How Dermatologists Can Help Address Gaps in the Diagnosis of Psoriatic Arthritis

It has been recommended that treatment with TNF-α blockers continue to prevent worsening of concurrent inflammatory disorders while aggressively treating the skin lesions with dermatologic pharmacotherapies, and alternative TNF-α blockers should only be considered if this treatment approach does not improve the skin lesions.2  If a TNF-α blocker must be discontinued, it is recommended that another systemic therapy be initiated for psoriasis during the transition.2 

A 2014 consensus report by a multidisciplinary group of rheumatologists, dermatologists, and epidemiologist in Spain recommends that “any patient who develops paradoxical psoriasis should be referred to a dermatologist for confirmation of the diagnosis and optimal management of the skin lesions.”7

As for dermatologists’ screening of patients for PsA, tools like the Psoriasis and Arthritis Screening Questionnaire (PASQ), the Psoriasis Epidemiology Screening Tool (PEST), and the Toronto Psoriatic Arthritis Screen (ToPAS) may be helpful, though results pertaining to their utility have been mixed.8 It may be more valuable for dermatologists to simply look for certain signs indicating the need for referral to a rheumatologist. 

In response to a questionnaire on the topic, rheumatologists recommended that dermatologists ask patients with psoriasis about joint pain, stiffness, swelling, and fatigue to evaluate for PsA, and that they refer to a rheumatologist if patients show signs of inflammatory joint disease that were not eased by the use of nonsteroidal antiinflammatory drugs. In addition, they recommended referral for patients with disabling joint symptoms, other causes of joint pain, or those who show no improvement with disease modifying agents.9 

Summary and Clinical Applicability

Rheumatologists are encouraged to seek opportunities to educate their colleagues in dermatology on potential signs of PsA that should cue referral, and to develop ongoing collaborative relationships with them to enhance the ongoing care of shared PsA patients. 

Rheumatologists are encouraged to share their expertise with dermatologists, to improve understanding of the clinical spectrum of PsA among dermatologists and to facilitate decisions about referral.10 Interaction between the two specialities can also facilitate the creation of multidisciplinary teams for more effective management of complex cases, which have been shown to greatly improve patient outcomes and satisfaction.11

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References

1.       Gottlieb A, Korman NJ, Gordon KB, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 2. Psoriatic arthritis: overview and guidelines of care for treatment with an emphasis on the biologics. J Am Acad Dermatol. 2008; 58(5):851-64.

2.       Sasaki JL, Koo JY.  Skin therapies: dermatologic perspective on the rheumatology-dermatology interface. Clin Exp Rheumatol. 2015; 33(5 Suppl 93):S78-81.

3.       Villani AP, Rouzaud M, Sevrain M, et al. Prevalence of undiagnosed psoriatic arthritis among psoriasis patients: Systematic review and meta-analysis. J Am Acad Dermatol. 2015; 73(2):242-8.

4.       Mease PJ, Gladman DD, Papp KA, et al. Prevalence of rheumatologist-diagnosed psoriatic arthritis in patients with psoriasis in European/North American dermatology clinics. J Am Acad Dermatol. 2013; 69(5):729-35.

5.       Richard MA, Barnetche T, Rouzaud M, et al. Evidence-based recommendations on the role of dermatologists in the diagnosis and management of psoriatic arthritis: systematic review and expert opinion. J Eur Acad Dermatol Venereol. 2014; 28 Suppl 5:3-12.

6.       Migliore A, Cusano F, Bianchi G, Malara G, Epis O, De Pità O. Management of psoriatic arthritis: should the interaction between dermatologists and rheumatologists in clinical practice be intensified? J Biol Regul Homeost Agents. 2015; 29(3):547-61.

7.       Cañete JD, Daudén E, Queiro R, et al. Recommendations for the coordinated management of psoriatic arthritis by rheumatologists and dermatologists: a Delphi study. Actas Dermosifiliogr. 2014; 105(3):216-32.

8.       Mease PJ, Gladman DD, Helliwell P, et al. Comparative performance of psoriatic arthritis screening tools in patients with psoriasis in European/North American dermatology clinics. J Am Acad Dermatol. 2014; 71(4):649-55.

9.       Taylor SL, Petrie M, O’Rourke KS, Feldman SR. Rheumatologists’ recommendations on what to do in the dermatology office to evaluate and manage psoriasis patients’ joint symptoms. J Dermatolog Treat. 2009; 20(6):350-3.

10.    Betteridge N, Boehncke WH, Bundy C, Gossec L, Gratacós J, Augustin M. Promoting patient-centred care in psoriatic arthritis: a multidisciplinary European perspective on improving the patient experience. J Eur Acad Dermatol Venereol. 2016; 30(4):576-85.

11.    Cobo-Ibáñez T, Villaverde V, Seoane-Mato D, et al. Multidisciplinary dermatology-rheumatology management for patients with moderate-to-severe psoriasis and psoriatic arthritis: a systematic review. Rheumatol Int. 2016; 36(2):221-9.