In this video blog, Chris Bunick, MD, PhD, discusses highlights from his lecture Review of the Molecular Differentiation of Dermatologic Therapeutics on July 25, 2024, during the inaugural Elevate-Derm Alliance Summer Conference at the Westin Copley Place in Boston, Massachusetts.

In this video

Interviewed by dermatology PA and Elevate-Derm advisory board member Buchi Nida, Dr. Bunick frames antibiotic stewardship not as "don't use antibiotics at all" but as "using the right antibiotic for the right patient and in the right way." Noting that roughly 75% of antibiotics prescribed by dermatology providers are tetracyclines, he makes the case for reaching for a narrow-spectrum agent first. He highlights sarecycline, whose molecular properties his lab has studied: it causes less gastrointestinal dysbiosis and protects gram-negative gut bacteria, has weight-based dosing, can be taken with or without food, and is approved down to age nine. Using cryo-electron microscopy, his lab found sarecycline uniquely contacts the messenger RNA and binds a second active site in the nascent peptide exit tunnel — two binding sites that make resistance far harder, at roughly one in 10 billion.

Dr. Bunick also previews rademikibart, a second-generation IL-4 receptor alpha inhibitor his lab has characterized. Unlike dupilumab, which hits only part of the naturally evolved IL-4/IL-13 binding interface, rademikibart engages all of it — an "optimized" agent that early Chinese trial data suggest may deliver higher efficacy with less frequent dosing. His overarching message: at a moment of "a flood of innovation, a flood of new molecules," clinicians can't fully care for patients without understanding how the drugs work at the level of atoms and bonds, because safety, efficacy, and knowing when to start or switch therapy all depend on those molecular differences.

  • Antibiotic stewardship means "the right antibiotic at the right time and the right patient for the right duration" — not avoiding antibiotics altogether; think narrow-spectrum first.
  • Sarecycline is the first narrow-spectrum tetracycline: it spares gram-negative gut bacteria and causes less dysbiosis, and its two ribosomal binding sites give it the lowest resistance rate among tetracyclines (~1 in 10 billion).
  • Rademikibart is a second-generation IL-4 receptor alpha inhibitor that binds the full IL-4/IL-13 interface, unlike dupilumab, with early data pointing to higher efficacy and less frequent dosing.
  • You can't gloss over mechanism — "an IL-23 inhibitor" isn't specific enough; know whether it's p19-specific and how it differs from the alternatives.
  • In an era of psoriasis, atopic dermatitis, acne, and soon hidradenitis therapies exploding, understanding molecular differences is the key to choosing the right drug for each patient.