QD 82 - Derm Alone Save

This is QD Clinic. I'm Jack Cush from RheumNow. QD Clinic is brought to you by RheumNow Live, a master class for the master rheumatologist. You can be there on March 13 in Fort Worth, roomnow.live to register. Today's case called Derm Alone, meant to be a little bit of a play on Home Alone.

You need to see the visual for that one. So what do I mean by DERMALONE? A 30 year old male comes in with psoriatic arthritis, having already been to the dermatologist comes to me to consider what his arthritis might be due to. There's a history of uveitis, there's enthesitis, there's an oligoarticular inflammatory arthritis, and yes, there's active psoriatic plaque and nail pitting and onycholysis. So the diagnosis is easy, and my stepping up and starting the patient on a biologic doesn't really matter whether it's a TNF inhibitor or an IL-seventeen inhibitor, IL-twenty three inhibitor, twelve twenty three inhibitor.

Whatever I did, it works, and it works really, really well. The question is, what's going to happen to the patient and their dermatologic care henceforth? How do you manage that? Do you take over the management of patients who have skin disease, and joint disease? And because you're the master biologic therapy person, then can you just manage the skin disease without the derm being involved?

Often the patient wants whoever is the one that helps them the most to manage the problem and they only want to go to one physician, but do they need to see two? Certainly, if it's all joints and very little skin and the skin goes away, there's not much reason to get the dermatologist, involved or is there? I tend more often than not to keep the dermatologist involved, one by getting copies of my notes just so they can see what's going on. But reasons why, and I'll give you a few, why you should send those patients back to the dermatologist for at least an annual visit would include mild to moderate skin or nail disease that might require other therapies other than the biologic. Topicals, I have no clue, they're all 0.1% ointments, creams, salves, poultices, God knows what it all is, and to me they all look the same and I don't want to have to refill not a one of them.

The extent of my topical steroid prescribing goes to one percent hydrocortisone cream from Walgreens. That's about it. So yeah, mild to moderate disease that may require topicals, maybe even Geckerman's therapy, UV therapy, or maybe even other therapies, it would be smart to have them involved. Secondly, there are some people who have really severe disease and are going to need the ongoing input. Remember, you're the low hanging fruit on the therapeutic challenge here.

Treating the joints is a whole lot easier than treating the skin. So, quite often, we'll do fabulous with whatever we do, but the skin is an incomplete responder, and they're gonna need more. So you'll need a good dermatologist to manage that. If the skin disease is still problematic and you're on aggressive therapy, combination therapies, and the derm doesn't know what to do, my advice is get a second opinion. Get another derm, maybe someone who's more skilled in medical dermatology and biologic therapy and psoriatic arthritis.

Maybe this isn't psoriatic arthritis. Maybe that's why you need a second opinion. But maybe the most important reason to send them back to the dermatologist is to continue that very strong relationship you have with the dermatologist in co managing these patients. In a perfect world, if you're like Eric Ruderman and others around the country, in Boston they have a combined clinic, Eric Ruderman has a combined clinic at Northwestern, dermatologists, rheumatologists getting together and all taking care of the patient in the same clinic. That would be ideal.

But you don't, you live in disparate locations, talk to each other rarely if ever, but you can talk to each other about these cases. Whether it's by phone, by text, by secure messaging, whatever, it fosters a really strong important relationship between you and the dermatologist that you may or may not need in the care of this particular psoriatic patient, but you may need in the future for another patient with another cutaneous articular condition that only the two of you can manage. I think that's a really smart approach. The other thing is of course to consider that the dermatologist will do the skin checks that you don't want to do. You know, doing skin checks means they got to get naked and you got to look at all their skin looking for moles and cancers.

If you don't really know this, the package insert for every TNF inhibitor says that patients on TNF inhibitors need to have annual skin exams done annually looking for skin cancer. I know you're not doing it if you're a dermatologist, and my patients on the table, God forbid, that they might have something serious going on. They sit in a chair and keep their clothes on for God's sakes. So sending them back to having a derm involved to do annual skin checks would be a really smart and important idea. That's it for this edition of QD Clinic.