December 16, 2025 • 24 mins
What if the most inflammatory driver of psoriasis isn’t on the skin at all, but deep in visceral fat? We sit down with Dr. James Song to unpack how adipose tissue acts like a hormone-secreting organ, releasing cytokines that can fuel psoriasis and psoriatic arthritis. From the brain’s weight “set point” to genetics linking obesity and psoriasis risk, we reframe weight as biology—not a moral failing—and explain why that matters for treatment.
We break down fat types, the cytokine cascade connecting metabolic health to skin disease, and what GLP-1 and GLP-1/GIP therapies may be doing beyond weight loss. The conversation also tackles biologic response in higher BMI patients, emerging combo trials, and real-world issues like access, cost, and compounded medications—ending with a practical, whole-system roadmap that protects both skin and heart health.
Thank you Eli Lilly for sponsoring this episode.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_01 (00:00):
This podcast is sponsored by Eli Lilly.
Weight is really determined by acertain part of our brain called
a hypothalamus that has a set wecall it a set point.
And that is geneticallydetermined, but there are also
other factors like stresslevels, the amount of sleep that
you're getting, certainmedications that could affect
that set point as well.
We now know that patients withpsoriasis have about a 50%
(00:23):
higher risk of havingcardiovascular disease.
Patients who have higher BMIstend to have more severe
disease.
And with more higher BMI, it'sgenerally harder to treat.
SPEAKER_00 (00:35):
Welcome to Dermot Trotter, Don't Swear About Skin
Care, where host Dr.
Shannon C.
Trotter, a board-certifieddermatologist, sits down with
fellow dermatologists andskincare experts to separate
fact from fiction and simplifyskincare.
Let's get started.
SPEAKER_02 (00:52):
Welcome to the Dermot Trotter Don't Swear About
Skin Care podcast.
I'm with Dr.
James Song.
He's a board-certifieddermatologist and director of
clinical research and serves asthe chief medical officer for
Frontier Dermatology.
And we're here today to talkabout psoriasis and obesity and
the connection that existsbetween the two.
I think that a lot of peopleyou're going to be shocked about
(01:14):
sort of what we've learned andwhere we can go from here.
But I want to welcome you to thepodcast.
It's great to have you on here,Dr.
Song.
SPEAKER_01 (01:20):
Hi Shannon, thank you so much for having me.
I've been following you forquite some time now, and I
always was looking forward tothe opportunity to be a part of
this.
So I thank you for making one ofmy dreams come true.
SPEAKER_02 (01:33):
Well, always happy to please.
And really excited to have youhere too, because we know
psoriasis is a passion of yoursand definitely very engaged,
obviously, in research andtreating patients and even at
the foundation level.
So I wanted to tackle, you know,this idea of psoriasis and
obesity because I think a lot ofpeople, you know, really aren't
(01:54):
familiar with the connection.
They don't realize that, oh, youknow, that there is a connection
in the first place.
And, you know, just talkingabout when we think about
ourselves, you know, all of uslook at ourselves and probably
complain or think, gosh, I couldlose a few pounds or I'm a
little overweight.
And not even knowing that whenwe look at fat in the body, that
there are different types offat.
So I wanted to talk a little bitmore about that, see if we can
(02:15):
walk our audience through thosedifferent types and do they have
a real role in the body too?
Because I think a lot of peoplejust think that's just hanging
out.
It's not doing much of anything.
SPEAKER_01 (02:24):
Yeah, yeah.
It's a great question, Shannon.
Yeah, I think when most peoplethink about fat, they think
about it like stuffing, youknow?
It's just excess calories thatyou're not burning.
So you're kind of just sittingthere.
That's not entirely true,though.
We do know there's severaldifferent types of fat,
depending on where the fat is onthe body, they have several
different functions.
It could be actually beneficialto a certain degree, uh, but
(02:47):
also harmful.
And we'll kind of just touch alittle bit on that.
I think for most people, whenthey think fat, they think about
the skin that you could pinch,right?
And that's what we callsubcutaneous fat.
And for the most part, that'spretty harmless.
It doesn't really do anythingbad.
It's really the fat that'saround our belly and our kind
of, we call it our viscera, wecall that visceral fat.
(03:09):
That's the dangerous fat.
That's the one that we know iskind of like a like a chemical
factory that is just pouring outwhat we call cytokines.
We'll get into that later.
These are kind of messages tothe rest of our immune system to
kind of overreact.
But that's really the mainreservoir of those kind of
harmful cytokines thatcontribute to a lot of the
(03:29):
diseases that we treat indermatology.
And just to kind of round thatout, Shannon, we have what we
call brown fat.
That is what we see more ininfants, where you actually burn
those calories to generate heatand then kind of goes away as we
get older.
But interestingly, um, forpeople who exercise and do like
cold plunges, that's kind of,you know, all the craze now.
(03:49):
There is some data to suggest itincreases the brown fat.
But as we get older and gainmore fat, that good brown fat
actually goes down as well.
So I think it's just importantthat not all fat is created
equal.
But also when you look atsomebody of different ethnic
racial backgrounds, you know,Asians, I'm going to use an
example.
A lot of a lot of us look thin.
(04:10):
We have, you know, lowsubcutaneous fat, but actually
we have a good amount ofvisceral fat.
And that's really the fat that'sbad for you.
SPEAKER_02 (04:17):
Very interesting.
Because I I think, you know,when people think of fat, they
just think of fat, right?
And like you mentioned, it'sjust sort of hanging out and not
really active in the body.
And what we've learned over timeis you mentioned with the
different roles, you know, thatlovely pinchable fat, which I
can get enough on my waist herethat keeps us warm and helps
with that temperatureregulation.
And then having, you know, arole of the body where visceral
(04:39):
fat serves a little bit of arole that's in a positive way,
but obviously too much of it,not so great for us.
Let's talk about where that kindof goes wrong and sort of what's
happening with fat, where again,I think people think it's just
kind of dormant, it's hangingout.
How is fat really metabolicallyactive?
Like what is it doing justhanging out in the body?
SPEAKER_01 (04:58):
Yeah, I think it's best to think about fat or what
we call dipocytes as a like abiologically active like
endocrine system.
I mean, that's really what itis.
It's an organ that spews outvarious different messages to
the rest of our body.
On the one hand, fat is goodbecause there are certain
hormones we call leptin thatonce you eat, it tells you that
(05:21):
you are full, right?
So it tells it's a satietysignal.
