Educating NPs and PAs

Speaker 1 (00:06): 

Welcome to The Practical Dermatology Podcast. In this episode, we have a conversation with Dr. Scott Boswell, a psoriasis update from Dr. Jennifer Cather and Melodie Young, and the latest news from around dermatology. Now, here'sDr. Jennifer Cather. 

Dr. Jennifer Cather (00:19): 

Hey, I'm Jen Cather. I'm a medical dermatologist in Dallas, Texas, and I've been practicing with Melodie for 25 years. Yes? 

Melodie Young (00:29): 

I'm Melodie Young. I'm a dermatology nurse practitioner, also in Dallas. Jennifer and I have the art and interest of being able to have deep conversations and difficult conversations with patients. She got me going on that. When you just start to realize what people tell you versus what they really want to tell you, and don't just assume they know how to get to that. And so seven, eight years ago, we started really talking about how much genital psoriasis we felt like was being missed. It was misdiagnosed and missed opportunities. Actually even sort of initiated with Eli Lilly when Taltz came out and said, "We are using it. And some people would have nothing but just genital psoriasis and it's incredibly effective." 

(01:28): 

And so they did the first studies really looking at genital psoriasis. Well, actually they did a survey here with our patients and just got them in a room and asked them, "Do you have this? Is this an issue? Is it bothering you?" To try to find out if there was an area of psoriasis that we as psoriasis experts were still missing. That kind of got the ball rolling where Jennifer and I started really focusing on this and just realizing you can be a shy little Southern belle all you want to, but she's a Southern Californian who's not ... People run naked up and down the beach in Southern California. 

Dr. Jennifer Cather (02:10): 

We're out there. The thing that was really upsetting also really early in this path was that people with genital psoriasis do not want to talk with you about it face-to-face. They would rather you call about it. So Melodie and I have had this clinic forever, and we've got medical assistants that have worked with us for 10 years, and it's great because they get a little bit of a relationship. It was an average of at least three times asking in different ways, "Do you have anything under your underwear, anywhere in a private area?" At the end of the day, they would never tell us. They'd call back and tell the medical assistant, "Yeah, by the way, I do." And I was like, "What is it about us that you cannot actually say it to our face?" And it was because I didn't understand the emotional impact. 

(02:58): 

That was one of the first things when we think about what we learned from the UPLIFT trial. The extent of disease has nothing to do with the impact of the disease. So your genitals are 1%. I don't care if you're a Californian or a Texan,it's only 1%. And the Texan boys are like, "It's worth more than that." I'm like, no doubt, it's worth a lot. But for insurance and prior auths, it's a 1% and it's the 1%, the rare things like that, that carry the most significant weight on a daily basis. 

Melodie Young (03:30): 

We had to retrain how we were communicating with patients. And then the more data that began to come out and the more conversations we began to have and presentations on ... Harris Poll came out and proved the point, which is if you don't look at it, ask the patients about it, diagnose it correctly, give them correct medications. About half of patients are going to just try to treat it on their own and it's going to be the wrong thing. They don't realize it's what it is. It doesn't look like psoriasis. They're going to use the wrong medications on it. 

(04:12): 

All of that background really had us within the opportunity with Arcutis when they had with roflumilast, or Zoryve, and they allowed patients to use the medication anywhere. So they had an interest in it and said, "How big of a deal is this?" Because they knew Dr. Cather and I had done some work in this area. They did some medical boards. They did a medical advisory board, and it was all physicians and myself and listening to how many of them don't examine the area at all. A lot of them were psoriasis experts. It was shocking. So we said, "We've got to do something." That's how it was decided amongst all of us, who do we need to have in the room? We need to get everybody together, which Arcutis funded. So we had psychologists, we had psychiatrists that are also dermatologists, dermatologists, gynecologists, different people in the room just to try to say, why aren't we looking? How are we going to make this where it'snot awkward for providers and not awkward for patients so that everybody knows this is a common place to get it? 

(05:33): 

Two-thirds of people in other surveys have reported that they have psoriasis in the intertriginous areas. A lot of the most common was in their butt crack, their gluteal cleft. And then of course, of all the places they have psoriasis, exactly what she says, it may only affect 1% if it's the genital area, but that 1%, incredibly painful, embarrassing, impactful on relationships, they itch. And most of the time, people don't even realize that it is psoriasis because it looks different. That's why we started the consortium is to get together just to analyze how big of a deal it was and what can we do about it. 

Dr. Jennifer Cather (06:13): 

Especially children too, if you think about it, because you certainly don't want a child and a teenager and a child having the isolation and the embarrassment early on because there will be a point at which the trajectory of psychosocial sexual development, it's hard to get back on track. And so we really enjoyed learning about the psychology behind it. I think that our goal as dermatologists, we like to save lives. You can find a skin cancer and save a life, but we'resaving lives by treating psoriasis with the appropriate medicines and having our targets. Are you doing everything you'd like to do? And people with genital psoriasis, sometimes they won't have sex, their sexual frequency might be diminished greatly, or they would never imagine to have sex because they would never be naked in front of another human being. That's horrible just to think that those people are out there and they've gone undiagnosed. 

(07:14): 

Finding an ICD-10 code is one of our missions because we don't even know the true incidents. And so just to get some data and to try to further define what is the incidence of this. We assume it's about two-thirds and it is not just an older demographic. It can be in the adolescents as well. We all have to figure out how are we comfortable talking to a young person about that as well. 

Melodie Young (07:43): 

Yeah. Psoriasis average age of onset is in your late 20s. And so those are formative years in finding relationships, reproducing. I've had patients, some of the things that I began to notice a lot of college kids, again, they may have seen someone about it who didn't correctly diagnose. They were being told it was everything but psoriasis and it was very emotionally traumatic. And then we were also realizing the impact sexually, developmentally. 

(08:19): 

I've had a patient tell me that it hurts so badly if he had an erection because his skin was tearing. This was a young man who was newlywed and he could not sleep in the bed with his wife. He said, "I have to plan to have sex. I have touse all these topical medicines, mostly corticosteroids, try to get my tissue in good enough shape that I could have sexual intercourse. And then knowing it was going to be really sore and uncomfortable for a few days afterwards." 

(08:53): 

Man, when you have those real earnest conversations with people and they tell you the struggles. I've had gynecologists send patients to me when people were trying to get pregnant and it could hurt too much. For women, it hurt too much to have sex to even try to get pregnant or deliver vaginally. I had one doctor send me a patient that's saying, "Her genitalia are so red and inflamed." I'm thinking about doing a C-section because I just think it's going to be too difficult. I mean, these are people's lives. Like she said, may not be something that is robbing them of a life, but it's robbing them of their living. They're normal things that we take for granted that we can fix. We have medicines. We in dermatology are trained to examine the scan, talk to patients about it, and correctly coach them on the right things to do to treat. 

(09:48): 

Now, we have therapies that you can use to treat this with, but that consortium conversation between the two of us, we've got 60 years of dermatology. Even with all of that experience, and there's very few clinics in the country that treat as much psoriasis as we do, but we learned a lot. We learned a lot about just the psychology behind what it's like at different ages and when it comes to genital. That's about the most personal part of your body. It's also incredibly important from a developmental perspective. 

