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Dermatologist versus rheumatologist in the management of lupus patients : This debate between father
(PF) and daughter (RF) is purely fictional, but it could have easily happened
RD Fritsch-Stork and PO Fritsch
Lupus 2010 19: 1153
DOI: 10.1177/0961203310370047
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Lupus (2010) 19, 1153–1155
http://lup.sagepub.com
VIEWPOINT
Dermatologist versus rheumatologist in the
management of lupus patients
This debate between father (PF) and daughter
(RF) is purely fictional, but it could have easily
happened
PF: Sometimes, medical disciplines behave like belligerent petty medieval states, trying to snatch territories from their neighbours and drive away a few
herds of sheep and cattle. Dermatology has always
been an easy prey for such waylaying activities – I
could give you examples. Rheumatology appears to
be another marauder, if you continue to argue that
lupus erythematosus (LE) and the other ‘collagen
vascular diseases’ rightfully belong to your
specialty.
RF: My approach is less martial but rather more
practical and efficient. Patients should be taken care
of by those who can handle them best. There is little
doubt that rheumatologists are specialists in systemic immunological diseases, which makes them
the first choice to manage an illness such as systemic LE.
PF: LE is ‘interdisciplinary’, as are the other collagen vascular diseases. Thus, it is nonsense to allot
LE to just one medical discipline – dermatology
never laid claims of this kind. The canon of medical
disciplines is just an attempt to sort diseases out
according to common features.
The traditional parameter was the organ most
commonly afflicted. This organ system-based
canon is simple and straightforward, but it obviously does not do justice to systemic diseases
where more than one organ system is involved.
Also, the ‘borders’ of disciplines are always fuzzy
Correspondence to: Dr Ruth D Fritsch-Stork, Department of
Rheumatology and Clinical Immunology, University Medical Center
Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
Email: [email protected]
due to varying traditions, differences in healthcare
systems, and to the impact of dominating personalities at individual institutions.
RF: In my view, a new approach of organizing
diseases is emerging based on common features
of pathogenesis and of shared diagnostic and therapeutic strategies. ‘Thematic’ specialties are being
established such as oncology or rheumatology/
clinical immunology. A better understanding of
the underlying mechanisms has compelled doctors to think out of their ‘organ system’ boxes.
I guess this was the way of thinking which led
Kaposi1 to detect the systemic nature of LE, and
it is certainly why some of our current treatment
options were ‘borrowed’ from other specialties,
such as oncology, haematology, transplant
medicine . . .
PF: . . . and dermatology, for that matter – don’t
forget that dermatology used methotrexate some
time before the rheumatologists did.
There is another point: the ‘organ system’ box is
deeply rooted in the minds of the people and in the
health systems. Patients who suffer from trouble
with one special organ will always attend the
respective specialist, and I guess this is not too different even in systems where ‘gatekeepers’ check the
patient streams. Dermatologists are responsible for
making a diagnosis on patients who seek their
advice because of skin problems. LE patients present to the dermatologist with tentative diagnoses
of all kinds, such as sunburn, drug eruption, or
viral exanthema – but very rarely with ‘suspected
LE’. This is even truer for chronic discoid lupus
erythematosus (CDLE), which is usually missed
as psoriasis by non-dermatologists (and some dermatologists). It is the task of the dermatologist to
prove or disprove LE, based on clinical judgment,
histopathology (if necessary), and laboratory
values. He or she is well equipped for this because
the differential diagnosis of LE is one of his/her
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10.1177/0961203310370047
Dermatologist versus rheumatologist in the management of lupus patients
RD Fritsch-Stork and PO Fritsch
1154
core skills. Also, at least in academic centres, histopathology and immunofluorescence labs are at
his/her disposal – close clinicopathological interaction is of paramount importance. As a rule, very
little help from other specialties, including rheumatology, is needed for a dermatologist to arrive at the
diagnosis of LE – by which I mean all forms of LE
with cutaneous symptoms, including systemic lupus
erythematosus (SLE).
RF: Perhaps you overestimate the role of skin signs
in SLE. I admit that a lot of SLE patients are sent
by dermatologists, which reflects the high percentage of skin symptoms (58–86%).2 However, the
number of patients with arthritis and/or vague constitutional symptoms (63–93%, 78–97%)2 is even
larger, and only some of them have skin signs.
These patients are usually referred to the rheumatologist by primary care physicians, bypassing
the dermatologist. The rheumatologist has then to
correlate the vague signs and symptoms with concrete physical and laboratory findings for which
purpose his/her background as internist serves
him/her well, and to obtain consultation from
appropriate specialists. Part of this is a visit to the
dermatologist, of course.
But I doubt if the study of the itinerary of LE
patients will carry us any further. By far the bigger
role for the rheumatologist is the management of
SLE patients.