But it also is a verypro-inflammatory signal as well.
It actually increases certaincytokines like T817, for
example.
But in addition to that, thereare other pro-inflammatory
cytokines like TNF alpha, IO1,IO6.
I mentioned T817.
And if they sound familiar, theyshould, because these are the
(05:43):
same cytokines that cause a lotof the autoimmune disorders that
we treat, whether that'spsoriasis and psoriatic
arthritis.
And so it's not a surprise thatif you have this major source of
inflammation, patients who areobese tend to be at higher risk
of developing certainconditions, such as psoriasis
and psoriatic arthritis.
SPEAKER_02 (06:05):
Wow, and and that's, you know, I think where it gets
a little confusing, right, forpeople to understand that it's
truly, like you said, a part ofthat endocrine system, really
being metabolically active andcontributing potentially to
inflammation in differentdisease states like psoriasis.
You know, when we think about,you know, somebody who is
overweight or obese, one of thethings that always, you know,
(06:26):
bothers me is we tend to bejudgmental, right?
We automatically look at thesepeople and think, oh, you know,
it's a lack of willpower.
You're just not able to controlyourself if you've got a bag of
Doritos in front of you.
And I really try to get peopleto understand, you know, it's
really not that simple.
I mean, we all have ourcravings, right?
We love our midnight runs, andpeople do that to Taco Bell, you
see the line out the door, orsomebody has, you know, their
(06:48):
chips they love, or they may notexercise as much as they want to
or need to.
But, you know, I think the ideaof obesity, what we need to
change in our mindset is this isreally more of a complex disease
state.
When we're overweight or we haveexcess fat, this is something
that it's multifactorial and alot of things contribute to
that.
How do you walk patients throughunderstanding that this isn't
just a lack of willpower, butsort of a combination of several
(07:11):
complex factors that actuallycontribute to them being
overweight or obese?
SPEAKER_01 (07:17):
It's such an important point, Shannon,
because I think until we startto think differently and frame
it differently, we're not goingto make any progress in this
area.
Um, to your point, a lot oftimes patients are told it's a
character flaw.
They don't have willpower,right?
And they need to try harder andtake care of themselves, and
this all goes away.
And we know that so much of thisis genetic.
Uh, we know that weight isreally determined by a certain
(07:40):
part of our brain called ahypothalamus that has a, we call
it a set point.
And that is geneticallydetermined, but there are also
other factors like stresslevels, um, the amount of sleep
that you're getting, certainmedications that could affect
that set point as well.
But you could try your darn bestto eat better, exercise.
And what does your set point do?
(08:00):
It tells you to be even morehungry.
It turns, it tells yourmetabolism to slow down, right?
Because it is trying to, it'slike a thermostat.
So until we can adjust that setpoint, it's very, very
difficult.
And, you know, this isn't thatdifferent than someone with high
blood pressure, right?
If someone has blood pressureproblems, you'd be like, hey,
diet and exercise first.
And if that doesn't work, thenwe're gonna put you on medical
(08:22):
therapy.
And we're not gonna make peoplefeel bad about not doing enough
diet and exercise to get yourblood pressure under control.
Why are we thinking aboutobesity any differently?
I mean, it's a disease.
And so we should be thinkingabout it in the same way of
hypertension, hyperlipidemia,and diabetes.
And that's why we call this kindof metabolic syndrome.
SPEAKER_02 (08:41):
Really good point.
Because I think for a lot ofpatients, they put it on
themselves.
There's a lot of shame, youknow, embarrassment.
And I think even as you know,dermatologists, we can kind of
admit to ourselves, I thinksometimes, you know, you have a
little you know, bias sometimesor when you see people and just
really changing that set pointand making us all realize, you
know, like you said, this is adisease like anything else.
Why would we treat it anydifferently?
(09:02):
Unfortunately, I think a lot ofyou know those cultural norms
kind of infiltrate into ourthoughts or, you know, our ideas
of what we were sort of toldabout, you know, being
overweight or obese, you know,truly what it is when we now
understand, you know, it's muchmore complex.
I think even over that hurdle,you know, as the dermatologist
or healthcare provider, and thenalso for patients to embrace
that and understand that we arehere to help, you know, and
(09:25):
beyond yes, diet and exerciseare essential, but there are
ways to kind of build on thatand really help them through
that process because it's goingto impact their overall health.
But I know from our standpoint,we're also obviously looking at
the skin health.
And then specifically, you know,in certain disease states, we
know hijodenitis separativa, weknow psoriasis, like these are
impacted.
In particular, psoriasis, Ithink, is a lot of interest to
(09:46):
our listeners that have reachedout and said, you know, we see
this craze about talking aboutnow weight and the psoriasis
connection.
So I I wanted to go back andkind of visit your thoughts on
this connection, sort of whatyou've seen over your career and
in the latest, you know, datacoming out, and how we
understand that connection toactually really exist between
the two.
SPEAKER_01 (10:06):
Yeah, yeah.
So as we uh said, you know, weknow psoriasis or excuse me,
obesity can increase one's riskof psoriasis.
There's no question.
And the same is true forpsoriatic arthritis, and that
connection or relationship maybe even stronger with the
latter.
A lot of times we have a hardtime separating out is it the
actual obesity that leads topsoriasis or are there other
(10:28):
confounding factors?
Um, but there's been actually anumber of really well done, what
we call Mendelian randomizationstudies, where you look at
genetic variants that predisposesomebody to obesity, and then
you follow those people who havethose genes and see who gets
psoriasis.
And that really controls for alot of the confounding
variables.
You're really just looking atgenetics here.
(10:49):
And we're seeing up to atwo-fold higher risk of
developing psoriasis orpsoriatic arthritis if you are
obese for many of the reasonsthat we talked about.
You have this big chemicalfactory that's pouring out these
cytokines that we know can causepsoriasis and psoriatic
arthritis.
Anecdotally, what we've seen, atleast in case reports and now
larger case series, is thatpatients who have both psoriasis
(11:12):
and type 2 diabetes, they go ona treatment for their diabetes,
right?
Specifically, a we call it aGLP1 receptor agonist or a GLP1
with a GIP, so it's a kind of acombo therapy.
And without any psoriasistherapies at all, not only do
their weight go down, not onlydoes their diabetes improve, but
their skin clears as well.
(11:32):
And I think that was the firstsignal that there is something
here to it.
Now the question, Shannon, is isit the weight loss itself that
actually leads to the psoriasisimprovement?