Dr. Jennifer Cather (10:30): 

I think it's important to remember that even though people might be... Let's say there's a couple different buckets. There's the new patient, and we are trying to limit corticosteroid use on genitals. So, we like these advanced topicals that are not corticosteroids, because the long-term toxicity of corticosteroids are problematic. The second thing is that people that are on systemic agents might not be adequately controlled in their genitals. I'm the person that had somebody on... I've known them for 15 years. They were on systemics for 15 years. They were never clearing their genitals. It was after this consortium that I finally... They said, "What did you do this week?" I go, "Well, by the way." 

(11:15): 

I had known him forever, and I was like, "Wow, I am a glaring nightmare," because I also didn't realize he wasn't clear. So every single time you see people, you should ask them, "By the way, are there any spots that aren't going away, and that includes under your underwear because I'm here for it?" So, those are the big things that I want to make sure people know. It's OK. When you talk about it and when you ask people about genital psoriasis, you're giving them permission. It might not be that day, but you're going to know them over their lifespan. That's our goal. We want long-term relationships in dermatology. So, I want to give you permission to discuss that stuff, and I'm able to handle viewing your genitals. I do it all day long. 

Melodie Young (12:02): 

Also because of even just in dermatology in general, doing skin cancer screenings on looking at those areas, we found out that a lot of times, patients, at least one out of five in self-reporting, said that they're never asked to disrobe for their dermatology visits. So, we thought about that as well. It's not just the genital dermatoses and genital psoriasis, but there are a lot of other things in the genital area that we in dermatology need to be correctly diagnosing and correctly treating with things that are effective and very easy to use, and not leaving it up to the patient to figure it out on their own. 

Speaker 2 (12:50): 

Next, Dr. Lisa Swanson is joined by Dr. Scott Boswell to talk about training NPs and PAs. 

Lisa Swanson (12:56): 

Hello, everybody, and welcome to another amazing episode of the Practical Dermatology Podcast. I'm your host, Lisa Swanson. Here tonight, one of my absolute favorite people in the world, we go way back, you guys, way back. This is the famous Scott Boswell, Fresno's own Scott Boswell, the hero of Fresno. Welcome to the pod, Scott. 

Scott Boswell (13:30): 

Thank you, Lisa. It's great to be with you again. 

Lisa Swanson (13:33): 

Yes. I know, right? Isn't it great? So, I want to tell the audience just how well we know each other. So, we went to medical school together at Tulane in New Orleans. Whoop, whoop for Tulane and- 

Scott Boswell (13:46): 

Yep. Go, Green Wave. 

Lisa Swanson (13:48): 

Go, Green Wave. We were there for four years together, and we're lucky enough to be two grads that each matched in dermatology, which is great. Now, we get to see each other all the time. 

Scott Boswell (13:59): 

I tell people that Lisa was always this nice and this smart, even in medical school. Medical school can be a cutthroat place. Tulane was not that way. Wasn't that great? 

Lisa Swanson (14:07): 

No, it really wasn't. 

Scott Boswell (14:08): 

We were all friends. I think the school, the administration, the professors were all very, "Hey, you guys get along. You're all going to be physicians." 

Lisa Swanson (14:16): 

Yes. 

Scott Boswell (14:17): 

I want your listeners to know that Lisa Swanson was always this smart and always this kind, was a great classmate. We had a lot of fun together in medical school all four years in New Orleans. 

Lisa Swanson (14:28): 

Yes, we did. It was wonderful. I loved my time there. If there are any listeners out there that are like, maybe they're pre-med, and they're bucking up on their dermatology knowledge, go to Tulane. It's awesome. It's awesome. Verysupportive environment. Everybody can succeed. Everybody can have their hopes and dreams come true. 

Scott Boswell (14:48): 

Absolutely. 

Lisa Swanson (14:48): 

You don't need to be cutthroat. 

Scott Boswell (14:50): 

I totally agree. It was a great experience for all four years. 

Lisa Swanson (14:52): 

Yes. Yes. Yes. Well, thrilled to have you on the pod, Scott, because you have contributed so much to the world of dermatology. I don't even know the impact that you've had with your little side project, the NP/PA Dermatology Bootcamp, but it has impacted so many people, so many practices, so many patients. It's pretty impressive what you've achieved, my friend. 

Scott Boswell (15:20): 

Well, it's been fun. It didn't start that way as a big project, but it became that about five or six years ago. So, it's been a lot of fun. We have over 1,500 enrollees now across the country, and I think I have a handful of international students as well that have taken the course. 

Lisa Swanson (15:38): 

That's amazing. 

Scott Boswell (15:39): 

Yeah, it's been fun. 

Lisa Swanson (15:39): 

So, where did this idea come from? Were you like, "I've got all this time on my hands? I'm just going to go ahead and create a full-fledged tutorial on dermatology in my spare time." 

Scott Boswell (15:51): 

No. So when I came out of residency, I used to make fun of people, dermatologists who would go into private practice, because I was going to be in academics. Not that I'm an amazing researcher or scientist, but I love to teach, and I had the teaching bug. So, I decided I wanted to start the UCSF Fresno Dermatology Residency Program. So, I was hired to do that. For various reasons, after three or four years when I did that, I tried to do that. It didn't work out for various reasons. I started my own private practice, of course, and left academics. I found that practicing dermatology in a very underserved area, Central California, that people couldn't get in with me in a timely manner, and that frustrated me. 

(16:37): 

So, I began to hire these amazing nurse practitioners and physician assistants who were wonderful, but did not have the book knowledge, the dermatology residency training that you and I had after medical school. So, I decided that I would look around, and I looked at our academy. I looked at some of these other PA and NP societies and the resources that they had, and they were frustrated with the resources that were out there. So I said, "I'm going to do my own thing." So, I got Andrews, which is Lisa, it's the same textbook that you and I went through. 

Lisa Swanson (17:09): 

Oh, yes. 

Scott Boswell (17:11): 

I mean, Bolognia is also a great textbook, and there's some other good textbooks that are overwhelming. But for me, Andrews was the best. That's what I did, and so I started going through An- 

Lisa Swanson (17:20): 

It's only one book. 

Scott Boswell (17:21): 

It's one book. They're not volumes. 

Lisa Swanson (17:24): 

It's one book. 

Scott Boswell (17:24): 

It's one book. Thank you. 

Lisa Swanson (17:26): 

Yes. 

Scott Boswell (17:26): 

Anyway, and so I decided to start making lessons and didactics out as I hired these nurse practitioners and physician assistants. I would meet with them twice a week. The original NPs and PAs in my practice would meet with me 7:00 AM to 8:00 AM Tuesdays and Thursdays, and then Wednesday afternoon at lunch, they would have an exam. It's kind of what you and I would learn in residency, right? So our approach to itch, rash, no rash, alopecia, scarring, non-scarring, these are the kind of things that a residency-trained dermatologist just thinks about when we're entering the room as these quick little 10-, 15-minute lessons of how we approach skin disease. And so from that, in conjunction with the book knowledge of Andrews, I developed these little 15-, 20-, 30-minute lessons, which then became my whiteboard lessons. And the exams became my exams and reading reviews that I put people through in my online course now. 