PF: What about the many patients with CDLE,
subacute cutaneous lupus erythematosus (SCLE),
or ‘latent’ SLE in whom relevant systemic involvement is ruled out? There is no good reason to hand
them over to rheumatology or any other specialty
because dermatologists are the expert in topical
treatment and have decade-long experience in the
systemic use of corticosteroids and immunosuppressive agents. Also, rheumatologists would
hardly be delighted to be flooded by scores of LE
patients displaying nothing but skin lesions. Things
are of course different if serious organ involvement
is present or emerges later on. It does not take a
wise man to say that the patient should then be
transferred to where he is best taken care of, even
rheumatology. This is quite clear, and all dermatologists I know follow this policy.
RF: This might be wise, but I do think it even wiser
if any patient with a suspected diagnosis of SLE
[e.g. according to the American College of
Rheumatology (ACR) criteria] were evaluated by
a rheumatologist. The assessment of internal
organ involvement critically depends on the focus
in history taking, physical examination, and ordering/evaluating the appropriate laboratory tests.
And this is a core skill of rheumatology.
PF: Did I ever tell you the story of the unfortunate
lady who suffered from rosacea and was treated by
a rheumatologist for SLE with systemic corticosteroids for more than a year? Dermatological input
was considered unnecessary because she had the
misfortune of having borderline positive antinuclear antibody (ANA; a common finding in the
elderly). My point is – a facial rash plus a positive
ANA does not yield the diagnosis of SLE.
RF: Well, rheumatologists who overestimate
their knowledge may be as bad for patients as
dermatologists who do not consult anybody and
overlook serositis or nephritis. Everybody should
know his/her boundaries – the best service a rheumatologist can provide a lupus patient with solely
skin manifestations may be to call the
dermatologist.
There is no question that dermatology has contributed a lot to the understanding of LE in the
past, but more recently, most progress has been
made by basic research, often carried out by
rheumatologists.
PF: There is no doubt on the role of basic research.
But I am surprised to hear that you are interested in
the history of dermatology.
RF: I am interested in the history of LE, and this
has been dominated by dermatologists for quite a
while – beginning with Willan, Bateman, Cazenave,
Biett, Hebra, Kaposi, and many others.3 Not surprisingly, these founding fathers focused mostly
(with commendable exceptions!) on the skin signs,
of which dermatology continues to discover a
bewildering array.
PF: They not only discover skin signs, they correlate them with biochemical findings and develop
models of pathogenesis, just think of Gilliam and
Sontheimer.4
RF: Although the skin manifestations in SLE and
their elucidation are important, don’t the systemic
symptoms of LE weigh much heavier? And those
have been brought to our attention mostly by nondermatologists. Think of Osler, Libman and Sacks,
Lupus
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Dermatologist versus rheumatologist in the management of lupus patients
RD Fritsch-Stork and PO Fritsch
1155
Klemperer et al., Hargraves et al., and Friou, to
name just a few.5–9
PF: How many rheumatologists are among these
non-dermatologists?
RF: Rheumatology is a young specialty. The ACR
is celebrating its 75th anniversary now, and the first
fellowships started only in the 1950s. Thus, rheumatology was not an option for the old guys,
unfortunately, although we can guess that they
would have chosen it. You should not belittle the
impact of rheumatology on the understanding and
management of LE. Just consider its role in the
characterization of ANA and their subsets,10–12 in
the elucidation of the familial occurrence of SLE,12
the (re)discovery of the interferon signature by
Crow, Pascual, and Behrends as reviewed by
Baechler et al.,14 the institution of a (ACR) classification system,15 and the introduction of corticosteroids in the treatment of SLE.16
PF: Great. But I think you should rather come
back to the present and to practical matters.
I think we do agree that both dermatology and
rheumatology have their own fields of expertise in
LE, but we are divided on the issue of who should
be responsible for LE with systemic symptoms.
Does it suffice to say that everybody should do it
who is adequately trained? Whoever takes care of
LE, the challenge is not only to make the diagnosis;
the patients also need exhaustive information on
the disease, the prospects including possible future
complications, treatment options, and in depth discussions of necessary life style changes. There is
also the need to organize consultations with other
medical disciplines, of a detailed treatment schedule, and of appropriate controls. This is the reason
why dedicated clinics have been set up in many
centres. I do think that these clinics generally
work very well, but they must guarantee an interdisciplinary approach.
Funding
This research received no specific grant from any
funding agency in the public, commercial, or not
for profit sectors.
References
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RD Fritsch-Stork1 and PO Fritsch2
1
RF: ‘Interdisciplinary approach’ is the keyword –
after all, our views might not be so far apart.
2
Department of Rheumatology and Clinical Immunology,
University Medical Center Utrecht, The Netherlands; and
Department of Dermatology, University Hospital Innsbruck,
Innsbruck Medical University, Austria
Lupus
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