James Q. Del Rosso, DO: Dr Brownstone, we’re older and carrying a lot of baggage—talking about therapies, corticosteroids from before, vitamin D analogs, and things. You’re part of the new generation. You’re learning about some of these things, but you’re coming out in a new era and looking at these newer agents. These new agents are what you’re being raised on, not so much the older agents. We’re the old people talking about what we used to do back in the day. But you’re in the beginning of your training, and you have experience before that in your fellowship. What’s your viewpoint in terms of how you’re approaching psoriasis with topical therapies in the residency and the trainers you have? You have some excellent trainers.

Nicholas Brownstone, MD: That’s a great question. First, I’m an old soul. I look very young but I’m an old soul. But you bring up a great point. In residency, we look in a textbook and have a bunch of agents that treat psoriasis. They all do different things. But I don’t think we’re learning how to use these creatively and the potential of some of these therapies. Some of our mentors and program directors teach that way, but some don’t. It’s very important for doctors to train with these agents while they’re in residency and get comfortable with them. You have 1 chance to train, and you have somebody backing you up. It’s OK to take some risks while you’re getting comfortable with everything. But when you get out, it’s on you. It’s very important for residents and for individuals who are younger to learn about cyclosporine, methotrexate, and acitretin, to know where we came from. As you said, there’s a lot of baggage, lab monitoring, and scary adverse effects, and you don’t know where you’re going unless you know where you came from. It’s still important to learn those and to know how they work because they can help you in some situations. But we’ve done a great job recently coming together with new therapies that have helped our patients. It’s good to look at the whole landscape.

James Q. Del Rosso, DO: From the standpoint of being a resident and learning about mechanisms of action, individuals have mentioned tapinarof, which is an aryl hydrocarbon receptor agonist, a new mechanism. How important is it to understand the mechanism of the drug?

Nicholas Brownstone, MD: It’s very important. That what separates us from everybody else. As physicians, we want to be in the know, down to the granular details about how these things work because that’s how you learn about new indications, new mechanisms, and new off-label treatments. I always like to say: the devil is in the details. It’s great to have medications like tapinarof because when I started residency, I got very scared about clobetasol. You hear very scary things. I say, “I’m going to give you this very strong start. I’ll have you back in a month, and then let me check on you in a month after that.” I don’t want any adverse effects. But with tapinarof, you can give it to them for 5 years, they can apply to the same spot, and you don’t have to worry about that much. That’s a beautiful thing.

James Q. Del Rosso, DO: If they disappear and they’re using it without coming back, you don’t have a concern about some of the other adverse effects.

Nicholas Brownstone, MD: I won’t lose any sleep.

James Q. Del Rosso, DO: I’ve seen individuals who continue to get a topical corticosteroid in the groin area and on the face. They’ve been using it for years, and they show up and you run into some big problems.

Nicholas Brownstone, MD: I’ve seen some bad stray. Once you see it, you’re like, “I don’t want that to happen again.”

James Q. Del Rosso, DO: That’s exactly right.

Transcript edited for clarity