1. Dermatologist’s Role in Managing Psoriatic Arthritis Steven R. Feldman, MD, PhD Professor of Dermatology, Pathology & Public Health Sciences Wake Forest University School of Medicine Winston-Salem, North Carolina, USA

2. Background Psoriasis patients present to dermatologists for management of skin disease –These patients often have other symptoms –Joint prolems are the most common of these Dermatologists are becoming more aware of the need to query psoriasis patients about joint pain –Often unsure about the appropriate evaluation and management of this complaint.

3. Purpose To develop a practical guideline for dermatologists to manage joint pain in the setting of psoriasis Assumptions –Dermatologists are great at managing the skin disease –Rheumatologists know best about managing joints Rheumatologists are in a good position to tell us dermatologists what to do & what not to do

4. Methods We surveyed rheumatologists to determine their advice on role dermatologists can play in the evaluation & management of joint pain We asked from the perspective of the problems faced by dermatologists –What physical examinations should be done –What laboratory and x-ray evaluation –When to refer

5. Show the Survey Here

6. Results Should dermatologists ask patients about joint pain –Yes, absolutely Ask about –Joint pain & stiffness –Joint swelling (50%) –Family and personal history, nails, heels, Crohns, UC, eye inflammation, tendonitis (10- 20%) –Fatigue (60%)

7. Examine the Joints 90% said yes Document joints involved –50% document timing (day/night) –70% document duration –60% document relation to exercise –20% document relation to sleep –10% document relief with rest

8. Which Joints Only affected joints should be examined: 20% Examine hands/ feet on all Ps pts: 30% Complete GALS screening exam on all Ps pts: 40%

9. When to Refer? Refer any patient with any joint pain: 30% Only refer patients who at least have joint pain that is unrelieved by OTC NSAIDs: 30% Only refer patients who at least have joint swelling: 30% Only refer patients who have multiple swollen joints: 10% Only refer patients who have significant, disabling symptoms: 0%

10. When to Expedite Referral? Expedite referral of any patient with any joint pain: 0% Expedited referral for patients who at least have acute joint pain: 30% Expedited referral for patients who at least have joint swelling: 60% Only for patients who have multiple swollen joints or disabling sx: 10%

11. X-Rays & Lab Tests Dermatologists should not order labs/x- rays for PsA: 60% Xray sx joints: 30% Order labs to r/o infection or gout: 30%

12. Treatment of Psoriatic Arthritis Dermatologists should prescribe only NSAIDs for joint pain: 70% Derms can manage skin disease with DMARDs and see how joints respond: 10% Dermatologists should add MTX when NSAIDs don't work for joint sx: 10%

13. Asked Slightly Differently Nothing prescription: 10% NSAIDs only: 70% Add MTX if needed: 10% Use any DMARD as skin disease warrants: 10%

14. How to Use NSAID’s Try multiple NSAIDs: 20% 2 wks:30% At least 1mo :30%

15. Other Reasons for Referral Refer to rheumatologist for –Enthesitis –Tenosynovitis –Dactilitis Uveitis –60% said rheumatology –50% said ophthalmology

16. Etanercept for Joint Symptoms Derms should use to treat for joint sx: 10% Derms should use for skin disease and watch joint sx: 20% Derms should not use: 70% –I presume this means that dermatologists should not use it for psoriatic arthritis

17. Conclusions Rheumatologists seem confident in dermatologists’ ability to diagnose psoriatic arthritis –Perhaps NSAIDs are ok even if it isn’t psoriatic arthritis Dermatologists can treat with NSAID Beyond that, rheumatologists want to be involved Not all that different from how I would want rheumatologists to approach the skin involvement