This article appeared in the Winter 2011 issue of Rheumatology Update.
Specialists offer Extensive Studies of Treatment and Risk Factors for Concomitant Systemic Rheumatic Disease and Skin Disease
Led by rheumatologist Elinor Mody, MD, and dermatologist Abrar Qureshi, MD, MPH, the Center for Skin and Related Musculoskeletal Diseases offers an innovative approach to the diagnosis and management of patients with diseases with both musculoskeletal and cutaneous involvement.
“Together, we are able to tackle many of the diagnostic and treatment challenges that these conditions present, while looking at the larger picture in order to determine the extent of the patient’s disease burden,” said Dr. Mody.
Formally established seven years ago, the Center is one of the few in the nation to deliver simultaneous rheumatologic and dermatologic evaluation of these patients. In addition to care for patients with psoriasis and psoriatic arthritis, the Center treats a wide range of diseases that can affect both the skin and the joints, such as discoid and systemic lupus, Sweet’s syndrome and other neutrophilic dermatoses, dermatomyositis, pyoderma gangrenosum, sarcoidosis, scleroderma, and vasculitis, among others. Residents and fellows from the Division of Rheumatology, Immunology, and Allergy and from the Department of Dermatology rotate simultaneously through the Center and thus reap extraordinary educational benefits from this collective enterprise. The Center often excels in the diagnosis and management of difficult clinical problems, as illustrated by the following vignette:
A 47-year-old woman with longstanding rheumatoid arthritis and rash was referred to the Center. Her RA had responded well to entanercept, but she now presented with a slightly pruritic, nonpainful rash on the forearms. On examination, she was found to have a maculopapular rash (at right), forming annular lesions on the arms and legs. Diascopy was positive, showing brownish discoloration after erythema had blanched out. As there was concern for a vasculopathic or vasculitic versus granulomatous eruption, a biopsy was performed. The biopsy demonstrated dermal multifocal non-necrotizing granulomas. Cultures were negative. Consideration was given to stopping etanercept, but rheumatologic evaluation suggested the importance of continuing TNF alpha blockade for continued control of RA. Instead, high potency topical steroids were used for successful management of the eruption.
Current Studies in Psoriasis and Psoriatic Arthritis
The Center has promoted the early detection and treatment for psoriasis and psoriatic arthritis through a number of publications over the last seven years, and is currently examining the long-term safety of current medications for psoriasis and psoriatic arthritis, as well participating in further studies to assess new agents:
- PSOLAR (Psoriasis Longitudinal Assessment and Registry) – Principal Investigator Abrar Qureshi, MD, MPH is leading this national registry to further evaluate the safety of infliximab (Remicade) and ustekinumab (Stelara) in patients with plaque psoriasis and other overlapping forms of psoriasis. The registry also will evaluate clinical outcomes, quality of life, and potential risks for patients who may receive standard therapies for psoriasis. (Please contact Abrar Qureshi, MD, MPH, for more information at email@example.com);
- ESPRIT (Post-marketing, Observational Study of Humira in Patients with Chronic Plaque Psoriasis) – Led by Principal Investigator Abrar Qureshi, MD, MPH, ESPRIT is a 10-year observational study of patients taking adamimubab (Humira) for chronic plaque psoriasis. (Please contact Abrar Qureshi, MD, MPH, for more information at firstname.lastname@example.org.)
- New Trials for Chronic Plaque Psoriasis – New trials for patients with moderate to severe chronic plaque psoriasis include a phase II, randomized, placebo-controlled, doserange finding study of subcutaneous SCH 900222 and a phase III, randomized, placebo-controlled study of oral CP-690,550. (Please contact Abrar Qureshi, MD, MPH, for more information at email@example.com);
“Approximately 20 to 30 percent of patients with psoriasis will develop psoriatic arthritis,” said Dr. Qureshi. “Using a novel approach, we are striving to improve screening of patients with psoriasis for symptoms of inflammatory arthritis through simple tools that can be used during a clinic visit, as well as studies to help us better understand the development and risk factors for psoriatic arthritis.”
Other tools developed by the Center for the study of psoriasis and psoriatic arthritis include:
- Psoriatic Arthritis and Psoriasis Follow-up Study (PAFS) – The Center has compiled clinical data, including responses to medications, on more than 900 patients with psoriasis and psoriatic arthritis. Plans are underway to expand the use of this registry for the inclusion of imaging modalities to determine whether patients may have evidence of psoriatic arthritis prior to the onset of symptoms, as well as studies on such co-morbidities as obesity and cardiovascular disease.
- Psoriatic Arthritis Screening and Evaluation (PASE) Questionnaire – Developed by specialists at the Center, this published self-administered patient questionnaire has been requested by dermatologists worldwide to help identify patients with psoriasis who should be referred to a rheumatologist for evaluation for psoriatic arthritis. PASE has been translated into 18 languages and used in more than 21 countries for clinical and research purposes. The benefits of this questionnaire and other screening tools were outlined in the Journal of Rheumatology (J Rheumatol, 2008. 35(7): p. 1423-5).
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