Psoriasis Therapeutics and Moving to Private Practice

Speaker 1:                    Every patient deserves to be seen. The Tremfya guselkumab photo library offers hundreds of real patient photos, easily filtered by patient characteristics, disease locations, and severity. Learn more about Tremfya for your patients at tremfyahcp.com.

Speaker 2:                    Welcome to the Practical Dermatology Podcast. This month we have an update from Dr. H.L. Greenberg on psoriasis, an interview with Dr. Lisa Swanson and Dr. Tina Bhutani, and the latest news. Now here's Dr. H.L. Greenberg.

Dr. H.L. Greenb...:         My name is H.L. Greenberg and I am the founder of Las Vegas Dermatology. I had the opportunity to do the lead article in Practical Dermatology for the August issue on psoriasis and psoriasis updates. And when I was in Lisbon at the 5CC meeting, I gave the Updates in Psoriasis talk. So it was nice to put that information together with the new information about what's going on in the psoriasis landscape. And one of the things that I pointed out in the article was that, depending on what the patient has in terms of other comorbid conditions, can affect which drugs that you prescribe for their psoriasis. For instance, if somebody has psoriatic arthritis but also has inflammatory bowel disease, you may want to go with an IL-23 inhibitor because it's FDA approved for both. Whereas if somebody has joint pain and is afraid to go on a biologic drug, you may want to go with a drug like apremilast.

                                    So there are a lot of opportunities out there to treat disease in patients who have psoriasis. And the newer drugs, like the deucravacitinib, which is a TYK2 inhibitor, which has a better efficacy than apremilast. According to the studies, they weren't... Actually, they were head-to-head studies, and it does work more effectively. The only downside is you still have to get that QuantiFERON test when you're writing for that drug. There has been an update in terms of the drug Tremfya for psoriatic arthritis with radiographic inhibition being one of their newer indications just showing that that is what happens. And that drug was approved for psoriatic arthritis before any other IL-23 drug.

                                    The landscape for people who have psoriasis is a very bright one in that, for other disease states we have really good drugs, for the psoriasis disease state we have fantastic drugs. People are seeing PASI 90s, PASI 100s scores. There's the new bimekizumab, Bimzelx, which is an IL-17A and F inhibitor for psoriasis and psoriatic arthritis. That's just showing great efficacy in both disease states. So as I said before, it's a great time to have psoriasis and a great time to have psoriatic arthritis in terms of the opportunities to improve your condition. And if you have the opportunity, I would enjoy you looking at the article in Practical Dermatology, maybe leaving some feedback and what your favorite tips are.

Speaker 2:                    Now, here's Dr. Lisa Swanson with this month's featured conversation.

Lisa Swanson:               Hello everybody and welcome to another Practical Dermatology Podcast. I'm Lisa Swanson, dermatologist and pediatric dermatologist in Boise, Idaho. And I have with me a very special guest. We have Tina Bhutani, you guys, whoop whoop. Tina Bhutani is here to talk to us about some big-time changes that have occurred in her practice over the past couple of years. Welcome, Tina. Do you want to go ahead and introduce yourself?

Tina Bhutani:                Of course. Thank you for having me, Lisa. I'm so excited to be here. My name is Tina Bhutani. I'm a dermatologist. I practice in San Francisco. I focus on inflammatory skin diseases, like psoriasis and atopic derm. And I do both clinical work, clinical trials, and then also a lot of speaking and teaching like you do too.

Lisa Swanson:               Yes. Isn't it fun? I find it keeps my passion alive for the field to do the-

Tina Bhutani:                Absolutely.

Lisa Swanson:               ... teaching and speaking. Absolutely. I agree.

Tina Bhutani:                I agree. I agree.

Lisa Swanson:               Well, Tina, this is probably too much, but I actually take credit for manifesting the changes that have occurred in your practice life. Because a couple years ago we were at Fall Clinical together and we were sitting next to each other in October of 2023. And I said, "Do you think you'll always work in academics at UCSF or do you ever see yourself going into private practice?" And then it feels like the very next time I saw you there had been a change, a big update.