Because we've seen other studieswhere hypocaloric diets,
bariatric surgery, or any othertype of lifestyle intervention
that reduces the weight can alsoindirectly improve psoriasis.
(11:54):
So there probably is somethingto that.
But what is interesting is thatthese patients are also clearing
their skin even before they haveany meaningful change in their
weight, which makes us wonder isthere a direct effect with these
weight loss medications that wesee on the inflammatory
component of psoriasis?
And the answer to that probablyis yes.
(12:16):
And we have some what we call invitro data, which isn't human
data, but some of the in vitrodata suggests that GLP1s can
actually modulate the immunesystem in such a way where it
decreases cytokine signaling,immune cell trafficking.
Some of the cytokines that wetalked about before, like TNF
and L17, they come down evenindependent of weight.
(12:37):
So I think it's a really kind offascinating and exciting area of
research how we can use weightloss medications that improve
inflammatory disordersindependently of the weight
loss.
SPEAKER_02 (12:49):
So if I was your psoriasis patient and came to
you and I, you know, saw that alittle blurb, you know, maybe on
my Yahoo news and you know, thatthis is happening and I have
psoriasis, how would youapproach that with me if you
know I am overweight or obese,have psorias to say, hey, Dr.
Song, I want to go on a GLP1?
Is it that simple or is it amore complex conversation to
(13:10):
talk about?
SPEAKER_01 (13:11):
Yeah, I think as with all things, you know,
benefit versus risk, right?
And I think people often focusso much on their risks, which is
understandable, right?
Safety is important, but wedon't talk enough about not
treating or under-treating thedisease and what are the
downstream consequences ofhaving not just psoriasis, but
(13:32):
also the meta the um thecomorbidities associated with
psoriasis as well.
We now know that patients withpsoriasis have about a 50%
higher risk of havingcardiovascular disease.
Okay, and that's independent oftraditional risk factors.
So you take the hypertension,the lipids, the cholesterol, and
the weight out, they still haveabout a 50% higher risk.
(13:52):
And this leads to about afive-year decrease in life
expectancy.
So I start with that.
And while the weight loss isgreat and all, and it's gonna
help, I think, with not justwith the weight, the diabetes,
and the psoriasis, we now havedata.
It's actually on the label,Shannon, for several of our
semaglutides, illyroglutides,that it actually lowers mace
(14:12):
risk.
I mean, that's on the label.
It decreases heart attacks,strokes, all cause
cardiovascular death.
Um, I just got back from theEADV in Paris, and there was a
very, very powerful podiumpresentation about people who
use GLP1s and glyphosis versusnon-GLP1 diabetes medications,
not only do they live longer,their risk of anxiety and
(14:35):
depression goes down.
Their use of substances likeillicit drugs and alcohol goes
significantly down too.
So I try to bring in all thepositive benefits, even outside
of the skin, of using thesetypes of medications.
So absolutely, if you qualifyfor a GLP1, right, you've done
all the lifestyle changes thatwe talked about, which isn't
(14:56):
easy, but you've done it, andyou meet the eligibility
criteria, which is fairlysimple.
It's you have a BMI of 30 orgreater, or a BMI of 27 or
greater, but you have oneweight-related comorbidity.
So blood pressure, diabetes,cholesterol, sleep apnea,
cardiovascular disease.
Then, yes, absolutely, this issomething that we bring up.
(15:16):
The question, though, Shannon,is you know, you have a five to
10 minute visit for thesepatients.
We don't have teams ofbiological coordinators that can
do these medications or pushthese medicines for us.
Do how do we have the time andthe resources to do all these
things?
And I I would be lying if I saidI have it figured out.
You know, I do this enough andI'm fortunate enough to be in a
bigger practice where we havethose means to do that.
(15:38):
But I certainly want to uh Iempathize with our colleagues
who may push back and say, Ijust don't have the time or
resources to do that.
At least what I would say tothose people would be that at
least have the conversation,make that connection, and then
if a patient is interested, atleast try to refer them to
someone that actually can helpget them on these steps and
medications.
SPEAKER_02 (15:59):
Well, very powerful what you mentioned about in the
label, because I think thatwould shock you know a lot of
our listeners out there thatmight be on one of these
medications and not even knowthe benefit, regardless if they
have psoriasis or anothercondition or not, and even some
of our healthcare providers onthe power that I can offer for
patients and being potentiallycardioprotective.
That's pretty amazing.
(16:19):
And for dermatology, you'reright, it is tough, you know, in
the environment that we work in,but also the opportunity to
collaborate with our colleaguesin the primary care space to
make that happen for patients,just knowing there's that
benefit.
I think there's an opportunitythere, you know, to offer it to
patients.
Do you feel like based on maybewhat we know with some of that
data or what we're looking atprobably going forward and
(16:40):
what's in clinical trials, doyou think for management of
psoriasis that it's sort of ayou know monotherapy where you
just go on a GLP1 or a GIF one,or maybe you're going to
actually, you know, combine it?
Or what are your thoughts mightmight be the ideal strategy on
what we might do?
SPEAKER_01 (16:56):
Well, we do have one study that is ongoing, actually,
two in parallel.
It's called a together psoriasisor the together psoriatic
arthritis studies.
And this is looking at uhixychizimab, which is an IL-17A
inhibitor, very effective forpsoriasis.
And you are combining that withterzepatide, which is a dual
GLP1 and GIP inhibitor, versusthose who just get ixychizimab
(17:19):
alone.
So you want to see, is there anadditive benefit or a
synergistic benefit of combiningthese therapies?
We should be getting thetop-line data here probably
sometime in later 2026, Ibelieve.
But that is the way that it isbeing studied.
Um, and and I do believe thatthat's the best way is to use
them as combination oradjunctive therapy versus just
monotherapy alone.
(17:40):
Although I will say, Shannon, ifyou have very mild psoriasis, so
just a couple little plaqueshere and there, and you have the
comorbidities that qualify youfor getting onto one of these
medicines, you may be able tojust go on monotherapy alone,
right?
And then one thing, you know, Ididn't mention here, I think
it's important, is that patientswho have higher BMIs tend to
have more severe disease.
(18:01):
And what more higher BMI, it'sgenerally harder to treat.
Even though we have reallyeffective medicines now in
psoriasis, the heavier you are,the medicines just don't work
quite as well.
