Setting Expectations for Conditions Without a Cure
PA Buchi Neita and PA Shanna Miranti open this episode with a reality check that shapes every conversation that follows: dermatology includes conditions with no FDA-approved cure, and some therapies clinicians have relied on for decades aren't reliable and require constant tweaking. Rather than avoiding that truth, Miranti frames the goal as coming to patients honestly — acknowledging there's no cure while committing to calm the condition down and offer the best therapeutic options currently available.
Miranti stresses the human side of these visits. Patients often arrive weeks to months into a condition, having tried everything including the kitchen sink, and they're frustrated. Her approach is to sit with that frustration and reassure them they're not alone — 'everybody fails at this.' That empathy, both hosts agree, is part of the treatment plan.
Perioral Dermatitis: Stop Everything, Then Calm It Down
Both hosts see perioral dermatitis nearly every day, predominantly in younger females. Their foundational move is the same: stop everything. Neita tells patients to discontinue all products — toners, astringents, masks — and switch to gentle, basic hydrating cleansers and moisturizers, with healing balms like Cicaplast and Cicalfate. Miranti adds a critical caveat: patients must stop all topical steroids, even the ones they're 'only' using on a bug bite or an elbow, because they inevitably transfer them to the face.
Neita's go-to regimen pairs oral antibiotics with topical calcineurin inhibitors, favoring pimecrolimus twice daily until clear and for a few weeks after, alongside doxycycline, sarecycline, or low-dose minocycline. Miranti breaks the condition into two buckets: an acneiform/rosacea-prone type and an eczematous, itchy type. For the acneiform variety, she reaches for clascoterone, dapsone, or topical minocycline foam; for the eczematous type, she agrees with pimecrolimus and nonsteroidal eczema agents like roflumilast and ruxolitinib. Both emphasize warning patients this takes eight to 12 weeks to resolve — 'you're in this for the long haul.'
Herpes Simplex: Counseling Around Stigma
Miranti reviews the epidemiology as she frames counseling: roughly 48% of U.S. adults carry HSV-1 and about 12% carry HSV-2, and neither strictly respects the waistband. Once HSV finds a home in the nerve endings, it stays there for life, and HSV-1 is an increasingly common cause of genital cases among younger, non-monogamous adults.
Neita generally doesn't test unless the diagnosis is uncertain or mixed, in which case she uses PCR over culture for its speed and breadth — and she notes testing is sometimes as much for the patient's peace of mind as her own. For oral HSV-1, she reassures patients it's extremely common and manageable, coaching them to start therapy at the first tingle, itch, or burn, with oral valacyclovir as her favorite. For sacral and genital disease, she avoids assigning blame or timing, sparing patients the feeling of being 'dirty.'
The hosts share the familiar clinical tells: the 'recurrent spider bite' in the exact same spot and the patient blaming 'recurrent shingles' every time the in-laws visit. Both agree sacral herpes deserves adequate treatment and honest education, including offering both episodic and suppressive therapy for patients in multiple relationships. They also flag herpes gladiatorum in wrestlers, often misdiagnosed as staph at urgent care and treated with antibiotics while the athlete feels miserable with swollen nodes.
Supplements and OTC Options for HSV
On L-lysine, Neita hasn't incorporated it because she leans heavily on valacyclovir, but Miranti considers it a supplement that can’t hurt for interested patients—citing preventive dosing around 500–1000 mg daily and 1000 mg TID during outbreaks, while noting the scientific evidence is mixed, and there are no formal studies.
Both are lukewarm on docosanol (Abreva). Miranti explains it's the only FDA-approved non-prescription option for cold sores and works by blocking viral entry into healthy cells, but it must be applied five or six times a day to do any good — and it's expensive for a tiny tube.
Lichen Planus, Granuloma Annulare, Morphea, and Notalgia Paresthetica
For generalized lichen planus, granuloma annulare, and morphea, Miranti is moving away from systemic steroids toward oral JAK inhibitors, reporting strong success and good tolerability with agents like upadacitinib and abrocitinib when samples are available — though insurance approval is 'near impossible.' She describes a morphea patient with concurrent RA and atopic dermatitis who improved dramatically within a month. Both hosts stress appropriate workups, PCP collaboration, careful documentation, and pulling case reports when using non-FDA-approved therapies, sometimes even printing publications for patients.
For notalgia paresthetica — a condition Neita says gets little airtime at conferences but shows up constantly in clinic — the hosts offer a layered toolkit. Miranti uses OTC capsaicin (warning patients about the initial sting and avoiding open skin) and the strontium-based OTC product Dermalive, which also comes as a scalp solution. Practical hacks include a $7 Amazon back applicator to reach the spot. Neita adds non-pharmacologic options: physical therapy or chiropractic care for suspected nerve compression, plus posture and shoulder exercises that may also help scalp dysesthesia. Both connect the anatomy to brachioradial pruritus and cervical nerve impingement, and encourage clinicians to 'phone a friend' when compression is suspected.