Tina Bhutani:                Yeah, yeah. No, I give all credit to you, Lisa. You can have all the credit. Because it was literally at that conference, right after our discussion, that I actually met someone that put me in touch with the person that got me into the practice that I'm at. So it literally just all happened in October of 2023. So yes, I think it all started with you feeling it before even I did.

Lisa Swanson:               Yes. Isn't that so funny? Isn't that so funny?

Tina Bhutani:                Yeah.

Lisa Swanson:               Tell us a little bit about how it all happened. You ran into somebody, there was a situation with a practice, they needed somebody to step in. Tell us how that cookie crumbled.

Tina Bhutani:                Yeah, yeah. So when we spoke at that point in time, I think I already knew that I was ready for something new. I love everything about UCSF, I wouldn't be here if it wasn't for UCSF, but it was the only job I had ever had. It's where I did my residency. It's where I did my research fellowship. I had been there for over 15 years. And I think I was just ready to see what else was out there. I hate to say it, but yeah, I was just ready for a little bit of a change. So I was already open to the idea of taking in new opportunities, talking to people and things of that sort. So actually at that conference, I was at an advisory board, and I happened to be sitting next to someone who's practicing out in Ohio. And he said, "I was actually just in San Francisco for the funeral of my friend," and this was the dermatologist that had passed away whose practice that I actually took over.

                                    And so we just got to talking and he said, "This colleague's wife is actually looking for someone to join the practice. If you know any graduating residents or anybody else, just let me know." And I said, "Sure, put her in touch with me. I'm happy to send an email out to all the residents and the fellows and see if anybody's looking." So to make a long story short, she emailed me. She said, "Do you know anybody? But also would you ever consider taking over this practice?" And I said, "Oh, no, I could never do that. I don't know how to run a business. I don't know anything about running a private practice." And she said, "Well, you know what? Just come and take a tour. Just see how it feels. Just get a feel for it and just do research. Just do research." And I said, yeah, she's right. It can't hurt.

                                    So I went and I toured the practice, and it's a practice here in the city that focuses on medical dermatology. They do phototherapy, they do clinical trials. It really was the perfect fit. If I was ever going to do private practice, this was the practice that was going to be. And so I told my husband before I left, I said, "I'm just going to go take a tour. I'm going to meet some people." And then I come home and I'm like, “I think we might have to consider this strongly.” And he was like, "What?" So I think we all surprised ourselves. But I think it's a good lesson that you shouldn't close any doors, because you don't know what's out there until you start talking to people and start evaluating things. The world is your oyster. You should just look at all of the opportunities in front of you.

Lisa Swanson:               It's so funny you say that because I had a little bit of a similar story that prompted my move to Idaho. I was in practice in Denver, everything was great. And then I get this email from this practice in Idaho, "Hey, would you ever move up here?" And it just goes to show if you're thinking about discussing something with somebody, reach out, because you just never quite know. People might be in a place where they're ready for a change and you don't even know that.

Tina Bhutani:                Exactly. Exactly.

Lisa Swanson:               And then when we were at the airport flying up to Boise to get a tour and a lay of the land, we were at a restaurant in DIA, Denver International, and I told my boyfriend, Larry, I was like, "Gosh, I feel kind of bad going. I don't really see us moving. And wouldn't it be better to just stay home and watch football this weekend?" And then at the end of the weekend in Boise, we're at the airport in Boise, and my boyfriend, Larry, says to me, "I think we might be moving to Boise." And so you just never know.

Tina Bhutani:                Never know.

Lisa Swanson:               And it's important to keep your options open, keep your eyes open to these things that can take your career in a whole new direction. It's pretty exciting.

Tina Bhutani:                Totally. Totally. But I also think I, that point, I think was a little scared to even put it out there that I was looking for something new. I was afraid to say it out loud. So I was lucky that this opportunity just fell into my lap. But I also tell others. I say, "If you're ready for a change, sometimes even just saying it..." I think you said it for me, like you said, but just putting it out there. Because again, people know people, it's a small world and connections can be made. So even just being brave enough to put it out there and put yourself out there is important as well.

