Biologics and Advanced Therapies in the Management of Psoriatic Arthritis - Episode 3
Anthony M. Turkiewicz, MD: Steve, if you don’t mind, we’ll start looking on the dermatology side at the importance of early and, to some extent, accurate diagnosis in psoriasis. I know in my clinic, I have some medical dermatologists who I have a close relationship with to help me figure out if this rash I’m looking at, whether it’s classic or is truly psoriasis.
Can comment on the importance of that early and accurate diagnosis of psoriasis, or perhaps a regression from psoriasis to psoriatic arthritis, as Hillary pointed out, often the skin occurs first before the joint, can you tell us a little bit from the dermatology standpoint?
Steven R. Feldman, MD, PhD: We talked about the skin, the joints, the other components of the disease. In terms of the skin, the diagnosis is very straightforward. We know it when we see it. And we don’t need to do a biopsy, we see the red scaly plaques and typical areas on the elbows, scalp, belly button, and nail changes that were mentioned.
The diagnosis of psoriasis for us is pretty straightforward. Patients come in for it, and when they do, we make the diagnosis.
Making the diagnosis of psoriatic arthritis is much more difficult. It seems to us that it’s difficult even for rheumatologists sometimes to tell whether somebody’s arthritis is psoriatic arthritis or not. It’s totally beyond my capability as a dermatologist to tell whether something is psoriatic arthritis or osteoarthritis, or gonococcal arthritis. You have 1 hot, swollen joint—I don’t know what it is, it could be psoriatic arthritis, it could be gonococcal disease, for all I can tell.
My role is to screen, to identify patients who might have psoriatic arthritis and get them to a rheumatologist early to identify the disease. We do tend to see the patients first because their skin disease comes up before the joints, and so we can make them aware that psoriatic arthritis is a possibility. My sense is most people with psoriasis don’t get psoriatic arthritis. That most people who do get psoriatic arthritis don’t get progressive disease, but sufficiently high numbers do that I need to get the person to a rheumatologist. I like to screen with very broad criteria: Are you having any joint stiffness? Any joint pain? Any back pain? If you have any of those I might tell you, “OK, well you can take some Motrin for now, but we need a rheumatologist to see you and evaluate you.”
My thinking on this is based on a study we did a few years ago where we asked rheumatologists, “When we dermatologists see somebody who has psoriatic arthritis, what should we do as dermatologists?” Now you can correct me if you think otherwise, but what I was told was, “Well start by doing a complete musculoskeletal examination, including range of motion and gait.” And I’m like, “No, I’m not doing that.” I’m sending patients to you. I wouldn’t know what laboratory tests to order, what x-rays to order, or how to interpret those x-rays if I did order them.
Anthony M. Turkiewicz, MD: That’s interesting insight. If you were to perhaps ask our group, and I’m certain John and Hillary would agree, we would never expert a dermatologist, as I would not expect to be sitting there doing skin biopsies or PASIs [Psoriasis Area and Severity Index scores] outside of clinical trials. But as you’ve mentioned, there are a number of tools that are trying to be developed and hopefully easy tools that are simple.
You also brought up back pain, which I thought was important as well. Not that we want our clinics flooded with degenerative disk disease or lumbago, but any hint of back pain in a 22-year-old that’s been going on for years….
But even that level, this is our job to figure that out for you. I agree. I’m not sure who told you to do a musculoskeletal exam, you wouldn’t have time for it, and honestly, that’s on us. I agree with how you were handling it before.
Steven R. Feldman, MD, PhD: I told the rheumatologist, “I’m not going to do that, I can’t do that.” And he said, “Well, you went to medical school, Steve, you learned to do those things.” I believe in the golden rule. If rheumatologists ask dermatologists, “What should we do to examine the skin,” the first thing we would tell you is, “Do a complete skin examination, top to bottom, every area,” and I’m pretty sure most rheumatologists would go, “No, that’s OK….”
I think depression is also common enough that I have a role to screen for depression, and I don’t do that in any formal way. If I see a patient sitting there like this, then I know they are probably depressed and I need to get them to seek some help.
Then there are the cardiovascular issues, and I don’t even screen for those, and I wonder how big an issue those are. If you’re between the ages of 20 and 30 and you have severe psoriasis, you’re at something like a 2- to 3-fold increased risk of having an MI [myocardial infarction], which sounds horrible. But then if you ask yourself, well what’s the chance that a 20-to-30-year-old without severe psoriasis is going to have an MI? You realize, well, it’s pretty close to zero. And 2 to 3 times close to zero is still close to zero. Maybe there is some cardiovascular importance, but we have to be careful and consider it objectively and not emotionally.
Anthony M. Turkiewicz, MD: That input from dermatology is very helpful. We do try to play a role as not just rheumatologists. Clearly I don’t manage, let’s say, cardiovascular risk or depression, but as you pointed out, when it’s identified, it’s fairly common in the patients that we see. I know that you see it as well, potentially increased risk of depression and suicide, we make sure these patients get into the right hands.
The cardiovascular risk, you’re right, for younger patients, if it’s an inflammatory disease, we want to talk about psoriatic today obviously. We do recognize that increased cardiovascular risk; clearly if there’s issues with diet, exercise early on, the traditional cardiovascular things you try to improve, that’s important. But this disease also does play a role irrespective of the traditional risk factors. But that’s helpful from a dermatologist’s standpoint. What’s key in this discussion is that interplay between rheumatologists and dermatologists. And we may not have official rheumatology/dermatology clinics in all of our community or academic practices, but having that relationship between a good medical dermatologist and rheumatology is critical.
Transcript Edited for Clarity