Dr Schairer discusses his presentation at the AIBD meeting on diagnosing and treating skin diseases that may present among patients with IBD, including patients of color.

Jason Schairer, MD, is a gastroenterologist with the Henry Ford Health System in Novi, Michigan.

TRANSCRIPT:

Dr. Jason Schairer:  Hello. My name is Jason Schairer. I'm the codirector of the Henry Ford Inflammatory Bowel Disease Center. Today, I had the pleasure of speaking at the Advances in IBD 2021 where I discussed what lies beneath skin lesions in IBD.

I personally feel that this is a very important topic because this is something that, as soon as we review it, we can start working on our physical exam skills, we can start expanding our differential, and most importantly, we can start helping people in the clinic right away.

This does not require the insurance company to authorize any special medications. It does not require anyone to change an algorithm. It does not require any special equipment. It is something that we can do for our patients in our offices and at the bedside.

I started my talk focusing on the nature of our analysis so far, and that largely, when you think back to our training, we focused on images in lighter-skinned individuals.

That's fine, because that helps us identify a lot of pathology, but we can do better. We know that humans exist on a continuous and variable scale, and that their differences can create differences in the way things appear, and it affects our ability to diagnose it.

For instance, some people have different levels of melanocytes and pigmentation of their skin, and that can affect the hues of lesions. We know that different people have different thicknesses of the dermis or collagen structures, and that can affect the way that lesions expand. My talk today largely highlighted that through a series of images.

I encourage you to look at the presentation on the Gastroenterology Learning Network to see the visuals for yourself, and see if some of your patients may be affected by these things. The first topic I covered was pyoderma gangrenosum, a hallmark lesion in IBD that I think we are very familiar with.

I emphasize that we think both locally and systemically, specifically, in terms of diagnosis. We think locally in terms of trying to recognize the lesions, the rapidly-expanding border, the deep edges, the violaceous border, and the concept of pathergy. A small injury can lead to a large, rapidly expanding ulcer.

I also emphasize that we should think systemically. Is there other inflammation in the GI tract that can be contributing to this? For instance, in the patient that I showed, there was an ostomy, and it was an end ileostomy. We need to look and make sure that there's no anus or Hartmann's pouch that could house inflammation driving this reaction.

In terms of treatment, we all also thought about locally or systemically, and that could be locally avoiding further pathergy by working in contact with a wound care nurse to ensure a better fit, to make sure that there's no stool in contact with the skin.

Working with the dermatologist if needed for intralesional steroid injections, and systemically looking at the medications for IBD, and can we use them to control the disease?

It should be noted that besides anti-TNFs, which have a good amount of data about their efficacy in pyoderma, we also have data in case reports that both ustekinumab and, surprisingly, mepolizumab can be helpful for some patients with pyoderma gangrenosum.

We have data for tofacitinib being helpful of the small molecules, but we don't yet have data from ozanimod, I suspect because it's a newer agent.

I went on to compare pyoderma gangrenosum in people with light skin to different varieties of skin, and noticing that, sometimes, the hue, that violaceous border could appear hyperpigmented. It could appear reddish at times, and in the picture, it looks like a pink border for our patient.

In addition, we talked about how the deep thick border can appear differently in people with different thicknesses to their dermis. Sometimes, it would be fairly superficial. Then, we took all that and contrasted that with other lesions that are common in IBD, and we try to focus on things that we don't talk about as much.

We talked about, for instance, dermatitis herpetiformis associated with celiac disease. We talked about the incident rate, and how it's important even for populations considered low risk for celiac disease to make sure that we are thorough in our workup, because many African Americans do suffer from celiac disease.

The manifestations of dermatitis herpetiformis can be slightly different than the general population. It can be darker, it can be hyperpigmentation with central hypopigmentation, and we showed how, over time, those vesicles can lead to large patches of hypopigmented spots with hyperpigmentation around them.

This was then contrasted with acrodermatitis enteropathica, which is from a zinc deficiency, and its relationship to patients living with IBD. We talked about how to replace it, and how this particular mineral does not exist by itself in the body.

For instance, if we are treating someone for osteopenia or osteoporosis with calcium and vitamin D supplementation, and we're doing that with large volume, we can in turn cause a reflexive low zinc level because of the calcium. As we replace the zinc with zinc sulfate, this, in turn, can cause low levels of copper and iron. We have to monitor for toxicity closely.

Lastly, we talked about acute febrile neutrophilic dermatosis, or Sweet's syndrome, and illustrated how in people with different skin tones, that typically flat-red rash that comes across the chest in the textbooks can appear, even the dermatitis herpetiformis with vesicles, with ulcerations to mimic pyoderma gangrenosum, and can even have the reddish or purplish border of other lesions.

There's a lot of things to consider in terms of differential. Simply put, it's very important to have other members who can turn to other teams. Like we mentioned, working with the hospice nurse, working with dermatologists, and in the case of pyoderma, sometimes, working -- in our center -- with plastic surgery.

The point is that medicine should be inherently inclusive, and that we should work hard to make sure that all our patients who seek help, we are there and ready to assist them. That by actively going out looking for what pathology looks like in different types of skin, we can do a better job of recognizing it in the person sitting across from us.

Thank you very much for your time. It was a great conference, and I look forward to seeing everybody there next year.