We see a much bigger drop-offwith our older medicines, like
TNF inhibitors, but even ournewer ones, like IL-17 or IL-23
(18:21):
inhibitors, you do start to seea drop-off in patients who get
beyond 250 pounds, which is whysome of these medicines are
weight-based.
And I think those medicinesmight be better for the heavier
patients because standard dosingdoesn't work for everybody.
But the biggest kind of, Ithink, data point here that's
important is that when youlooked at Ixy Kizimab in their
phase three studies, Shannon,and you looked at PAS C100,
(18:44):
that's 100% clear, thedifference of being less than 25
BMI versus 40 BMI or greater wasprofound.
We're talking about a 20% plusdifference in the likelihood of
getting to 100% clear.
So about a two-fold difference.
And this was the same withpsoriatic arthritis.
When we look at minimal diseaseactivity, which is a very high
(19:05):
bar, very low levels of diseaseactivity in your joints and your
skin, you're still twice aslikely to get to that high bar
if you were under a BMI of 25versus over 40.
So that makes a lot of sensethen why using a GLP1 in
addition to Kismab may provideadditional benefits for these
patients.
SPEAKER_02 (19:25):
I know you and I are familiar with BMI.
Do you mind commenting on BMIhow that's sort of calculated?
Because for some area listeners,I think I've heard of that, but
I really don't know what itmeans, but I've been told I have
a very high one.
SPEAKER_01 (19:35):
And yep, yep.
So BMI is just one way ofmeasuring weight, right?
Or obesity.
Um it's not perfect.
So the way we calculate it, wetake your weight in kilograms
and divide it by your height inmeters squared, and you get a
number.
Um, let's say a 25 might meanthat you're overweight.
(19:56):
A number over 30 means you'reobese.
Over 40, you're severely obese.
That's a really kind of it's animperfect way of measuring um
fat, but it's kind of probablythe simplest way of doing it.
Uh, we know that there arepeople out there that have who
are very, very muscular andathletic and they can have very
high BMIs, right?
You look at the rock, right?
(20:18):
Dwayne Johnson, the guy isripped and shredded.
I think he's like 6'2 or 6'3 andweighs like upper 200 pounds.
You do the math, he he isseverely obese, right?
Right.
No one will say that to him,right?
Not in front of his face, buteven still objectively, he is
very, very good shape, right?
Muscular.
But it just goes to show thatBMI actually overestimates um
the score in muscularindividuals.
(20:40):
And there are a lot of otherexamples of that as well.
There's other ways to measure uhbody fat, though.
You know, there's DEXA scans,which are like X-rays that look
at the density of bone, muscle,uh fat.
There's um impedance tests whereyou could just hold on to
something.
It sends electrical currents,you could do caliper studies.
So there's a lot of differentways to do it.
BMI is just kind of our quickand dirty way of measuring uh
(21:02):
the fat levels, which again isnot perfect.
SPEAKER_02 (21:05):
But you're right, it gives us a really good gauge, at
least to work from from now.
And maybe we'll improve uponthat, you know, as a metric as
we kind of go forward andclassify, you know, patients a
little bit better, you know,regarding their weight.
But you're right, it's the bestthing we've kind of got now,
although imperfect.
So if somebody's out therelistening, you know, in the last
few minutes we're having,they're thinking, you've kind of
sold me on this.
You know, I've I've gotpsoriasis, I'm worried about my
(21:26):
risk factors.
They may or may not, you know,have diabetes already, or one of
the other, you know, riskfactors are comorbidities like
high blood pressure orcholesterol.
What would you say to them aspotentially, you know, a reason
maybe you wouldn't considerdoing it?
And then if it was, you know,meant for them, how would you
move forward with that?
SPEAKER_01 (21:44):
Yeah, the the biggest barrier, Shannon, is
going to be cost and access.
There's no question these areexpensive medications, but I
would argue that the cost of nottreating is even more expensive,
right?
Because we're just you're justdelaying the inevitable and
having to get an open heartsurgery or some other major
medical intervention will cost alot more money.
(22:05):
But that's the main barrier,right?
And then the the naturalquestion that comes up is if I
can get insurance to pay for it,what about compounded
medications, right?
And I think this is aconversation for another day,
but you you really have to becareful of what you're getting
with compounded medications.
I understand it's cheaper, butyou don't always know what
you're getting there.
If you have diabetes or obesity,and you as an office, as a
(22:29):
dermatology practitioner, justdon't know how to do it or don't
have the means to do it, atleast refer them to somebody,
whether it's a primary caredoctor or an endocrinologist
that can really do the heavy uhwork to get disapproved, because
truly these are life-changingdrugs.
And I think that we are doing adisservice to our patients if we
(22:51):
don't at least bring it up tothem.
SPEAKER_02 (22:54):
And and I think too, patients out there now are going
to be asking about it, you know,listening to this, just seeing
that there's value and you know,looking at, you know, being
overweight or obese is more thanwe talked about, that lack of
willpower.
Hopefully, for you know, thedermatologists and providers
listening out there that they'rethinking, you know what, I
should probably be approachingmy patient maybe a bit more
holistically.
I think that's a shift we'regoing to see in dermatology as a
(23:16):
whole as we look at a lot of ourskin conditions as, you know,
more so systemic inflammation.
We've known this for years, butnow that we have opportunities
to treat it, I think it's goingto shift.
It's interesting.
I think, you know, we used tohave the internal med and then
Durham model.
I don't see us going back tothat paradigm for training, but
boy, is it going to beintegrated more into how we
manage patients?
Yes.
SPEAKER_01 (23:35):
Yes, yes, yes.
SPEAKER_02 (23:38):
Well, I want to thank you so much for coming on
and kind of going over this.
You know, I know it's succinct,but this gives people really a
taste, I think, for listeners ofunderstanding, you know, that
how complex, you know, obesitycan be and then link, you know,
to psoriasis and otherinflammatory disease and skin
that um we'll obviously touchupon in the future.
But thank you so much forsharing your expertise with us
today.
SPEAKER_01 (23:57):
Shannon, it's my pleasure.
Thank you for having me.
SPEAKER_02 (24:00):
For our listeners that want to track you down
online, how can they find you?
SPEAKER_01 (24:03):
Uh, my Instagram handle is E as an Edward, J as
in James and song, like singinga song 812.
And then it's the same one onLinkedIn.
So I try to be active, notnearly as active as you,
Shannon.
I need to up my social mediagame, but um, yes, you can find
me on there.
