Skin and bones—mind the gap

L. Robertson and D. de Berker1

Bristol Royal Infirmary, Bristol BS2 8HW and 1 Bristol Dermatology Centre, Bristol Royal Infirmary, Bristol BS2 8HW, UK

Correspondence to: D. de Berker. E-mail: david.deberker{at}ubht.swest.nhs.uk

How often do you scratch your head and think—I wonder what this rash really is? Is it a bit of eczema, sun damage or the early stages of a connective tissue disease? How many forms of cutaneous photosensitivity do you know? Taken from another angle, the jobbing dermatologist will often ask themselves when does a sore joint stand alone and when does it fit in with a global diagnosis? What is the current best bet for non-steroidal analgesia? Is rest or exercise a good thing in psoriatic arthritis? In this issue there is a paper by Lyn Williamson describing psoriatic nail disease. An area of overlap, or is it a gap, between rheumatology and dermatology.

The disciplines of rheumatology and dermatology share considerable common ground. Yet one person's bread and butter is another person's terra infirma. Think of our shared diseases—the seronegative arthropathies (psoriatic arthritis, Reiter's disease), connective tissue diseases (systemic lupus erythematosus (SLE), scleroderma and dermatomyositis), the vasculitides, Behçet's syndrome, adult-onset Still's disease, some sexually transmitted diseases (Reiter's disease, gonococcal infections) and other infections such as Lyme disease. The spectrum is wide and diverse. Due to continuing and rapid advances in technology and improved understanding of the pathophysiology of disease, modern medical practice has become increasingly specialized. As a result of this there are undoubted benefits to patients with ‘uni-system’ disease processes requiring specialist input. Such individuals are managed by doctors with high levels of experience and expertise in their chosen field. However, for those with conditions that can be multisystem, the evolution of autonomous speciality groups can result in less than efficient care, and most frustratingly for patients, different and sometimes contrasting advice from the separate specialists they see.

Psoriasis and psoriatic arthritis are the conditions that most often lead a patient to be seen by a dermatologist and a rheumatologist. There are some similarities, particularly with respect to systemic treatments but several important differences [1] that can have a negative impact on the dermatological management of psoriasis, e.g. the use of systemic steroids is often not helpful for psoriasis. Perhaps most importantly, the trend in rheumatology to use higher doses of methotrexate in rheumatoid disease (post-dating the use of such doses for psoriasis), may lead to an inaccurate extrapolation to psoriatic arthritis by rheumatologists. Psoriatic patients appear to have a higher risk of hepatotoxicity than rheumatoid patients [2] and therefore monitoring beyond regular serum hepatic transaminases with intermittent liver biopsies, or more recently with serum pro-collagen III N-peptide [3], is recommended [4]. However, this latter serum marker is less helpful in the monitoring of arthritic patients as levels have been found to correlate with the inflammatory response [5, 6], although not in all studies [7]. Furthermore lower levels have been found to be associated with slower rates of radiographic progression in rheumatoid arthritis [5]. In contrast to histological studies in psoriatic arthritis, serum transaminases in rheumatoid patients treated with methotrexate correlate well with hepatic histological changes [8] and if transaminases and albumin are kept within the normal range there is no significant deterioration of liver histology [9, 10]. Rheumatologists are alert to the possibility of the pulmonary complications of methotrexate, but this is vanishingly rare in dermatological patients.

Combined clinics with the separate specialists reviewing patients together are probably the ideal situation for managing those with multisystem disease. The complex field of connective tissue disease (CTD) management is perhaps furthest forward with respect to this, with individuals from disciplines such as renal, chest and obstetric medicine regularly involved in the follow-up of these patients with rheumatologists. CTD patients often demonstrate atypical skin involvement rather than the classical textbook rashes. Dermatologists are already successfully involved in combined clinics in various specialist centres. However, the challenge is to facilitate this mode of practice more widely outside the tertiary centres in the UK.

If we think of the more common problem of psoriasis, it sometimes seems odd to a patient that they see two different doctors to juggle their methotrexate for the same condition, which affects different parts of their body. How can we explain it? The doctors have different timetables, they trained separately, they are too busy. All true, but not very convincing. Add to that the political pressures, where numerical targets are compromised if one patient sits in front of two doctors. Most of us spend our time splitting attention over numerous patients. At present, quality is not top of the agenda.

