Rheumatologist survey provides guidance on managing psoriatic arthritis

National report - Dermatologists should be routinely screening their psoriasis patients for psoriatic arthritis and may feel comfortable prescribing nonsteroidal anti-inflammatory drugs (NSAIDs) for modest joint complaints.

"Dermatologists play a critical role in identifying patients with psoriatic arthritis as well as an important part in their management, both directly and as a referral source, to make sure they seek specialist care when indicated. Therefore, dermatologists should be certain to ask psoriasis patients about problems with pain, stiffness and swelling in their joints, and have a low threshold for referring them to a rheumatologist if there are any signs of active inflammatory joint disease." Dr. Feldman says.

"It seemed the best way to delineate some management strategies was to gather the opinions of experts in this area rather than to poll dermatologists. The number of rheumatologists who completed the survey was not large. However, we felt the responses we had gave us a reasonable breadth of opinion," Dr. Feldman says.

Joint pain exam

The ten rheumatologists agreed uniformly that dermatologists should ask psoriasis patients about joint symptoms at all visits, and their responses also conveyed a consistent message that dermatologists should be recording historical information regarding onset, duration and association with exercise.

With one exception, the rheumatologists also consistently indicated that dermatologists should be performing a joint exam in patients who were experiencing symptoms. However, they were more divided in their opinions about how extensive that exam should be and if specialist referrals were indicated for all patients with joint complaints.

"I do not plan to incorporate a thorough joint exam into my psoriasis patient visits nor do I expect it is something that will be adopted by most dermatologists. However, it is important to evaluate patients for any acute joint swelling or disabling symptoms and recommend to those individuals that they promptly consult a rheumatologist," Dr. Feldman says.

Treat skin disease

Regarding treatment, there was a general consensus that dermatologists should select their intervention for the skin disease irrespective of any joint disease rather than let the joint symptoms guide treatment for the skin lesions.

The rheumatologists' opinions suggested that dermatologists should feel comfortable using an NSAID to manage modest joint symptoms, while if the psoriasis was severe enough to warrant use of a disease-modifying antirheumatic drug (DMARD), such as methotrexate or a biological, that treatment might simultaneously relieve the joint symptoms.

"Patients' care still needs to be individualized," Dr. Feldman says.

"In some locations, it may be more or less difficult for patients to access care from a rheumatologist."