Dermatologist’s Role in Managing Psoriatic Arthritis

Steven R. Feldman, MD, PhDProfessor of Dermatology, Pathology &

Public Health SciencesWake Forest University School of Medicine

Winston-Salem, North Carolina, USA

Background

• Psoriasis patients present to dermatologists for management of skin disease – These patients often have other symptoms– Joint prolems are the most common of these

• Dermatologists are becoming more aware of the need to query psoriasis patients about joint pain– Often unsure about the appropriate evaluation and

management of this complaint.

Purpose

• To develop a practical guideline for dermatologists to manage joint pain in the setting of psoriasis

• Assumptions– Dermatologists are great at managing the skin

disease– Rheumatologists know best about managing

joints• Rheumatologists are in a good position to tell us

dermatologists what to do & what not to do

Methods

• We surveyed rheumatologists to determine their advice on role dermatologists can play in the evaluation & management of joint pain

• We asked from the perspective of the problems faced by dermatologists– What physical examinations should be done– What laboratory and x-ray evaluation– When to refer

Show the Survey Here

Results

• Should dermatologists ask patients about joint pain– Yes, absolutely

• Ask about– Joint pain & stiffness– Joint swelling (50%)– Family and personal history, nails, heels,

Crohns, UC, eye inflammation, tendonitis (10-20%)

– Fatigue (60%)

Examine the Joints

• 90% said yes

• Document joints involved– 50% document timing (day/night)– 70% document duration– 60% document relation to exercise– 20% document relation to sleep– 10% document relief with rest

Which Joints

• Only affected joints should be examined: 20%

• Examine hands/ feet on all Ps pts: 30%

• Complete GALS screening exam on all Ps pts: 40%

When to Refer?

• Refer any patient with any joint pain: 30% • Only refer patients who at least have joint pain

that is unrelieved by OTC NSAIDs: 30% • Only refer patients who at least have joint

swelling: 30% • Only refer patients who have multiple swollen

joints: 10% • Only refer patients who have significant,

disabling symptoms: 0%

When to Expedite Referral?

• Expedite referral of any patient with any joint pain: 0%

• Expedited referral for patients who at least have acute joint pain: 30%

• Expedited referral for patients who at least have joint swelling: 60%

• Only for patients who have multiple swollen joints or disabling sx: 10%

X-Rays & Lab Tests

• Dermatologists should not order labs/x-rays for PsA: 60%

• Xray sx joints: 30%

• Order labs to r/o infection or gout: 30%

Treatment of Psoriatic Arthritis

• Dermatologists should prescribe only NSAIDs for joint pain: 70%

• Derms can manage skin disease with DMARDs and see how joints respond: 10%

• Dermatologists should add MTX when NSAIDs don't work for joint sx: 10%

Asked Slightly Differently

• Nothing prescription: 10%

• NSAIDs only: 70%

• Add MTX if needed: 10%

• Use any DMARD as skin disease warrants: 10%

How to Use NSAID’s

• Try multiple NSAIDs: 20%

• 2 wks:30%

• At least 1mo :30%

Other Reasons for Referral

• Refer to rheumatologist for – Enthesitis– Tenosynovitis– Dactilitis

• Uveitis– 60% said rheumatology– 50% said ophthalmology

Etanercept for Joint Symptoms

• Derms should use to treat for joint sx: 10%

• Derms should use for skin disease and watch joint sx: 20%

• Derms should not use: 70%– I presume this means that dermatologists

should not use it for psoriatic arthritis

Conclusions

• Rheumatologists seem confident in dermatologists’ ability to diagnose psoriatic arthritis– Perhaps NSAIDs are ok even if it isn’t psoriatic

arthritis• Dermatologists can treat with NSAID• Beyond that, rheumatologists want to be

involved• Not all that different from how I would want

rheumatologists to approach the skin involvement