(18:22): 

So basically through that effort of teaching the nurse practitioners and PAs in my own practice, that's how Derm Boot Camp was born. So I accumulated about 78 lessons by teaching them and torturing them early in the morning with didactics that you and I kind of had in residency as well. 

Lisa Swanson (18:40): 

I think it's wonderful and we have... At my practice in Boise, Idaho, Ada West Dermatology, we years ago started training all of our NP/PAs by using your bootcamp. You did all the work for us. Thank you. 

Scott Boswell (18:54): 

No. Yeah, no problem. Well, I'm glad it was helpful. And that's been rewarding. So I didn't think I'd go online. It was really for the providers at my own office, but then sort of at the beginning of COVID, I thought, "By golly, I'm going to put this online because I've already done the work." It was all in a binder at that point. But one of my pet peeves about medical education is we tend to teach at learners instead of reason and teach with them. 

(19:18): 

So there's something about a classroom environment that I try to make that feel in my course of just being able to reason with the learner and the student and maybe injecting a little bit of humor and just sort of practical advice about what we do and not talking in so much medical mumbo jumbo about how we approach skin disease. And so I decided to hire a local high school videography teacher and he taped me every Friday afternoon and all day Saturday for nine months. So it took me- 

Lisa Swanson (19:46): 

Oh my god. 

Scott Boswell (19:47): 

... 10 years to develop the curriculum to fine tune it- 

Lisa Swanson (19:49): 

Wow. 

Scott Boswell (19:50): 

... and then nine months of Fridays and Saturdays to film it. And if you look through the course, I'm getting more tired. The bags under my eyes are getting worse. I think my chair stops working. I'm like... It's going down, down, down, and I have to reframe it in the camera. It was pretty funny. So a lot of outtakes, a lot of bloopers. 

Lisa Swanson (20:09): 

Yes. 

Scott Boswell (20:10): 

And I didn't have to be perfect. But yeah, so then I found an online platform called Thinkific and I decided to upload all these MP4 videos and make it available for purchase for those who needed CME credit. And I priced it for basically an annual CME budget since it's over 32 hours of CME credit. 

Lisa Swanson (20:28): 

Yeah. Yeah. And so we have all of our new NP/PA providers go through it and you have a wonderful little workbook with it too, which is really nice. And they get a lot from it. Even some of our NP/PAs that have been at the practice for a while, they actually did the course kind of as a refresher because some of the stuff in the course is not stuff you get just shadowing a clinician day to day, but it's that background knowledge that actually helps make you an excellent clinician. 

Scott Boswell (20:59): 

Absolutely. I mean, some classic examples I give is... If you're new to dermatology, I'll say, "OK, I'm going to quiz you. Epidermis, dermis, or fat: where does cellulitis occur?" And people will say, "The dermis." 

(21:12): 

And I say, "How many patients with cellulitis have you taken care of?" 

(21:14): 

"Oh, dozens. I've done inpatient and outpatient." 

(21:18): 

I said, "Nobody likes their cellulite. It's actually in this... Cellulitis is an infection of the cellulite. It's the fat, you guys." And nobody's ever pointed out that simple explanation that cellulitis and cellulite, that's why those words are there. 

Lisa Swanson (21:31): 

Yes. 

Scott Boswell (21:32): 

Or I tease them about, "What does the word tinea mean? You've treated tinea. Is that an organism or is that a disease?" 

(21:38): 

And they say, "It's an organism." 

(21:39): 

I say, "No, it's a disease. It's like saying pneumonia. You learn there's a lot of bugs that cause pneumonia, right? So the tinea, there's a lot of different dermatophyte fungus species that cause tinea infections that are named by the body part where that tiny infection is occurring." 

(21:54): 

So anyway, just these simple connections that are so important for the clinician to kind of put together. If they don't have that three-year dermatology residency, they need that medical book knowledge to kind of connect those dots. 

Lisa Swanson (22:07): 

I love it. Has anybody ever embroidered Boswell-isms on pillows for you? 

Scott Boswell (22:12): 

No, and I don't need that. I have not. But you said something about improving patient care. What's been fun is I get these emails from students. I remember I had a physician assistant who works in an underserved area, I think somewhere in the Midwest, and he was so excited because an elderly patient came in with this sort of asymmetric erosive plaques in the genital area in the inguinal thighs and he thought, "This isn't just yeast or fungus." He said, "I knew from your course to think about Extramammary Paget's disease. And so I knew to do some biopsies and I caught his colon cancer." 

(22:48): 

And so that was really fun. And that was an unsolicited email. And so I love that the physician assistants and nurse practitioners are catching Extramammary Pagets and Muir-Torre syndrome and Birt-Hogg-Dubé are just treating psoriasis better or being real comfortable with a biologic or a JAK inhibitor because of what they've learned in my course. 

Lisa Swanson (23:10): 

Absolutely. Absolutely. And you recorded this a few years ago. People have been benefiting from it. Medicine is constantly changing though, Scott. Is there a way that people can get updates? 

Scott Boswell (23:21): 

Yeah, you're right. Absolutely. So I decided to be a huge pain in the neck to go back and refilm everything, but with the last few years. So what I've done is I've made available Derm Boot Camp updates with Dr. Boswell free to anyone on Spotify and Apple podcasts. So they would just search Derm Boot Camp basically on those platforms. 

(23:42): 

And it's been coming out every Wednesday for the last month or two. So there's going to be 26 weeks worth of material. I think we're up to maybe week 15 or 16 coming out and it's about 12 to 15 or 20, 30 minutes of material. I just comment on updates to that corresponding week of material found in my original course. 

Lisa Swanson (24:03): 

I love it. So people can get back to the basics with your course, learn so much, but also stay up to date in the bootcamp family. 

Scott Boswell (24:10): 

That's right. So melanoma will go over GEP testing and we'll go over the new biologics that come out. We talk about the new topicals, for example, the new exciting nonsteroids that we're using nowadays. And so that's been fun to give those updates. And I plan on re-updating that every once in a while to keep people abreast of the most current information. 

Lisa Swanson (24:31): 

Yeah. Things are constantly changing and evolving, which is wonderful for patient care. Well, Scott, in our closing moments, I wanted to play my favorite game, two truths and a lie. 

Scott Boswell (24:42): 

Oh boy. 

Lisa Swanson (24:43): 

And so you will tell me three things about yourself, two of which are true, one is a lie, and then I will ask you questions and then try to guess which one is the lie. 

Scott Boswell (24:51): 

OK. I'm ready. You ready? 

Lisa Swanson (24:53): 

Yes, I'm ready. 

Scott Boswell (24:54): 

OK. OK. Number one. 

Lisa Swanson (24:56): 

Yes. 

Scott Boswell (24:56): 

I personally had Stevens-Johnson syndrome when I was 12 years old, hospitalized. That's number one. 

Lisa Swanson (25:02): 

OK. 

Scott Boswell (25:03): 

Number two, I took 13 years, from kindergarten through 12th grade, of bagpipe lessons and I still play, not bad, but have competed professionally a little bit with bagpiping. 

Lisa Swanson (25:18): 

Wow. 

