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Dermatologist’s Role in
Managing Psoriatic Arthritis
Steven R. Feldman, MD, PhD
Professor of Dermatology, Pathology &
Public Health Sciences
Wake 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 (1020%)
– 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/xrays 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