Once upon a time there was a rheumatologist who was treating a patient with psoriatic arthritis. This rheumatologist was well trained in internal medicine and rheumatology and was dedicated to providing patients the best possible medical care.
The patient came in for treatment of joint stiffness. It was worse in the mornings, and there was a personal and family history of psoriasis. A careful physical examination revealed no signs of any joint swelling, tenderness or inflammation. Range of motion was completely normal. X-rays had been taken and they showed no signs of joint damage. The rheumatologist made the diagnosis of psoriatic arthritis. Given that the patient had no signs of progressive or debilitating arthritis, the rheumatologist decided to start the patient on a non-steroidal anti-inflammatory drug (NSAID).
Just before the rheumatologist was about to say goodbye, the patient mentioned having a rash on the elbows. The rash was red and scaly, and while the rheumatologist did not have much skill in diagnosing and managing skin disease, it was clear that there were two patches of psoriasis.
The rheumatologist was aware of the tremendous impact psoriasis can have on patients’ lives. The rheumatologist also knew that the NSAID would not help the skin disease. Wanting to help with both the skin and the joints, the rheumatologist decided to prescribe a TNF inhibitor, confident that the TNF inhibitor would likely treat both the joint symptoms and the skin disease.
The Best Treatment?
Do dermatologists think it is appropriate for rheumatologists to treat patients with a TNF inhibitor because of very limited skin disease when the joints would otherwise be managed with more conservative treatment?
Probably not.
If the rheumatologist had all of the skills of a dermatologist in assessing the skin, could make an accurate diagnosis of psoriasis (versus a host of potential mimics), and knew all the variations and nuances of topical, photo and systemic treatments, the rheumatologist probably could manage all aspects of the disease; otherwise, the rheumatologist should probably treat the joints
as he or she normally would and let the dermatologist manage whatever psoriasis was left . While we would applaud the rheumatologist for doing his or her best to provide terrific comprehensive medical care to save the patient from needless extra office visits, we probably wouldn’t want rheumatologists to use a TNF inhibitor when a topical corticosteroid would likely treat the skin component.
We dermatologists share the commitment to provide the best possible medical care. We, too, would love to save patients unnecessary visits and to take care of their joints when they come see us for their psoriasis. However, should the presence of limited joint disease make us use a TNF inhibitor when we might otherwise treat the skin with topicals or phototherapy?
Co-Managing Psoriatic Arthritis Patients
Psoriatic arthritis is very common in our psoriasis patients. Psoriatic arthritis can be destructive and progressive, and TNF inhibitors offer an extraordinary advance in our ability to control the disease. We should remember, though, that many patients with psoriatic arthritis do not have progressive disease and can often be treated with more conservative options. Choosing which patients need a TNF inhibitor for their joints is not entirely straightforward, requiring a detailed musculoskeletal examination, range of motion testing and radiologic studies.
We sometimes see patients whose skin disease clearly requires TNF treatment. These patients may have psoriatic arthritis, too. Do these patients need to see a rheumatologist if we’ve started them on a TNF inhibitor?
TNF inhibitors “prevent joint destruction.” This has been dramatically demonstrated in large clinical trials. However, while most subjects in those trials do not have progression (and on average there may be no progression at all in patients treated with TNF inhibitors), a subset of patients do have progression despite TNF inhibitor treatment.
Having the patient on a TNF inhibitor is not enough, even if the joint symptoms improve. Detailed physical examination of the joints and radiologic studies are essential to assess whether joint progression has been controlled. If there is still progressive disease, TNF inhibitor dose modification and/or treatment with different or additional agents (such as methotrexate, sulfasalazine, plaquenil or prednisone) may be needed.
Two is Better Than One
Dermatologists play a critical role in the evaluation and management of psoriatic arthritis. We should be screening for arthritis in all our psoriasis patients. By doing so, dermatologists can help identify, arrest, and even prevent debilitating joint destruction.
Rheumatologists and dermatologists should collaborate in the management of patients with psoriatic arthritis. Both specialties bring an expertise to the management of the disease not replaced by the other. Perhaps in an ideal world there would be psoriasis/
psoriatic arthritis clinics where patients could see both a rheumatologist and a dermatologist on the same visit. When we detect
psoriatic arthritis, we ought to encourage involvement with a rheumatologist to evaluate whether there is progressive disease and to treat accordingly.