SPEAKER_02 (24:21):
Well, thank you for sharing.
I'm sure some people will checkit out.
And stay tuned for the nextepisode of Dermotrotter Don't
Swear About Skincare.
SPEAKER_00 (24:29):
Thanks for listening to Dermotter.
For more about skincare, visitdermittrotter.com.
Don't forget to subscribe, leavea review, and share this podcast
with anyone who needs a littleskincare sanity.
Until next time, stay skinsmart.
This podcast is sponsored by Eli Lilly.
Weight is really determined by acertain part of our brain called
a hypothalamus that has a set wecall it a set point.
And that is geneticallydetermined, but there are also
other factors like stresslevels, the amount of sleep that
you're getting, certainmedications that could affect
that set point as well.
We now know that patients withpsoriasis have about a 50%
(00:23):
higher risk of havingcardiovascular disease.
Patients who have higher BMIstend to have more severe
disease.
And with more higher BMI, it'sgenerally harder to treat.
SPEAKER_00 (00:35):
Welcome to Dermot Trotter, Don't Swear About Skin
Care, where host Dr.
Shannon C.
Trotter, a board-certifieddermatologist, sits down with
fellow dermatologists andskincare experts to separate
fact from fiction and simplifyskincare.
Let's get started.
SPEAKER_02 (00:52):
Welcome to the Dermot Trotter Don't Swear About
Skin Care podcast.
I'm with Dr.
James Song.
He's a board-certifieddermatologist and director of
clinical research and serves asthe chief medical officer for
Frontier Dermatology.
And we're here today to talkabout psoriasis and obesity and
the connection that existsbetween the two.
I think that a lot of peopleyou're going to be shocked about
(01:14):
sort of what we've learned andwhere we can go from here.
But I want to welcome you to thepodcast.
It's great to have you on here,Dr.
Song.
SPEAKER_01 (01:20):
Hi Shannon, thank you so much for having me.
I've been following you forquite some time now, and I
always was looking forward tothe opportunity to be a part of
this.
So I thank you for making one ofmy dreams come true.
SPEAKER_02 (01:33):
Well, always happy to please.
And really excited to have youhere too, because we know
psoriasis is a passion of yoursand definitely very engaged,
obviously, in research andtreating patients and even at
the foundation level.
So I wanted to tackle, you know,this idea of psoriasis and
obesity because I think a lot ofpeople, you know, really aren't
(01:54):
familiar with the connection.
They don't realize that, oh, youknow, that there is a connection
in the first place.
And, you know, just talkingabout when we think about
ourselves, you know, all of uslook at ourselves and probably
complain or think, gosh, I couldlose a few pounds or I'm a
little overweight.
And not even knowing that whenwe look at fat in the body, that
there are different types offat.
So I wanted to talk a little bitmore about that, see if we can
(02:15):
walk our audience through thosedifferent types and do they have
a real role in the body too?
Because I think a lot of peoplejust think that's just hanging
out.
It's not doing much of anything.
SPEAKER_01 (02:24):
Yeah, yeah.
It's a great question, Shannon.
Yeah, I think when most peoplethink about fat, they think
about it like stuffing, youknow?
It's just excess calories thatyou're not burning.
So you're kind of just sittingthere.
That's not entirely true,though.
We do know there's severaldifferent types of fat,
depending on where the fat is onthe body, they have several
different functions.
It could be actually beneficialto a certain degree, uh, but
(02:47):
also harmful.
And we'll kind of just touch alittle bit on that.
I think for most people, whenthey think fat, they think about
the skin that you could pinch,right?
And that's what we callsubcutaneous fat.
And for the most part, that'spretty harmless.
It doesn't really do anythingbad.
It's really the fat that'saround our belly and our kind
of, we call it our viscera, wecall that visceral fat.
(03:09):
That's the dangerous fat.
That's the one that we know iskind of like a like a chemical
factory that is just pouring outwhat we call cytokines.
We'll get into that later.
These are kind of messages tothe rest of our immune system to
kind of overreact.
But that's really the mainreservoir of those kind of
harmful cytokines thatcontribute to a lot of the
(03:29):
diseases that we treat indermatology.
And just to kind of round thatout, Shannon, we have what we
call brown fat.
That is what we see more ininfants, where you actually burn
those calories to generate heatand then kind of goes away as we
get older.
But interestingly, um, forpeople who exercise and do like
cold plunges, that's kind of,you know, all the craze now.
(03:49):
There is some data to suggest itincreases the brown fat.
But as we get older and gainmore fat, that good brown fat
actually goes down as well.
So I think it's just importantthat not all fat is created
equal.
But also when you look atsomebody of different ethnic
racial backgrounds, you know,Asians, I'm going to use an
example.
A lot of a lot of us look thin.
(04:10):
We have, you know, lowsubcutaneous fat, but actually
we have a good amount ofvisceral fat.
And that's really the fat that'sbad for you.
SPEAKER_02 (04:17):
Very interesting.
Because I I think, you know,when people think of fat, they
just think of fat, right?
And like you mentioned, it'sjust sort of hanging out and not
really active in the body.
And what we've learned over timeis you mentioned with the
different roles, you know, thatlovely pinchable fat, which I
can get enough on my waist herethat keeps us warm and helps
with that temperatureregulation.
And then having, you know, arole of the body where visceral
(04:39):
fat serves a little bit of arole that's in a positive way,
but obviously too much of it,not so great for us.
Let's talk about where that kindof goes wrong and sort of what's
happening with fat, where again,I think people think it's just
kind of dormant, it's hangingout.
How is fat really metabolicallyactive?
Like what is it doing justhanging out in the body?
SPEAKER_01 (04:58):
Yeah, I think it's best to think about fat or what
we call dipocytes as a like abiologically active like
endocrine system.
I mean, that's really what itis.
It's an organ that spews outvarious different messages to
the rest of our body.
On the one hand, fat is goodbecause there are certain
hormones we call leptin thatonce you eat, it tells you that
(05:21):
you are full, right?
So it tells it's a satietysignal.
But it also is a verypro-inflammatory signal as well.
It actually increases certaincytokines like T817, for
example.
But in addition to that, thereare other pro-inflammatory
cytokines like TNF alpha, IO1,IO6.
I mentioned T817.
And if they sound familiar, theyshould, because these are the
(05:43):
same cytokines that cause a lotof the autoimmune disorders that
we treat, whether that'spsoriasis and psoriatic
arthritis.