Scott Boswell (25:19): 

And number three, we'll say my feet are two sizes different than one another. We'll say my right foot is size 11 and my left foot is size nine. 

Lisa Swanson (25:33): 

OK. So I actually know that number one is true because you shared that with me one time. So I know that that's true. 

Scott Boswell (25:40): 

That's why I'm a dermatologist. 

Lisa Swanson (25:42): 

Yes. Yes. 

Scott Boswell (25:42): 

I had Stevens-Johnson syndrome. True. 

Lisa Swanson (25:43): 

Yes, which is crazy and I'm so glad you're OK. Number two, bagpipes. Do you have Scottish heritage? Where did the bagpipe interest come from? 

Scott Boswell (25:55): 

Well, yes, I do have some Scottish heritage. I'm a white pasty guy with some Scottish heritage, that is true, with a good set of lungs. 

Lisa Swanson (26:04): 

Yes. And so what- 

Scott Boswell (26:06): 

So there's some truth to that. 

Lisa Swanson (26:07): 

What was like... "Hey, this bagpipe, this is something I could get into." What prompted that? 

Scott Boswell (26:12): 

Well, are we saying this is true or is this the lie? Have you guessed yet? 

Lisa Swanson (26:15): 

No, I haven't guessed yet. So I ask you questions to help me figure out if it's a lie. 

Scott Boswell (26:19): 

I see. I see. 

Lisa Swanson (26:19): 

Yeah. 

Scott Boswell (26:20): 

I see. So OK. So you asked me how did I get into it. I actually had a friend in high school who was also into it. His name was Rob. And I found that he was so good at bagpipes, he actually, I remember bought a Dodge Stealth. Remember those cars? 

Lisa Swanson (26:35): 

Yes. 

Scott Boswell (26:35): 

I said, "Dude, this guy is a teenager?" And so I was loosey-goosey for a while with the bagpipes, but I got more serious competing with my friend, Rob, because I thought I could buy a cool Dodge Stealth car like he did with the winnings of competing. 

Lisa Swanson (26:50): 

OK. OK. OK. And then number three was the... I'm blanking on it. 

Scott Boswell (26:56): 

Right foot is size 11. 

Lisa Swanson (26:58): 

Oh yeah. 

Scott Boswell (26:58): 

Left foot is size nine. 

Lisa Swanson (26:59): 

And so how do you buy shoes? 

Scott Boswell (27:01): 

So I've heard there's some places on Reddit and other websites where you can find people with the opposite problem. But the majority of my life I have just purchased for my right foot. And with this big empty space in my left foot, because I have what's called pes cavus, very high arches and especially on my left foot. But in general, my tennis shoes and my work shoes, I will splurge and, for most of my life, buy two different pairs of shoes. And right now in my closet, I have a whole collection of brand new shoes with the opposite 9 and 11s up there on my closet that I don't know what to do with because I haven't found people who have the opposite problem. Although Brooks lets you buy one 11 and one 9 separately if you buy it at one of their stores and I don't have to return them. 

Lisa Swanson (27:53): 

So I think the lie is the bagpipe. 

Scott Boswell (27:57): 

You're right. Of course I don't know the bagpipes. I don't play the bagpipes. I took piano lessons. That was the story about my friend, Rob. He was a bagpiper. I was not the bagpiper. 

Lisa Swanson (28:07): 

Wow. 

Scott Boswell (28:07): 

I took piano lessons. 

Lisa Swanson (28:09): 

Oh my gosh. So I never knew this about your feet. That's crazy. 

Scott Boswell (28:13): 

So don't you remember, you were probably not in the anatomy lab, but the first year of med school, our anatomy professor when we were doing the feet in our dissections at Tulane- 

Lisa Swanson (28:22): 

Yeah. 

Scott Boswell (28:23): 

... we were talking about pes planus, which is flat feet and pes cavus, which is a high arch. And he says, "This happens. Does anybody have this?" And I said, "Well,” I raised my hand sheepishly. And no joke, he made me take my shoes and socks off and I had to walk around all the different lab areas in the different rooms and show 150 fellow first-year Tulane medicines my bare feet. It was so embarrassing. So I actually buy special shoes because we all have our issues, right? 

Lisa Swanson (28:48): 

Right. So Scott, you've been teaching people for a really long time. 

Scott Boswell (28:54): 

Including with my feet, right? 

Lisa Swanson (28:58): 

Well, thank you so much for joining us on the podcast, Dr. Boswell. You are a hero to me, a hero to your patients, and a hero to all the NP/PAs that you've inspired and gave remarkable lessons to during the course of your career. Sothank you for all that you've done. And thank you for being here. Thank you audience for tuning in. I hope you enjoyed it and I hope you learned a lot about Scott Boswell. Thanks everybody. 

Scott Boswell (29:23): 

Thanks, Lisa. 

Speaker 1 (29:24): 

And now for the news. In our top story, new data from the SCRATCH-AD study suggests that ruxolitinib cream 1.5% can provide itch relief and broader improvements in atopic dermatitis severity. The study evaluated how quickly ruxolitinib 1.5% cream alleviates itch and improves disease activity in adults with AD, while also examining associated changes in skin biomarkers. Patients with moderate AD and significant pruritus who receive ruxolitinib cream twice daily for 28 days experienced fast and significant itch relief. Additionally, by day 29, 77% of patients achieved IgA defined success and 96% reached EASI-75. The research team noted that the cream downregulated key skin and serum biomarkers associated with AD pathophysiology, demonstrating rapid molecular effects in conjunction with clinical effects. 

(30:16): 

A new post-hoc analysis found a favorable efficacy and safety profile for the IL-4 receptor alpha monoclonal antibodies to stapokibart in elderly adults with moderate to severe atopic dermatitis. The study pulled data from a randomized placebo-controlled 16-week treatment period followed by an open label 36-week extension. Patients received a 600 milligram loading dose of stapokibart followed by 300 milligrams every two weeks. Outcomes were compared between patients 60 and older and patients 18 to 59. At week 16, the older cohort demonstrated marked improvements with stapokibart versus placebo, with 56% reaching EASI-75. The younger patients exhibited similar trends, and both age groups continue to show incremental improvement through the 36- week maintenance phase. With consistent safety findings as well, the researchers emphasized to stapokibart's potential utility in elderly populations who may face limitations with existing treatments and have been traditionally underrepresented in clinical trials. 

(31:15): 

And finally, a recent Journal of Allergy and Clinical Immunology article evaluated effector cell response inhibitors for treatment of allergic diseases such as chronic spontaneous urticaria. In a recent edition of C-suite chats, Excellergy co-founder Alexander Eggel and CEO Todd Zavodnick discuss how that article validated the ECRIs trifunctional mechanism of action. 

(31:35): 

Here's a clip from that discussion. 

Speaker 3 (31:37): 

For us at Excellergy, it's all about the patient, right? It's about patients today that are being treated. And as Alex said, really current therapies have limitations. They're not bad, they just have limitations. And I think healthcare providers working with Alex and Ted, and our team at Excellergy, are saying, "How do we take where we are and how do we get to this next step of total allergic control through our trifunctional effector cell response inhibition?" 

