The Journal of the Dermatology Nurses' Association has launched a series of articles focusing on dermatologic manifestations of rheumatic diseases. In an effort to improve knowledge and recognition by dermatology nurses of rheumatic conditions, it is hoped that this will improve patient outcomes. This series of articles is spearheaded by faculty and fellows of the Division of Rheumatology of the Loma Linda University in Loma Linda, California.
Many patients with dermatologic diseases have signs and symptoms that overlap with their rheumatologic diagnosis and vice versa. Some may initially present with skin manifestations in their rheumatic illness. Recognition of skin manifestations of rheumatic diseases leads to early detection of an underlying systemic or inflammatory condition (Firestein et al., 2017). Obtaining a history of dermatologic lesions and close physical examination of the skin are key components in the evaluation of various rheumatic diseases. Patients with psoriasis should be screened for inflammatory arthritis as about 20%–30% will develop psoriatic arthritis in their lifetime. Patients with lupus may present with various cutaneous complaints (rash, photosensitivity, mucosal lesions, alopecia, livedo). Patients with dermatomyositis may show characteristic rashes/lesions with or without muscle weakness. Systemic sclerosis presents with abnormal skin thickening, ulcers, and telangiectasias. Cutaneous and systemic vasculitis may present early with rashes and/or ulcers. Those with rheumatoid arthritis may develop rheumatoid nodules and other lesions.
A high suspicion for rheumatic disease can assist in deciding on who needs a skin biopsy and even in determining who needs a second biopsy for direct immunofluorescence. On some occasions, patients may present with cutaneous lesions consistent with lupus, despite having negative serologies. Skin biopsy of affected skin may show interface dermatitis or the lymphocytic infiltration of the dermal–epidermal junction (Kuhn & Landmann, 2014). Some conditions have no specific laboratory tests to confirm the diagnosis. Sarcoidosis is such and is proven by histopathology showing noncaseating granulomas (Sanchez et al., 2015). Vasculitis is a large group of disorders of which skin manifestations are also predominant. Antineutrophil-cytoplasmic-antibody-associated vasculitis is one of its subgroups and affects the small–medium blood vessels. Again, in some patients, laboratory tests may be negative. Vasculitis is confirmed by histopathology of affected tissue. Skin biopsy findings include the hallmark perivascular inflammatory infiltrates consisting of neutrophils with lymphocytes and eosinophils (Marzano et al., 2017).
It is also notable that side effects of medications used for both rheumatic and dermatologic conditions may present with cutaneous manifestations. Biologic medications especially tumor necrosis factor inhibitor agents used by specialists in both fields may lead to systemic side effects including drug-induced lupus (He & Sawalha, 2018), and infections (Koo et al., 2010). Tumor necrosis factor inhibitor agents are also associated with an increased risk for the development of certain skin cancers (Mariette et al., 2011). A regular screening for skin cancer is thus important. On the other hand, a general understanding of the nondermatologic side effects of drugs used by both specialties is useful. Corticosteroids and immunosuppressant medications may lead to adverse effects such as bone loss, infection, fatigue, and weakness, among others. When both rheumatologists and dermatologists have a recognition of these side effects, effort should be made to ensure that these are minimized and are screened for early on.
It is not uncommon for rheumatologists and dermatologists to work collaboratively. In many institutions, a combined dermatology–rheumatology clinic is an option for patients to obtain expedited and comprehensive care (Campagna et al., 2018). The partnership between rheumatologists and dermatologists sets the stage for an exchange of knowledge, improved systems of practice, and better care for the patient. Close coordination may lead to a simpler and safer yet more comprehensive therapy that would treat both the dermatologic and rheumatologic manifestations of the patient's disease. It opens better communication and relationship between the two specialties. As a result, referrals may be expedited and may cut down on delays to see specialists in either field of which there is a shortage of (Glazer et al., 2017; Kilian et al., 2019).
Most importantly, the overall goal is to improve patient outcomes. By having specialists in both fields appreciate that dermatologic manifestations of rheumatic diseases are a major component in the evaluation of such patients, patients benefit from a more cohesive approach to their care. Early detection of rheumatic diseases leads to better treatment outcomes, which in turn prevents irreversible damage and disability.
Campagna M., Castillo R., Mattessich S., Mandhadi R., Lu J. (2019). Impact of a combined dermatology–rheumatology clinic on management of autoimmune connective tissue disorders. Clinical and Experimental Dermatology
, 44(2), e24–e25. https://doi.org/10.1111/ced.13766
Firestein G. S., Gabriel S. E., Mcinnes I. B., O'dell J. R. (2017). Kelley and Firestein's textbook of rheumatology
. Elsevier. https://doi.org/10.1016/B978-0-323-31696-5.00070-X
Glazer A. M., Farberg A. S., Winkelmann R. R., Rigel D. S. (2017). Analysis of trends in geographic distribution and density of US dermatologists. JAMA Dermatology
, 153(4), 322. https://doi.org/10.1001/jamadermatol.2016.5411
He Y., Sawalha A. H. (2018). Drug-induced lupus erythematosus. Current Opinion in Rheumatology
, 30(5), 490–497. https://doi.org/10.1097/bor.0000000000000522
Kilian A., Upton L. A., Battafarano D. F., Monrad S. U. (2019). Workforce trends in rheumatology. Rheumatic Disease Clinics of North America
, 45(1), 13–26. https://doi.org/10.1016/j.rdc.2018.09.002
Koo S., Marty F. M., Baden L. R. (2010). Infectious complications associated with immunomodulating biologic agents. Infectious Disease Clinics of North America
, 24(2), 285–306. https://doi.org/10.1016/j.idc.2010.01.006
Kuhn A., Landmann A. (2014). The classification and diagnosis of cutaneous lupus erythematosus. Journal of Autoimmunity
, 48–49, 14–19. https://doi.org/10.1016/j.jaut.2014.01.021
Mariette X., Matucci-Cerinic M., Pavelka K., Taylor P., van Vollenhoven R., Heatley R., Walsh C., Lawson R., Reynolds A., Emery P. (2011). Malignancies associated with tumour necrosis factor inhibitors in registries and prospective observational studies: A systematic review and meta-analysis. Annals of the Rheumatic Diseases
, 70(11), 1895–1904. https://doi.org/10.1136/ard.2010.149419
Marzano A. V., Raimondo M. G., Berti E., Meroni P. L., Ingegnoli F. (2017). Cutaneous manifestations of ANCA-associated small vessels vasculitis. Clinical Reviews in Allergy & Immunology
, 53(3), 428–438. https://doi.org/10.1007/s12016-017-8616-5
Sanchez M., Haimovic A., Prystowsky S. (2015). Sarcoidosis. Dermatologic Clinics
, 33(3), 389–416. https://doi.org/10.1016/j.det.2015.03.006