Rheumatology and Dermatology: When to treat, when to refer
Featuring Jennifer Clarke, MD
Dr. Jennifer Clarke began Thursday’s SDPA conference with a comprehensive review of rheumatologic conditions for the dermatology provider. Dr. Clarke emphasized dermatology providers play a key role in the diagnosis of autoimmune disease through investigation of disease based on a constellation of systemic systems with the skin playing an important role.
Dr. Clarke spent a great deal of her lecture giving an excellent review of lupus. She explained when considering the diagnosis of lupus with patients, it is important to remember there is lupus specific skin disease and lupus non-specific skin disease. While lupus specific skin disease can be best diagnosed with a biopsy, lupus non-specific skin disease encompasses a heterogeneous group of skin findings or dermatoses that may occur in association with or at an increased frequency among patients with lupus. If you suspect a patient may have discoid cutaneous lupus, Dr. Clark conveyed identification of disease in the conchal bowl may be a clue to diagnosis.
While lupus specific skin disease can be best diagnosed with a biopsy, lupus non-specific skin disease encompasses a heterogeneous group of skin findings or dermatoses that may occur in association with or at an increased frequency among patients with lupus.
When considering a diagnosis of lupus in a patient, drug induced lupus must be ruled out. Among the long list of possible causes, two types of medications discussed specifically include PPIs and antifungals. Drug induced lupus is more common in white females over the age of 50. Onset can be weeks to years after initiation of medication. Typically, 6 weeks after discontinuing the medication, improvement occurs. Fortunately, the majority of lupus patients with skin disease do improve. Dr. Clarke stressed photoprotection should be a key part of counseling at every visit with a lupus patient. There may be up to a 3-week lag between sun exposure and skin flare.
Next, Dr. Clarke reviewed the typical presentation of dermatomyositis. In addition to the known heliotrope rash, central face and scalp edema and erythema may be noted. Other signs and symptoms include Gottron’s papules on DIP and dilated blood vessels at the proximal nail fold. It is critical to aggressively work up an internal malignancy in a patient who presents with dermatomyositis as up to 30% of adults will have a malignancy associated. This is highest within the first 3 years of diagnosis. Additionally, up to 20% of patients will have interstitial lung disease.
Further, Dr. Clarke reviewed local and systemic scleroderma. Management of patients with both local scleroderma and systemic sclerosis may involve working with physical and occupational therapy to maintain function. Treatment of linear scleroderma should be more aggressive and may include an ophthalmologic work up. Dr. Clarke concluded her lecture discussing vasculitis.