Speaker 1 (00:06): 

Welcome to The Practical Dermatology Podcast. In this episode, we have a conversation with Dr. Scott Boswell, a psoriasis update from Dr. Jennifer Cather and Melodie Young, and the latest news from around dermatology. Now, here'sDr. Jennifer Cather. 

Dr. Jennifer Cather (00:19): 

Hey, I'm Jen Cather. I'm a medical dermatologist in Dallas, Texas, and I've been practicing with Melodie for 25 years. Yes? 

Melodie Young (00:29): 

I'm Melodie Young. I'm a dermatology nurse practitioner, also in Dallas. Jennifer and I have the art and interest of being able to have deep conversations and difficult conversations with patients. She got me going on that. When you just start to realize what people tell you versus what they really want to tell you, and don't just assume they know how to get to that. And so seven, eight years ago, we started really talking about how much genital psoriasis we felt like was being missed. It was misdiagnosed and missed opportunities. Actually even sort of initiated with Eli Lilly when Taltz came out and said, "We are using it. And some people would have nothing but just genital psoriasis and it's incredibly effective." 

(01:28): 

And so they did the first studies really looking at genital psoriasis. Well, actually they did a survey here with our patients and just got them in a room and asked them, "Do you have this? Is this an issue? Is it bothering you?" To try to find out if there was an area of psoriasis that we as psoriasis experts were still missing. That kind of got the ball rolling where Jennifer and I started really focusing on this and just realizing you can be a shy little Southern belle all you want to, but she's a Southern Californian who's not ... People run naked up and down the beach in Southern California. 

Dr. Jennifer Cather (02:10): 

We're out there. The thing that was really upsetting also really early in this path was that people with genital psoriasis do not want to talk with you about it face-to-face. They would rather you call about it. So Melodie and I have had this clinic forever, and we've got medical assistants that have worked with us for 10 years, and it's great because they get a little bit of a relationship. It was an average of at least three times asking in different ways, "Do you have anything under your underwear, anywhere in a private area?" At the end of the day, they would never tell us. They'd call back and tell the medical assistant, "Yeah, by the way, I do." And I was like, "What is it about us that you cannot actually say it to our face?" And it was because I didn't understand the emotional impact. 

(02:58): 

That was one of the first things when we think about what we learned from the UPLIFT trial. The extent of disease has nothing to do with the impact of the disease. So your genitals are 1%. I don't care if you're a Californian or a Texan,it's only 1%. And the Texan boys are like, "It's worth more than that." I'm like, no doubt, it's worth a lot. But for insurance and prior auths, it's a 1% and it's the 1%, the rare things like that, that carry the most significant weight on a daily basis. 

Melodie Young (03:30): 

We had to retrain how we were communicating with patients. And then the more data that began to come out and the more conversations we began to have and presentations on ... Harris Poll came out and proved the point, which is if you don't look at it, ask the patients about it, diagnose it correctly, give them correct medications. About half of patients are going to just try to treat it on their own and it's going to be the wrong thing. They don't realize it's what it is. It doesn't look like psoriasis. They're going to use the wrong medications on it. 

(04:12): 

All of that background really had us within the opportunity with Arcutis when they had with roflumilast, or Zoryve, and they allowed patients to use the medication anywhere. So they had an interest in it and said, "How big of a deal is this?" Because they knew Dr. Cather and I had done some work in this area. They did some medical boards. They did a medical advisory board, and it was all physicians and myself and listening to how many of them don't examine the area at all. A lot of them were psoriasis experts. It was shocking. So we said, "We've got to do something." That's how it was decided amongst all of us, who do we need to have in the room? We need to get everybody together, which Arcutis funded. So we had psychologists, we had psychiatrists that are also dermatologists, dermatologists, gynecologists, different people in the room just to try to say, why aren't we looking? How are we going to make this where it'snot awkward for providers and not awkward for patients so that everybody knows this is a common place to get it? 

(05:33): 

Two-thirds of people in other surveys have reported that they have psoriasis in the intertriginous areas. A lot of the most common was in their butt crack, their gluteal cleft. And then of course, of all the places they have psoriasis, exactly what she says, it may only affect 1% if it's the genital area, but that 1%, incredibly painful, embarrassing, impactful on relationships, they itch. And most of the time, people don't even realize that it is psoriasis because it looks different. That's why we started the consortium is to get together just to analyze how big of a deal it was and what can we do about it. 

Dr. Jennifer Cather (06:13): 

Especially children too, if you think about it, because you certainly don't want a child and a teenager and a child having the isolation and the embarrassment early on because there will be a point at which the trajectory of psychosocial sexual development, it's hard to get back on track. And so we really enjoyed learning about the psychology behind it. I think that our goal as dermatologists, we like to save lives. You can find a skin cancer and save a life, but we'resaving lives by treating psoriasis with the appropriate medicines and having our targets. Are you doing everything you'd like to do? And people with genital psoriasis, sometimes they won't have sex, their sexual frequency might be diminished greatly, or they would never imagine to have sex because they would never be naked in front of another human being. That's horrible just to think that those people are out there and they've gone undiagnosed. 

(07:14): 

Finding an ICD-10 code is one of our missions because we don't even know the true incidents. And so just to get some data and to try to further define what is the incidence of this. We assume it's about two-thirds and it is not just an older demographic. It can be in the adolescents as well. We all have to figure out how are we comfortable talking to a young person about that as well. 

Melodie Young (07:43): 

Yeah. Psoriasis average age of onset is in your late 20s. And so those are formative years in finding relationships, reproducing. I've had patients, some of the things that I began to notice a lot of college kids, again, they may have seen someone about it who didn't correctly diagnose. They were being told it was everything but psoriasis and it was very emotionally traumatic. And then we were also realizing the impact sexually, developmentally. 

(08:19): 

I've had a patient tell me that it hurts so badly if he had an erection because his skin was tearing. This was a young man who was newlywed and he could not sleep in the bed with his wife. He said, "I have to plan to have sex. I have touse all these topical medicines, mostly corticosteroids, try to get my tissue in good enough shape that I could have sexual intercourse. And then knowing it was going to be really sore and uncomfortable for a few days afterwards." 

(08:53): 

Man, when you have those real earnest conversations with people and they tell you the struggles. I've had gynecologists send patients to me when people were trying to get pregnant and it could hurt too much. For women, it hurt too much to have sex to even try to get pregnant or deliver vaginally. I had one doctor send me a patient that's saying, "Her genitalia are so red and inflamed." I'm thinking about doing a C-section because I just think it's going to be too difficult. I mean, these are people's lives. Like she said, may not be something that is robbing them of a life, but it's robbing them of their living. They're normal things that we take for granted that we can fix. We have medicines. We in dermatology are trained to examine the scan, talk to patients about it, and correctly coach them on the right things to do to treat. 

(09:48): 

Now, we have therapies that you can use to treat this with, but that consortium conversation between the two of us, we've got 60 years of dermatology. Even with all of that experience, and there's very few clinics in the country that treat as much psoriasis as we do, but we learned a lot. We learned a lot about just the psychology behind what it's like at different ages and when it comes to genital. That's about the most personal part of your body. It's also incredibly important from a developmental perspective. 

