoriasis and hydratinitis suburativa, are the uh two indications that we're really concentrating it on more so with uh dermatology. And again, it makes sense because those conditions tend to go along with the things that uh GLP1s and trap rest, which is uh anything associated with metabolic syndrome. So um, and and of course, metabolic syndrome in and of itself drives inflammation. So it totally makes sense why that would also drive conditions like HS and psoriasis. There has also been uh trials that have been done, or studies rather that have been done that have shown there are actually GLP receptors in the skin in both psoriatic plaques and lesions of HS. So, I mean, again, that you can't quite translate that straight to saying, okay, yes, it means it will work for those conditions, but it's definitely evidence leading in the right direction that we do have clinical trials that are going to be forthcoming looking at these molecules specifically to treat these diseases. Now, one thing that's going to be interesting to see that uh assuming and hoping that they do get FDA approval for it is will insurance cover it? Because again, we know GLP ones are, you know, they help with cardiac protection, with renal protection, uh, and with obesity. But right now, I feel like unless you have severe OSA or if you have diabetes, good luck getting it covered, even though you may have an FDA-approved reason to get them.

SPEAKER_00 20:29

Yeah, that's true. I mean, I think the FDA coverage, like you said, that's always going to be at the heart of the matter or insurance coverage and the FDA approval can play a role with that. And even like you said, we try to get FDA approved drugs all the time for our patients and we hit roadblocks with cost. But but it is exciting to kind of see how those medications might play a role in treatment of skin conditions. And maybe one day we'll get those approvals in place where it'll be a

JAK Inhibitors For Autoimmune Skin Disease

SPEAKER_00 20:50

little bit easier. One of my favorite class of drugs that I tend to have to use on a regular basis, also had some experience using off-labor, are the JAC inhibitors. And some you know, patients out there might not be familiar with these drugs, but I found them to be phenomenal for a whole host of different autoimmune skin conditions, especially the ones that I think of that are completely, you know, underrated from the standpoint of how they affect patients. And of course, on a smaller scale, they don't affect a large population, so they don't often get the attention of studies, but we've always had to go creative and kind of off-label for those folks too. So uh Jack inhibitors, I know you're a fan. So I wanted to talk more about where you found these to be useful beyond what they're FDA approved for right now, atopic dermatitis, with some other things in the pipeline. And then obviously we have subset for allop chariata, some other conditions too. What are your thoughts on that and where we're headed?

SPEAKER_01 21:38

No, I agree a hundred percent. Uh uh, you know, I I think immunology, JAC inhibitors, all of that as a class, uh not only within dermatology, but other medical specialties as well, is exploding. Like that is such a hotbed as far as not only what it's actively FDA approved to treat, but uh things again, off label and even things that they're still investigating for what else it can treat. But yeah, for me, what I tend to use it off label for, I like it for the lycanoid dermatidities. So uh ranging from uh lycan planus, oroleycan plantus, lichen planopylaris, lichen sclerosis. Um uh it works well for uh granuloma annulari, uh it works well for, especially if it's really recalcitrant. Um, it it also works well for uh some HS patients. Um, and you know, there's definitely trials that are still actively going on. There's medications that are like on the cusp of getting approved. So um uh yes, that is definitely a big hotbed of lots of inflammatory and uh immune-mediated conditions that these medications will be able to help and are helping right now.

SPEAKER_00 22:41

Yeah, and I think this is a great example too of where cost can be the real challenge. But I think with more publications, especially case reports or even just small cohorts or case series of patients, maybe for these less common conditions, we'll be able to prove to insurance that these are an effective and a safe option, especially compared to some of our more traditional drugs that change the immune system and come with a whole host of other side effects, you know, potentially including, you know, cancer or even end organ damage and things that we'd have to monitor. I think that the JAC inhibitors, although nobody argued perfect, I think, you know, definitely safer than some of our more traditional therapies. And hopefully over time, I think we'll see that evolution. I always talk about if there's a day and age when a JAC inhibitor goes generic, I mean, watch out because I do think, I mean, it's gonna explode. Um, but you're you're also like you mentioned earlier on, like how you can kill two birds with one stone. A lot of our dermatology patients do suffer from more than one condition. And sometimes one of those is already approved for a medication. So we we can get lucky. Like I had a patient that had topic dermatitis, but also alopeciariata. And before we had drugs approved for alopeciariata, we actually went to one of the Jack inhibitors for atopic dermatitis and put them on it. And actually both conditions responded. So we got lucky, you know, where we could actually see the benefit. And I think too to let our patients know, even if we're considering doing it off label, a lot of these conditions do have clinical trials that we're just waiting, you know, for the approval. And I think that's exciting to see in the future, especially for Vitiligo and things that really haven't had a lot of attention drawn to them, that we're gonna have drugs potentially to really help these patients.