And so it's not a surprise thatif you have this major source of
inflammation, patients who areobese tend to be at higher risk
of developing certainconditions, such as psoriasis
and psoriatic arthritis.
SPEAKER_02 (06:05):
Wow, and and that's, you know, I think where it gets
a little confusing, right, forpeople to understand that it's
truly, like you said, a part ofthat endocrine system, really
being metabolically active andcontributing potentially to
inflammation in differentdisease states like psoriasis.
You know, when we think about,you know, somebody who is
overweight or obese, one of thethings that always, you know,
(06:26):
bothers me is we tend to bejudgmental, right?
We automatically look at thesepeople and think, oh, you know,
it's a lack of willpower.
You're just not able to controlyourself if you've got a bag of
Doritos in front of you.
And I really try to get peopleto understand, you know, it's
really not that simple.
I mean, we all have ourcravings, right?
We love our midnight runs, andpeople do that to Taco Bell, you
see the line out the door, orsomebody has, you know, their
(06:48):
chips they love, or they may notexercise as much as they want to
or need to.
But, you know, I think the ideaof obesity, what we need to
change in our mindset is this isreally more of a complex disease
state.
When we're overweight or we haveexcess fat, this is something
that it's multifactorial and alot of things contribute to
that.
How do you walk patients throughunderstanding that this isn't
just a lack of willpower, butsort of a combination of several
(07:11):
complex factors that actuallycontribute to them being
overweight or obese?
SPEAKER_01 (07:17):
It's such an important point, Shannon,
because I think until we startto think differently and frame
it differently, we're not goingto make any progress in this
area.
Um, to your point, a lot oftimes patients are told it's a
character flaw.
They don't have willpower,right?
And they need to try harder andtake care of themselves, and
this all goes away.
And we know that so much of thisis genetic.
Uh, we know that weight isreally determined by a certain
(07:40):
part of our brain called ahypothalamus that has a, we call
it a set point.
And that is geneticallydetermined, but there are also
other factors like stresslevels, um, the amount of sleep
that you're getting, certainmedications that could affect
that set point as well.
But you could try your darn bestto eat better, exercise.
And what does your set point do?
(08:00):
It tells you to be even morehungry.
It turns, it tells yourmetabolism to slow down, right?
Because it is trying to, it'slike a thermostat.
So until we can adjust that setpoint, it's very, very
difficult.
And, you know, this isn't thatdifferent than someone with high
blood pressure, right?
If someone has blood pressureproblems, you'd be like, hey,
diet and exercise first.
And if that doesn't work, thenwe're gonna put you on medical
(08:22):
therapy.
And we're not gonna make peoplefeel bad about not doing enough
diet and exercise to get yourblood pressure under control.
Why are we thinking aboutobesity any differently?
I mean, it's a disease.
And so we should be thinkingabout it in the same way of
hypertension, hyperlipidemia,and diabetes.
And that's why we call this kindof metabolic syndrome.
SPEAKER_02 (08:41):
Really good point.
Because I think for a lot ofpatients, they put it on
themselves.
There's a lot of shame, youknow, embarrassment.
And I think even as you know,dermatologists, we can kind of
admit to ourselves, I thinksometimes, you know, you have a
little you know, bias sometimesor when you see people and just
really changing that set pointand making us all realize, you
know, like you said, this is adisease like anything else.
Why would we treat it anydifferently?
(09:02):
Unfortunately, I think a lot ofyou know those cultural norms
kind of infiltrate into ourthoughts or, you know, our ideas
of what we were sort of toldabout, you know, being
overweight or obese, you know,truly what it is when we now
understand, you know, it's muchmore complex.
I think even over that hurdle,you know, as the dermatologist
or healthcare provider, and thenalso for patients to embrace
that and understand that we arehere to help, you know, and
(09:25):
beyond yes, diet and exerciseare essential, but there are
ways to kind of build on thatand really help them through
that process because it's goingto impact their overall health.
But I know from our standpoint,we're also obviously looking at
the skin health.
And then specifically, you know,in certain disease states, we
know hijodenitis separativa, weknow psoriasis, like these are
impacted.
In particular, psoriasis, Ithink, is a lot of interest to
(09:46):
our listeners that have reachedout and said, you know, we see
this craze about talking aboutnow weight and the psoriasis
connection.
So I I wanted to go back andkind of visit your thoughts on
this connection, sort of whatyou've seen over your career and
in the latest, you know, datacoming out, and how we
understand that connection toactually really exist between
the two.
SPEAKER_01 (10:06):
Yeah, yeah.
So as we uh said, you know, weknow psoriasis or excuse me,
obesity can increase one's riskof psoriasis.
There's no question.
And the same is true forpsoriatic arthritis, and that
connection or relationship maybe even stronger with the
latter.
A lot of times we have a hardtime separating out is it the
actual obesity that leads topsoriasis or are there other
(10:28):
confounding factors?
Um, but there's been actually anumber of really well done, what
we call Mendelian randomizationstudies, where you look at
genetic variants that predisposesomebody to obesity, and then
you follow those people who havethose genes and see who gets
psoriasis.
And that really controls for alot of the confounding
variables.
You're really just looking atgenetics here.
(10:49):
And we're seeing up to atwo-fold higher risk of
developing psoriasis orpsoriatic arthritis if you are
obese for many of the reasonsthat we talked about.
You have this big chemicalfactory that's pouring out these
cytokines that we know can causepsoriasis and psoriatic
arthritis.
Anecdotally, what we've seen, atleast in case reports and now
larger case series, is thatpatients who have both psoriasis
(11:12):
and type 2 diabetes, they go ona treatment for their diabetes,
right?
Specifically, a we call it aGLP1 receptor agonist or a GLP1
with a GIP, so it's a kind of acombo therapy.
And without any psoriasistherapies at all, not only do
their weight go down, not onlydoes their diabetes improve, but
their skin clears as well.
(11:32):
And I think that was the firstsignal that there is something
here to it.
Now the question, Shannon, is isit the weight loss itself that
actually leads to the psoriasisimprovement?
Because we've seen other studieswhere hypocaloric diets,
bariatric surgery, or any othertype of lifestyle intervention
that reduces the weight can alsoindirectly improve psoriasis.
(11:54):
So there probably is somethingto that.
But what is interesting is thatthese patients are also clearing
their skin even before they haveany meaningful change in their
weight, which makes us wonder isthere a direct effect with these
weight loss medications that wesee on the inflammatory
component of psoriasis?
