Reviving the Classics: The Role of Older Medications in Modern Dermatology

Older, generic medications can treat patients with various dermatological conditions while combatting factors like cost and the prior authorization process, according to experts during a Saturday evening session at the 2025 American Academy of Dermatology annual meeting in Orlando, Florida.

The older, generic medications highlighted, including cyclosporine, nicotinamide, and dapsone, can effectively treat patients with various dermatological conditions while helping to reduce insurance and cost barriers. | Image Credit: RHJ - stock.adobe.com

Matthew S. Keller, MD, FAAD, of Thomas Jefferson University began the session, “The Utility of Older Generic Medicines in the Current Practice of Dermatology,” by discussing the motivations for using older, less expensive medications, including cost. He noted that older therapies are significantly more affordable than newer options like biologics or Janus kinase (JAK) inhibitors, which can be 10 to 50 times more expensive.

Keller added that prescribing these older, generic medications can help patients receive proper treatment sooner, avoiding delays due to prior authorization processes. This approach can also prevent large out-of-pocket costs, especially for patients who are underinsured, uninsured, or on Medicare.

While newer medications may be safer at times, Keller explained that some older, generic treatments have substantial safety data across various populations, including the elderly and pregnant women.

He concluded his introduction by emphasizing the importance of equity. Keller described the “colonial curriculum,” which he learned from a dermatologist from South Africa. This concept describes the practice of physicians from more developed countries traveling to developing nations to provide care and educate other physicians.

However, these clinicians often lack the knowledge or ability to use the tools commonly available in these countries. Also, they cannot teach these physicians about the newer treatments used back home, as those options are not as accessible in developing nations.

“They can’t afford to use biologics; they can’t afford to use some of these JAK inhibitors all the time,” Keller said. “The ability to be facile with these [older, generic] medications helps us to be better citizens of the world.”

Cyclosporine

Keller discussed a few older, generic medications used in dermatology, including cyclosporine. It blocks interleukin (IL)-2 and IL-4 and is metabolized by the liver’s cytochrome P450 3A enzyme system. It is FDA-approved for treating severe plaque psoriasis in adult, non-immunocompromised patients who have not responded to one systemic therapy. However, it can be used in other circumstances as well.

Keller typically prescribes cyclosporine at 3 mg/kg to 5 mg/kg, with a preference for the higher dose in sicker patients. For most, the daily dose is 300 mg to 350 mg, split into 100 mg in the morning and 200 mg at night for better gastrointestinal (GI) tolerance. He said he prefers the modified version of cyclosporine for more consistent blood levels among patients.

Keller emphasized the decreasing comfortability that younger clinicians have with this drug; it is falling out of practice due to concerns over side effects. Therefore, he highlighted the importance of monitoring renal function, particularly in older patients or those with pre-existing kidney disease. Keller noted that dose reduction or cessation can help patients regain function.

“At least early on, this is not true kidney damage,” he said. “It’s more kidney injury or kidney insult. It can be remedied by reducing the dose or stopping it.”

Additionally, Keller highlighted the need to monitor diastolic blood pressure over 90, which he considers the “greatest controllable risk factor” for kidney disease associated with cyclosporine use. To control blood pressure and reduce hypertension, he said most patients are also prescribed nifedipine.

Ultimately, Keller recommends cyclosporine for patients who are rapidly flaring or those with significant morbidity. He also recommended it for both pregnant patients or those who are family planning who are on oral JAK inhibitors or medications incompatible with pregnancy since there is no evidence of teratogenicity associated with cyclosporine.

Nicotinamide

Neda Nikbaht, MD, PhD, FAAD, of Jefferson Health, followed up by describing the uses of nicotinamide, also known as niacinamide. It is a form of vitamin B3, commonly used in dermatology for its anti-inflammatory and skin-protective properties. She highlighted that nicotinamide is an over-the-counter medication with no specific FDA indications. However, many off-label dermatological applications for the medication exist.

Nikbaht noted that nicotinamide's ability to reduce inflammation makes it effective for conditions like acne, rosacea, and atopic dermatitis. Therefore, nicotinamide is widely used in creams and serums to improve skin hydration, reduce hyperpigmentation, and manage acne and rosacea.

Additionally, she highlighted the treatment's chemoprevention abilities. Oral nicotinamide, usually at higher doses, may reduce the risk of non-melanoma skin cancers by enhancing DNA repair after ultraviolet radiation damage, promoting overall skin health.

As for its safety profile, Nikbaht said that nicotinamide is generally well-tolerated with minimal adverse effects. Rare side effects of topical use may include redness, dryness, or mild irritation. However, she said these symptoms are usually temporary and mild.

Lastly, Nikbaht noted that oral doses of nicotinamide may cause mild GI issues. She clarified that this is only possible with higher doses and is not typically seen in those taking more typical doses of 500 mg to 1500 mg daily.

“Overall, evidence suggests that nicotinamide is a safe and well tolerated medication for a range of inflammatory dermatosis and an excellent choice for chemoprevention,” Nikbhat concluded.

Dapsone

Elizabeth Jones, MD, FAAD, of Thomas Jefferson University Hospital concluded by discussing dapsone, which is FDA-approved to treat leprosy and dermatitis herpetiformis but can also treat other conditions, like acne. Jones added that it is often prescribed with corticosteroids and other immunosuppressive agents for conditions like bullous pemphigoid and pemphigus vulgaris, enhancing therapeutic effects while reducing systemic steroid use.

She explained that dapsone inhibits dihydropteroate synthetase, which prevents folic acid synthesis in bacteria and some skin cells, preventing bacterial growth. It also has an anti-inflammatory effect that helps treat autoimmune and inflammatory conditions by suppressing the activation of inflammatory cells, such as neutrophils.

Jones noted that dapsone daily doses typically range between 50 mg and 200 mg; higher doses may be used for severe cases, but they require more careful monitoring.

Dapsone is known to cause hemolytic anemia, particularly in those with glucose-6-phosphate dehydrogenase (G6PD) deficiency, so regular blood count monitoring is needed to identify any early signs of anemia; Jones recommended clinicians assess patients’ G6PD status before starting treatment.

Similarly, elevated liver enzymes may occur in some patients, so Jones recommended regularly monitoring their liver function. Other common side effects include rash, nausea, and vomiting, but she noted that these are typically mild and reversible upon discontinuation of the drug.

In an on-site interview with The American Journal of Managed Care^®, Jones reflected on the benefits of using older, generic medications to treat patients with dermatological conditions, especially rare ones.

“As dermatologists, we come into these situations where the condition we're treating is, overall, pretty rare, so we don't have a lot of medications that have been vetted,” she said. “We do have a couple select medications that, historically, work very well. We must be very keen on what's out there and what we can use for our patients in these select cases where the disease is rare.”

Reference

Keller MS, Nikbaht N, Jones E. The utility of older generic medicines in the current practice of dermatology. Presented at: 2025 American Academy of Dermatology Annual Meeting; March 7-11, 2025; Orlando, FL.