NEW YORK CITY — Dermatologists should be thinking about offering hormonally-active weight loss drugs such as glucagon-like peptide-1 receptor agonists (GLP-1 RAs) as part of routine care for psoriasis and hidradenitis suppurativa (HS) in patients with overweight or obesity, according to those experienced with this approach. 

"I usually referred psoriasis patients for obesity control, but I am increasingly assuming a more direct role," Jennifer Soung, MD, director of clinical research, Southern California Dermatology, Santa Ana, said at the Skin of Color Update (SOCU) 2025.

Soung and another expert acknowledged that not all dermatologists are ready to take responsibility for prescribing and monitoring GLP-1 agonists, but both argued that they should be assuring access to effective weight control, typically through multidisciplinary care, as part of patient care.

Speaking at the meeting on October 1, Soung and fellow panelist Karan Lal, DO, who provides patient care and conducts clinical research at Affiliated Dermatology, Scottsdale, Arizona, noted they were well aware that weight loss is not a new idea in psoriasis or HS, but argued that the role of weight loss has evolved.

GLP-1 Agonists Have Changed Attitudes

"GLP-1 agonists have really changed the way we see obesity and weight management," Soung said. Lecturing patients about diet and weight loss often yielded disappointing results, but now there is an opportunity to act on an important modifiable risk factor for inflammatory skin diseases with a greater success rate.

However, the importance of hormonally active weight loss drugs is not just related to their efficacy, which is far greater than previous pharmacologic options, but the fact that they modify the proinflammatory state that drives both psoriasis and HS, according to Soung and Lal.

"We know from the experimental trials that there are major reductions in proinflammatory cytokines" with treatment, Lal said, showing a diagram of downregulated mediators of both obesity and HS that explains why the pathophysiology of these disorders is so intertwined. 

"In HS, the first part of my management is now controlling the factors that I cannot see," he said, referring to the inflammation that can be targeted along with metabolic dysregulation by reducing adipose tissue.

Soung, relying on a series of published trials, said evidence that weight loss can improve objective measures of psoriasis, such as the Psoriasis Area and Severity Index (PASI) score, is at least 20 years old. Weight loss has also been associated with improvements in response to therapy, including an increase in the proportion of patients who reach clear or almost clear skin, as well as with a reduced risk of flares and relapse.

Although HS was described as a "more complicated disease," with more potential etiologic factors and phenotypes, the evidence is nearly as strong that disease control improves in patients with HS and obesity who lose weight, according to Lal.

Metabolic Disorders Now Screened for Skin Care 

At the initial examination, Lal now evaluates patients with HS or other inflammatory skin diseases for metabolic disorders such as diabetes, lipid imbalances, and inflammatory markers while also establishing a baseline body mass index. This involves ordering biomarker testing for these disorders if they are not available in the patient's chart.

If there are no alternative explanations for metabolic abnormalities and no contraindications to GLP-1 agonists or other hormonally-active weight loss drugs, he discusses the role these agents might play in the control of their skin disease. The goal is to explain risks and benefits.

"If they do agree [with starting a weight loss therapy] and you do not feel comfortable prescribing these drugs, please refer them to a primary care physician or an endocrinologist," Lal said.

For those being treated with a GLP-1 agonist or related drug for the skin disease, Lal recommended starting with semaglutide (administered subcutaneously) at a dose of 0.25 mg once a week for 4 weeks before titrating up to 0.5 mg for another 4 weeks and then treating at a weekly dose of 1.0 mg until the skin is cleared. At this time, he returns to 0.25 mg weekly or even every 2 weeks.

For tirzepatide, which activates both GLP-1 and glucose-dependent insulinotropic polypeptide (GIP), another incretin hormone, the regimen is similar, involving uptitration from a 2.5-mg weekly dose after 4 weeks to 5.0 mg (administered subcutaneously). This dose is maintained until skin is cleared before returning to a lower dose. Both drugs are used alongside dietary recommendations or referral to a nutritionist to ensure healthy eating, particularly adequate protein consumption, Lal advised.

The question of whether inflammatory skin diseases are a trigger of obesity or vice versa is not easily answered, according to Soung, who presented a chart depicting a vicious circle of factors that suggest a bidirectional relationship. 

"Each worsens the severity and the progression of the other," she said. In addition, both relate to the increased risk of other inflammatory conditions related to metabolic disturbances, such as cardiovascular disease and fatty liver disease. It is for this reason that she does not limit her attention to weight from a dermatologic perspective.

"Weight discussions can be tricky," Soung acknowledged. It is likely that individuals with overweight are aware that losing weight would be beneficial, so Soung brings up the topic delicately, telling patients that she is worried about the impact of overweight on the skin condition, essentially eliciting their permission to address this topic.

"Patients want healthcare professionals to initiate a conversation about weight loss but they do not want to be lectured," she explained. 

Both Soung and Lal have found that the substantial — sometimes even dramatic — weight loss achieved with hormonally-active drugs often produces a reorientation in patients, motivating them to stay with treatment not only to improve control of their skin disease but to attain the array of other health benefits.

Soung has reported financial relationships with AbbVie, Amgen, Arcutis, Bristol Myers Squibb, Corval, Dermavant, Incyte, UCB, Eli Lilly, LEO Pharma, Novartis, Regeneron, Pfizer, Sanofi, and Johnson & Johnson. Lal has reported financial relationships with AbbVie, Aerolase, Arcutis, Boehringer Ingelheim, Galderma, Lilly, L’Oréal, Pfizer, Sciton, and Sun Pharma.