Dr. Jennifer Cather (10:30): 

I think it's important to remember that even though people might be... Let's say there's a couple different buckets. There's the new patient, and we are trying to limit corticosteroid use on genitals. So, we like these advanced topicals that are not corticosteroids, because the long-term toxicity of corticosteroids are problematic. The second thing is that people that are on systemic agents might not be adequately controlled in their genitals. I'm the person that had somebody on... I've known them for 15 years. They were on systemics for 15 years. They were never clearing their genitals. It was after this consortium that I finally... They said, "What did you do this week?" I go, "Well, by the way." 

(11:15): 

I had known him forever, and I was like, "Wow, I am a glaring nightmare," because I also didn't realize he wasn't clear. So every single time you see people, you should ask them, "By the way, are there any spots that aren't going away, and that includes under your underwear because I'm here for it?" So, those are the big things that I want to make sure people know. It's OK. When you talk about it and when you ask people about genital psoriasis, you're giving them permission. It might not be that day, but you're going to know them over their lifespan. That's our goal. We want long-term relationships in dermatology. So, I want to give you permission to discuss that stuff, and I'm able to handle viewing your genitals. I do it all day long. 

Melodie Young (12:02): 

Also because of even just in dermatology in general, doing skin cancer screenings on looking at those areas, we found out that a lot of times, patients, at least one out of five in self-reporting, said that they're never asked to disrobe for their dermatology visits. So, we thought about that as well. It's not just the genital dermatoses and genital psoriasis, but there are a lot of other things in the genital area that we in dermatology need to be correctly diagnosing and correctly treating with things that are effective and very easy to use, and not leaving it up to the patient to figure it out on their own. 

Speaker 2 (12:50): 

Next, Dr. Lisa Swanson is joined by Dr. Scott Boswell to talk about training NPs and PAs. 

Lisa Swanson (12:56): 

Hello, everybody, and welcome to another amazing episode of the Practical Dermatology Podcast. I'm your host, Lisa Swanson. Here tonight, one of my absolute favorite people in the world, we go way back, you guys, way back. This is the famous Scott Boswell, Fresno's own Scott Boswell, the hero of Fresno. Welcome to the pod, Scott. 

Scott Boswell (13:30): 

Thank you, Lisa. It's great to be with you again. 

Lisa Swanson (13:33): 

Yes. I know, right? Isn't it great? So, I want to tell the audience just how well we know each other. So, we went to medical school together at Tulane in New Orleans. Whoop, whoop for Tulane and- 

Scott Boswell (13:46): 

Yep. Go, Green Wave. 

Lisa Swanson (13:48): 

Go, Green Wave. We were there for four years together, and we're lucky enough to be two grads that each matched in dermatology, which is great. Now, we get to see each other all the time. 

Scott Boswell (13:59): 

I tell people that Lisa was always this nice and this smart, even in medical school. Medical school can be a cutthroat place. Tulane was not that way. Wasn't that great? 

Lisa Swanson (14:07): 

No, it really wasn't. 

Scott Boswell (14:08): 

We were all friends. I think the school, the administration, the professors were all very, "Hey, you guys get along. You're all going to be physicians." 

Lisa Swanson (14:16): 

Yes. 

Scott Boswell (14:17): 

I want your listeners to know that Lisa Swanson was always this smart and always this kind, was a great classmate. We had a lot of fun together in medical school all four years in New Orleans. 

Lisa Swanson (14:28): 

Yes, we did. It was wonderful. I loved my time there. If there are any listeners out there that are like, maybe they're pre-med, and they're bucking up on their dermatology knowledge, go to Tulane. It's awesome. It's awesome. Verysupportive environment. Everybody can succeed. Everybody can have their hopes and dreams come true. 

Scott Boswell (14:48): 

Absolutely. 

Lisa Swanson (14:48): 

You don't need to be cutthroat. 

Scott Boswell (14:50): 

I totally agree. It was a great experience for all four years. 

Lisa Swanson (14:52): 

Yes. Yes. Yes. Well, thrilled to have you on the pod, Scott, because you have contributed so much to the world of dermatology. I don't even know the impact that you've had with your little side project, the NP/PA Dermatology Bootcamp, but it has impacted so many people, so many practices, so many patients. It's pretty impressive what you've achieved, my friend. 

Scott Boswell (15:20): 

Well, it's been fun. It didn't start that way as a big project, but it became that about five or six years ago. So, it's been a lot of fun. We have over 1,500 enrollees now across the country, and I think I have a handful of international students as well that have taken the course. 

Lisa Swanson (15:38): 

That's amazing. 

Scott Boswell (15:39): 

Yeah, it's been fun. 

Lisa Swanson (15:39): 

So, where did this idea come from? Were you like, "I've got all this time on my hands? I'm just going to go ahead and create a full-fledged tutorial on dermatology in my spare time." 

Scott Boswell (15:51): 

No. So when I came out of residency, I used to make fun of people, dermatologists who would go into private practice, because I was going to be in academics. Not that I'm an amazing researcher or scientist, but I love to teach, and I had the teaching bug. So, I decided I wanted to start the UCSF Fresno Dermatology Residency Program. So, I was hired to do that. For various reasons, after three or four years when I did that, I tried to do that. It didn't work out for various reasons. I started my own private practice, of course, and left academics. I found that practicing dermatology in a very underserved area, Central California, that people couldn't get in with me in a timely manner, and that frustrated me. 

(16:37): 

So, I began to hire these amazing nurse practitioners and physician assistants who were wonderful, but did not have the book knowledge, the dermatology residency training that you and I had after medical school. So, I decided that I would look around, and I looked at our academy. I looked at some of these other PA and NP societies and the resources that they had, and they were frustrated with the resources that were out there. So I said, "I'm going to do my own thing." So, I got Andrews, which is Lisa, it's the same textbook that you and I went through. 

Lisa Swanson (17:09): 

Oh, yes. 

Scott Boswell (17:11): 

I mean, Bolognia is also a great textbook, and there's some other good textbooks that are overwhelming. But for me, Andrews was the best. That's what I did, and so I started going through An- 

Lisa Swanson (17:20): 

It's only one book. 

Scott Boswell (17:21): 

It's one book. They're not volumes. 

Lisa Swanson (17:24): 

It's one book. 

Scott Boswell (17:24): 

It's one book. Thank you. 

Lisa Swanson (17:26): 

Yes. 

Scott Boswell (17:26): 

Anyway, and so I decided to start making lessons and didactics out as I hired these nurse practitioners and physician assistants. I would meet with them twice a week. The original NPs and PAs in my practice would meet with me 7:00 AM to 8:00 AM Tuesdays and Thursdays, and then Wednesday afternoon at lunch, they would have an exam. It's kind of what you and I would learn in residency, right? So our approach to itch, rash, no rash, alopecia, scarring, non-scarring, these are the kind of things that a residency-trained dermatologist just thinks about when we're entering the room as these quick little 10-, 15-minute lessons of how we approach skin disease. And so from that, in conjunction with the book knowledge of Andrews, I developed these little 15-, 20-, 30-minute lessons, which then became my whiteboard lessons. And the exams became my exams and reading reviews that I put people through in my online course now. 

