A 25 year-old female recently diagnosed with seronegative rheumatoid arthritis was started on a TNF inhibitor. She came in for a follow-up visit and noted that her toenails were brittle and discolored when she removed her nail polish recently. She is concerned that she may have psoriasis or that this may be a side effect of the TNF inhibitor.
What is your next step?
A. The patient has psoriatic arthritis and not rheumatoid arthritis; change the ICD10 code.
B. Get a nail scraping, this is likely a dermatophyte.
C. Reassure her and continue therapy as TNF-inhibitor induced toenail psoriasis is not an issue.
D. Reassure her and have her use a basecoat before applying the polish.
If you answered “D”, you are practicing Lipstick Rheumatology. Many nail polishes contain pigments that can discolor the nail, and those with formaldehyde can cause the nails to be yellow and brittle. The rule of thumb is to apply a basecoat to the nail before applying the polish. Hence, there’s no need to blame the TNF inhibitor or change the diagnosis!
Lipstick Rheumatology is an emerging subspecialty. It recognizes real complaints, unique to female patients with rheumatic disease, and underscores the need to educate our male colleagues on issues that are unique to a woman’s life—after all, the majority of patients are women.
Lipstick Rheumatology is represented in the classic board exam question:
“A woman just had a baby and is now complaining of bilateral hand swelling and tingling, what is your diagnosis?”
The obvious answer is carpal tunnel syndrome for reasons most women recognize: when holding a baby, the wrist is flexed and can stay flexed for extended periods of time, trapping the median nerve. Extensive testing is not needed, only carpal tunnel splints and involving others in the care of the infant. (Editor's note: another common cause here would be also deQuervain’s tenosynovitis, for the same reasons).
In another case, I spoke with a 45 year old female lupus patient with iron-deficiency anemia. I asked this steak-loving Texan if she had bloody or black stools or if her menstrual cycles had been heavy or prolonged. She answered in the negative to both questions. I was a bit puzzled since her iron intake should be adequate and there is no significant, obvious blood loss. I pressed her further on her menstrual cycle by asking how many pads she uses a day. She noted that she normally has to use 3 pads a day for 5 days, which is typical. I was still not satisfied with the answer and asked her if she used tampons with the pads. She noted that she does—typically the pads are to catch the extra menstrual blood from the tampon. She noted that pads would need changing about 3 times a day, which she thought was normal.
I doubt that my male colleagues would have pushed further beyond the first 2 questions, perhaps referring her to the GI specialist to look for an occult bleed instead of a gynecologist.
Do women in rheumatology have an advantage over their male counterparts, especially since the majority of our patients are women? The workforce statistics show that our previously male-dominated rheumatology workforce will undergo significant changes, as the next 10 years will see a wave of older males retiring and being replaced with incoming rheumatologists who will be predominantly young women.
I always wanted to have an Elle Woods like moment. Elle Woods (played by Resse Witherspoon) was the lead character in the 2001 movie, Legally Blonde. At the movie's climax she discovered the identity of the killer and exonerated her client with the rhetorical question, “ Because isn't the first cardinal rule of perm maintenance that you're forbidden to wet your hair for at least 24 hours after getting a perm at the risk of deactivating the ammonium thioglycolate?"
Change is upon us.