At the SDPA 2022 Annual Summer Dermatology Conference, a session on both common and rare dermatological disorders.
Gabriela A. Cobos, MD, director of the Connective Tissue Clinic and instructor in Dermatology at Harvard Medical School in Boston, Massachusetts began her presentation by taking a look at psoriatic arthritis (PsA). “Psoriasis is a chronic inflammatory disease, with increased rates of other comorbid conditions, and the systemic inflammation of this condition is not only in skin,” she began. A majority of patients (85%) who have psoriatic arthritis initially developed psoriasis. Presentations include nail psoriasis, peripheral arthritis, dactylitis, and axial disease.
Risk factors for PsA include a first-degree relative with PsA, obesity, and subclinical musculoskeletal inflammation. To help identify the condition, Cobos will ask (citing a 28-year-old patient): do you wake up in the morning feeling 28, or does the stiffness and pain make you feel like you are in your 80s? Does the pain improve with exercise? She also asks about family history, swollen fingers or toes, and description of pain (gnawing, throbbing, deep). Younger adults are at a greater risk for this disease, and this psoriasis is also an independent risk factor for myocardial infarction. Cobos advises routine monitoring of hemoglobin A1c, blood pressure and lipids, as well as counseling on weight loss, smoking cessation and NSAID use. “Often, you might be the only health care provider this patient is seeing, so this kind of counseling is important,” Cobos advises.
Next, Cobos delved into identification and treatment for systemic sclerosis, presented as a triad of excessive fibrosis, vascular component such as endothelial cell dysfunction, and autoimmunity. Asking the patient about smoking habits, frequency and severity of symptoms (eg, puffy fingers and color changes in fingers, an immediate red flag for this condition), and a medication review are crucial. Limited systemic sclerosis affects the area from the elbow to the knees, while the diffuse subset can appear anywhere on the body. An indicator of systemic sclerosis can be Raynaud’s phenomonen, blood vessel constriction of the fingers, toes, nose and/or ears. Cobos suggests behavioral modifications to treat this conditions which include smoking cessation, keeping core temperature warm, limit or stop caffeine use, and avoiding vasoconstrictors.
While calcium channel blockers are usually the first intervention for Raynaud’s, Cobos enthusiastically endorsed botulinum toxin (Botox) as an effective therapy as well. “Although my patients say there was some pain involved in getting the injections, they felt it was worth it, as symptoms would often decrease in 2 weeks, and the treatment lasts for 4 to 6 months,” Cobos noted.
Chronic cutaneous lupus (LE) can manifest in a variety of ways. Cobos shared one patient’s experience, with hair loss, and rashes and lesions on her cheeks. If one has a diffuse involvement of this condition, there is a higher risk of systemic Lupus (SLE). Cobos warns, “it is important to recognize and treat early to prevent permanent scarring,” With subacute cutaneous LE (SCLE), there is usually an annular or psoriasiform presentation in sun-exposed areas; dyspigmentation, no scarring; and a 50% risk of SLE. With this, it is important to note medication history: More than 1/3 of SCLE cases could be attributed to drug exposure such as PPIs, terbinafine, antiepileptics or TNF alpha inhibitors.
Finally Cobos discussed dermatomyositis, is a rare inflammatory disease, with muscle weakness and extracutaneous manifestations. “Prompt diagnosis is crucial here,” says Cobos, with risks of myositis, pulmonary conditions and cancer. Screenings for this should include, but are not limited to, an EKG, CBC, LFTs and Creatinine/GFR, CK, and aldolase, as well as esophageal studies (eg, barium swallow, manometry). “A patient should also have a full physical exam with an internist yearly, as the risk remains elevated for 3 years,” says Cobos.
Cobos GA. Presented at: The Society for Dermatology Physician Assistants Annual Summer Meeting. June 16-19, 2022. Austin, Texas.