And the answer to that probablyis yes.
(12:16):
And we have some what we call invitro data, which isn't human
data, but some of the in vitrodata suggests that GLP1s can
actually modulate the immunesystem in such a way where it
decreases cytokine signaling,immune cell trafficking.
Some of the cytokines that wetalked about before, like TNF
and L17, they come down evenindependent of weight.
(12:37):
So I think it's a really kind offascinating and exciting area of
research how we can use weightloss medications that improve
inflammatory disordersindependently of the weight
loss.
SPEAKER_02 (12:49):
So if I was your psoriasis patient and came to
you and I, you know, saw that alittle blurb, you know, maybe on
my Yahoo news and you know, thatthis is happening and I have
psoriasis, how would youapproach that with me if you
know I am overweight or obese,have psorias to say, hey, Dr.
Song, I want to go on a GLP1?
Is it that simple or is it amore complex conversation to
(13:10):
talk about?
SPEAKER_01 (13:11):
Yeah, I think as with all things, you know,
benefit versus risk, right?
And I think people often focusso much on their risks, which is
understandable, right?
Safety is important, but wedon't talk enough about not
treating or under-treating thedisease and what are the
downstream consequences ofhaving not just psoriasis, but
(13:32):
also the meta the um thecomorbidities associated with
psoriasis as well.
We now know that patients withpsoriasis have about a 50%
higher risk of havingcardiovascular disease.
Okay, and that's independent oftraditional risk factors.
So you take the hypertension,the lipids, the cholesterol, and
the weight out, they still haveabout a 50% higher risk.
(13:52):
And this leads to about afive-year decrease in life
expectancy.
So I start with that.
And while the weight loss isgreat and all, and it's gonna
help, I think, with not justwith the weight, the diabetes,
and the psoriasis, we now havedata.
It's actually on the label,Shannon, for several of our
semaglutides, illyroglutides,that it actually lowers mace
(14:12):
risk.
I mean, that's on the label.
It decreases heart attacks,strokes, all cause
cardiovascular death.
Um, I just got back from theEADV in Paris, and there was a
very, very powerful podiumpresentation about people who
use GLP1s and glyphosis versusnon-GLP1 diabetes medications,
not only do they live longer,their risk of anxiety and
(14:35):
depression goes down.
Their use of substances likeillicit drugs and alcohol goes
significantly down too.
So I try to bring in all thepositive benefits, even outside
of the skin, of using thesetypes of medications.
So absolutely, if you qualifyfor a GLP1, right, you've done
all the lifestyle changes thatwe talked about, which isn't
(14:56):
easy, but you've done it, andyou meet the eligibility
criteria, which is fairlysimple.
It's you have a BMI of 30 orgreater, or a BMI of 27 or
greater, but you have oneweight-related comorbidity.
So blood pressure, diabetes,cholesterol, sleep apnea,
cardiovascular disease.
Then, yes, absolutely, this issomething that we bring up.
(15:16):
The question, though, Shannon,is you know, you have a five to
10 minute visit for thesepatients.
We don't have teams ofbiological coordinators that can
do these medications or pushthese medicines for us.
Do how do we have the time andthe resources to do all these
things?
And I I would be lying if I saidI have it figured out.
You know, I do this enough andI'm fortunate enough to be in a
bigger practice where we havethose means to do that.
(15:38):
But I certainly want to uh Iempathize with our colleagues
who may push back and say, Ijust don't have the time or
resources to do that.
At least what I would say tothose people would be that at
least have the conversation,make that connection, and then
if a patient is interested, atleast try to refer them to
someone that actually can helpget them on these steps and
medications.
SPEAKER_02 (15:59):
Well, very powerful what you mentioned about in the
label, because I think thatwould shock you know a lot of
our listeners out there thatmight be on one of these
medications and not even knowthe benefit, regardless if they
have psoriasis or anothercondition or not, and even some
of our healthcare providers onthe power that I can offer for
patients and being potentiallycardioprotective.
That's pretty amazing.
(16:19):
And for dermatology, you'reright, it is tough, you know, in
the environment that we work in,but also the opportunity to
collaborate with our colleaguesin the primary care space to
make that happen for patients,just knowing there's that
benefit.
I think there's an opportunitythere, you know, to offer it to
patients.
Do you feel like based on maybewhat we know with some of that
data or what we're looking atprobably going forward and
(16:40):
what's in clinical trials, doyou think for management of
psoriasis that it's sort of ayou know monotherapy where you
just go on a GLP1 or a GIF one,or maybe you're going to
actually, you know, combine it?
Or what are your thoughts mightmight be the ideal strategy on
what we might do?
SPEAKER_01 (16:56):
Well, we do have one study that is ongoing, actually,
two in parallel.
It's called a together psoriasisor the together psoriatic
arthritis studies.
And this is looking at uhixychizimab, which is an IL-17A
inhibitor, very effective forpsoriasis.
And you are combining that withterzepatide, which is a dual
GLP1 and GIP inhibitor, versusthose who just get ixychizimab
(17:19):
alone.
So you want to see, is there anadditive benefit or a
synergistic benefit of combiningthese therapies?
We should be getting thetop-line data here probably
sometime in later 2026, Ibelieve.
But that is the way that it isbeing studied.
Um, and and I do believe thatthat's the best way is to use
them as combination oradjunctive therapy versus just
monotherapy alone.
(17:40):
Although I will say, Shannon, ifyou have very mild psoriasis, so
just a couple little plaqueshere and there, and you have the
comorbidities that qualify youfor getting onto one of these
medicines, you may be able tojust go on monotherapy alone,
right?
And then one thing, you know, Ididn't mention here, I think
it's important, is that patientswho have higher BMIs tend to
have more severe disease.
(18:01):
And what more higher BMI, it'sgenerally harder to treat.
Even though we have reallyeffective medicines now in
psoriasis, the heavier you are,the medicines just don't work
quite as well.
We see a much bigger drop-offwith our older medicines, like
TNF inhibitors, but even ournewer ones, like IL-17 or IL-23
(18:21):
inhibitors, you do start to seea drop-off in patients who get
beyond 250 pounds, which is whysome of these medicines are
weight-based.
And I think those medicinesmight be better for the heavier
patients because standard dosingdoesn't work for everybody.