SPEAKER_01 24:10

I agree with you 100%. Yeah, that's what we're saying. Like the uh HS in particular, but yeah, you're right, uh alopece areata, there's still more coming out, you know, like all these conditions, but the companies have applied for their FDA approval. They've already completed their clinical trials. Now they're just waiting for the FDA to give their yay or nay, and you know, when it'll happen.

SPEAKER_00 24:29

So yeah, exciting time in dermatology.

Off-Label Meds For Chronic Itch

SPEAKER_00 24:31

And as we can definitely as we end here last, I wanted to talk about maybe off label your thoughts on itching. And I'm I'm ending with itching because of how common it is and how prevalent because so many people come in, report itching as a common condition. You know, we talk about geriatric or elder dermatology, and we see it as the primary concern people tend to come in and report for a whole host of reasons. And we get pretty creative with itching. I think a lot of people just go to the antihistamines, right? Go to the counter, the drugstore, that's your first choice. But I want to talk about what you found to be effective off-label, and it could be for various types of itching too, that you've maybe seen some results for patients that, you know, a lot of people wouldn't think as a first-line treatment to control their itch.

SPEAKER_01 25:09

Yeah. So yeah, you're right. Uh antihistamines by far are the first line, but you also bring up a good point with geriatric uh dermatology, you know, with a lot of them, especially the um first-level ones, uh uh, they can tend to cause drowsiness, which can uh create a fall risk. They also, over time, as someone's consistently taking them, may increase a risk for dementia. So, you know, it it's one thing if you're you have a short bout of something and you're gonna take them and then you're done. Right. But ideally, they're probably not preferable to do long term. So then that's when you can start looking into other things, whether uh oral medications, you can look at things like naltrexone or gabapentin. Um, uh, or of course, you know, some of our biologics that we have for uh atopic dermatitis or perigonodularis, just because those conditions also inherently have a lot of itch in them. Uh uh, some of those medications uh can be helpful. Or even uh one of the medications that's in trial right now is a medication we have approved right now uh for uh CSU or chronic spontaneous urticaria uh uh remarutinib or rhapsido. Um uh that medication is also being looked at for uh chronic itch. So uh yes, that's kind of where uh I go and some of the things that I'll use off label for it.

SPEAKER_00 26:23

So yeah, I think it's fascinating because you know the mechanism of itch can be quite different depending upon why, obviously, the patient's itching and how are we going to tackle it. If it's you know related to a primary condition, atopic derm, psoriasis, you know, maybe it's medication induced, maybe it's it's neurogenic. You know, there's so many factors that we have to look at. It could be underlying kidney or liver problems, and then how we use drugs, I think people will be like, gosh, I never thought that I'd ever see a dermatologist potentially prescribe that. And so I do think it's one of the greatest examples where we can go off label and really make a difference for our patients. Well, I think overall, you know, talking with our patients about off-label medication use, it is a challenge that I think that, you know, can be easily met because once the patients understand our logic and rationale before it, you know, I think they get why we are going this route. And knowing alternatives, I think for them is important, right? They they should know what's available, but maybe why. And sometimes what's available just hasn't worked. So we're simply motivated by that and telling them potential benefits and risks, I think like any other conversation, because we can have some of our best successful successes with the use of off-label medications. Wouldn't you agree? I mean, I think that's where I've seen some of the greatest things in Durham.

SPEAKER_01 27:26

100%. And I think you also hit the nail on the head that discussing the risk benefits, like that risk-benefit ratio, which if patients, you may not have heard that uh statement before in medicine, we use it all the time. But honestly, on us, all of us as human beings use that in real life, you know, like risk-benefit ratio. Okay, driving to work, I might get in an accident, but how else am I gonna get to work? So uh I can't afford to do an Uber every day. So uh I don't have a personal driver. So, you know what? The risk benefit is I'm gonna get more benefit driving myself to work uh despite the risk of getting in a car accident. Uh it's the same thing with some of these medications, depending on what the underlying condition is. Uh uh, then the the benefit you get from it when it starts to significantly outweigh the risk, then that's when that medication is probably gonna be a good option for that patient or potentially could be a good option for that patient. But you're also right too. You have to ask all the right questions about their uh previous uh medical history, what other medications they're on, uh, and any other workup because you you also have to make sure you're doing that piece of the puzzle as well.

SPEAKER_00 28:32

You got it. I mean, do no harm, right? We took an oath to do that, but we also took an oath to treat our patients, and so it's the conversation that needs to be had.

Risk Benefit Thinking And Closing

SPEAKER_00 28:40

Well, thank you so much, Victoria, for coming on the podcast. It was great having you on today.

SPEAKER_01 28:44

Fantastic. It was great to be here.

SPEAKER_00 28:46

Well, stay tuned for the next episode of Dermot Trotter Don't Swear About Skin Care