Lisa Swanson:               Oh, a hundred percent. Quick question about staying at the academic setting in which you trained. I have heard from some others that when you train at a place, you're there for three years for derm, maybe an additional year for fellowship, that sometimes it's hard for the other people that work there to see you as a staff member, because sometimes you can perpetually feel like you're being treated maybe more like a perpetual resident.

Tina Bhutani:                Right, right. You're always a resident. Yeah.

Lisa Swanson:               Yes. Did you encounter that at all? Or was it like UCSF has this transition happen all the time and everybody knows how to adapt and adjust?

Tina Bhutani:                Yeah, yeah. No, that's a great question. And I actually, when I was evaluating my first jobs and looking at other options, I actually got that advice from people that said, "If you want to stay at UCSF, just go somewhere else for two years and then come back, because it's going to be a completely different experience. You're going to be in a different ball game." But life circumstances, I decided to stay because I wanted to stay in San Francisco. At the time, I trained under John Koo. And when I was graduating, residency was right when he was about to retire. So the position opened up where it was, again, this director of clinical trials. I was going to be able to help run the psoriasis center. And so it was an opportunity I just couldn't say no to, basically. So I ended up staying.

                                    And luckily I actually didn't have that experience. I think for a few reasons. I think first of all, I had some amazing colleagues and co-faculty that really respected me and the work that I was bringing to the department. But also I think they all knew that this was going to be my path. I think even before I knew it, everybody else knew that I was going to be the next clinical trials person, and I was going to be the next person to bring this into the department. So they almost welcomed me with very open arms and helped propel me up into the position that I was at. So I was lucky enough not to have that experience. But I  can't say that everybody does. I've heard that from a lot of different people.

Lisa Swanson:               Well, I love that so much. And then for how long have you been settled in the private practice environment now?

Tina Bhutani:                I don't know if I'm still settled in, but I've officially been out full-time for a little over a year. So it's still very, very new, very fresh. And so, like I said, yeah, I think I still don't feel completely settled, because I'm still learning new skills and new things each day. But it also, it keeps it fun to learn new things again. I think a lot of, again, maybe the reason I was looking for something new is I was just in a rut and doing the same thing every day, and maybe I just needed to shake things up a little bit. And this definitely did that.

Lisa Swanson:               Yes, yes. And for everybody, the name of your practice is?

Tina Bhutani:                Synergy Dermatology. We're in the Sunset District of San Francisco. It's a small suburb, I guess, of... It's in San Francisco, but it feels more like a suburb of San Francisco. So again, it's a small, very community-based practice. And even though we're in a big city, it doesn't feel like it out there. I have free parking, which is great.

Lisa Swanson:               That's great. Especially in San Francisco.

Tina Bhutani:                San Francisco, yeah. Yeah.

Lisa Swanson:               And do you have a sense for maybe two really positive things about private practice that you've learned and two maybe positive things from the academic world that maybe you miss a little bit?

Tina Bhutani:                Yeah. Yeah. Well, two positives from the private practice world, I will say, one is I think the, although I love complex medical dermatology, it's really where I thrive, I also realize that I like seeing the normal stuff again. I started seeing the acne, the rosacea, the warts. I started seeing kids again a little bit, which I hadn't done in a long time, and adolescents. And so it sounds cliche, because these are all the things that people say like, "Oh, I love dermatology because I get to do all of these things," but it's true. And doing some surgical procedures again. And so it just keeps the day fun. Because when I was in academics, I was locked into this subspecialty clinic where I was mostly seeing patients with psoriasis and AD, which is also great. But this keeps it fresh, I think. So I think that's one thing that I have really enjoyed about private practice.

                                    And then for me, I think this is more probably being a practice owner, but I think if you work in a small practice, I think it's the same thing, but the ability to control the culture a little bit. And I try to keep it a fun place. My motto, even when I was at UCSF, was just work hard, play hard. That's always how I managed things. And now I feel like I'm really able to expand that to not only my residents and fellows and students, but also my MAs and my office manager and my office staff. And I think the patients can feel it. They know when they walk in that everybody's happy to be there and we're having a good time. So I really love that part of it. I love that part.

