Dermatologist’s Role in Managing Psoriatic Arthritis

1. 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

2. 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.

3. 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

4. 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

5. Show the Survey Here

6. 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 (10-20%) • Fatigue (60%)

7. 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

8. 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%

9. 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%

10. 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%

11. X-Rays & Lab Tests • Dermatologists should not order labs/x-rays for PsA: 60% • Xray sx joints: 30% • Order labs to r/o infection or gout: 30%

12. 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%

13. Asked Slightly Differently • Nothing prescription: 10% • NSAIDs only: 70% • Add MTX if needed: 10% • Use any DMARD as skin disease warrants: 10%

14. How to Use NSAID’s • Try multiple NSAIDs: 20% • 2 wks:30% • At least 1mo :30%

15. Other Reasons for Referral • Refer to rheumatologist for • Enthesitis • Tenosynovitis • Dactilitis • Uveitis • 60% said rheumatology • 50% said ophthalmology

16. 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

17. 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