Once upon a time there was a rheumatologist who was treating a patient with psoriatic arthritis. This rheumatologist was well trained in internal medicine and rheumatology and was dedicated to providing patients the best possible medical care.
The patient came in for treatment of joint stiffness. It was worse in the mornings, and there was a personal and family history of psoriasis. A careful physical examination revealed no signs of any joint swelling, tenderness or inflammation. Range of motion was completely normal. X-rays had been taken and they showed no signs of joint damage. The rheumatologist made the diagnosis of psoriatic arthritis. Given that the patient had no signs of progressive or debilitating arthritis, the rheumatologist decided to start the patient on a non-steroidal anti-inflammatory drug (NSAID).
Just before the rheumatologist was about to say goodbye, the patient mentioned having a rash on the elbows. The rash was red and scaly, and while the rheumatologist did not have much skill in diagnosing and managing skin disease, it was clear that there were two patches of psoriasis.
The rheumatologist was aware of the tremendous impact psoriasis can have on patients’ lives. The rheumatologist also knew that the NSAID would not help the skin disease. Wanting to help with both the skin and the joints, the rheumatologist decided to prescribe a TNF inhibitor, confident that the TNF inhibitor would likely treat both the joint symptoms and the skin disease.
The Best Treatment?
Do dermatologists think it is appropriate for rheumatologists to treat patients with a TNF inhibitor because of very limited skin disease when the joints would otherwise be managed with more conservative treatment?
Probably not.
If the rheumatologist had all of the skills of a dermatologist in assessing the skin, could make an accurate diagnosis of psoriasis (versus a host of potential mimics), and knew all the variations and nuances of topical, photo and systemic treatments, the rheumatologist probably could manage all aspects of the disease; otherwise, the rheumatologist should probably treat the joints
as he or she normally would and let the dermatologist manage whatever psoriasis was left . While we would applaud the rheumatologist for doing his or her best to provide terrific comprehensive medical care to save the patient from needless extra office visits, we probably wouldn’t want rheumatologists to use a TNF inhibitor when a topical corticosteroid would likely treat the skin component.
We dermatologists share the commitment to provide the best possible medical care. We, too, would love to save patients unnecessary visits and to take care of their joints when they come see us for their psoriasis. However, should the presence of limited joint disease make us use a TNF inhibitor when we might otherwise treat the skin with topicals or phototherapy?
Co-Managing Psoriatic Arthritis Patients
Psoriatic arthritis is very common in our psoriasis patients. Psoriatic arthritis can be destructive and progressive, and TNF inhibitors offer an extraordinary advance in our ability to control the disease. We should remember, though, that many patients with psoriatic arthritis do not have progressive disease and can often be treated with more conservative options. Choosing which patients need a TNF inhibitor for their joints is not entirely straightforward, requiring a detailed musculoskeletal examination, range of motion testing and radiologic studies.
We sometimes see patients whose skin disease clearly requires TNF treatment. These patients may have psoriatic arthritis, too. Do these patients need to see a rheumatologist if we’ve started them on a TNF inhibitor?
TNF inhibitors “prevent joint destruction.” This has been dramatically demonstrated in large clinical trials. However, while most subjects in those trials do not have progression (and on average there may be no progression at all in patients treated with TNF inhibitors), a subset of patients do have progression despite TNF inhibitor treatment.
Having the patient on a TNF inhibitor is not enough, even if the joint symptoms improve. Detailed physical examination of the joints and radiologic studies are essential to assess whether joint progression has been controlled. If there is still progressive disease, TNF inhibitor dose modification and/or treatment with different or additional agents (such as methotrexate, sulfasalazine, plaquenil or prednisone) may be needed.
Two is Better Than One
Dermatologists play a critical role in the evaluation and management of psoriatic arthritis. We should be screening for arthritis in all our psoriasis patients. By doing so, dermatologists can help identify, arrest, and even prevent debilitating joint destruction.
Rheumatologists and dermatologists should collaborate in the management of patients with psoriatic arthritis. Both specialties bring an expertise to the management of the disease not replaced by the other. Perhaps in an ideal world there would be psoriasis/
psoriatic arthritis clinics where patients could see both a rheumatologist and a dermatologist on the same visit. When we detect
psoriatic arthritis, we ought to encourage involvement with a rheumatologist to evaluate whether there is progressive disease and to treat accordingly.
