Transcript
Dr. Neal Bhatia:
I think the other part, again, when we think about goals and we say, "Okay, well, we do have data that keeps things away," like you brought up, are we overselling that?
Dr. Joshua Grosshandler (25:33):
Yeah. I mean, honestly, Neal, I find this really tough. I've found this tough since the beginning of some of this data coming out. And not in a negative way, but I think, again, it's very easy to say to somebody and a patient, and I'll admit, I did it in the beginning, like, "Hey, you can expect 120 days." But when they don't get that, I think it's tough, because the way that averages and medians work is you've got a group of people who it's shorter, and you've got a group of people who it's a lot longer.
So, I think I try to use it more conceptually, more big picture, think about what are your goals as a patient. "If you're having to use medication every day, if we can really cut that down, whether that's 30 days or whether that's 100 days, is that going to make you happy?" And I think when you utilize it that way and you say to them and break it down, I think it makes it more micro in their mind where it's like, "OK, a lot of this is better than where I'm at right now." And I always say it's the bonus, right? If you get this amount of time, that's amazing. But if you get more than that, you're living in the bonus, you're that super responder, take it and we'll run with it, and I hope it continues, but-
Dr. Neal Bhatia (26:41):
No, that bonus coverage idea, that's actually really good.
Dr. Joshua Grosshandler (26:43):
Yeah.
Dr. Neal Bhatia (26:44):
Yeah.
Dr. Joshua Grosshandler (26:44):
So I think setting up that way is always a little bit easier in talking to patients versus giving them the specific days, at least in my opinion, in my experience so far.
Dr. Neal Bhatia (26:55):
Yeah. Well, and I think too, it's up to us to talk about crescendo like, "OK, let's wean down to every other day. Let's take it down a couple of times a week or once a week and then turn it off," for example. Or how long is a real holiday? Because like you said, patients are going to ask, "How long do I need to be on this?"
And my first thing, knowing the study data, like we all do, we just say, "Look, the study was for 12 weeks. The other part was longer. Let's at least get through three months and then we'll figure it out." But by the same token, if they say, "Well, I skipped a day and things are fine," I said, "then do that. Go with every other day and maintain yourself." And again, the stereo example, "Turn it up, turn it down, but don't turn it off" comes into play. But do you have any other strategies on thinking about holidays or what they should do?
Dr. Joshua Grosshandler (27:48):
Yeah, I mean, I think I'm very much like you. I think I try to get people out of the gate, especially I think with these non-steroidal-esque options, whether it be tapinarof or the others, trying to stay mostly to how things were done in the trial, because I want to know, is it working? And if they come in, which patients all do, unfortunately, they're not very compliant, and some of that's just because things are hard and some of it's because maybe they don't understand.
And then some of it is them maybe not seeing things out of the gate, but I really try to emphasize to them, like you do, "Listen, this was studied at 8 weeks," or, "This was studied at 12 weeks, and let's really see what it does. Full tilt, you're using it, you're using it the appropriate way, and let's really see how powerful or how much of an impact it does." And then to your point, I usually do the same, "Let's dial it down and let's see."
I mean, I think the one interesting thing about this mechanism, and truly we only have today, well, one drug that we use and one old that maybe we can talk about here in a second, but the drug that we use, it's got data. They literally went, "If you got completely clear, you stopped it. You were off of it." And that's where these days, these remittive days that we're talking about, I like more treatment-free days, right? I like to think of it more that way, this interval that way.
And listen, go as long as you can, but don't be afraid to start it back up because we want to try to shut it down and then you've got the other. So, I let patients play and try to give them the framework of how to do it, but I'm with you, I think out of the gate, really good.
As an aside, because I think it's worth mentioning, because listen, Neal, you've been around a little bit. I've been around for a little bit. Coal tar, interestingly enough, if we're really talking about other mechanisms, coal tar is an aryl hydrocarbon receptor agonist, OK?
Dr. Neal Bhatia (29:42):
That's right. Oh, yeah.
Dr. Joshua Grosshandler (29:43):
The days of Goeckerman, which I think you probably remember, we did it a little bit in my residency. I won't even tell you, I don't want to age myself too much, but that's how that worked, and we didn't know that. We didn't know that back then, right? Listen, it's been used for centuries and nobody really knew, but that's one of the cool, interesting things about what we do in dermatology. Sometimes we don't know, but it's something that worked.
And they figured it out in, I think it was 2011 or 2013, there was a study and really, "Well, how does coal tar work?" Because again, back to it works on both. And really, this is the story. And so again, we've had a lot of experience, maybe you didn't realize it, some of us with this mechanism, but now we've got this other smells better, not as staining, not as sticky way to still work on some things that we're used to.
Dr. Neal Bhatia (30:40):
No, that totally goes back to the old school ways of just, "Oh, let's throw something against the wall," or, "Whatever sticks, we're going to do it." Right?
Dr. Joshua Grosshandler (30:46):
Right.
Dr. Neal Bhatia (30:47):
I mean, that's how we learn about subdermal tinea versus color and everything else, where it's all recipe-driven and, "Let's see where it works."
