Are we dermatologists or physicians (or both?)

December 1, 2005

I am certain that most of you have heard the following comments made by a well-meaning patient: "I first saw a dermatologist for my problem. I then went to a doctor for further evaluation."

The first 10 times that I heard this I cringed. I have now gotten used to these sorts of statements, as I have come to understand the origins of the patients' perceptions somewhat better.

Redefining

In this endeavor, we have an unlikely ally: the pharmaceutical industry. Over the past few years, a number of exciting new drugs have been developed or have been rediscovered, which are valuable in the treatment of cutaneous and internal diseases at the same time. Like other physicians, we can become skilled in the use of these agents.

Examples

An example of this is cyclosporine. This is an extremely useful drug with effects on a number of T-cell-mediated diseases, including rheumatoid arthritis, inflammatory bowel disease, psoriasis and atopic dermatitis.

Careful attention to potential toxic effects of this drug requires one to scrutinize renal functions, serum magnesium levels and blood pressure, as well as carefully perform assessment of several possible mucocutaneous side effects, including hypertrichosis and gingival hyperplasia.

Thalidomide is a versatile medication which has been prescribed to patients with certain malignancies of the bone marrow, HIV disease, and several recalcitrant skin diseases, including cutaneous lupus erythematosus, aphthous stomatitis and prurigo nodularis. In order to use this medication appropriately, the treating physician must inquire about symptoms associated with peripheral neuropathy and perform a physical examination looking for clues of neurologic toxicity. We dermatologists can do this. I will guarantee that after you perform a simple neurologic examination on the patient who is on this medication, that person will have little doubt that his dermatologist is a real doctor.

Another opportunity

The new biologic agents offer us another opportunity to display our credentials as physicians. These interesting new drugs have re-invigorated the medical side of dermatology.

One class of the biologics, the TNF-alpha inhibitors, offers a chance to enlarge the spectrum of diseases that can be managed by dermatologists. Psoriatic arthritis and/or enthesitis (inflammation of the region where tendons and ligaments insert into the bone) affects up to 30 percent of patients with psoriasis. Many of these patients do not relate their chronic pain and stiffness to their skin disease. In the course of the examination, we can ask a few questions about the state of musculoskeletal health and examine the joint and tendon insertions for evidence of inflammation. If one makes the diagnosis of psoriatic arthritis, TNF-alpha inhibitors are excellent choices for both the psoriasis and psoriatic arthritis. In fact, there is some data to suggest that treatment with etanercept, for example, may actually retard disease progression of the destructive component of the arthritis.

Early aggressive therapy can change people's lives. One of my patients was a champion bowler, who stopped participating in the sport because of chronic pain and swelling of her fingers. She consulted with us for psoriasis, but we actually treated her psoriatic arthritis. She's back to being a national amateur champion bowler once again, after several months of etanercept therapy.

CME explosion

Many of you are probably asking yourselves, "How am I going to learn about psoriatic arthritis, to the point where I will feel comfortable in caring for these patients?" Part of the answer lies in what will soon be an explosion of CME offerings on the subject, directed specifically at dermatologists. I predict that this will happen because there are now, or soon will be, three competing TNF-alpha inhibitors marketed to dermatologists for patients with psoriatic arthritis. I suspect that there will be many after-dinner seminars sponsored by the makers of these agents. I would suggest that you take the drug company representative's offer for a good meal and a potentially important session discussing the subject of psoriatic arthritis, and the uses of therapeutic agents in patients with this rheumatologic disorder.