Combined clinics for management of psoriatic disease take many forms

In this issue of Healio Psoriatic Disease, we focus on the advent of combined dermatology-rheumatology clinics for the management of patients with psoriatic disease.

A critical motivating factor for these initiatives is that psoriasis is a systemic and dynamic chronic inflammatory disease. Invariably, most clinicians will need the expertise of others to successfully manage patients with psoriasis long term. Most combined clinics focus on the intersection of the skin and the joints, but it is important to emphasize that comorbid mood disorders and cardiometabolic disease are also highly prevalent in patients with psoriatic disease and that major cardiovascular events are the leading cause of excess premature mortality in patients with psoriasis. As a result, clinicians who manage psoriasis should have a plan in place for comanagement of these patients. This plan may mean having the patient seen by multiple specialists at once, as is done in the Rochester model exemplified by Ritchlin and Tausk, or it can be a virtual approach in which the clinician establishes relationships with relevant specialists for the management of psoriatic disease and has pathways available that allow for good communication and rapid consultation.

In my academic practice at Penn, our “combined” clinic is virtual. We have an established group of expert dermatologists who specialize in psoriasis, rheumatologists who specialize in psoriatic arthritis, and internists who specialize in preventive cardiology and are knowledgeable about the impact psoriasis has on cardiovascular risk. Our communications and referrals are aided tremendously by the electronic medical record we share. As a dermatologist, I screen all patients with psoriasis regularly for signs and symptoms of inflammatory arthritis. If the patient has signs or symptoms of psoriatic arthritis, I initiate a workup that includes blood tests for inflammation (CRP, ESR), rheumatoid arthritis (RF, CCP antibody) and uric acid (gout can present with similar symptoms) and get X-rays of the hands and feet if they are affected to look for signs of joint damage such as erosions. If the workup is abnormal or the signs and symptoms of psoriatic arthritis are clinically significant, then I arrange for an expedited referral to my rheumatology colleagues, and I may initiate a disease-modifying antirheumatic drug (DMARD) even if the skin disease is mild. Similarly, I screen my patients with psoriasis for risk factors for cardiovascular disease (blood pressure, lipids and HbA1c) based on age-appropriate guidelines.

These simple screenings are especially important as many patients with psoriasis in the U.S. do not have regular contact with primary care. If these screening tests are abnormal, I connect the patient with our preventive cardiology clinicians. Over the years, we have picked up a lot of subclinical atherosclerotic cardiovascular disease, with many patients crediting us for saving their life when particularly high-risk coronary or carotid lesions are identified on imaging. In return, I help my rheumatology colleagues optimally select DMARD treatment to ensure a good response in the skin, help establish a diagnosis of psoriasis in atypical presentations, treat residual skin psoriasis in patients whose joints are under good control and conduct skin cancer surveillance. I also routinely do consults for my colleagues in preventive cardiology who often see patients with untreated psoriasis in their practice.

Combined clinics to manage psoriatic disease need to be flexible in their organization and management given our highly variable and disjointed health care system. That said, with advances in our knowledge about psoriasis and the advent of EMRs that interact across systems, the opportunity to achieve better outcomes not only in the skin and joints but also overall health and well-being for our patients with psoriatic disease has never been greater.

• References:
• Abuabara K, et al. Br J Dermatol. 2010;doi:10.1111/j.1365-2133.2010.09941.x.
• Barbieri JS, et al. JAAD International. 2021;doi:10.1016/j.jdin.2020.10.010.
• Elmets CA, et al. J Am Acad Dermatol. 2019;doi:10.1016/j.jaad.2018.11.058.
• Takeshita J, et al. J Am Acad Dermatol. 2017;doi:10.1016/j.jaad.2016.07.064.