Lisa Swanson:               That's good. I think that keeps employees at a workplace, you know?

Tina Bhutani:                Totally.

Lisa Swanson:               I think if people are excited to go to work, excited to work around the people that you work with, that's everything. That culture is everything. Yeah, yeah.

Tina Bhutani:                Totally. Totally. And then academics, I will say the things I miss, the teaching. That is one thing, working with the residents and working very closely with the trainees. They still come and shadow every now and then, but just being immersed in those teaching clinics I think is something I truly, truly miss. But again, I get a lot of that giving talks to the community and other providers. I think that fills my teaching bucket a little bit, but I do miss that part of it. And I think probably the community, like the colleagues just doing clinic in a hallway with four other people and being able to pull in your friend when you have a question or something like that is really nice. Luckily, I have a great text string with a lot of my old colleagues. And I can still phone a friend when I need help, or I can just refer them to UCSF, which is very nice. But yeah, that community aspect I think is hard. But as the practice grows, I hope that I'll be able to build my own community here.

Lisa Swanson:               I think you certainly will. I found that too when I move to Idaho. I'm the only peds derm in the state of Idaho, and so I lost all my phone a friends at University of Colorado. And so I reached out to the folks in Utah, the folks in Seattle. And everybody was like, "Yes, of course, come and visit and reach out anytime." I think you can easily build a community however you want that community to be built.

Tina Bhutani:                Yeah, yeah. And I think it's changing too. Because now again, that I'm here, there's a lot of private practice dermatologists who in the city who have actually taken me in with open arms and told me, "Call me anytime you need help. If you want to know what vendor we use for this or vendor we use for that." I mean, people have been so forthcoming and kind. It's been really great. So I think I'm just going to be building a different community from here on out.

Lisa Swanson:               Yes. Oh my gosh, that's wonderful. I'm so happy for you, Tina.

Tina Bhutani:                Thank you.

Lisa Swanson:               And we will conclude this Practical Dermatology Podcast with one of my favorite things, two truths and a lie.

Tina Bhutani:                Oh goodness.

Lisa Swanson:               So go ahead and tell me two truths and a lie, and then I might have some questions, and then I'm going to guess which one's the lie.

Tina Bhutani:                Okay.

Lisa Swanson:               Okay.

Tina Bhutani:                These things are always hard for me because I feel like I'm not creative when it comes to this kind of stuff. But let's see. Okay. In my prior life, I have been both a professionally trained dancer and a Mohs technician. Second, I hate chocolate. And third, I have never had jet lag.

Lisa Swanson:               Oh, wow. Okay. Why do you hate chocolate?

Tina Bhutani:                I'm more of a savory person. I like sweets, but if you give me the choice between savory and sweet, I would always go towards the savory. I don't know when it comes to sweets, when I have to rank my sweets, chocolate is just at the bottom. I don't love it.

Lisa Swanson:               Okay. Okay. With regards to never having jet lag, what's the longest flight you've ever taken?

Tina Bhutani:                Oh goodness. Probably either, I'm thinking, either South Africa or India.

Lisa Swanson:               Whoa, yeah. You've been to those places? That's amazing.

Tina Bhutani:                Yeah.

Lisa Swanson:               Wow.

Tina Bhutani:                I love to travel.

Lisa Swanson:               Yeah. So those are long flights, and you didn't have jet... Okay. And then dance, what kind of dancing did you do?

Tina Bhutani:                I did Indian classical dance since I was seven years old, seven or eight years old, and yeah. Yeah.

Lisa Swanson:               So I think the lie is you've never had jet lag.

Tina Bhutani:                Ding, ding, ding.

Lisa Swanson:               Yay.

Tina Bhutani:                You're too good. You know me too well.