Once upon a time there was a rheumatologist who was treating a patient with psoriatic arthritis. This rheumatologist was well trained in internal medicine and rheumatology and was dedicated to providing patients the best possible medical care.
The patient came in for treatment of joint stiffness. It was worse in the mornings, and there was a personal and family history of psoriasis. A careful physical examination revealed no signs of any joint swelling, tenderness or inflammation. Range of motion was completely normal. X-rays had been taken and they showed no signs of joint damage. The rheumatologist made the diagnosis of psoriatic arthritis. Given that the patient had no signs of progressive or debilitating arthritis, the rheumatologist decided to start the patient on a non-steroidal anti-inflammatory drug (NSAID).
Just before the rheumatologist was about to say goodbye, the patient mentioned having a rash on the elbows. The rash was red and scaly, and while the rheumatologist did not have much skill in diagnosing and managing skin disease, it was clear that there were two patches of psoriasis.
The rheumatologist was aware of the tremendous impact psoriasis can have on patients’ lives. The rheumatologist also knew that the NSAID would not help the skin disease. Wanting to help with both the skin and the joints, the rheumatologist decided to prescribe a TNF inhibitor, confident that the TNF inhibitor would likely treat both the joint symptoms and the skin disease.
The Best Treatment?
Do dermatologists think it is appropriate for rheumatologists to treat patients with a TNF inhibitor because of very limited skin disease when the joints would otherwise be managed with more conservative treatment?
Probably not.
If the rheumatologist had all of the skills of a dermatologist in assessing the skin, could make an accurate diagnosis of psoriasis (versus a host of potential mimics), and knew all the variations and nuances of topical, photo and systemic treatments, the rheumatologist probably could manage all aspects of the disease; otherwise, the rheumatologist should probably treat the joints
as he or she normally would and let the dermatologist manage whatever psoriasis was left . While we would applaud the rheumatologist for doing his or her best to provide terrific comprehensive medical care to save the patient from needless extra office visits, we probably wouldn’t want rheumatologists to use a TNF inhibitor when a topical corticosteroid would likely treat the skin component.
We dermatologists share the commitment to provide the best possible medical care. We, too, would love to save patients unnecessary visits and to take care of their joints when they come see us for their psoriasis. However, should the presence of limited joint disease make us use a TNF inhibitor when we might otherwise treat the skin with topicals or phototherapy?
Co-Managing Psoriatic Arthritis Patients
Psoriatic arthritis is very common in our psoriasis patients. Psoriatic arthritis can be destructive and progressive, and TNF inhibitors offer an extraordinary advance in our ability to control the disease. We should remember, though, that many patients with psoriatic arthritis do not have progressive disease and can often be treated with more conservative options. Choosing which patients need a TNF inhibitor for their joints is not entirely straightforward, requiring a detailed musculoskeletal examination, range of motion testing and radiologic studies.
We sometimes see patients whose skin disease clearly requires TNF treatment. These patients may have psoriatic arthritis, too. Do these patients need to see a rheumatologist if we’ve started them on a TNF inhibitor?
TNF inhibitors “prevent joint destruction.” This has been dramatically demonstrated in large clinical trials. However, while most subjects in those trials do not have progression (and on average there may be no progression at all in patients treated with TNF inhibitors), a subset of patients do have progression despite TNF inhibitor treatment.
Having the patient on a TNF inhibitor is not enough, even if the joint symptoms improve. Detailed physical examination of the joints and radiologic studies are essential to assess whether joint progression has been controlled. If there is still progressive disease, TNF inhibitor dose modification and/or treatment with different or additional agents (such as methotrexate, sulfasalazine, plaquenil or prednisone) may be needed.
Two is Better Than One
Dermatologists play a critical role in the evaluation and management of psoriatic arthritis. We should be screening for arthritis in all our psoriasis patients. By doing so, dermatologists can help identify, arrest, and even prevent debilitating joint destruction.
Rheumatologists and dermatologists should collaborate in the management of patients with psoriatic arthritis. Both specialties bring an expertise to the management of the disease not replaced by the other. Perhaps in an ideal world there would be psoriasis/
psoriatic arthritis clinics where patients could see both a rheumatologist and a dermatologist on the same visit. When we detect
psoriatic arthritis, we ought to encourage involvement with a rheumatologist to evaluate whether there is progressive disease and to treat accordingly.
