Dermatologists As Obesity’s Primary Care Physicians | AAD 2025

Dermatologists need to venture beyond the traditional boundaries of their specialty to treat obesity and insulin resistance, the root cause of many skin conditions, according to Lindsey A. Bordone, M.D.

“Without addressing obesity, we’re leaving our patients partially treated,” Bordone said at a well-attended session on incorporating glucagon-like peptide 1 (GLP-1) drugs and another diabetes drugs into dermatologic practice at the 2025 annual meeting of the American Academy of Dermatology in Orlando, Florida.

Lindsey A. Bordone, M.D.

Bordone suggested that dermatologists, rather than other specialists or primary care physicians, should play a lead role in diagnosing metabolic syndrome. “What I say to everyone is, ‘If not you, then who?’ If you have a patient that comes in for acne, a skin check or psoriasis and there’s obvious signs of metabolic disease, if you don’t flag this, it’s not like they’re going to make an appointment to go to primary care because they otherwise feel fine,” she said. “So we are the ones that need to find this and help patients.”

Metabolic syndrome is a group of conditions that includes excess abdominal fat (as measured by waist circumference), high blood pressure, high blood sugar levels (100 mg/dL or higher), elevated triglyceride levels and low HDL cholesterol levels. Researchers, clinicians and disease groups have linked metabolic syndrome to an increased risk for heart attacks, stroke and type 2 diabetes for decades.

Bordone told the AAD audience that the syndrome — particularly two of its components, insulin resistance and obesity — play a causative role in a number of skin diseases.

Acanthosis nigricans (dark, velvety areas of skin that form in skin folds and creases), acrochordons (skin tags), acne and hirsutism (excessive hair growth in women on the face and other areas where women don’t grow hair) are skin conditions that traditionally have been associated with obesity.

But Bordone said the inflammation caused by obesity can result in psoriasis, hidradenitis suppurativa, rosacea and atopic dermatitis. She said insulin resistance (when liver, fat and muscle stop taking up blood glucose because they stop responding to insulin) is both the result and cause of inflammation that results in these skin diseases.

Bordone says she now orders metabolic lab tests in patients with a body-mass index (BMI) of 27 and skin conditions associated with metabolic syndrome, such as acne and psoriasis, and in every patient with a BMI over 30. She said she also now checks the BMI of all her patients.

Bordone stressed the importance of checking for insulin resistance, not just blood sugar levels or hemoglobin A_1c, because of the role that insulin resistance plays in skin diseases. Insulin resistance is measured by the homeostatic model assessment for insulin resistance, more commonly known by its acronym, HOMA-IR. It is calculated by multiplying the result of a fasting blood glucose test by the result of a fasting insulin test and then dividing the product by 405. Bordone told the audience not to worry about doing the calculations themselves because it was easy to find online calculators.

Five GLP-1 prescriptions daily

Bordone spoke about prescribing metformin and the GLP-1s for skin conditions. Metformin, a first-line diabetes drug, increases the insulin sensitivity of peripheral tissue and decreases glucose production in the liver. Bordone noted that it was very inexpensive — a bottle of 90,750-milligram extended-release pills cost $8.26 from the online drug discounter, Mark Cuban Cost Plus Drug. She discussed the case of an overweight woman whose skin condition on her neck cleared up after taking metformin.

The GLP-1s include semaglutide, sold as Ozempic for diabetes and Wegovy for weight loss, and tirzepatide, sold as Mounjaro for diabetes and Zepbound for weight loss. Tirzepatide has an additional mechanism of action but is often grouped with the GLP-1s. The GLP-1s slow gastric emptying and decrease glucagon production by the pancreas, among other actions. In the short term, it also increases insulin levels. But Bordone said the net effect over a longer period is longer insulin levels as well as the well-known weight loss.

Bordone said metformin has been associated with multiple benefits but not with weight loss. Sneh said she would prescribe metformin for someone with a BMI of 24 who has hormonal acne or someone.

She said that if someone had a case of hidradenitis suppurativa that was “not that bad” and they didn’t want to go on biologic, she would treat them with topical medication and prescribe a GLP-1. If someone is “very bothered” by psoriasis, she’ll prescribe a biologic and a GLP-1, but she would prefer to start with just a metabolic drug. “If we can get their disease to go away, and we have that as monotherapy, then we know what did what.”

“I think there’s still a role for biologics. At the same time, there’s a role for these metabolic meds,” said Bordone.

Bordone said she sees between 55 and 60 patients per day and probably writes five prescriptions for GLP-1s daily.