Lisa Swanson:               Although Taylor Swift once said, "Jet lag..." What did she say? Like, "Jet lag is a state of mind," or something like that. Because she flew from Japan to get to the Super Bowl to see Travis play. She'd flown all night and she's like, "Jet lag is a choice." I think that's what she said.

Tina Bhutani:                No, I am terrible with jet lag, actually. I feel like I sometimes can't function. And I look at some of our colleagues, some of whom are much older than I am, and who just keep going, and I'm like, I don't understand.

Lisa Swanson:               I know, right?

Tina Bhutani:                I need my sleep. I cannot function without sleep.

Lisa Swanson:               And it does get worse as you get older. I've just noticed that coming back from Hawaii. It's like, I need to take a couple days to recover.

Tina Bhutani:                Yeah. Yeah, totally.

Lisa Swanson:               Well, thank you so much, Tina, for being with us today. Thank you to all of those listening. I hope you enjoyed it, learned something, and learned something about Tina Bhutani. Thanks everybody.

Speaker 1:                    Every patient deserves to be seen. The Tremfya guselkumab photo library offers hundreds of real patient photos, easily filtered by patient characteristics, disease locations, and severity. Learn more about Tremfya for your patients at tremfyahcp.com.

Speaker 2:                    And now for the news. A new study in JAMA Dermatology finds that switching between biologic classes can significantly improve PASI scores in patients with plaque psoriasis who experienced biologic failure. The review and meta-analysis included 24 randomized controlled trials and more than 12,600 adults. Reasons for switching included primary non-response, biologic fatigue, adverse events, and cost barriers. Researchers analyzed both PASI scores and patient-reported outcomes such as the Dermatology Life Quality Index and psoriasis symptoms and science diary. Switching to a different biologic class was associated with marked clinical improvement. Between weeks one and four, PASI 90 response rates increased with sustained gains in PASI 75, PASI 90, and PASI 100. The study author said, "The diverse mechanisms of action resulting from the introduction of different biologics can result in a viable or even superior therapy," but cautioned that further confirmatory data from larger patient cohorts and longer follow-up periods are required to obtain more conclusive results. The authors caution that while switching may offer meaningful benefit, careful monitoring for infection is essential.

                                    DermaRite Industries has issued a voluntary recall of four skincare products due to potential contamination with burkholderia cepacia complex, a bacteria that can cause serious infections in immunocompromised individuals. According to a news release from the FDA, the affected products include DermaKleen antiseptic lotion soap with vitamin E, DermaSarra external analgesic, KleenFoam antimicrobial foam soap with aloe vera, and PeriGiene antiseptic cleanser, all distributed between October 2023 and July 2025. The recall was initiated after routine testing identified the presence of B. cepacia in some batches. While no adverse events have been reported to date, the FDA warns that contaminated products pose an infection risk, particularly for hospitalized or chronically ill patients. Consumers and healthcare providers are advised to stop using the recalled products immediately and return them to the point of purchase. DermaRite stated it is cooperating fully with the FDA to ensure product safety and prevent recurrence. Full lot details are available on the FDA's website.

                                    And finally, August 13 marked the observance of global Generalized Pustular Psoriasis Awareness Day aimed at raising recognition of this rare and potentially life-threatening skin disease. Practical Dermatology chief medical editor Dr. Neal Bhatia talks more about the significance of this new awareness campaign.

Dr. Neal Bhatia:             We really have incorporated GPP, generalized pustular psoriasis, if you remember, as part of the dermatology community's urgency for treatment. If you look at some of the more important and emerging conditions we treat, there really are as few as GPP in terms of severity and pain as far as the patient's quality of life and their poor impact goes. And we really want to make sure that we're not only recognizing it but also teaching it to our non-dermatology colleagues and making sure that every level of awareness from the medical assistant to the receptionist and every clinician in the office is understanding the importance of treating these patients early and getting them on a good maintenance.

Speaker 2:                    Experts stress that earlier recognition of GPP signs, including widespread pustules, fever, and systemic symptoms is critical to preventing complications. Patient advocates hope greater awareness will lead to faster diagnoses and improved access to emerging treatments.