(18:22): 

So basically through that effort of teaching the nurse practitioners and PAs in my own practice, that's how Derm Boot Camp was born. So I accumulated about 78 lessons by teaching them and torturing them early in the morning with didactics that you and I kind of had in residency as well. 

Lisa Swanson (18:40): 

I think it's wonderful and we have... At my practice in Boise, Idaho, Ada West Dermatology, we years ago started training all of our NP/PAs by using your bootcamp. You did all the work for us. Thank you. 

Scott Boswell (18:54): 

No. Yeah, no problem. Well, I'm glad it was helpful. And that's been rewarding. So I didn't think I'd go online. It was really for the providers at my own office, but then sort of at the beginning of COVID, I thought, "By golly, I'm going to put this online because I've already done the work." It was all in a binder at that point. But one of my pet peeves about medical education is we tend to teach at learners instead of reason and teach with them. 

(19:18): 

So there's something about a classroom environment that I try to make that feel in my course of just being able to reason with the learner and the student and maybe injecting a little bit of humor and just sort of practical advice about what we do and not talking in so much medical mumbo jumbo about how we approach skin disease. And so I decided to hire a local high school videography teacher and he taped me every Friday afternoon and all day Saturday for nine months. So it took me- 

Lisa Swanson (19:46): 

Oh my god. 

Scott Boswell (19:47): 

... 10 years to develop the curriculum to fine tune it- 

Lisa Swanson (19:49): 

Wow. 

Scott Boswell (19:50): 

... and then nine months of Fridays and Saturdays to film it. And if you look through the course, I'm getting more tired. The bags under my eyes are getting worse. I think my chair stops working. I'm like... It's going down, down, down, and I have to reframe it in the camera. It was pretty funny. So a lot of outtakes, a lot of bloopers. 

Lisa Swanson (20:09): 

Yes. 

Scott Boswell (20:10): 

And I didn't have to be perfect. But yeah, so then I found an online platform called Thinkific and I decided to upload all these MP4 videos and make it available for purchase for those who needed CME credit. And I priced it for basically an annual CME budget since it's over 32 hours of CME credit. 

Lisa Swanson (20:28): 

Yeah. Yeah. And so we have all of our new NP/PA providers go through it and you have a wonderful little workbook with it too, which is really nice. And they get a lot from it. Even some of our NP/PAs that have been at the practice for a while, they actually did the course kind of as a refresher because some of the stuff in the course is not stuff you get just shadowing a clinician day to day, but it's that background knowledge that actually helps make you an excellent clinician. 

Scott Boswell (20:59): 

Absolutely. I mean, some classic examples I give is... If you're new to dermatology, I'll say, "OK, I'm going to quiz you. Epidermis, dermis, or fat: where does cellulitis occur?" And people will say, "The dermis." 

(21:12): 

And I say, "How many patients with cellulitis have you taken care of?" 

(21:14): 

"Oh, dozens. I've done inpatient and outpatient." 

(21:18): 

I said, "Nobody likes their cellulite. It's actually in this... Cellulitis is an infection of the cellulite. It's the fat, you guys." And nobody's ever pointed out that simple explanation that cellulitis and cellulite, that's why those words are there. 

Lisa Swanson (21:31): 

Yes. 

Scott Boswell (21:32): 

Or I tease them about, "What does the word tinea mean? You've treated tinea. Is that an organism or is that a disease?" 

(21:38): 

And they say, "It's an organism." 

(21:39): 

I say, "No, it's a disease. It's like saying pneumonia. You learn there's a lot of bugs that cause pneumonia, right? So the tinea, there's a lot of different dermatophyte fungus species that cause tinea infections that are named by the body part where that tiny infection is occurring." 

(21:54): 

So anyway, just these simple connections that are so important for the clinician to kind of put together. If they don't have that three-year dermatology residency, they need that medical book knowledge to kind of connect those dots. 

Lisa Swanson (22:07): 

I love it. Has anybody ever embroidered Boswell-isms on pillows for you? 

Scott Boswell (22:12): 

No, and I don't need that. I have not. But you said something about improving patient care. What's been fun is I get these emails from students. I remember I had a physician assistant who works in an underserved area, I think somewhere in the Midwest, and he was so excited because an elderly patient came in with this sort of asymmetric erosive plaques in the genital area in the inguinal thighs and he thought, "This isn't just yeast or fungus." He said, "I knew from your course to think about Extramammary Paget's disease. And so I knew to do some biopsies and I caught his colon cancer." 

(22:48): 

And so that was really fun. And that was an unsolicited email. And so I love that the physician assistants and nurse practitioners are catching Extramammary Pagets and Muir-Torre syndrome and Birt-Hogg-Dubé are just treating psoriasis better or being real comfortable with a biologic or a JAK inhibitor because of what they've learned in my course. 

Lisa Swanson (23:10): 

Absolutely. Absolutely. And you recorded this a few years ago. People have been benefiting from it. Medicine is constantly changing though, Scott. Is there a way that people can get updates? 

Scott Boswell (23:21): 

Yeah, you're right. Absolutely. So I decided to be a huge pain in the neck to go back and refilm everything, but with the last few years. So what I've done is I've made available Derm Boot Camp updates with Dr. Boswell free to anyone on Spotify and Apple podcasts. So they would just search Derm Boot Camp basically on those platforms. 

(23:42): 

And it's been coming out every Wednesday for the last month or two. So there's going to be 26 weeks worth of material. I think we're up to maybe week 15 or 16 coming out and it's about 12 to 15 or 20, 30 minutes of material. I just comment on updates to that corresponding week of material found in my original course. 

Lisa Swanson (24:03): 

I love it. So people can get back to the basics with your course, learn so much, but also stay up to date in the bootcamp family. 

Scott Boswell (24:10): 

That's right. So melanoma will go over GEP testing and we'll go over the new biologics that come out. We talk about the new topicals, for example, the new exciting nonsteroids that we're using nowadays. And so that's been fun to give those updates. And I plan on re-updating that every once in a while to keep people abreast of the most current information. 

Lisa Swanson (24:31): 

Yeah. Things are constantly changing and evolving, which is wonderful for patient care. Well, Scott, in our closing moments, I wanted to play my favorite game, two truths and a lie. 

Scott Boswell (24:42): 

Oh boy. 

Lisa Swanson (24:43): 

And so you will tell me three things about yourself, two of which are true, one is a lie, and then I will ask you questions and then try to guess which one is the lie. 

Scott Boswell (24:51): 

OK. I'm ready. You ready? 

Lisa Swanson (24:53): 

Yes, I'm ready. 

Scott Boswell (24:54): 

OK. OK. Number one. 

Lisa Swanson (24:56): 

Yes. 

Scott Boswell (24:56): 

I personally had Stevens-Johnson syndrome when I was 12 years old, hospitalized. That's number one. 

Lisa Swanson (25:02): 

OK. 

Scott Boswell (25:03): 

Number two, I took 13 years, from kindergarten through 12th grade, of bagpipe lessons and I still play, not bad, but have competed professionally a little bit with bagpiping. 

Lisa Swanson (25:18): 

Wow. 

