Year : 2019 | Volume
: 3 | Issue : 1 | Page : 1--2
The rheumatodermatology interface
Smitha Prabhu1, Mukhyaprana M Prabhu2,
1 Department of Dermatology and Venereology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
2 Department of General Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
Mukhyaprana M Prabhu
Department of General Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka
Rheumatodermatology is an area of clinical medicine, wherein rheumatological and dermatological features dominate in various connective tissue disorders. It can occur as a systemic rheumatic disease where there is major skin manifestation, inflammatory arthropathies, or complications of immunological dysfunction caused by the rheumatological condition or of the immunosuppressants administered. There are also subtle skin signs of rheumatodermatological conditions which are apparent only to dermatologists and significant joint and internal involvement which may be diagnosed only by the rheumatologist. Hence, a liaison between these two specialties is advisable for optimal management of such diseases.
|How to cite this article:|
Prabhu S, Prabhu MM. The rheumatodermatology interface.Clin Dermatol Rev 2019;3:1-2
|How to cite this URL:|
Prabhu S, Prabhu MM. The rheumatodermatology interface. Clin Dermatol Rev [serial online] 2019 [cited 2019 May 23 ];3:1-2
Available from: http://www.cdriadvlkn.org/text.asp?2019/3/1/1/252307
Medicine is a vast specialty, hence the need to categorize and divide it into various branches, aimed at the ease of evaluation and treatment. This division, though convenient, is not natural, and diseases do not follow this artificial boundary, and hence can encroach upon varying specialties, pathologically as well as clinically.
Rheumatodermatology is one such interface, wherein rheumatological and dermatological features dominate in various connective tissue disorders.
Rheumatodermatology overlap can occur in the following scenarios:
A systemic rheumatic disease where there is major skin manifestation, e.g., systemic lupus erythematosus (SLE), dermatomyositis, and systemic sclerodermaInflammatory arthropathies, for example, psoriatic arthritis and rheumatoid arthritisComplications of immunological dysfunction caused by the rheumatological condition, or of the immunosuppressants administered, for example, cutaneous infection and cutaneous adverse drug reactions.
Some of these have cutaneous signs and symptoms as diagnostic features, especially diseases such as SLE, dermatomyositis, and scleroderma. Some have prominent rheumatological components such as rheumatoid arthritis and polyarthritis. Some diseases have combined cutaneous and joint manifestations.
Skin can also be the target of toxicity of drugs used in rheumatology, often at high and prolonged doses.
This union between rheumatology and dermatology is increasingly being recognized, and rheumatodermatology clinics are being established worldwide.
Rheumatodermatology interface is necessary as rheumatologists may not be well versed in diagnosing the less common dermatological manifestations of rheumatological diseases, and may be confounded by the nonspecific and unrelated cutaneous findings in their patients, whereas the dermatologist may be ill equipped to diagnose and manage subtle internal abnormalities and complications arising in due course. Often, the disease manifests with intimate and interrelated rheumatological and dermatological features, e.g.,, distal interphalangeal arthritis along with acral psoriasis.
A close association is also needed to monitor and manage the cutaneous adverse effects of many systemic drugs used in rheumatology.
The significance of dermatology rheumatology interface is exemplified by the following cases:
Psoriatic arthritis: In up to 42% people, cutaneous lesions and arthritis coexist, and often the patient is managed separately by a rheumatologist as well as a dermatologist for joint and skin symptoms, respectively. Up to 15% of psoriatic arthritis goes misdiagnosed. If the psoriatic cause for arthritis is not apparent to a rheumatologist, the patient may end up receiving systemic steroids or anti-tumor necrosis factor therapy which is detrimental to the cutaneous lesions. A single medication like methotrexate can cause improvement in both systems, and unless each practitioner is aware of the treatment given by the other, double dosing of the same drug, or additive toxicity by two different drugs, is a possibility. Rarely, drug given for one can worsen the other symptom, as exemplified by systemic corticosteroids leading to rebound psoriasis on withdrawal. Dermatologists usually avoid aggressive treatment with systemic immunosuppressants and immunomodulators, with a possibility of suboptimal treatment, whereas a rheumatologist can give more aggressive doses leading to early disease control.
SLE is a disease which can have a variety of presentations with varying degrees of involvement of dermatological, hematological, rheumatological, immunological, and other systems. Often, a skin biopsy and direct immunofluorescence test which detects the lupus band aids the immunological diagnosis. Photoprotection in SLE is must, not only in the treatment of malar and maculopapular rashes but also to contain system involvement. Advise on proper photoprotection and sunscreen usage is still in the domain of dermatologist. On the other hand, cutaneous LE is often treated only with photoprotection and hydroxychloroquine, which may not be sufficient to control the systemic involvement. A rheumatologist is of use to interpret the various immunological tests and detect organ involvement at the earliest, to contain further ravage of the body and immune system.
This scenario stresses upon the importance of the two specialties working in tandem for optimal patient care.
A dermatologist can often help the rheumatologist in diagnosing and differentiating subtle skin signs of connective tissue diseases. To the inexperienced eye, rosacea may mimic butterfly rash of SLE and minimal heliotrope rash in the dark-skinned suggestive of dermatomyositis; mild sclerodactyly and nail fold capillary changes suggestive of scleroderma can be missed, thus leading to a misdiagnosis of polyarthritis instead of arthritis associated with respective connective tissue disease. A rheumatologist often helps a dermatologist in treating difficult disease scenarios.
Interdisciplinary coordination between dermatology and rheumatology is, thus, established as norm of the day. This interface clinic will help in reducing mortality, morbidity, as well as disability in rheumatology patients, as the patient will have access to specialists without the lag period between consultations and referrals. Treatment guidelines can be standardized, and treatment-associated morbidity can be considerably reduced.
Rheumatodermatology can further be strengthened by establishing liaison clinics and conducting continuing medical education programs as a combined venture by rheumatologists as well as dermatologists.
Integrated patient care is the norm of the day; patients as well as physicians will benefit from rheumatodermatology clinic which can address patient concerns and treatment issues effectively.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
|1||Mallia C. The interface between rheumatology and dermatology. Why rheumaderm? Adv Exp Med Biol 1999;455:1-6.|
|2||Jagadeesan S, Shenoy P. Arthropathy in dermatology: A Comprehensive review. Indian Dermatol Online J 2017;8:79-93.|
|3||Samycia M, McCourt C, Shojania K, Au S. Experiences from a combined dermatology and rheumatology clinic: A Retrospective review. J Cutan Med Surg 2016;20:486-9.|
|4||Sasaki JL, Koo JY. Skin therapies: Dermatologic perspective on the rheumatology-dermatology interface. Clin Exp Rheumatol 2015;33:S78-81.|
|5||D. Caceres V. Tips that Dermatologists want Rheumatologists to know. The Rheumatologist; 02 November, 2014. Available from: https://www.the-rheumatologist.org/article/7-tips-that-dermatologists-want-rheumatologists-to-know/(internet). [Last accessed on 2018 Jul 30].|