But the biggest kind of, Ithink, data point here that's
important is that when youlooked at Ixy Kizimab in their
phase three studies, Shannon,and you looked at PAS C100,
(18:44):
that's 100% clear, thedifference of being less than 25
BMI versus 40 BMI or greater wasprofound.
We're talking about a 20% plusdifference in the likelihood of
getting to 100% clear.
So about a two-fold difference.
And this was the same withpsoriatic arthritis.
When we look at minimal diseaseactivity, which is a very high
(19:05):
bar, very low levels of diseaseactivity in your joints and your
skin, you're still twice aslikely to get to that high bar
if you were under a BMI of 25versus over 40.
So that makes a lot of sensethen why using a GLP1 in
addition to Kismab may provideadditional benefits for these
patients.
SPEAKER_02 (19:25):
I know you and I are familiar with BMI.
Do you mind commenting on BMIhow that's sort of calculated?
Because for some area listeners,I think I've heard of that, but
I really don't know what itmeans, but I've been told I have
a very high one.
SPEAKER_01 (19:35):
And yep, yep.
So BMI is just one way ofmeasuring weight, right?
Or obesity.
Um it's not perfect.
So the way we calculate it, wetake your weight in kilograms
and divide it by your height inmeters squared, and you get a
number.
Um, let's say a 25 might meanthat you're overweight.
(19:56):
A number over 30 means you'reobese.
Over 40, you're severely obese.
That's a really kind of it's animperfect way of measuring um
fat, but it's kind of probablythe simplest way of doing it.
Uh, we know that there arepeople out there that have who
are very, very muscular andathletic and they can have very
high BMIs, right?
You look at the rock, right?
(20:18):
Dwayne Johnson, the guy isripped and shredded.
I think he's like 6'2 or 6'3 andweighs like upper 200 pounds.
You do the math, he he isseverely obese, right?
Right.
No one will say that to him,right?
Not in front of his face, buteven still objectively, he is
very, very good shape, right?
Muscular.
But it just goes to show thatBMI actually overestimates um
the score in muscularindividuals.
(20:40):
And there are a lot of otherexamples of that as well.
There's other ways to measure uhbody fat, though.
You know, there's DEXA scans,which are like X-rays that look
at the density of bone, muscle,uh fat.
There's um impedance tests whereyou could just hold on to
something.
It sends electrical currents,you could do caliper studies.
So there's a lot of differentways to do it.
BMI is just kind of our quickand dirty way of measuring uh
(21:02):
the fat levels, which again isnot perfect.
SPEAKER_02 (21:05):
But you're right, it gives us a really good gauge, at
least to work from from now.
And maybe we'll improve uponthat, you know, as a metric as
we kind of go forward andclassify, you know, patients a
little bit better, you know,regarding their weight.
But you're right, it's the bestthing we've kind of got now,
although imperfect.
So if somebody's out therelistening, you know, in the last
few minutes we're having,they're thinking, you've kind of
sold me on this.
You know, I've I've gotpsoriasis, I'm worried about my
(21:26):
risk factors.
They may or may not, you know,have diabetes already, or one of
the other, you know, riskfactors are comorbidities like
high blood pressure orcholesterol.
What would you say to them aspotentially, you know, a reason
maybe you wouldn't considerdoing it?
And then if it was, you know,meant for them, how would you
move forward with that?
SPEAKER_01 (21:44):
Yeah, the the biggest barrier, Shannon, is
going to be cost and access.
There's no question these areexpensive medications, but I
would argue that the cost of nottreating is even more expensive,
right?
Because we're just you're justdelaying the inevitable and
having to get an open heartsurgery or some other major
medical intervention will cost alot more money.
(22:05):
But that's the main barrier,right?
And then the the naturalquestion that comes up is if I
can get insurance to pay for it,what about compounded
medications, right?
And I think this is aconversation for another day,
but you you really have to becareful of what you're getting
with compounded medications.
I understand it's cheaper, butyou don't always know what
you're getting there.
If you have diabetes or obesity,and you as an office, as a
(22:29):
dermatology practitioner, justdon't know how to do it or don't
have the means to do it, atleast refer them to somebody,
whether it's a primary caredoctor or an endocrinologist
that can really do the heavy uhwork to get disapproved, because
truly these are life-changingdrugs.
And I think that we are doing adisservice to our patients if we
(22:51):
don't at least bring it up tothem.
SPEAKER_02 (22:54):
And and I think too, patients out there now are going
to be asking about it, you know,listening to this, just seeing
that there's value and you know,looking at, you know, being
overweight or obese is more thanwe talked about, that lack of
willpower.
Hopefully, for you know, thedermatologists and providers
listening out there that they'rethinking, you know what, I
should probably be approachingmy patient maybe a bit more
holistically.
I think that's a shift we'regoing to see in dermatology as a
(23:16):
whole as we look at a lot of ourskin conditions as, you know,
more so systemic inflammation.
We've known this for years, butnow that we have opportunities
to treat it, I think it's goingto shift.
It's interesting.
I think, you know, we used tohave the internal med and then
Durham model.
I don't see us going back tothat paradigm for training, but
boy, is it going to beintegrated more into how we
manage patients?
Yes.
SPEAKER_01 (23:35):
Yes, yes, yes.
SPEAKER_02 (23:38):
Well, I want to thank you so much for coming on
and kind of going over this.
You know, I know it's succinct,but this gives people really a
taste, I think, for listeners ofunderstanding, you know, that
how complex, you know, obesitycan be and then link, you know,
to psoriasis and otherinflammatory disease and skin
that um we'll obviously touchupon in the future.
But thank you so much forsharing your expertise with us
today.
SPEAKER_01 (23:57):
Shannon, it's my pleasure.
Thank you for having me.
SPEAKER_02 (24:00):
For our listeners that want to track you down
online, how can they find you?
SPEAKER_01 (24:03):
Uh, my Instagram handle is E as an Edward, J as
in James and song, like singinga song 812.
And then it's the same one onLinkedIn.
So I try to be active, notnearly as active as you,
Shannon.
I need to up my social mediagame, but um, yes, you can find
me on there.
SPEAKER_02 (24:21):
Well, thank you for sharing.
I'm sure some people will checkit out.
And stay tuned for the nextepisode of Dermotrotter Don't
Swear About Skincare.
SPEAKER_00 (24:29):
Thanks for listening to Dermotter.
For more about skincare, visitdermittrotter.com.
Don't forget to subscribe, leavea review, and share this podcast
with anyone who needs a littleskincare sanity.
Until next time, stay skinsmart.
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