Scott Boswell (25:19): 

And number three, we'll say my feet are two sizes different than one another. We'll say my right foot is size 11 and my left foot is size nine. 

Lisa Swanson (25:33): 

OK. So I actually know that number one is true because you shared that with me one time. So I know that that's true. 

Scott Boswell (25:40): 

That's why I'm a dermatologist. 

Lisa Swanson (25:42): 

Yes. Yes. 

Scott Boswell (25:42): 

I had Stevens-Johnson syndrome. True. 

Lisa Swanson (25:43): 

Yes, which is crazy and I'm so glad you're OK. Number two, bagpipes. Do you have Scottish heritage? Where did the bagpipe interest come from? 

Scott Boswell (25:55): 

Well, yes, I do have some Scottish heritage. I'm a white pasty guy with some Scottish heritage, that is true, with a good set of lungs. 

Lisa Swanson (26:04): 

Yes. And so what- 

Scott Boswell (26:06): 

So there's some truth to that. 

Lisa Swanson (26:07): 

What was like... "Hey, this bagpipe, this is something I could get into." What prompted that? 

Scott Boswell (26:12): 

Well, are we saying this is true or is this the lie? Have you guessed yet? 

Lisa Swanson (26:15): 

No, I haven't guessed yet. So I ask you questions to help me figure out if it's a lie. 

Scott Boswell (26:19): 

I see. I see. 

Lisa Swanson (26:19): 

Yeah. 

Scott Boswell (26:20): 

I see. So OK. So you asked me how did I get into it. I actually had a friend in high school who was also into it. His name was Rob. And I found that he was so good at bagpipes, he actually, I remember bought a Dodge Stealth. Remember those cars? 

Lisa Swanson (26:35): 

Yes. 

Scott Boswell (26:35): 

I said, "Dude, this guy is a teenager?" And so I was loosey-goosey for a while with the bagpipes, but I got more serious competing with my friend, Rob, because I thought I could buy a cool Dodge Stealth car like he did with the winnings of competing. 

Lisa Swanson (26:50): 

OK. OK. OK. And then number three was the... I'm blanking on it. 

Scott Boswell (26:56): 

Right foot is size 11. 

Lisa Swanson (26:58): 

Oh yeah. 

Scott Boswell (26:58): 

Left foot is size nine. 

Lisa Swanson (26:59): 

And so how do you buy shoes? 

Scott Boswell (27:01): 

So I've heard there's some places on Reddit and other websites where you can find people with the opposite problem. But the majority of my life I have just purchased for my right foot. And with this big empty space in my left foot, because I have what's called pes cavus, very high arches and especially on my left foot. But in general, my tennis shoes and my work shoes, I will splurge and, for most of my life, buy two different pairs of shoes. And right now in my closet, I have a whole collection of brand new shoes with the opposite 9 and 11s up there on my closet that I don't know what to do with because I haven't found people who have the opposite problem. Although Brooks lets you buy one 11 and one 9 separately if you buy it at one of their stores and I don't have to return them. 

Lisa Swanson (27:53): 

So I think the lie is the bagpipe. 

Scott Boswell (27:57): 

You're right. Of course I don't know the bagpipes. I don't play the bagpipes. I took piano lessons. That was the story about my friend, Rob. He was a bagpiper. I was not the bagpiper. 

Lisa Swanson (28:07): 

Wow. 

Scott Boswell (28:07): 

I took piano lessons. 

Lisa Swanson (28:09): 

Oh my gosh. So I never knew this about your feet. That's crazy. 

Scott Boswell (28:13): 

So don't you remember, you were probably not in the anatomy lab, but the first year of med school, our anatomy professor when we were doing the feet in our dissections at Tulane- 

Lisa Swanson (28:22): 

Yeah. 

Scott Boswell (28:23): 

... we were talking about pes planus, which is flat feet and pes cavus, which is a high arch. And he says, "This happens. Does anybody have this?" And I said, "Well,” I raised my hand sheepishly. And no joke, he made me take my shoes and socks off and I had to walk around all the different lab areas in the different rooms and show 150 fellow first-year Tulane medicines my bare feet. It was so embarrassing. So I actually buy special shoes because we all have our issues, right? 

Lisa Swanson (28:48): 

Right. So Scott, you've been teaching people for a really long time. 

Scott Boswell (28:54): 

Including with my feet, right? 

Lisa Swanson (28:58): 

Well, thank you so much for joining us on the podcast, Dr. Boswell. You are a hero to me, a hero to your patients, and a hero to all the NP/PAs that you've inspired and gave remarkable lessons to during the course of your career. Sothank you for all that you've done. And thank you for being here. Thank you audience for tuning in. I hope you enjoyed it and I hope you learned a lot about Scott Boswell. Thanks everybody. 

Scott Boswell (29:23): 

Thanks, Lisa. 

Speaker 1 (29:24): 

And now for the news. In our top story, new data from the SCRATCH-AD study suggests that ruxolitinib cream 1.5% can provide itch relief and broader improvements in atopic dermatitis severity. The study evaluated how quickly ruxolitinib 1.5% cream alleviates itch and improves disease activity in adults with AD, while also examining associated changes in skin biomarkers. Patients with moderate AD and significant pruritus who receive ruxolitinib cream twice daily for 28 days experienced fast and significant itch relief. Additionally, by day 29, 77% of patients achieved IgA defined success and 96% reached EASI-75. The research team noted that the cream downregulated key skin and serum biomarkers associated with AD pathophysiology, demonstrating rapid molecular effects in conjunction with clinical effects. 

(30:16): 

A new post-hoc analysis found a favorable efficacy and safety profile for the IL-4 receptor alpha monoclonal antibodies to stapokibart in elderly adults with moderate to severe atopic dermatitis. The study pulled data from a randomized placebo-controlled 16-week treatment period followed by an open label 36-week extension. Patients received a 600 milligram loading dose of stapokibart followed by 300 milligrams every two weeks. Outcomes were compared between patients 60 and older and patients 18 to 59. At week 16, the older cohort demonstrated marked improvements with stapokibart versus placebo, with 56% reaching EASI-75. The younger patients exhibited similar trends, and both age groups continue to show incremental improvement through the 36- week maintenance phase. With consistent safety findings as well, the researchers emphasized to stapokibart's potential utility in elderly populations who may face limitations with existing treatments and have been traditionally underrepresented in clinical trials. 

(31:15): 

And finally, a recent Journal of Allergy and Clinical Immunology article evaluated effector cell response inhibitors for treatment of allergic diseases such as chronic spontaneous urticaria. In a recent edition of C-suite chats, Excellergy co-founder Alexander Eggel and CEO Todd Zavodnick discuss how that article validated the ECRIs trifunctional mechanism of action. 

(31:35): 

Here's a clip from that discussion. 

Speaker 3 (31:37): 

For us at Excellergy, it's all about the patient, right? It's about patients today that are being treated. And as Alex said, really current therapies have limitations. They're not bad, they just have limitations. And I think healthcare providers working with Alex and Ted, and our team at Excellergy, are saying, "How do we take where we are and how do we get to this next step of total allergic control through our trifunctional effector cell response inhibition?"