Among the extraintestinal manifestations of inflammatory bowel disease (IBD), skin conditions are second only to arthritis in how often they affect patients. The Crohn’s & Colitis Foundation of America estimates that about 5% of patients with IBD experience some type of dermatologic complication.
The Advances in Inflammatory Bowel Diseases (AIBD) 2020 virtual meeting last month featured a discussion entitled “IBD Is More Than Skin Deep,” in which the panel members discussed the presentation, diagnosis, and treatment of dermatological conditions among patients with IBD.
Among those panelists was Jason Schairer, MD, associate program director of gastroenterology fellowship for the Henry Ford Health System in Detroit, Michigan. Following the meeting, the Autoimmune Learning Network caught up with Dr Schairer to ask him more about the topic.
AUTOIMMUNE LEARNING NETWORK: How common is it for patients with IBD to develop skin disorders, including oral lesions?
Jason Schairer: Skin and oral lesions can come from a wide range of causes. They can be related to IBD activity such as erythema nodosum, pyoderma gangrenosum, and Sweet syndrome. There are also Melkerssen-Rosenthal syndrome and nutritional deficiencies. Comorbid autoimmune conditions such as eczema, psoriasis, and hidradenitis suppurativa (HS) occur more often among people living with IBD. Medication side effects such as paradoxical psoriasis and serum sickness can also occur. Each of these happens among a small percentage of people living with IBD, but cumulatively it is common to have dermatologic issues. By recognizing conditions and their etiology, the physician can help the patient get well sooner and find the best regimen for them.
ALN: What should a practicing gastroenterologist look for when examining a patient with IBD for signs of dermatologic manifestations?
JS: It would be nice to say that a full skin examination is part of a complete office physical examination, but to be frank, there is not enough time in a visit to accomplish everything. It is reasonable to ask each patient if there are any rashes and perform a targeted examination if needed.
The key features are 1) location, 2) morphology, and 3) associated symptoms. The familiar lesions are the familiar lesions display pathergy with rapidly expanding borders, such as pyoderma gangrenosum, and the pretibial raised, tender, and red lesions of erythema nodosum. It should be noted that erythema nodosum may have started to resolve and after several days appears as flat bruises.
Rashes that are on the extensor surfaces of the arm, macular, and have a silver scale may reflect psoriasis. Macular rashes on the upper chest and back may suggest Sweet syndrome. Itching, bullae, pain, swelling, and pathergy are other important features of which to make note.
HS may resemble cutaneous Crohn of the perineal and vulvar region. Key distinguishing features would include lesions in the axilla or under the breast, which favor HS, and the typical “knife like” lesions of Crohn.
ALN: What’s the first thing you would suggest a gastroenterologist should do if a patient with IBD shows dermatologic symptoms?
JS: Luckily we can leverage technology in 2021 to help people sooner. I ask patients to take a picture with their smart phone of the rash. It needs to be in focus and with good lighting. Then they can upload it into the electronic medical record or email it to the clinic. Often that is enough to start the process.
First, I think locally and systemically. Locally, the lesion may require biopsies, topical steroids, or injections of steroids. Systemically, they may need therapy for their IBD, steroids, or antibiotics.
The next question becomes, “Is this related to disease activity?” If so, then we need to figure out the location and severity of the inflammation. Adjustments to the IBD medication are often enough to control the disease.
If the lesion is suspected to be from the medication, often the answer is to change to a different agent. Some key points here are that 1) paradoxical psoriasis can often be controlled with a topical steroid ointment; 2) with so many options in 2021 to medically treat IBD, I am comfortable moving on to a different agent rather than forcing a person to live with side effects from our therapy; and 3) paradoxical psoriasis with anti-tumor necrosis factor agents (TNF) has a 60% chance of being a class effect. Switching out of class would be appropriate.
If the lesion is not related to disease activity or medication side effect, then dermatology investigation can be quite helpful. In addition, for lesions like pyoderma gangrenosum and HS, we may need assistance from dermatology or plastic surgery depending on who has expertise in the area.
ALN: During the AIBD session, you mentioned that in your practice you see a high proportion of Black patients, in whom the standard signs and symptoms may manifest a bit differently than in White patients. Can you explain some of these differences and what gastroenterologists should be careful to look for in their patients of color?
JS: Often our medical texts don’t represent the person we are treating. This can be quite pronounced as skin types may result in different appearances of skin lesions. A hallmark of pyoderma gangrenosum is a purplish rim. In some skin tones this may appear red or brown. In some people, HS appears as raised, red lesions. In others it may appear as dark brown lesions. Psoriasis often appears as a red and scaly macular rash, but in people with darker skin tone, the palmar variation can appear as hyperpigmented spots.
It is important to become familiar with how these dermatologic lesions appear in people with different skin tones so that we can ensure a quick and accurate diagnosis.
ALN: Skin manifestations may be paradoxical responses to anti-TNF agents used to treat people with IBD. How do you go about pinpointing this as the cause of skin symptoms, and how do you proceed from there to manage both the dermatologic condition and IBD?
JS: Anti-TNFs have been used to treat psoriasis for years, so it may seem contradictory that one of their side effects is psoriasis. We know that by suppressing the TNF-alpha there may be a rise in the interferon alpha, IL-17 and IL-23. Locally, this can produce psoriasis and can occur anywhere on the body. The variant commonly associated with IBD and anti-TNF is the palmar plantar pustular psoriasis. This can lead to red or hyperpigmented pustules on the palms of the hands and soles of the feet. It can also lead to cracked skin that can be quite painful. People often feel self-conscious about the lesions, and that can cause stress.
If I see the palmar/plantar variety, I am comfortable that this is from the medication, and the first-line treatment would be a topical steroid ointment. This can allow us to continue medication in up to 90% of patients. In 2021, there are many other medication options for IBD, and if the patient has persistent symptoms or stress from the lesions, then I would opt to switch medications. About 60% of patients will have the same reaction with another anti-TNF. I often opt for ustekinumab as an agent that treats both IBD and psoriasis.
ALN: When do you call in your colleagues from dermatology to help pinpoint skin disorders and devise treatment plans? Are there other medical experts you work with to diagnose and treat these conditions?
JS: Just as not every gastroenterologist is a specialist in hereditary colon cancers, not every dermatologist may be comfortable diagnosing or treating these skin conditions. It is important to communicate with them directly to ensure that you picked the right provider. For HS, it may take a multidisciplinary approach with colorectal surgery or plastics being involved.