Nonrheumatologists, and dermatologists in particular, need to be conscious of the signs and symptoms of psoriatic arthritis (PsA), because delayed diagnosis is associated with worse outcomes, said Alice Gottlieb, MD, and Joseph Merola, MD, at the final live session of the virtual Interdisciplinary Autoimmune Summit (IAS) on July 12.
Dr Gottlieb is the medical director at Mount Sinai Beth Israel Dermatology and the Kimberly and Eric J. Waldman Department of Dermatology at the Icahn School of Medicine at Mount Sinai in New York.
Dr Merola is the director of the Clinical Unit for Research Innovation and Trials and the director of the Center for Skin and Related Musculoskeletal Diseases at Brigham and Women’s Hospital in Boston. He is also an assistant professor in the Departments of Dermatology and Medicine at Harvard Medical School.
Telehealth visits can be useful for preventing delays in diagnosing and treating PsA, Drs Gottlieb and Merola said, sharing information about signs and symptoms that be found even without a direct patient visit. They noted that the American Academy of Dermatology guidelines for management of patients with psoriasis state that the risk of PsA “should be considered in all patients at every visit.” Dr Gottlieb discussed how early diagnosis can prevent disability in these patients, with the administration of interleukin-17 (IL-17) blockers and tumor necrosis factor (TNF) inhibitors.
Dr Merola noted, “The first doctor to see a patient with PsA is probably the dermatologist, who is treating the patient for psoriasis.” He suggested that physicians use the mnemonic PSA: P for pain in joints; S for stiffness after waking or after 30 minutes of inactivity or for swelling of fingers (dactylitis); and A for axial symptoms such as low back pain.
Dr Gottlieb pointed out that non-dermatologists, including rheumatologists treating patients with PsA, should also care about the skin. She emphasized, “Clear skin matters. Patient-reported quality of life relates directly to both skin and joints being adequately cared for.”
In a role-playing exercise they demonstrated how during telehealth visits the physician can take the patient through a process to identify any pain or stiffness in key areas. “You also have to ask about areas where the video camera doesn’t ‘shine’,” Dr Merola pointed out, “such as the scalp, the genital areas, and other areas where inverse disease may appear.” Gottlieb noted that up to 60% of PsA patients have genital area involvement, which is “very impactful on quality of life.”
They further suggested using the “handprint” concept to help patients self-assess. The area of the palm and fingers equals about 1% of total body surface area; by using that as a guide, the physician can ask the patient how many “handprints” of the body surface show active psoriasis.
Dr Merola said that telehealth is “very useful for follow-up and maintenance, especially for patients who are doing well. If the patient is maintained well on current therapy, why do I need to bring the patient into the office?” Telehealth can also be useful in higher-level screening for PsA, he said, and some changes in management, such as discussions about changing medications, can be navigated as well.
Dr Gottlieb agreed with these observations, adding, “It can be tricky to distinguish PsA from osteoarthritis in patients with psoriasis. You need to feel the areas to determine if it’s hard or bony, as it would be in osteoarthritis, vs softer and swollen, which is more common with PsA.” However, she said, “We can use telehealth to our advantage despite its limitations and can get a lot of information to help work toward a confirmatory diagnosis.”
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Gottlieb A, Merola J. Telehealth in the era of COVID-19. Presented at: Interdisciplinary Autoimmune Summit 2020; July 12, 2020; virtual.