Perhaps a model to be copied is the evolution of multidisciplinary teams in the management of cancers, where quality has got its foot in the door. Dermatologists are familiar with this as in many centres 50% of their work is related to the diagnosis and management of skin cancer. The struggle has been to free up the time of the pathologist, the plastic surgeon, the oncologist and the specialist nursing and support staff at times that coincide. The answer has been government compulsion and local efforts to comply, which have dragged money towards the problem. There is no doubt that there is some benefit to this model of care, if it does not compromise the treatment of others. Which at present, it probably does.

In the end, apart from cash, it comes down to education, education, education. As dermatology and rheumatology training in the UK are mutually exclusive and they also rarely form part of general medical training before specialization, few rheumatologists will feel confident prescribing topical treatments for psoriasis and indeed other skin complaints. Conversely, whilst dermatologists are familiar with oral steroids, hydroxychloroquine and immunosuppressants for skin disease, they are less confident in using them in multisystem pathology. Teamwork between rheumatologists and dermatologists could enable rational treatment plans with appropriate consideration of effects (both positive and negative) of these types of medication on all aspects of a multisystem disease including potential drug interactions. This is going to be particularly relevant in the emerging field of biological therapies. Etanercept and infliximab are currently under consideration by the National Institute for Clinical Excellence (NICE). The expectation is that they will be commenting largely on the use of these drugs in rheumatological disease, although they have an important role in skin disease also. In most of the UK, funding is by local arrangements with primary care trusts. Although there may be a more defined budget with a formal pronouncement by NICE, it is unlikely that this will be adequate. Imagine the alliance between rheumatologist and dermatologist where they define the double bounty of treating a medically complex and disabled patient with a single agent to cover several aspects of their ill-health. It has long been the pattern in gaining research grants that the breadth and number of backers plays an important part in obtaining funds. There may even end up being a cost–benefit argument in their favour if costs are not solely calculated in terms of those borne by the health service. The converse of a shared approach is the kind of dilemma that can develop with methotrexate. When the joints are bad the dermatologist thinks that the rheumatologist is in charge because they have put up the dose. When the skin is bad, the opposite applies. But at some phases in the process it is possible that no person is clearly in charge and this is where poor monitoring and problems develop.

Another potentially shared resource would be in-patient beds. There are similar characteristics to many of our patients. There are the sick and then there are those with a specific problem that requires some specialist intensive in-patient nursing help. Daily physiotherapy and use of the pool equates with daily applications of skin treatments and phototherapy. People needing these facilities do not always benefit from the more extreme and technical aspects of the hospital environment. But they need the staff seen in these specialist centres. Whilst both specialties need access to high-level acute medical care, the immediate clinical environment works best as a more benign and low-key setting. Such settings are not ideal for acute medical and surgical admissions—which might provide some protection against bed loss to the unexpected.

Probably the best place to begin to improve liaison between dermatologists and rheumatologists is during the specialist training years. The shorter specialist training evolved over the last decade in the UK has made it difficult for trainees to develop ‘hands-on’ experience in specialities allied or associated with their own. However, the structured training programmes that have evolved provide an opportunity for involvement of different specialities in each other's training. Regional training days and periods of clinical attachment are realistic aims. As the NHS eventually moves towards the desired consultant-led service trainees should become more and more supernumerary. Let's hope that the consultants are not too busy leading to benefit from these opportunities. Continuing professional development for specialists clearly needs to continue this cross-communication with regular updates at local, national and international meetings.

Is this all cloud-cuckoo land? We don’t think so. Local efforts by specialists can alter the way in which services are delivered—even if it is only a little at a time. Train the trainees with new expectations. And perhaps most important of all, maybe we should the hear the patients on this one.

In summary, rheumatology and dermatology practice have much in common but also important variations. Awareness of these differences by rheumatologists and dermatologists is important for optimal, safe and appropriate management of the multisystem conditions we jointly manage. Some headway has been made in the field of CTD management with the advent of combined clinics. However, the other much larger population of psoriatic arthritis patients are more often than not managed separately for their skin and joint manifestations. Incorporating allied speciality awareness and education in our specialist training programmes is the most useful place to start in trying to improve the current situation. But specialists already practising also need to take on the responsibility for advocating the most appropriate setting for the management of our shared patients and ensure that a dialogue promoting this is open with the commissioners/funders of our health service in the UK.

The authors have declared no conflicts of interest.

References

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  4. Clinical guidelines. Psoriasis. British Association of Dermatologists, 2001. www.bad.org.uk
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  8. Kremer JM, Furst DE, Weinblatt ME, Blotner SD. Significant changes in serum AST across hepatic histological biopsy grades: prospective analysis of 3 cohorts receiving methotrexate therapy for rheumatoid arthritis. J Rheumatol 1996;23:459–61.[ISI][Medline]
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