Dermatologists may diagnose and treat patients with conditions that span a variety of specialties, but rheumatology is at the top of the crossover list, says dermatologist Mark Lebwohl, MD, professor and system chair, dermatology, Mount Sinai Medical Center, New York.
Rheumatologists and dermatologists usually don’t hesitate to refer to each other as needed, says rheumatologist Kelly Weselman, MD, WellStar Medical Group, Smyrna, Ga. “There’s no reluctance to think about each other. It’s always nice to keep the lines of communication open,” she says.
The crossover reaches into three main areas, says rheumatologist Susan M. Goodman, MD, an associate attending physician at the Hospital for Special Surgery in New York. First, there’s systemic rheumatic disease with major skin manifestations, such as systemic lupus erythematosus (SLE), dermatomyositis and scleroderma. Seventy percent of SLE patients will have a rash at some point, Dr. Goodman says. The other conditions can lead a patient to develop inflammatory skin features.
Next, there are inflammatory joint diseases, in which psoriatic arthritis emerges as the most prominent. “As many as 30% of patients attending a psoriasis clinic have evidence of psoriatic arthritis when systematically examined. In these conditions where systemic features may be prognostically significant, a collaborative approach is optimal,” Dr. Goodman says. There’s also rheumatoid arthritis, in which leg ulcers or splinter hemorrhages can indicate vasculitis as a complication of the disease, Dr. Goodman says.
Finally, infections can present with a rash that is a complication from a disordered immune system of the rheumatic diseases or because of the immunosuppressant medications used to treat these illnesses, Dr. Goodman added.
Rheumatologists and dermatologists also work collaboratively on skin biopsies, says rheumatologist Alan Baer, MD, director, Johns Hopkins Jerome L. Greene Sjögren’s Syndrome Center, Johns Hopkins University School of Medicine, Baltimore. “Skin biopsies may be required for the definitive diagnosis of certain skin eruptions seen in the context of rheumatic disease, and these are often done by the dermatologist, although they can be done by rheumatologists if they have the expertise,” he says.
The crossover between rheumatology and dermatology doesn’t stop with patient care, Dr. Lebwohl says. The two specialties even align from time to time on regulatory agendas. “It’s smart for us to work together on things like HIPAA, the Sustainable Growth Rate fix and other political issues,” he says.
Even with the natural collaboration, there are still pearls rheumatologists can follow to improve care when patients have dermatological symptoms.
7 Tips from Dermatologists
1. Aim for collaborative care—and education—when possible. Dermatologist and rheumatologist Joseph F. Merola, MD, Brigham and Women’s Hospital, and instructor, Harvard Medical School, Boston, has heard of more academic medical centers combining rheumatology and dermatology care in one area, enabling patients to get one-stop, holistic care, which he says that patients love. “It also opens up a lot of other opportunities for crosspollination between the fields,” he says.
Although combined clinics may not be possible in all settings, Dr. Merola also encourages collaborative education between the two specialties, be it at the medical school level, during fellowships, or during conferences, where a dermatologist may be invited to a rheumatology conference to discuss cases—or vice versa. Dr. Merola spoke of a fellowship program at his organization that gives experience in both specialties. “It’s a one-year training opportunity to increase one’s skills and comfort level with the other specialty. That’s been a unique way to educate as well,” he says.
At Mt. Sinai, Dr. Lebwohl says they are hiring a rheumatologist who would complete a dermatology residency, to help address issues from both specialties.
Dermatologist Delphine Lee, MD, PhD, director of translational immunology, Dirks/Dougherty Laboratory for Cancer Research, the John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, Calif., believes that collaborative care between the two fields is the right approach to properly guide patients in their treatment decisions. For example, if she is considering biologic or systemic therapy for a patient, she’ll first discuss it with their primary physician, who might be a rheumatologist. “I like to get a consensus,” she says.
Both rheumatologists and dermatologists can talk to patients about other risks they should monitor for, such as cardiovascular disease or watching their weight, particularly for psoriasis patients at risk for metabolic syndrome, Dr. Lee adds.
2. Find a dermatologist who enjoys handling tougher cases, Dr. Lee advises. She says there’s a perception of dermatologists focusing more on acne, Botox injections or other more cosmetic aspects of care. However, some dermatologists specialize in complex medical dermatology; finding such a person for your referrals will benefit everyone, she says.
3. Don’t overuse oral steroids in psoriasis patients. “In dermatology, we sometimes see the effects of prednisone leading to psoriasis flares,” Dr. Merola says. Systemic steroids can cause psoriasis to become unstable, especially when the oral steroid dose is lowered, Dr. Lebwohl says. “I think every dermatologist has had a harder time treating psoriasis because of steroid use, but I wouldn’t say this was a mistake on the rheumatologist’s part, [because] their reason for using it was correct,” he says. He says other options to use instead include methotrexate, nonsteroidal antiinflammatory drugs, and biologics.
4. Get comfortable with topical steroids. “For patients who are mostly but not completely clear on systemic medications, such as anti-tumor necrosis factor drugs, it would be helpful for a rheumatologist to also use adjunctive therapy like topical steroids to get the patient’s skin more comfortable and clear without having to wait to see a dermatologist,” Dr. Merola says.
Kaleroy Papantoniou, MD, Advanced Dermatology, with various locations in New York and New Jersey, also encourages rheumatologists to get more comfortable with the use of topical steroids when indicated. Class 1 or 2 topical steroids can help obtain better disease control, she says. “A good tip is to alternate your treatments to include corticosteroid-sparing agents, such as topical pimecrolimus and calcipotriene in the treatment of psoriasis,” she says. “Using these steroid-sparing agents on weekdays with the use of pulse topical steroids limited to the weekend can also help lower the risk for side effects.”
5. Refer to dermatologists when your patients might need more time to address their skin treatment, suggests Dr. Papantoniou. “Rheumatologists may not have extra time to discuss details of a skin regimen,” she says. “Also, in the office we can incorporate intralesional injections and phototherapy, which are often potent and can spare the patient from needing systemic medications or help lower the dosages for those already treated with systemics.”
6. Be thoughtful in your referrals to dermatologists. The experts interviewed all agreed that collaboration is helpful. However, also consider how long it might take the patient to be able to see a busy dermatologist, Dr. Merola says. That’s why he advocates rheumatologists getting more comfortable with topical therapy.
Dr. Goodman refers to a dermatologist any patient with disease manifestations who would benefit from focused local therapy, such as intralesional corticosteroids for alopecia or discoid lupus, or phototherapy for psoriasis.
“More importantly, I refer when the skin manifestation may not be related to the underlying diagnosis and may represent a complication, such as infection,” Dr. Goodman says. A dermatologist’s input is particularly valuable on varicella in an immunosuppressed patient or for skin cancer detection, because certain rheumatological medications require surveillance for skin cancer, she adds.
If a rash is questionable, it’s easier to have a dermatologist take a look or do a tissue biopsy if necessary, Dr. Weselman says. However, she wishes skin specialists would be more willing to readily perform biopsies with direct immunofluorescence; she finds it takes a couple of phone calls to get done.
A referral to a dermatologist—be it from a rheumatologist or any other specialty—can sometimes help patients stop various treatments that might be inappropriate and get on a clearer, simpler treatment course, Dr. Lee says.
7. Use technology to your advantage. If you have an electronic health record that you share with other specialists, insert photos of a skin manifestation that you want examined, Dr. Merola advises. This will help the dermatologist take a quick look, although an in-person examination will likely still be needed, Dr. Lee says.
Vanessa Caceres is a medical writer in Bradenton, Fla.
