Diagnosis Detective: Deciphering dermatologic symptoms of rheumatic diseases
Many rheumatic diseases – including systemic lupus erythematous, scleroderma and the various forms of psoriasis – present with a multitude of dermatologic symptoms that clinicians can easily confuse with other conditions.
According to M. Elaine Husni, MD, MPH, vice chair of the department of rheumatic and immunologic diseases, and director of the Arthritis Center at the Cleveland Clinic, rheumatologists must think and work like a detective to properly examine a patient’s symptoms and determine the proper diagnosis.
“The most challenging part for rheumatologists regarding these dermatologic symptoms — because we are not looking at skin complaints all the time like a dermatologist would — are the really hidden psoriasis types, for example in the ear and on the scalp,” Husni told Healio Rheumatology. “Unless you lift up the hair, you might never notice that the patients have psoriasis; sometimes you have to play detective and think more objectively to find the diagnosis.”
It also helps, she noted, to have a great partner in a dermatologist who can lend their expertise during physical exams, and advise on possible treatments.
“I think when you have diseases that affect multiple organs, it is important to collaborate with other specialists to improve patient outcomes,” Husni added. “This includes having someone who specializes in skin conditions to help you with the exam and come up with a treatment regimen.”
Anthony P. Fernandez, MD, PhD, staff physician at the Comprehensive Lupus Clinic, and the departments of dermatology and pathology at the Cleveland Clinic, often works with rheumatologists, including Husni, to assist with examinations and develop treatment plans, he said.
According to Fernandez, that can often include advising on the telltale dermatologic signs of various rheumatic conditions.
“With psoriasis, the most common subtype is plaque psoriasis, which typically has well-demarcated plaques and lesions, commonly on the elbows and knees, and scalp and gluteal cleft,” he said. “Dermatomyositis is another one that we see at a tertiary care center relatively frequently, with symptoms including pink papules that tend to occur on the hands and overlying the interphalangeal joint.”